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Healthy Living Special Report

Impulse Control: The Link Between Parkinson's and Gambling

You may be familiar with the most typical symptoms of Parkinson's disease -- tremor, rigidity, and trouble initiating movement -- but many people don't know that therapy for Parkinson's is linked to a startling array of impulse-control disorders, like pathological gambling and hypersexuality.

"Many patients and even doctors don't realize that impulse-control disorders and other psychiatric disturbances are treatable, and once these are under control, physical Parkinson's symptoms become much easier to cope with," says Laura Marsh, M.D., Director of the Movement Disorders Psychiatry Clinic and the Parkinson's Disease Clinical Research Program at Johns Hopkins.

Parkinson's is caused by the death of brain cells that produce dopamine, a neurotransmitter necessary for motor control. To manage the disease, most patients take a drug called levodopa, which the brain converts to dopamine. But after several years of treatment with levodopa, the drug may cause the onset of motor side effects, like hyperactive uncontrollable movements. To delay these phenomena, particularly among younger patients, doctors may first prescribe a different class of drugs called dopamine agonists, which stimulate receptors in the brain that are normally activated by dopamine.

But manipulating dopamine activity in the brain can have unintended consequences. During activities people find exciting or pleasurable, this neurotransmitter is released in large quantities, and higher levels are associated with risk taking and addiction. Nicotine, opiates, and many illegal drugs increase dopamine levels in the brain, which is one reason people abuse them.

Therapy for Parkinson's appears to have a similar effect on a small number of patients, who start feeling irresistible urges to engage in gambling, sex, shopping, and overeating. Patients may also abuse their Parkinson's medications. In fact, Dr. Marsh points out, "Parkinson's patients who develop these disorders may act just like other people struggling with addictions. They may be in denial or lie about their behavior, and some even borrow or steal money to support gambling or shopping habits."

Who is affected? Most people with Parkinson's won't develop these disorders; some researchers estimate that 3–8% of patients are affected. While patients on any kind of Parkinson's therapy are at risk, prevalence jumps among those taking dopamine agonists: When researchers for the National Institutes of Health surveyed 297 people with Parkinson's, 14% of respondents on dopamine agonists reported symptoms like pathological gambling.

"Even when I ask patients directly how often they gamble, some conceal their behaviors for years or just don't recognize they have a problem," says Dr. Marsh. "Often, a relative comes forward to discuss these issues. But some families give patients a 'free pass' for a while, because they think the patient is just trying to cope with his or her Parkinson's diagnosis by seeking enjoyable distractions -- which is a misinterpretation.”

Unfortunately, many patients and their families do not bring up these impulsive-behavior patterns with their doctors until their personal lives start to unravel. "Left unchecked," Dr. Marsh cautions, "these disorders may have staggering personal and financial repercussions." In a study published in Neurology, patients with Parkinson's who became pathological gamblers lost an average of $100,000 before getting their addiction under control. Nearly half of these patients reported their marriages had become unstable because of gambling, and some couples even divorced.

The bottom line: Anyone with Parkinson's should be screened for a variety of psychiatric side effects, including diminished impulse control. Patients who had gambling problems before developing Parkinson's may be at particular risk for side effects from dopamine agonists and might consider alternative therapies at the outset.

No matter what Parkinson's therapy is prescribed, it's important for patients, families, and all members of the patient's healthcare team to keep open the lines of communication. Being honest and direct about psychiatric complications can help stop these problems before they escalate.

Posted in Healthy Living on May 5, 2010

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