Hallie Lwvine wrote . . . . . . . . .
Norman Dill, 69, never thought he was the anxious type. But when he was diagnosed in 2019 with posterior cortical atrophy (PCA)—a neurologic condition in which the posterior cortex, the area of the brain involved with visual processing, is damaged—anxiety became part of his life. In the early stages of the disease, people may experience problems seeing and recognizing faces and objects. “I began to have trouble driving,” says Dill, who lives in Charlottesville, VA. “I’d turn into the wrong lane or hit a curb. When my grandchildren came to visit me that Thanksgiving, I realized I didn’t feel comfortable driving with them in the car.”
His anxiety only deepened over the next few years as the disease increasingly affected his life. When PCA advances, people tend to develop symptoms of dementia, such as memory loss and confusion. Dill forgot the names of his employees at the natural food store he’d owned for more than 30 years. He struggled to read the labels of the food items that he stocked on his shelves. He had stopped driving, but taking public transportation confused him. “It’s a free-floating anxiety,” says Dill. “I feel a sense of frustration that things aren’t right, and I want to get back to how things were before.”
Research suggests that about half of people with PCA or Alzheimer’s disease report symptoms of anxiety, and it’s common in many other neurologic diseases, too. But “it’s always hard to tell if the anxiety is a manifestation of the condition or if the anxiety is related to living with the disease,” says Danny Bega, MD, associate professor of neurology at Northwestern University in Chicago.
In some cases, it may be a little of both. Denise Glassner, 47, has had migraine attacks for most of her life, and by 2016 they had worsened to the point that she had to quit her job as a veterinary technician and even stop driving. “I’ve always had anxiety, but this really brought it to the next level,” says Glassner, who lives in Boca Raton, FL. “I’m often at home alone. That’s when the little demons come out. With nothing to distract me, I spend a lot of time worrying, which only makes my migraine worse.”
There’s no doubt that anxiety is on the rise in general. Global prevalence of anxiety and depression has increased by 25 percent since the start of the COVID-19 pandemic, according to research released last year by the World Health Organization. But anxiety can be particularly challenging to detect in people with neurologic disease, says Dr. Bega, since symptoms of anxiety overlap with symptoms of some neurologic conditions, such as Parkinson’s disease. In addition, patients themselves may not bring it up. “They may expect that feeling anxious is ‘normal’ for the condition and thus don’t raise their concerns with their providers,” says Zahra Goodarzi, MD, assistant professor of geriatrics at the University of Calgary.
This may start to change with recent guidelines advocating for increased screening. Last October, the U.S. Preventive Services Task Force (a panel of medical professionals that advises Congress on disease prevention) issued a draft recommendation that adults younger than age 65 be screened for anxiety by their primary care providers. While the recommendation didn’t specify screening tools, most doctors use the generalized anxiety disorder scale and the geriatric anxiety scale. Other questionnaires include the hospital anxiety and depression scale and the PHQ-4 scale, both of which measure symptoms of anxiety and depression and can be filled out in the doctor’s office. “A lot of interventions are available to treat anxiety, so it’s important that patients be evaluated and diagnosed appropriately,” says Dr. Goodarzi.
Understanding the Emotion
Anxiety—defined as a feeling of fear, dread, or uneasiness—is a normal reaction to stress. There are three types of anxiety disorders: generalized anxiety disorder (worrying excessively about health, money, work, or family), panic disorder (having panic attacks), and phobia (an intense fear of something, such as spiders or flying).
Most of the time, people with neurologic conditions experience generalized anxiety disorder, says Dr. Goodarzi. They may also develop phobias, but with good reason: “A person with Parkinson’s disease may have a very real fear of falling, which leads them to avoid activity,” she explains. “This in turn causes more muscle loss, which makes them even more likely to fall and reinforces their fear. It’s a vicious cycle.”
Isolation also can exacerbate anxiety. “Family, friends, co-workers—they all can buffer some of the impact of anxiety because you can talk to them,” says Indu Subramanian, MD, a movement disorder specialist at UCLA Health. “But if you have limited mobility and spend most of your time at home alone, it’s easy to fixate on the uncertainty of your future and feelings of lack of control.”
Some neurologic diseases can amplify these emotions. “We know with migraine, for example, certain areas of the brain are dysregulated even in the absence of an actual migraine attack,” says Katherine T. Hamilton, MD, a neurologist at MedStar Georgetown University Hospital in Washington, D.C. “We think the migraine brain in general is more hypersensitive and hyperexcitable, and this may also make people more predisposed to anxiety.”
That is how Jill Feinstein describes her experience with migraine. “It’s both physical and emotional,” says the 65-year-old, who lives in Stamford, CT. “My body is hypersensitive to touch, and I get upset easily. If someone looks at me the wrong way, I’m a mess.” Her migraine attacks have always been triggered by stress. When she was 10, she was hospitalized for two weeks with an abdominal migraine, a type of migraine that causes not just headache but intense abdominal pain, nausea, and vomiting. “I’d switched elementary schools and was stressed about being the new girl,” she says.
High levels of stress and anxiety may increase vulnerability to neurologic disease. A 2021 study published in Frontiers in Neurology found that people diagnosed with post-traumatic stress disorder were more likely to develop seizures, and a 2022 study in Neurology found that people who reported increased stress at home or at work or who had experienced recent stressful events such as a divorce had an increased risk of stroke.
Medication and Meditation
Christine Morrisey, 53, cared for her mother, Jean, who had PCA, for three years before her death in 2020. “She was always a slightly anxious person, but her condition heightened it,” recalls Morrisey, who lives in Scituate, MA. “She was seeing things that weren’t there, like people and small animals. She’d recognize my voice but not know who I was. We’d sit and watch TV together, and I’d peek over at her and see her sobbing because she didn’t understand what was happening to her.”
Toward the end of her mother’s life, Morrisey and her sisters could calm her down only with medication. “She was intensely paranoid and confused. When my siblings came to take care of her, she thought they were nurses there to steal from her,” Morrisey says. Doctors prescribed a high dose of the antidepressant escitalopram (Lexapro) and, as needed, alprazolam (Valium). “We’d give her 5 mg of alprazolam, which is a very large dose, and within 15 to 20 minutes we’d see a noticeable difference where she’d level out,” Morrisey says. “Eventually she began to request it when she’d get worked up about something, because she recognized that it helped her stop feeling so anxious.”
Some people can manage their anxiety using relaxation techniques like meditation and yoga, says Dr. Subramanian. A study published last year in JAMA Psychiatry found that for adults with anxiety disorder, eight weeks of yoga was just as effective a treatment as eight weeks on escitalopram. “In the past, doctors often considered yoga a tool to help improve motor ability among patients with neurologic diseases such as Parkinson’s, studying it to see if it helped improve balance or reduce stiffness or tremor,” says Dr. Subramanian. “But we know it can be incredibly effective in relieving anxiety as well, and, unlike medication, it doesn’t cause side effects.”
Dill says he’s turned to meditation to manage his anxiety. He also attends Buddhist retreats with his wife and does mindfulness exercises such as deep breathing every day. “It’s not a formal practice—it’s just part of my life,” he says. “I get on the bus and practice awareness, focusing on what’s going on around me—the sounds and the smells. I just try to be present and not let myself get consumed with worries.”
Therapy and Exercise
Cognitive behavioral therapy (CBT), which teaches people a variety of ways to think and behave, is used sometimes to combat anxiety. People who have specific phobias, for example, can be encouraged to confront their fears, which may help them realize that the phobias aren’t as overwhelming as they thought. CBT helped reduce anxiety among people with dementia who had mild cognitive impairment, according to a study published in Alzheimer Disease & Associated Disorders in 2021.
Exercise, including yoga, also has been found to tamp down anxiety. According to a study in the Journal of Affective Disorders in 2021, people with anxiety who exercised moderately or strenuously for 60 minutes three days a week for 12 weeks saw a significant decrease in anxiety symptoms compared with a control group. A study published in Annals of Behavioral Medicine in October 2022 looked at almost 140 people with Parkinson’s disease who were randomized to eight weeks of either yoga or stretching. Yoga not only relieved depression and anxiety but also eased some symptoms, such as trouble walking, tremors, and rigidity. “Any activity like yoga that affects the autonomic nervous system—the part of your body that regulates your heart rate, blood pressure, and breathing—will help relieve anxiety,” says Dr. Subramanian.
Identifying what can and cannot be controlled is another way to manage anxiety. This helped Maureen Foster, 72, of Lafayette, CO. She had to quit her job as a payroll clerk in 2016 because of her PCA diagnosis, and her anxiety escalated in the ensuing years as she burned through all her savings. Her feelings of dread eased after she confided in her son about her financial worries and he offered to take over her mortgage payments. She then sat down and figured out how to get around town without driving. “I walk everywhere now or take the bus,” she says. Friends pick her up several times a week to go out for coffee and provide social support. Her son comes once a week to take her to lunch and grocery shopping. “It was hard to adjust at first, but now I look on the bright side,” says Foster. “I eat lunch and dinner when I want and cook and clean when I want. I don’t have pressure to be somewhere. That helps relieve anxiety too.”
When Feinstein feels stressed and her attacks intensify, she tries to focus on what makes her feel good: her five children, her 6-month-old grandchild, and her relaxing hobbies, like watching Audrey Hepburn movies. Recently, she went on a family vacation to Anguilla and was pleasantly surprised not to experience a single headache during the weeklong trip. “Being surrounded by so much love helped alleviate my stress,” she says. Another source of support: her French bulldog. “Remy is my life,” she says. “I cook for him and design halters and collars for him. It’s good to have such a sense of purpose.”
Source: Brain&Life
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