Impulse Control Disorders in Parkinson’s

Impulse control disorders (ICDs) are common in people with Parkinson’s disease (PD) who also take dopamine agonists, a class of drugs often used to treat the symptoms of PD. Behaviours like compulsive gambling, hypersexuality, excessive spending, or binge eating are some of the most common behaviours seen in ICDs. Individuals with an ICD often feel urged to engage in harmful behaviours repeatedly, and lack self-control over these behaviours, leading to emotional distress. ICDs can have a significant impact on quality of life for the individual and their loved ones – however, management techniques and medication adjustments can often control or even eliminate these disorders.

Recognizing Impulsive Behaviours

According to Grant et al. (2013), ICDs are characterized by the following:

engaging in ongoing, obsessive, or destructive behaviours despite negative consequences
a progressive lack of control over these behaviours
an intense urge or craving to engage in these behaviours
a sense of relief or pleasure once these behaviours are performed

Impulsive behaviours can take many forms, and at times, can be difficult to identify. Many people with ICDs can even be aware of their bad behaviours, and fully understand their consequences. The problem lies in an inability to resist or control their impulses. Some individuals may feel a sense of embarrassment or shame for engaging in certain behaviours, and make excuses to justify them.

This is an important distinction that reveals whether one’s tendencies are a result of a cognitive disorder or a behavioural one. In contrast to ICDs and similar issues, cognitive disorders are largely categorized by a person’s inability to understand right and wrong. If you notice that a loved one is displaying behaviours that they are unable to recognize as wrong or harmful, or you are having trouble identifying issues you may be experiencing yourself, seek help from a healthcare professional.

Dopamine Agonists and ICDs

Dopamine is a neurotransmitter, a chemical released by brain cells (neurons), in order to communicate with other nerve cells. It plays a role in motor function, hormone release, and decision-making. Parkinson’s causes the cells that produce dopamine to die off, resulting in a low supply of the neurotransmitter. Without enough dopamine, motor symptoms of PD arise.

Dopamine cannot be given directly as a treatment, because it cannot pass from the bloodstream to the central nervous system. Instead, medications like levodopa or dopamine agonists (DAs) are used to address dopamine depletion.

Levodopa is a building-block of dopamine, and is used to naturally stimulate production of the neurotransmitter in the brain. It is the most effective drug treatment for PD, but it can often cause severe motor fluctuations, called dyskinesia, after prolonged use. DAs are frequently prescribed in combination with, or instead of levodopa. Unlike levodopa, which has to be converted into dopamine in the body, DAs have a more immediate release, and tend to last longer in the body. Popular DAs include Mirapex (pramipexole), Requip (ropinirole), and Neupro (rotigotine).

Although DAs have fewer movement-related side effects compared to levodopa, individuals may experience other side effects such as nausea, hallucinations, sudden sleepiness, and dizziness or light-headedness. DAs also significantly increase the risk of developing ICDs.

In a longitudinal study of over 400 people with PD, the risk of developing an ICD for those who had taken a DA was found to be 52%, compared to a risk of only 12% for those who had not been exposed to a DA (Corvol, 2018). Although the prevalence of ICDs is unknown, studies suggest that the risk for developing ICDs is highest among younger males, those with a personal or family history with addiction, and those with symptoms of depression, irritability, and changes in appetite (Pontone, 2018).

Evaluating and Managing ICDs

If left unaddressed, ICDs can have very serious consequences, including health risks, financial ruin, divorce, or loss of employment. An ICD can often make the person experiencing it feel helpless, shameful, or embarrassed, causing them to lie and hide their behaviour. Though difficult, it is extremely important to recognize that these behaviours are not the individual’s fault — an ICD should be regarded as a medical condition that can be effectively treated. In order to identify and prevent the progression of ICDs, it is important to be knowledgeable about the risks and potential causes, and to remain open and honest about your experience with healthcare professionals and loved ones.

Treatment often involves discontinuing the use, or lowering the dose, of any DA believed to be linked to ICD symptoms. Some individuals may be switched to levodopa if not already taking it, or the dosage of levodopa may be increased to counteract the effects of the DA. Adjusting medications can present challenges, as stopping or reducing DAs can sometimes cause withdrawal symptoms or other unwanted side effects, such as decreased motor control. Thus, it is important to continue working with your neurologist and healthcare team to find the most effective combination of medications.

Solutions for ICDs may also focus on behavioural changes. These strategies may include, for example, removing access to credit cards and internet browsing to restrict shopping, gambling, and the viewing of pornography. Seeking support from a counsellor can help to identify and change disruptive behaviours associated with ICDs and navigate emotions to cope in a more adaptive way. Additionally, individuals can work with loved ones to distract themselves and fill the time they spent engaging in these negative behaviours with more positive activities, such as socializing with friends, learning a new skill, or spending time outdoors. While symptoms of ICDs can be upsetting, these treatment options often result in significant improvement.

How Carepartners Can Help

It may be troubling as a carepartner to see your loved one with PD struggling with an ICD, and you may feel helpless to stop it. However, there are some things you can do to intervene. Here are some ways you can help ensure your loved one receives the treatment they need (Davis Phinney Foundation, 2020):

Educate yourself by obtaining all the details on ICDs before your loved one with Parkinson’s begins dopamine agonist therapy – prevention is one of the best treatments.
Do not be afraid to ask your loved one about unusual behaviours like random absences, unexplained changes in finances, and other forms of secrecy.
Inform the person with PD’s doctor if you notice any potential signs of an ICD.
Treat ICD symptoms as medical concerns, not personal weaknesses – avoiding blame will make your loved one will feel more comfortable opening up.
Work together with your loved one with PD, and a healthcare professional, to develop a plan on how to address and manage ICD symptoms.

By taking these steps as a carepartner, you can ensure your loved one receives proper medical attention and does not feel alone while facing the challenges of an ICD.

Sources

Davis Phinney Foundation. (2018). Impulse Control Disorders and Parkinson’s: What They Are and How to Manage Them. Retrieved from https://bit.ly/3kgKU6w

Corvol, J.C., et al. (2018) Longitudinal analysis of impulse control disorders in Parkinson disease. Neurology, 91(3). Retrieved from https://bit.ly/35qta4x

Grant, J., Odlaug, B., & Kim, S. (2013). Impulse Control Disorders: Clinical Characteristics and Pharmacological Management. Psychiatric Times, 24(10). Retrieved from https://bit.ly/2Ue6YnB

Pontone, G. (2018) What are impulse control disorders? American Parkinson’s Disease Association. Retrieved from https://bit.ly/3p0ErjI

This content was published in the Winter 2020 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.

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