Dopamine dysregulation syndrome in Parkinson's disease: case report

Abstract

-We report a 67-year-old man with Parkinson's disease for 9 years who developed compulsive use of levodopa. This phenomenon is the main feature of the dopamine dysregulation syndrome. Other related symptoms presented by our patient were mood fluctuation and increased writing activity suggestive of punding.KEY WORDS: Parkinson's disease, dopamine dysregulation syndrome, punding.Síndrome de desregulação dopaminérgica na doença de Parkinson: relato de caso RESUMO -Relatamos sobre um homem de 67 anos de idade com doença de Parkinson por 9 anos e que desenvolveu uso compulsivo de levodopa. Esse fenômeno é a principal característica da síndrome de desregulação dopaminérgica. Outros sintomas apresentados pelo paciente foram flutuações do humor e atividade de escrita aumentada, comportamento este sugestivo de punding. PALAVRAS-CHAVE: doença de Parkinson, síndrome de desregulação dopaminérgica, punding.Parkinson's disease (PD) is associated with a prog ressive dysfunction of the dopaminergic neuro t r a n smission in the basal ganglia. On pathological examination, the dopaminergic neurons in the pars compacta of the substantia nigra a re markedly re d u c e d , and cytoplasmic proteinaceous aggregates known as Lewy bodies are present in the residual neurons. Dopamine replacement therapy (DRT), with the dopamine precursor levodopa or synthetic dopamine agonists, is considered the mainstem of the pharm a c ological approach for the symptoms of PD 1 , 2 . However long-term DRT is commonly associated with a series of motor complications, such as dyskinesias and the o n -o ff phenomenon. More re c e n t l y, interest has been drawn to non-motor complications of PD and treatm e n t -related psychiatric symptoms, such as depre ssive disorders, fatigue, apathy and cognitive impairment 3 . We describe a man with PD since 58 year-old who developed compulsive use of levodopa. In off periods he presented severe non-motor symptoms, including craving for levodopa, intense feelings of dysphoria, worsening of depressive symptoms, painful tru n k sensations and profuse sweating. During peak dose period, he also became hypomanic and had diff i c u lty in perceiving his severe dyskinesias. This behavior has been recently described in literature as a quite r a renon-motor complication of DRT. This syndro m e of increased use of levodopa beyond that needed to achieve relief of motor symptoms, associated with disabling mood and behavioral features is re f e rre d by some authors as dopamine dysregulation syndrome ( D D S ) 4 , 5 . To the best of our knowledge, this is the first case of this syndrome re p o rted in the Brazilian l i t e r a t u re. The patient gave informed consent for this case report. CASEA 67-year-old man, married, a retired surgeon had PD for 9 years. He had no previous history of alcohol or any

Neuropsychiatry of Parkinson's disease

“…Despite the limited evidence regarding therapy of ICD and DDS, it is generally indicated adjustment of dopaminergic therapy, behavioral and pharmacological therapy used in ICD without PD, and psychosocial support 63 . These patients present a challenge to the clinician 64 . There are case reports of successful treatment of ICD in DP with clo-zapine, quetiapine, valproate, lithium, topiramate, donepezil, amantadine, cyproterone (for hypersexuality), and deep brain stimulation 65 .…”

Low frequency of bipolar disorder, dopamine dysregulation syndrome, and punding in Brazilian patients with Parkinson's disease

“…The core features of DDS are self-medication, levodopa-seeking and hoarding associated with disabling mood and behavioral changes. 3 In DDS, mood dysregulation comprises alternation between depressed and elated affect, and is frequently associated with hypersexuality, aggression, pathological gambling, compulsive shopping and social isolation, resembling a bipolar-like syndrome. [2][3][4] An additional behavioral disorder supposedly associated with changes in dopaminergic neurotransmission is punding, which consists of repetitive, stereotyped, aimless and disrupted behaviors related to the person's past work or hobby.…”

“…3 In DDS, mood dysregulation comprises alternation between depressed and elated affect, and is frequently associated with hypersexuality, aggression, pathological gambling, compulsive shopping and social isolation, resembling a bipolar-like syndrome. [2][3][4] An additional behavioral disorder supposedly associated with changes in dopaminergic neurotransmission is punding, which consists of repetitive, stereotyped, aimless and disrupted behaviors related to the person's past work or hobby. 5,6 In a previous study by our group we found that the lifetime frequency of bipolar I and II disorders in PD seems to be similar to that observed in the general population.…”

Parkinson’s Disease Impulsive-Compulsive Disorders Questionnaire – Current Short (QUIP-CS) – Translation and validation of content of Portuguese Version

“…Information on these conditions are rare in Brazilian patients 17 . Thus, we believe it is underreported in Brazilian literature, due to the fact that there have not been any valid instruments to identify ICDs in affected individuals.…”