Ires Ghielen

154 Chapter 8 The BEWARE treatment did improve emotional wellbeing, which is well explained by the psychological principles of ACT. The valued living exercises may have resulted in an attitude shift in the patients, now focusing more on what is important for them and trying to live life according to those positive values. Another possibility is that the body awareness exercises might have normalized the patients’ awareness of internal body sensations so that the perceived impact and actual severity of motor symptoms are more congruent, resulting in a less stressful experience during wearing-off. The improvement in standing balance might be explained by the additional physical therapy components. The combination of physical and mental components in the BEWARE treatment might have increased patients’ balance confidence, which could have improved their standing balance. Since this improvement was superior to the TAU group, the improvement in mental state might have been beneficial, due to strong reciprocal interactions between physical and mental symptoms. The connection between an improved mental state and balance is, however, not yet been investigated. Future research should therefore include the falls efficacy scale to assess fear of falling and relate this outcome to psychological outcomes [44]. Although feeling stigmatized did not show a statistically significant reduction in the BEWARE condition compared with the TAU condition, the regression coefficient is of potential interest for future investigation, especially at follow-up (table 3). The items of the stigma subscale of the PDQ-39 assess avoidance behavior and the experience of being in public places in the context of the disease. Reducing avoidance behavior is being specifically addressed in the BEWARE treatment, using FEEL exercises. A recent review [45] states that a more avoidant personality predicts heightened anxiety in PD patients. The fact that the stigma subscale shows an improvement only at trend-level might be explained by the limited number of items, also not covering the whole spectrum of stigmatization. In addition, the treatment and follow-up duration might not have been long enough to measure a longer term decrease in avoidance behavior and social distress related to disease characteristics. The BEWARE treatment seemed to be most beneficial for patients that were emotionally most affected (e.g. higher BDI score), but were cognitively most intact. Therefore, patients should be better screened on cognitive dysfunction before starting an adapted and improved BEWARE treatment study. In addition, because of the small sample size, this result needs to be further investigated in a larger (multi-center) study sample.