Your Mind & Your Emotions

YOUR MIND & YOUR EMOTIONS:  Psychiatric Disturbance or Normal Response?

by Laura Marsh, MD

"Is it normal for me to have feelings of depression or is this a part of my disease?" This is one of the questions I am frequently asked by patients with Parkinson's disease (PD). This question is important and relevant because 40-50% of patients develop depressive disorders at some point. When identified, depressive disorders can be treated successfully, giving patients improved quality of life and reducing disability. However, since everyone experiences emotional variations, determining whether the emotions are part of a clinical condition that needs medical attention can be especially challenging. Therefore, this distinction should be made by your doctor and may require specific assessment by a psychiatrist. However, I also stress that patients should become informed about mood disorders and how they overlap with other features of PD. As a psychiatrist, I find it much easier to evaluate treatment response and detect or prevent a return of the depressive disorder when my patients are taught to monitor relevant mental and physical symptoms.

Distinctions between depressive disorders and depressed emotions can often be unclear because depression can be part of a normal reaction to difficult circumstances or may be part of a variety of psychiatric conditions that are related to the underlying brain changes in PD. In general, the term depression refers to an emotion characterized by sad and unhappy feelings. Depressed emotions are normal, especially in the setting of loss. In patients with PD, changes in function can be associated with a sense of loss resulting in depressed feelings. However, it is not uncommon for people to use the term "depression" somewhat loosely, when they are really experiencing feelings of anger, disgust, anxiety, apathy, or tiredness. Thus, it is important and helpful to explain to your doctor how you are feeling emotionally so the doctor can then determine why you have these feelings and provide proper treatment.

When determining how to treat depression properly, the doctor will do an assessment to differentiate whether the patient's depressive symptoms include such components as normal states of grief or demoralization, interpersonal difficulties, adjustment disorders, apathetic syndromes, anxiety disorders, pathological tearfulness (also called emotionalism), fluctuating mood states that correspond to "on-off" effects of Parkinson medications or dementia. Sometimes patients or doctors resist exploration of this differential diagnosis because of fears about the implications of a psychiatric diagnosis, but I think that an unacknowledged psychiatric disturbance is a much more frightening prospect.

One important clue to the presence of a depressive disorder is the inability to effectively respond at an emotional or behavioral level to life's challenges, including those brought on by PD. Many people think that mood disorders result from a lack of coping skills—but it's just the opposite! With PD (or any chronic illness), successful coping and adaptation are virtually impossible in the face of an untreated mood disorder. Individuals who are ordinarily resilient and resourceful when faced with adversity will often say, "I keep trying, but I just can't keep my chin up." Recognition of this state may be more difficult in individuals who have always "coped well" and continue to attempt to compensate as best as possible despite their untreated mood disorders. Once the depressive disorder is treated, however, the person is better able to face the challenges associated with PD, respond to encouragement, develop ways to compensate satisfactorily, and exploit new opportunities. In fact, such changes are often taken as signs that the mood disorder is responding to treatment.

From the viewpoint of a person with a depressive disorder, one of the most important coping strategies—maintaining a positive attitude, or at least not dwelling on negative thoughts—does not even seem to be an option. However, since ineffective coping and poor adjustment also occur in the absence of mood disorders, it is important to be familiar with the more fundamental features of depressive disorders in PD. The key features of a depressive disorder are a sad mood and/or the inability to enjoy or be interested in activities that would ordinarily be pleasurable (also referred to as anhedonia). In addition, the sad or anhedonic feelings are usually persistent and pervasive. Feeling sadness or a sense of loss over having to stop working because of PD can be an understandable cause for feeling discouragement.

However, in the absence of a depressive disorder, the feelings are transient and the person usually continues to pursue and achieve satisfaction from other activities; the sadness does not color virtually all aspects of life. Negative ruminations, especially about oneself, or morbid thoughts about death (especially one's own death), and excessive and inappropriate feelings of guilt are also very common in depressive disorders. While it may be normal to feel guilt over past mistakes or sadness over losses or resentment because of the impact of PD on daily functioning, these feelings become a preoccupying source of distress in the setting of a depressive disorder. There may also be significant anxiety as a feature of a depressive disorder, although anxiety disorders are fairly common in PD and can occur independent of depressive disturbances.

A variety of intellectual and physical symptoms are frequently present in PD-related depressive disorders. These symptoms also occur in PD without depression, but they tend to be worse when the patient has an untreated depressive disorder. The intellectual symptoms include problems with concentration, attention, and memory, slowed thinking, and difficulties multi-tasking. Physical symptoms include fatigue, low energy, slowed movements, aches and pains, and appetite and sleep disturbances. When there is a depressive disorder, these symptoms will be accompanied by the fundamental mood changes mentioned above and they are usually associated with greater disability. In fact, when patients describe a degree of disability that is far greater than their motor examination suggests, it is important to look for signs of a depressive disorder. Successful treatment of depression improves intellectual deficits, fatigue, and slowness and patients are better able to pursue regular exercise and other compensatory strategies that maximize function, such as modulating the pace of their activities and using memory aides.

The need for specific treatment of a depressed mood is based on the underlying diagnosis. Psychotherapy may help gain perspectives and maintain behaviors that promote well-being. Antidepressant medications are generally indicated when depressive disorders persist and contribute to significant distress and dysfunction. The National Institutes of Health (NIH) is sponsoring clinical trials at sites across the nation to evaluate the effectiveness of antidepressant medications relative to placebo for treatment of major and non-major depressive disorders. After depressive disorders respond to antidepressant medications, self-management approaches such as exercise, pacing daily activities, avoiding sleep deprivation, maintaining a positive attitude and engaging in healthy emotional activities become the focus of treatment and relapse prevention, and hopefully will become the focus of future research studies explicitly for symptom management in PD.

Dr. Marsh is a psychiatrist and Associate Professor in the Department of Neurology and in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine in Baltimore, MD.

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