Identification and Management of Impulse Control Disorders Among Individuals with Parkinson s Disease

Transcription

1 Movement Disorders Identification and Management of Impulse Control Disorders Among Individuals with Parkinson s Disease Abstract Although Parkinson s disease is primarily considered to be a motor disorder, it has inarguable effects on cognition and personality. The cluster of neuropsychiatric sequelae known as impulse-control disorders has been of particular interest in recent years, perhaps owing to the potentially disastrous effects that such behaviors can have on individuals and families. Research has suggested that impulse control disorders are significantly more prevalent among individuals with Parkinson s disease, particularly with regards to pathological gambling and hypersexuality, and has further suggested that these disorders are significantly and substantively affected by the use of dopamine agonists. Treatment options for impulse control disorders tend to revolve around dopamine agonist dose reduction or cessation. The use of psychosocial strategies, or deep-brain stimulation of the subthalamic nucleus may also be considered in the management of patients with impulse control disorders. Keywords: Impulse control disorders, Parkinson s disease, dopamine agonists service use? Pre-test CME Quiz Parkinson s disease (PD) is a complex neurodegenerative disease, with symptoms that generally revolve around progressive loss of movement control. Although the motor symptoms of PD are generally the result of dopamine depletion within the basal ganglia, caused by the loss of dopaminergic neurons within About the authors Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON. H. Christopher Hyson, MD, FRCPC, Assistant Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON. Kaitlyn P. Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia Okanagan, Kelowna, BC.

2 Impulse-control disorders may be defined as behaviours that result from an individual s inability to resist an impulse, drive or temptation. Key Point Impulse-control disorders may be defined as behaviours that result from an individual s inability to resist an impulse, drive, or temptation. the substantia nigra 1, PD has been demonstrated to result in dopaminergic, noradrenergic, serotonergic, and cholinergic degeneration. 2 The presentation of PD is very heterogeneous, and although most individuals manifest several of the classic motor symptoms (tremor, rigidity, akinesia, and postural instability), there is some evidence to suggest that it may be worthwhile to identify sub-types of PD, with the two most commonly cited symptom clusters being tremor-dominant PD and akinesia-dominant (or rigidity-dominant ) PD. 3 In addition to its commonly cited motor sequelae, PD has been shown to lead to cognitive impairments, 4-6 and neuropsychiatric sequelae. 7 The cognitive dysfunction seen among individuals with PD is primarily related to dysfunctional visual-spatial processing, 8 or impaired speed of information processing, 9 while neuropsychiatric disorders tend to be related to an individual s increasing cognitive inflexibility. 7 The aforementioned sub-types of PD are particularly useful when considering the neuropsychiatric consequences of PD although close to 60% of individuals with PD will demonstrate at least one of the neuropsychiatric symptoms (typically depression or anxiety), these non-motor features of PD are more prevalent among individuals with rigidity-dominant PD. 3 Impulse Control Disorders in Parkinson s disease Despite the fact that depression and anxiety are the most prevalent neuropsychiatric sequelae of PD, there is increasing interest in the prevalence of impulse-control disorders among individuals with PD. Impulse-control disorders may generally be defined as behaviors that result from an individual s inability to resist an impulse, drive, or temptation. These behaviors tend to be out of character for the individual, will generally be performed without enjoyment, and produce significant social, personal, or professional distress. 10 The three most commonly cited impulse-control disorders found among individuals with PD are hypersexuality, pathological gambling, and compulsive shopping, with hypersexuality and pathological gambling generally considered to be the most prevalent of the three behaviors. 11 The prevalence of impulsecontrol disorders among individuals with PD is not precisely known, and varies according to the behavioral manifestation of the disorder. Pathological gambling has seen the 34 Journal of Current Clinical Care September/October 2011

3 Figure 1: Levodopa Therapy for the Treatment of Parkinson s Disease 35 Journal of Current Clinical Care September/October 2011

4 Key Point The three most commonly cited impulse-control disorders found among individuals with Parkinson s disease are hypersexuality, pathological gambling, and compulsive shopping. greatest amount of research activity, with prevalence estimates ranging from 0.5% to 8%. 12,13 Stamey and Jankovic 14 presented aggregated data on 9 studies involving individuals with PD, between 2000 and 2007, and among the 3220 individuals observed across these studies, 77 (2.4%) were judged to have demonstrated pathological gambling behaviors. Within the general North American population, the prevalence of pathological gambling is approximately 1.6%. 15 The prevalence of hypersexuality and compulsive shopping have been less frequently studied among individuals with Parkinson s disease, but recent research places the prevalence of hypersexuality between 2.4% and 8.4%, and the prevalence of compulsive shopping between 0.4% and 1.5%. 13 It should be noted, of course, that the prevalence of impulsecontrol disorders are very likely to be under-reported among individuals with PD. Beyond the obvious social stigma attached to impulse control disorders such as pathological gambling, most individuals with PD are primarily interested in seeking treatment for the motor symptoms of the disease. Indeed, most will not make the connection between behavioral or cognitive dysfunction, and PD. Anecdotally, the primary neuropsychiatric symptom that concerns most individuals with PD is dementia. Individuals with PD and impulsecontrol disorders are only likely to report behaviors that fall well within the pathological spectrum. The Effects of Dopaminergic Treatments on Impulse Control Disorders in PD Much of the current literature addressing the link between impulse-control disorders and PD has focused on the impact of dopamine agonist usage, and the results appear to be unequivocal. In one of the largest studies to investigate the link between impulse-control disorders and dopamine agonist usage, Driver- Dunckley et al. 16 noted that 9 out of 9 individuals with pathologi- Table 1: Risk Factors for the Development of Impulse-Control Disorders Male Early onset PD Currently taking dopamine agonists History of sensation-seeking behaviours history of participation in high-risk sports or activities history of alcohol or drug abuse History of impulse control disorders (including punding) 36 Journal of Current Clinical Care September/October 2011

5 Key Point Treatment options for impulse-control disorders tend to revolve around dopamine agonist dose reduction or cessation. cal gambling were taking dopamine agonists. Similarly, a study by Dodd et al. 17 noted that all 11 of their participants reporting pathological gambling were taking dopamine agonists while experiencing symptoms, and Klos et al. 18 demonstrated that dopamine agonists were implicated in 14 out of 15 identified cases of compulsive hypersexuality. Finally, Weintraub et al. 11 conducted a case-control study of 272 individuals with idiopathic PD, in which approximately half of the participants (n=137) were taking dopamine agonists at the time of screening. The logistic regression model fit to the data suggested that the odds ratio for dopamine agonist use was for impulse control disorders in general. It is important to note that the causal factor for the expression of impulse-control disorders may be linked to the progression of the disease, to the pharmacological management of the disease, or some combination thereof. 3 Indeed, the literature concerning the personality changes that accompany PD date back more than one hundred years. 19 Most of the prevailing evidence linking dopamine with sensation-seeking behaviors (as are frequently seen within the cluster of impulse-control disorders) has, however, suggested that there is a positive correlation between sensation-seeking tendencies and dopamine levels within the brain, 20 suggesting that the dopamine depletion inherent to Parkinson s disease produces fewer sensationseeking behaviors and that the progression of Parkinson s disease may indeed be a protective factor, of sorts. It is, however, inarguable that dopamine plays a significant role in the reward systems of the brain, 20 and the increased prevalence of pathological gambling among individuals with PD is likely due to an interaction of intrinsic effects of dopamine deficiency in Parkinson s disease, and extrinsic effects of dopaminergic treatments. Specifically, the depletion of dopamine within the nigrostriatal pathway has been linked with cognitive and emotional impairment, 12 and the Table 2: Punding Intense fascination with repetitive, meaningless movements such as collecting, arranging, or disassembling objects is recognized by the individual as disruptive (to sleep, eating, medication schedules, social interaction, etc.) often used as a self-soothing ritual, and is usually performed in the absence of obsessive thought Sometimes referred to as compulsive hobbyism as the behaviours may be correlated with past hobbies or occupations 37 Journal of Current Clinical Care September/October 2011

6 Table 3: DSM-IV Criteria for the Diagnosis of Pathological Gambling 10 Essential Feature: persistent and recurrent maladaptive gambling behavior that is not better accounted for by a manic episode Diagnostic Criteria (5 or more of): preoccupied with gambling (reliving past experiences, planning next gamble, planning means of getting money with which to gamble) individual tends to be more interested in the excitement associated with the gambling (as opposed to monetary reward) has tried to control his or her gambling behavior restless or anxious when cutting back on gambling may gamble as a means of escaping negative affect (guilt, anxiety, depression) long-term loss chasing often with larger bets or greater risks may lie to friends and family in order to conceal gambling may resort to antisocial behavior (theft, fraud, etc.) in order to obtain money for gambling may have jeopardized or lost a significant relationship, job, educational, or job opportunity because of gambling may turn to others for a bailout of a desperate financial situation caused by gambling Differential Diagnosis: distinguishable from social gambling, which: typically occurs with friends or colleagues lasts for a limited period of time has predetermined acceptable losses distinguishable from professional gambling, which: exhibits discipline demonstrates systematic risk (and loss) management degeneration of frontal-striatal tracts has been demonstrated to produce deficits in executive functioning. 21 Taken together, these factors may markedly increase one s susceptibility to the development of impulse-control disorders. Management of Impulse Control Disorders Among Individuals with Parkinson s Disease Arguably, the most important component to identifying and managing impulse control disorders among individuals with PD 38 Journal of Current Clinical Care September/October 2011

7 Summary of Key Points Impulse-control disorders may be defined as behaviours that result from an individual s inability to resist an impulse, drive, or temptation. The three most commonly cited impulse-control disorders found among individuals with Parkinson s disease are hypersexuality, pathological gambling, and compulsive shopping. Treatment options for impulse-control disorders tend to revolve around dopamine agonist dose reduction or cessation. Use of psychosocial strategies, or deep-brain stimulation of the subthalamic nucleus may also be considered in the management of patients with impulse-control disorders.? Post-test CME Quiz Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program. is patient education. As stated earlier, most individuals with PD will not associate impulse control disorders with PD (nor with dopaminergic treatment), and most will avoid disclosing these stigmatized behaviors unless directly questioned. This suggests that all individuals with PD should be routinely queried for the presence of unusual patterns of behavior that may suggest nascent hypersexuality or pathological gambling. Individuals possessing risk factors associated with the development of impulse control disorders (e.g., males who experienced early onset PD, with a history of alcohol or substance abuse, or who demonstrated premorbid impulse control disorders) should be followed particularly closely in this regard. Fortunately, most reports indicate that impulse control disorders resolve with dopamine agonist dose reductions (or dopamine agonist cessation). 16,17 Related to this, several recent case series have suggested that deep brain stimulation of sub-thalamic nuclei may be worthwhile treatment options, if only to assist in dopaminergic dose reduction without compromising motor symptom relief. Beyond this, there are few treatments that have been validated within samples of individuals with PD. Although behavioral treatments (such as cognitive behavioral therapy) have been effective within non-pd samples, 12 the cognitive deficits extant among individuals with PD may make such treatments difficult. The addictive behaviors (i.e., pathological gambling, hypersexuality, and compulsive medication usage) are probably best managed using psychosocial strategies, 3,25 although there is a general lack of evidence 39 Journal of Current Clinical Care September/October 2011

8 Clinical Pearls All patients on dopamine agonists should be routinely screened for symptoms related to impulse control disorders. Spouses can be a useful source of information, should the patient be ashamed of the activities. While impulse control disorders are more common with dopamine agonists, they can occur with highdose levodopa therapy. Key Point Use of psychosocial strategies, or deep-brain stimulation of the subthalamic nucleus may also be considered in the management of patients with impulse-control disorders. surrounding the effectiveness of programs such as Gambler s Anonymous, among individuals with PD. Given the potentially dire effects associated with impulse control disorders (particularly pathological gambling), psychiatric referral should be considered in serious cases. References 1. Waters CH. Diagnosis and Management of Parkinson s Disease. Los Angeles, CA: Professional Communications, Inc., Wolters E, Braak H. Parkinson s disease: premotor clinico-pathological correlations. J Neural Transm Suppl 2006(70): Wolters EC, van der Werf YD, van den Heuvel OA. Parkinson s disease-related disorders in the impulsivecompulsive spectrum. J Neurol 2008;255 Suppl 5: Brown RG, Marsden CD. Cognitive function in Parkinson s disease: from description to theory. Trends Neurosci 1990;13(1): Johnson AM, Almeida QJ, Stough C, Thompson JC, Singarayer R, Jog MS. Visual inspection time in Parkinson s disease: Deficits in early stages of cognitive processing. Neuropsychologia 2004;42(5): Johnson AM, Pollard CC, Vernon PA, Tomes JL, Jog MS. Memory perception and strategy use in Parkinson s disease. Parkinsonism Relat Disord 2005;11(2): Hubble JP, Koller WC. The parkinsonian personality. Adv Neurol 1995;65: Raskin SA, Borod JC, Tweedy J. Neuropsychological aspects of Parkinson s disease. Neuropsychol Rev 1990;1(3): Gauntlett-Gilbert J, Brown VJ. Reaction time deficits and Parkinson s disease. Neurosci Biobehav Rev 1998;22(6): American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Washington, DC: American Psychiatric Association, Weintraub D, Siderowf AD, Potenza MN, et al. Association of dopamine agonist use with impulse control disorders in Parkinson disease. Arch Neurol 2006;63(7): Weintraub D, Potenza MN. Impulse control disorders in Parkinson s disease. Curr Neurol Neurosci Rep 2006;6(4): Voon V, Potenza MN, Thomsen T. Medication-related impulse control and repetitive behaviors in Parkinson s disease. Curr Opin Neurol 2007;20(4): Stamey W, Jankovic J. Impulse control disorders and pathological gambling in patients with Parkinson disease. Neurologist 2008;14(2): Shaffer HJ, Hall MN, Vander Bilt J. Estimating the prevalence of disordered gambling behavior in the United States and Canada: a research synthesis. Am J Public Health 1999;89(9): Driver-Dunckley E, Samanta J, Stacy M. Pathological gambling associated with dopamine agonist therapy in Parkinson s disease. Neurology 2003;61(3): Dodd ML, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 2005;62(9): Klos KJ, Bower JH, Josephs KA, Matsumoto JY, Ahlskog JE. Pathological hypersexuality predominantly linked to adjuvant dopamine agonist therapy in Parkinson s disease and multiple system atrophy. Parkinsonism Relat Disord 2005;11(6): Booth G. Psychodynamics in Parkinsonism. Psychosom Med 1948;10: Johnson AM, Vernon PA. The genetics of substance abuse: Mediating effects of sensation seeking. In: Stelmack R, ed. On the Psychobiology of Personality: Essays in Honor of Marvin Zuckerman. London: Elsevier Science Ltd., 2004: Brand M, Labudda K, Kalbe E, et al. Decision-making impairments in patients with Parkinson s disease. Behav Neurol 2004;15(3-4): Ardouin C, Voon V, Worbe Y, et al. Pathological gambling in Parkinson s disease improves on chronic subthalamic nucleus stimulation. Mov Disord 2006;21(11): Bandini F, Primavera A, Pizzorno M, Cocito L. Using STN DBS and medication reduction as a strategy to treat pathological gambling in Parkinson s disease. Parkinsonism Relat Disord 2007;13(6): Witjas T, Baunez C, Henry JM, et al. Addiction in Parkinson s disease: impact of subthalamic nucleus deep brain stimulation. Mov Disord 2005;20(8): Kurlan R. Disabling repetitive behaviors in Parkinson s disease. Mov Disord 2004;19(4): Journal of Current Clinical Care September/October 2011