Psychiatria Danubina, 2024; Vol. 36, No. 1, pp 135-136 https://doi.org/10.24869/psyd.2024.135
© Medicinska naklada – Zagreb, Croatia

Case Report

PATIENT WITH PARKINSON’S DISEASE AND DEPRESSIVESYMPTOMS ASSOCIATED WITH IMPULSE CONTROLDISORDER
Kanae Migita1, Naomichi Okamoto1, Atsuko Ikenouchi1,2, Reoto Kijima1, Tomoyo Hashimoto3,
Hiroaki Adachi3 & Reiji Yoshimura1
1 Department of Psychiatry, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
2 Dementia Centre, Hospital of Occupational and Environmental Health, Fukuoka, Japan
3 Department of Neurology, School of Medicine, Occupational and Environmental Health, Fukuoka, Japan
received: 27. 5. 2023;     revised: 20. 6. 2023;     accepted: 8. 7. 2023*****

INTRODUCTION
Parkinson’s disease (PD) is characterized mainly by
motor symptoms such as tremors, bradykinesia, and rigidity; however, they are also often cause psychiatric symptoms such as depressive symptoms (Reijnders et al. 2008).
Furthermore, impulse control disorders (ICD) may occur
during the treatment of patients with PD and are characterized by severe behavioral and affective disturbances that interfere with social life. To date, there have been few reportson the treatment progress of depressive symptoms caused
by ICD that emerge during PD treatment. Here, we report apatient with a case of PD presenting with depressive symptoms that appeared along with exhibitionism as ICD.

CASE PRESENTATION
A 59-year-old Japanese male patient with PD wasreferred to our psychiatry department. One year prior tothe current admission, he was arrested and detained twice
for exposing himself to women due to sudden uncontrollable lust after drinking. He entered a convenience store
wearing only stockings; therefore, he was admitted to ourneurology department with a suspected drug-induced ICD
due to dopamine agonists. He had been receiving levodopa-carbidopa hydrate 700 mg, rotigotine 18 mg, and opicapone 25 mg. During hospitalization, another patient saw
him touching his genitalia outside his hospital room. In
addition, when a nurse visited his hospital room, he exposed his lower body and continued touching his privateparts without paying attention to the nurse’s question. He
stated that he had engaged in these series of acts withoutawareness. He was referred to a psychiatrist because ofdepressive symptoms; he appeared conflicted, distressed,depressed, and anxious. He was not taking antidepressantsat the time. He believed that sexual harassment and other
antisocial behaviors were unacceptable. His Mini-Mental

State Examination scores were 26/30 (decreased attention,memory retention, and comprehension) and Frontal Assessment Battery scores were 12/18 (decreased flexibilityof thought and inhibitory control), with no marked cognitive decline, including frontal lobe function. He scored 14
points on the Hamilton Depression Rating Scale, which
grades depression, guilt, insomnia, decreased activity,thought suppression, anxiety, appetite, physical symptoms,
and psychosomatic symptoms. His symptoms backgroundsuggested that the depressive symptoms were due to regret
and psychosocial distress over sexually deviant behavior.
Because of suspected drug-induced ICD, rotigotine wasdiscontinued and changes in psychiatric symptoms prior
to initiation of antidepressants were monitored. The patient was discharged from the neurology department on
the 15th day after admission without Parkinsonism exacerbation due to rotigotine discontinuation. Three months
after being released from the hospital, the patient’s sexual desire continued to decline, and no additional signs ofabnormal sexual behavior or impulse control issues wereobserved. Furthermore, it appeared that the patient’s depression did not worsen, as they were able to manage theirimpulsiveness effectively, leading to the conclusion that
antidepressants were not required. The patient’s Hamilton
Depression Rating Scale score decreased to five points,
indicating improvement in depression, guilt, thought
suppression, appetite, and physical and psychosomaticsymptoms. Since then, the patient has remained free ofany problematic social behaviors or depressive symptoms.

DISCUSSION
To our best knowledge, this is the first report of improvement in depressive symptoms without antidepressants by assessing social and symptom backgrounds in acase of drug-induced ICD in a Japanese patient with PD.
Because some types of antidepressants have been reported

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Kanae Migita, Naomichi Okamoto, Atsuko Ikenouchi, Reoto Kijima, Tomoyo Hashimoto, Hiroaki Adachi & Reiji Yoshimura:
PATIENT WITH PARKINSON’S DISEASE AND DEPRESSIVE SYMPTOMS ASSOCIATED WITH IMPULSE CONTROL DISORDER
Psychiatria Danubina, 2024; Vol. 36, No. 1, pp 135-136

to worsen parkinsonian motor features, unnecessary antidepressant administration should be avoided. Exhibitionism causes clinically meaningful distress or social andoccupational dysfunction because of sexual urges andfantasies. Earlier onset, male sex, and use of high-dose
dopamine agonist stimulants are thought to contributeto the development of ICD (Solla et al. 2015)—this casefits these characteristics in several aspects. Exhibitionistic disorder is generally difficult to treat, and it is mainly
treated with antidepressant drugs. Behavioral disorders
with an uncontrolled desire for pleasure are associatedwith overactivity of ventral striatal circuits forming thebrain reward system and overstimulation of dopamine receptors distributed in the nucleus accumbens. Dopamineagonists are thought to induce sensitization of the limbic ventral striatum and motor dorsal striatum, leading
to a transition from apathy to impulse control disorder(Garcia-Ruiz 2018). Excessive dopaminergic stimulationin the striatum may reflect dysregulation of dopaminergic signaling pathways (Alexander et al. 1990). However,dopamine blockers have been reported to induce sexual
hyperactivity (Stefanou et al. 2020), the mechanism isspeculated to be an indirect increase in dopamine activity
in the mesocortical-dopaminergic pathway due to blockade of serotonergic neurotransmission. Although dopamine may have a significant role in paraphilic disorders,the actual pathophysiology is presumably more complex.
In this case, although it was not possible to clearly determine the cause, it was suspected that rotigotine might
have been the cause of the exhibitionism, based on thecourse of the symptom improvement. We could improvedifficult-to-treat exhibitionism by only discontinuing dopamine agonists without administering antidepressants.
Before using antidepressants, clinicians should always

consider the possibility that reducing the medication dose
may improve exhibitionism.

CONCLUSION
We reported a case of PD with depressive symptoms
associated with ICD. In this case, exhibitionism improved after rotigotine discontinuation, suggesting theimportance of detecting drug-induced exhibitionism. In
the treatment of depressive symptoms associated withPD, the patient’s social and symptom background should
be considered when making treatment choices.

Acknowledgments: None
Conflict of Interest: None declared.
Authors Contributions: All authors made a signif-

icant contribution to the case report in terms of conception, study design, execution, acquisition of data, analysis, interpretation, drafting, revising, or critically reviewing
the article. All authors gave final approval of the version
to be published, have agreed on the journal to which thearticle has been submitted, and agree to be accountable
for all aspects of the work.

Ethical Approval and Consent to participate: All actions described in this case report wereconducted in accordance with ethical guidelines of theDeclaration of Helsinki in 1995 (as revised in Edinburgh
2000). This was a case report and the Ethics Committeeof the University of Occupational and Environmental
Health excused the review.
Informed consent: Informed consent was obtained
from the patient for participation and publication of anonymous information in this case report.

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Correspondence:
Reiji Yoshimura
807-8555. 1-1, Iseigaoka, Yahatanishi-ku, Kitakyushu-shi
Department of Psychiatry, University of Occupational
and Environmental Health, Fukuoka, Japan
yoshi621@med.uoeh-u.ac.jp / +81-93-691-7253

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