Dopamine agonist withdrawal syndrome and non-motor symptoms after Parkinson's disease surgery

ARTICLESir, I read with interest the manuscript by Dr Thobois and colleagues (Thobois et al. , 2010), in which the authors report the occurrence of depression and apathy after deep brain stimulation surgery for Parkinson’s disease and correlate these symptoms with mesolimbic dopaminergic denervation on neuroimaging studies. I agree with the authors’ interpretation of post-surgical apathy as a drug withdrawal state precipitated by the rapid tapering of dopaminergic medications (Rabinak and Nirenberg, 2010). My strong suspicion, however, is that severe non-motor symptoms that occur after deep brain stimulation are largely attributable to dopamine agonist withdrawal syndrome (DAWS) rather than a non-specific dopamine withdrawal state (Rabinak and Nirenberg, 2010). Furthermore, I have significant safety concerns about the use of piribedil as a treatment for these withdrawal symptoms.Recognition of DAWS is critical because it: (i) exclusively occurs in patients with baseline dopamine agonist-related impulse control disorders; (ii) responds only to dopamine agonist repletion and not to levodopa or other Parkinson’s disease medications; and (iii) includes not only apathy and depression, but also a broad …