Jim and List,

 *I am a 64 year old  psychiatrist.  who has been off and on this list 
for most of the approximately 15 years of its existence.  I  had been 
diagnosed  with PD in 1989  and retired from practice in 1997.  I also 
participated,  in the double blind  fetal transplant study done around 
1997.  I have Bilateral DBS STN stimulators  and am wheelchair bound at 
this time.

I would like to comment on Jim Slattery's excellent summary on his 
experience of psychiatric aspects of PD.  I will comment on the issues 
he brings up one by one
*

    J/im Slattery wrote:/
>     /Here is my personal view of apparent personality disorders in PD, from my 25 
>     years of having PD, and 10 years of  intensive research. I am not a doctor 
>     of medicine and anything I say here is my personal opinion only.
>
>     1. I prefer to use the term "parkinsonism" to avoid needless petty argument 
>     as to whether or not a particular group of symptoms is "true IPD" 
>     (idiopathic Parkinson's Disease). If it looks like a duck, walks like a duck 
>     and quacks like a duck, it probably is a duck, though not necessarily an 
>     Anas platyrhynchos. Strange when you think about it, since "idiopathic" 
>     means "arising from an unknown cause". However, PD is quicker, so lets stick 
>     to that./


> *Comment:  The reason that physicians use the term Idiopathic PD is to differentiate it from other causes of parkinsonism.  There are several parkinsons-like diseases which start out looking like IPD. Most of these have a much worse prognosis than PD.  Also PD symptoms can be caused by certain medications which can be reversed by by stopping the meds.  For the physician it is important to differentiate between these causes of PD in order to properly inform the patient as well as to develop an effective treatment plan.  
> *

>     *
>     */2. If you look up the drugs used to treat PD and/or its side-effects, you 
>     will find they many of them are "psychotropic" (affecting the mind or mood 
>     or other mental processes). For example selegeline metabolises in the body 
>     to meth-amphetamine, hard to explain if you get pulled over for a traffic 
>     bust!/*
>     *

*Comment:  Psychotropic  meds  are used in  treatment  of depressed or 
otherwise psychiatrically affected PD patients.  Selegiline is an MAOI   
which is used primaily  in treatment of PD  and generally is not used in 
psychiatry
*
>   

        /3. One of the most often quoted side-effects is "depression" (chemically 
        induced in this case, although it often rides on top of depression arising 
        out of the circumstances of the PWP and family). 
        /


*Comment:  This is very true and important to recognize to minimize the 
symptoms and the impairment in general functioning this condition 
causes!!   BTW. The depreesion  not a side effect of the medication but 
is from the PD itself.

*
> /* *
> /
>
>     /4. Most PWPs have the so called Parkinson's "facies" (a facial
>     appearance /
>     /typical of a particular disorder). A psychologist or psychiatrist
>     might say /
>     /they have a "flat aspect", often attributing it to depression,
>     whereas it is /
>     /brought about by lack of muscle tone as a direct consequence of PD./
>
>   
*Comment: The parkinsons facies and flat affect often  mimics depression 
ans it becomes difficult  to tell them apart even for the experienced 
clinician. .*

>     /5. Most PWPs have, at one time or another (often on and off throughout the 
>     day), "anarthria", a partial or total loss of articulate speech, directly 
>     arising from loss of muscle tone in the organs of speech. Paradoxically, the 
>     PWP often thinks they are speaking in a reasonable tone and volume./
>         

C*omment: I believe that dysarthria - difficulty in articulation that is 
due to the dysfunction of the  muscles which are used to form words and 
dysphonia  occur widely in PD-  including me-  and  create a significant 
handicap.  Lee Silverman Voice training can minimize yhese symptoms- 
especially  the dysphonia (or aphonia) which are related  to the vocal 
chords themselves.  Also a symptom I have which is troublesome is word 
finding difficulty and loss of fluof ency of .*
>
>     6/. The above two symptomspeechs can give rise to a feeling that
>     the PWP is /
>     /"disinterested" or "uncaring" about family or personal matters,
>     whereas they /
>     /themselves may think they are acting perfectly normally. Children
>     especially /
>     /are prone to believe that "Gran doesn't love us anymore."/
>
>   
(*Comment: I agree but also can be signs of loss of executive function 
(Explanation to follo*w).

>     /7. Again checking the manufacturer's own data, a combination of symptoms 
>     from medication may give the appearance of dementia, or even Alzheimer's 
>     Disease. If this is suspected, a doctor may recommend a "drug holiday" 
>     where, under strict professional supervision, the PWP is taken off all 
>     medication, and they are re-instituted one at a time in small increasing 
>     doses. This is known as drug "titration". This process can be very dangerous 
>     if mishandled, and should only be undertaken by a doctor skilled in the 
>     process./
>         

*Comment:  Alzheimer's Disease is an  irreversible (to date) dementing 
illness where the patient  suffers significant loss of brain cells.  
while delirium  is an acute problem and may mimic  Alzheimers .  Toxic 
delerium can be  secondary to either one or a combination  of 
prescription - including PD-(or non-prescription) drugs.  It can for 
instance occur post surgery from presumed metabolic causes.  This has 
happened to several friends  one with PD  and one without. .  The PD 
patient was given antipsychotic meds and had her PD meds adjusted while 
the other  had his pneumonia treated. Both resolved completely after 
several days of  bizarre behavior  requiring restraints.
*
*I agree with the necessity of having a skilled person- who knows PD and 
psychiatry both- involved with titration of PD meds*

>     /8. The difference between dementia or Alzheimer's from natural causes, and 
>     that chemical induced, is that the former is irreversible, where, with care 
>     and skill, the later usually disappears when the causative agent is removed/.
>         

Comment: See above
>   
>
>     /9. Common or garden variety constipation can be very detrimental
>     in PD, /
>     /rendering some medication partially or totally ineffective. For
>     example /
>     /l-dopa, the principal ingredient of dopamine-replacement
>     medication, has a /
>     /half-life of 30-45 mins. It is induced into the blood stream by
>     absorbtion /
>     /from the small intestine, so any delay amounting to more than
>     about 22 mins /
>     /between swallowing and absorption may render that dose useless.
>     Without /
>     /going into too much detail, PD affects "motility" (movement of
>     food through /
>     /the digestive system), the muscle tone of the rectum walls, the
>     anorectal /
>     /flap, and the anal sphincter. If constipation persists, the PWP
>     can become /
>     /seriously un/dermedicated.
>
>   
*Comment: It can be dangerous as well as uncomfotable. It can cause 
rupture of the gut if it goes untreated.  I take Miralax which seems to 
be effective.*

>     /10. PWPs seem loath to drink sufficient fluids during the day. Chronic 
>     dehydration can have deleterious effects on the chemical processes within 
>     the brain.
>      /
>         

*comment:  Agreed*

>     /11. PWPs can descend into a mental "fugue", a dream-like state of altered 
>     consciousness that may last for hours or even days unless the PWP is forced 
>     out of it. This might involve definite eye-contact and physical 
>     intervention.
>
>     /
    /C*omment.  This often occurs with "freezing" or going  "off"  and
    can usually be resolved   with levo-dop*/*a or an agonist,  I am not
    familliar though with the type that you mention.
    *

>     *12. Dopamine, the substance in short supply in PD, is a member of *the 
>     "catecholamine" chain of neuro-transmitters which contains, among others, 
>     adrenaline, of which dopamine is a precursor, so any excessive stress can 
>     severly deplete the supply of dopamine. The details of these processes are 
>     too complex to go into here.
>         

*Comment:  Agreed*
>
>     /So, all in all, the business of balancing the salutary effects of
>     medication
>     against the deleterious side-effects, coupled with the symptoms of
>     the
>     disease, is no easy process, and it is useful to have some
>     knowledge of the
>     complexities, whether medical practicioner or carer./
>
>   
*Comment:  Agreed  and I certainly believe that  it is necessary to have 
a Movement Disorders Specialisst with whom you are comfortable to treat 
your PD .

Also the type of mental deterioration that is common  in those of us who 
have been diagnosed the longest is loss of executive function  
specifically deficits in planning and  inhibitory control .  Working 
memory deficits are often noted.  This accounts for my difficulty with 
flow of speech. . Longterm memory  unlike in Alzheimer's Dementia, 
remains relatively intact . 


Jim , Thanks for your sharing  your  personal  experience and research .  .
*

*
Chsrles T. Meye MD
Middleton WI*

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