Tips for impulse control disorder disorder (ICD) and Parkinson's disease

We had the pleasure of sitting down with Dr. Tamara Stiep who is doing research on impulse control disorders and Parkinson’s disease (PD). She was kind enough to allow Dr. Subramanian and I to pick her brain on useful tips for people living with Parkinson’s disease. (PWP)

Who is Tamara Stiep MD?

Dr. Tamara Stiep is a Movement Disorder fellow at the University of Florida Norman Fixel Institute for Neurological Diseases. She received her medical degree at New York Medical College and completed her residency in Neurology at the University of Miami Miller School of Medicine, and Jackson Memorial Hospital.  Dr. Stiep has always been interested in the brain and its workings, even as an undergraduate student at UF. She is pursuing research projects on the effects of deep brain stimulation on neuropsychiatric conditions such as apathy and impulse control disorders. 

1.     What are impulse control disorders?

Impulse control disorders in PD are characterized by behaviors either new to the person or a new elevated obsession with an activity that was previously not important to the PWP. These activities usually involve a sense of reward, however in ICD the person performs the activity to an extreme.

It has been reported that there are 4 common behaviors- “the Four Horsemen” of ICDs in PD (Weintraub 2019)

1.     Pathologic Gambling

This behavior can manifest in people with or without a history of gambling. With the ICD, however, this behavior quickly becomes troublesome due to its compulsiveness to the extreme. There have been reports by persons with PD or their caregivers of compulsive gambling either at casinos, slot machines, scratchers, or purchasing lottery tickets, resulting in gambling away fortunes of thousands to even millions of dollars.

2.     Compulsive buying

This behavior can include being frequently preoccupied with buying— and feeling an irresistible, intrusive or developing a senseless impulse to shop. This behavior frequently results in buying unneeded items or items in excess of what can be afforded. It can also manifest in shopping for periods longer than intended or in experiencing marked distress, impaired social or occupational functioning and/or financial problems due to the excessive buying. Items bought tend to not be particularly expensive— like clothing, shoes, cosmetics, and household items. (Cho et al 2008, Lee et al 2004)

3.     Hypersexuality

This behavior includes a marked increase in sexual interest, arousal and behavior which has adverse consequences for the person or caregiver. It can be characterized by a preoccupation with sexual thoughts, frequent demands, and desire for sexual activity that might be quite different from those activities previously engaged in— there may also be habitual use of sex lines (talk), internet pornography or contact with sex workers. (Codling et al 2015)

4.     Eating

Compulsive eating can manifest as eating too much, thinking too much about eating, having urges or desires for excessive eating behavior, difficulty controlling eating behavior and engaging in excessive activities specifically to continue eating. It can also include episodes of binge eating where the person can eat an amount of food that is larger than what most people would eat during the same period, coupled with a lack of control over one’s eating. (de Chazeron et al 2019)

Other variations of behaviors have also been noted such as hobbyism, internet addiction, and hoarding.

Art by our blog co-contributor Jonny Acheson

2.     Why is it important to know about impulse

control disorders?

As you can imagine any behavior taken to an extreme can have bad effects on a person. We know these disorders can cause significant adverse effects on mental and physical health, quality of life and interpersonal relationships, sometimes with devastating consequences.

Often ICDs are not diagnosed or recognized by both patients or their doctors. Many times, patients or family members do not report the symptoms due to embarrassment or limited awareness of these types of behaviors. They do not suspect an association with these behaviors and with PD or the medications use to treat PD. We believe that knowledge is power. So if you know that a problem could develop, it will help you to seek help and get support as soon as it does occur. Open lines of communication between the PWP, their loved ones and the treatment team are imperative.. 

3.     Why do impulse control disorders occur?

Impulse control disorders are more common in PWPntreated with dopamine agonists than in PWP not taking dopamine agonists.

Dopamine Agonists:

Apomorphine (Apokyn)

Bromocriptine (Parlodel)

Pramipexole (Mirapex)

Pramipexole dihydrochloride extended release (Mirapex ER)

Ropinerole (Requip)

Ropinerole extended-release tablets (Requip XLTM)

Rotigotine transdermal system (Neupro)

In PD we know that the dopamine system is affected, and that many brain structures and circuits do not function normally. Dopamine function plays an important role in behaviors involving reward and reinforcement, so it is thought that the use of these dopamine agonist medications, for some PWP can result in an imbalance— and lead to an altered reward system ultimately contributing to the behavioral changes we see in ICDs.

Art by our blog co-contributor Jonny Acheson

4.     Who is most at risk in developing impulse control disorders?

There seems to be certain variables that increase the risk for developing an impulse control disorder. This includes: a personal or family history of alcohol use disorder or gambling, impulsive or novelty seeking traits, younger age, male sex, young onset Parkinson’s disease, being unmarried, and a past or current history of cigarette smoking.

There also seems to be sex differences in the frequency of specific ICDs: with compulsive sexual behavior more common in men and compulsive buying and binge eating more common in women. (Weintraub et al, 2019)

5.     What can I do about impulse control disorders?

The first step is always to stay vigilant about the emergence of these behaviors— both from a personal perspective as well as from the caregiver perspective. If you notice a new pattern of impulsivity or a change in personal habits that include over-spending, over-eating, or sexual obsessions, it is important to alert your neurologist or care team.

Once an ICD has been identified, it is important to discuss with your neurologist about how to adjust your dopaminergic medications. They may decide to slowly taper off the dopamine agonist. Usually, once the PWP is off of the dopamine agonist, the symptoms tend to resolve— but it is important to taper the medications very slowly under medical supervision. There have been reports of a syndrome called dopamine agonist withdrawal syndrome (DAWS) in which there may be symptoms that occur from withdrawal of the agonist that have been likened to cocaine withdrawal. Acute withdrawal of dopaminergic medication can be life threatening, so it is important to have a medical advisor.

Finally, in some cases the PWP. with the ICD may actually enjoy how they feel and may not want to report the issue despite potential harmful consequences. Hence, when starting a dopamine agonist we always recommend a monitoring plan which includes a care-partner or loved one.

To read more books and articles by Michael S. Okun MD check on Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonsFromTheBedside

He also serves as the Medical Advisor for the Parkinson’s Foundation.

To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.  

References:

Weintraub D. (2019). Impulse control disorders in Parkinson's disease: A 20-year odyssey. Movement disorders : official journal of the Movement Disorder Society, 34(4), 447–452. https://doi.org/10.1002/mds.27668

Lee, S., & Mysyk, A. (2004). The medicalization of compulsive buying. Social science & medicine (1982), 58(9), 1709–1718. https://doi.org/10.1016/S0277-9536(03)00340-X

Cho, H. Kwan, J. and Seo, H.J (2008), Compulsive Shopping in Parkinson’s Disease- A Care Report. Journal of Movement Disorders 1(2), 97-100. https://doi.org/10.14802/jmd.08019

Codling, D., Shaw, P. and David, A.S. (2015), Hypersexuality in Parkinson's Disease: Systematic Review and Report of 7 New Cases. Mov Disord Clin Pract, 2: 116-126. https://doi.org/10.1002/mdc3.12155

de Chazeron, I., Durif, F., Chereau-Boudet, I. et al. Compulsive eating behaviors in Parkinson’s disease. Eat Weight Disord 24, 421–429 (2019). https://doi.org/10.1007/s40519-019-00648-1

Weintraub, D., & Mamikonyan, E. (2019). Impulse Control Disorders in Parkinson's Disease. The American journal of psychiatry, 176(1), 5–11. https://doi.org/10.1176/appi.ajp.2018.18040465