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      The Parkinsonian Personality: More Than Just a “Trait”

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          Abstract

          Since 1913 patients with Parkinson's disease (PD) have been described as particularly industrious, devoted to hard work, inflexible, punctual, cautious, and moralist (1). These psychological characteristics have been so constantly reported that the concept of “Parkinsonian personality” emerged. In this regards, in the last few years PD patients have been evaluated according to several models of personality assessment (2), with the Big Five Model (BFM) (3) and the Cloninger's Psychobiological Model (CPM) (4) as the most used. Studies following the BFM reported that PD patients presented high levels of Neuroticism and low levels of both Openness and Extraversion (5, 6), while studies using the CPM described the temperament of PD patients as characterized by low Novelty Seeking (NS) and high Harm Avoidance (HA) (2, 7, 8). As a matter of fact, the high HA could be responsible for the Parkinsonians' tendency to be cautious, fearful, pessimistic and shy, while the low levels of NS could account for the tendency to be unsocial, frugal and orderly. Under different points of view, the “Parkinsonian personality,” as it has been consistently reported in literature (7, 9), shares several clinical features with the obsessive compulsive personality disorder (OCPeD) as classified in the Diagnostic and Statistical Manual for Mental Disorders (DSM) (10). The OCPeD is defined as a “chronic, pervasive, maladaptive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control at the expense of flexibility, openness, and efficiency” (10). In the general population, it is the most common personality disorder with a lifetime prevalence reaching the 9.3% (11). Classically considered as stable over time, an increasing number of observations allow to hypothesize that the clinical presentation of OCPeD is less stable than originally assumed, being possible to detect the occurrence, attenuation, or relapse of obsessive symptoms across the life-time (12, 13). While the correspondence between the presence of high HA and low NS levels and OCPeD has been investigated in the general population over the years (14–16), no studies on the correspondence between these temperament traits, configuring the parkinsonian personality, and OCPeD have been conducted in PD patients. However, studying the “Parkinsonian personality” according to the DSM diagnostic criteria could be more useful in terms of clinical practice, since it would allow to reach a diagnosis of personality disorder rather than merely describe temperamental traits. On the contrary, nowadays there is a limited amount of studies using the DSM criteria. In particular, we have carried out a study with the aim of investigating the presence of personality disorders in PD patients and controls, reporting a significantly higher frequency of OCPeD among PD patients (respectively 40 vs. 10%) (17). In agreement with some literature evidences that reported a quite common prevalence of OCPeD in the elderly (18), the frequency of OCPeD was higher among PD patients aged 60 years and above (17). These findings suggest that even among PD patients, OCPeD are probably not so stable in the life-span, worsening during senescence (11). Furthermore, the high frequency of OCPeD was also confirmed in de novo PD patients with a short disease duration, thus supporting the hypothesis that this personality disorder could be considered as an early non-motor manifestation of PD, being present regardless disease duration, motor impairment or dopaminergic treatment (19). Regarding other movement disorders, a high prevalence of OCPeD has been also found among patients with Progressive Supranuclear Palsy (PSP) but not among those with multiple system atrophy or essential tremor (20). PSP is an atypical parkinsonism characterized by perseverations, rigid perfectionism, restricted affectivity and executive function deficit (21). Actually, from a pathophysiological point of view, the high prevalence of OCPeD both in PD and in PSP patients, could be linked to a common frontostriatal circuit dysfunction (22); indeed, it may be useful to deepen the knowledge regarding the possible association between personality changes and executive dysfunctions. Also the latters, in fact, essential for everyday decision-making (such as planning, monitoring, manipulating information and attention), are mostly modulated by dorsal fronto-striatal loops (23). It has been reported that more than 30% of PD patients present, even at an early stage of the disease, a cognitive condition “intermediate” between normal cognition and dementia, primarily marked by attention and executive functions impairment (24). Few studies have investigated the possible association between the “parkinsonian personality” and executive dysfunction reporting controversial results, also considering methodological differences used by different studies (6, 25, 26). In particular, Volpato et al. (6), assessing the personality according to the BFM, reported a certain correlation between specific personality traits (emotional stability and openness to experience) and executive functions. Luca et al. (25), assessing the personality according to the CPM, reported a strong association between high HA score and executive dysfunctions, while Koerts et al. (26) did not. Unfortunately, while in the general population the association between OCPeD and executive dysfunction has been elucidated (27, 28), no literature data on PD patients are now available. However, due to the aforementioned close correspondence between high HA score and OCPeD, it is not unlikely that the reported association between high HA and executive dysfunction could be just an epiphenomenon, reflecting the well-known association between OCPeD and executive dysfunctions. As a matter of fact, the corticostriatal circuit dysfunction (orbitofrontal cortex, medial prefrontal cortex and striatum) could represent the pathophysiological explanation of both cognitive and behavioral inflexibility characterizing OCPeD (29). In any case, regardless the co-occurrence of executive function deficits, the assessment of parkinsonian personality through a clinical interview evaluating the possible presence of an OCPeD should be encouraged for different reasons. First of all, as previously mentioned, the OCPeD is not just a “temperament trait,” but a nosographically defined clinical entity that can be diagnosed according to worldwide accepted criteria (10). Moreover, OCPeD frequently occurs in association with other psychiatric disturbances, such as anxiety disorders, depression, alcohol or drug dependence, hypochondriasis and obsessive-compulsive spectrum disorders (30), pathological gambling, and internet addiction, above all (31, 32). In the light of what has been said, the assessment of OCPeD in PD patients could be useful also in the stratification of frailty allowing neurologists to identify those patients at risk of impulse control disorders or cognitive decline. Finally, severe OCPeD can benefit from antidepressants and/or psychotherapeutic interventions (33–35). In conclusion, the assessment of personality disorders in PD patients according to the DSM would impact clinical practice, guaranteeing the formulation of a clear diagnosis, thus enabling the clinicians to take the right therapeutic path, in line with a patient-centered point of view. Author Contributions AL, AN, GM, and MZ: conception; AL and AN: writing of the first draft; All authors: review and critique the manuscript. Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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          Most cited references31

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          Probing compulsive and impulsive behaviors, from animal models to endophenotypes: a narrative review.

          Failures in cortical control of fronto-striatal neural circuits may underpin impulsive and compulsive acts. In this narrative review, we explore these behaviors from the perspective of neural processes and consider how these behaviors and neural processes contribute to mental disorders such as obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder, and impulse-control disorders such as trichotillomania and pathological gambling. We present findings from a broad range of data, comprising translational and human endophenotypes research and clinical treatment trials, focussing on the parallel, functionally segregated, cortico-striatal neural projections, from orbitofrontal cortex (OFC) to medial striatum (caudate nucleus), proposed to drive compulsive activity, and from the anterior cingulate/ventromedial prefrontal cortex to the ventral striatum (nucleus accumbens shell), proposed to drive impulsive activity, and the interaction between them. We suggest that impulsivity and compulsivity each seem to be multidimensional. Impulsive or compulsive behaviors are mediated by overlapping as well as distinct neural substrates. Trichotillomania may stand apart as a disorder of motor-impulse control, whereas pathological gambling involves abnormal ventral reward circuitry that identifies it more closely with substance addiction. OCD shows motor impulsivity and compulsivity, probably mediated through disruption of OFC-caudate circuitry, as well as other frontal, cingulate, and parietal connections. Serotonin and dopamine interact across these circuits to modulate aspects of both impulsive and compulsive responding and as yet unidentified brain-based systems may also have important functions. Targeted application of neurocognitive tasks, receptor-specific neurochemical probes, and brain systems neuroimaging techniques have potential for future research in this field.
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            Personality Disorders and The Five-Factor Model of Personality

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              Compulsivity in obsessive-compulsive disorder and addictions.

              Compulsive behaviors are driven by repetitive urges and typically involve the experience of limited voluntary control over these urges, a diminished ability to delay or inhibit these behaviors, and a tendency to perform repetitive acts in a habitual or stereotyped manner. Compulsivity is not only a central characteristic of obsessive-compulsive disorder (OCD) but is also crucial to addiction. Based on this analogy, OCD has been proposed to be part of the concept of behavioral addiction along with other non-drug-related disorders that share compulsivity, such as pathological gambling, skin-picking, trichotillomania and compulsive eating. In this review, we investigate the neurobiological overlap between compulsivity in substance-use disorders, OCD and behavioral addictions as a validation for the construct of compulsivity that could be adopted in the Research Domain Criteria (RDoC). The reviewed data suggest that compulsivity in OCD and addictions is related to impaired reward and punishment processing with attenuated dopamine release in the ventral striatum, negative reinforcement in limbic systems, cognitive and behavioral inflexibility with diminished serotonergic prefrontal control, and habitual responding with imbalances between ventral and dorsal frontostriatal recruitment. Frontostriatal abnormalities of compulsivity are promising targets for neuromodulation and other interventions for OCD and addictions. We conclude that compulsivity encompasses many of the RDoC constructs in a trans-diagnostic fashion with a common brain circuit dysfunction that can help identifying appropriate prevention and treatment targets.
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                Author and article information

                Contributors
                Journal
                Front Neurol
                Front Neurol
                Front. Neurol.
                Frontiers in Neurology
                Frontiers Media S.A.
                1664-2295
                15 January 2019
                2018
                : 9
                : 1191
                Affiliations
                Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”, Università degli Studi di Catania , Catania, Italy
                Author notes

                Edited by: Antonio Pisani, University of Rome Tor Vergata, Italy

                Reviewed by: Tommaso Schirinzi, University of Rome Tor Vergata, Italy; Matteo Bologna, Sapienza University of Rome, Italy

                *Correspondence: Mario Zappia m.zappia@ 123456unict.it

                This article was submitted to Movement Disorders, a section of the journal Frontiers in Neurology

                †These authors have contributed equally to this work

                Article
                10.3389/fneur.2018.01191
                6340987
                30800093
                b53981e9-8313-4704-bf34-ff28ecef3370
                Copyright © 2019 Luca, Nicoletti, Mostile and Zappia.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 11 October 2018
                : 27 December 2018
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 35, Pages: 3, Words: 2255
                Categories
                Neurology
                Opinion

                Neurology
                personality disorders,obsessive-compulsive personality disorder,parkinson's disease,temperament,harm avoidance

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