Anxiety can occur in HD before motor symptoms and at all stages of disease after motor diagnosis. Anxiety as it presents in HD is similar to that in the general population. It can take the form of a general feeling of tenseness, or generalized anxiety that is more severe and can interfere with day to day function, or social anxiety and panic. The experts agree that anxiety is a treatable symptom complication of HD. In general, the treatment recommendations in HD are similar to those for the general population except that drug choice is influenced by other HD symptoms which may be present.

Anxiety can occur at any stage of disease and does not increase with disease duration.

Anxiety and depression often occur together. Drugs commonly used to treat anxiety can simultaneously treat depression and obsessive compulsive behaviors. Anxiety in HD can be triggered by external factors like unfamilier situations, changes in routine, and physical discomfort. There can be "performance anxiety" when the indivual is asked to perform activities which have become more difficult due to HD. Anxiety can look like restlessness and will worsen chorea.

Clinical Practice Guidelines for Anxiety in HD

Note that this author has changed some of the wording that appears in the journal article for purposes of making it more user friendly. If you wish to share with your medical provider, it would be best to copy the journal link [Anderson KE 2018] for the doctor's review.

General Recommendations

  1. Identify and treat other symptoms of HD or other medical conditions that can cause or contribute to anxiety
  2. Identify and modify external factors that can cause anxiety

Behavior Recommendation

  1. Offer psychological behavioral therapy as first step in treating anxiety (if available and if this is patient preference)

Drug Recommendations (highly dependent on other symptoms that are present)

  1. First choice drug is an SSRI (like sertraline (Zoloft®) or citalopram (Celexa®)) whether it occurs as a single symptom or occurs with depression or obsessive compulsive behaviors (perseveration) because this type of drug treats all three of these symptoms
  2. Warning should be given that anxiety may worsen briefly after starting an SSRI. (Best to start with a low dose). If worsening of anxiety occurs when starting an SSRI, adding a benzodiazepine short term may be helpful
  3. If the SSRI first used is not helpful or gives unacceptable side effects, alternative SSRI drugs (a different SSRI, or an NSRI (like venlafaxine (Effexor®), or clomipramine (Anafranil®) may be used
  4. Mirtazapine (Remeron®) is an alternative treatment for anxiety particularly if sleep disorder is present
  5. An antipsychotic is an alternative treatment if already needed for treatment of chorea or more severe neuropsychiatic symptoms
  6. Clomipramine (Anafranil®) is an alternative treatment for anxiety when this drug is needed for treatment of obsessive perseverative symptoms
  7. Long term use of a benzodiazepine drug for the treatment of anxiety is discouraged in ambulatory persons unless all other options have failed

Author's take home points: Anxiety is a highly treatable symptom. Treatment of this symptom complication will decrease the burden of HD. Its management in HD is similar to that in the general population realizing that best drug choice can depend on other symptoms which may be present.

References

Anderson KE, van Duijn E, Craufurd D, Drazinic C, Edmondson M, Goodman N, van Kammen D, Loy C, Priller J, Goodman LV. Clinical Management of Neuropsychiatric Symptoms of Huntington Disease: Expert-Based Consensus Guidelines on Agitation, Anxiety, Apathy, Psychosis and Sleep Disorders. J Huntingtons Dis. 2018;7(3):239-250. doi: 10.3233/JHD-180293. PubMed abstract