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February 26, 2013; 80 (9) Article

Trial of CBT for impulse control behaviors affecting Parkinson patients and their caregivers

David Okai, Sally Askey-Jones, Michael Samuel, Sean S. O’Sullivan, K. Ray Chaudhuri, Anne Martin, Joel Mack, Richard G. Brown, Anthony S. David
First published January 16, 2013, DOI: https://doi.org/10.1212/WNL.0b013e3182840678
David Okai
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Sally Askey-Jones
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Michael Samuel
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Sean S. O’Sullivan
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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K. Ray Chaudhuri
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Anne Martin
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Joel Mack
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Richard G. Brown
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Anthony S. David
From the Departments of Psychosis Studies (D.O., A.S.D.) and Psychology (R.G.B.), Institute of Psychiatry, Department of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Midwifery (S.A.-J.), Department of Neurology (M.S.), and National Parkinson Foundation Centre of Excellence (K.R.C.), King's College Hospital, London; Institute of Neurology (S.S.O.), University College London, London, UK; and Department of Psychiatry (J.M.), Oregon Health and Science University, Portland.
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Citation
Trial of CBT for impulse control behaviors affecting Parkinson patients and their caregivers
David Okai, Sally Askey-Jones, Michael Samuel, Sean S. O’Sullivan, K. Ray Chaudhuri, Anne Martin, Joel Mack, Richard G. Brown, Anthony S. David
Neurology Feb 2013, 80 (9) 792-799; DOI: 10.1212/WNL.0b013e3182840678

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Abstract

Objective: To test the effects of a novel cognitive-behavioral therapy (CBT)–based intervention delivered by a nurse therapist to patients with Parkinson disease (PD) with clinically significant impulse control behaviors (ICB).

Methods: This was a randomized controlled trial comparing up to 12 sessions of a CBT-based intervention compared to a waiting list control condition with standard medical care (SMC). A total of 27 patients were randomized to the intervention and 17 to the waiting list. Patients with a Mini-Mental State Examination score of <24 were excluded. The coprimary outcomes were overall symptom severity and neuropsychiatric disturbances in the patients and carer burden and distress after 6 months. Secondary outcome measures included depression and anxiety, marital satisfaction, and work and social adjustment in patients plus general psychiatric morbidity and marital satisfaction in carers.

Results: There was a significant improvement in global symptom severity in the CBT intervention group vs controls, from a mean score consistent with moderate to one of mild illness-related symptoms (χ2 = 16.46, p < 0.001). Neuropsychiatric disturbances also improved significantly (p = 0.03), as did levels of anxiety and depression and adjustment. Measures of carer burden and distress showed changes in the desired direction in the intervention group but did not change significantly. General psychiatric morbidity did improve significantly in the carers of patients given CBT.

Conclusions: This CBT-based intervention is the first to show efficacy in ICB related to PD in terms of patient outcomes. The hoped-for alleviation of carer burden was not observed. The study demonstrates the feasibility and potential benefit of a psychosocial treatment approach for these disturbances at least in the short term, and encourages further larger-scale clinical trials.

Classification of evidence: The study provides Class IV evidence that CBT plus SMC is more effective than SMC alone in reducing the severity of ICB in PD, based upon Clinical Global Impression assessment (χ2 = 16.46, p < 0.001): baseline to 6-month follow-up, reduction in symptom severity CBT group, 4.0–2.5; SMC alone group, 3.7–3.5.

GLOSSARY

BAI=
Beck Anxiety Inventory;
BDI=
Beck Depression Inventory;
CBT=
cognitive-behavioral therapy;
CGI=
Clinical Global Impression;
DSM-IV=
Diagnostic and Statistical Manual of Mental Disorders, 4th edition;
GHQ=
General Health Questionnaire;
GRIMS=
Golombok Rust Inventory of Marital State;
ICB=
impulse control behaviors;
ICD=
Impulse control disorders;
ICDSS=
Impulse Control Behavior Symptom Scale;
MMSE=
Mini-Mental State Examination;
NPI=
Neuropsychiatric Inventory;
PD=
Parkinson disease;
QUIP=
Questionnaire for Impulsive-Compulsive Behaviors in Parkinson's Disease;
SMC=
standard medical care;
UPDRS=
Unified Parkinson's Disease Rating Scale

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 782

  • Received May 1, 2012.
  • Accepted October 10, 2012.
  • © 2013 American Academy of Neurology
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