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 addiction, wealth 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 Parkinsons.co.uk 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 Parkinsons.co.uk 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
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.
In a number of previous blogs I have made reference to the fact that I am a music obsessive. One of the consequences of my insatiable desire for music is that I often find myself unconsciously singing (either along with the music itself or just spontaneously as the mood takes me). Although I do not believe I have a compulsion to break into song, I was surprised to find that there are a number of case studies in the psychological literature on compulsive singing and other music related compulsions such as compulsive humming and whistling (although these all appear to be consequences of other underlying conditions). As noted in a previous blog, compulsive behaviour typically involves a repetitive and irresistible urge to perform a particular action (or set of actions) where the person feels they have no control to inhibit or stop the habitual behaviour. Compulsivity is part of obsessive-compulsive disorder (OCD), but may occasionally occur as stand-alone symptom following the onset of various physiological disorders.
One of the earliest papers I came across on the phenomenon was by Dr. Daniel Jacome in a 1984 issue of the Journal of Neurology, Neurosurgery and Psychiatry. Dr. Jacome described the case of a “musically naive patient with dominant fronto-temporal and anterior parietal infarct developed transcortical mixed aphasia. From early convalescence, he exhibited elated mood with hyperprosody and repetitive, spontaneous whistling and whistling in response to questions”. In addition to the whistling, Jacome also reported that the individual spontaneously sang without any error in melody, lyrics, pitch, and rhythm. The man also developed the desire to spend long periods of time listening to music.
Compulsive whistling was also reported in a 2012 issue of BMC Psychiatry by Dr. Rosaura Polak and her colleagues. Their paper reported the case of a 65-year-old man who started whistling compulsively following a heart attack. The heart attack had caused some brain damage due to a lack of oxygen to the brain. Prior to the cardiac arrest, the man had never displayed any obsessive-compulsive symptoms or psychiatric complaints. He was treated with clomipramine (a seretonin reuptake inhibitor) and this decreased time spent compulsively whistling. The authors concluded that:
“This case shows that the whistling can be explained in the context of compulsivity with its repetitive character. It illustrates that the compulsive behavior can be present as an independent symptom of cortico-striatal dysfunction, and may not always belong to frontal syndrome, punding or OCD. Finally, this case illustrates that pharmacological treatment with clomipramine is effective and suggests that similar cases of compulsivity may benefit from this treatment”
A paper published in a 2000 issue of the Journal of the Korean Neurological Association examining 25 patients with fronto-temporal dementia (20 women and five men with an average age of 56 years) noted that compulsive behaviour is one of the commonest early manifestations of the condition. The researchers analyzed their symptoms and compulsive behaviours and 22 of the patients (88%) showed various compulsive behaviours including “reading signboards, stereotypy of speech, ordering, hoarding, washing, checking, counting, singing, and wandering a fixed route”. However, no real detail was provided in relation to the compulsive singing. Other papers – such as one in a 2002 issue of European Psychiatry by Dr. F. Muratori and colleagues – have reported compulsive singing in people that have Kleine-Levin syndrome (i.e., recurrent primary hypersomnia where individualscan lapse into a deep sleep at any time without warning, sometimes lasting as long as 16 hours).
One of the most interesting and detailed papers on compulsive singing is a 2007 paper by Dr. Christophe Bonvin and colleagues in the Annals of Neurology. They reported two case studies of individuals with advanced Parkinson’s disease who exhibited “a peculiar and stereotyped behavior characterized by an irrepressible need to sing compulsively when under high-dose dopamine replacement therapy”. They argued that the compulsive singing behaviour shared many features with punding (i.e., repetitive behaviour that is a side effect of some drugs). Here is a brief summary of the two cases:
Patient 1: “A 70-year-old female university professor and amateur piano player while being treated with 1,268 L-dopa equivalent units (LEU)…exhibited a repetitive, compulsive behavior characterized by singing endlessly…It started with an irrepressible urge to hum the rhythm and then the main melody of Francesca di Foix, a jocular opera written in 1831 by Gaetano Donizetti. She had heard this rarely produced piece in Milan years ago, and although she did not particularly like it, she had an obsessive need to repeat this song again and again for hours. Even though it was disruptive, preventing sleep and social interactions, singing was reported as pleasant and associated with a feeling of calmness and relief. If interrupted, she became irritated…All symptoms improved minimally after quetiapine (25mg twice daily) had been introduced”.
Patient 2: “A 71-year-old male painter…[that] grew up in a family of musicians and used to spend time listening to classical music and singing willingly…While being treated with 634 LEU, he started to hum repeatedly the same melody, initially once a week, then several times daily, mostly in the evening…Although he asserted singing exclusively Mozart’s 7th Serenade (‘Haffner’ KV 250), his wife reported also about 10 different poorly elaborated songs. This stereotyped behavior was reported as irrepressible and gave him a sensation of relief and ‘peace of mind’. On demand, he could stop singing for short periods but felt somewhat frustrated, demonstrating some aggressive behavior toward his spouse. There were no concomitant auditory or visual hallucinations. This phenomenon exacerbated dramatically when LD/benserazide was increased to 1,000/250mg daily (1134 LEU)…[This resulted in] the patient losing control over the compulsion and singing almost unendingly all day…Eventually, compulsive singing improved, but did not disappear, when LD/benserazide was reduced to the minimal daily doses (500/125mg)”.
The authors noted that in both of these patients developed a peculiar, stereotyped, and compulsive behaviour characterized by an urge to sing repeatedly the same song. They also concluded that in both cases:
“[The] compulsive singing developed as an isolated, elaborate, and selective feature, unrelated to mania or psychosis…Although the singing behavior was fully recognized by both patients as inadequate and socially disruptive, they were unable to stop singing for more than a few seconds to minutes, partly because the singing-induced sensation of pleasure felt was overwhelming. To the best of our knowledge, this phenomenon has not been consistently identified in [Parkinson’s disease] thus far…Moreover, PET and functional magnetic resonance imaging studies conducted in humans have correlated pleasure and reward from music listening with a significant activation of the ventral tegmental area and accumbens nucleus, as well as of the hypothalamus, insula, and orbitofrontal cortex. These findings suggest that music listening may recruit similar neural circuitry of reward and emotions as other pleasure inducing stimuli like food and sex, and this may also be the case for singing”.
In 2010, Dr. Hiroshi Kataoka and Dr. Satoshi Ueno described the case of an 82-year old woman (also with Parkinson disease) who started to sing compulsively (in the absence of any other types of pathologic behaviour) following treatment with pergolide. In the journal Cognitive and Behavioral Neurology, the authors reported that she would hum the same melody and sing songs repeatedly. When she stopped taking her ergolide medication, the compulsive singing and humming considerably subsided. Drs. Kataoka and Ueno suggested that a dopamine agonist in the patient’s medication may have contributed to her compulsive singing. The same phenomenon was also reported in three Parkinson’s patients treated with dopamine agonists by a Dr. C. Borrue-Fernandez at a Spanish conference on treating Parkinson’s disease in 2011.
It would appear from the few papers that have been published on compulsive singing that it almost always occurs alongside or as a consequence of other primary medical conditions and that some excessive or sensitized dopaminergic stimulation is a necessary prerequisite for such musical stereotypies to occur.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Bonvin, C., Horvath, J., Christe, B., Landis, T., & Burkhard, P. R. (2007). Compulsive singing: another aspect of punding in Parkinson’s disease. Annals of Neurology, 62, 525-528.
Borrue-Fernandez, C. (2011). Compulsive singing as an Impulse Control Disorder in dopamine agonist treated patients: Review of three cases. The 15th Congress of the European Federation of Neurological Societies.
Jacome, D. E. (1984). Aphasia with elation, hypermusia, musicophilia and compulsive whistling. Journal of Neurology, Neurosurgery and Psychiatry, 47, 308-310.
Kataoka, H., & Ueno, S. (2010). Compulsive singing associated with a dopamine agonist in Parkinson disease. Cognitive and Behavioral Neurology, 23(2), 140-141.
Muratori, F., Bertini, N., & Masi, G. (2002). Efficacy of lithium treatment in Kleine–Levin syndrome. European Psychiatry, 17, 232–3.
Polak, A. R., van der Paardt, J. W., Figee, M., Vulink, N., de Koning, P., Olff, M., & Denys, D. (2012). Compulsive carnival song whistling following cardiac arrest: a case study. BMC Psychiatry, 12(1), 75.
Yoon, S. J., Jeong, J. H., Kang, S. J., & Na, D. L. (2000). Compulsive behaviors and presenting symptoms of frontotemporal dementia. Journal of the Korean Neurological Association, 18, 681-686