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Strange fascinations: A brief look at unusual compulsive and addictive behaviours

In previous blogs, I have examined lots of strange types of addictive and compulsive behaviours including compulsive singing, compulsive hoarding, carrot eating addiction, Argentine tango addiction, compulsive nose-picking, compulsive punning, compulsive helping, obsessive teeth whitening, compulsive list-making, chewing gum addiction, hair dryer addictionwealth addiction, and Google Glass addiction (to name just a few).

However, while doing some research for a paper I am writing on ‘fishing addiction’ (yes, honestly), I came across an interesting paper on unusual compulsive behaviours caused by individuals receiving medication for Parkinson’s disease ([PD] a degenerative disorder of the central nervous system) and multiple system atrophy ([MSA] a degenerative neurological disorder in which nerve cells inside the brain start to degenerate and with symptoms similar to Parkinson’s disease).

In the gambling studies field there are now numerous papers that have been published showing that some Parkinson’s patients develop compulsive gambling after being treated for PD. According to the website, those undergoing PD treatment can have many side effects including addictive gambling, obsessive shopping, binge eating, and hypersexuality. The website also notes other types of compulsive behaviour that have been associated with PD medication including “punding or compulsive hobbyism [when someone does things such as collecting, sorting or continually handling objects]. It may also be experienced as (i) a deep fascination with taking technical equipment apart without always knowing how to put it back together again, (ii) hoarding things, (iii) pointless driving or walking, and (iv) talking in long monologues without any real content”.

The paper that caught my eye was published in a 2007 issue of the journal Parkinsonism and Related Disorders by Dr. Andrew McKeon and his colleagues. They reported seven case studies of unusual compulsive behaviours after treating their patients with dopamine agonist therapy (i.e., treatment that activates dopamine receptors in the body). The paper described some compulsive behaviours that most people would not necessarily associate with being problematic. Below is a brief description of the seven cases that I have taken verbatim from the paper.

  • Patient 1: “A 65-year-old female with PD for 9 years developed compulsive eating, and also felt compelled to repetitively weigh herself at frequent intervals during the day and at night. She found her behavior both purposeless and repetitive. Obsessive thoughts were also a feature, as the patient ‘had to’ weigh herself three times each occasion she used the weighing scales”.
  • Patient 2: “A 67-year-old female with PD for 8 years played computer games and solitaire card games for hours on end, often continuing to do so through the night. She did not enjoy the experience and found it purposeless, but did so as she felt she had ‘to be doing something’. She also developed compulsive eating and gambling”.
  • Patient 3: “A 48-year-old male with PD for 5 years, with little prior interest, developed an intense interest and fascination with fishing. His wife was concerned that he fished incessantly for days on end, and his interest did not abate despite never catching anything. This patient also developed compulsive shopping, spending large amounts of time and money in thrift stores”.
  • Patient 4: “A 53-year-old male with PD for 13 years became intensely interested in lawn care. He would use a machine to blow leaves for 6h without rest, finding it difficult to disengage from the activity, as he found the repetitive behavior soothing. He also developed compulsive gambling”.
  • Patient 5: “The wife of a 52-year-old male with an 11-year history of PD complained that her husband now spent all of his time on his hobbies, to the detriment of their marriage. The patient made small stained glass windows, day and night. In addition, he would frequently stay awake arranging rocks into piles in their yard, intending to build a wall, but never doing so. He would start multiple projects but complete nothing. He was also noted to have become hypersexual, demanding sexual intercourse from his wife several times daily”.
  • Patient 6: “This 60-year-old male, with a history of alcohol abuse and ultimately diagnosed with MSA, relentlessly watched the clock, locked and unlocked doors and continually arranged and lined up small objects on his desk. He also became hyperphagic and hypersexual, developing an intense fascination with pornographic films”.
  • Patient 7: “The wife of a 59-year-old male with PD for 1 year described how her husband dressed and undressed several times daily. On one occasion, while guests were at their house for dinner, he spent most of his time in his bedroom repeatedly changing from one pair of trousers into another. This behavior deteriorated considerably on increasing levodopa dose to 1100mg/day, and on a subsequent occasion after reducing quetiapine from 100 to 75 mg/day”.

These cases highlight that the compulsive behaviours that develop following dopamine agonist therapy often co-occur with one or more other compulsive behaviour and that much of these behaviours are repetitive and unwanted. As the authors noted:

“The temporal association between medication initiation and the onset of these behaviors led to our suspicion that medications were causative. In the aggregate, these patients illustrate that the behaviors provoked by drug therapy in parkinsonism cover a broad spectrum, ranging from purposeless and repetitive to complex, reward-oriented behaviors. Punding is the term typically applied to the former, and was seen in Patient 5 (arranging rocks into piles) and Patient 6 (lining up small objects on a desk)…Previous descriptions of pathological behaviors occur- ring with dopaminergic therapy in PD have been notable for the absence of obsessive thoughts accompanying compulsive behaviors, unlike Patient 1 who was remark- able for a counting ritual accompanying repetitive use of a weighing scale. In six of the seven cases, other reward- seeking behaviors (gambling, shopping, hypersexuality or overeating) were present and contemporaneous with these other unusual compulsive behaviors. This suggests that all of these behaviors, while phenomenologically distinct, are all part of the range of psychopathology encapsulated by obsessive-compulsive spectrum disorders”.

According to the website, PD sufferers are more likely to experience impulsive and compulsive behaviour if the person is (i) diagnosed with Parkinson’s at a young age, (ii) male, (iii) single and live alone, (iv) a smoker, and (v) someone with a personal or family history of addictive behaviour. The same article also notes that if the PD sufferer has a history of ‘risk-taking’, such as gambling, drug abuse or alcoholism, [they] may be more likely to develop dopamine addiction”. This is where the PD sufferer takes more of their medication than is needed to control their Parkinson’s symptoms (and known as dopamine dysregulation syndrome). Similarly, Dr. McKeon and colleagues concluded:

“Previously described associated clinical features include a prior history of depressed mood (four patients in this series), disinhibition, irritability and appetite disturbance…A history of problems with impulse control prior to the diagnosis of PD may be a risk factor for developing compulsive behaviors with dopaminergic therapies…although this only pertained to Patient 6…The compulsions were not found to be troublesome by three patients, with complaints regarding behavioral change coming from the patient’s spouse. Our observations affirm the need to check with both patient and family at follow-up visits for the emergence of a variety of troublesome pathological behaviors that may result from dopaminergic therapy, particularly dopamine agonists”.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Dodd, M. L., Klos, K. J., Bower, J. H., Geda, Y. E., Josephs, K. A., & Ahlskog, J. E. (2005). Pathological gambling caused by drugs used to treat Parkinson disease. Archives of Neurology, 62, 1377-1381.

Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.

Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Klos, K. J., Bower, J. H., Josephs, K. A., Matsumoto, J. Y., & Ahlskog, J. E. (2005). Pathological hypersexuality predominantly linked to adjuvant dopamine agonist therapy in Parkinson’s disease and multiple system atrophy. Parkinsonism and Related Disorders, 11, 381-386.

McKeon, A., Josephs, K. A., Klos, K. J., Hecksel, K., Bower, J. H., Michael Bostwick, J., & Eric Ahlskog, J. (2007). Unusual compulsive behaviors primarily related to dopamine agonist therapy in Parkinson’s disease and multiple system atrophy. Parkinsonism and Related Disorders, 13(8), 516-519.

Nirenberg, M. J., & Waters, C. (2006). Compulsive eating and weight gain related to dopamine agonist use. Movement Disorders, 21, 524-529.

Pontone, G., Williams, J. R., Bassett, S. S., & Marsh, L. (2006). Clinical features associated with impulse control disorders in Parkinson disease. Neurology, 67, 1258-1261.

Voon, V., Hassan, K., Zurowski, M., De Souza, M., Thomsen, T., Fox, S.,…& Miyasaki, J. (2006). Prevalence of repetitive and reward-seeking behaviors in Parkinson disease. Neurology, 67, 1254-1257.

High performer to hyper former: A brief overview of Klüver–Bucy syndrome‬

While I was researching a previous blog on coprophagia (eating faeces), I came across a finding that coprophagia was prevalent in those with Klüver-Bucy Syndrome (KBS). I have to be honest and say I had never heard of KBS until that point so I thought I would investigate a little further. Back in 1937, Dr. Heinrich Klüver and Dr. Paul Bucy described an unreported behavioural syndrome in rhesus monkeys following removal of the bilateral temporal lobe in the brain, and described by Klüver himself as “the most striking and apparent alteration ever observed in consequence of surgical experiments performed on animal brains”. The surgical procedure resulted in (i) psychic blindness or visual agnosia (i.e., a deficiency in the ability to recognize visual objects), (ii) strong oral tendencies, (iii) hypermetamorphosis (i.e., an irresistible impulse to notice and react to everything within sight), (iv) decrease in aggressive behaviour, and fear reaction, and (v) hypersexuality.

The first human case was reported in 1955 by Dr. H. Terzian and Dr. G. Ore (in the journal Neurology). They carried out a bilateral removal of the temporal lobes in an adult male that resulted in KBS. The second case (although many papers I have read claim this was the first human case) – a 22-year-old man – was reported by Marlowe and colleagues in a 1975 issue of the journal Cortex. In this individual, KBS occurred following bilateral temporal lobe damage due to herpes simplex meningoencephalitis.

Since those two early cases, KBS has been associated with numerous disorders of the central nervous system. For instance, a treatment study of six KBS cases in a 2004 issue of Neurology India, Dr. Jha and Dr. Patel noted that the range of conditions associated with KBS included Alzheimer’s disease, juvenile neuronal lipofuscinosis, Huntington’s disease, herpes simplex encephalitis, toxoplasmosis, traumatic brain injury, hypoglycemia, acute intermittent porphyria, traumatic head/brain injury, tuberculous meningitis, heat stroke and Shigellosis. Other conditions may also contribute to a diagnosis of KBS including ischaemia, anoxia, progressive subcortical gliosis, Rett Syndrome, Pick’s Disease, porphyria, and carbon monoxide poisoning.

In humans, KBS is a rare behavioural impairment resulting from damage to both of the anterior temporal lobes of the brain. The disorder is not life threatening, but health practitioners can find KBS sufferers difficult to manage. The condition can be caused by either (i) bilateral temporal lobectomy, or (ii) bilateral temporal lobe damage from degenerative disorders, trauma, and encephalitis. At present, there is no known cure for KBS. Research carried out on human case studies have recorded a variety of symptoms including:

  • Hyperorality: Typified by KBS sufferers compulsively examining everything by mouth
  • Hypersexuality: Typified by KBS sufferers experiencing a heightened sex drive and/or seeking sexual stimulation from unusual or inappropriate items.
  • Docility: Typified by KBS sufferers exhibiting low aggressive tendencies and diminished fear responses.
  • Dietary changes and/or hyperphagia: Typified by KBS sufferers eating non-nutritive items or substances (i.e., pica) and/or overeating.
  • Visual agnosia: Typified by KBS sufferers as the inability to recognize normally familiar objects or people.

Other types of behaviour reported in KBS sufferers include (i) amnesia (i.e., memory loss), (ii) hypermetamorphosis (as noted in rhesus monkeys above), (iii) lack of emotional response and diminished emotional affect amnesia, (iv) dementia, (v) dysphasia (i.e., inability to communicate following brain injury), and (vi) seizures. In humans, the three most common symptoms are docility, hyperorality and dietary changes.

The natural history of KBS is still unknown, but in the case of trauma, a recent paper by Dr. Amaresh Deginal and Dr. Siddling Changty in the Indian Journal of Neurotrauma (2011) reported that the course is temporary, ranging from seven days to one year. They also noted there is no specific treatment apart from oral Carbamazepine (CBZ). CBZ and leuprolides have been used to decrease the hypersexuality in KBS sufferers. Other medications (e.g., anti-cholinergics and haloperidol) have also been used in treating other behavioural consequences associated with KBS as highlighted in the paper by Jha and Patel above. However, as Dr. John Anson and Dr. Donald Kuhlman concluded:

“Klüver-Bucy syndrome remains a fascinating syndrome whose exact neuroanatomicalbasis is unclear. As neurosurgical treatment of seizure disorders increases, the consequences of mesial temporal lobectomy must be considered. Although most patients with intractable seizures improve after surgical intervention, they may develop neuro-behavioural complications such as the Kluver-Bucy syndrome. A more limited surgical resection, particularly one that spares more of the amygdala, may minimize the chance of this type-of complication”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Anson, J.A. & Kuhlman, D.T. (1993). Post-ictal Kliuver-Bucy syndrome after temporal lobectomy. Journal of Neurology, Neurosurgery and Psychiatry, 56, 311-313.

Deginal, A. & Changty, S. (2011). Post traumatic Klüver-Bucy syndrome: A case report. Indian Journal of Neurotrauma, 8, 41-42.

Jha, S. & Patel, R. (2004). Klüver-Bucy syndrome – an experience with six cases. Neurology India, 52, 369-71.

Klüver, H. &  Bucy, P.C. (1937). Psychic blindness and other symptoms following bilateral temporal lobectomy in rhesus monkeys. American Journal of Physiology, 119, 352-353.

Kwiatkowski, S., Starowicz, A., Milczarek, O. & Kawecki, Z. (2011). Neuropsychological characteristic of post-traumatic Klüver-Bucy Syndrome. Archives of Psychiatry and Psychotherapy, 4, 59-65

Lilly, R., Cummings, J.L., Benson, F. & Frankel, M. (1983). The human Klüver‐Bucy syndrome, Neurology, 33, 1141.

Marlowe, W.B., Mancall, E.L. & Thomas J.J. (1975). Complete Klüver-Bucy syndrome in man. Cortex, 11, 53-59.

Ozawa, H., Sasaki, M., Sugai, K., et al. (1997). Single-Photon Emission CT and MR findings in Klüver-Bucy syndrome after Reye syndrome. American Journal of Neuroradiology, 18, 540-42.

Stewart, J.T. (1985). Carbamazepine treatment of patient with Klüver-Bucy syndrome. Journal of Clinical Psychiatry, 46, 496-497.

Terzian, H. & Ore, G.D. (1955) Syndrome of Kluver and Bucy. Reproduced in man by bilateral removal of the temporal lobes. Neurology, 5, 373-80.