Levodopa Addiction and Factitious Disorder in a Patient With Idiopathic Parkinson’s Disease

Our patient was self-prescribing her Parkinson’s medications with subsequent hallucinations and disinhibited behavior.

Many of the drugs used to treat Parkinson’s disease have reinforcing properties due to dopamine’s link to the brain reward system and addiction. 1 This case illustrates a probable l -dopa addiction given the patient’s repeatedly increased l -dopa usage despite psychiatric side effects. The literature reports that patients who develop a cyclical mood disorder, such as periods of depression and mania or hypomania, after misuse of dopamine replacement therapy have what is termed hedonistic homeostatic dysregulation. 2, 3 In such cases, patients may take excessive doses of l -dopa to attain a psychological state rather than improve motor function. In our patient’s case, there may have been some level of improvement of motor function with the increased l -dopa usage, but the inconsistency of the motor symptoms and the atypical presentation both on physical exam and in her neuropsychological evaluation suggest that the medication was being used more for psychological comfort. Once patients are started on l -dopa, attempts to wean the medication often result in psychological and physiologic symptoms and signs of withdrawal. 4 In addition, it appears that our patient experienced the depression associated with l -dopa withdrawal and therefore may have exaggerated her motor symptoms in order to justify increased usage of the medication.

We believe that a large part of our patient’s symptoms were due to factitious disorder. Her children provided important details which revealed a possible financial incentive; however, in general, our patient’s need to assume the sick role did not appear to be externally motivated. Her children noted that if no one is present to assist her, she will resume normal activity in a reasonable period of time. When caregivers or potential caregivers are around, she will often have very dramatic freezing episodes, use pokers to help her reach even nearby objects, and insist on using a walker. However, in other cases, she walks and even dances, rearranges her house, and cleans without any difficulty at all. Her freezing episodes came at random, sometimes even minutes after a dose of l -dopa, and were not related to wearing off of medications.

It is important that l -dopa addiction in conjunction with factitious disorder presenting as exaggeration or invention of motor symptoms for the purpose of obtaining higher dosages of l -dopa be considered in patients with Parkinson’s disease because of the challenges it presents for the patients, caregivers, and physicians.