Patients with Parkinson’s Disease (PD) may develop levodopa-induced hypersexuality.
+1 We report a patient with profound changes in sexuality after pallidotomy surgery for PD and review the literature on possible neurological mechanisms for hypersexuality.
A 59-year-old, right-handed man underwent a right pallidotomy for PD of 16 years duration. Prior to surgery, he had left-sided rigidity and bradykinesia, left upper extremity tremor, postural instability, bradyphrenia, and hypophonia. He had moderate disability and remained independent in activities of daily living, but he could no longer work as an engineer. After the pallidotomy, his left-sided symptoms significantly improved. His past medical history included hypertension and a remote closed head injury. There was no history of psychiatric illness, unusual sexual behavior, or drug-induced behavioral changes prior to his surgery.
Immediately after the pallidotomy, the patient began demanding oral sex up to 12 to 13 times a day from his wife of 41 years. He forced her to have sex with him despite her serious cardiac condition. He masturbated frequently and propositioned his wife's female friends for sex. His antiparkinsonian medications (8 carbidopa/levodopa 25/250 mg q.d.; pramipexole 1.5mg q.i.d) were not decreased postoperatively, and his sexual behavior was worsened with drug-induced dyskinesias.
There was additional aberrant behavior. He began hiring strippers and driving around town searching for prostitutes. He spent hours on the Internet looking for sex and buying pornographic materials. At one point, his wife found him trying to sexually relieve himself while viewing a photograph of his 5-year-old granddaughter. He was later accused of touching the child inappropriately and asking her to touch his penis. His granddaughter was removed from the home by child protection services.
The patient wanted his libidinal urges to become "normalized" again. He complained of recurrent and intrusive sexual thoughts, increased sexual urges, and being "awash in hormones like an 18 year-old." He complained that satisfying his libido had become of overwhelming importance, overshadowing all other activities and interests.
His examination did not reveal other mental status abnormalities. He did not manifest euphoria, pressured speech, or flight of ideas. He was oriented and had a digit span of 8 forward. Language was normal, and he generated word lists of 17 animals/minute and 23 "F" words/minute. His 15-minute verbal delayed recall was 7/10. He had normal constructions, calculations, alternate tapping, multiple loops, and abstractions. Neurological examination disclosed mild hypophonia, a stooped posture with decreased arm swing, mild cogwheel rigidity, a positive glabellar reflex, and a left upgoing toe not present preoperatively.
One year after his pallidotomy, the patient was reported missing for 4 days. The police found him in a motel where he had been seeking prostitutes. On admission, his mental status and neurological evaluations, including neuroimaging, were unchanged beyond evidence for his pallidotomy (
+Figure 1). While in the hospital, he was found sneaking into the bathroom to have sex with his wife. A taper of his anti-parkinsonian medications was begun, with a gradual decrease in his sexual behavior. He was discharged with reduction of his carbidopa/levodopa (25/250 mg) to four tablets per day and pramipexole (0.75 mg t.i.d).
Shortly after discharge, the patient's sexual behavior decreased further, but his parkinsonism worsened. His sexual activity decreased to about 6 times/day, but his speech became slighly dysarthric with a logoclonic output, bradyphrenia, and a festinating speech. Tone was increased slightly, bilaterally, but there was no tremor. Valproate (250mg b.i.d.) was started for further amelioration of his sexual behavior. At 6-month follow-up, his sexual activity had decreased to about once/week, and he had discarded all pornographic materials.