Huntington’s disease damages the brain, leading directly to psychiatric problems. In addition, patients may react to their diagnosis and the disease itself with depression and anxiety. Although the psychiatric issues linked to Huntington’s have been less researched than the disease’s characteristic movement problems, patients and their families often consider them more burdensome. Yet, they are often underdiagnosed and undertreated.
People with Huntington’s may have well-defined syndromes such as major depressive disorder or obsessive-compulsive disorder as well as subtle changes in mood and personality like irritability or loss of interest. Most of these conditions can be treated with medication and behavioral interventions.
Depression is very common in Huntington’s patients. Symptoms include decreased ability to enjoy or take interest in once-engaging activities, lack of energy, difficulty concentrating, indecisiveness and feelings of worthlessness. Depression can sometimes lead to thoughts of suicide — a particularly high risk since Suicide risk since these thoughts are accompanied by the impulsivity and anger management problems sometimes caused by Huntington’s. Physicians should talk about such thoughts with Huntington’s patients.
Depression associated with Huntington’s can be treated with anti-depressant medications like selective serotonin reuptake inhibitors (SSRIs). Coping strategies or behavioral interventions like counseling, support groups, hobbies and exercise can also help to relieve depression.
Anxiety in Huntington’s patients can be caused by both physical changes in the brain and the stress of having to cope with other symptoms of the disease like chorea. Patients may experience generalized anxiety (excessive, uncontrollable worry), social anxiety (excessive fear of embarrassment) and obsessive-compulsive type (preoccupations, repetitive thoughts and actions) anxiety. All are treatable with medications including SSRIs, benzodiazepines and neuroleptics such as Haldol. As with depression, behavioral interventions are very important for treating anxiety. Cognitive behavioral therapy and relaxation exercises may also bring relief.
Irritability and anger
Huntington’s patients are often irritable and angry. They may feel frustrated, become stubborn and lose their tempers, and sometimes these feelings result in violent outbursts.
Many of the same medications — including SSRIs and neuroleptics — used to treat depression and anxiety may also relieve symptoms of irritability and anger. Mood stabilizers and anti-seizure medications such as Depakote may be helpful. Identifying triggers of irritability and anger, and working to reduce them, can help patients cope with these symptoms. Talk therapy and anger management strategies are also useful.
Huntington’s patients may sometimes lose the ability to control the impulse to say or do socially inappropriate things. Behaviors caused by such disinhibition, like embarrassing remarks or exhibitionism, can be very disturbing for families and caregivers. Disinhibition may be a facet of psychotic problems sometimes seen in Huntington’s disease. As with other psychiatric symptoms, medications like SSRIs as well as behavioral interventions can help.
Difficulty initiating activities, lack of engagement, and sluggishness are all symptoms of apathy, which often coexists with depression — though they are not equivalent. Apathy can be treated with SSRIs and stimulants such as Ritalin. Behavioral interventions are important; caregivers and families can encourage patients to participate in activities they’ll enjoy. Set schedules and routines can also encourage activity.
The importance of managing psychiatric problems
It’s important for families and caregivers to make mental healthcare of Huntington’s patients a priority, because in many cases patients may not be aware of these changes in their behavior. Nevertheless, these psychiatric problems are treatable, and helping patients maintain their personality will help them face the losses caused by the disease. Support groups and social workers can be located through organizations like the Huntington’s Disease Society of America.
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