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ORIGINAL RESEARCH

Objective:

To study clinical correlates of religiosity in Parkinson’s disease (PD).

Methods

Measures of life goals, religiosity, mood, and neuropsychologic function wereassessed in 22 persons with mid-stage PD and 20 age-matched healthy controls. Levodopadose equivalents (LDE) were also computed for the patients.

Results:

Relative to other major life goals parkinsonian patients were significantly morelikely to report that “my religion or life philosophy” was less important than were age-matchedcontrols. Scores on a battery of religiosity scales were consistently lower for Parkinson’spatients than those of age-matched controls. While Mini Mental State Exam, logical memoryrecall, Stroop, and selected (depression and anxiety) mood scales reliably distinguished patientsfrom controls, only measures of prefrontal function correlated with religiosity scores.

Conclusions:

Patients with PD express less interest in religion and report consistently lowerscores on measures of religiosity than age-matched controls. Prefrontal dopaminergic networksmay support motivational aspects of religiosity.

Keywords:

religiosity, Parkinson’s disease, neuropsychology, mood, executive functions,dopamine agonists

Introduction

Religiousness or life philosophy can be a potent factor in people’s mental andbehavioral make-up, influencing every level of personality from daily habits/practicesto long-term strategies and goals (Batson et al 1993; Emmons and Paloutzian 2003),yet it has only recently received significant experimental attention from the cognitiveneuroscience community. Several recent carefully controlled neuroimaging (Newberget al 1997, 2001; Azari et al 2001) and neuropsychological (Ramachandran et al1997; McNamara 2001; McNamara et al 2003) investigations of potential braincorrelates of religiosity consistently implicate neo-striatal, limbic, and prefrontalcortical networks as key nodes in the widely distributed neural networks thatapparently support common religious practices such as prayer and meditation.If the neuroimaging and neuropsychological studies of religiousness have indeeduncovered reliable brain correlates of religiosity, then religiosity should varysignificantly in clinical populations that exhibit significant alterations in neo-striataland limbic-prefrontal brain functions. Although no direct test of this hypothesis hasyet been conducted, circumstantial evidence is consistent with the prediction.Religiosity-related symptomology is relatively common in disorders that areassociated with neo-striatal and limbic-prefrontal alterations such as schizophrenia(Siddle et al 2002), obsessive-compulsive disorder (Tek and Ulug 2001), and certainforms of temporal lobe epilepsy (Dewhurst and Beard 1970; Geschwind 1983). Toour knowledge, however, there are no published reports of similar religiosity-relatedsymptomology in Parkinson’s disease (PD) – another prominent disorder of neo-striatal and prefrontal dysfunction (Agid et al 1987; Starkstein and Merello 2002).We therefore sought to conduct a pilot investigation into PD patients’ religiousattitudes and practices as well as whether these attitudes and practices correlate with

Religiosity in patients with Parkinson’s disease

Patrick McNamaraRaymon DursoAriel Brown

Department of Neurology, BostonUniversity School of Medicine,Boston, MA, and VA BostonHealthcare System, Boston, MA, USACorrespondence: Patrick McNamaraDepartment of Neurology (127), 150South Huntington Avenue, Boston, MA02130, USATel +1 617 2329500Fax +1 857 3644454Email mcnamar@bu.edu.

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key clinical aspects of PD such as age, medication regimes,mood, and cognitive function.

Methods

Participants

Twenty-two male patients with PD were recruited from theoutpatient Movement Disorders Clinic at the VA BostonHealthcare System, Boston, MA. Patients were individuallydiagnosed by Dr Raymon Durso, director of the clinic, andall met standard criteria for idiopathic PD. Twelve of thepatients were at Hoehn-Yahr stage II, and 10 at stage III(Hoehn and Yahr 2001). None of the patients were dementedaccording to clinical examinations and DSM-III criteria. Allwere on some form of dopaminergic medication and weretested while on medications. Patients with a history of substance abuse or head injury were excluded. Twentyhealthy control subjects (5 of whom were female) wererecruited from the community and were matched in age tothe group of PD patients.While the two groups did not differ significantly in termsof age (PD mean 72.1 (6.9), range 54–82; controls mean70.5 (6.0), range 55–79, p=0.19), the controls reportedhigher levels of education (PD mean 13 years; controls mean16 years, p=0.002). Mean Mini Mental State Exam (MMSE)Score was 27.6 (1.4) for PD patients and 29.2 (0.8) forhealthy controls (p<0.003). Demographic characteristics of the two groups are summarized in Table 1.A wide range of religious preferences were representedby patients and controls who participated in these pilotstudies (see Table 2). While Roman Catholics made up thebulk of the parkinsonian sample (45%), several other faithswere represented in both the PD and control samples.

Measures

Medication effects

To assess effects of medication type and dose on cognitiveand affective functions we compared different medicationsdirectly at dosages of equivalent efficacy. We followedRazmy et al (2004) who used a formula to convertmedication dosages to levodopa dosage equivalents (LDE).The only relevant medications taken by patients in oursample were carbidopa–levodopa and pramipexole.Consequently our formula was a simplified version of Razmy’s, namely:LDE=67 * (pramipexole dose) + (regular levodopa dose).

Measures of religiosity and life goals

We used the Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS; Fetzer Institute 1999)to measure religious attitudes and practices. The BMMRS

Table 1

Demographic and neuropsychological variables on Parkinson’s disease (PD) subjects and controls

PD-NPD-mean Control-NControl-mean P value (Bonferroni(SD)(SD)corrected)

Age2272 .1(6.9)2070.5 (6.0)0.19Education2213 (3.1)1716 (1.8)0.002*MMSE1727.6 (1.4)2029.2 (0.8)0.003Logical memory recall229.2 (2.8)2012.7 (3.5)0.001*Tower of London (TAS)2014.9 (4.8)2016.9 (4.4)0.19Ravens (B) total2026.7 (9.2)1821.9 (7.7)0.09Stroop interference–switching19107.4 (56.4)2072 (22.4)0.016*DASS total2115.3 (8.1)188.7 (7.9)0.01*DASS anxiety215.1 (2.9)181.8 (3.2)0.003*DASS depression214.8 (3.8)182.1 (2.6)0.01*DASS stress215.6 (3.6)184.8 (3.4)0.47LDE22570 (81)---

*p<0.01

Abbreviations:

DASS, Depression Anxiety and Stress Scale; LDE, levodopa dose equivalents; MMSE, Mini Mental State Exam, TAS, total achievement score.

Table 2

Religious preferences of participants

Parkinson’sControlTotalsdisease

none314agnostic011atheist101Catholic10313Greek orthodox022 Jewish437Protestant033Unitarian101Baptist112Episcopalian112Methodist112unknown044Totals222042

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contains 38 statements with Likert scale formats that cover11 religious domains. These are: daily spiritual experiences,values–beliefs, forgiveness, private religious practices,religious and spiritual coping, religious support, religious–spiritual history, commitment, organizational religiousness,religious preference, and overall self-ranking (eg, “To whatextent do you consider yourself a religious person?”). TheBMMRS was developed by a panel of experts on religionand health convened by the Fetzer Institute and the NationalInstitutes of Health and Aging. It has excellent psychometricproperties as well as publicly available norms for healthyolder individuals. Higher scores indicate less religiosity onthese scales.We used the Rivermead Life Goals inventory (Nair andWade 2003)

to measure participant’s subjective estimationsof their major life goals. These included 9 areas of personalconcern ranging from residential domestic arrangements andability to personally care for oneself, to financial status andwork-related goals. Participants were asked to rate each lifegoal domain in importance from 0 (no importance) to 3(extreme importance). After subjects rated the importanceof these life goals we then asked them to go back and rateeach domain as to whether they felt it was on track or off track (0

totally off track to 3

totally on track). We usedthe question “My religion or life philosophy is…”, to assessthe subjective importance of religion to PD patients.

Neuropsychological measures

Our cognitive test battery was chosen with an emphasis onexamining prefrontal neuropsychological function. Thesetests have previously been shown to be altered in patientswith PD (Taylor and Saint-Cyr 1995).The Stroop color-word interference procedure (Stroop1935) requires the subject to name the color of the ink or toname the word of a color-word that is printed. The task involves four test cards: the first containing rows of coloredrectangles with the task being to name the colors as quicklyas possible, the second containing rows of color words(printed in black ink) with the task being to read the wordsas quickly as possible, and the third “interference” testconsisting of rows of color words printed in ink colorsincongruent with the word represented, with the task beingto name the ink colors as quickly as possible. The fourthcard is the “switching card” where subjects are prompted toeither name the color of the ink or to read the worddepending on whether the item is in a box or not. For boththe interference card and some of the switching cards thesubject must ignore the word and name the color. In thispaper we focus on the score derived from the fourth or“switching” task. Susceptibility to cognitive interference iscalculated as the total time taken to name the colors andread the words. PET studies show that frontal cortex isactivated in normals during the Stroop task (Bench et al1993; Vendrell et al 1995).In the Tower of London (TOL) task (Shallice 1982),disks have to be moved from a starting configuration onthree sticks of equal length to a target arrangement, whichis presented as a colored drawing. The starting position of the disks is varied, and in each trial there is a minimumnumber of moves in which the solution can be reached. Thesubject’s task is to solve the problem as quickly as possiblein as few moves as possible. We tabulated the totalachievement score (TAS) for this task, which takes intoaccount whether the subject completed each trial withina given time and how many errors were made. A SPECTstudy has demonstrated left prefrontal cortex activationin subjects attempting to plan their moves (Morris et al1993).We administered a logical memory test adapted fromthe version presented in the Wechsler Memory Scales –Revised (WMS-R; Wechsler 1987). Briefly, participants areread a story and then asked immediately, and again after adelay of 20 minutes, to recall the story. They are given pointsfor each of the major elements of the story they recall. Thegreater the number of points received the better the recall.Episodic recall of stories and other verbal material is thoughtto be mediated by widely distributed diencephalic structuresdeep to the temporal lobes (Lezak 1995).The Ravens Colored Progressive Matrices (RCPM SeriesB; Raven 1965) consists of a series of abstract, complex,non-representational visual designs that progress in designcomplexity as the test progresses. Subjects are presentedwith an array of designs from which they must select a targetdesign that will visually complete a problem target design.The RCPM is a test of general intelligence as it requires thesubject to conceptualize complex spatial and numericalrelationships in order to successfully select the correct matchfrom the array of false lures. Lezak (1995) reviews theevidence for sensitivity of RCPM to posterior corticallesions.

Mood tests

We assessed depression, stress and anxiety with theDepression, Anxiety and Stress Scale (DASS) developedby Lovibond and Lovibond (1995). Crawford and Henry(2003) and Antony et al (1998) have demonstrated excellent