Clozapine use for refractory impulse control disorders in Parkinson's disease: a case report.

Abstract

Impulse control disorders (ICDs) are characterized by the failure to resist an impulse, drive, or temptation to achieve an act that may be deleterious to self or others. These behaviors include pathological gambling, hypersexuality, compulsive shopping, and binge eating (Vilas et al. 2012). Despite proposed diagnostic criteria for hypersexual disorder (Kafka 2010), this psychiatric disorder was not included in the DSM-5 classification because of the lack of data regarding its physiopathology (American Psychiatric Association 2013). However, hypersexuality was widely described in the literature with the following criteria: excessive time consumed by sexual fantasies, urges, or behaviors and by planning for and engaging in it while disregarding the risk for harm to self or others, associated with repetitive and unsuccessful efforts to control or reduce these sexual fantasies, urges, and behaviors (Kafka 2010; Pereira et al. 2013). The prevalence of ICD in Parkinson’s disease (PD) patients varies in the literature from 8 % (Poletti et al. 2013) to 25 % (Perez-Lloret et al. 2012). Moreover, 2.4 % (Voon et al. 2006) to 10% (Garcia-Ruiz et al. 2014) of subjects combining ICD and PD present compulsive sexual or hypersexual features. This variability could be explained by the fact that most patients did not report this serious side effect because of embarrassment or because they did not suspect an association with PD treatment, and only few patients spontaneously complained of this disorder (GarciaRuiz et al. 2014). If PD does not seem to play a direct role in ICDs, dopamine agonists (DA) and a combination of DA plus levodopa appears to increase the risk of developing ICDs (Garcia-Ruiz et al. 2014). ICDs have important consequences on the quality of life of the patients and their families (Marechal et al. 2015) and must be diagnosed and treated as early as possible. Nevertheless, no consensual treatment guidelines are currently available (Reiff and Jost 2011). However, it has been suggested that the treatment of hypersexuality should start with reduction of the dopamine agonist (Klose et al. 2005). If hypersexuality does not decrease, the discontinuation of the use of the DA could be effective (Klose et al. 2005; Bronner and Vodusek 2011). If necessary, reduction or discontinuation of DA treatment can be balanced by an increase in levodopa treatment (Reiff and Jost 2011). Unfortunately, this strategy may prove to be impossible because of motor symptoms, and ICDs may persist despite the discontinuation of DA treatment. We report the case of a PD patient who developed hypersexuality features after treatment with DA, resistant after DA reduction, and following DA discontinuation. The symptoms eventually decreased with clozapine medication.