behavioral problems and treatments in PD, chronic illness, parkinson's disease, Parkinson's treatment

Anger in Parkinson’s Disease? myth, reality or cop- out? By Dr. De Leon

” Anger is an acid that can do more harm to the vessel in which is stored than to that into which is poured…”

 

I thought I would write today about a very sensitive topic for all of us especially for me as of late. it seems that my docile, kind, friendly disposition has been taken over by a “she- Tasmanian devil” I am ashamed to say. As I try to patch and mend the path of wrath I have left in the wake of my anger outbursts this week, I am doing a lot of soul searching as to the cause of this sudden behavior. Surely, I have always been high strong ( and head strong) and known to get heated a time of two but lately it seems this is the norm rather than the exception.  Of course I recall since the onset of my illness the increase proneness to irritability which improved and settled with starting treatment and as my disease has progressed I notice increased bouts of irritability with tapering levels of medication right before the next one is due. So is this a biochemical manifestation possibly. However, what I am talking about here is right out uncontrolled anger outburst set off by the mildest of provocations or difficult situations.

Anger is a real thing in those of us with neurological disease and merits proper attention and treatment!

As a Parkinson expert I know that men are more likely to behavioral outburst and anger which often were attributed to poor boundaries or coping skills or even onset of dementia. However, looking at my own situation I am neither unhappy, lack boundaries, nor am I getting demented yet; I feel at times as if my anger button is suddenly pushed by an invisible fiend -perhaps more prayer is required but what if medication is contributing to these outbursts? I know I should not be bad the situation does not call for such exaggerated response of fight or flight yet, I am like an evil queen ready to defend her throne to the death! perhaps it has to do with the amount of epinephrine in our bodies or perhaps more likely the disruption of the brainstem-basal ganglia pathways involving serotonin and dopamine. for you see, the metabolism, synthesis and uptake of both dopamine and serotonin are intertwined. Both neurotransmitters are both metabolized by MAO  enzymes. Also they sometimes compete for this enzyme. thus, when we create a dysregulation by blocking one or taking more of one than another we are disrupting this fine balance.

After all we take gobs of dopamine and block its degradation in every fashion and form so it must follow its normal path of synthesis- ultimately leading to excess epinephrine and disruption of serotonin, dopamine connections. we are learning that mood disorders are very complex and require treatment with various monoamines because dopamine is just as important as serotonin. Although low levels of  serotonin are the ones implicated in “anger outburst.” These anger outburst seem to be correlated with higher intake of dopamine since I have been writing I need extra dopamine. (losing hours of manuscript did not help situation, I might add). The consequences and side effects however, could be too high a price to pay to be able to function mentally for a few hours. I don’t like myself and feel bad when I get mad but seems I don’t have  power to stop is like a horse once release from its standing place in a race it must run its course no matter how hard I try to stop. These feelings if untreated can potentially cause a vicious down fall with feelings of remorse and shame leading to depression thus increasing likelihood of anger. I knew that my brain was out of sorts and have increased my serotonin producing meds and I have felt normal again.

I have read several blogs and post of people experiencing this same phenomena, which I believe in the past as caregivers and health providers have been too quick to dismiss. I know that dealing with dementia patients this is a common problem even in their lucid states. So, perhaps the microscopic and macroscopic changes occurring in our brains are sufficient enough to disinhibit us especially since part of our primitive brains (entorhinal cortex- including the limbic system, amygdala) involved in emotion are at the core of this disease. I don’t believe that we are angry because we have an illness although, there may be a few out there who could fit into this category. I, for one, have fully embraced my Parkinson’s and have thoroughly enjoyed making a new life. Thus, this theory does not make sense plus this is a sudden uncontrolled behavior. These events have made me recall my own patients, of course all those whom I could conjure up having similar outburst of anger were all men.

This fact however, does not preclude us women from experiencing similar phenomena. I myself was attacked by a PD patient when he suddenly became angry at my medical recommendations. He went from a docile sweet gentlemen to a fierce tiger in less than a second a similar thing happened to a friend who actually suffered grave bodily injuries as a result of such unprovoked attack. Then there is the saddest story of all, one who actually shot his wife in a moment of rage which immediately regretted and  was attributed to medications. This is because we are seriously disrupting this system- many speculate that this disruption is the cause for schizophrenia not just excess dopamine (which in effect is what we are producing in our bodies by replacing massive quantities of dopamine without considering other chemical imbalances caused by this). This disruption in brainstem basal ganglia as a cause of psychosis and out burst of anger are supported by new treatment of PD psychosis with drug Nuplazid (pimavanserin) which acts on the serotonergic system.

I want all my readers to realize that this is a neurological problem that stems from unbalanced chemicals in brain due to both illness and unfortunately to medication effect. As I have often said, the brain is not only a complex intricate organism but is in constant balance and altering one chemical will have many repercussions because of its intricate connections. Thus we can’t simply disregard these and act in a vacuum when treating the many symptoms of Parkinson’s and must always think of what could possibly be affected to try to maintain order. Most common causes of explosive anger is brain injury (trauma, stroke, tumors, encephalitis) or neurological neurodegenerative disease, Parkinson’s, Alzheimer’s, etc.

I know that this is particularly a HUGE problem with those who have end-stage PD especially those with dementia.

Symptoms of Anger /rage outbursts: out of proportion to situation!!!

Things to watch out for preceding aggression:

  • irritability
  • increased energy
  • racing thoughts palpitations
  • chest tightness
  • mad
  • increased tremors
  • tingling

(myself the night before or day of episodes felt almost manic, irritable upon awakening, out of sorts, with increased heightened awareness and energy and racing thoughts)

of course if you have any of these is a sign YOU are out of control and NEED HELP ASAP! if reason has left the building and consequences don’t matter….

  • physical fights
  • property damage
  • threatening or assaulting people/animals

 

Recommendations: Being aware there is a problem is the first step to healing

  1.  Seek professional health ASAP –
  2. Get evaluation for thyroid disorder, metabolic abnormalities and diabetes ( remember that increased dopamine can increase sugar levels)
  3. Get neuropsychological evaluation to rule out depression and underlying dementia
  4. adjustment of Parkinson’s medication
  5. Treatment with SSri’s ( purely serotonin) or preferably compound drugs like those which have SSri’s and NRi’s  ( serotonin plus norepinephrine) like Cymbalta and venlafaxine (Effexor).
  6. anticonvulsants  like Tegretol, Lamictal, etc.
  7. antipsychotics in some cases or Nuplazid if dementia present.
  8. Counseling individual and family
  9. (treatments if persistent behavior should be in tandem with psychotherapy and family therapy)
  10. work on relaxation techniques- since all of us with PD and other chronic neurological disease have trouble dealing with multiple stressors at a time and get easily overwhelmed and flustered- do as I am attempting to do- cognitive restructuring- train my brain not to get excited in face of critical situations just like when I was a doctor  in practice -YOU got THIS! if you lived as long as I have I am pretty sure you have gone through some very harry situations and come out ahead – use that imagery to handle these stressors.
  11. propranalol- sometimes can be used to help with symptoms ( the fact this works shows that there is an increased epinephrine component to anger outbursts).

I should try practicing what I preached a thousand times as a neurologist- when we avoid acting on impulse we are actually rewiring our brains to be calmer and more loving!

Recommendations for caregivers:

  1. do not confront in moments of rage especially if someone demented – because you might incur injury to yourself or loved one.
  2. if destroying property or hurting self call 911- explain they have an illness and need medical care/ call their doctor ASAP
  3. wait till calm to confront and discuss situation if not demented and get treatment – if demented and cant reason get treatment asap as well.
  4. be supportive-
  5. jot down triggers- alcohol a BIG trigger, lack of sleep etc.
  6. what helps to calm them down
  7. create an escape plan
  8. keep all firearms locked away/hidden/safe
  9. call domestic hotline 1-800-799-SAFE (7233)
  10. confide in friends to help in emergency and have a code word or visual sign which means call police

Sources:

Serotonin involvement in the basal ganglia pathophysiology: could the 5-HT2C receptor be a new target for therapeutic strategies? Curr Med Chem. 2006;13(25):3069-81.

5-HT Modulation of Dopamine Release in Basal Ganglia in Psilocybin-Induced Psychosis in Man—A PET Study with [11C]raclopride Neuropsychopharmacology (1999) 20, 424–433. doi:10.1016/S0893-133X(98)00108-0

Imbalanced Dopaminergic Transmission Mediated by Serotonergic Neurons in L-DOPA-Induced Dyskinesia. Parkinsons Dis. 2012;2012:323686. doi: 10.1155/2012/323686. Epub 2011 Oct 11.

http://www.mayoclinic.org/diseases-conditions/intermittent-explosive-disorder/basics/definition/con-20024309

@2017 All rights reserved Maria De Leon MD