In mid-May, the Parkinson’s and Movement Disorder (PMD) Alliance hosted movement disorder specialist Dr. Joseph Friedman to speak on impulse control disorders in Parkinson’s disease (PD).  Impulse control disorders (ICD) is a term used to describe the numerous compulsory disorders associated with dopamine agonist drugs, primarily in PD but also in other disorders.  Examples are gambling, hypersexuality, shopping, etc.

Dr. Friedman said that impulse control is not a symptom of PD, rather a side effect of drugs used to treat PD.  Patients with ICD behave like addicts, in that they don’t see these problems as problems and aren’t able to step back and see it objectively.  It’s an irresistible need to do these things.  Patients who have it will not necessarily talk about it with their doctors because they don’t want anyone to interfere in it. 

ICD occur in 10-14% of patients who take dopamine agonist drugs, according to Dr. Friedman.  Such issues are more likely to occur in people who had a history of a similar type of behavior.  To help prevent severe ICDs, the neurologist should warn the patient at the time of diagnosis or when certain drugs are prescribed, and ask them to discuss the potential problem with their caregiver and family.  It’s important to remember that the patient’s physiology has been altered by the medications.  The patient is not a bad person; behavior is due to medication.

For a recording of this webinar, please see the PMD Alliance YouTube Channel webpage here.

Please see below for notes on the May 12th webinar.

Regards, 

– Joëlle Kuehn

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“Impulse Control Disorders” (in Parkinson’s) – Webinar notes

Speaker: Joseph Friedman, MD, director, movement disorder program, Butler Hospital

Webinar Host: PMD Alliance

Webinar Date:  May 12, 2021 

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

We have learned that dopamine agonists (drugs that have chemical activity similar to dopamine) are associated with an increased risk of compulsive behaviors, known as impulse control disorders.

Dopamine agonist drugs increase risk of impulse controls.

Some drugs are:

• Carbidopa levodopa
• Pramipexole… Mirapex
• Ropinirole… Requip
• Rotigotine… Neupro
• Cabergoline…Dostinex (for stopping lactation in postpartum women)

Obsessions vs. Compulsions:

• Obsession: 
  • Dictionary: an idea or thought that continually preoccupies or intrudes on a person’s mind
  • Psychiatric text: persistent ideas, thoughts, impulses, or images that are experienced as inappropriate or intrusive and that cause distress. Content is often perceived as alien and not under the person’s control
• Compulsions:
  • Repetitive acts, behaviors, thoughts that are designed to treat the anxiety associated with an obsession
  • If not taken to an extreme, they can be normal
• Impulse: 
  • Sudden strong and unreflective urge or desire to act

Impulse control disorders (ICD):

• Term used to describe the numerous compulsory disorders associated with dopamine agonist drugs, primarily in PD but in other disorders
• OCD used to be considered anxiety disorders, but not currently
• Not associated with anxiety
  • Unlike pathological gambling, they are not associated with regret or embarrassment

History of ICD in PD:

• “Punding” first described in 1994 
  • This behavior in amphetamine addicts
  • People who had used the dose at large doses for a long time had these spells where they would take apart objects and put them back together over and over again, or read fine print on every can in a store
  • Didn’t like to be disturbed, but they spent hours doing a behavior that had no meaning
  • Researchers called the behaviors “punding”
• In 2000, it was described as “hedonic homeostatic dysregulation” in PD in 2000.  
  • Researches called it a levodopa addiction, and even if it caused problems they insisted they needed to take more
• Described in 2002 with two articles on connection between use of dopamine agonists and gambling

ICD can manifest in:

• Gambling:  Most common
• Hypersexuality (mostly in men):  Sexual preoccupation
• Completing:  Need to finish a task if they start
• Punding
  • Repetitive act of something with no meaning
  • Tallying figures, reading prints, clipping hedge, polishing pennies, tidying a drawer, weeding, cleaning the oven, clipping toenails
• Overeating:  Eating a certain kind of apples
• Overspending
• Collecting:  Collecting glass, broken lawn mowers
• Shopping.  Example – wouldn’t buy unless she knew it was for the cheapest price, which would result in her never being able to accomplish any purchases
• Hobbyism.  Fixing your house, playing computer games, being unable to stop, don’t want people over, fishing
• Walkabout:  Like to leave home and walk for long periods of time

These people behave like addicts, people who develop these problems don’t see them as problems and are unable to step back and try to see it objectively and continue to do it. It’s an irresistible need to do these things. Patients who have it will not necessarily talk about it with their doctors because they don’t want anyone to interfere in it. If you are starting drugs, you need to mention that to your family. 

Occurs in 10-14% of patients who take the drugs, and are more likely to occur in people who had a history of a similar type of behavior.

Risk factors:

• History of gambling
• History of obsessive compulsive disorders
• History of substance abuse
• Male gender
• Younger age

Early detection:

• Neurologist should warn patient
• Neurologist should ask patient to discuss this potential problem with spouse, caregiver, or close person before starting the drug
• Caregiver or closest contact should accompany patient to the office, especially if a problem has been detected
• Assume that the PD patient with the problem will minimize or deny the problem

It’s important to remember that their physiology has been altered by the medications, and they are not a bad person, it’s because of the medications.

Question & Answer:

Question: Is having OCD a prodromal symptom of PD?

Answer: No, because it isn’t related to PD, it’s because of the medications in someone with PD. It’s also been identified in those taking the drug who don’t have PD. People who have a history of this behavior are at a greater risk if they are treated with a dopamine agonist. 

Question: Other than dopamine agonists, can this happen just in PD alone, or is it only medication related? Does it happen with increases of carbidopa levodopa without the dopamine agonist?

Answer: It can happen in carbidopa levodopa alone, but I don’t know how oten it occurs in untreated PD patients. It’s thought that people on carbidopa levodopa and those with untreated to have the same amount.

Question: I stopped dopamine agonist 4 years ago but still have impulse disorders?

Answers: I don’t know, usually it goes away but not in everyone. 

Question: How to address issues to someone who is a hoarder?

Answer: You should think about if a person is engaging in behaviors that aren’t harmful to themselves or others, should you interfere. There are the extremes, like the ones on the hoarding reality TV shows, and that is a problem. It should be addressed if it affects others, such as if they don’t live alone. If they live alone, it’s up to them unless it’s a fire hazard. Just like if a person gambles and they are spending their spouses money, it affects other people. By knowing that medication is the cause, it’s easier to confront the person if you focus on how it is the medication. 

Question: How do care partners manage behaviors that are bothersome to them?

Answer: Confront the patient in a supportive way. Point out that it’s related to the PD treatment and bring it to the attention to the neurologist.