CNS Drugs

, Volume 22, Issue 5, pp 407–416 | Cite as

Antiparkinsonian Medication and Pathological Gambling

  • Malcolm Lader
Review Article


Parkinson’s disease is a common condition, usually treated by dopaminergic agents, both ergot and non-ergot. Many behavioural abnormalities are associated with such usage, including impulse control disorders (ICDs), dopamine dysregulation syndrome and ‘punding’. Pathological gambling, a form of ICD, comprises persistent and maladaptive gambling of various types that disrupts personal, family or occupational activity. Pathological gambling may be associated with other abnormal actions such as pathological shopping, hoarding and hypersexuality. The incidence varies widely from study to study but may be up to 7% of users of dopaminergic agents. Recognition of this problem has led drug regulatory agencies to add precautions concerning pathological gambling to official drug information for the entire class of antiparkinsonian medications. The literature is not entirely consistent and opinions differ greatly, but pramipexole (a dopamine D2 and D3 agonist), and perhaps ropinirole (also a D2/D3 agonist), may be especially likely to be associated with pathological gambling, although the precise nature of the relationship is unclear. Treatment involves reducing the dose of the medication or switching to another medication; unfortunately, the Parkinson’s disease may worsen. The mechanism of this adverse effect is believed to be excessive dopaminergic stimulation but probably not specifically involving D3 receptors. A parallel to addictive behaviour with stimulant drugs has been noted.


Levodopa Dopamine Agonist Pathological Gambling Pramipexole Gambling Behaviour 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this review. The author has advised or lectured for the following companies in the past 5 years: Evotec, Lundbeck, Neurim, Pfizer, Procter and Gamble, Sepracor, Servier and Takeda. He is also advising a firm of solicitors on the adverse effects of antiparkinsonian medication; nevertheless, in English law, his duty is to the Court and not to either party.


  1. 1.
    National Collaborating Centre for Chronic Conditions. Parkinson’s disease: national clinical guidelines for diagnosis and management in primary and secondary care. London: Royal College of Physicians, 2006Google Scholar
  2. 2.
    Goetz CG, Koller WC, Poewe W, et al. Treatment of depression in idiopathic Parkinson’s disease. J Neuro Neurosurg Psychiat 2002; 17Suppl. 4: SI 12–9Google Scholar
  3. 3.
    Aarsland D, Andersen K, Larsen JP, et al. Prevalence and characteristics of dementia in Parkinson’s disease: an 8-year prospective study. Arch Neurol 2003; 60: 387–92PubMedCrossRefGoogle Scholar
  4. 4.
    Fenelon G, Mahieux F, Huon R, et al. Hallucinations in Parkinson’s disease: prevalence, phenomenology and risk factors. Brain 2000; 123: 733–45PubMedCrossRefGoogle Scholar
  5. 5.
    National Institute for Health and Clinical Excellence (NICE). Parkinson’s disease: diagnosis and management in primary and secondary care (NICE guideline 2006) [online]. Available from URL: [Accessed 2008 Feb 26]
  6. 6.
    Diamond A, Jankovic J. Treatment of advanced Parkinson’s disease. Expert Rev Neurother 2006; 6: 1181–97PubMedCrossRefGoogle Scholar
  7. 7.
    Jankovic J. An update on the treatment of Parkinson’s disease. Mount Sinai J Med 2006; 73: 682–9Google Scholar
  8. 8.
    Burn DJ, Tröster AI. Neuropsychiatric complications of medical and surgical therapies for Parkinson’s disease. J Geriatr Psychiatry Neurol 2004; 17: 172–80PubMedCrossRefGoogle Scholar
  9. 9.
    Philips M, Breen K. Parkinson’s disease. Geriatr Med 2007; 37: 19–25Google Scholar
  10. 10.
    Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. Mov Disord 2006; 21: 524–9PubMedCrossRefGoogle Scholar
  11. 11.
    Shapiro MA, Chang TL, Munson SK, et al. Hypersexuality and paraphilias induced by selegeline in Parkinson’s disease: report of 2 cases. Parkinsonism Relat Disord 2006; 12: 392–5PubMedCrossRefGoogle Scholar
  12. 12.
    Tippmann-Peikert M, Park JG, Boeve BF, et al. Pathological gambling in patients with restless legs syndrome treated with dopaminergic agonists. Neurol 2007; 68: 301–3CrossRefGoogle Scholar
  13. 13.
    Silveira-Moriyama L, Evans AH, Katzenschlager R, et al. Punding and dyskinesias. Mov Disord 2006; 21(12): 2214–7PubMedCrossRefGoogle Scholar
  14. 14.
    Frieling H, Hillemacher T, Ziegenbein M, et al. Treating dopamimetic psychosis in Parkinson’s disease: structured review and meta-analysis. Eur Neuropsychopharmacol 2007; 17: 165–71PubMedCrossRefGoogle Scholar
  15. 15.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association, 2000Google Scholar
  16. 16.
    World Health Organization. ICD-10 classification of mental and behavioral disorders. Edinburgh: Churchill Livingstone, 1994Google Scholar
  17. 17.
    Wong SH, Steiger MJ. Pathological gambling in Parkinson’s disease. BMJ 2007; 334: 810–1PubMedCrossRefGoogle Scholar
  18. 18.
    Molina JA, Saniz-Artiga MJ, Fraile A, et al. Pathologic gambling in Parkinson’s disease: a behavioral manifestation of pharmacologic treatment? Mov Disord 2000; 15: 869–72PubMedCrossRefGoogle Scholar
  19. 19.
    Giovannoni G, O’Sullivan JD, Turner K, et al. Hedonistic homeostatic dysregulation in patients with Parkinson’s disease on dopamine replacement therapies. J Neurol Neurosurg Psychiatry 2000; 68: 423–8PubMedCrossRefGoogle Scholar
  20. 20.
    Cantello R. Hedonistic homeostatic dysregulation in patients with Parkinson’s disease on dopamine replacement therapies. J Neurol Neurosurg Psychiatry 2000; 69: 566–7PubMedCrossRefGoogle Scholar
  21. 21.
    Hall GW, Carriero NJ, Takushi RY, et al. Pathological gambling among cocaine dependent outpatients. Am J Psychiatry 2000; 157: 1127–33PubMedCrossRefGoogle Scholar
  22. 22.
    Gschwandtner U, Aston J, Renaud S, et al. Pathological gambling in patients with Parkinson’s disease. Clin Neuropharmacol 2001; 24(3): 170–2PubMedCrossRefGoogle Scholar
  23. 23.
    Serrano-Duenas M. Chronic dopamimetic drug addiction and pathologic gambling in patients with Parkinson’s disease: presentation of 4 cases. German J Psychiatry 2002; 5: 62–6Google Scholar
  24. 24.
    Avanzi M, Uber E, Bonfa F. Pathological gambling in two patients on dopamine replacement therapy for Parkinson’s disease. Neurol Sci 2004; 25: 98–101PubMedCrossRefGoogle Scholar
  25. 25.
    Kurlan R. Disabling repetitive behaviors in Parkinson’s disease. Mov Disord 2004; 19: 433–7PubMedCrossRefGoogle Scholar
  26. 26.
    Tyne HL, Medley G, Ghadiali E, et al. Gambling in Parkinson’s disease. Mov Disord 2004; 19Suppl. 19: S195Google Scholar
  27. 27.
    Driver-Dunckley E, Samanta J, Stacy M. Pathological gambling associated with dopamine agonist therapy in Parkinson’s disease. Neurology 2003; 61: 422–3PubMedCrossRefGoogle Scholar
  28. 28.
    Dodd ML, Klos KJ, Bower JH, et al. Pathological gambling caused by drugs used to treat Parkinson’s Disease. Arch Neurol 2005; 62: 1–5CrossRefGoogle Scholar
  29. 29.
    Lu C, Bharmal A, Suchowersky O. Gambling and Parkinson’s disease. Arch Neurol 2006; 63: 298PubMedCrossRefGoogle Scholar
  30. 30.
    Morgan JC, Iyer SS, Sethi KD. Impulse control disorders and dopaminergic drugs. Arch Neurol 2006; 63: 298–9PubMedCrossRefGoogle Scholar
  31. 31.
    Stocchi F. Pathological gambling in Parkinson’s disease. Lancet Neurol 2005; 4(10): 590–2PubMedCrossRefGoogle Scholar
  32. 32.
    Grosset KA, Macphee G, Pal G, et al. Problematic gambling on dopamine agonists: not such a rarity. Mov Disord 2006; 21: 2206–8PubMedCrossRefGoogle Scholar
  33. 33.
    Avanzi M, Baratti M, Cabrini S, et al. Prevalence of pathological gambling in patients with Parkinson’s disease. Mov Disord 2006; 21(12): 2068–72PubMedCrossRefGoogle Scholar
  34. 34.
    Voon V, Hassan K, Zurowski M, et al. Prospective prevalence of pathologic gambling and medication association in Parkinson’s disease. Neurology 2006; 66: 1750–2PubMedCrossRefGoogle Scholar
  35. 35.
    Voon V, Thomsen T, Miyasaki JM, et al. Factors associated with dopaminergic drug-related pathological gambling in Parkinson disease. Arch Neurol 2007; 64: 212–6PubMedCrossRefGoogle Scholar
  36. 36.
    Szarfman A, Doraiswamy PM, Tonning JM, et al. Association between pathologic gambling and parkinsonian therapy as detected in the Food and Drug Administration adverse event database. Arch Neurol 2006; 63: 299–300PubMedCrossRefGoogle Scholar
  37. 37.
    Medicines and Healthcare Products Regulatory Agency. Dopamine agonists: pathological gambling and increased libido. London: MHRA, 2006Google Scholar
  38. 38.
    Parkinson’s Disease Society. Gambling and Parkinson’s. London: Parkinson’s Disease Society of the United Kingdom, 2006Google Scholar
  39. 39.
    Chaudhuri KR, Healy DG, Schapira AHV. Non-motor symptoms of Parkinson’s disease: diagnosis and management. Lancet Neurol 2006; 5: 235–45PubMedCrossRefGoogle Scholar
  40. 40.
    Seedat S, Kesler S, Niehaus DJH, et al. Pathological gambling behavior: emergence secondary to treatment of Parkinson’s disease with dopaminergic drugs. Depress Anxiety 2000; 11: 185–6PubMedCrossRefGoogle Scholar
  41. 41.
    Ardouin C, Voon V, Worbe Y, et al. Pathological gambling in Parkinson’s disease improves on chronic subthalamic nucleus stimulus. Mov Disord 2006; 21: 1941–6PubMedCrossRefGoogle Scholar
  42. 42.
    Moreno I, Saiz-Ruiz J, Lòpez-Ibor JJ. Serotonin and gambling dependence. Human Psychopharmacol 1991; 6: S9–12CrossRefGoogle Scholar
  43. 43.
    Pallanti S, Bernardis S, Quercioli L, et al. Serotonin dysfunction in pathological gamblers: increased prolactin response to oral m-CPP versus placebo. CNS Spectrums 2006; 11: 12–8Google Scholar
  44. 44.
    Schultz W. Getting formal with dopamine and reward. Neuron 2002; 36: 241–63PubMedCrossRefGoogle Scholar
  45. 45.
    Shizgal P, Arvanitogiannis A. Gambling on dopamine. Science 2003; 299: 1856–8PubMedCrossRefGoogle Scholar
  46. 46.
    Fiorillo CD, Tobler PN, Schultz W. Discrete coding of reward probability and uncertainty by dopamine neurons. Science 2003; 299: 1898–902PubMedCrossRefGoogle Scholar
  47. 47.
    Potenza MN, Steinberg MA, Skudlarski P, et al. Gambling urges in pathological gambling: a functional magnetic resonance imaging study. Arch Gen Psychiatry 2003; 60: 828–36PubMedCrossRefGoogle Scholar
  48. 48.
    Robbins TW, Everitt B. Drug addiction: bad habits add up. Nature 1999; 398: 567–70PubMedCrossRefGoogle Scholar
  49. 49.
    Reuter J, Raedler T, Rose M, et al. Pathological gambling is linked to reduced activation of the mesolimbic reward system. Nat Neurosci 2005; 8: 147–8PubMedCrossRefGoogle Scholar
  50. 50.
    Pontone G, Williams JR, Bassett SS, et al. Clinical features associated with impulse control disorders in Parkinson disease. Neurology 2006; 67: 1258–61PubMedCrossRefGoogle Scholar
  51. 51.
    Sokoloff P, Giros B, Martres M-P, et al. Molecular cloning and characterization of a novel dopamine receptor (D3) as a target for neuroleptics. Nature 1990; 347: 146–50PubMedCrossRefGoogle Scholar
  52. 52.
    Perachon S, Schwartz J-C, Sokoloff P. Functional potencies of new antiparkinsonian drugs at recombinant human dopamine D1, D2 and D3 receptors. Eur J Pharmacol 1999; 366: 293–300PubMedCrossRefGoogle Scholar
  53. 53.
    Gerlach M, Double K, Arzberger T, et al. Dopamine receptor agonists in current clinical use: comparative dopamine receptor binding profiles defined in the human striatum. J Neurol Transm 2003; 110: 1119–27CrossRefGoogle Scholar
  54. 54.
    Hubble JP. Pre-clinical studies of pramipexole: clinical relevance. Eur J Neurol 2000; 7Suppl. 1: 15–20PubMedCrossRefGoogle Scholar
  55. 55.
    Montastruc JL, Sommet A, Olivier P, et al. Drugs, Parkinson’s disease and parkinsonian syndromes: recent advances in pharmacovigilance [in French]. Therapie 2006; 61: 29–38PubMedCrossRefGoogle Scholar
  56. 56.
    Ibànez A, Blanco C, Perez de Castro I, et al. Genetics of pathological gambling. J Gambl Stud 2003; 19: 11–22PubMedCrossRefGoogle Scholar
  57. 57.
    Kettle P, Marks I. Neurological factors in obsessive-compulsive disorder: two case reports and a review of the literature. Br J Psychiatry 1986; 149: 315–9CrossRefGoogle Scholar
  58. 58.
    Stein DJ, Grant JE. Betting on dopamine. CNS Spectrums 2005; 10: 268–70PubMedGoogle Scholar
  59. 59.
    Lawrence AD, Evans AH, Lees AJ. Compulsive use of dopamine replacement therapy in Parkinson’s disease: reward systems gone awry? Lancet Neurol 2003; 2: 595–604PubMedCrossRefGoogle Scholar
  60. 60.
    Evans AH, Lees AJ. Dopamine dysregulation syndrome in Parkinson’s disease. Curr Opin Neurol 2004; 17: 393–8PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2008

Authors and Affiliations

  1. 1.Institute of PsychiatryKing’s CollegeLondonEngland

Personalised recommendations