The neuropathological basis of anxiety in Parkinson’s disease

Evidence suggests that 24.5%–46.7% (mean 31%) of patients with Parkinson’s disease experience an anxiety disorder, a much higher prevalence than in controls. Anxiety does not appear to be a consequence of diagnosis or the motoric symptoms of the disorder and can manifest as Generalised Anxiety Disorder, phobias or panic attacks. At present, the neural underpinnings of anxiety disorders in Parkinson’s disease is unknown. Here, we make the novel proposal that the superior colliculus (SC), one component of a rapid, reflexive threat detection system in the brain, consisting of the colliculus, pulvinar and amygdala, becomes hyper-responsive to sensory stimuli following dopamine denervation of the striatum in Parkinson’s disease. This in turn leads to heightened responses to existing threat-related stimuli (giving rise to phobias and panic attacks), and heightened responses to anticipated threats (giving rise to Generalised Anxiety Disorder). This proposal is supported by a range of evidence, in particular elevated visual responses in the SC in an animal model of Parkinson’s disease and in Parkinson’s disease itself. Also facilitated saccadic eye movements (prosaccades, express saccades and fixational saccades) and increased distractibility in Parkinson’s disease, both of which involve the SC. Identifying one potential locus of change in the brain in Parkinson’s disease relevant to anxiety gives a potential target for interventions to combat a non-motor symptom that has a substantial negative effect on quality of life in the disorder.