Prognosis of impulse control disorders in Parkinson's disease: a prospective controlled study

BACKGROUND

The long-term prognosis of impulsive compulsive disorders (ICD) remains poorly studied in Parkinson's disease (PD).

OBJECTIVE

Evaluating the natural history of ICD and its impact on PD symptoms including cognition and treatment adjustments.

MATERIALS AND METHODS

We assessed PD patients at baseline (BL) with (BL-ICD+) or without (BL-ICD-) ICD despite dopamine agonist (DA) exposure of > 300 mg levodopa-equivalent daily dose for > 12 months at baseline and after more than two years of follow-up. ICD were assessed using the Ardouin's Scale of Behaviors in PD (ASBPD), cognition using the Mattis scale, and PD symptoms using the UPDRS score. Treatment adjustments, DA withdrawal-associated symptoms, and ICDs social consequences were recorded.

RESULTS

149 patients were included (78 cases and 71 controls), mean duration of follow-up was 4.4 ± 1 years. At baseline, psychiatric disorders were more common among BL-ICD + (42.3 vs 12.3% among BL-ICD-, p < 0.01). At follow-up, 53.8% of BL-ICD + were not ICD-free while 21.1% of BL-ICD- had developed ICD. BL-ICD + more frequently experienced akinesia (21.8 vs 8.5%, p = 0.043) and rigidity worsening (11.5 vs 1.4%, p = 0.019) following therapeutic modifications. Decision to decrease > 50% DA doses (12.8 vs 1.4%, p = 0.019) or to withdraw DA (19.2 vs 5.6%, p = 0.025) was more frequently considered among BL-ICD+ . At follow-up, the prevalence of cognitive decline was lower among BL-ICD + (19.2 vs 37.1%, p = 0.025).

CONCLUSION

ICDs were associated with increased psychiatric burden at baseline and better cognitive prognosis. Most patients were still showing ICDs at the follow-up visit, suggesting ICD to be considered as a chronic, neuropsychiatric disorder.

Anatomical correlates of apathy and impulsivity co-occurrence in early Parkinson's disease

BACKGROUND

Although apathy and impulse control disorders (ICDs) are considered to represent opposite extremes of a continuum of motivated behavior (i.e., hypo- and hyperdopaminergic behaviors), they may also co-occur in Parkinson's disease (PD).

OBJECTIVES

We aimed to explore the co-occurrence of ICDs and apathy and its neural correlates analyzing gray matter (GM) changes in early untreated PD patients. Moreover, we aimed to investigate the possible longitudinal relationship between ICDs and apathy and their putative impact on cognition during the first five years of PD.

METHODS

We used the Parkinson's Progression Markers Initiative (PPMI) database to identify the co-occurrence of apathy and ICDs in 423 early drug-naïve PD patients at baseline and at 5-year follow-up. Baseline MRI volumes and gray matter changes were analyzed between groups using voxel-based morphometry. Multi-level models assessed the longitudinal relationship (across five years) between apathy and ICDs and cognitive functioning.

RESULTS

At baseline, co-occurrence of apathy and ICDs was observed in 23 patients (5.4%). This finding was related to anatomical GM reduction along the cortical regions involved in the limbic circuit and cognitive control systems. Longitudinal analyses indicated that apathy and ICDs were related to each other as well as to the combined use of levodopa and dopamine agonists. Worse apathetic and ICDs states were associated with poorer executive functions.

CONCLUSIONS

Apathy and ICDs are joint non-exclusive neuropsychiatric disorders also in the early stages of PD and their co-occurrence was associated with GM decrease in several cortical regions of the limbic circuit and cognitive control systems.

Morphometric alterations of the mesocorticolimbic network in Parkinson's disease with impulse control disorders

Impulse control disorders (ICDs) are a group of non-motor symptoms of Parkinson disease (PD) leading to significant psychosocial detrimental outcome. The mesocorticolimbic network plays a distinctive role in reward learning and executive decision making and has been suggested to be involved in ICDs in PD. To study morphometric changes of the mesocorticolimbic network in PD with ICD. A total of 18 patients of PD with ICD (PD + ICD), 19 patients of PD without ICD (PD - ICD) and 19 healthy controls (HC) were included in the study. ICDs were diagnosed using Questionnaire for Impulsive-Compulsive Disorders in PD-Rating Scale (QUIP-RS). MRI was done using a 3T scanner and assessment of cortical thickness and subcortical volumes were done using FreeSurfer. Brain regions known to be part of the mesocorticolimbic network were extracted and included for statistical analysis. There was no difference between PD + ICD and PD - ICD with regard to duration of illness or total dopaminergic medication. In comparison to HC, patients with PD + ICD demonstrated atrophy of the left frontal pole, and this atrophy neared significance in comparison to PD - ICD. The QUIP-RS had a negative correlation with left caudate volume in PD + ICD. The PD + ICD group showed distinct morphometric changes in regions involved in the mesocorticolimbic system which may contribute to the presence of ICD.

Management of Impulse Control and Related Disorders in Parkinson's Disease: An Expert Consensus

BACKGROUND

Impulse-control and related behavioral disorders (ICBDs) significantly impact the lives of Parkinson's disease (PD) patients and caregivers, with lasting consequences if undiagnosed and untreated. While ICBD pathophysiology and risk factors are well-studied, a standardized severity definition and treatment evidence remain elusive.

OBJECTIVE

This work aimed to establish international expert consensus on ICBD treatment strategies. To comprehensively address diverse treatment availabilities, experts from various continents were included.

METHODS

From 2021 to 2023, global movement disorders specialists engaged in a Delphi process. A core expert group initiated surveys, involving a larger panel in three iterations, leading to refined severity definitions and treatment pathways.

RESULTS

Experts achieved consensus on defining ICBD severity, emphasizing regular PD patient screenings for early detection. General treatment recommendations focused on continuous monitoring, collaboration with significant others, and seeking specialist advice for legal or financial challenges. For mild to severe ICBDs, gradual reduction in dopamine agonists was endorsed, followed by reductions in other PD medications. Second-line treatment strategies included diverse approaches like reversing the last medication change, cognitive behavior therapy, subthalamic nucleus deep brain stimulation, and specific medications like quetiapine, clozapine, and antidepressants. The panel reached consensus on distinct treatment pathways for punding and dopamine dysregulation syndrome, formulating therapy recommendations. Comprehensive discussions addressed management strategies for the exacerbation of either motor or non-motor symptoms following the proposed treatments.

CONCLUSION

The consensus offers in-depth insights into ICBD management, presenting clear severity criteria and expert consensus treatment recommendations. The study highlights the critical need for further research to enhance ICBD management. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Impulse control disorders in Parkinson's disease: a retrospective analysis of 1824 patients in a 12-year period

OBJECTIVE

This study aims to clinically evaluate the impulse control disorders (ICDs) encountered in treating Parkinson's disease.

METHOD

This is a retrospective analysis between 2010 and 2022. We retrieved the medical records of all patients diagnosed with idiopathic Parkinson's disease. The demographic and clinical findings were recorded. ICDs constituted a specific item in the examination, and each one (compulsive shopping, compulsive eating, pathological gambling, hypersexuality, punding, dopamine dysregulation syndrome, and hobbyism) was noted separately.

RESULTS

In the study period, we identified 1824 patients (56.2% men, n = 1025). The mean age was 70.5 ± 11.9 years. In the cohort, 128 (7%) patients with Parkinson's disease had one or more ICDs. The ICDs were compulsive shopping, punding/hobbyism, compulsive eating, hypersexuality, pathological gambling, and dopamine dysregulation syndrome. When we compared patients with and without ICDs, patients with ICDs were younger (p ≤ 0.001), and the men/women ratio was higher in this group with ICDs. Although the mean daily pramipexole dose was higher in patients with ICDs, mean daily long-acting pramipexole dose was only 1.4 ± 0.92 mg/day.

CONCLUSION

The significant findings in this study were (i) the lower frequency of ICDs (7%); (ii) the common occurrence of compulsive shopping, punding/hobbyism, and compulsive eating; and (iii) the development of ICDs under relatively lower doses of pramipexole. We suggest that ICDs in Parkinson's disease should be associated with a personal trait with dopamine agonists, and potential electrophysiological or genetic markers of this trait warrant further analysis to avoid treatment in these patients.

Efficacy and safety of clonidine for the treatment of impulse control disorder in Parkinson's disease: a multicenter, parallel, randomised, double-blind, Phase 2b Clinical trial

BACKGROUND

Impulse control disorders (ICDs) are frequently encountered in Parkinson's disease (PD).

OBJECTIVES

We aimed to assess whether clonidine, an α2-adrenergic receptor agonist, would improve ICDs.

METHODS

We conducted a multicentre trial in five movement disorder departments. Patients with PD and ICDs (n = 41) were enrolled in an 8-week, randomised (1:1), double-blind, placebo-controlled study of clonidine (75 μg twice a day). Randomisation and allocation to the trial group were carried out by a central computer system. The primary outcome was the change at 8 weeks in symptom severity using the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease-Rating Scale (QUIP-RS) score. A reduction of the most elevated subscore of the QUIP-RS of more than 3 points without any increase in the other QUIP-RS dimension defined success.

RESULTS

Between 15 May 2019 and 10 September 2021, 19 patients in the clonidine group and 20 patients in the placebo group were enrolled. The proportion difference of success in reducing QUIP-RS at 8 weeks, was 7% (one-sided upper 90% CI 27%) with 42.1% of success in the clonidine group and 35.0% in the placebo group. Compared to patients in the placebo group, patients in the clonidine group experienced a greater reduction in the total QUIP-RS score at 8 weeks (11.0 points vs. 3.6).

DISCUSSION

Clonidine was well tolerated but our study was not enough powerful to demonstrate significant superiority compared to placebo in reducing ICDs despite a greater reduction of total QUIP score at 8 weeks. A phase 3 study should be conducted.

TRIAL REGISTRATION

The study was registered (NCT03552068) on clinicaltrials.gov on June 11, 2018.

Impulse Control Disorders in the Polish Population of Patients with Parkinson's Disease

Background and Objectives: Parkinson's disease (PD) is one of the most common neurodegenerative diseases in the world. It is characterized by the presence of not only typical motor symptoms but also several less known and aware non-motor symptoms (NMS). The group of disorders included in the NMS is Impulse Control Disorders (ICDs). ICDs are a group of disorders in which patients are unable to resist temptations and feel a strong, pressing desire for specific activities such as gambling, hypersexuality, binge eating, and compulsive buying. The occurrence of ICDs is believed to be associated primarily with dopaminergic treatment, with the use of dopamine agonists (DA), and to a lesser extent with high doses of L-dopa. The aim of our study was to develop a profile of Polish ICDs patients and assess the frequency of occurrence of ICDs, as well as determine the risk factors associated with these disorders against the background of the PD population from other countries. Materials and Methods: Our prospective study included 135 patients with idiopathic PD who were hospitalized between 2020 and 2022 at the Neurological Department of University Central Hospital in Katowice. In the assessment of ICDs, we used the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP). Other scales with which we assessed patients with PD were as follows: MDS-UPDRS part III and modified Hoehn-Yahr staging. Clinical data on age, gender, disease duration and onset, motor complications, and medications were collected from electronic records. Results: ICDs were detected in 27.41% of PD patients (binge eating in 12.59%, hypersexuality in 11.11%, compulsive buying in 10.37%, and pathological gambling occurred in only 5.19% of patients. In total, 8.89% had two or more ICDs). The major finding was that ICDs were more common in patients taking DA than in those who did not use medication from this group (83.78% vs. 54.07%, respectively; p = 0.0015). Patients with ICDs had longer disease duration, the presence of motor complications, and sleep disorders. An important finding was also a very low detection of ICDs in a routine medical examination; only 13.51% of all patients with ICDs had a positive medical history of this disorder. Conclusions: ICDs are relatively common in the population of Polish PD patients. The risk factors for developing ICDs include longer duration of the disease, presence of motor complications, sleep disorders, and use of DA and L-dopa. Due to the low detectability of ICDs in routine medical history, it is essential for physicians to pay more attention to the possibility of the occurrence of these symptoms, especially in patients with several risk factors. Further prospective studies on a larger group of PD patients are needed to establish a full profile of Polish PD patients with ICDs.

Do Impulse Control Disorders Impair Car Driving Performance in Patients with Parkinson's Disease?

BACKGROUND

Based on data regarding the prevalence of Parkinson's disease (PD), the prevalence of impulsive control disorders (ICD) in PD, and the percentage of PD patients driving a car, it has to be assumed that at least 50,000 PD patients with ICD in Germany actively drive a car. However, these patients might be at risk for unsafe driving due to ICD-related dysfunctions such as failure to resist an impulse or temptation, to control an act or other altered neurobehavioral processes.

OBJECTIVE

This study determines the influence of ICD on driving ability in PD.

METHODS

We prospectively compared driving simulator performance of 23 PD patients with and 23 matched patients without ICD. ICD had to be socially compensated and presence was defined clinically for primary and questionnaire-based (QUIP-RS) for post-hoc analyses. Furthermore, between-group comparisons of driving-relevant neuropsychological tests were executed.

RESULTS

Except from a lower blinking frequency when changing lanes, overall driving safety of patients with ICD did not differ significantly from those without-regardless of the clinical or QUIP-RS-based ICD definition. ICD severity did not correlate with driving performance, but the latter correlated significantly with mean reaction times and certain neuropsychiatric tests (MoCA, TMT-A, TAP-M "flexibility" and DBQ "error").

CONCLUSION

Clinically compensated ICD does not seem to impair driving safety in PD patients. Rather, cognitive and attentional deficits appear to be clinical markers for driving uncertainty.

Attentional dysfunction and the punding spectrum in Parkinson's disease

BACKGROUND

Punding is a complication of Parkinson's disease (PD) treatment and stimulant abuse that features excessive preoccupation with repetitive and/or aimless behaviors. We hypothesized that cognitive impairment and functional limitations influence how punding behaviors manifest in PD.

METHODS

We extracted data on punding, hobbyism, and cognition from the Parkinson's Progression Marker Initiative (PPMI). Punding and hobbyism were measured with the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP) scale. We determined how cognition predicted punding and hobbyism behaviors-adjusting for levodopa dose, Hoehn & Yahr stage, disease duration, and age-using generalized estimating equation (GEE) logistic regression. Activities of daily living (ADL) and motor impairment were measured with the MDS-UPDRS scale.

RESULTS

In GEE logistic regression models, punding was selectively associated with lower scores on the Letter Number Sequencing test (LNS), the primary attention test in PPMI (Odds ratio: 0.87 (95% CI: 0.79-0.96); p = 0.022). This was corroborated by a subscale-analysis of Montreal Cognitive Assessment (MoCA) scores, as only the attention subscale was significantly associated with punding (OR: 0.59 (0.45-0.77); p < 0.001). Baseline impairment in LNS (Hazard ratio: 2.52 (1.22-5.20); p = 0.012) and MoCA attention (HR: 2.68 (1.32-5.42); p = 0.006) predicted earlier punding in Cox regression. In turn, ADL dysfunction predicted punding (OR: 1.55 (1.20-2.00); p < 0.001), but not hobbyism.

CONCLUSION

Attentional dysfunction is a domain-specific cognitive biomarker of punding risk in PD. Further, attentional capacity and functional impairment may determine the complexity of perseverative behaviors on the continuum from rudimentary punding to semi-purposeful hobbyism.

What drugs modify the risk of iatrogenic impulse-control disorders in Parkinson's disease? A preliminary pharmacoepidemiologic study

INTRODUCTION

Parkinson's disease (PD) patients treated with pramipexole (PPX) and ropinirole (ROP) exhibit a higher risk of developing impulse control disorders (ICDs), including gambling disorder, compulsive shopping, and hypersexuality. The management of ICDs in PD is challenging, due to the limited availability of effective therapeutic alternatives or counteractive strategies. Here, we used a pharmacoepidemiological approach to verify whether the risk for PPX/ROP-associated ICDs in PD patients was reduced by drugs that have been posited to exert therapeutic effects on idiopathic ICDs-including atypical antipsychotics (AAs), selective serotonin reuptake inhibitors (SSRIs), and glutamatergic modulators (GMs).

METHODS

To quantify the strength of the associations between PPX/ROP and other medications with respect to ICD risk, odds ratios (ORs) were calculated by multivariable logistic regression, adjusting for age, gender, marital status race, psychiatric comorbidities, and use of cabergoline and levodopa.

RESULTS

A total of 935 patients were included in the analysis. Use of GMs, SSRIs, and AAs was not associated with a decreased ICD risk in PD patients treated with PPX/ROP; conversely, ICD risk was significantly increased in patients treated with either GMs (Adjusted Odds Ratio, ORa: 14.00 [3.58-54.44]) or SSRIs (ORa: 3.67 [1.07-12.59]). Results were inconclusive for AAs, as available data were insufficient to compute a reliable ORa.

CONCLUSIONS

These results suggest that some of the key pharmacological strategies used to treat idiopathic ICD may not be effective for ICDs associated with PPX and ROP in PD patients. Future studies with larger cohorts are needed to confirm, validate, and extend these findings.

Internet Gaming Disorder: Exploring Its Impact on Satisfaction in Life in PELLEAS Adolescent Sample

Among adolescents, heavy video game use and socializing online may be valued socially by peers, depending on gender and age, which can increase life satisfaction. However, heavy video gaming may also be linked to symptoms of Internet Gaming Disorder, which can decrease life satisfaction. Overall, when symptoms of Internet Gaming Disorder are present, do subjects experience decreased or increased life satisfaction, all other things being equal? The aim of this study was to explore the association between Internet Gaming Disorder symptoms and life satisfaction, while controlling for gender, age, and other conditions that may impact life satisfaction. More than 2000 adolescents filled out an anonymous questionnaire at school, and 43 patients in a care center filled out the same questionnaire. Sociodemographic characteristics, family life conditions, use of screens (videos, video games, and social networks), mental health screenings, and a life satisfaction measure were collected. Distribution of participants' characteristics was provided, and stratified multivariate analyses by young male, older male, young female, and older female school populations were carried out. Results suggested that Internet Gaming Disorder symptoms had similar prevalence before and after the age of 15 in males (21% vs. 19%) and in females (6% vs. 7%) respectively and was significantly associated with decreased life satisfaction in older males, even after adjusting for parental support, depression, and economic conditions. Associations between symptoms of Internet Gaming Disorder and life satisfaction may be different depending on adolescent gender and age group.

Brain Imaging and Impulse Control Disorders in Parkinson's Disease

Purpose of Review

Parkinson’s disease (PD) has a wide spectrum of symptoms including the presence of psychiatric disease. At present, most treatment plans, comprised of dopaminergic drugs, are chronic and complex. Though dopaminergic agents are quite efficient in managing the motor aspects of the disease, chronic pharmacotherapy specifically with dopamine receptor agonists has been highly linked to the occurrence of Impulse Compulsive disorder (ICD), which can be problematic for individual patients.

Recent Findings

Much of what is known today about PD-related ICD stems from brain imaging studies, however, evidence is not quite conclusive. Research in the field has been focused on identifying the underlying mechanisms of PD-related ICD and understanding the functions of the structures involved in the reward network.

Summary

This article presents an update of recent findings from key neuroimaging studies in PD-related ICD, discusses results from controversial studies, and identifies areas for future research in the field.

Unmasking neurobiological commonalities between addictive disorders and impulse control disorders in Parkinson’s disease

Changes in reward circuitry have been studied extensively in substance and behavioural addictions. However, comparatively little is known about the neurobiology underlying impulse control disorders (ICDs) in Parkinson's disease, which show roughly similar risk factors and behavioural presentations to both stimulant and behavioural addictions. ICDs occur in a subset of susceptible patients with Parkinson's disease (PD) following intake of dopamine replacement therapy (DRT). These behavioural disorders often have debilitating effects on a patient's quality of life and increase caregiver burden. This comprehensive review examined findings of 40 neuroimaging studies of ICDs in PD to determine (a) whether there are putative neurobiological commonalities between traditional substance and behavioural addictions and DRT-induced ICD in PD and (b) opportunities for future studies to advance current neurobiological understanding of the phenomenon. Results revealed that strikingly similar (a) deficits in dopaminergic receptor expression, (b) connectivity changes in corticostriatal circuitry and (c) neural responses to cue exposure are observed in both ICDs in PD and addictive disorders. These findings point to the value of adopting a transdiagnostic approach when studying addicted populations and pave the way for demystifying this peculiar, often-devastating phenomenon in PD that has so far proven extremely difficult to treat and predict with any precision.

Behavioral Addictions as Mental Disorders: To Be or Not To Be?

Should excessive and problematic engagement in nonsubstance use behaviors be mental disorders? The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) repositioned gambling disorder in the substance use disorders section and introduced Internet gaming disorder in the research appendix; the International Classification of Diseases (ICD-11) is also considering it. This article outlines pros and cons of considering behavioral addictions as mental disorders and also reviews the DSM-5 decision-making processes. It focuses on three conditions: gambling disorder, Internet gaming disorder (IGD), and Internet addiction (IA). We detail assessment methods and prevalence rates for these conditions and outline psychiatric comorbidities, demographic and biological risk factors, and promising treatment approaches. We also briefly discuss other putative behavioral addictions: eating/food, sex, exercise, shopping, and tanning "addictions." Overall, data are inconclusive, and consistent terminology and methodology are needed to define and evaluate these conditions more fully prior to considering them mental disorders.

Markers of impaired motor and cognitive volition in Parkinson's disease: Correlates of dopamine dysregulation syndrome, impulse control disorder, and dyskinesias

INTRODUCTION

Dopaminergic therapy in Parkinson's disease (PD) can be associated with both motoric (e.g., dyskinesias) and neuropsychiatric adverse effects. Examples of the latter include Dopamine Dysregulation Syndrome (DDS) and impulse control disorder (ICD), which are separate but related behavioral/psychiatric complications of treatment in PD. Dysregulation of volition characterizes both dyskinesias and DDS/ICD; thus, we analyzed potential disease-related correlates in a large PD cohort.

METHODS

We analyzed cross-sectional data from 654 participants collected through the NINDS Parkinson's Disease Biomarkers Program. DDS/ICD symptoms and dyskinesias were assessed using the Movement Disorders Society (revised) Unified Parkinson's Disease Rating Scale. Potential associated variables were selected from PD-validated or PD-specific scales of neuropsychiatric or motoric status. Multivariable models with DDS/ICD or dyskinesia presence outcomes were produced with backward stepwise regression to identify factors independently associated with DDS/ICD and/or dyskinesias.

RESULTS

Fifty-three (8.1%) participants endorsed DDS and/or ICD symptoms and 150 (22.9%) were dyskinetic. In multivariable analysis, psychosis was independently associated with both dyskinesias (p = 0.006) and DDS/ICD (p < 0.001). Unpredictable motor fluctuations (p = 0.026) and depression (p = 0.023) were also associated with DDS/ICD; female sex (p = 0.025), low tremor score (p = 0.001) and high akinesia-rigidity score (p < 0.001) were associated with dyskinesias.

CONCLUSIONS

Our findings suggest that psychosis may be an important marker of impaired volition across motor and cognitive domains. Unpredictable motor fluctuations, psychosis, and depression may together comprise a phenotypic profile of patients at increased risk for DDS/ICD. Similarly, dyskinetic PD patients should be closely monitored for psychotic symptoms and treated appropriately.

Cognitive and behavioral disorders in Parkinson's disease: an update. II: behavioral disorders

Patients with Parkinson's disease (PD) can experience several behavioral symptoms, such as apathy, agitation, hypersexuality, stereotypic movements, pathological gambling, abuse of antiparkinsonian drugs, and REM sleep behavioral disorders. Psychoses and hallucinations, depression and anxiety disorders, and difficulties in recognizing and experiencing emotions also impair behavior and can cause severe psychosocial problems in patients with PD. Symptoms can be present since early stages of the disease, sometimes even before the appearance of classical motor symptoms, likely in relation to dopamine depletion in basal ganglia and/or to dysfunctions of other neurotrasmitter systems, and others can develop later, in some cases in relation to dopaminergic treatment. In this paper, we review recent literature, with particular attention to the last 5 years, on the main behavioral and emotional disturbances described in PD patients as well as the hypothesized neurofunctional substrate of such impairments. Finally, we provide some suggestions on the most suitable instruments to check and assess PD-associated behavioral defects over time.

Pathological grooming: Evidence for a single factor behind trichotillomania, skin picking and nail biting

Although trichotillomania (TTM), skin picking (SP), and nail biting (NB) have been receiving growing scientific attention, the question as to whether these disorders can be regarded as separate entities or they are different manifestations of the same underlying tendency is unclear. Data were collected online in a community survey, yielding a sample of 2705 participants (66% women, mean age: 29.1, SD: 8.6). Hierarchical factor analysis was used to identify a common latent factor and the multiple indicators and multiple causes (MIMIC) modelling was applied to test the predictive effect of borderline personality disorder symptoms, impulsivity, distress and self-esteem on pathological grooming. Pearson correlation coefficients between TTM, SP and NB were between 0.13 and 0.29 (p < 0.01). The model yielded an excellent fit to the data (CFI = 0.992, TLI = 0.991, χ2 = 696.65, p < 0.001, df = 222, RMSEA = 0.030, Cfit of RMSEA = 1.000), supporting the existence of a latent factor. The MIMIC model indicated an adequate fit (CFI = 0.993, TLI = 0.992, χ2 = 655.8, p < 0.001, df = 307, RMSEA = 0.25, CI: 0.022-0.028, pclose = 1.000). TTM, SP and NB each were loaded significantly on the latent factor, indicating the presence of a general grooming factor. Impulsivity, psychiatric distress and contingent self-esteem had significant predictive effects, whereas borderline personality disorder had a nonsignificant predictive effect on the latent factor. We found evidence that the category of pathological grooming is meaningful and encompasses three symptom manifestations: trichotillomania, skin picking and nail biting. This latent underlying factor is not better explained by indicators of psychopathology, which supports the notion that the urge to self-groom, rather than general psychiatric distress, impulsivity, self-esteem or borderline symptomatology, is what drives individual grooming behaviours.

Compulsive skin-picking behavior after deep brain stimulation in a patient with refractory obsessive-compulsive disorder: A case report

RATIONAL

The therapeutic effect of deep brain stimulation (DBS) for refractory obsessive-compulsive disorder (OCD) has been studied, but complications after this treatment have rarely been noted.

PATIENT CONCERNS

A 28-year-old man with treatment-resistant OCD received bilateral ventral capsule/ventral striatum stimulation for 12 months.

DIAGNOSIS

Compulsive skin-picking behavior and infection were noted following 12-month DBS treatment.

INTERVENTION

We removed the implanted right-side pulse generator.

OUTCOMES

The local inflammation and skin-picking behavior gradually improved. The stimulator device was re-implanted 4 months later.

LESSONS

We suggest that patients with the OC spectrum should be evaluated for skin-picking behaviors during presurgical and postsurgical follow-up to reduce the infection and device removal rates.

Cognitive-behavioural therapy for non-motor symptoms of Parkinson's disease: a clinical review

Neuropsychiatric symptoms are common in Parkinson's disease (PD) and have a disproportionate impact on quality of life and carer burden. Pharmacological treatment is the main approach in dealing with these symptoms, but it is limited by variable efficacy and risk of drug interactions. Non-pharmacological approaches using the cognitive-behavioural therapy (CBT) model are viable alternatives and in this review paper we summarise the evidence of CBT for three of the most common psychiatric manifestations of PD: depression and anxiety, impulse-control disorders and insomnia. Most studies modified the usual CBT format to include modules accounting for problems specific to PD: activity scheduling around motoric function, motor symptoms as triggers of anxiety, fear of falling and preparation for disease progression as well as accommodation of materials for suspected executive dysfunction. We found a growing evidence base that CBT (modified to account for PD-specific problems) is effective in the treatment of PD psychiatric symptoms. Where controlled study design was used, moderate effect sizes are reported for the efficacy of CBT for depression, including with distance administration of CBT. The effects were sustained during follow-up which was between 1 and 6 months. In addition, there are some initial data on the effects of CBT on impulse-control disorders and insomnia. The studies were limited by their small and potentially unrepresentative samples and the quality of sample reporting (eg, concomitant antidepressant and dopaminergic therapy use). Additional well-designed and adequately powered studies are required to determine the utility of CBT in PD.

Impulse Control Disorders - The Continuum Hypothesis

The group Parkinson Inside Out is composed of health professionals and academic researchers who have been diagnosed with Parkinson's Disease. In our discussions we try to make use of both our inside perspective as patients, and our outside perspective as professionals. In this paper, we apply the two perspectives to the Impulse Control Disorders. These impulsive behaviour patterns are thought to be relatively uncommon side effects of some of the medication used in dopamine replacement therapy. The phenomenon is usually described as relatively rare (<15%), and mainly confined to patients with special vulnerabilities. In contrast, we propose that having some problems with controlling impulses is a very common experience for patients undergoing dopamine replacement therapy. They result from difficulties in decision making engendered by variations in dopamine accessibility in the reward centre of the brain. Only in a minority do the consequences grow to the damaging proportions of a disorder, but most patients are probably affected to some degree. Seeing, and measuring, decision difficulties as a continuous dimension, rather than as a discrete category, brings increased possibilities for early detection and continuous monitoring. With reliable measures of the propensity for impulsive decision making, it may become possible to both reap the benefits and avoid the dangers of the dopamine agonists. We point to ways of empirically testing our continuity hypothesis.

Neuropsychiatric Issues in Parkinson's Disease

Cognitive and neuropsychiatric symptoms are common in Parkinson's Disease and may surpass motor symptoms as the major factors impacting patient quality of life. The symptoms may be broadly separated into those associated with the disease process and those that represent adverse effects of treatment. Symptoms attributed to the disease arise from pathologic changes within multiple brain regions and are not restricted to dysfunction in the dopaminergic system. Mood symptoms such as depression, anxiety, and apathy are common and may precede the development of motor symptoms by years, while other neuropsychiatric symptoms such as cognitive impairment, dementia, and psychosis are more common in later stages of the disease. Neuropsychiatric symptoms attributed to treatment include impulse control disorders, pathologic use of dopaminergic medications, and psychosis. This manuscript will review the current understanding of neuropsychiatric symptoms in Parkinson's Disease.

[Prevalence of neuropsychiatric disorders in drug-naive subjects with Parkinson's disease (PD)]

INTRODUCTION

Parkinson's disease is characterized by a broad spectrum of neuropsychiatric manifestations. Its pathophysiology has been associated with the disease itself as well as with the dopaminergic treatment.

MATERIAL AND METHODS

A cross-sectional study was conducted in drug-naive patients with early Parkinson's disease. All participants were evaluated through a set of scales for specific neuropsychiatric symptoms including: cognition, depression, anxiety, apathy, psychosis, and impulse control disorder.

RESULTS

A total of 63 patients with Parkinson were included, of whom 26 (41.3%) subjects had some degree of cognitive impairment; seven (11.1%) had depression and 11 (15.8%) subjects had anxiety. Regarding the other symptoms, a total of 12 (19%) patients showed apathy, seven (11.1%) had psychosis, and eight (12.6%) patients had symptoms related to impulse control disorders.

CONCLUSION

Neuropsychiatric disorders are common in drug-naive patients with early Parkinson's disease. Given the impact of these symptoms on quality of life, identification and proper treatment is essential.

Executive functioning and risk-taking behavior in Parkinson's disease patients with impulse control disorders

Impulse control disorders (ICD) are common in Parkinson's disease (PD) and are associated with dopaminergic medication. The purpose of this study was to investigate executive function and risk-taking behavior in PD patients with ICD. 17 PD patients with ICD (ICD-PD) were compared to 20 PD patients without ICD (CTRL-PD) using neuropsychological and experimental tasks. Executive functions were assessed using standard executive testing (Conner's Performance Test, Modified Wisconsin Card Sorting Test, Trail Making Test and phonological verbal fluency). Subjects were also submitted to an experimental gambling task consisted of three decks of money cards: neutral deck (equal opportunity for gains as losses), winning deck (small amount of money with a positive balance) and loser deck (high amount of money with a negative balance), evaluating risk-taking behavior (number of cards picked in each deck) and valuation of the reward (subjective appreciation of the value of each deck). There was no significant difference in executive functioning between groups. Both groups selected more cards in the losing deck (high amount of money) as compared to the neutral deck (Mann-Whitney test, ICD-PD, p = 0.02; CTRL-PD, p = 0.003) and to the winning deck (Mann-Whitney test, ICD-PD p = 0.0001; CTRL-PD p = 0.003), suggesting an increased risk-taking behavior. Interestingly, we found that ICD-PD patients estimated the value of decks differently from CTRL-PD patients, taking into account mainly the positive reinforced value of the decks (Mann-Whitney test, p = 0.04). This study showed that executive pattern and risk-taking behavior are similar between ICD-PD and CTRL-PD patients. However, ICD-PD patients showed a specific deficit of the subjective estimation of the reward. Links between this deficit and metacognitive skills are discussed.

'A disease that makes criminals': encephalitis lethargica (EL) in children, mental deficiency, and the 1927 Mental Deficiency Act

Encephalitis lethargica (EL) was an epidemic that spread throughout Europe and North America during the 1920s. Although it could affect both children and adults alike, there were a strange series of chronic symptoms that exclusively affected its younger victims: behavioural disorders which could include criminal propensities. In Britain, which had passed the Mental Deficiency Act in 1913, the concept of mental deficiency was well understood when EL appeared. However, EL defied some of the basic precepts of mental deficiency to such an extent that amendments were made to the Mental Deficiency Act in 1927. I examine how clinicians approached the sequelae of EL in children during the 1920s, and how their work and the social problem that these children posed eventually led to changes in the legal definition of mental deficiency. EL serves as an example of how diseases are not only framed by the society they emerge in, but can also help to frame and change existing concepts within that same society.

Cognitive development from two to ten years after pediatric epilepsy surgery

The development of cognitive functions and the sustainability of seizure control between two and ten years after epilepsy surgery were prospectively investigated in 17 children and adolescents. Intelligence quotient remained stable. Learning capacity improved. Verbal memory improved in half of the subjects and declined in half, whereas figurative memory declined in most patients. Working memory improved as did attention regarding sustained attention and impulse control. In contrast, reaction times were longer, and the auditory attention span was shorter. Executive functions were not affected. Six subjects (35%) were seizure free at the 10-year follow-up, and a seizure reduction of more than 75% had been achieved in 13 (76%). Seizure control improved in five and seizures recurred in two subjects between the two- and the 10-year follow-up.

[Pharmacological update in attention deficit hyperactivity disorder: models of intervention and new drugs]

INTRODUCTION. Attention deficit hyperactivity disorder (ADHD) is the most frequent neurodevelopmental problem in childhood, with significant repercussions that continue into adulthood. This means that an appropriate therapeutic intervention is vital to improve its prognosis. AIMS. To identify the ideal pharmacological options according to the characteristics of the patient and to report on the new drugs. DEVELOPMENT. The work analyses how therapeutic interventions can be conditioned by the anatomical substrate of the brain, the biochemical bases, genetics, neurophysiological examinations, neuropsychological studies and the clinical symptoms and subtypes. A significant amount of importance is granted to neuropsychological studies, especially those dealing with the executive functions, including evaluation of attention, impulse control, and interference and cognitive flexibility. Taking into consideration the signal-to-noise characteristics can be useful when it comes to choosing the drug. CONCLUSIONS. The development of the pharmacological therapeutic options in ADHD opens up expectations concerning applicability and greater specificity in daily practice to fit the characteristics of each patient. Psychoeducation must always be included and a thorough study of each particular child is recommended. This should involve analysing the neuropsychological features of his or her brain function in order to be able to reflect on the ideal pharmacological option that allows more favourable progress.

Behavioural disorders, disability and quality of life in Parkinson's disease

BACKGROUND

although non-motor symptoms of Parkinson's disease (PD) are known to adversely affect disability and health-related quality of life, the impact that specific disorders of reward and motivation have remains unclear. Impulse control disorders are more likely in those with a younger disease onset although there is no strong evidence to date that apathy is related to age of onset or correlated with a longer duration of disease.

OBJECTIVE

to examine the effects of apathy and impulse controls disorders on disability and health-related quality of life.

METHODS

a total of 99 non-demented participants with PD (35 with impulse control disorders, 26 with apathy and 38 with neither behavioural complication) were assessed using the Unified Parkinson's Disease Rating Scale (Activities of Daily Living component) and the Schwab-England scale to evaluate disability, and the PDQ (eight items) to assess quality of life.

RESULTS

quality of life was reduced in both behavioural groups compared with participants without either condition. Disability was greater in the group with apathy. Variation in disability score (56%, P < 0.001) was explained by greater levels of apathy, depression, motor impairment and longer disease duration. Variation in quality of life score (54%, P < 0.001) was explained by higher levels of impulsivity, depression, dopaminergic load, motor complications, working memory problems and younger age at onset.

CONCLUSION

apathy and impulsivity negatively impact on disability and health-related quality of life, emphasising the importance of effective diagnosis and management of these PD-related behavioural disturbances.

A case with hyperkinetic frontal lobe epilepsy presenting as a psychiatric disturbance

We report a case emphasizing the association of epilepsy with psychopathology. The patient was first referred for impulsive and inattentive behavior at the age of 4, and was diagnosed with attention deficit hyperactive disorder. At the age of 7, intermittent daytime episodes characterized with sudden fear and purposeless running, jumping, clapping, and rocking started. Electroencephalography (EEG) recordings did not reveal any abnormality. Two years later, night-time episodes started, which were quite similar to the daytime spells. An overnight EEG showed bilateral frontal spike and wave discharges predominating on the right. Magnetic resonance imaging revealed gliotic changes in the anterior frontal areas, and neuropsychologic assessment findings were compatible with frontal lobe damage. Treatment with carbamazepine not only controlled hyperkinetic motor seizures but also helped interictal inattentiveness and behavioral impulsivity. In our case, ictal behavioral changes were masked by interictal behavioral disturbances and the normal findings in some of EEG records delayed the diagnosis.

Disordered gambling as defined by the Diagnostic and Statistical Manual of Mental Disorders and the South Oaks Gambling Screen: evidence for a common etiologic structure

In a previous article, we demonstrated in a large twin study that disordered gambling (DG), as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV), ran in families, that about half of the variation in liability for DG was due to familial factors, and that all of this was explained by shared genetic rather than shared environmental influences (Slutske, Zhu, Meier, & Martin, 2010). The purpose of the present study is to extend this work to include an alternative conceptualization of DG that is provided by the South Oaks Gambling Screen (SOGS) item set in order to (a) compare the magnitude of the familial resemblance obtained when using the two definitions of DG (based on the DSM-IV and the SOGS), (b) examine the extent to which the 2 definitions tap the same underlying sources of genetic and environmental variation, and (c) examine whether the same results will be obtained among men and women. The results of bivariate twin model-fitting analyses suggested that DG, as defined by the DSM-IV and the SOGS, substantially overlapped at the etiologic level among both men and women, which supports the construct validity of both the DSM and the SOGS conceptualizations of DG. This study highlights the utility of twin studies for appraising the validity of the diagnostic nomenclature.

Impulse control disorders in patients with Parkinson's disease

In patients with Parkinson's disease with higher prevalence than in current population there appear pathological behaviours characterized by compulsion, repetitiveness and impulsivity, which are connected with material profit or pleasurable experience. They are, in particular, pathological gambling, hypersexuality, compulsive shopping and compulsive eating (in the literature they are collectively referred to as impulse control disorders). Pathological preoccupation with repeated mechanical activities (so-called punding) and excessive compulsive intake of dopaminergic medication (so-called dopamine dysregulation syndrome or also syndrome of hedonistic homeostatic dysregulation) are of similar nature. The paper treats briefly the risk factors and prevalence of these pathological behaviours. In current clinical practice, these psychiatric complications frequently escape doctors' attention, they are underdiagnosed. Although no generally valid recommendations for their therapy are currently available, they can be influenced medically. Of advantage can be modified dopaminergic medication (usually dose reduction ofdopaminergic agonists); multidisciplinary approach to the problem is appropriate. The pathological behaviours given above can frequently lead to considerable material losses and markedly aggravate patients' handicap in the social sphere; it can be expected that in the future they can become a problem also from the ethical and legal points of view.

Decreased ventral striatal activity with impulse control disorders in Parkinson's disease

A range of impulse control disorders (ICDs) are reported to occur in Parkinson's disease (PD). However, alterations in brain activity at rest and during risk taking occurring with ICDs in PD are not well understood. We used both arterial spin labeling perfusion functional magnetic resonance imaging (fMRI) to directly quantify resting cerebral blood flow (CBF) and blood oxygenation level dependent (BOLD) fMRI to measure neural responses to risk taking during performance on the Balloon Analogue Risk Task (BART). Eighteen PD patients, either with a diagnosis of one or more ICDs (N = 9) or no lifetime ICD history (N = 9), participated. BOLD fMRI data demonstrated that PD patients without an ICD activate the mesocorticolimbic pathway during risk taking. Compared with non-ICD patients, ICD patients demonstrated significantly diminished BOLD activity in the right ventral striatum during risk taking and significantly reduced resting CBF in the right ventral striatum. ICDs in PD are associated with reduced right ventral striatal activity at rest and diminished striatal activation during risk taking, suggesting that a common neural mechanism may underlie ICDs in individuals with PD and those without PD. Thus, treatments for ICDs in non-PD patients warrant consideration in PD patients with ICDs.

[Disorders affecting the emotional sphere and impulse control in Parkinson's disease]

INTRODUCTION

Parkinson's disease (PD) is associated with mood and behavioral symptoms contributing to morbidity and reduced quality of life of the patients. Most characteristic are depression, anxiety and impulse control disorder.

DEVELOPMENT

Identification and treatment of neuropsychiatric symptoms is necessary for an appropriate management of PD. Affective symptoms may be the initial manifestation of PD, are highly prevalent and pathogenically complex. Impulse control disorders are usually not a spontaneous complaint, so asking about these symptoms may be the only way to detect and treat a serious socio-familial problem. Pharmacological treatment of these manifestations is difficult to balance with an adequate control of motor symptoms. Psychological support from early stages and throughout the evolution of PD is fundamental.

CONCLUSIONS

Neurologist and other healthcare professionals treating PD patients need to be aware of behavioral and emotional manifestations of the disease. This will lead to an appropriate patient management and better adaptation of the familial and social situation.

[Urinary disorders, sexual dysfunction and hypersexuality in Parkinson's disease]

INTRODUCTION

As Parkinson's disease progresses, its non-motor manifestations become increasingly more apparent to the point where, in advances phases of the disease, they are the most important clinical symptoms. A very wide range of non-motor symptoms can appear in Parkinson's disease. Impairment of the urinary function and the sexual function (understood as the capacity to carry out sexual activity) can be seen as belonging to the dysautonomic disorders. Hypersexuality would be included within the group of impulse control disorders.

DEVELOPMENT

This study reviews the epidemiology, phenomenology and treatment of urinary disorders, sexual dysfunction and hypersexuality as non-motor symptoms of Parkinson's disease.

CONCLUSIONS

Urinary disorders are the most frequent non-motor symptom in Parkinson's disease. They usually present as nocturia, urgency and increased mictional frequency (pollakiuria). Preferred treatment is with anticholinergic agents. Sexual dysfunction is a frequent complaint in patients with Parkinson. It has a multifactorial aetiology and is more frequent in males than in females. In males it manifests mainly as incapacity to achieve an erection, premature ejaculation or loss of the capacity to ejaculate, whereas in females the predominant signs are decreased libido, lowered arousal and difficulty in reaching an orgasm. Hypersexuality affects young males above all and has been related to the use of dopamine agonists.

[Compulsive buying or oniomania: an overview]

BACKGROUND

Compulsive buyers feel a continual urge to buy things, irrespective of their financial means. Interest in compulsive buying has increased in the last 30 to 40 years. Since excessive buying is a regularly occurring feature of various illnesses encountered in clinical practice, one wonders whether it should be regarded as a sign of the times, as a symptom of a psychiatric illness or as a distinct psychiatric syndrome.

AIM

To gain insight into the concept of compulsive buying.

METHOD

We searched the literature via Medline, PubMed and PsycInfo for the period from 1966 to August 2008. results Compulsive buying is a relatively unknown and poorly defined phenomenon, despite its high incidence and high comorbidity. It is characterised by chronic, repetetive behaviour; it occurs mainly among women and should be classified as an impulsive-control disorder nos. Current aetiological models lack explanatory power and, so far, the most successful treatment results seem to have been achieved with behavioural therapy.

CONCLUSION

Compulsive buying should be considered from a neuroscientific perspective. Future research needs to have a neuropsychiatric focus and a contextual psychological and behavioural analytical approach in which inhibition, self-control and rule-governed behaviour play a central role.

Impulsive choice and response in dopamine agonist-related impulse control behaviors

RATIONALE

Dopaminergic medication-related impulse control disorders (ICDs) such as pathological gambling and compulsive shopping have been reported in Parkinson's disease (PD).

HYPOTHESIS

We hypothesized that dopamine agonists (DAs) would be associated with greater impulsive choice or greater discounting of delayed rewards in PD patients with ICDs (PDI).

METHODS

Fourteen PDI patients, 14 PD controls without ICDs, and 16 medication-free matched normal controls were tested on the Experiential Discounting Task (EDT), a feedback-based intertemporal choice task, spatial working memory, and attentional set shifting. The EDT was used to assess choice impulsivity (hyperbolic K value), reaction time (RT), and decision conflict RT (the RT difference between high conflict and low conflict choices). PDI patients and PD controls were tested on and off DA.

RESULTS

On the EDT, there was a group by medication interaction effect [F(1,26) = 5.62; p = 0.03] with pairwise analyses demonstrating that DA status was associated with increased impulsive choice in PDI patients (p = 0.02) but not in PD controls (p = 0.37). PDI patients also had faster RT compared to PD controls [F(1,26) = 7.51, p = 0.01]. DA status was associated with shorter RT [F(3,24) = 8.39, p = 0.001] and decision conflict RT [F(1,26) = 6.16, p = 0.02] in PDI patients but not in PD controls. There were no correlations between different measures of impulsivity. PDI patients on DA had greater spatial working memory impairments compared to PD controls on DA (t = 2.13, df = 26, p = 0.04).

CONCLUSION

Greater impulsive choice, faster RT, faster decision conflict RT, and executive dysfunction may contribute to ICDs in PD.

Risk/reward decision-making in schizophrenia: a preliminary examination of the influence of tobacco smoking and relationship to Wisconsin Card Sorting Task performance

BACKGROUND

Individuals with schizophrenia show deficits in cognitive functioning, as evidenced by deficits on neurocognitive tasks such as the Wisconsin Card Sorting Task (WCST). Studies of risk/reward decision-making in individuals with schizophrenia have yielded mixed results, and few studies have examined systematically the relationship between these domains and their relationship with clinical factors.

METHOD

Thirty-two smokers with schizophrenia, ten non-smokers with schizophrenia, nine non-psychiatric non-smokers and ten non-psychiatric smokers were administered computerized versions of the Iowa Gambling Task (IGT) and the WCST. Smokers were allowed to smoke adlibitum during designated breaks in order to prevent deprivation.

RESULTS

Subjects with schizophrenia performed significantly worse than non-psychiatric controls on both the IGT and the WCST, and performance on these tasks was significantly correlated across subject groups. Among women with schizophrenia, smokers performed significantly better than non-smokers on the IGT.

CONCLUSIONS

Individuals with schizophrenia perform worse than controls on the IGT, suggesting impairments in risk/reward decision-making. Correlations between IGT and WCST performance suggest a shared element underlying task performance, such as a deficit in set-shifting or perseverance. Further research is needed to establish the relationship between cigarette smoking and IGT performance in schizophrenia.

Dopamine and impulse control disorders in Parkinson's disease

There is an increasing awareness that impulse control disorders (ICDs), including compulsive gambling, buying, sexual behavior, and eating, can occur as a complication of Parkinson's disease (PD). In addition, other impulsive or compulsive disorders have been reported to occur, including dopamine dysregulation syndrome (DDS) and punding. Case reporting and prospective studies have reported an association between ICDs and the use of dopamine agonists (DAs), particularly at greater dosages, whereas dopamine dysregulation syndrome has been associated with greater dosages of levodopa or short-acting DAs. Data suggest that risk factors for an ICD may include male sex, younger age or younger age at PD onset, a pre-PD history of ICD symptoms, personal or family history of substance abuse or bipolar disorder, and a personality style characterized by impulsiveness. Although psychiatric medications are used clinically in the treatment of ICDs, there is no empiric evidence supporting their use in PD. Therefore, management for clinically significant ICD symptoms should consist of modifications to dopamine replacement therapy, particularly DAs, and there is emerging evidence that such management is associated with an overall improvement in ICD symptomatology. It is important that PD patients be aware that DA use may lead to the development of an ICD, and that clinicians monitor patients as part of routine clinical care. As empirically validated treatments for ICDs are emerging, it will be important to examine their efficacy and tolerability in individuals with cooccurring PD and ICDs.

[Pathological gambling and Parkinson disease]

Pathological gambling (PG) is defined by the DSM IV criteria as inappropriate, persistent, and maladaptive gambling behavior that has repercussions on family, personal, and professional life. It is classified as an impulse control disorder and is widely understood as a nonpharmacological addiction. PG has been reported as a complication in the treatment of Parkinson disease (PD). The prevalence of PG in PD has been reported to range between 1.7 and 7% compared to a prevalence of approximately 1% in the general population. Though there is no survey that indicates the prevalence of PG in Japanese PD patients, problematic gambling behaviors in PD are occasionally observed. In addition to PG other impulse control behaviors and punding (repetitive stereotyped behavior) are recognized as components of the dopamine dysregulation syndrome (DDS), which is characterized by the compulsive use of dopaminergic medications, including levodopa and subcutaneous apomorphine. Though PG can occur with DDS it often occurs in isolation. The vast majority of PG seen in PD is related to dopamine agonists (DA). With regard to the administration of oral DA, pramipexole may induce a higher degree of PG than other types of oral DA due to its disproportionate stimulation of dopamine D3 receptors. However, the differences between the observed effects of various classes of oral DA were insignificant. PG associated with levodopa mono-therapy is uncommon, but in the majority of cases levodopa is co-prescribed. Subthalamic nucleus deep brain stimulation (STN-DBS) was recently introduced to treat advanced PD. An improvement in PG symptoms following STN-DBS has been reported due to a marked decrease in dopaminergic medications. However, in some patients, PG developed following STN-DBS despite the significant reduction or discontinuation of DA. STN-DBS per se may be a potential initiator of PG. Younger age of PD onset, novelty seeking personality traits, history of alcohol abuse, and impulsivity traits were significant predictors of PG. Patients especially those with individual susceptibility to PG should be warned of the potential risks of PG before DA treatment is initiated.

Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers

BACKGROUND

Early abstinence from chronic alcohol dependence is associated with increased emotional sensitivity to stress-related craving as well as changes in brain systems associated with stress and emotional processing. The aim of the current study was to examine potential difficulties in emotion regulation during early alcohol abstinence using the recently validated Difficulties of Emotion Regulation Scale (DERS).

METHOD

Recently abstinent treatment-seeking alcohol abusers (n=50) completed the DERS during their first week of inpatient treatment and at discharge (5 weeks later). These responses were compared to a group of social drinkers (n=62).

RESULTS

Compared with social drinkers, alcohol-dependent patients reported significant differences in emotional awareness and impulse control during week 1 of treatment. Significant improvements in awareness and clarity of emotion were observed following 5 weeks of protracted abstinence. However, significant difficulties with impulse control persisted until discharge.

CONCLUSION

Findings from the DERS indicate protracted stress-related impulse control problems in abstinent alcoholics, which may contribute to increased relapse vulnerability.

[Factors predisposing to pathological gambling]

An examination of 150 patients suffering from pathological gambling (PG) has shown that a PG predisposition includes 3 components: personal, morphofunctional and gender. The personal component is a combination of lability and hyperthymia, higher extraversion, easy communication, riskiness, low empathic ability, inclination to emotional satiation. The morphofunctional component embraces structural (a pathology of cortical and subcortical areas, localized mainly in the frontal region and limbic structure of brain) and functional (abnormalities of regulatory processes, signs of cerebral immaturity) peculiarities of the central nervous system. The gender component is reflected in the notable predominance of males, weak and medium-weak sexual constitution, psychosexual development peculiarities manifested as a reduced romantic stage. This complex predisposition, though non-fatal, raises the risk of the disorder.

The neurobiology and genetics of impulse control disorders: relationships to drug addictions

Impulse control disorders (ICDs), including pathological gambling, trichotillomania, kleptomania and others, have been conceptualized to lie along an impulsive-compulsive spectrum. Recent data have suggested that these disorders may be considered addictions. Here, we review the genetic and neuropathological bases of the impulse control disorders and consider the disorders within these non-mutually exclusive frameworks.

[Case report: kleptomania and other psychiatric symptoms after carbon monoxide intoxication]

Carbon monoxide (CO) intoxication is usually a serious condition, which can result in neurological disturbances or death. In some patients with CO intoxication, but not usually, a biphasic pattern can be seen. In this condition, after antitoxic treatment, patients may completely recover and after a short recovery period, neurological and/or psychiatric symptoms appear again. This condition is known as delayed encephalopathy and its occurrence rate is between 0.06% and 11.8%. Herein, we report a case with delayed encephalopathy after CO intoxication, which began with neurological symptoms and continued with obsessive-compulsive disorder, depression, kleptomania, and psychotic disorder. The 41-year-old female patient had no psychiatric or neurological symptoms or disorders prior to CO intoxication. Increased signal intensity changes in the basal region of the left temporal lobe (including the cortex and subcortical white matter), globus pallidus (bilateral), and cerebellar cortical and subcortical white matter (bilaterally symmetrical) was detected on axial T2-weighted magnetic resonance imaging (MRI). In addition, there were atrophic changes in both cerebellar hemispheres. To the best of our knowledge, this is the first case of kleptomania described after CO intoxication in the literature. We discuss the organic etiology of kleptomania and the other psychiatric symptoms of this patient in the light of recent research. We concluded that the kleptomania seen in this patient was related to concurrent lesions in the temporal lobe and globus pallidus; in other words, her kleptomania may have been related to dysfunction simultaneously seen in both the temporolimbic and frontal-subcortical circuits.