Thinking about motor fluctuations: An examination of metacognitions in Parkinson's disease

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Highlights

  • Rumination and worry may exacerbate off-period distress.

  • Symptom focus may increase off-period distress.

  • Metacognitions may play role in off-period distress.

Abstract

Objective

Motor fluctuations (characterised by a sudden increase in symptom intensity, referred to as an ‘off-period’) are common side effects after treatment of Parkinson's disease (PD) with dopaminergic medication. A proportion of these people find motor fluctuations highly distressing. This study aimed to identify metacognitions associated with cognitive and attentional responses to these experiences.

Methods

Ten individuals with PD who experience motor fluctuations were interviewed for this study using an adapted metacognitive profiling schedule. Participants were asked about their metacognitions, and the cognitive processes and attentional strategies activated in response to a distressing off-period.

Results

Metacognitions identified were more often related to conceptual thinking about symptoms rather than symptom focus and data suggested trends for increased depressive symptoms among individuals with stronger metacognitive beliefs.

Conclusion

Metacognitions may play a role in determining or maintaining off-period distress in PD.

Introduction

Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease. A recent systematic review and meta-analysis revealed a population prevalence of approximately 250 per 100,000, but this increases to more than one in a hundred in those over the age of 70 [1]. PD is defined by a constellation of motor symptoms including slowness in the initiation and execution of movement, reduced movement amplitude, tremor and stiffness, leading to progressive disability affecting mobility and fine motor control, balance, swallowing and speech. PD is also associated with a wide range of non-motor symptoms, although their pattern and severity can vary more widely. These can include cognitive impairment, anxiety, depression, psychosis, pain, autonomic dysfunction, sleep problems, and fatigue [2]. Such symptoms have been shown to have a greater impact on health related quality of life than the motor symptoms [3], [4].

In the first few years of the disease, effective management of the motor symptoms is offered by the use of dopaminergic medication such as levodopa or dopamine agonists. With progression of the disease, however, such drugs become less effective, and complications can emerge with long-term use. The most commonly used drug, levodopa, is associated with the emergence of fluctuations in symptoms over the course of the day. These periods of symptom worsening (off-periods) can happen at the end of a dose before the next tablet (‘wearing off’), or less predictably with the dose stopping working unexpectedly or possibly not working at all [5]. Apart from a worsening of the motor symptoms, many patients report the emergence or exacerbation of non-motor symptoms during these off-periods [5] including depression and anxiety, as well as pain, fatigue, and other symptoms.

Off-periods can be a significant source of distress for patients. Some of this may reflect from a physiological response to variations in brain dopamine during the off-period, or a reaction to unpleasant symptoms such as pain, fatigue, or immobility. Another potential psychological factor is the role of metacognitions. This psychological construct refers to higher order ‘thinking about thinking’. Specifically, in the context of mental health, it refers to explicit beliefs held by an individual about the value of the specific cognitive (thinking) processes (such as worry and rumination) and attentional strategies. Metacognitions can be positive (e.g. ‘worry helps me prepare’) or negative (e.g. ‘my worry is uncontrollable’). Evidence suggests that both types of beliefs can result in the activation and persistence of worry and ruminative thinking [6], [7] because, while the goal of these cognitive processes is often a reduction in or elimination of distress, this ‘stop signal’ is seldom achieved. Metacognitions have been shown to be associated with levels of worry and the severity of anxiety in GAD [8], as well as a tendency to ruminate and depressive symptoms in Major Depressive Disorder [6]. More relevant to this study, metacognitions about conceptual thinking about symptoms (CTS: i.e. worry and rumination about symptoms) and symptom focus (SF) have been shown to predict the severity of fatigue symptoms in Chronic Fatigue Syndrome (CFS; 9). In PD, metacognitive style has previously been shown to be associated with psychological distress [10], while a recent study demonstrated that general metacognitions concerning a patients' beliefs about uncontrollability and danger were found to be significantly related to distress reported during off-periods, while the predictability of motor fluctuations was not [11].

We report here a small proof-of-concept, mixed-methods study aimed to: [1] determine whether patients express metacognitions specifically related to their individual off-period experiences, [2] characterise those metacognitions, and [3] examine whether they might be meaningfully related to psychological distress in relation to current models. The existence of potentially maladaptive metacognitions associated with off-periods and off-period symptoms, even in some patients, would support the exploration of novel tailored treatment approaches to help manage off-period distress.

Section snippets

Participants

Ten participants with PD (six males; mean age 59.2 years, SD 7.0 years, range 48 to 71 years) reporting motor fluctuations were recruited from movement disorders services at King's College Hospital NHS Foundation Trust and Lewisham University Hospital, London. The mean number of years since PD diagnosis was 9.6 (SD 5.2; range 3 to 20). All but one participant self-identified as White-British.

Eligibility criteria were: [1] a clinical confirmed diagnosis of idiopathic PD; [2] current use of

Relationship between metacognitions and distress

Table 1 shows that the mean PHQ-9 score for the sample was above the clinical cut-off of 10 [19] and that the mean self-rated PAS was above both the screening and diagnostic (13 and 14 respectively) cut-offs for any anxiety disorder [16], suggesting that that the sample represented high-distress PD patients.

The planned sample size was not intended to enable a quantitative test of the relationship between metacognitions and distress. Nevertheless, it is possible to discern interpretable

Discussion

This small study employed a convenience sample of patients attending a movement disorder service. It was intended to explore whether patients with PD express conceptually meaningful and interpretable metacognitions about off-periods. All 10 participants were able to recall a recent off-period that they found difficult or distressing in some way, and were able to describe at least one thought identified as metacognitive. The same individual revealed both positive and negative metacognitions,

Acknowledgements

Authors BAF and RGB receive salary support from the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre and Dementia Research Unit at South London and Maudsley NHS Foundation Trust and King's College London. KRC is supported in part by NIHR CRN salary. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

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