Ires Ghielen

141 BEWARE: Results of the pilot RCT Introduction The typical motor symptoms in Parkinson’s disease (PD) include tremor, rigidity, slowness of movement, postural instability, and freezing. Besides these symptoms, PD is accompanied by non-motor symptoms, such as autonomic failure, fatigue, pain, cognitive rigidity, depression and anxiety. Non-motor symptoms often have a higher impact on patients’ quality of life than motor symptoms [1]. First line treatment for PD symptoms is dopamine replacement therapy (DRT), e.g., levodopa [2]. In reaction to chronic DRT, PD patients eventually develop response fluctuations, including wearing-off. During wearing-off, both motor and non-motor symptoms can occur and/or become more prominent. Wearing-off is common already at the early stages of PD and is underestimated by routine neurological clinical evaluation. The number of wearing-off symptoms, both motor and non-motor, increases along with disease duration and has a negative impact on quality of life [3]. In PD, motor and non-motor symptoms have reciprocal influences [4]. About 75% of patients with motor fluctuations experience fluctuations in mood and/or anxiety in parallel [5], and anxiety is more common in patients that experience motor fluctuations compared to those who do not [6]. Anxiety associated with wearing-off, referred to as wearing-off related anxiety (WRA), is characterized not only by subjective feelings of anxiety but also by physical complaints, such as sweating, abdominal distress and shortness of breath. According to Rutten et al [7], anxiety symptoms in PD show significant overlap with both autonomic and motor symptoms, which makes it difficult to disentangle them. The high impact of the physical symptoms accompanying WRA on daily life functioning is often incongruent with the actual severity of the motor symptoms of wearing-off. This suggests heightened body awareness in these patients. Body awareness involves an attentional focus on and awareness of internal bodily sensations [8]. An abnormal increase in body awareness can be maladaptive [8] and is common in anxiety disorders [9]. Normalizing body awareness may therefore help patients to cope with WRA. A first therapeutic approach to treat WRA is optimization of DRT [10], since the anxiety symptoms experienced by PD patients are sometimes responsive to dopaminergic medication [11-13]. As the disease progresses, this becomes insufficient and is complicated by response fluctuations and increased occurrence of dyskinesias that become unpredictable in nature [14]. Such random fluctuations are difficult to treat with pharmacotherapeutic approaches since they are not directly 8