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BMJ Case Reports 2011; doi:10.1136/bcr.07.2011.4459 1 of 3
BACKGROUND
Introduction
Restless legs syndrome (RLS) can often be a very disabling
sensorimotor disorder. Although there are no UK-based
prevalence studies, international studies have found rates
of between 3% and 10%.
1 The four essential diagnostic cri-
teria for RLS are: urge to move, onset or exacerbation with
rest, relief with movement and night time onset or wors-
ening of symptoms.
2 Although the precise pathophysi-
ological mechanisms underlying RLS have not been clearly
elucidated, some point to dopaminergic depletion, thereby
implicating the nigrostriatal dopaminergic loop.
3 Given
this etiological explanation, it follows that dopaminergic
drugs such as levadopa/carbedopa, ropinirole, pramipexole
and pergolide can be useful treatments in alleviating the
symptoms of RLS. Although not very common, impulse
control disorders (such as gambling addiction, which is the
focus of this case report) are potentially devastating side
effects of dopaminergic treatment.
4
–
6 Gambling addiction
and other impulse control disorders have previously been
reported as a common side effect of dopaminergic treat-
ment for Parkinson’s disease
7
8 – a disorder sharing sev-
eral commonalities with RLS, in its underlying aetiology,
characteristics and treatment. However, iatrogenic gam-
bling addiction as a result of dopaminergic treatment for
RLS has been less studied, although some case reports and
prevalence surveys have emerged recently (see discussion
section); and clinicians and patients are not adequately
aware of this.
Hence this side effect (iatrogenic gambling addiction),
during the course of treatment for RLS, often goes unrecog-
nised and unaddressed, leading to even more detrimental
consequences for the affected individual and family. What
motivated us to share this patient’s story was his comment
to one of the authors, ‘they should have forewarned me
that this medication could turn me into a gambler. Then
things would not have got as bad as they did, and cer-
tainly I would not have blamed myself’. Through this case
description, we hope to raise clinicians’ awareness of this
iatrogenic condition and we call for more regular screen-
ing for gambling behaviours prior to and during treatment
with dopaminergic agents.
CASE PRESENTATION
Given below is the patients own account of his gambling
addiction, a direct consequence of dopaminergic treatment
for his RLS.
‘I am a 62-year-old retired school teacher, and this is
my story of how I turned into a gambler, or to be more
precise, how I was turned into a gambler. I had restless
legs ever since I can remember; started very early in child-
hood I think. My father had it too. About 20 years ago, it
became more of a concern, so I went and saw my general
practitioner. He referred me to a neurologist for special-
ist treatment. The neurologist started me on dopaminer-
gic medications (sinemet and cabergoline). I have been on
some medication or the other since. Medications make my
condition better and I sleep better. Apart from this, my life
was okay until I retired about 2 years ago. I had never gam-
bled, except for a fl utter, once a year – a pound or so, on
the Grand National; nothing more, ever.
So, I had been on these medications (sinemet and caber-
goline, then cabergoline was switched to ropinirole, later
changed to rotigotine) for over 18 years and I was doing
Reminder of important clinical lesson
‘You never told me I would turn into a gambler’: a fi rst person
account of dopamine agonist – induced gambling addiction in
a patient with restless legs syndrome
Henrietta Bowden Jones, 1 Sanju George 2
1 Department of Neurosciences and Mental Health, Imperial College, London, UK ;
2 Department of Addiction Psychiatry, Birmingham and Solihull Mental Health NHS Trust, Birmingham, UK
Correspondence to Dr Sanju George, sanju.george@bsmhft.nhs.uk
Summary
Dopaminergic agents are commonly used and effective treatments for restless legs syndrome (RLS), a disabling sensorimotor disorder.
Less known are some of the potentially disabling side effects of these treatments, particularly iatrogenic gambling addiction, as is described
here. Here the authors present a 62-year-old man, with a 20–year history of RLS, who developed gambling addiction while on dopaminergic
treatment. He was not forewarned of this side effect, nor was he ever screened for gambling behaviours prior to or during treatment. Eight
months after discontinuation of dopaminergic treatment and after 10 sessions of cognitive–behavioural therapy for gambling addiction, his
gambling behaviours have partially resolved. To our knowledge, this is the fi rst ever fi rst person account of this condition. To prevent the
devastating consequences of gambling addiction or to minimise its impact by early intervention, the authors call for clinicians involved in
treatment of RLS to follow these simple measures: screen patients for gambling behaviours prior to the onset and during dopaminergic
treatment; forewarn patients of this potential side effect; and if patients screen positive, refer them to specialist gambling treatment services,
in addition to making necessary changes to their medication regime.
BMJ Case Reports 2011; doi:10.1136/bcr.07.2011.4459
2 of 3
good. It was when I retired 2 years ago that I started gam-
bling. It started with minor stuff, like the bets you could
make in the daily papers – I started betting for no money.
But very soon, I was going to the bookies, round the cor-
ner from where I lived. I would bet on horses, football
matches and also play blackjack and slot machines. Before
I realised, it escalated from once or twice a week to an eve-
ryday pastime. Actually, it became more than a pastime.
And from spending a couple of pounds a week, I had got
to spending hundreds of pounds everyday: I was hooked.
I had to do it whether I had the money or not. I would
lie, borrow or steal from home. I would ask anyone and
everyone. Because I knew I could win and then could pay
it all back. I even started to gamble online, so no one had
to know and I did not even have to get out of the house.
In those 2 to 3 mad years, I lost over £50,000. Apart from
the money side of things, I lost the respect of my family
as well: my kids hated me and my wife blamed me for it.
I lost my ambition in life, apart from the need to gamble. I
had no time for anything or anyone else.
All this time, I was not associating my gambling with
the medication. How was I to know? One time, at my
sixth monthly check up with my specialist, I told him and
he immediately switched my medication. He also referred
me to the gambling clinic. And then over the next few
months I stopped gambling, or nearly stopped. I am still
frightened because the cravings are still there. Say, every
time I walk past a betting shop, if I have money in my
pocket, I’m scared, or when I get an e-mail offering a £5
free bet. I have had a few lapses in the past few months.
The way I control my gambling these days is by control-
ling my lifestyle; having other things to do. I go for walks,
swim and read a lot. I have got my ambition back and I’m
me again. My family is beginning to trust me again. My
advice to others would be – do not ever get into a betting
shop if you are on this medication. And to doctors – please
forewarn your patients about this side effect so it can be
nipped in the bud. And to fellow patients- certainly, do not
blame yourself, and get help as soon as you can’.
TREATMENT
The patient received 10 sessions of individual cognitive–
behavioural therapy for his gambling addiction, between
September 2010 and March 2011. Key issues discussed in
these sessions were: the role of behavioural conditioning
in gambling and triggers for the occasional lapses (seemed
to mostly involve complacency with regard to both carry-
ing reasonably large amounts of cash and a lack of fore-
sight when entering into high-risk situations). Discussions
also encompassed the patient’s lifestyle and adaptation to
retirement. Finally, the need for roles in order to provide a
sense of purpose and impose some structure on his spare
time was also discussed.
OUTCOME AND FOLLOW-UP
Details of the patient’s treatment aspects are covered in
other sections. In summary, the patient has, since com-
pletion of his 1:1 cognitive–behavioural therapy in March
2011 been completely abstinent from gambling. He still
reports occasional cravings, especially triggered by high-
risk situations such as walking past betting shops and
getting e-mail reminders from online betting schemes.
He is highly motivated to continue total abstinence from
gambling. He spends more time with his family and keeps
himself busy by pursuing other recreational activities.
DISCUSSION
The subject of dopaminergic treatment – induced gam-
bling addiction in patients with RLS had not been suffi -
ciently explored until recently. But encouragingly, over the
past few years researchers have attempted to understand
this area better. In perhaps one of the earliest accounts
Driver–Dunckley et al
9 studied 77 patients with idiopathic
RLS who were on one or more dopaminergic medica-
tions, for medication-induced gambling behaviours and
other compulsions. They found that 6% of their sample
had increased urges to gamble and spent increased time
gambling, specifi cally after the initiation of dopaminergic
medication. In a similar and more recent study, Dang et al
10
found the prevalence of impulse control disorders (ICDs)
in this cohort of patients to be 2.7%; these ICDs included
gambling addiction, kleptomania, compulsive shopping
and hypersexuality. They failed to establish a linear rela-
tionship between duration of dopaminergic treatment and
risk of onset of ICDs, but found that some of these iatro-
genic symptoms persisted beyond cessation of dopaminer-
gic treatment. This combined with the multiple fi nancial,
forensic, social and marital implications of these behav-
iours they found in this study made them call for ‘careful
consideration by clinicians of the emergence of ICDs and
discussion with patients.
In perhaps the most comprehensive review to date, of
all cases published, of patients with RLS who developed
gambling addiction while on dopaminergic therapy, d’Orsi
et al
11 identifi ed 15 cases. Key features found in this review
included the following: average age of onset was 59.8 (range
was 27 to 77), gender distribution – male: female was 7:8,
they were all on dopaminergic monotherapy, they had all
been on treatment for several months, some also experi-
enced other compulsive behaviours, none had a history of
gambling addiction but four were recreational gamblers in
the past, and gambling addiction ‘improved-resolved’ in all
patients upon cessation of dopaminergic treatment.
In light of the above published evidence, the patient’s
case described above seems not uncommon and fi ts with
previous reports. The patient had suffered from RLS since
early childhood and he had a family history of RLS. He
commenced dopaminergic treatment at the age of 40,
with sinemet and cabergoline. His symptoms of RLS were
reasonably well-controlled initially but as he developed
an augmentation phenomenon, he was switched from
cabergoline to ropinirole. On this medication, although
his symptoms of RLS improved, he developed a gambling
problem; he had had no history of such a problem. As soon
as this was identifi ed, he was switched to rotigotine but
his addiction to gambling persisted. It was then that his
medication was changed over to gabapentin and he was
also referred to the gambling clinic. He received 10 ses-
sions of cognitive–behavioural therapy for his gambling
addiction. Six months on, he is no longer addicted to gam-
bling but he has had a few lapses. His symptoms of RLS
are better controlled but he still struggles to get a refreshing
night’s sleep.
In our view what makes this case unusual from previ-
ous ones and hence all the more relevant to the clinician
are the following. First, the patient was never forewarned
BMJ Case Reports 2011; doi:10.1136/bcr.07.2011.4459 3 of 3
about this potential side effect (i.e. gambling addiction)
any time before, nor was he ever screened for gambling
behaviours during his dopaminergic treatment. Second,
it was not until well over 18 years of dopaminergic treat-
ment that he developed gambling addiction. Third, while
it would appear that the patient’s gambling is in remis-
sion 6 months after cessation of dopaminergic treatment,
he still continues to have cravings and occasional lapses
into gambling. Hence we call for clinicians involved in
treatment of RLS to follow these simple measures: screen
patients for gambling behaviours prior to the onset and
during dopaminergic treatment; forewarn patients of this
potential side effect; and if patients screen positive, refer
them to specialist gambling treatment services, in addition
to making necessary changes to their medication regime;
consider collaborative working between neurologists and
addiction specialists in treating these patients.
In conclusion, we hope this patient’s story has suc-
ceeded in raising clinicians’ awareness of this condition.
We end with a call to forewarn patients of this side effect
(i.e. iatrogenic gambling addiction) of dopaminergic medi-
cations, and stress the importance of regularly screening
patients for the development of gambling behaviours.
Learning points
▶ Iatrogenic gambling addiction is a less known side
effect of dopaminergic agents, commonly used
treatments for RLS.
But very often this side effect goes unrecognised and
▶
hence unaddressed.
We call for clinicians to forewarn patients of this
▶
potential side effect and to screen patients for
gambling behaviours prior to the onset and during
dopaminergic treatment.
If patients screen positive, refer them to specialist
▶
gambling treatment services, in addition to making
necessary changes to their dopaminergic medication
regime.
Acknowledgements We thank the patient for agreeing to share his story.
Competing interests None.
Patient consent Obtained.
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Jones HB, George S. ‘You never told me I would turn into a gambler’: a fi rst person account of dopamine agonist – induced gambling addiction in a patient with
restless legs syndrome. BMJ Case Reports 2011;10.1136/bcr.07.2011.4459, date of publication
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