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ing less elastic, whereas in dystonia, it results from the
muscles contracting without relaxing. Dystonia of the
calves, forearms, thigh, or upper arms may be an early
symptom of PD, usually in people who are less than 40
years old. It may appear in people with PD who are
taking Sinemet. Usually it appears as Sinemet wears
off, typically in the early morning when Sinemet levels
are low. This is called an off dystonia. It s worse on
the side that is more affected by PD. It s treated by
adding a dopamine agonist. The pain of dystonia can
appear as Sinemet peaks, called on dystonia. It s
harder to treat, thus requiring you to rearrange all of
your drugs to reduce the highs and lows of Sinemet.
If you feel pain, only you can describe it. Be as specific
as you can. Asking the following questions is helpful:
" Location. Where does it hurt most? The shoulder?
The hip? The back? Does it stay in one place, or
does it radiate? If so, where?
" Intensity. How bad is it? Describe it on a scale of 0
to 10, where 0 is no pain and 10 feels as if your arm
(or leg) was yanked off or your skin was ripped off.
The pain of PD is usually a 4 to 7. It s never a 10.
" Duration. How long have you had the pain? Hours?
Days? Weeks? Years? During a typical day, how
long does it last?
" Associations. Is the pain associated with inflamma-
tion, redness, swelling, or warmth of the overlying
skin? The pain of PD shouldn t be associated with
any of these.
" Position. What positions, if any, make it better?
What, if any, make it worse?
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" Quality. Words used to describe the pain include
aching, biting, burning, cramping (like a Charlie-
horse), gripping (like being caught in between a pair
of pliers), hurting, nipping, pinching, ripping,
smarting, stabbing, and throbbing. A diffuse, not
well-localized burning or throbbing pain may some-
times occur in an arm or a leg or across the chest.
Whether this is related to PD, anxiety, or depres-
sion is difficult to pin down. It probably results from
a disorder of the autonomic nervous system.
49. I can t sleep. Is this PD or am I
anxious or depressed?
Anxiety and depression are common in PD and can
interfere with sleep; however, insomnia (difficulty falling
asleep or difficulty staying asleep or both) is part of PD.
It is normal during sleep for people to awaken during
the night to roll over, to change positions, and then
to fall back to sleep without any problem. People with
PD may awaken and find themselves so stiff that they
are unable to make such adjustments and then can t go
back to sleep. The problem may be that your last dose
of Sinemet wasn t enough to give you the mobility that
you need in bed to sleep through the night. This prob-
lem can be helped by adding Comtan or a dopamine
agonist. Insomnia consists of one or more of the fol-
lowing: difficulty falling asleep, difficulty remaining
asleep, frequent nighttime awakenings, early-morning
awakening, and unrefreshing sleep.
Temporary insomnia lasting less than 4 weeks is self-
limited and has no serious repercussions. It occurs in
up to 50% of all people and is more frequent in older
people, shift workers, international travelers, and peo-
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ple who are under stress. Chronic insomnia, such as
occurs in PD, lasts longer than 4 weeks, is not self-
limited, and may have repercussions. Such insomnia
usually results in daytime fatigue, grogginess, irritabil-
ity, mood swings, and difficulty paying attention or
concentrating. People with chronic insomnia are more
likely to suffer from anxiety, depression, mood swings,
or paranoia. Whether these disorders came first and
insomnia is part of them or whether the insomnia
came first and unmasked them is a source of debate. In
discussing insomnia with your doctor, you should be
prepared to answer questions such as these:
" What time do you go to bed? Before midnight?
After midnight?
" How long does it take for you to fall asleep? Less
than an hour? More than an hour?
" While trying to fall asleep, what do you do?
Read? Listen to the radio? Watch TV? Worry?
Stare into space?
" Do you wake up during the night? For what reason?
Bad dream? Going to the bathroom? Worry? Rest-
less legs? No reason?
" How many times do you wake up? Once? More
than once?
" How many hours do you sleep? Four hours? Two
hours?
" When do usually wake up? Before 4:00 a.m.?
After 4:00 a.m.?
" After you wake up, do you get out of or stay in bed?
How long? Less than an hour? More than an hour?
" When you wake up, are you refreshed? Or groggy?
" Do you nap during the day? Once? More than once?
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