Parkinson's disease-related disorders in the impulsive-compulsive spectrum

Neural substrates of substance use disorders

PURPOSE OF REVIEW

Substance use disorders account for a tremendous burden to society, yet despite substantial progress in basic studies, our understanding of the brain-basis of these disorders is still emerging. This review summarizes the recent findings of neuroimaging studies with substance use disorder individuals.

RECENT FINDINGS

Resting-state functional connectivity studies support for some but not all substances of abuse and disruption in executive control. Structural neuroimaging findings point towards reduced subcortical volumes, which may emerge as an interaction between preexisting factors and recent substance use. Longitudinal studies implicate some of the same core brain structures and their functional role that have also been identified via case-control studies. Finally, meta-analyses support the idea of dysregulation of cortical control over subcortical salience processing.

SUMMARY

Although progress has been made and there is both structural and functional imaging evidence of an imbalance between brain structures involved in executive control and salience processing, there is emerging evidence that brain-behaviour relationships, which are core to discovering the neural processes that lead to and maintain substance use, are small and require larger consortia that prospectively examine individuals with substance use disorder.

Hypothesizing in the Face of the Opioid Crisis Coupling Genetic Addiction Risk Severity (GARS) Testing with Electrotherapeutic Nonopioid Modalities Such as H-Wave Could Attenuate Both Pain and Hedonic Addictive Behaviors

In the United States, amid the opioid overdose epidemic, nonaddicting/nonpharmacological proven strategies are available to treat pain and manage chronic pain effectively without opioids. Evidence supporting the long-term use of opioids for pain is lacking, as is the will to alter the drug-embracing culture in American chronic pain management. Some pain clinicians seem to prefer classical analgesic agents that promote unwanted tolerance to analgesics and subsequent biological induction of the "addictive brain". Reward genes play a vital part in modulation of nociception and adaptations in the dopaminergic circuitry. They may affect various sensory and affective components of the chronic pain syndromes. The Genetic Addiction Risk Severity (GARS) test coupled with the H-Wave at entry in pain clinics could attenuate pain and help prevent addiction. The GARS test results identify high-risk for both drug and alcohol, and H-Wave can be initiated to treat pain instead of opioids. The utilization of H-Wave to aid in pain reduction and mitigation of hedonic addictive behaviors is recommended, notwithstanding required randomized control studies. This frontline approach would reduce the possibility of long-term neurobiological deficits and fatalities associated with potent opioid analgesics.

Impulse Control Disorders in Parkinson's Disease: Epidemiology, Pathogenesis and Therapeutic Strategies

Impulse control disorders (ICDs) in Parkinson's disease (PD) are aberrant behavior such as pathological gambling, hypersexuality, binge eating, and compulsive buying, which typically occur as a result of dopaminergic therapy. Numerous studies have focused on the broad spectrum of ICDs-related behaviors and their tremendous impact on patients and their family members. Recent advances have improved our understanding of ICDs. In this review, we discuss the epidemiology, pathogenesis and treatment of ICDs in the setting of PD.

Tumor Necrosis Factor-Like Weak Inducer of Apoptosis (TWEAK) Enhances Activation of STAT3/NLRC4 Inflammasome Signaling Axis through PKCδ in Astrocytes: Implications for Parkinson's Disease

Astrocytic dysfunction has been implicated in Parkinson's disease (PD) pathogenesis. While the Tumor necrosis factor-like weak inducer of apoptosis (TWEAK)/Fn14 signaling axis is known to play a role in PD-like neuropathology, the molecular mechanisms that govern this process remain poorly understood. Herein, we show that TWEAK levels are elevated in PD serum compared to controls. Moreover, using both U373 human astrocyte cells and primary mouse astrocytes, we demonstrate that TWEAK induces mitochondrial oxidative stress as well as protein kinase C delta (PKCδ) and signal transducer and activator of transcription 3 (STAT3) activation, accompanied by NLRC4 inflammasome activation and upregulation and release of proinflammatory cytokines, including IL-1β, TNF-α, and IL-18. Mechanistically, TWEAK-induced PKCδ activation enhances the STAT3/NLRC4 signaling pathway and other proinflammatory mediators through a mitochondrial oxidative stress-dependent mechanism. We further show that PKCδ knockdown and mito-apocynin, a mitochondrial antioxidant, suppress TWEAK-induced proinflammatory NLRC4/STAT3 signaling and cellular oxidative stress response. Notably, we validated our in vitro findings in an MPTP mouse model of PD and in mice receiving intrastriatal administration of TWEAK. These results indicate that TWEAK is a key regulator of astroglial reactivity and illustrate a novel mechanism by which mitochondrial oxidative stress may influence dopaminergic neuronal survival in PD.

White Matter Tract Alterations in Drug-Naïve Parkinson's Disease Patients With Impulse Control Disorders

Impulse control disorders (ICDs) are relatively frequent in patients with Parkinson’s disease (PD), although it is still unclear whether an underlying pathological process plays a significant role in the development of ICD in PD apart from dopaminergic replacement therapy. In this study, we have investigated alterations of white matter tract in drug-naïve PD patients with ICDs via diffusion MRI connectometry. Our results showed that disrupted connectivity in the complex network of dynamic connections between cerebellum, basal ganglia, cortex, and its spinal projections serves as the underlying neuropathology of ICD in PD not interfered with the contribution of dopaminergic replacement therapy. These findings provide the first evidence on involved white matter tracts in the neuropathogenesis of ICD in drug-naïve PD population, supporting the hypothesis that neural disturbances intrinsic to PD may confer an increased risk for ICDs. Future studies are needed to validate the attribution of the impaired corticocerebellar network to impulsivity in PD.

Introduction to Parkinson disease (PD) and its complications

Parkinson disease (PD) is a common neurodegenerative disorder in older adults characterized by motor and nonmotor symptoms and complications. Impulse control disorders (ICDs), such as pathological gambling, compulsive shopping, compulsive sexual behavior (hypersexuality), and binge eating disorder, affect 13.6% of the PD population. Use of dopamine receptor agonists (DRAs) is considered a major risk factor for ICD development. Amantadine and a high dose of levodopa were linked to ICDs to a lesser extent than DRAs. Based on the severity of behavior(s), ICDs can negatively impact social, professional, and familial lives of patients and their families. Ideally, all PD patients taking DRAs, high doses of levodopa, and/or amantadine should be routinely asked about or monitored for ICDs during therapy initiation and continuation. Dose decrease or withdrawal of the offending agent, primarily DRAs, is usually the most effective first step in ICD management. Careful dose adjustment with close monitoring is warranted due to risk for worsening of motor symptoms or emergence of dopamine agonist withdrawal syndrome (DAWS). About 1/3 of PD patients with ICD who decrease or discontinue DRA experienced DAWS. The lowest dose of DRA will need to be continued to balance ICDs and DAWS as it is not alleviated by other dopaminergic or psychotropic medications. Other therapies with low empiric evidence, such as amantadine, naloxone, cognitive behavior therapy, deep brain stimulation, and psychopharmacotherapy showed mixed results for ICD management. It is crucial that clinicians are familiar with the psychiatric complications of PD, including ICDs, beyond mere recognition and management of motor symptoms.

E-health Support in People with Parkinson's Disease with Smart Glasses: A Survey of User Requirements and Expectations in the Netherlands

Recent advances in smart glasses, wearable computers in the form of glasses, bring new therapeutic and monitoring possibilities for people with Parkinson's disease (PD). For example, it can provide visual and auditory cues during activities of daily living that have long been used to improve gait disturbances. Furthermore, smart glasses can personalize therapies based on the state of the user and/or the user environment in real-time using object recognition and motion tracking. To provide guidelines for developers in creating new PD applications for smart glasses, a self-reported questionnaire was designed to survey the requirements, constraints, and attitudes of people with PD with respect to this new technology. The survey was advertised online over an 11 month period on the website of the Parkinson Vereninging. The results were derived from 62 participants (54.8% men and 45.2% women, average age of 65.7 ± 9.1), representing a response rate of 79.5% . The participants were overall very enthusiastic about smart glasses as an assistive technology to facilitate daily living activities, especially its potential to self-manage motor problems and provide navigational guidance, thereby restoring their confidence and independence. The reported level of usage of mobile technologies like tablets and smartphones suggests that smart glasses could be adopted relatively easily, especially by younger people with PD. However, the respondents were concerned about the cost, appearance, efficacy, and potential side effects of smart glasses. To accommodate a wide range of symptoms, personal preferences, and comfort level with technology, smart glasses should be designed to allow simple operation and personalization.

Stress-Induced Executive Dysfunction in GDNF-Deficient Mice, A Mouse Model of Parkinsonism

Maladaptive reactivity to stress is linked to improper decision making, impulsivity, and discounting of delayed rewards. Chronic unpredictable stress (CUS) alters dopaminergic function, re-shapes dopaminergic circuits in key areas involved in decision making, and impairs prefrontal-cortex dependent response inhibition and working memory. Glial-derived neurotrophic factor (GDNF) is essential for regulating dopamine (DA) release in the basal ganglia and for the survival of dopaminergic neurons; GDNF-deficient mice are considered an animal model for aging-related Parkinsonism. Recently, GDNF expression in the striatum has been linked to resilience to stress. Here we investigated the effects of CUS on decision making in GDNF-heterozygous (HET) mice and their wild-type littermate controls (WT). Before CUS no differences in temporal discounting (TD) were found between genotypes. However, following CUS GDNF HET mice, having a partial reduction of GDNF levels, showed increased impulsive choice indexed by a reduction in percent Larger-Later (LL) choices in the TD paradigm, and a reduction in area under the TD curve. Moreover, stressed GDNF HET mice, but not their WT controls, showed decreased neuronal activation (number of cFos positive neurons) in the orbitofrontal cortex (OFC), nucleus accumbens (NA) core, and NA shell, suggestive of a maladaptive response to stress. Interestingly, area under the TD curve positively correlated with cFos activation in the NA core, and NA shell, but not with orbitofrontal activity. These results provide further evidence of the differential involvement of the OFC, NA core, and NA shell in impulsive choice, and identify GDNF-deficient mice as a double-hit (gene × environment) model of stress-related executive dysfunction, particularly relevant to substance abuse and Parkinson’s disease (PD).

[(123)I]-Ioflupane SPECT in combination with MIBG myocardial scintigraphy in Parkinson's disease: a case series study

Metaiodobenzylguanidine (MIBG) myocardial scintigraphy is widely accepted as a beneficial tool for differentiating Parkinson's disease (PD) from other Parkinson-related disorders (PRD). In Japan, dopamine transporter (DAT) imaging, which can evaluate presynaptic degeneration of dopamine neurons, has been applied in clinics since 2014. The present study investigated the utility of [(123)I]-Ioflupane single photon emission computed tomography (SPECT) combined with MIBG myocardial scintigraphy for the diagnosis of PD. We performed [(123)I]-Ioflupane SPECT and MIBG myocardial scintigraphy in 63 PD patients, 8 PRD patients and 1 essential tremor patient, and obtained the specific binding ratio (SBR [cut-off: 4.5]) and the heart-to-mediastinum ratio (H/M [cut-off: 2.2]). In 70% of the PD patients, both parameters were significantly reduced. In 22% of the PD patients, the SBR was smaller than 4.5 with normal H/M, and H/M was less than 2.2 with normal SBR in 5% of all subjects. Either the SBR or H/M was significantly reduced in 97% of the study population. The SBR showed low disease specificity to PD (11%), and the SBR and H/M negatively correlated with disease duration. These findings indicate that [(123)I]-Ioflupane SPECT combined with MIBG myocardial scintigraphy can improve the detection rate of PD. However, careful interpretation of these results is required because [(123)I]-Ioflupane SPECT poorly differentiates PD from PRD. Progression of PD may reflect the gradual reduction of isotope accumulation, hence, both [(123)I]-Ioflupane SPECT and MIBG myocardial scintigraphy should be tested repeatedly even in clinically suspected PD cases showing negative results.

Dyskinesias and impulse control disorders in Parkinson's disease: From pathogenesis to potential therapeutic approaches

Dopaminergic treatment in Parkinson's disease (PD) reduces the severity of motor symptoms of the disease. However, its chronic use is associated with disabling motor and behavioral side effects, among which levodopa-induced dyskinesias (LID) and impulse control disorders (ICD) are the most common. The underlying mechanisms and pathological substrate of these dopaminergic complications are not fully understood. Recently, the refinement of imaging techniques and the study of the genetics and molecular bases of LID and ICD indicate that, although different, they could share some features. In addition, animal models of parkinsonism with LID have provided important knowledge about mechanisms underlying such complications. In contrast, animal models of parkinsonism and abnormal impulsivity, although useful regarding some aspects of human ICD, do not fully resemble the clinical phenotype of ICD in patients with PD, and until now have provided limited information. Studies on animal models of addiction could complement the previous models and provide some insights into the background of these behavioral complications given that ICD are regarded as behavioral addictions. Here we review the most relevant advances in relation to imaging, genetics, biochemistry and pharmacological interventions to treat LID and ICD in patients with PD and in animal models with a view to better understand the overlapping and unique maladaptations to dopaminergic therapy that are associated with LID and ICD.

Correlation between impulsivity and executive function in patients with Parkinson disease experiencing depression and anxiety symptoms

BACKGROUND

Depression and anxiety are comorbidities often associated with Parkinson disease (PD). Recent studies debate on how affective disorders can influence the cognition of patients with PD. This study sought to investigate how depression and anxiety affect specific executive functions and impulsivity traits in these patients.

METHODS

Twenty-eight patients with advanced PD and 28 closely matched healthy volunteers (HV) were assessed for depressive and anxiety symptoms, impulsivity, executive function and control attention and behavioral response.

RESULTS

Compared to the HV group, the PD group showed significantly higher perseverative responses and slowness to adapt to changes in environmental stimuli and longer reaction time for inter-stimulus interval change. Depression symptoms were significantly correlated to motor impulsivity score and total Barratt Impulsiveness Scale (BIS -11) score. Moreover, there was also significant correlation between anxiety symptoms and attentional impulsivity score and total BIS-11 score. Correlation analysis between impulsivity and control attention indicated a positive correlation in commission and a negative correlation in reaction time and detectability in the PD group.

CONCLUSIONS

The present results suggest that depression and anxiety were highly correlated to impulsivity but not to executive functions changes in these PD patients.

Impulsivity and comorbid traits: a multi-step approach for finding putative responsible microRNAs in the amygdala

Malfunction of synaptic plasticity in different brain regions, including the amygdala plays a role in impulse control deficits that are characteristics of several psychiatric disorders, such as ADHD, schizophrenia, depression and addiction. Previously, we discovered a locus for impulsivity (Impu1) containing the neuregulin 3 (Nrg3) gene, of which the level of expression determines levels of inhibitory control. MicroRNAs (miRNAs) are potent regulators of gene expression, and have recently emerged as important factors contributing to the development of psychiatric disorders. However, their role in impulsivity, as well as control of Nrg3 expression or malfunction of the amygdala, is not well established. Here, we used the GeneNetwork database of BXD mice to search for correlated traits with impulsivity using an overrepresentation analysis to filter for biologically meaningful traits. We determined that inhibitory control was significantly correlated with expression of miR-190b, -28a, -340, -219a, and -491 in the amygdala, and that the overrepresented correlated traits showed a specific pattern of coregulation with these miRNAs. A bioinformatics analysis identified that miR-190b, by targeting an Nrg3-related network, could affect synaptic plasticity in the amygdala, targeting bot impulsive and compulsive traits. Moreover, miR-28a, -340, -219a, and possibly -491 could act on synaptic function by determining the balance between neuronal outgrowth and differentiation. We propose that these miRNAs are attractive candidates of regulation of amygdala synaptic plasticity, possibly during development but also in maintaining the impulsive phenotype. These results can help us to better understand mechanisms of synaptic dysregulation in psychiatric disorders.

Impulsive and compulsive behaviors in Parkinson's disease

BACKGROUND

Impulsive and compulsive behaviors (ICBs) are a heterogeneous group of conditions that may be caused by long-term dopaminergic replacement therapy (DRT) of Parkinson's disease (PD). The spectrum of ICBs includes dopamine dysregulation syndrome (DDS), punding, and impulse control disorders (ICDs).

CONTENTS

We made a detailed review regarding the epidemiology, pathology, clinical characteristics, risk factors, diagnosis as well as treatment of ICBs.

RESULTS

The prevalence of ICBs in PD patients is approximately 3-4% for DDS, 0.34-4.2% for punding, and 6-14% for ICDs, with higher prevalence in Western populations than in Asian. Those who take high dose of levodopa are more prone to have DDS, whereas, ICDs are markedly associated with dopamine agonists. Different subtypes of ICBs share many risk factors such as male gender, higher levodopa equivalent daily dose, younger age at PD onset, history of alcoholism, impulsive, or novelty-seeking personality. The Questionnaire for Impulsive-Compulsive Disorder in Parkinson's Disease-Rating Scale seems to be a rather efficacious instrument to obtain relevant information from patients and caregivers. Treatment of ICBs is still a great challenge for clinicians. Readjustment of DRT remains the primary method. Atypical antipsychotics, antidepressants, amantadine, and psychosocial interventions are also prescribed in controlling episodes of psychosis caused by compulsive DRT, but attention should be drawn to balance ICBs symptoms and motor disorders. Moreover, deep brain stimulation of the subthalamic nucleus might be a potential method in controlling ICBs.

CONCLUSION

The exact pathophysiological mechanisms of ICBs in PD remains poorly understood. Further researches are needed not only to study the pathogenesis, prevalence, features, and risk factors of ICBs, but to find efficacious therapy for patients with these devastating consequences.

Impulse control disorders in Parkinson's disease: an overview from neurobiology to treatment

Parkinson's disease (PD) is the second most common neurodegenerative brain disorder and is characterized by motor symptoms such as tremor, bradykinesia, rigidity and postural instability. A majority of the patients also develop non-motor symptoms. Impulse control disorders (ICD) are behavioural changes that often fail to be detected in clinical practice. The prevalence of ICD in PD varies widely from 6.1 to 31.2 % and treatment with dopaminergic medication is considered to be the greatest risk factor. Management consists mainly of reducing dopaminergic medication. In our experience, ICD has a tremendous impact on the quality of life of the patients and their families and should therefore not be disregarded. Studies addressing the role of ICD in PD caregiver strain are imperative. We attempt to give a comprehensive overview of the literature on the complicated neurobiology of ICD and discuss risk factors, genetic susceptibility, screening modalities and management.

Multiple modes of impulsivity in Parkinson's disease

Cognitive problems are a major factor determining quality of life of patients with Parkinson's disease. These include deficits in inhibitory control, ranging from subclinical alterations in decision-making to severe impulse control disorders. Based on preclinical studies, we proposed that Parkinson's disease does not cause a unified disorder of inhibitory control, but rather a set of impulsivity factors with distinct psychological profiles, anatomy and pharmacology. We assessed a broad set of measures of the cognitive, behavioural and temperamental/trait aspects of impulsivity. Sixty adults, including 30 idiopathic Parkinson's disease patients (Hoehn and Yahr stage I–III) and 30 healthy controls, completed a neuropsychological battery, objective behavioural measures and self-report questionnaires. Univariate analyses of variance confirmed group differences in nine out of eleven metrics. We then used factor analysis (principal components method) to identify the structure of impulsivity in Parkinson's disease. Four principal factors were identified, consistent with four different mechanisms of impulsivity, explaining 60% of variance. The factors were related to (1) tests of response conflict, interference and self assessment of impulsive behaviours on the Barrett Impulsivity Scale, (2) tests of motor inhibitory control, and the self-report behavioural approach system, (3) time estimation and delay aversion, and (4) reflection in hypothetical scenarios including temporal discounting. The different test profiles of these four factors were consistent with human and comparative studies of the pharmacology and functional anatomy of impulsivity. Relationships between each factor and clinical and demographic features were examined by regression against factor loadings. Levodopa dose equivalent was associated only with factors (2) and (3). The results confirm that impulsivity is common in Parkinson's disease, even in the absence of impulse control disorders, and that it is not a unitary phenomenon. A better understanding of the structure of impulsivity in Parkinson's disease will support more evidence-based and effective strategies to treat impulsivity.

Impulse control and related behaviors after bilateral subthalamic stimulation in patients with Parkinson's disease

The effect of subthalamic nucleus deep brain stimulation (STN DBS) on impulse control and related behaviors (ICRB) in patients with Parkinson's disease (PD) is conflicting. We evaluated ICRB before and after bilateral STN DBS in patients with PD. A total of 89 patients with PD treated with bilateral DBS of STN underwent retrospective assessment of ICRB before and after DBS. Of the 89 patients studied, 20 patients (22.5%) had ICRB in the preoperative period. In 13 of those 20 patients (65%), preoperative ICRB improved, including resolution in six patients. Nine patients developed de novo ICRB after DBS, thus 23 patients (25.8%) had ICRB in the postoperative period. There was no demographic difference between the patients with or without ICRB in the preoperative state. In the postoperative state, the patients with ICRB had higher levodopa equivalent daily dose (LEDD) levels and lower Mini-Mental State Examination (MMSE) scores than the patients without ICRB. However, postoperative worsening or de novo ICRB did not correlate with LEDD levels or MMSE scores. Severity of ICRB worsened more after DBS in older patients. Patients with worsened or de novo ICRB after surgery had a greater decrease in Beck Depression Index scores after surgery compared with patients whose ICRB improved. In conclusion, ICRB may resolve or improve, or new ICRB may appear, after bilateral STN DBS. The difference in risk factors for preoperative vs. postoperative ICRB suggests that the pathogenesis of those conditions is different, at least in part.

Increased reflection impulsivity in patients with ephedrone-induced Parkinsonism

AIMS

To examine a syndrome of chronic manganism that occurs in drug addicts in eastern Europe who use intravenous methcathinone (ephedrone) contaminated with potassium permanganate. In many cases the basal ganglia, especially the globus pallidus and the putamen, are damaged irreversibly. Routine neuropsychological assessment has revealed no cognitive deficits, despite widespread abnormalities on brain imaging studies and severe extrapyramidal motor handicap on clinical examination.

DESIGN

Case-control study.

SETTING

Ephedrone patients and patients with opioid dependence were recruited from Lviv, Ukraine.

PARTICIPANTS

We tested 15 patients with ephedrone-induced toxicity, 13 opiate-dependent patients who were receiving opioid replacement therapy and 18 matched healthy volunteers.

MEASUREMENTS

The 'beads task', an information-gathering task to assess reflection impulsivity, was used and feedback learning, working memory and risk-taking were also assessed.

FINDINGS

Opiate-dependent patients differed from controls on three of four tasks, whereas ephedrone patients differed from controls on only one task. More specifically, both patient groups were more impulsive and made more irrational choices on the beads task than controls (P < 0.001). However, ephedrone patients had no deficits in working memory (P > 0.1) or risk-taking (P > 0.1) compared with controls. Opioid-dependent patients had significantly worse working memory (P < 0.001) and were significantly more risk-prone than controls (P = 0.002).

CONCLUSIONS

Ephedrone patients may have similar deficits in information-gathering and decision-making to opiate-dependent patients, with preservation of working memory and risk-taking. This may reflect specific damage to anterior cingulate- basal ganglia loops.

Attenuated neural response to gamble outcomes in drug-naive patients with Parkinson's disease

Parkinson's disease results from the degeneration of dopaminergic neurons in the substantia nigra, manifesting as a spectrum of motor, cognitive and affective deficits. Parkinson's disease also affects reward processing, but disease-related deficits in reinforcement learning are thought to emerge at a slower pace than motor symptoms as the degeneration progresses from dorsal to ventral striatum. Dysfunctions in reward processing are difficult to study in Parkinson's disease as most patients have been treated with dopaminergic drugs, which sensitize reward responses in the ventral striatum, commonly resulting in impulse control disorders. To circumvent this treatment confound, we assayed the neural basis of reward processing in a group of newly diagnosed patients with Parkinson's disease that had never been treated with dopaminergic drugs. Thirteen drug-naive patients with Parkinson's disease and 12 healthy age-matched control subjects underwent whole-brain functional magnetic resonance imaging while they performed a simple two-choice gambling task resulting in stochastic and parametrically variable monetary gains and losses. In patients with Parkinson's disease, the neural response to reward outcome (as reflected by the blood oxygen level-dependent signal) was attenuated in a large group of mesolimbic and mesocortical regions, comprising the ventral putamen, ventral tegmental area, thalamus and hippocampus. Although these regions showed a linear response to reward outcome in healthy individuals, this response was either markedly reduced or undetectable in drug-naive patients with Parkinson's disease. The results show that the core regions of the meso-cortico-limbic dopaminergic system, including the ventral tegmental area, ventral striatum, and medial orbitofrontal cortex, are already significantly compromised in the early stages of the disease and that these deficits cannot be attributed to the contaminating effect of dopaminergic treatment.

Decision making, impulsivity, and addictions: do Parkinson's disease patients jump to conclusions?

Links between impulsive-compulsive behaviors (ICBs) in treated Parkinson's disease (PD), behavioral addictions, and substance abuse have been postulated, but no direct comparisons have been carried out so far. We directly compared patients with PD with and without ICBs with illicit drug abusers, pathological gamblers, and age-matched healthy controls using the beads task, a test of reflection impulsivity, and a working memory task. We found that all patients with PD made more impulsive and irrational choices than the control group. PD patients who had an ICB showed similar behavior to illicit substance abusers, whereas patients without ICBs more closely resembled pathological gamblers. In contrast, we found no difference in working memory performance within the PD groups. However, PD patients without ICBs remembered distractors significantly less than all other patients during working memory tests. We were able to correctly classify 96% of the PD patients with respect to whether or not they had an ICB by analyzing three trials of the 80/20 loss condition of the beads task with a negative prediction value of 92.3%, and we propose that this task may prove to be a powerful screening tool to detect an ICB in PD. Our results also suggest that intact cortical processing and less distractibility in PD patients without ICBs may protect them from developing behavioral addictions.

Comparison of personality characteristics in Parkinson disease patients with and without impulse control disorders and in healthy volunteers

OBJECTIVE

We aimed to assess personality characteristics in patients with Parkinson disease (PD) with and without impulse control disorders (ICD).

METHODS

We tested patients and controls with the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales that have expected high sensitivity to apparent addictive behavior. We recorded mean disease duration and mean levodopa dose in the PD groups.

RESULTS

Of the 46 PD patients, 13 had ICD: hypersexuality, binge eating, or dopamine dysregulation. The PD patients with ICD had a longer duration of disease (11 vs. 5 y) and were taking higher doses of levodopa (900 vs. 500 mg/d). They scored above the pathologic threshold in 4 domains of the MMPI-2 Clinical Scales and in 8 Clinical Subscales and Content Scales. The most significant abnormality was Alienation-Self and Others.

CONCLUSIONS

ICDs in the general population have similarities to disorders of substance addiction. In PD patients, some personality profiles could play a role in development of ICDs or dopamine dysregulation syndrome. The MMPI-2 may be a useful test for PD patients in general, and for detecting ICD in particular.

Drug therapy in patients with Parkinson's disease

Parkinson`s disease (PD) is a progressive, disabling neurodegenerative disorder with onset of motor and non-motor features. Both reduce quality of life of PD patients and cause caregiver burden. This review aims to provide a survey of possible therapeutic options for treatment of motor and non motor symptoms of PD and to discuss their relation to each other. MAO-B-Inhibitors, NMDA antagonists, dopamine agonists and levodopa with its various application modes mainly improve the dopamine associated motor symptoms in PD. This armentarium of PD drugs only partially influences the onset and occurrence of non motor symptoms. These PD features predominantly result from non dopaminergic neurodegeneration. Autonomic features, such as seborrhea, hyperhidrosis, orthostatic syndrome, salivation, bladder dysfunction, gastrointestinal disturbances, and neuropsychiatric symptoms, such as depression, sleep disorders, psychosis, cognitive dysfunction with impaired execution and impulse control may appear. Drug therapy of these non motor symptoms complicates long-term PD drug therapy due to possible occurrence of drug interactions, - side effects, and altered pharmacokinetic behaviour of applied compounds. Dopamine substituting compounds themselves may contribute to onset of these non motor symptoms. This complicates the differentiation from the disease process itself and influences therapeutic options, which are often limited because of additional morbidity with necessary concomitant drug therapy.

Selective IGT decision-making impairment in a patient with juvenile Parkinson's disease and pathological gambling: a role for dopaminergic therapy?

The orbitofrontal cortex and the dopaminergic system are structures involved in managing impulsivity and sensibility to reinforcements, and both are typically impaired in Parkinson's disease (PD). Also, l-DOPA treatment can contribute to the development of the 'Dopamine Dysregulation Syndrome', a syndrome that can influence the patients' personality and lead to risk-taking behaviors. In this study, we describe the case of a 42-year-old woman (LT) affected by juvenile PD, treated with both l-DOPA and dopamine agonists, who showed a sudden onset of pathological gambling (PG), as the only neuropsychiatric symptom. We assessed LT with a full neuropsychological battery and the Iowa Gambling Task (IGT), in order to describe her specific failure in decision making. LT's performance on the IGT is compared with that of 15 non-demented PD patients under therapy with dopamine agonists and no behavioral dysregulations and with that of 16 age- and education-matched healthy subjects. Results showed fully preserved memory, executive functions, and reasoning abilities for LT, but a remarkable and stable impairment in the IGT. Performance of LT on the IGT is significantly lower than that of both control groups. This case shows, for the first time, that high cognitive functioning and preserved executive functions are no guarantee for advantageous decision making, and that the onset of PG is consistent with selective orbitofrontal disruption and side-effects of dopamine agonist therapy. It is also showed that the IGT is a useful neuropsychological device to detect specific risk-taking behaviors, which compromise functioning in real life.

The prevalence and clinical characteristics of punding in Parkinson's disease

BACKGROUND

Punding (the display of stereotyped, repetitive behaviors) is a relatively recently discovered feature of Parkinson's disease (PD). Little is known about the prevalence and clinical characteristics of punding in PD.

METHODS

In this review, four large scientific databases were comprehensively searched for literature in relation to punding prevalence and clinical correlates in the context of PD.

RESULTS

Prevalence was found to vary greatly (between 0.34 to 14%), although there were large disparities in study populations, assessment methods, and criteria. We observed an association between punding, dopaminergic medications, and impulse control disorder. Other characteristics, which may be more common among punders, include a higher severity of dyskinesia, younger age of disease onset, longer disease duration, and male gender.

DISCUSSION

More research in large clinical datasets is required in many areas before conclusions are drawn. The pathophysiology behind the punding phenomenon is also poorly understood at present, rendering it difficult to develop targeted therapy. The current mainstay of treatment is the reduction in the dose of dopaminergic medications, the evidence for other suggested therapies being purely empirical.

Neural reward processing under dopamine agonists: imaging

Impulse control disorders (ICDs) are increasingly reported as a considerable side-effect of treatment with dopaminergic medication (both levodopa and dopamine agonists (DA)). ICDs together with punding are described within the entity of dopamine dysregulation syndrome along with immediate reward seeking and addictive behaviors. The brain functions involved in reward processing in general and their modulation by medication can be characterized by neuropsychological assessments and underlying neurobiology can be investigated by functional neuroimaging techniques such as functional magnetic resonance imaging (fMRI) or positron emission tomography (PET). By this approach, functional changes of brain areas involved in reward processing under short-term or chronic DA therapy were studied. Functional changes in a network involving striatal-thalamic loops, key structures of the reward system, together with limbic areas (such as the amygdala) and the ventral tegmental area could be related to pharmacological alterations of reward processing by dopaminergic medication. In particular, altered ventral striatal functioning seems to relate to ICDs such as pathological gambling. A general medication effect in patients under DA in terms of a sensitization toward ICD could be demonstrated. A synopsis is given on the applications of functional neuroimaging to investigate reward processing and the influence of dopaminergic medication.

Impulsive behavior and associated clinical variables in Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a degenerative brain disorder accompanied by the loss of dopaminergic neurons and the presence of motor and non-motor symptoms.

OBJECTIVE

We performed a cross-sectional, questionnaire-based analysis of impulsive behavior in our PD clinic population to assess prevalence and associated characteristics.

RESULTS

We found a higher prevalence of impulsive behavior (29.7%) than previously reported, and found multiple, concurrent impulsive behaviors in 26% of subjects reporting impulsive behavior.

CONCLUSIONS

Our findings contribute to the growing awareness of impulsive behavior in PD, and support the need for longitudinal studies to assess changes in impulsive behaviors in Parkinson's patients.

Binge eating in Parkinson's disease: prevalence, correlates and the contribution of deep brain stimulation

Of 96 Parkinson's disease patients surveyed at the University of Florida Movement Disorders Center, one (1%) met diagnostic criteria for binge-eating disorder. Eight (8.3%) exhibited subthreshold binge eating. Psychometric criteria classified problem gambling in 17.8%, hoarding in 8.3%, compulsive buying in 11.5%, hypersexuality in 1.0%, and mania in 1.0% of patients. More overeaters met psychometric criteria for at least one additional impulse-control disorder (67% versus 29%). No more overeaters than non-overeaters were taking a dopamine agonist (44% versus 41%). More overeaters had a history of subthalamic deep brain stimulation (DBS; 44% versus 14%). History of DBS was the only independent predictor of overeating.

Lesions of the medial prefrontal cortex cause maladaptive sexual behavior in male rats

BACKGROUND

An inability to inhibit behaviors once they become maladaptive is a component of several psychiatric illnesses, and the medial prefrontal cortex (mPFC) was identified as a potential mediator of behavioral inhibition. The current study tested if the mPFC is involved in inhibition of sexual behavior when associated with aversive outcomes.

METHODS

Using male rats, effects of lesions of the infralimbic and prelimbic areas of the mPFC on expression of sexual behavior and ability to inhibit mating were tested using a paradigm of copulation-contingent aversion.

RESULTS

Medial prefrontal cortex lesions did not alter expression of sexual behavior. In contrast, mPFC lesions completely blocked the acquisition of sex-aversion conditioning and lesioned animals continued to mate, in contrast to the robust behavioral inhibition toward copulation in mPFC intact male animals, resulting in only 22% of intact male animals continuing to mate. However, rats with mPFC lesions were capable of forming a conditioned place preference to sexual reward and conditioned place aversion for lithium chloride, suggesting that these lesions did not alter associative learning or sensitivity for lithium chloride.

CONCLUSIONS

The current study indicates that animals with mPFC lesions are likely capable of forming the associations with aversive outcomes of their behavior but lack the ability to suppress seeking of sexual reward in the face of aversive consequences. These data may contribute to a better understanding of a common pathology underlying impulse control disorders, as compulsive sexual behavior has a high prevalence of comorbidity with psychiatric disorders and Parkinson's disease.

Impulsive smoking in a patient with Parkinson's disease treated with dopamine agonists

Impulse control disorders, including pathological gambling, binge eating, compulsive shopping and hypersexual behaviors, have frequently been reported as a side effect of dopaminergic medications for Parkinson's disease (PD). Here we describe a patient with PD who developed an unusual manifestation of impulsive behaviors, including cigarette smoking, associated with an increase in dopamine agonist medication. We postulate this to be related to an overstimulation of mesolimbic dopamine receptors responsible for reward-seeking behaviors. Further research is needed to examine impulsive cigarette smoking in PD.

Influence of conditioned reinforcement on the response-maintaining effects of quinpirole in rats

D2-like agonists, such as quinpirole, maintain responding in monkeys, rats, and mice when they are substituted for cocaine. This study examined the influence of operant history and cocaine-paired stimuli (CS) on quinpirole-maintained responding in rats trained to nose poke for cocaine. Upon acquisition of responding for cocaine, substitutions were performed in the presence or absence of injection-CS pairings. Although cocaine maintained responding regardless of whether injections were accompanied by CS, quinpirole maintained responding only when CS were paired with injections. To assess the influence of operant history, injections of cocaine, quinpirole, remifentanil, nicotine, or saline were made available on a previously inactive lever, while nose pokes continued to result in CS presentation. Although responding was reallocated from the nose poke to the lever when cocaine or remifentanil was available, lever presses remained low, and nose poking persisted when quinpirole or nicotine was made contingent upon lever presses. Finally, quinpirole pretreatments resulted in high rates of nose poking when nose pokes resulted in CS presentation alone, but failed to maintain nose poking when the CS was omitted. Taken together, these results suggest that the response-maintaining effects of quinpirole are primarily mediated by an enhancement of the conditioned reinforcing effects of earlier CS, rather than by a reinforcing effect of quinpirole.

Reward-learning and the novelty-seeking personality: a between- and within-subjects study of the effects of dopamine agonists on young Parkinson's patients

Parkinson's disease is characterized by the degeneration of dopaminergic pathways projecting to the striatum. These pathways are implicated in reward prediction. In this study, we investigated reward and punishment processing in young, never-medicated Parkinson's disease patients, recently medicated patients receiving the dopamine receptor agonists pramipexole and ropinirole and healthy controls. The never-medicated patients were also re-evaluated after 12 weeks of treatment with dopamine agonists. Reward and punishment processing was assessed by a feedback-based probabilistic classification task. Personality characteristics were measured by the temperament and character inventory. Results revealed that never-medicated patients with Parkinson's disease showed selective deficits on reward processing and novelty seeking, which were remediated by dopamine agonists. These medications disrupted punishment processing. In addition, dopamine agonists increased the correlation between reward processing and novelty seeking, whereas these drugs decreased the correlation between punishment processing and harm avoidance. Our finding that dopamine agonist administration in young patients with Parkinson's disease resulted in increased novelty seeking, enhanced reward processing, and decreased punishment processing may shed light on the cognitive and personality bases of the impulse control disorders, which arise as side-effects of dopamine agonist therapy in some Parkinson's disease patients.

Frequency of new-onset pathologic compulsive gambling or hypersexuality after drug treatment of idiopathic Parkinson disease

OBJECTIVE

To determine the frequency of new-onset compulsive gambling or hypersexuality among regional patients with Parkinson disease (PD), ascertaining the relationship of these behaviors to PD drug use.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients from 7 rural southeastern Minnesota counties who had at least 1 neurology appointment for PD between July 1, 2004, and June 30, 2006. The main outcome measure was compulsive gambling or hypersexuality developing after parkinsonism onset, including the temporal relationship to PD drug use.

RESULTS

Of 267 patients with PD who met the study inclusion criteria, new-onset gambling or hypersexuality was documented in 7 (2.6%). All were among the 66 patients (10.6%) taking a dopamine agonist. Moreover, all 7 (18.4%) were among 38 patients taking therapeutic doses (defined as >/=2 mg of pramipexole or 6 mg of ropinirole daily). Behaviors were clearly pathologic and disabling in 5: 7.6% of all patients taking an agonist and 13.2% of those taking therapeutic doses. Of the 5 patients, 2 had extensive treatment for what was considered a primary psychiatric problem before the agonist connection was recognized.

CONCLUSION

Among the study patients with PD, new-onset compulsive gambling or hypersexuality was documented in 7 (18.4%) of 38 patients taking therapeutic doses of dopamine agonists but was not found among untreated patients, those taking subtherapeutic agonist doses, or those taking carbidopa/levodopa alone. Behaviors abated with discontinuation of agonist therapy or dose reduction. Because this is a retrospective study, cases may have been missed, and hence this study may reflect an underestimation of the true frequency. Physicians who care for patients taking these drugs should recognize the drug's potential to induce pathologic syndromes that sometimes masquerade as primary psychiatric disease.