Written by Roseanne D. Dobkin, PhD
Depression and anxiety are very common in Parkinson’s and can significantly impact physical and cognitive functioning, quality of life, and relationships. But, despite these detrimental effects, there is good news: you have control over depression and anxiety. You didn’t have a choice in your Parkinson’s diagnosis; however, you do have a choice in how you cope. A powerful way is through cognitive behavioral therapy.
COGNITIVE BEHAVIORAL THERAPY
Cognitive behavioral therapy (CBT) is a skills-based, non-pharmacological treatment that teaches practical strategies to help people living with Parkinson’s and their family members more effectively navigate the challenges of living with Parkinson’s. It is a kind of psychotherapy or “talk therapy” that focuses on examining the connections between thoughts, feelings, and behaviors to provide individuals with the skills needed to change thinking patterns (e.g., negative thoughts about self, world, and future) and behaviors (e.g., procrastination, social isolation and withdrawal, lack of structure in the day) that may be related to uncomfortable feelings like depression or anxiety.
Unlike some other talk therapies, CBT is highly instructive and involves active one-to-one collaboration between the person living with Parkinson’s and the therapist. Sessions are usually structured, and specific techniques and coping skills are explained during each session. CBT is tailored to each person’s unique goals, and people are encouraged to practice their newly acquired coping skills between sessions to work toward their goals.
CBT is generally a brief, time-limited treatment (three to six months). However, the number of sessions varies, depending on the needs of each individual. With ongoing practice, you can continue to benefit from your newly acquired coping skills long after your therapy sessions have ended.
Learning new information is not enough: change requires putting different coping skills into action in daily life.
Here’s an analogy: If you fill your prescription for your Parkinson’s medication but don’t open the bottles and swallow the pills, your tremor and stiffness likely will not improve. Similarly, if you learn innovative tools to combat depression and anxiety in the face of Parkinson’s but do not use them daily, they will not help you. Consistent practice over time is key.
You can use several different CBT strategies to help you cope more effectively with depression and anxiety, as well as with the daily stress of living with Parkinson’s. Some tools focus on what you are doing or not doing in response to the current challenges that you are experiencing, while others focus on how you are thinking about yourself and your changing life circumstances. Behavioral tools include:
- Daily goal setting
- Increasing involvement in meaningful, pleasurable, and social activities
- Safely increasing daily exercise
All the people living with Parkinson’s with whom I work are encouraged to set three realistic, achievable goals per day: one exercise goal, one social goal, and one other goal, which might be something productive like paying a bill or doing some self-soothing like taking an Epsom salt bath. An example of a realistic social goal could be answering the phone when your sister calls instead of letting it go to voicemail. Effective behavioral goal setting often involves collaborative problem-solving and thinking outside the box to meet the challenging demands of Parkinson’s. This point is nicely illustrated in the case of Howard (Table 1, below).
Managing Your Thoughts
Regaining control of your thoughts is another necessary ingredient for improving your mood. In the CBT model, negative feelings like depression and anxiety don’t come out of the blue; feelings come in response to your thoughts and interpretations of the situations you face. Often, thoughts might come so quickly that you might not even be aware that you have them, yet they linger long enough to have a negative impact on how you feel and how you act.
Importantly, the negative thoughts we observe in depression (and anxiety) are often not as accurate as they feel and are guided more by emotion than by fact.
To further illustrate this point, let’s consider the fictional case below. “Mary” and “Joe” are newly diagnosed with Parkinson’s and experience similar physical symptoms and comparable levels of impairment. They both experience tremor when they eat in public and struggle to button their clothes. Mary thinks, “My life is ruined, and I have no control.” In response to this thought, Mary is likely to feel scared and isolate herself. She may avoid eating out and decline social invitations from friends. She is unlikely to be proactive regarding her own self-care.
Joe, on the other hand, thinks, “I wish this didn’t happen, but I know I can still have a meaningful life even with Parkinson’s.” While Joe is certainly not happy about his diagnosis, he is likely to feel more hopeful than Mary and remain active and engaged in his life. The likelihood that he obtains all the multidisciplinary services recommended to optimize his health and well-being is very high, and he may proactively seek referrals from his physicians.
This vignette highlights that different thoughts about the same situation can lead to different feelings and behaviors.
A primary goal of cognitive therapy is to “press pause” on negative thoughts, evaluate them to determine if they are as accurate as they feel, and replace them, as appropriate, with more balanced, realistic thoughts.
Several different tools can be used to facilitate these efforts. Tables 2 and 3 illustrate examples of two common techniques you can use to test your thoughts and see if they are as accurate as they feel or if modification is necessary. The goal of “cognitive restructuring” (revising your thoughts after further examination) is not to think more positively; the goal is to turn excessively skewed and negative thoughts that impede successful coping efforts into balanced and realistic thoughts that fuel healthy responses to life stress.
Table 4 presents a sampling of self-assessment questions. If you suspect that you are suffering from depression or anxiety, and/or that there is room for improvement in your mood and coping efforts, there are resources and practical strategies you can implement to help you manage these symptoms. You have the power, control, and inner strength to make the changes necessary to improve your health and quality of life today!
Table 1: Behavioral Activation Example
Howard was a volunteer firefighter for more than 40 years. He stopped responding to calls when he felt he was no longer physically able to do so due to the worsening of his Parkinson’s symptoms. At this point, he became quite depressed and no longer went down to the firehouse to spend time with friends. He also stopped participating in all firehouse- related activities, including those that required no physical exertion, like the monthly chili dinner.
Part of Howard’s treatment included reconnecting with the local fire department. He began to bring coffee down to the station and visit his friends one evening per week. He slowly began to explore ways he could remain connected to this organization that was near and dear to his heart. Four months later, he reported that he was spearheading all fundraising efforts for the fire department and his mood greatly improved. Even though Howard was no longer in the physical condition needed to fight fires, he found an alternative way to make a meaningful contribution to the cause.
Table 2: Examining the Evidence
This technique involves examining the “facts” that support and do not support your negative thoughts. Use the evidence that is gathered to come up with a more balanced thought, as appropriate.
- Situation: Freezing in the bathroom
- Automatic Thought: I’m helpless
- Evidence For: I was alone in the bathroom in the middle of the night and was unable to move
- Evidence Against: This happens quite a bit, so I planned for it. I had my cell phone in my pocket. I called my wife on the house phone, and she helped me back to bed
- Rational Response: Even though I was physically unable to move my feet, I was able to help myself out of the situation. I am not helpless
Table 3: Behavioral Experiment
This technique involves engaging in a specific behavior designed to test out a negative prediction and evaluate the outcome.
- Negative Thought or Prediction: It will be impossible to have dinner in a restaurant because of my tremor
- Experiment: I will go out to dinner with my partner on Saturday
- Outcome: I was able to eat dinner at our favorite restaurant. I ordered food that did not need to be cut and requested a straw and lid for my drink. I enjoyed getting out of the house and had a fun evening
Experiment results suggest that the negative prediction was not accurate.
Table 4: Self-Assessment Questions
Is your mood as good as you would like it to be? Think about your average day. Which of these activities are you engaged in?
- Socializing with family members and friends
- Engaging in hobbies
- Engaging in other leisure activities
Describe activities that you engage in that bring you meaning, joy, and pleasure.
Since your Parkinson’s diagnosis, are you as actively involved in things you used to enjoy? Explain. Have you decreased the time you spend on any of your activities? Have you stopped any activities altogether? Explain.
What does a Parkinson’s diagnosis mean to you?
- What strategies are you using to cope with the daily challenges that Parkinson’s presents?
- Does fear often guide what you do or don’t do?
- Do you predict the future in a negative light?
- Do you often focus on the worst-case scenario?
- Do you overestimate the extent of your physical and functional limitations?
More advanced Parkinson’s
- Do you underestimate your ability to cope effectively with the challenges
Every Victory Counts
As with all aspects of Parkinson’s, your experience may or may not include all (or any) of these symptoms related to emotional health. The good news is that if you experience depression, anxiety, or apathy, you now know that you can take action to manage and treat them. Talk to your care team about the best strategies for you and how cognitive behavioral therapy for Parkinson's may help. Whatever you do, remember that you are not alone. Be compassionate with yourself. Be committed to exploring ways to manage these symptoms. Be prepared to live well...today and every day.
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