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Cognitive-Behavioral Therapy May Improve Impulse Control in Parkinsonís Disease

A form of cognitive-behavioral therapy (CBT) may help people with Parkinson’s disease (PD) who do not respond to other methods of treating impulse control disorders (ICDs) such as gambling or overeating, according to new research published in the February 26 issue of Neurology. However, this therapy may not significantly lessen the burden for care partners of people with PD.

People with PD who take certain medications may develop impulsive behaviors such as compulsive eating, gambling, shopping or sexual activity. Primary among these medications are a class called dopamine agonists, which include bromocriptine (Parlodel®), pramipexole (Mirapex®), pramipexole dihydrochloride extended-release (Mirapex ER®), ropinirole (Requip®), ropinirole extended-release tablets (Requip® XL™), and rotigotine transdermal system (Neupro®). 

While dopamine agonists may play an important role in PD care, they present the risk of impulsive behaviors which can negatively impact the finances, relationships, and psychological health of people with PD and their care partners. Tapering or stopping dopamine agonist therapy (under the care of a doctor) can ease or stop ICDs. However, some people are unable to discontinue the drugs because their motor symptoms worsen, or because they develop severe withdrawal symptoms. 

Therefore, researchers led by Anthony David, M.D., at King’s College Hospital in London studied whether a modified type of CBT could ease impulsive behaviors in people with PD and the burden of their care partners. The researchers worked with 45 people with PD who were experiencing impulsive behaviors, and who had been unable to reduce dosages of dopamine agonists as a solution. These people were randomly assigned to one of two groups: a) one treated with standard medical care plus up to 12 sessions of CBT and b) another treated with standard medical care, but with CBT sessions delayed until a later date. 

At the beginning of the study and six months later, the researchers assessed impulse control and psychological problems in each person, as well as burden and distress in their care partners, using personal interviews and questionnaires.  During the study period, doses of dopamine agonists were kept as constant as possible. CBT, typically involves a professional (in this case a nurse therapist) who helps the participants recognize their problems, identify their motivations, and monitor their behavior. The sessions also included relaxation training and practical advice, for example, canceling credit cards and not driving past gambling establishments for people with gambling problems.

Results

  • In the CBT group, 58 percent of participants completed all 12 sessions of therapy. 88 percent completed at least six sessions, and all participants completed at least one CBT session.
  • 75 percent of people who received CBT showed improved impulse control behaviors after six months, compared with 29 percent who did not receive any CBT.
  • People who received CBT were less likely to suffer from depression, anxiety and certain other psychological problems than those who received only standard medical care.
  • No differences in burden or distress were seen between care partners of the two treatment groups. However, care partners of people treated with CBT showed reduced levels of anxiety and depression.

What Does It Mean?

Impulsive behaviors can have serious financial, medical, legal and social consequences in the lives of those who suffer from them. Yet, other than reducing medications, there are not effective treatment options.

This study is the first to show that CBT could be a helpful tool to reduce impulsive behaviors in people with PD, particularly when people cannot decrease or completely stop taking the medications that trigger the behaviors. 

The researchers found that CBT reduced impulsive behaviors and improved psychological problems such as anxiety, and depression in people with PD. Although the care partners whose loved ones were treated with CBT also showed reduced anxiety and depression, they did not show significant changes in burden or distress. It’s possible that the study period (six months) was too short for care partners to change their perceptions of burden and distress, especially if the impulsive behaviors had been going on for many months or years.

The study does have some limitations. For example, the study was small, had a short duration, and included mostly younger men (average age around 58 years). In addition, people who failed to recognize their impulsive behaviors or tried to hide them may have declined to participate in the study, affecting the results. Also, the study may have been biased if the participants and their doctors had preconceived notions that CBT would be effective for treating impulsive behaviors. It is very difficult to conduct a double blinded study for an intervention such as CBT.

The best treatment for impulse control behavior remains avoidance. People at risk for developing impulse control disorders should probably refrain from taking dopamine agonists, and if they take these medications they should be very closely monitored for these side effects. This study suggests that CBT may be helpful when other methods fail. Future studies should focus on finding additional risk factors for impulsive and compulsive behavior under dopamine agonist treatment so clinicians can avoid these medications in at-risk populations. 

Learn More

Do you have questions about impulse control disorders? Contact PDF's National HelpLine at (800) 457-6676 or info@pdf.org, or use the free resources below, including an online PD ExpertBriefing.

Watch PD ExpertBriefing: Impulsive and Compulsive Behaviors in Parkinson's

Download Fact Sheet: Impulse Control in PD

Reference: Okai D, Askey-Jones S, Samuel M, O’Sullivan SS, Chaudhuri KR, Martin A, Mack J, Brown RG, David AS (2013) Trial of CBT for impulse control behaviors affecting Parkinson patients and their caregivers. Neurology. 80:792-799; doi: 10.1212/WNL.0b013e3182840678  <http://dx.doi.org/10.1212/WNL.0b013e3182840678>

 

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Source Date: Apr 09 2013