Impulse Control Disorders

 Key Facts

  • Impulse control disorder (ICD) can be caused by dopaminergic agents; however, it can also be present in PD patients who have not initiated treatment.
  • Family should be engage in the treatment.
  • Address ICD in every office visit.

Clinical Best Practices

  • Inform patient and family of risks and benefits of any PD treatment prior to initiation, including ICDs.
  • Ask patient regularly about development of ICDs.
  • Refer to psychiatry if changes in medication do not work.

Impulse control disorders include compulsive gambling, shopping, eating and hypersexuality, among others, and can occur in PD patients without treatment.  When patients are treated with dopamine agonists they maybe 2 to 3 times as likely to develop an ICD relative to those treated with levodopa. Depending on the severity and type of behavior, intervention may be necessary with the patient and family. Regular monitoring is advised.

Common Factors

  • May occur prior to onset of medications
  • Dopamine agonists
  • Levodopa
  • Rasagiline (Azilect) or selegiline (Atapryl, Carbex, Eldepryl, Zelapar);
  • Young male
  • Depression

Diagnosis

Note: See scoring sheet for QUIP here

 

Barriers to Diagnosis 

  • Lack of patient insight–you must have an informed other (spouse or family member)
  • Lack of disclosure-shame, stigma, patient does not associate behavior with PD

Treatment Options

  • Reduce/stop dopamine agonists
  • Treat depression
  • Refer to psychiatrist to extinguish behavior
  • Consider clozapine
  • Engage family to limit access to money/equipment for tinkering/only have healthy food in house, etc.

Important Caveats to Therapy 

  • Motor function may worsen.
  • Dopamine dysregulation syndromei may be seen–it may take weeks to a year to resolve, or patient may find it intolerable to withdraw.
  • Engage family to encourage withdrawal from dopamine agonist.
  • In order to start clozapine, the WBC must be at least 3500 mm3, and the ANC must be at least 2,000 mm3.
References: 

Weintraub D, Hoops S, Shea JA, et al. Validation of the questionnaire for impulsive-compulsive disorders in Parkinson's disease. Mov Disord. 2009;24(10):1461-1467.

Barns Neurauter MP, Rickards H, Cavanna AE. The prevalence and clinical characteristics of pathological gambling in Parkinson's disease: an evidence-based review. Funct Neurol. 2010;25(1):9-13.