The nigrostriatal and mesocorticolimbic dopamine networks regulate reward-driven behavior. Regional alterations to mesolimbic dopamine D_2/3receptor expression are described in drug-seeking and addiction disorders. Parkinson's disease (PD) patients are frequently prescribed D₂-like dopamine agonist (DAgonist) therapy for motor symptoms, yet a proportion develop clinically significant behavioral addictions characterized by impulsive and compulsive behaviors (ICBs). Until now, changes in D_2/3receptor binding in both striatal and extrastriatal regions have not been concurrently quantified in this population. We identified 35 human PD patients (both male and female) receiving DAgonist therapy, with (n= 17) and without (n= 18) ICBs, matched for age, disease duration, disease severity, and dose of dopamine therapy. In the off-dopamine state, all completed PET imaging with [¹⁸F]fallypride, a high affinity D₂-like receptor ligand that can measure striatal and extrastriatal D_2/3nondisplaceable binding potential (BP_ND). Striatal differences between ICB+/ICB− patients localized to the ventral striatum and putamen, where ICB+ subjects had reduced BP_ND. In this group, self-reported severity of ICB symptoms positively correlated with midbrain D_2/3receptor BP_ND. Group differences in regional D_2/3BP_NDrelationships were also notable: ICB+ (but not ICB−) patients expressed positive correlations between midbrain and caudate, putamen, globus pallidus, and amygdala BP_NDs. These findings support the hypothesis that compulsive behaviors in PD are associated with reduced ventral and dorsal striatal D_2/3expression, similar to changes in comparable behavioral disorders. The data also suggest that relatively preserved ventral midbrain dopaminergic projections throughout nigrostriatal and mesolimbic networks are characteristic of ICB+ patients, and may account for differential DAgonist therapeutic response.SIGNIFICANCE STATEMENTThe biologic determinants of compulsive reward-based behaviors have broad clinical relevance, from addiction to neurodegenerative disorders. Here, we address biomolecular distinctions in Parkinson's disease patients with impulsive compulsive behaviors (ICBs). This is the first study to image a large cohort of ICB+ patients using positron emission tomography with [18F]fallypride, allowing quantification of D_2/3receptors throughout the mesocorticolimbic network. We demonstrate widespread differences in dopaminergic networks, including (1) D2-like receptor distinctions in the ventral striatum and putamen, and (2) a preservation of widespread dopaminergic projections emerging from the midbrain, which is associated with the severity of compulsive behaviors. This clearly illustrates the roles of D_2/3receptors and medication effects in maladaptive behaviors, and localizes them specifically to nigrostriatal and extrastriatal regions.