Parkinson Disease

  • Andrea E. Cavanna


Parkinson disease is a neurodegenerative condition characterised by the motor features of rest tremor, bradykinesia, and rigidity. The neuropathological process of Parkinson disease consists in the progressive loss of dopaminergic neurons at the level of the basal ganglia (substantia nigra). Over the last few years, the focus of clinical research has shifted from the motor symptoms to the non-motor features of Parkinson disease, especially changes in mental state and behaviour. Behavioural symptoms are common and have been shown to affect patients’ health-related quality of life to a greater extent than motor disability. The intrinsic neuropsychiatric manifestations are mainly related to hypodopaminergic states and encompass depression, anxiety, and apathy. The iatrogenic neuropsychiatric manifestations are mainly related to hyperdopaminergic states and include psychosis, dopamine dysregulation syndrome, and impulse control disorders. Impulse control disorders can occur in about 30% of patients with Parkinson disease treated with dopamine replacement therapy, particularly dopamine receptor agonists. Modulation of dopamine replacement therapy is the first-line treatment approach for iatrogenic behavioural problems, followed by targeted psychotherapy and, where appropriate, pharmacotherapy with atypical antipsychotics.


Basal ganglia Dopamine Non-motor features Parkinson disease Movement disorder 

Suggested Reading


  1. Aarsland D, Cummings J, Weintraub D, Chaudhuri KR. Neuropsychiatric and cognitive changes in Parkinson’s disease and related movement disorders. Cambridge: Cambridge University Press; 2013.CrossRefGoogle Scholar
  2. Chaudhuri KR, Martinez-Martin P, Odin P, Antonini A. Non-motor symptoms of Parkinson’s disease. New York: Springer; 2012.Google Scholar
  3. Chaudhuri KR, Tolosa E, Schapira AHV, Poewe W, editors. Non-motor symptoms of Parkinson’s disease. 2nd ed. Oxford: Oxford University Press; 2014.Google Scholar
  4. Ebmeier KP, O’Brien JT, Taylor J-P. Psychiatry of Parkinson’s disease. Basel: Karger; 2012.CrossRefGoogle Scholar
  5. Jankovic J, Tolosa E. Parkinson’s disease and movement disorders. 6th ed. Baltimore: Lippincott Williams & Wilkins; 2015.Google Scholar
  6. McNamara P. The cognitive neuropsychiatry of Parkinson’s disease. Cambridge: MIT Press; 2011.CrossRefGoogle Scholar
  7. National Institute for Health and Care Excellence (NICE) Guideline (NG71) Parkinson’s disease in adults: diagnosis and management. NICE; 2017.Google Scholar
  8. Parkinson J. An essay on the shaking palsy. London: Sherwood, Neely, and Jones; 1817.Google Scholar
  9. Starkstein SE, Merello M. Psychiatric and cognitive disorders in Parkinson’s disease. Cambridge: Cambridge University Press; 2002.CrossRefGoogle Scholar


  1. Aarsland D, Kramberger MG. Neuropsychiatric symptoms in Parkinson’s disease. J Parkinsons Dis. 2015;5:659–67.CrossRefPubMedGoogle Scholar
  2. Alobaidi H, Pall H. The role of dopamine replacement on the behavioural phenotype of Parkinson’s disease. Behav Neurol. 2013;26:225–35.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Ascherio A, Schwarzschild MA. The epidemiology of Parkinson’s disease: risk factors and prevention. Lancet Neurol. 2016;15:1257–72.CrossRefPubMedGoogle Scholar
  4. Balarajah S, Cavanna AE. The pathophysiology of impulse control disorders in Parkinson disease. Behav Neurol. 2013;26:237–44.CrossRefPubMedPubMedCentralGoogle Scholar
  5. Balestrino R, Martinez-Martin P. Neuropsychiatric symptoms, behavioural disorders, and quality of life in Parkinson’s disease. J Neurol Sci. 2017;373:173–8.CrossRefPubMedGoogle Scholar
  6. Barns MPN, Rickards H, Cavanna AE. The prevalence and clinical characteristics of pathological gambling in Parkinson disease: an evidence-based review. Funct Neurol. 2010;25:9–13.Google Scholar
  7. Blonder LX, Slevin JT. Emotional dysfunction in Parkinson’s disease. Behav Neurol. 2011;24:201–17.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Boeve BF. Idiopathic REM sleep behaviour disorder in the development of Parkinson disease. Lancet Neurol. 2013;12:469–82.CrossRefPubMedPubMedCentralGoogle Scholar
  9. Bora E, Walterfang M, Velakoulis D. Theory of mind in Parkinson’s disease: a meta-analysis. Behav Brain Res. 2015;292:515–20.CrossRefPubMedGoogle Scholar
  10. Bugalho P, Oliveira-Maia AJ. Impulse control disorders in Parkinson’s disease: crossroads between neurology, psychiatry and neuroscience. Behav Neurol. 2013;27:547–57.CrossRefPubMedPubMedCentralGoogle Scholar
  11. Castrioto A, Lhommée E, Moro E, Krack P. Mood and behavioural effects of subthalamic stimulation in Parkinson’s disease. Lancet Neurol. 2014;13:287–305.CrossRefPubMedGoogle Scholar
  12. Chaudhuri KR, Schapira AH. Non-motor symptoms of Parkinson’s disease: dopaminergic pathophysiology and treatment. Lancet Neurol. 2009;8:464–74.CrossRefPubMedGoogle Scholar
  13. Connolly B, Fox SH. Treatment of cognitive, psychiatric, and affective disorders associated with Parkinson’s disease. Neurotherapeutics. 2014;11:78–91.CrossRefPubMedGoogle Scholar
  14. de Roos P, Bloem BR, Kelley TA, Antonini A, Dodel R, Hagell P, Marras C, Martinez-Martin P, Mehta SH, Odin P, Chaudhuri KR, Weintraub D, Wilson B, Uitti RJ. A consensus set of outcomes for Parkinson’s disease from the International Consortium for Health Outcomes Measurement. J Parkinsons Dis. 2017;7:533–43.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Demetriades P, Rickards H, Cavanna AE. Impulse control disorders following deep brain stimulation of the subthalamic nucleus in Parkinson’s disease: clinical aspects. Parkinsons Dis. 2011;2011:658415.PubMedPubMedCentralGoogle Scholar
  16. Diederich NJ, Fenelon G, Stebbins G, Goetz CG. Hallucinations in Parkinson disease. Nat Rev Neurol. 2009;5:331–42.CrossRefPubMedGoogle Scholar
  17. Divac N, Stojanović R, Savić Vujović K, Medić B, Damjanović A, Prostran M. The efficacy and safety of antipsychotic medications in the treatment of psychosis in patients with Parkinson’s disease. Behav Neurol. 2016;2016:4938154.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Djamshidian A, Averbeck BB, Lees AJ, O’Sullivan SS. Clinical aspects of impulsive compulsive behaviours in Parkinson’s disease. J Neurol Sci. 2011;310:183–8.CrossRefPubMedGoogle Scholar
  19. Fasano A, Daniele A, Albanese A. Treatment of motor and non-motor features of Parkinson’s disease with deep brain stimulation. Lancet Neurol. 2012;11:429–42.CrossRefPubMedGoogle Scholar
  20. Ffytche DH, Creese B, Politis M, Chaudhuri KR, Weintraub D, Ballard C, Aarsland D. The psychosis spectrum in Parkinson disease. Nat Rev Neurol. 2017;13:81–95.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Friedman JH. Parkinson disease psychosis: update. Behav Neurol. 2013;27:469–77.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Gallagher DA, Schrag A. Psychosis, apathy, depression and anxiety in Parkinson’s disease. Neurobiol Dis. 2012;46:581–9.CrossRefPubMedGoogle Scholar
  23. Giovannoni G, O’Sullivan JD, Turner K, Manson AJ, Lees AJ. Hedonistic homeostatic dysregulation in patients with Parkinson’s disease on dopamine replacement therapies. J Neurol Neurosurg Psychiatry. 2000;68:423–8.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Goetz CG, Pal G. Initial management of Parkinson’s disease. Br Med J. 2014;349:g6258.CrossRefGoogle Scholar
  25. Jahanshahi M, Obeso I, Baunez C, Alegre M, Krack P. Parkinson’s disease, the subthalamic nucleus, inhibition, and impulsivity. Mov Disord. 2015;30:128–40.CrossRefPubMedGoogle Scholar
  26. Jethwa KD, Onalaja OA. Antipsychotics for the management of Parkinson’s disease: a systematic review and meta-analysis. Br J Psychiatry Open. 2015;1:27–33.CrossRefGoogle Scholar
  27. Kalia LV, Lang AE. Parkinson’s disease. Lancet. 2015;386:896–912.CrossRefGoogle Scholar
  28. Katzenschlager R. Dopaminergic dysregulation syndrome in Parkinson’s disease. J Neurol Sci. 2011;310:271–5.CrossRefPubMedGoogle Scholar
  29. Lees A. The bare essentials: Parkinson’s disease. Pract Neurol. 2010;10:240–6.CrossRefPubMedGoogle Scholar
  30. Lees AJ, Hardy J, Revesz T. Parkinson’s disease. Lancet. 2009;373:2055–66.CrossRefPubMedGoogle Scholar
  31. Loas G, Krystkowiak P, Godefroy O. Anhedonia in Parkinson’s disease: an overview. J Neuropsychiatry Clin Neurosci. 2012;24:444–51.CrossRefPubMedGoogle Scholar
  32. Maréchal E, Denoiseux B, Thys E, Crosiers D, Pickut B, Cras P. Impulse control disorders in Parkinson’s disease: an overview from neurobiology to treatment. J Neurol. 2015;262:7–20.CrossRefPubMedGoogle Scholar
  33. Martinez-Martin P. What is quality of life and how do we measure it? Relevance to Parkinson’s disease and movement disorders. Mov Disord. 2017;32:382–92.CrossRefPubMedGoogle Scholar
  34. Martinez-Martin P, Leentjens AF, de Pedro-Cuesta J, Chaudhuri KR, Schrag AE, Weintraub D. Accuracy of screening instruments for detection of neuropsychiatric syndromes in Parkinson’s disease. Mov Disord. 2016;31:270–9.CrossRefPubMedGoogle Scholar
  35. Mosley PE, Marsh R. The psychiatric and neuropsychiatric symptoms after subthalamic stimulation for Parkinson’s disease. J Neuropsychiatry Clin Neurosci. 2015;27:19–26.CrossRefPubMedGoogle Scholar
  36. Nakum S, Cavanna AE. The prevalence and clinical characteristics of hypersexuality in patients with Parkinson’s disease following dopaminergic therapy: a systematic literature review. Parkinsonism Relat Disord. 2016;25:10–6.CrossRefPubMedGoogle Scholar
  37. Onofrj M, Taylor JP, Monaco D, Franciotti R, Anzellotti F, Bonanni L, Onofrj V, Thomas A. Visual hallucinations in PD and Lewy body dementias: old and new hypotheses. Behav Neurol. 2013;27:479–93.CrossRefPubMedPubMedCentralGoogle Scholar
  38. Pagano G, Rengo G, Pasqualetti G, Femminella GD, Monzani F, Ferrara N, Tagliati M. Cholinesterase inhibitors for Parkinson’s disease: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2015;86:767–73.CrossRefPubMedGoogle Scholar
  39. Pagonabarraga J, Kulisevsky J, Strafella AP, Krack P. Apathy in Parkinson’s disease: clinical features, neural substrates, diagnosis, and treatment. Lancet Neurol. 2015;14:518–31.CrossRefPubMedGoogle Scholar
  40. Poewe W, Seppi K, Tanner CM, Halliday GM, Brundin P, Volkmann J, Schrag AE, Lang AE. Parkinson disease. Nat Rev Dis Primers. 2017;3:17013.CrossRefPubMedGoogle Scholar
  41. Postuma RB, Berg D. The new diagnostic criteria for Parkinson’s disease. Int Rev Neurobiol. 2017;132:55–78.CrossRefPubMedGoogle Scholar
  42. Postuma RB, Berg D, Stern M, Poewe W, Olanow CW, Oertel W, Obeso J, Marek K, Litvan I, Lang AE, Halliday G, Goetz CG, Gasser T, Dubois B, Chan P, Bloem BR, Adler CH, Deuschl G. MDS clinical diagnostic criteria for Parkinson’s disease. Mov Disord. 2015;30:1591–601.CrossRefPubMedGoogle Scholar
  43. Pringsheim T, Jette N, Frolkis A, Steeves TD. The prevalence of Parkinson’s disease: a systematic review and meta-analysis. Mov Disord. 2014;29:1583–90.CrossRefPubMedGoogle Scholar
  44. Ravina B, Marder K, Fernandez HH, Friedman JH, McDonald W, Murphy D, Aarsland D, Babcock D, Cummings J, Endicott J, Factor S, Galpern W, Lees A, Marsh L, Stacy M, Gwinn-Hardy K, Voon V, Goetz C. Diagnostic criteria for psychosis in Parkinson’s disease: report of an NINDS, NIMH work group. Mov Disord. 2007;22:1061–8.CrossRefPubMedGoogle Scholar
  45. Rodriguez-Oroz MC, Jahanshahi M, Krack P, Litvan I, Macias R, Bezard E, Obeso JA. Initial clinical manifestations of Parkinson’s disease: features and pathophysiological mechanisms. Lancet Neurol. 2009;8:1128–39.CrossRefPubMedGoogle Scholar
  46. Santangelo G, Trojano L, Barone P, Errico D, Grossi D, Vitale C. Apathy in Parkinson’s disease: diagnosis, neuropsychological correlates, pathophysiology and treatment. Behav Neurol. 2013;27:501–13.CrossRefPubMedPubMedCentralGoogle Scholar
  47. Sauerbier A, Rosa-Grilo M, Qamar MA, Chaudhuri KR. Nonmotor subtyping in Parkinson’s disease. Int Rev Neurobiol. 2017;133:447–78.CrossRefPubMedGoogle Scholar
  48. Seppi K, Weintraub D, Coelho M, Perez-Lloret S, Fox SH, Katzenschlager R, Hametner EM, Poewe W, Rascol O, Goetz CG, Sampaio C. The Movement Disorder Society evidence-based medicine review update: treatments for the non-motor symptoms of Parkinson’s disease. Mov Disord. 2011;26(Suppl 3):42–80.CrossRefGoogle Scholar
  49. Shotbolt P, Moriarty J, Costello A, Jha A, David A, Ashkan K, Samuel M. Relationships between deep brain stimulation and impulse control disorders in Parkinson’s disease, with a literature review. Parkinsonism Relat Disord. 2012;18:10–6.CrossRefPubMedGoogle Scholar
  50. Sierra M, Carnicella S, Strafella AP, Bichon A, Lhommée E, Castrioto A, Chabardes S, Thobois S, Krack P. Apathy and impulse control disorders: Yin & Yang of dopamine dependent behaviors. J Parkinsons Dis. 2015;5:625–36.CrossRefPubMedGoogle Scholar
  51. Spencer AH, Rickards H, Fasano A, Cavanna AE. The prevalence and clinical characteristics of punding in Parkinson’s disease. Mov Disord. 2011;26:578–86.CrossRefPubMedGoogle Scholar
  52. Sprenger F, Poewe W. Management of motor and non-motor symptoms in Parkinson’s disease. CNS Drugs. 2013;27:259–72.CrossRefPubMedGoogle Scholar
  53. Svenningsson P, Westman E, Ballard C, Aarsland D. Cognitive impairment in patients with Parkinson’s disease: diagnosis, biomarkers, and treatment. Lancet Neurol. 2012;11:697–707.CrossRefPubMedGoogle Scholar
  54. Tan LC. Mood disorders in Parkinson’s disease. Parkinsonism Relat Disord. 2012;18(Suppl 1):S74–6.CrossRefPubMedGoogle Scholar
  55. Volkmann J, Daniels C, Witt K. Neuropsychiatric effects of subthalamic neurostimulation in Parkinson disease. Nat Rev Neurol. 2010;6:487–98.CrossRefPubMedGoogle Scholar
  56. Voon V, Napier TC, Frank MJ, Sgambato-Faure V, Grace AA, Rodriguez-Oroz M, Obeso J, Bezard E, Fernagut PO. Impulse control disorders and levodopa-induced dyskinesias in Parkinson’s disease: an update. Lancet Neurol. 2017;16:238–50.CrossRefPubMedGoogle Scholar
  57. Weintraub D, Burn DJ. Parkinson’s disease: the quintessential neuropsychiatric disorder. Mov Disord. 2011;26:1022–31.CrossRefPubMedPubMedCentralGoogle Scholar
  58. Wen MC, Chan LL, Tan LC, Tan EK. Depression, anxiety, and apathy in Parkinson’s disease: insights from neuroimaging studies. Eur J Neurol. 2016;23:1001–19.CrossRefPubMedGoogle Scholar
  59. Yeung EYH, Cavanna AE. Sleep attacks in patients with Parkinson’s disease on dopaminergic medications: a systematic review. Mov Disorders Clin Pract. 2014;1:307–16.CrossRefGoogle Scholar
  60. Zhuo C, Xue R, Luo L, Ji F, Tian H, Qu H, Lin X, Jiang R, Tao R. Efficacy of antidepressive medication for depression in Parkinson disease: a network meta-analysis. Medicine. 2017;96:e6698.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Andrea E. Cavanna
    • 1
  1. 1.Dept of NeuropsychiatryUniversity of BirminghamBirminghamUnited Kingdom

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