ALTHOUGH LEVODOPA AND dopamine agonists (DA) are effective in treating motor symptoms of Parkinson's disease (PD), they may cause motor and behavioral adverse events, such as motor fluctuations, levodopa-induced dyskinesia, mood and anxiety disorders, psychosis and impulsive or compulsive behaviors. Impulse control disorders (ICD) are characterized by obsessive shopping, pathologic gambling, hypersexuality, compulsive eating, punding, and compulsive dopaminergic drug use.[1, 2] It is important to recognize these behaviors because they can cause personal, financial and familial consequences.[3]

A 35-year-old man with familial PD was on pramipexole for 10 years. He had no history of alcohol or drug abuse. His wife complained about his jealousy, excessive money spending, gambling and talking too much. Recommended treatment dose was 4 mg/day. But he revealed that he had started using larger doses up to 12 mg/day of pramipexole without developing peak-dose dyskinesias for 4 years. During the course of his self-medication, he manifested symptoms of pathological gambling and manic attack. Psychiatric examination revealed increased psychomotor activity, hypomaniac affect, increased amount and speed of speech, decreased need for sleep, jealous delusions and ICD as gambling. He said that he used to send more than 2000 text messages every day for betting for approximately 1 year and explained that he could not stop texting because of his irresistible desire to press the numbers on his mobile phone. He also bought more than 100 scratch lottery cards each day. Olanzapine 5 mg/day doses were given to treat acute psychotic symptoms. For compulsive behaviors, pramipexole doses were gradually decreased.

It is known that cultural differences may cause DA-related ICD and punding behaviors many different ways. It is stated that decreasing DA exposure is an effective way to manage ICD that occur during DA treatment.[4] A tertiary care movement disorder center in our country reported that 5.9% of PD patients had ICDs and gambling was lower than in Western series.[5] Many forms of gambling, like casinos, card games, and sports betting, are illegal in our country, and this may be the reason why our patient started betting by text message. Texting was itself a part of the patient's problem. We think that the repetition of pressing the numbers on the phone and scratching lottery cards may be new examples of punding.


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