Ires Ghielen

173 General discussion be very useful in clinical practice, and facilitates a more personalized treatment approach. Research on the treatment of anxiety in PD, and especially in the context of motor symptoms, is extremely limited. More research is warranted, both pharmacological and non-pharmacological, in order to treat anxiety in PD more effectively. We investigated a multidisciplinary treatment combining Acceptance & Commitment therapy with physical therapy. This showed promising results and together with the feedback of the participants, we optimized this BEWARE training, and we are currently investigating its effectivity in a better powered multicenter study. When the BEWARE training is considered effective, we intend to optimize the treatment further and add an online training module in order for patients to practice more intensively at home. Since patients with intact cognitive abilities benefited the most from BEWARE, it would be interesting to develop a more behavioural variant of the treatment that demands less cognitive abilities. In this variant, the primary focus lies on behavioural change. The Patient Education Program Parkinson (PEPP) also incorporated a more behavioural option in their CBT-based program, showing good results [45]. After proving its effectiveness, the BEWARE treatment can be implemented in clinical practice. Implementation is achieved by training therapists in the treatment protocol and making the treatment available for patients through health care providers. Ideally, in order to increase evidence for its effectiveness, the treatment needs to be investigated in an independent PD patient sample. Final conclusions PD is characterized by a variety of motor and non-motor symptoms. This thesis confirms that consideration of motor and other PD-related symptoms is important in diagnosing anxiety and in the treatment of response fluctuations. The reciprocal associations between motor and anxiety symptoms should be taken into account in both the diagnostic and treatment process. Especially the temporal interactions of these symptoms are in need of further investigation, as well as alternative treatment options for anxiety and wearing-off in PD. The suggested strong interplay between motor and non-motor symptoms in PD warrants a holistic approach to treatment of anxiety in clinical practice. The BEWARE training is the first attempt to treat anxiety in a multidisciplinary manner, in the context of response fluctuations with the aim to improve coping and valued living in spite of (inevitable) PD symptoms. 9