Cognitive–behavioural therapy for non-motor symptoms of Parkinson's disease: a clinical review

Abstract

Neuropsychiatric symptoms are common in Parkinson's disease (PD) and have a disproportionate impact on quality of life and carer burden. Pharmacological treatment is the main approach in dealing with these symptoms, but it is limited by variable efficacy and risk of drug interactions. Non-pharmacological approaches using the cognitive-behavioural therapy (CBT) model are viable alternatives and in this review paper we summarise the evidence of CBT for three of the most common psychiatric manifestations of PD: depression and anxiety, impulse-control disorders and insomnia. Most studies modified the usual CBT format to include modules accounting for problems specific to PD: activity scheduling around motoric function, motor symptoms as triggers of anxiety, fear of falling and preparation for disease progression as well as accommodation of materials for suspected executive dysfunction. We found a growing evidence base that CBT (modified to account for PD-specific problems) is effective in the treatment of PD psychiatric symptoms. Where controlled study design was used, moderate effect sizes are reported for the efficacy of CBT for depression, including with distance administration of CBT. The effects were sustained during follow-up which was between 1 and 6 months. In addition, there are some initial data on the effects of CBT on impulse-control disorders and insomnia. The studies were limited by their small and potentially unrepresentative samples and the quality of sample reporting (eg, concomitant antidepressant and dopaminergic therapy use). Additional welldesigned and adequately powered studies are required to determine the utility of CBT in PD. INTRODUCTIONParkinson's disease (PD) is classically defined by a triad of motor symptoms (tremor, rigidity and bradykinesia). It is, however, increasingly conceptualised as a neuropsychiatric disorder 1 in view of the high prevalence of psychiatric features, including depression, impulse control disorders (ICD) and sleep difficulties.2 These non-motor complications are better predictors of disability, distress and rates to institutionalisation than the motor symptoms.3 Of the non-motor complications, mixed depression and anxiety is the most common psychiatric comorbidity, affecting ∼50% of PD patients, significantly more common that rates in the general population.4 Depression and anxiety are the strongest predictors of poorer quality of life, 5 even in the advanced stages of the illness where the motor features have progressed fully.6 ICD are characterised by repetitive, reward-based behaviours, linked to the dopaminergic medication used to treat the motor symptoms. They affect ∼14% of all PD patients 7 and are associated with psychiatric comorbidity and high carer burden.8 Sleep disturbance is another neuropsychiatric symptom that affects up to 60% of all PD patients.9 It is associated with somnolence 10 and impairment in attention and executive function.11 On the basis of their impact on quality of life and outcome, the recognition and treatment of neuropsych...

Sensory focused exercise improves anxiety in Parkinson’s disease: A randomized controlled trial

“…These findings are also consistent with the null findings from our Sham exercise group. Mixed findings have been found for the effectiveness of Cognitive Behavioral therapy (CBT) for improving anxiety in PD [63]. To the best of our knowledge, no studies to date have investigated the effectiveness of CBT using the PAS, and therefore it remains difficult to directly compare findings.…”

Management of impulse control disorders in Parkinson's disease

“…The therapy aims to identify and modify dysfunctional thoughts and change maladaptive behaviours that maintain and reinforce distorted thinking. 19,20 There is the task of cognitive restructuring, along with a review of the past and planning for the present; these techniques aim to introduce change in the inner experiences of patients. 19,20 An integral part of CBT is psychoeducation.…”

“…19,20 There is the task of cognitive restructuring, along with a review of the past and planning for the present; these techniques aim to introduce change in the inner experiences of patients. 19,20 An integral part of CBT is psychoeducation. This is a systematic, didactic psychotherapeutic intervention, which informs both patients and relatives about the illness and the treatment.…”

“…7 Other therapy components that can be used to treat pathological gambling include motivational interviewing techniques, stimulus control measures (triggers and high risk behaviour) and addressing maintaining factors (see Box 3 for further details). 7,18,19,20 Current evidence for the use of CBT in the management of ICDs There remains a shortage of studies that centre on the use of CBT to treat ICDs or associated behaviours in PD. Theoretically CBT may be effective for treating ICDs, punding behaviours, dopamine dysregulation syndrome and a number of symptoms associated with DAWS.…”

Pathogenesis, clinical features, and treatments of depression in Parkinson's disease

“…Лекарственную терапию рационально дополнять немедикаментозными методами: психотерапией и физической реабилитацией. Среди психотерапевтических методик самой успешной признана когнитивно-поведенческая терапия (КПТ) [55]. Физическая активность способствует уменьшению выраженности депрессии, при этом аэробные тренировки дают наилучшие результаты [56].…”