Behavioral Relaxation Training for Parkinson's Disease Related Dyskinesia and Comorbid Social Anxiety.

Parkinson's disease (PD) is a progressive, neurodegenerative neurological disorder of unknown etiology. Loss of dopaminergic cells in the substantia nigra of the brain is responsible for motor, affective and cognitive changes observed. No cure is available. Common motor symptoms are tremor, rigidity, and bradykinesia, as well as postural instability in later stages of the disease (Weiner, Shulman, & Lang, 2001). As the disease progresses medication induced motor symptoms, such as dyskinesia--involuntary gross motor wiggling or dance-like movement affecting upper and lower extremities--may emerge (Weiner et al, 2001). Awareness of the importance and impact of nonmotor symptoms has grown with clinical and research experience indicating cognitive and behavioral components substantially contributing to impaired quality of life and increased severity of motor symptoms. Yet, anxiety remains unrecognized and under treated among PD patients. (O'Sullivan, Williams, & Gallagher, 2008; Schulman, Taback, Rabinstein & Weiner, 2002). Anxiety disorders are the most common psychological disorder in the general population (Thyer et al., 1985), while anxiety disorders among older adults often co-occur with medical and neurological disorders (Raj et al., 1993). PD and comorbid anxiety have been documented repeatedly with estimates of 40-75% (Schiffer, et al., 1988; Shulman et al., 2002; Stein, Heuser, Juncos, Uhde, 1990). Clinical treatment, when provided, is primarily pharmacological with anxiolytics, benzodiazepines or antidepressants used. Pathological neurodegenerative changes in noradrenergic mechanisms may be responsible for anxiety experienced by patients with PD (Marsh, 2000). No experimental studies have examined the efficacy of medication in this population. The effects of anxiety on functioning of PD are formidable and further diminish quality of life (Marinus, Leentjens, Visser, Striggelbout & Van Hilten, 2002). Comorbid anxiety results in increased motor dysfunction including more severe tremor, "freezing" (sudden inability to move), dyskinesia and situational anxiety. Indeed, anxiety may produce excess disability than that observed solely due to PD. Treatment of motor and non motor symptoms of PD focuses on maintaining and improving quality of life. Addressing comorbid anxiety is an important target in this process and relaxation training has been suggested (Marsh, 2000). Despite the wide spread occurrence of comorbid anxiety and PD, few reports of relaxation training with PD patients are available. Schumaker (1980) examined the effect of frontal electromyographic (EMG) biofeedback and progressive muscle relaxation training on manual motor performance of PD patients. No effect of intervention on motor performance was observed. Behavioral Relaxation Training (BRT) has been used to successfully manage tremor of two older adults; one with essential tremor (ET) and another with ET and PD (Chung et al., 1995). Chung et al reported decreased tremor severity and improved performance in activities of daily. Improved psychological adjustment was anecdotally reported. Lundervold (1997) reported that BRT and coping self-instructions were effective with an ET patient in reducing tremor severity related to negative arousal (anger in specific social situations). Decreased emotional distress and EMG activity among four muscle groups was observed. More recently, Lundervold, Pahwa and Lyons (2009) reported using behavioral intervention that included BRT for management of PD and comorbid general anxiety. Two contemporary behavioral accounts describe anxiety and distress among movement disorder patients (Lundervold & Poppen, 2004; Macht & Ellgring, 1998). These reports describe a three component behavioral model. From a behavioral perspective, identification of current maintaining contextual variables, (i.e., setting events, antecedents and consequences) is critical in selection appropriate interventions (Speigler & Guevremont, 2003). …