An unstructured screening interview for ICDs compulsive gambling, buying, and sexual behavior followed by a telephone-administered structured interview for screen-positive patients.
A convenience sample of patients with idiopathic PD who were screened for psychiatric complications. Presence of compulsive gambling, buying, or sexual behavior as assessed by the Minnesota Impulsive Disorders Interview. Compulsive gambling and compulsive sexual behavior were common.
PD patients treated with a dopamine agonist should be made aware of the risk of developing an ICD and monitored clinically. As dopamine agonists are increasing being used for other indications, future research should assess the dopamine agonist-associated risk for ICDs in other populations.
ICDs constitute a group of psychiatric disorders Paul g stern wife sexual dysfunction the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR 4their essential feature being a failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others.
Although there are case reports of levodopa-induced ICDs in PD 6recent case series have implicated treatment with dopamine agonists as a more frequent cause of pathological gambling.
In another case series, all 11 PD patients identified as meeting DSM-IV criteria for pathological gambling were taking a dopamine agonist, 9 of whom were on pramipexole and 2 on ropinirole 3. Regarding other ICDs in PD, in a series of 15 patients with either PD or multiple system atrophy and compulsive hypersexuality, dopamine agonist treatment was implicated as the cause of the behavior in 14 cases 7.
There have also been anecdotal reports compulsive buying in association with dopamine replacement therapies 8. We hypothesized that ICDs in PD are associated with dopamine agonist treatment, and that this association is dose-dependent and similar across the entire class of dopamine agonists.
The study population was outpatients diagnosed with idiopathic PD, predominantly of mild to moderate severity, confirmed by a movement disorders specialist. Participants completed a psychiatric screening interview as part of Paul g stern wife sexual dysfunction study of the frequency and correlates of depression in PD. The Institutional Review Boards at the two institutions approved the study, and written informed consent was obtained from all subjects.
Patients were screened between July and June Movement disorders clinicians were instructed to refer any willing PD patient, without regard for their psychiatric status e. Two trained research assistants administered the screening battery, which included open-ended questions about the existence lifetime, anytime during PD, and currently of recurrent compulsive buying, gambling, or sexual behaviors.
Those who screened positive for an ICD during the course of PD were contacted by phone in August or September by one of the study authors DW or JG and administered a modified Minnesota Impulsive Disorders Interview MIDI 11which includes queries for the presence of clinically-significant compulsive gambling, sexual, and buying behaviors.
Patients were instructed to answer the questions based on their state at the time they were symptomatic. The same threshold has been used to define problem gambling in other studies For patients with an ICD sometime during the course of PD but no longer symptomatic, their charts were reviewed and their medications recorded for the time period when they were most symptomatic.
For analytic purposes, a levodopa equivalent daily dose LEDD was calculated on the basis of the following formula, similar to that previously reported 13 ; Other PD medications e. To probe for possible risk factors for the development of ICDs in PD, data was obtained for factors that have been reported to be associated with ICDs in PD type and dose of dopamine replacement therapy, disease duration, age, and sex 1 — 3 or were factors of interest history of ICD behavior, global cognition, educational level, and marital status.
For the purposes of this study, dopamine agonists were considered to be pramipexole, ropinirole, and pergolide.
Amantadine, which has an unclear mechanism of action but has some dopamine agonist properties 15was considered separately, and no patient was prescribed bromocriptine or apomorphine. Reliable data was not available for the duration treatment with dopamine replacement therapies. All clinical and demographic data was obtained directly from the patient during the screening interview, and when possible verified by chart review. The association between dopamine agonist dosage and ICDs was determined using the Wilcoxon two-sample test.
Variables significant at the 0. For the logistic regression model, all continuous measures were dichotomized at the median. Analyses were performed with SPSS version Two hundred seventy-two patients, ranging in age from 35 to 91 years, completed the screening process.
The frequencies of one or more ICDs were 4. Of patients with an active ICD, the problem was documented in their clinical record in 3 Compulsive sexual behavior was as common as compulsive gambling among both active cases 2. The frequency of compulsive buying was 0.
For these 5 subjects, their ICD behavior during the course of PD was the same as the behavior exhibited prior to PD onset 3 cases of compulsive sexual behavior and 1 each of compulsive gambling and buying. All 11 active ICD cases were currently taking a dopamine agonist.
Examining the larger group of 18 patients who had experienced an ICD sometime during the course of PD, all were taking a dopamine agonist while symptomatic. Based on the univariate results, age, PD duration, history of ICD symptomatology prior to development of PD, dopamine Paul g stern wife sexual dysfunction or amantadine use, and total LEDD met criteria to enter the multivariate model. At screening, approximately half of PD patients were taking a dopamine agonist Table 3.
Pramipexole was most frequently prescribed Examining the larger group of patients who had experienced an ICD sometime during the course of PD, 8 were taking ropinirole, 7 pramipexole, and 3 pergolide while symptomatic.
Estimated frequencies of compulsive gambling in PD range from 0. Our frequency estimate for compulsive gambling 2. We may have underestimated the frequency of ICDs in our population, as patients may have been either hesitant to acknowledge symptoms or less likely to be present in the clinic and therefore unavailable for screening.
We found that compulsive sexual behavior was as common as compulsive gambling, though may have been due to the predominance of males in our sample. Regardless, our findings are consistent with recent reports 7 suggesting an association between dopamine agonist treatment and compulsive sexual behavior in PD.
Of the six potential risk factors for ICDs identified in preliminary analyses, only dopamine agonist treatment and a history of ICD symptomatology prior to PD predicted presence of an active ICD in the multivariate model.
Previous reporting of younger PD patients being disproportionately affected with ICDs may reflect prescribing patterns e. Our data suggest that Paul g stern wife sexual dysfunction history of ICD symptomatology prior to PD is the main demographic or clinical variable that predicts an increased risk for the development of an ICD in the setting of dopamine agonist treatment.
The risk associated with ICDs was specific to the dopamine agonist medication class. Although there was a suggestion on univariate analysis of an association between the total LEDD and ICDs, this relationship was no longer observed after controlling for dopamine agonist use. These results suggest a distinct mechanism of action, as opposed to an additive effect, for dopamine agonists in the development of ICDs. Our findings did not support a differential association between specific dopamine agonists and ICDs, suggesting a class effect.
Two case series 2 ; 3 implicated pramipexole as the agent most likely to cause an ICD, but neither accounted for the relative frequency Paul g stern wife sexual dysfunction pramipexole use in comparison with other dopamine agonists.
There is great variability in the dosing of dopamine agonists in PD. These findings are consistent with two case series 2 ; 3 suggesting that the greatest risk for ICDs may involve dopamine agonist doses at the high end of the therapeutic range.
If true, that may help explain why the highest frequency of ICD cases, even though not statistically significant, was in pergolide-treated patients, as this group was more likely to receive doses at the upper end of the therapeutic range. Limitations of our study include the following: Multi-site studies involving larger, random samples of patients are needed to definitively determine the prevalence and clinical correlates of ICDs in PD.
Our findings highlight the importance of screening for a variety of ICDs in PD patients
Paul g stern wife sexual dysfunction with a dopamine agonist, particularly since only one-quarter of active ICD cases in this study had been identified clinically. It is not known whether the risk for ICDs with exposure to this medication class is specific to PD patients.
As dopamine agonists are increasingly prescribed for other indications e. The authors acknowledge Ms. Katherine Oehlberg, and Ms. Kirsten Saboe for the collection of the data. Dr Weintraub had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
National Center for Biotechnology InformationU. Author manuscript; available in PMC Dec Daniel WeintraubM. Author information Copyright and License information Disclaimer. The publisher's final edited version of this article is available at Arch Neurol. See other articles in PMC that cite the published article.
Design An unstructured screening interview for ICDs compulsive gambling, buying, and sexual behavior followed by a telephone-administered structured interview for screen-positive patients. Setting Two university-affiliated movement disorders centers. Participants A convenience sample of patients with idiopathic Paul g stern wife sexual dysfunction who were screened for psychiatric complications. Main Outcome Measures Presence of compulsive gambling, buying, or sexual behavior as assessed by the Minnesota Impulsive Disorders Interview.
Conclusions PD patients treated with a dopamine agonist should be made aware of the risk of developing an ICD and monitored clinically. Open in a separate window.
The rest were on other non-dopamine agonist medications or no PD medications at all. Pathological gambling caused by drugs used to treat Parkinson disease. Fourth Edition, Text Revision.