Clinical Gerontologist

ISSN: 0731-7115 (Print) 1545-2301 (Online) Journal homepage: http://www.tandfonline.com/loi/wcli20

Cognitive Behavior Therapy for Anxiety in

Parkinson’s Disease: Outcomes for Patients and
Caregivers

Nadeeka N. W. Dissanayaka PhD, Deidre Pye BPsychSci (Hons), MPsychClin,

MAPS, Leander K. Mitchell BSc (Psych-Hons), DPsych, MAPS, Gerard J. Byrne
BSc(Med), MBBS (Hons), PhD, FRANZCP, John D. O’Sullivan MBBS (Hons),
FRACP, MD, Rodney Marsh MBBS, FRANZCP & Nancy A. Pachana PhD, FAPS,
FASSA

To cite this article: Nadeeka N. W. Dissanayaka PhD, Deidre Pye BPsychSci (Hons), MPsychClin,
MAPS, Leander K. Mitchell BSc (Psych-Hons), DPsych, MAPS, Gerard J. Byrne BSc(Med), MBBS
(Hons), PhD, FRANZCP, John D. O’Sullivan MBBS (Hons), FRACP, MD, Rodney Marsh MBBS,
FRANZCP & Nancy A. Pachana PhD, FAPS, FASSA (2017) Cognitive Behavior Therapy for
Anxiety in Parkinson’s Disease: Outcomes for Patients and Caregivers, Clinical Gerontologist, 40:3,
159-171, DOI: 10.1080/07317115.2016.1240131

To link to this article: http://dx.doi.org/10.1080/07317115.2016.1240131

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CLINICAL GERONTOLOGIST
2017, VOL. 40, NO. 3, 159–171
http://dx.doi.org/10.1080/07317115.2016.1240131

ARTICLES

Cognitive Behavior Therapy for Anxiety in Parkinson’s Disease: Outcomes for

Patients and Caregivers
Nadeeka N. W. Dissanayaka, PhDa,b, Deidre Pye, BPsychSci (Hons), MPsychClin, MAPSa, Leander K. Mitchell, BSc
(Psych-Hons), DPsych, MAPSa, Gerard J. Byrne, BSc(Med), MBBS (Hons), PhD, FRANZCPa,b, John D. O’Sullivan,
MBBS (Hons), FRACP, MDa,b, Rodney Marsh, MBBS, FRANZCPa,b, and Nancy A. Pachana, PhD, FAPS, FASSAa
a
The University of Queensland, Brisbane, Australia; bRoyal Brisbane & Women’s Hospital, Brisbane, Australia

ABSTRACT KEYWORDS
Objective: Anxiety negatively impacts the quality of life of Parkinson’s disease (PD) patients and Anxiety; caregivers; cogni-
caregivers. Despite high prevalence, there is a paucity of trials investigating effective treatments tive behavioral therapy;
for anxiety in PD. This uncontrolled study investigated the use of a manualized and tailored Parkinson’s disease
Cognitive Behavior Therapy (CBT) for anxiety in PD.
Methods: Participants completed 6 weekly CBT sessions. Pre-, post- and follow-up (3 and
6 months) assessments were made. Change in outcomes were analysed using t-tests and
Reliability Change Index. Of 17 PD patients who agreed to CBT, 12 completed the intervention.
Results: This study showed a significant reduction in Hamilton Anxiety Rating Scale scores in PD
immediately post CBT (t(11) = 3.59, p < .01), maintained at 3-month (t(8) = 2.83, p = .02) and 6-
month (t(7) = 2.07, p = .04) follow-up. A reduction in caregiver burden (t(11) = 2.68, p = .03) was
observed post intervention. Improvements in motor disability (t(11) = 2.41, p = .04) and cognitive
scores (t(11) = −2.92, p = .01) were also observed post intervention and at follow-up.
Conclusions: Tailored CBT can be used to treat anxiety in PD.
Clinical Implications: This study provides preliminary evidence suggesting that tailored CBT
reduces anxiety in PD with persisting benefits, and lowers caregiver burden.

Introduction clinical trials. Pharmacotherapy for anxiety in

PD may result in unfavourable adverse effects,
Anxiety is common in Parkinson’s disease (PD)
and PD patients with severe anxiety can be
with a prevalence exceeding 50%, and detri-
resistant to such treatment (Chen & Marsh,
mentally impacts patients’ quality of life
2014). Despite the high prevalence of anxiety
(Dissanayaka et al., 2016, 2010, 2015). Anxiety
in PD compared to anxiety in the general popu-
disorders commonly observed in PD are
lation (Dissanayaka et al., 2014), currently there
Generalized Anxiety Disorder (GAD), Panic
is no evidence-based treatment for anxiety that
Disorder, and Social Phobia (Dissanayaka
can be recommended. Benzodiazepines and
et al., 2014) which are diagnosed according to
selective serotonin reuptake inhibitors (SSRIs)
the Diagnostic and Statistical Manual criteria
are generally preferred as the pharmacological
(DSM-IV) (Association, 1994). Anxiety
treatment of choice for anxiety in PD
Disorder Not Otherwise Specified (Anxiety dis-
(Casacchia, Zamponi, Squitieri, & Meco, 1975;
order NOS) or Other Specified or Unspecified
Chen & Marsh, 2014; Connolly & Fox, 2014;
Anxiety disorder termed in the new DSM-5 is
Djamshidian & Friedman, 2014).
also common in PD (Dissanayaka et al., 2016,
Benzodiazepines can cause unfavourable effects
2014, 2015). Our recent study suggests that 72%
on alertness, cognition and gait, and increase
of significant current anxiety in PD occurs
the risk of falls in PD (Cumming & Le Couteur,
independent of depressive disorders
2003). Although case studies have suggested
(Dissanayaka et al., 2016, 2015), yet anxiety is
SSRIs such as citalopram (Menza, Marin,
often overlooked as secondary to depression in
Kaufman, Mark, & Lauritano, 2004), paroxetine

CONTACT Nadeeka N. W. Dissanayaka n.dissanayaka@uq.edu.au University of Queensland, UQ Centre for Clinical Research, Building 71/918 Royal
Brisbane & Women’s Hospital, Herston QLD4029, Brisbane, Australia.
© 2017 Taylor & Francis
160 N. N. W. DISSANAYAKA ET AL.
(Tarczy & Szombathelyi, 1998), and sertraline
(Shulman et al., 1996) are useful to treat anxiety
in PD, a recent large (N = 115) randomized
controlled trial focussed on treatment for
depression did not show improvement in sec-
ondary anxiety with paroxetine or the selective
noradrenaline reuptake inhibitor (SNRI), venla-
faxine extended release (Richard et al., 2012).
SSRIs are relatively well tolerated, however
adverse effects like agitation, akathisia, nausea,
diarrhoea, insomnia, and somnolence can
occur. Use of SSRIs can also result in hypona-
tremia, sexual dysfunction and weight gain
(Chen & Marsh, 2014). Moreover, higher levels
of anxiety are associated with poorer response
to anti-depressant treatment in depressed PD
patients, and therefore targeted alternative
treatment strategies such as psychotherapy are
required for such treatment resistant patients
(Moonen et al., 2014).
The present study aims to evaluate the immedi-
ate and follow-up effects of a manualized and
tailored Cognitive Behavior Therapy (CBT)
aimed primarily at treating anxiety in PD. While
anxiety is examined as the primary outcome mea-
sure, depression, apathy, cognition, PD severity
and quality of life are investigated as secondary
outcome measures. CBT is the most common psy-
chotherapy trialled in PD (Armento, Stanley,
Marsh, Kunik, & York, 2012). To date, CBT stu-
dies in PD have focussed on anxiety secondary to
depression (Armento, Stanley, Marsh, Kunik, &
York, 2012). The majority of these studies demon-
strate reductions in anxiety (Dobkin et al., 2011,
2011; Kraepelien, Svenningsson, Lindefors, &
Kaldo, 2015; Troeung, Egan, & Gasson, 2014;
Veazey, Cook, Stanley, Lai, & Kunik, 2009), while
two studies found no change (Dobkin, Allen, &
Menza, 2007; Feeney, Egan, & Gasson, 2005).
Another recent study on Impulse Controlled
Behaviors in PD also demonstrated significant
reductions in secondary anxiety following CBT
(Okai, Askey-Jones, Samuel, O’Sullivan, &
Chaudhuri, 2013). Given the high prevalence of
anxiety in PD, there is an urgent need for devel-
oping CBT primarily focussed on anxiety. For
effective treatment of psychotherapy interventions
for anxiety require adaptations tailoring for needs
of PD (Pachana, Byrne, Siddle, & Koloski, 2005).
Based on previous CBT studies showing improve-
ment in secondary anxiety in PD, we hypothesized
that a reduction in anxiety will be a primary out-
come of our CBT intervention for anxious PD
patients. In our secondary analysis we hypothe-
sized that the treatment would lead to improve-
ment in depression, apathy, cognitive functioning,
PD severity and quality of life.
The present study also aims to include a dyad
of PD patients and caregivers when CBT is deliv-
ered to PD patients, and to investigate the impact
of the intervention on caregiver burden and psy-
chological wellbeing. The progressive and dis-
abling nature of PD often results in a high
dependence on others. Caregiver burden and an
increased sense of responsibility may negatively
impact psychological wellbeing in caregivers and
the care they provide (McLaughlin et al., 2011;
Nielsen et al., 2014). A recent study demonstrated
that anxiety in PD is a significant predictor of
caregiver burden (Viwattanakulvanid et al., 2014).
Another study suggests that caregiver participa-
tion in separate educational sessions enhances the
response to CBT for depression in PD; however,
the impact of the intervention on caregivers was
not examined in this study (Dobkin et al., 2012).
In a study of CBT for impulse control disorders
in PD, although caregivers were not included in
the intervention, a significant improvement in
caregiver depression and anxiety was observed
post intervention (Okai et al., 2013). Another
study demonstrated that CBT delivered to care-
givers of PD patients improved their global health
quality, caregiver strain and subjective burden
(Secker & Brown, 2005). The importance of
including caregivers in treatment of depression
in persons with dementia was noted in previous
study (Teri, McCurry, Logsdon, & Gibbons,
2005), and the same approach is likely to be
important in the treatment of anxiety in PD.
Therefore, the present study includes caregivers
when CBT is delivered to patients and evaluates
outcomes for both PD patients and caregivers. It
is hypothesized that the dyadic approach of CBT
will improve caregiver psychological wellbeing
and caregiver burden.

Methods
Participants and ethics
A convenience sample of PD patients was recruited
from private and public hospitals neurology outpati-
ent clinics. A diagnosis of PD was made according to
the UK Brain Bank criteria by neurologists with
special interest in movement disorders (Hughes,
Daniel, Kilford, & Lees, 1992). Anxiety was initially
screened in outpatient clinics by the treating neurol-
ogist or psychiatrist or during participation in a pre-
vious study of anxiety in PD (Dissanayaka et al., 2016;
Dissanayaka, Torbey, & Pachana, 2015; Dissanayaka
et al., 2015). Patients with comorbid depression were
included in this study. Patients were excluded if they
had a history of neurosurgery, an elevated suicide risk
level identified by the Mini International
Neuropsychiatric Interview (MINI-plus) (Sheehan
et al., 1998), or evidence of cognitive impairment
identified by a Standardized Mini Mental State
Examination (MMSE) (Molloy, Alemayehu, &
Roberts, 1991) score of ≤ 24. Patients with PD often
experience daily fluctuations in their symptomatol-
ogy due to wearing off of PD medication. This phe-
nomenon is known as “on/off” fluctuations. All
assessments were performed when the PD medica-
tion was at optimal response, which is known as “on”
state. Details of all medications were obtained from
patients and patients were asked to attend assessment
when they are at optimal PD medication response
state. Patients were asked to take their PD medication
during assessment sessions, if required, to maintain
optimal PD medication response, accounting for
minimal wearing-off of medication (known as “off”
state). Patients who were treated with anxiolytics or
antidepressants were included in this study and were
asked to continue their medication during the study
period. Any adjustments to medications during the
intervention were recorded. Caregivers of the
patients were also invited into the study. All partici-
pants provided written informed consent prior to
commencing the study. This study was approved by
the Human Research Ethics Committee at the
University of Queensland.
Study procedure
Baseline assessments included two separate self-
report questionnaires for PD patients and
CLINICAL GERONTOLOGIST 161
caregivers, and a semi-structured interview for
PD patients. Eligible participants were invited to
attend the therapy sessions with their caregiver;
two participants without caregivers also attended
on their own. Participants completed 6 weekly
CBT sessions. Each CBT session took between
1–1.5 hours. Upon completion of the CBT course,
participants repeated baseline measures. Follow-up
assessments and CBT booster sessions were con-
ducted at 3- and 6-months from the baseline.
Follow-up assessments included the same mea-
sures employed at baseline. CBT booster sessions
were conducted after each follow-up assessment.
All assessments were conducted by the first author
(Dissanayaka) who has extensive experience in
conducting neuropsychological assessment in PD
or clinical doctorate students enrolled in the
advanced postgraduate psychology program and
were provisionally registered psychologists.
Assessments
Patients
Anxiety. Anxiety disorder diagnoses were made
according to the DSM-IV criteria using the MINI-
plus diagnostic interview (Sheehan et al., 1998).
Anxiety disorder NOS was also diagnosed. We did
not use strict hierarchical criteria when applying the
DSM-IV. The DSM-5 was not available when this
study was conducted. While there are no major
changes in the diagnostic criteria for anxiety dis-
orders between the DSM-IV and DSM-5, the
Anxiety disorder NOS is termed Other Specified
Anxiety in the DSM-5. Severity of anxiety was mea-
sured by the self-report, Geriatric Anxiety
Inventory (GAI) (Pachana et al., 2005), and the
observer-rated, Hamilton Anxiety Scale (HAM-A)
(Hamilton, 1969). The GAI is a validated and
recommended instrument in PD, while HAM-A is
a widely used measure of clinical change in
response to treatment (Dissanayaka et al., 2015;
Matheson et al., 2012). The Informant
Questionnaire for Anxiety in Dementia (IQAD)
(Byrne, 2012) was also used to asses PD patient’s
anxiety from a caregiver point of view. IQAD is a
new scale and there is no validity data in PD.
Depression and apathy. A diagnosis of current
depressive disorders (major or minor depression
162 N. N. W. DISSANAYAKA ET AL.
or dysthymia) was made using the MINI-plus. Past
major depression was also assessed, if current
depressive disorder was not met. The severity of
depression was measured by the self-report,
Geriatric Depression Scale (GDS-15) (Yesavage &
Sheikh, 1986) and the observer-report, Hamilton
Depression Rating Scale (HAM-D) (Potts, Daniels,
Burnam, & Wells, 1990). Both GDS-15 and HAM-
D are validated scales in PD (Dissanayaka et al.,
2007), and are appropriate instruments to use in
PD (Torbey, Pachana, & Dissanayaka, 2015). In
addition to depression, apathy is commonly
observed in PD patients and is often an additional
measure where depression screening in PD is uti-
lized (Starkstein, Jorge, & Mizrahi, 2006).
Therefore, we used the validated Starkstein
Apathy Scale (SAS) to assess apathy in PD patients
(Starkstein, Fedoroff, Price, Leiguarda, &
Robinson, 1993).
Cognition. Cognition was measured using brief
instruments, the Standardized Mini Mental State
Examination (sMMSE) (Molloy et al., 1991) and
the Montreal Cognitive Assessment (MoCA)
(Nasreddine et al., 2005), and the PD specific
measure, the Parkinson’s Disease Cognitive
Rating Scale (PD-CRS) (Pagonabarraga et al.,
2008). sMMSE is used to screen for dementia
and patients scoring ≤24 in the sMMSE were
excluded. The PD-CRS is a comprehensive test to
assess for cognitive impairment by measuring pos-
terior cortical and fronto-subcortical functioning;
areas implicated in cognitive dysfunction in people
living with PD. The test covers 9 items and 7 of
them includes fronto-subcortical items like
immediate and delayed free recall memory, atten-
tion, working memory, clock drawing, action ver-
bal fluency and alternate verbal fluency. The
Informant Questionnaire on Cognitive Decline in
the Elderly (IQCODE) (Jorm & Jacomb, 1989) was
also used.
Severity of PD. The Movement Disorders Society-
Unified Parkinson’s Disease Rating Scale (MDS-
UPDRS; and the Hoehn and Yahr scale were used
to assess the severity of PD (Goetz et al., 2008).
The MDS-UPDRS is in four parts of (I) Non-
motor experiences of daily living (II) Motor
experiences of daily living, (III) Motor
examination and (IV) complications of PD ther-
apy. Scoring is completed on Likert scales (range
from 0; no impairment/normal to 4: severe impair-
ment) and higher scores on the MDS-UPDRS
indicate greater functional impairment for the per-
son living with PD. The Hoehn and Yahr scale is
widely used to classify the stage of PD (Hoehn &
Yahr, 1967). This scale covers five stages ranging
from unilateral only involvement of PD motor
symptoms through to confinement to bed or a
wheelchair. Levodopa Equivalent Daily Dose
(LEDD) calculations were performed using pre-
vious criteria (Tomlinson et al., 2010). The con-
version formulae provide a standardisation of
reporting of medication dosages per day and
allows for comparison across studies and across
various common types of PD medications.
Quality of life. The PD-specific quality of life mea-
sure, the Parkinson’s Disease Questionnaire-Short
Form (PDQ-8) (Jenkinson, Fitzpatrick, Peto,
Greenhall, & Hyman, 1997) was used. The Disability
Assessment for Dementia Scale (DAD) (Gelinas &
Gauthier, 1994) also assessed impairment of daily
livings of the PD patient reported by the caregivers.
There is no validity data on the use of DAD in PD.
Caregivers
The GAI (Pachana et al., 2005) and GDS-15
(Yesavage & Sheikh, 1986) were used to assess
anxiety and depression, respectively. The Zarit
Burden Inventory (ZBI) (Bédard et al., 2001;
Zarit, Reever, & Bach-Peterson, 1980) was
employed to assess caregiver burden.
Intervention and follow-up sessions
A manualized CBT intervention that focussed on
anxiety and has previously been used in dementia
patients was adopted for PD (Mitchell, Beattie,
Pachana, & Byrne, 2015). Six intervention sessions
covered the following domains: (i) psychoeduca-
tion; (ii) symptom monitoring; (iii) calming tech-
niques including deep breathing; (iv) progressive
muscle relaxation and imagery; (v) sleep hygiene;
and (vi) self-management and relapse prevention
planning. At each session, participants were given
a take home handout to be completed prior to
attending the subsequent session. The CBT

intervention was directed at PD patients.
Caregivers were asked to actively participate in
these CBT sessions.
Tailoring the CBT protocol for PD
Adaptations made to the CBT included reducing
the breadth of content delivered in each session
and the content of sessions was tailored to suit PD.
Sessions 1 (psychoeducation) and 2 (symptom
monitoring) included discussing PD-specific anxi-
ety symptoms such as anxiety associated with
motor symptoms, motor fluctuations, iatrogenic
addictive behaviors and dyskinesias (Dissanayaka
et al., 2016). At session 4, the dyad was given the
option of choosing either progressive muscular
relaxation or visual imagery relaxation strategy.
Patients with severe muscular rigidity and asso-
ciated cramping may find it difficult to practise
progressive muscle relaxation; in such instances
they were given the option of practicing imagery.
Session 5 included psychoeducation of sleep issues
and addressed sleep hygiene due to high preva-
lence of sleep disturbances in anxious PD.
Booster sessions conducted at 3-and 6-months
follow-up were a modified version of session 6,
which included self-management and relapse pre-
vention planning. Booster sessions included revi-
sion of all strategies, and focussing on any
strategies that the patient had had difficulty
practicing.
Therapist training procedure
As described earlier, all therapists were post-grad-
uate students of the clinical psychology program
(enrolled in Doctorate in Clinical Psychology and
Neuropsychology or Masters in Clinical
Psychology) at the University of Queensland, and
were provisionally registered psychologists with
the Psychology Board of Australia. Students were
supervised by experienced registered doctoral-level
psychologists (Pachana and Mitchell) who are also
experienced researchers in conducting psychologi-
cal interventions in older adults, and a senior
clinical research fellow (Dissanayaka) who has
extensive experience in conducting research into
PD. Supervisors conducted weekly individual and
monthly group supervision sessions. All therapists
participated in mandatory workshops focussed on
CLINICAL GERONTOLOGIST 163
introduction to neuropsychiatry in PD, CBT man-
ual training, neuropsychological assessment in PD
and MDS-UPDRS training, prior to conducting
therapy. These workshops were conducted by the
supervisory team.
Data analysis
Paired t-tests were computed to investigate change
in outcome measures between baseline and post
intervention, and baseline and follow-up time
points of 3 and 6 months. Repeated measures
ANOVA approach for the 4 time points was not
made due to insufficient sample size. All tests were
two-tailed and a p value of < .05 was considered
significant. Alpha reduction techniques were not
applied to adjust for multiple comparisons because
this was a preliminary study. To identify indivi-
duals who demonstrated clinically significant
change in anxiety and depression, the Reliability
Change Index (RCI) was employed (Bauer,
Lambert, & Nielsen, 2004). The RCI is a statistical
measure used when there is a small sample size. It
determines whether the change observed at post
intervention compared to the pre intervention for
an individual is greater than a level that is unlikely
to occur due to chance. Individuals exceeding a
RCI threshold of 1.96 will demonstrate clinically
significant change (Bauer et al., 2004).
Results
Participant characteristics and attrition
Seventeen (17) PD patients completed baseline
assessments. There were 10 males and 7 females,
aged 66.59 years on average (standard deviation;
SD = 7.95, range 51–78). There were 10 PD
patients with a current DSM-IV anxiety disorder,
and 7 with anxiety disorder NOS. Nearly half
(47%) were taking medication to manage anxiety,
depression or both anxiety and depression, and
continued their medication throughout the course
of the study. Of the 15 caregivers who participated,
there were 7 males and 8 females, and their aver-
age age was 63.40 years (SD = 9.70; range 43–75).
In 13 of the 15 cases, the caregiver was the spouse
of the PD patient.
164 N. N. W. DISSANAYAKA ET AL.

Of the 17 PD patients with baseline data, 12 Table 1. Characteristics of the study participants who com-
completed the 6-week CBT intervention and pleted the intervention.
Mean (standard deviation)
post-treatment assessments, an attrition rate of Measure or N (%)
30% (Table 1). One participant was excluded fol- Patients (N = 12)
lowing the baseline assessment due to high risk of Age 66.36 (7.12)
Gender (Male/Female) 7/5 (58% males)
suicide. Three participants provided no reason for Cognition
their withdrawal, and one participant died. Three sMMSE 29.45 (.69)
participants were lost to follow-up at 3 months, MOCA 24.64 (2.80)
PD-CRS 95.82 (19.27)
and one additional participant was lost to follow- IQCODE 3.41 (.59)
up at 6 months (Figure 1). Thus, 8 of 17 partici- Anxiety
HAM-A 12.18 (5.91)
pants (47%) with baseline data completed all GAI 9.00 (5.92)
phases of the study. No significant differences in IQAD 22.89 (6.86)
age, gender, baseline cognition, anxiety, depres- DSM-IV current anxiety/Other 8/4 (67% DSM-IV anxiety)
significant anxiety
sion, apathy, quality of life or PD severity were Depression
observed between completers of post assessments GDS-15 3.18 (1.17)
HAM-D 11.91 (6.53)
and non-completers. The mean GDS-15 score of Quality of life
the caregivers was significantly higher (M = 4.25; DAD 96.39 (9.02)
SD = 2.50) in those who did not complete in PDQ-8 3.00 (1.41)
Severity of PD
comparison to those who completed (M = 1.38; MDS-UPDRS Total 24.73 (10.46)
SD = 1.06) (t = 2.88; p = .02), although both mean MDS-UPDRS I 11.27 (4.10)
MDS-UPDRS II 8.27 (6.33)
scores were lower than the clinical cut-off for MDS-UPDRS III 22.00 (8.94)
depression in the GDS-15, which is ≥6. Statistical MDS-UPDRS IV 3.00 (2.06)
comparisons between completers and non-com- Hoehn and Yahr staging of PD 2.22 (.67)
Levodopa Equivalent Dose 614.90 (341.88)
pleters of follow-up assessments were not made Apathy
due to low sample sizes. SAS 12.33 (6.86)
Caregivers (N = 10)
Anxiety: GAI 3.25 (4.50)
Depression: GDS-15 1.38 (1.06)
Burden: ZBI 6.38 (4.44)
Outcomes of the intervention for PD patients
MINI-plus = Mini International Neuropsychiatric Interview; HAM-
A = Hamilton Anxiety Rating Scale; GAI = Geriatric Anxiety Inventory;
Primary outcome IQAD = Informant Questionnaire for Anxiety in Dementia; HAM-
Anxiety. Compared to baseline, a significant D = Hamilton Depression Rating Scale; GDS = Geriatric Depression
reduction in the clinician rated HAM-A was Scale; DSM-IV = Diagnostic and Statiscal Manual edition IV;
SAS = Starkstein Apathy Scale; SMMSE = Standardized Mini Mental
observed at post intervention, and at 3-month State Examination; MoCA = Montreal Cognitive Assessment; PD-
and 6-month follow-up (Table 2A and Table 3). CRS = Parkinson’s disease Cognitive Rating Scale; IQCODE = Informant
Questionnaire on Cognitive Decline in the Elderly; MDS-
At post intervention, the mean HAM-A scores UPDRS = Movement Disorders Society- Unified Parkinson’s Disease
were lower than the clinically significant anxiety Rating Scale; PDQ-8 = Parkinson’s disease Quality of Life Questionnaire;
score determined by the cut-off score of >12 DAD = Disability Assessment for Dementia Scale; ZBI = Zarit Burden
Inventory.
(Leentjens et al., 2011).
Out of 12 patients completed the CBT sessions,
at baseline, 8 (67%) had a current DSM-IV anxiety RCI analysis using HAM-A scores demon-
disorder and 4 had Anxiety disorder NOS. At post strated clinically significant improvement in 5
assessment, current DSM-IV anxiety disorders out of 12 (42%) patients at post intervention com-
were reduced (N = 5 (42%)), 6 had Anxiety dis- pared to baseline. Four patients showed clinically
order NOS, and 1 had no anxiety. At 3 months, 1 significant improvement at 3 months and at
patient had current DSM-IV anxiety disorder 6 months compared to baseline.
(11%), 4 had Anxiety disorder NOS and 4 had
no current anxiety. At 6 months, there were no Secondary outcomes
patients with DSM-IV anxiety (0%), 4 had Anxiety Depression and apathy. Both the GDS-15 and
disorder NOS, and 4 had no current anxiety. HAM-D did not show significant differences between
 CLINICAL GERONTOLOGIST 165

Enrolment
Consented to participate and
enrolled to the study

N=17

Baseline
Completed Pre assessments Excluded due to high
risk of suicide N=1
N=17

Intervention

Completed 6 sessions of CBT Drop outs from

intervention intervention N=3

N=12 Passed away N=1

Post intervention

Completed post intervention

assessments

N=12

Completed 3 months follow- Lost to follow-up N= 3

3 months

up assessments and
booster session

N=9

Completed 6 months follow-

Lost to follow-up N=1
6 months

up assessments and
booster session

N=8

Figure 1. Participant involvement in the study.

pre and post assessment (Table 2A). However, at
3 months a significant reduction in HAM-D scores
was observed compared to baseline (Table 3).
At baseline, 1 patient had major depression and
2 had minor depression (comorbidity of current
depressive disorder = 25%). A past history of
major depression was diagnosed in an additional
3 patients. At post assessment and follow-up, none
were diagnosed with current depressive disorder.
RCI analysis using the clinician rated HAM-D
suggested a clinically significant improvement in
3 PD patients at post intervention, 5 at 3 months
and 7 at 6 months compared to baseline.
The SAS showed no significant change post
intervention, and follow-up for apathy.
Cognition. Parkinson’s Disease Cognitive Rating
Scale (PDCRS) scores were significantly higher
at post intervention compared to the baseline (t
(11) = −2.92, p = .01). The fronto-subcortical scale
of the PDCRS (which includes tests of memory,
attention, executive function and language)
showed a significant increase in the mean scores
following the intervention (t(12) = −3.05, p = .01),
suggesting an improvement in cognitive function-
ing (Table 2A). The significant change in PDCRS
166 N. N. W. DISSANAYAKA ET AL.

Table 2. A comparison between pre and post CBT intervention for all measures.
Mean (standard deviation)
Measure Pre Intervention Post Intervention df t p (* p < .05 = significant)
Anxiety
HAM-A 11.83 (5.77) 6.83 (4.76) 11 3.59 <.01*
GAI 8.64 (5.84) 6.73 (6.65) 10 1.94 .08
IQAD 23.33 (6.78) 25.00 (5.94) 8 −.82 .44
Depression
GDS-15 3.09 (1.22) 4.36 (4.2) 10 −1.03 .33
HAM-D 11.67 (6.23) 8.17 (6.31) 11 2.12 .06
Apathy
SAS 12.70 (6.57) 12.70 (5.54) 9 .00 .00
Cognition
PDCRS_Total 94.42 (19.00) 101.83 (21.18) 11 −2.92 .01*
PDCRS_Subcortical 65.08 (18.88) 73.00 (20.50) 11 −3.05 .01*
PDCRS_Cortical 29.33 (.98) 28.83 (2.86) 11 .79 .45
sMMSE 29.25 (.97) 29.42 (1.17) 11 −.62 .55
MoCA 24.67 (2.65) 26.00 (3.08) 11 −1.48 .17
IQCODE 3.51 (.59) 3.19 (.79) 8 1.52 .17
Parkinson’s disease
MDS-UPDRS Total 24.17 (10.16) 18.25 (9.25) 11 2.76 .02*
MDS-UPDRS I 11.75 (4.25) 9.17 (4.45) 11 2.35 .04*
MDS-UPDRS II 7.92 (6.16) 6.42 (5.42) 11 1.21 .25
MDS-UPDRS III 21.67 (8.61) 16.58 (8.84) 11 2.41 .04*
MDS-UPDRS IV 3.14 (2.19) 2.86 (1.68) 6 .37 .73
Hoehn and Yahr 1.88 (.64) 2.00 (.54) 7 −.42 .69
Levodopa Equivalent Dose 685.51 (324.82) 704.26 (298.23) 7 −1.43 .20
Function and Quality of life
DAD 96.25 (9.64) 98.75 (2.67) 7 −.98 .36
PDQ-8 2.91 (1.58) 2.64 (1.96) 10 .45 .66
B: Caregivers
Mean (SD)
Measure Pre Intervention Post Intervention df t p Value
GAI 4.75 (5.20) 5.25 (6.90) 7 −.19 .86
GDS-15 1.56 (1.13) 2.56 (3.81) 8 −.71 .50
ZBI 8.63 (7.63) 5.63 (6.91) 7 2.68 .03*
HAM-A = Hamilton Anxiety Rating Scale; GAI = Geriatric Anxiety Inventory; IQAD = Informant Questionnaire for Anxiety in Dementia; HAM-
D = Hamilton Depression Rating Scale; GDS = Geriatric Depression Scale; SAS = Starkstein Apathy Scale; SMMSE = Standardized Mini Mental State
Examination; MoCA = Montreal Cognitive Assessment; PD-CRS = Parkinson’s disease Cognitive Rating Scale; IQCODE = Informant Questionnaire on
Cognitive Decline in the Elderly; MDS-UPDRS = Movement Disorders Society- Unified Parkinson’s Disease Rating Scale; PDQ-8 = Parkinson’s disease
Quality of Life Questionnaire; DAD = Disability Assessment for Dementia Scale; ZBI = Zarit Burden Inventory.

total score and the subcortical score remained at 3
and 6 months follow-up (Table 3).
Parkinson’s disease impairment. Compared to
baseline, a significant reduction in the MDS-
UPDRS-III motor score was observed post inter-
vention (t(11) = 2.41, p = .04) (Table 2A), and at
3-month and 6-month follow-up (Table 3).
Outcomes of the intervention for caregivers
(Table 2B)
A significant reduction in the caregiver burden
based on the ZBI scores was observed at post
intervention compared to baseline (t(7) = 2.68,
p = .03). There were no observed significant dif-
ferences following the intervention across care-
giver anxiety (GAI) or depression measures
(GDS-15).

Functional disability and quality of life. The

DAD or the PDQ-8 did not show any significant
change post intervention, suggesting no change in
the caregiver reporting of the activities of daily
living based on the DAD or the patient reporting
of PD related quality of life based on the PDQ-8.
Discussion
To our knowledge, the present study is the first to
investigate a manualized and tailored CBT psy-
chotherapeutic approach aimed at treating anxiety
in PD and suggest positive gains. Modifying the
 CLINICAL GERONTOLOGIST 167

Table 3. Significant results at post intervention and at 3-month and 6-month follow-up.
Mean (standard deviation) t; p (*p < .05 significant)
Pre Intervention Post Intervention 3 month follow-up 6 month follow-up Pre-Post Pre-3 month Pre-6 month
Measure (N = 12) (N = 12) (N = 9) (N = 8) (N = 12) (N = 9) (N = 8)
Significant at post assessment and follow-up
HAM-A 11.83 (5.77) 6.83 (4.76) 7.00 (6.96) 5.88 (6.56) 3.59; <.01* 2.83; .02* 2.47; .04*
PDCRS_Total 94.42 (19.00) 101.83 (21.18) 111.78 (13.63) 104.25 (14.66) −2.92; .01* −3.76; .01* −2.81; .03*
PDCRS_Subcortical 65.08 (18.88) 73.00 (20.50) 82.00 (13.42) 74.75 (14.37) −3.05; .01* −3.61; .01* −2.97; .02*
MDS-UPDRS Total 24.17 (10.16) 18.25 (9.25) 13.22 (6.28) 17.88 (13.45) 2.76; .02* 4.34; <.01* 2.13; .07
MDS-UPDRS I 11.75 (4.25) 9.17 (4.45) 5.11 (4.00) 10.33 (2.94) 2.35; .04* 3.53; .01* .76; .45
MDS-UPDRS III 21.67 (8.61) 16.58 (8.84) 11.33 (5.03) 13.88(11.37) 2.41; .04* 3.91; <.01* 2.56; .04*
ZBI (caregiver) 8.63 (7.63) 5.63 (6.91) 6.17 (6.65) 7.00 (4.24) 2.68; .03* 1.53; .20 1.30; .26
Significant at follow-up
GAI 8.64 (5.84) 6.73 (6.65) 6.29 (6.34) 5.50 (6.00) 1.94; .08 3.02; 0.02* 2.44; .05
HAM-D 11.67 (6.23) 8.17 (6.31) 6.11 (7.32) 5.75 (8.21) 2.12; .06 3.55; 0.01* 2.22; .06
MDS-UPDRS-II 7.92 (6.16) 6.42 (5.42) 5.13 (3.94) 7.25 (4.30) 1.21; .25 3.04; .02* 1.67; .14
MDS-UPDRS-IV 3.14 (2.19) 2.86 (1.68) 3.50 (2.08) 5.00 (2.83) .37; .73 .70; .52 −4.57; .01*
PDQ-8 2.91 (1.58) 2.64 (1.96) 2.00 (2.45) 2.29 (1.80) .45; .66 2.12; .08 2.37; .05
HAM-A = Hamilton Anxiety Rating Scale; GAI = Geriatric Anxiety Inventory; HAM-D = Hamilton Depression Rating Scale; PD-CRS = Parkinson’s
disease Cognitive Rating Scale; MDS-UPDRS = Movement Disorders Society- Unified Parkinson’s Disease Rating Scale; PDQ-8 = Parkinson’s disease
Quality of Life Questionnaire; ZBI = Zarit Burden Inventory.

CBT protocol to suit patients with PD is a novel
and practical approach. This included addressing
PD-specific anxiety symptomatology outlined in
our previous study, which are often missed in
conventional assessments (Dissanayaka et al.,
2016). CBT encompasses a range of elements, not
only cognitive, but also behavioral and emotional
elements. The focus of this study was mainly on
the behavioral components, providing practical
and concrete strategies to manage symptoms of
anxiety in the moment. Similar to our previous
study, in the present study 75% of PD patients
had no comorbid depression (Dissanayaka et al.,
2015). The study is also the first of its kind to
include a dyadic approach, delivering the CBT
intervention to both PD patients and caregivers,
and measuring outcomes focussed on caregiver
psychological wellbeing and burden, together
with outcomes for patients. Previous CBT in PD
studies that included caregivers, either (i) delivered
separate educational sessions for caregivers with-
out collating the benefits for caregivers (Dobkin
et al., 2007, 2011, 2012), (ii) measured impact of
caregiver wellbeing when the intervention was
delivered to PD patients without including care-
givers in treatment sessions (Okai et al., 2013), or
(iii) delivered CBT for caregivers only and exam-
ined outcomes for them (Secker & Brown, 2005).
Our dyadic approach allowed psychoeducation of
anxiety symptoms of patients in the presence of
caregivers, and assisted caregivers to reinforce the
learned strategies to patients, while they also prac-
ticed the strategies themselves. Our inclusion of
the follow-up at 3-month and 6-month time
points with assessments and booster sessions
allowed investigating the long-term sustainability
of the intervention. The majority of previous CBT
trials in PD did not investigate maintenance of
treatment beyond post assessment (Armento,
Stanley, Marsh, Kunik, & York, 2012).
The primary outcome of the study was the sig-
nificant reduction in PD patients’ anxiety levels
post treatment, and maintenance of decreased anxi-
ety at 3- and 6- month follow-up. Together with
behavioral strategies, our approach of addressing
both general and PD-specific anxiety symptoms in
psychoeducation and symptom monitoring ses-
sions may have contributed to these primary
gains. Our relapse prevention strategies of booster
sessions may have assisted with long-term sustain-
ability of reduced anxiety in PD. The present study
results are in line with previous CBT studies in PD
that examined anxiety as a secondary outcome
measure, and suggest a significant decrease in anxi-
ety from CBT interventions (Dobkin et al., 2011;
Kraepelien et al., 2015; Okai et al., 2013; Troeung
et al., 2014; Veazey et al., 2009).
Our study also demonstrated valuable secondary
gains such as clinically significant improvement in
concomitant depression, significant improvements
168 N. N. W. DISSANAYAKA ET AL.
in motor and cognitive functions in PD patients
immediately post intervention, and at follow-up.
Our results suggested that maintaining low anxiety
levels using the CBT intervention may improve
secondary depression. Progressive neurodegenera-
tion in PD results in decreases in both motor and
cognitive functioning over time. Interestingly, our
study suggested that treating anxiety using CBT
may assist with maintenance of motor symptoms,
and thus an improved management of the disease.
Cognitive decline is a common complication in PD,
and 80% of PD patients experience dementia in
advanced PD (Aarsland, Andersen, Larsen, Lolk,
& Kragh-Sorensen, 2003). We limited our sample
to cognitively intact patients. Our results highlight
the need for future prospective studies identifying
the impact of anxiety on cognitive decline in PD,
and evaluating the effectiveness of CBT for such PD
patient subgroups.
Another major finding of the present study is the
reduction of caregiver burden following the inter-
vention. This study is the first to demonstrate such
decreases in caregiver burden in a CBT study
designed for PD. A previous CBT study in PD
focussed on impulse control behaviors failed to
demonstrate any change in caregiver burden (Okai
et al., 2013), while another CBT study solely focussed
on caregivers of PD patients showed a significant
reduction in caregiver burden post intervention
(Secker & Brown, 2005). The reduction in the report-
ing of caregiver burden may be associated with
improvement in PD patients anxiety and depression.
Factors associated with a decrease in caregiver bur-
den warrants future research in a randomized con-
trolled CBT trial. Although, patients sustained their
improvement in anxiety at follow-up, the reduction
in caregiver burden was not retained at follow-up.
The caregivers who participated in the present study
had lower scores in depression and anxiety at base-
line, and therefore no change was seen in these
measures post treatment.
Limitations and future directions
Despite the positive primary and secondary gains
observed from our tailored CBT intervention,
there are major limitations of this study. The lack
of having a control condition limits our results.
Our results warrant future study in a randomized
controlled trial. Our convenience sample was too
small to perform Bonferroni alpha reductions. We
also had a high attrition rate, in particularly at
follow up, which is not surprising for a small
study of patients with neurological disease. The
progressive neurodegeneration may increase dis-
ability over time and therefore PD patients may
drop out of completing interventions. The present
study excluded patients with dementia or have had
neurosurgery. CBT for these patient groups war-
rant future studies.
Clinical Implications
● Our positive preliminary results in a conve-
nience uncontrolled and small sample of PD
patients and caregivers warrant future inves-
tigations in a randomized controlled trial
design using a large sample.
● The present study demonstrated clinically
significant improvement in anxiety follow-
ing a tailored CBT intervention with sus-
tained gains at 3 and 6 months follow up.
● Improvement in depression, motor and cog-
nitive functions for PD, and reducing care-
giver burden for caregivers were secondary
gains of this intervention.
Acknowledgements
The authors thank all Clinical Psychology post graduate
students who assisted with the study as a part of their clinical
program. We also acknowledge the Queensland Parkinson’s
Project for assisting with patient recruitment for the
“Anxiety, depression and related disorders in PD study,”
where a few patients were recruited to the present study.
We thank the research assistant Tiffany Au for her help
with various aspects of the project. We acknowledge the
Lions Medical Research Foundation for supporting Dr
Nadeeka Dissanayaka’s fellowship and the Royal Brisbane &
Women’s Hospital Foundation for funding the project.
Funding
This research was funded by a Royal Brisbane & Women’s
Hospital Foundation research grant.
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