Impulsive and compulsive behaviour - education film for consultants

This film explains how important it is that consultants screen for risk factors for impulsive and compulsive behaviour. 

Last reviewed
Topic
  • Care strategies
  • Mental health
  • Side effects
  • Treatments and medication
Resource type
  • Videos
Profession
  • Doctor (Geriatrician)
  • Doctor (Neurologist)
Stage
  • Complex
  • Maintenance

Impulsive and compulsive behaviour is a difficult side effect that can significantly impact people with Parkinson's and those around them. It’s more common in certain types of people (including men and people with a family history of addiction).

It's vital that consultants do initial screening to identify patients at most risk, and carefully monitor them from then on.

Find out more by watching this film. 

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Duration: 8 minutes 2 seconds

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GSK have funded the development of this film

Up to 17% of people with Parkinson's taking dopamine agonists will experience impulsive and compulsive behaviour.

Our research found 82% of consultants had identified a patient as experiencing impulsive and compulsive behaviour.

Research shows there are factors that put some people at a greater risk than others.

Yet only 48% of consultants pre-screen patients before prescribing Parkinson's medications.

TYPES OF IMPULSIVE AND COMPULSIVE BEHAVIOUR

Dr Nin Bajaj, Consultant Neurologist:

Impulsive behaviours can manifest in a variety of ways. In some people they can be very subtle. Some people just start doing hobbies that they always did a bit more often.

Beyond that, there are varieties of behaviour which cause more concern. We've had patients who start to shop obsessively and start to spend very large amounts of money. We've had others who start to gamble.

We also see a change in sexuality in patients - some patients become hypersexual and that causes difficulties in their relationship with their spouse.

RISK FACTORS

Nin:

There have been studies published that suggest that some people are more at risk of developing impulse control disorder than others. And that must be the case, because not everybody that you put on a dopamine agonist gets impulse control disorder. We know that the instance might be as high as 17% of patients that are started on these drugs. It means 83% don’t get this disorder.

Footnote - Impulsive and compulsive behaviour is also known as Impulse Control Disorder.

Dr Graeme McPhee, Elderly Care Physician:

The risk factors for impulsive and compulsive behaviour include things like being young, being male, having a family or a personal history of addictive behaviour. Having a history or a family history of depression and other affective disorders is also important.

IMPULSIVE AND COMPULSIVE BEHAVIOUR CAN HAVE A DEVASTATING AFFECT

Stephen, diagnosed in 2001:

Prior to taking the medication I was a high flying executive for a major retail company. I had a pretty good life style.

And two and a half years later, I was homeless, lost my job and on the verge of going bankrupt. So a pretty devastating side effect of medication caused those problems.

There was a family history of alcoholism and gambling on my mother's side of the family - my grandfather was a gambler, I had an uncle who was an alcoholic, and another uncle who was a gambler. So there is definitely some history there. My father also had a drink problem - I didn't have a drink problem and I didn't have a gambling problem but there clearly was some genetic tendency towards that.

Added to the fact that my age, I was single - I fitted a profile of someone who was quite high risk to those potential issues.

PRE-SCREENING AND ONGOING MONITORING

Graeme:

It's important to ask people about their history because this may give us a pointer as to who is at greater risk.

It's very important to discuss impulsive and compulsive behaviour at every visit because people can be apparently stabilised on dopaminergic therapy without any manifest problems and then suddenly, almost out of the blue, these behaviours can appear.

Now there may be other drivers to that - particularly things like depression or other neuro-psychiatric problems. But it is very important not to assume that everything is satisfactory just because it has been so in the past.

Stephen:

Whilst back in 2001 when I was diagnosed, I can partially accept that maybe those questions weren't being asked because of the lack of knowledge about the issue, I find it almost staggering in 2012 that still half the consultants out there don't do any form of pre-screening.

PARKINSON'S UK HAS A FREE DOWNLOADABLE INFORMATION TOOL

Graeme:

The Parkinson's UK information tool is useful because it allows us to try and identify people who are at high risk by going through the personal and family history of risk factors that might predispose to compulsive behaviour.

It's also useful in that it's a written source of information that we can give to the patient to take away with them from the clinic. And we can also give a copy to carers and family and also the GP who will be involved in the care of the patient.

INCLUDING FAMILIES AND CARERS IN THE CONVERSATION

Nin:

It's always important to include a spouse or partner in discussions about impulse control disorder. The main reason is that the patient is not aware of these behaviours. They're not doing it on purpose. Often they're the last to know. These are subconscious behaviours.

So it's vital to have a spouse involved right from the start, because in a sense, they're the clinician's eyes and ears on the ground - they're the people who are going to tell you if there's a disorder, because patients are often the last people to tell you about it.

MANAGING IMPULSIVE AND COMPULSIVE BEHAVIOUR

Nin:

How to manage patients who unfortunately get impulsive control disorder is not fully understood. There haven't been any large-scale trials looking at the best way of managing patients.

What we do know is patients suffer less impulse control disorder on levodopa than they do on dopamine agonists. Levodopa might have an incidence of impulse control disorder of 7-8% in some studies, but this compares to the 17% with some dopamine agonists.

So the first rule of thumb is you might take away some of that dopamine agonist and convert it instead to levodopa. And that might be one way of reducing impulse control disorder in a patient on large doses of dopamine agonist who is manifesting symptoms.

Now it's important that drug changeover is done in a very controlled way. The other things we have to be careful of is another syndrome called dopamine agonist withdrawal syndrome. And some patients don’t do well on fast removal of dopamine agonist, so there has to be a phased conversion of dopamine agonist to levodopa.

Stephen:

Impulsive and compulsive behaviour side effects destroyed my life. It took me from being a career person with a great lifestyle to living homeless on the streets of London in less than 14 months.

It all could have been prevented if I had been pre-screened for suitability for the medication and I'd been monitored whilst taking the medication.