DATE, March 1, 2024

Dopamine Medications and Impulse Control Disorders

By Stephen Smith, PE
Stephen Smith has been an RLS Foundation Discussion Board moderator and RLS Foundation member since 2013.

Dopaminergic medications (such as carbidopa/ levodopa, pramipexole, ropinirole and rotigotine) are frequently prescribed to treat RLS. Doctors often – though not universally – warn patients receiving the drugs that they may cause a dramatic worsening of RLS symptoms over time, an effect known as augmentation. However, few physicians and patients are aware of another serious side effect of these drugs: impulse control disorders (ICDs). Studies found 6-17% of patients on dopaminergic medications may be affected. Anyone taking these drugs needs to be aware of the potential for such effects and be proactive in educating their providers if side effects develop. As a moderator for the RLS Foundation’s Discussion Board forum, I often see this brought up in conversations, and I would like to bring awareness to it here.

ICDs show themselves as behaviors that are disturbing and out of the patient’s former patterns. They could emerge as compulsive gambling, compulsive eating, compulsive shopping, hypersexuality or punding (compulsive, repetitive behaviors). Oddly, the patient may not be aware of these new, harmful behaviors. Most ICDs are behaviors that, left unchecked, can destroy financial savings, break up families, cause excessive weight gain or destroy careers. These are serious situations that need to be identified and dealt with promptly. Family members and friends need to be alert and assertive in calling attention to these often-destructive behaviors and ensuring that they are taken seriously by both the sufferer and the medical professional.

ICD-induced compulsive gambling doesn’t refer to friendly, low-stakes, weekly poker games; light-hearted card games with friends; or occasional trips to a casino, assuming those were activities a person enjoyed before starting on the medication. Instead, it is a powerful need to take excessive and frequent financial risks for a perceived immediate gain, whether at the casino, at the horseracing track, or on day trading stocks.

Compulsive eating is another kind of ICD. Raiding the refrigerator day and night can be an indication of compulsion that may lead to rapid weight gain. To be sure, these medications can cause weight gain on their own, but compulsion needs to be ruled out if the patient eats compulsively.

Compulsive shopping does not include your daily essential purchases or even the occasional retail therapy. Compulsive shopping is an unrestrained need to buy unnecessary, sometimes unwanted, items. It is shopping purely to satisfy the desire to buy something – anything.

Hypersexuality is not simply defined as an increase in libido. It is an uncontrolled drive to participate in high-risk sexual activities that often do not include one’s typical partner. This compulsion presents an obvious risk to familial and friend relationships.

Punding is engaging in a repetitive action, such as compulsively assembling and disassembling something over and over again. Assembling a jigsaw puzzle several times in a row only becomes punding when it becomes an uncontrollable urge to work the puzzle again and again. Punding does not carry some of the dangers of the other ICDs, but it is still cause for concern and a reason to consider another medication to treat your RLS.

The one commonality that ICDs have is that the activity, though it may be of high risk and of high consequence, brings pleasure to the individual when they engage in it. The activity stimulates the dopamine pleasure center of the brain. When the patient becomes addicted to this form of stimulation and needs to fulfill the compulsion repeatedly, there can be serious long-term consequences.

As an additional danger, some studies suggest that patients with ICDs are more likely to develop an additional complication, dopamine agonist withdrawal syndrome (DAWS), a long-term condition that can cause severe depression, anxiety and other psychological symptoms that often do not respond to treatment.

Once an ICD is identified and the offending medication is discontinued or even if the dose is significantly decreased, an individual will cease all compulsive behaviors. There is no other effective treatment for the compulsive behavior. Familial support and perhaps even professional therapy may be required in some cases to repair damage to relationships that ICD-induced behavior may have caused.