Pathological gambling in Parkinson's disease improves on chronic subthalamic nucleus stimulation

Abstract

Pathological gambling (PG) related to dopaminergic treatment in Parkinson's disease (PD) is part of a spectrum of behavioral disorders called the dopamine dysregulation syndrome (DDS). We describe a series of PD patients with preoperative active PG due to dopaminergic treatment from a total of 598 patients who have undergone surgery for subthalamic nucleus stimulation for disabling motor fluctuations. The patients had systematic open assessment of behavioral symptoms and standardized assessments of motor symptoms, mood, and apathy. Seven patients (6 men, 1 woman; age, 54 +/- 9 years; levodopa equivalent dose, 1,390 +/- 350 mg/day) had preoperative PG over a mean of 7 years, intolerant to reduction in medication. Six had nonmotor fluctuations and four had other behavioral symptoms consistent with a diagnosis of the DDS. After surgery, motor symptoms improved, allowing for 74% reduction of dopaminergic treatment, below the dosage of gambling onset. In all patients, PG resolved postoperatively after 18 months on average (range, 0-48), although transient worsening occurred in two. Improvement paralleled the time course and degree of reduction in dopaminergic treatment. Nonmotor fluctuations, off period dysphoria, and other symptoms of the DDS improved. Two patients developed persistent apathy. In conclusion, PG and other symptoms of the DDS-associated dopaminergic treatment improved in our patients following surgery. Dopaminergic dysregulation commonly attributed to pulsatile overstimulation of the limbic dopaminergic system may be subject to desensitization on chronic subthalamic stimulation, which has a relative motor selectivity and allows for decrease in dopaminergic treatment.

Long-term outcome of subthalamic nucleus DBS in Parkinson's disease: From the advanced phase towards the late stage of the disease?

“…Interestingly, this was observed despite the significant reduction of dopaminergic therapies, whose role in the ICD development is well documented [21]. The possibility of induction of new onset ICD by STN-DBS has been already reported [22], even if other studies demonstrated an improvement of pre-existing ICD after DBS [23]. The central position of the STN within the basal ganglia thalamo-cortical associative and limbic circuits could explain its role in promoting the onset of ICD in some patients [24]; STN-DBS can indeed interfere with the response inhibition pattern, leading to an increase of impulsivity [25].…”

“…In addition to total score (items 18-31), specific subscores were taken into account: bradykinesia (items 19,[23][24][25][26]31), tremor (items 20-21), rigidity (item 22), speech (item 18), gait (item 29), postural stability (item 30) and axial score (items 18, 27-30).…”

Dianas quirúrgicas en el tratamiento de enfermedades psiquiátricas. Desde el movimiento a las emociones

“…Desde el movimiento a las emociones [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Toda la información emocional o afectiva es transmitida a través de las porciones límbicas de los GB. Así el hipocampo, amígdala, áreas límbicas y paralímbicas envían sus proyecciones al estriado ventral (VS: ventral striatum) 5,89 .…”

“…Para algunos autores, el beneficio en el ICD tras la cirugía podría estar relacionado con la reducción de los dopaminérgicos DA 9,62 . Otros autores, por el contrario, han referido la aparición de ICD en pacientes tratados con DBS a pesar de la reducción de agonistas DA 49,72,104 .…”

Effects of Deep Brain Stimulation on Cognition, Mood and Behaviour in Parkinson’s Disease

“…38 A topic of increasing interest has been the phenomenon of pathological gambling, and isolated cases of this condition have been reported after DBS. 39,78 A large retrospective study 79 …”