June 18, 2014
The Strange Compulsions Of Parkinson’s Disease
Back in March, I spent a week in the hospital in London. I always seem to meet an interesting character or two on one of these jolly jaunts. It helps the week go quicker and learning of other people’s problems can help put your own life in perspective. That March visit was no exception. On the ward that week were two men suffering from Parkinson’s Disease — let’s call them Mike and Andy. As the week went by, we all began to open up a little to each other. I knew a little bit about Parkinson’s, as a couple of relatives have had the illness. But I found out a lot more that week and one thing that began to fascinate me was the way Parkinson’s often leads to the patient exhibiting serious behavioral changes, including extreme compulsions.
It turned out that the disease had progressed quite badly for both Mike and Andy. They were both reasonably mobile and active after taking their medication, but as it wore off, their condition gradually worsened and the illness reclaimed them. It was an endless and relentless cycle. Then Mike began to tell me about how Parkinson’s had affected his everyday life. He was an upbeat sort of a bloke with a great sense of humor, a bank manager who had to retire in his early 50s. Mike had never been a gambler, but when Parkinson’s took hold, he suddenly developed a passion for visiting casinos. On his first visit, he got lucky and cleaned up, winning nearly £2,000. His luck continued and he made a lot of money, but found he couldn’t stop playing. Eventually his wife realized what was happening and tried to stop the gambling. Mike’s consultants told him this was a common problem. He needed help to curb his obsession and was reluctant to give up the casino — after all, he was winning!
Andy’s experience was not so rewarding. He was a jazz pianist and hoping to make a final record before playing became impossible. He, too, developed a gambling drive, but poor old Andy just kept losing. Horse racing, greyhounds, casinos, and slot machines all gobbled up his money until he also realized it was part of his illness and he received help in kicking his habits.
What happened to Mike and Andy was the onset of an Impulse Control Disorder, or ICD. Many people suffer from ICDs, usually as part of a more general psychiatric problem, but doctors specializing in Parkinson’s believe that something different is happening — patients are seeking gratification and pleasure and the drive to do so comes from deep inside the brain. The neurotransmitter dopamine is known to play a big part in the experience of pleasure and reward. Dopamine levels are thought to be altered in Parkinson’s sufferers, partly because of the illness itself (dopamine producing brain cells are lost) but also as a result of the medications such as dopamine agonists and levodopa that they take. Yet only around 10 percent of sufferers have ICD problems. The explanation may be that those who do develop ICDs have genetically different dopamine receptors and metabolisms. Doperminergic drugs are a mainstay of Parkinson’s treatment and ICD’s frequently follow increases in dosage, or a “top-up” when a dopamine med is added in. Good medical practice will prepare patients for potential ICD issues. Dopamine-based meds are so effective in reducing Parkinson’s worst symptoms that it is not normally possible even to consider withdrawing them purely to alleviate an ICD incidence. One option is to change the type of dopamine drug or even to treat the ICD with an anti-psychotic medication like quetiapine, which can suppress the abnormal drives, but quetiapine is often poorly tolerated and can even make some symptoms of Parkinson’s worse. So the best option is treating the behavior itself. In the case of gambling, this might mean withdrawing access to funds by taking away credit cards and access to cash, for example.
After discussing their gambling addictions, Mike asked Andy if he had experienced another common Parkinson’s ICD.
“What about sex? Did you have an overactive sex drive?”
Andy looked wistful and said that sadly he hadn’t had that one.
“No,” said Mike. “Neither did I.” We all looked at Mike’s wife, who had been in on the conservation. She was smiling wistfully and shaking her head with an “if only” written all over her face and it set us all off laughing. As she said, it’s often those who care for their loved ones who miss out on a lot of things but get none of the attention.
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