Punding is defined as a constellation of complex, sterile and stereotyped behaviours including an intense fascination with repetitive manipulations of technical equipment, the continual handling, examining, and sorting of common objects, excessive grooming, hoarding, incessant fidgeting at clothes or oneself, pointless driving or walkabouts, and the engagement in extended monologues devoid of rational content.1 It was first described in amphetamine and cocaine addicts in 1972,2 and the term comes from the Swedish slang for "block-head" used by amphetamine addicts to describe their repetitive and pointless activities.3 Since Friedman’s first description of punding in an L-dopa treated patient in 1994, there has been increased interest in this largely unrecognised behavioural disorder leading to appreciable morbidity in Parkinson’s disease.4 It has also been attributed to the use of dopamine agonists,5 and two cases of punding behaviours have been described after starting the antipsychotic quetiapine, although the patients were also on L-dopa.6
A TYPICAL CASE
A 42-year-old man was diagnosed with Parkinson’s disease. There was a preceding history of binge drinking and his father had died with Parkinson’s disease. In the eighth year of his disease and while receiving treatment with cabergoline 4 mg/day, co-careldopa 100/25 mg and entacapone 200 mg qds, he developed a tendency to do unnecessary housework, and would spend up to 10 hours a day cleaning and tidying up. These behaviours caused disruptions to his sleep pattern because he felt unable to stop his "tidying" even at night. He also started to fiddle constantly with his watch strap and some items of clothing. An accompanying video clip shows dyskinesias during an on-phase of treatment (see http://pn.bmj.com/supplemental).
EPIDEMIOLOGY OF PUNDING IN PARKINSON’S DISEASE
In the only two published prevalence studies, punding was present in 1.4–14% of patients.1, 7 There were no differences in gender, age or severity of disease between the punders and non-punders.1 However, punding is almost certainly under-recognised because of a low awareness among physicians, and the reluctance of patients to divulge "irrelevant" or embarrassing details of their behaviour.
PHENOMENOLOGY
Punding is characterised by repetitive pointless behaviours that are carried out for long periods of time at the expense of all other activities. They have a compulsive flavour to them and any interruption or disruption of the activity from an outside source frequently leads to irritation, anxiety and frustration. The behaviour is irresistible but rarely considered to be pleasurable. It is often carried out overnight leading to sleep deprivation. The chosen behaviour is frequently related to the individual’s previous occupation, hobbies and pastimes. One of our patients who was a musician wrote thousands of musical lyrics over a short period, while a retired carpenter occupied himself with unnecessary joinery projects in his home. A retired seamstress spent hours cataloguing and sorting her large collection of buttons. One patient spent many hours pointlessly drawing (fig 1) while another spent most of the day on his computer cataloguing all types of data, including excessive detailing of medications and sleeping patterns, which he emailed to his doctor every month (fig 2). A feature of the behaviour is that it is never ending, it is disorganised and frequently leaves chaos in its wake. Most patients concede its pointlessness and often acknowledge its ultimate self-destructiveness. Punding can cause social avoidance, severe sleep deprivation, and disintegration of family relationships.1 In most cases it is the family members who describe the full social and functional impact of these behaviours on the patients’ lives.7
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Figure 1 Drawing/"doodling" punding.
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Figure 2 Computer cataloguing punding.
Punding is often associated with the dopamine dysregulation syndrome/impulse control disorders such as hypersexuality, pathological gambling and L-dopa-induced dyskinesias 1, 8 Evans and colleagues showed that punders were taking higher daily amounts of dopaminergic medications than non-punders.1 Punding behaviours may be homologous to amphetamine-induced stereotypies in animals, suggesting that punding is related to plastic changes in the ventral and dorsal striatal structures, including the nucleus accumbens.8
In contrast to obsessional compulsive disorder, intrusive fears and thoughts causing distress are not an associated feature in punding, and the motor behaviours are quite different.1 Punding also differs from mania and hypomania because punders do not demonstrate features such as excessive talking or pressured speech, racing thoughts or flight of ideas and grandiosity. Mania is often associated with an indiscriminate enthusiasm for multiple tasks, unlike punding where the focus usually remains on a single prolonged and repetitive motor activity.
IDENTIFICATION AND TREATMENT OF PUNDING IN PARKINSON’S DISEASE
A high index of suspicion is required if punding is to be detected early. Family members may need to be interviewed separately. Some specific questions may help to tease out the possibility of punding (table).1
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Table Suggested screening questionnaire for punding
Management can be difficult but the gradual reduction of dopaminergic treatment with the help of the family is often effective and the discontinuation of rescue doses of treatment should be enforced. Treatment of insomnia may need to be addressed independently by a combination of patient- and family-enforced restrictions of nocturnal activities, often in addition to short-term prescription of hypnotics. A trial of low dose quetiapine (12.5–50 mg at night) may be indicated if these measures are ineffective, and any associated psychotic or depressive symptoms should be treated appropriately.
Practice points
Punding is characterised by repetitive pointless motor behaviours for long periods of time at the expense of all other activities—for example, repetitive manipulations of technical equipment, continual handling, examining, and sorting of common objects, excessive grooming, hoarding, and aimless long driving or walking routines.
It is underreported but may have serious psychosocial consequences; it may even be associated with impulsive control disorders such as pathological gambling or inappropriate sexual behaviour.
It is due to excessive dopaminergic stimulation and is analogous to the stereotypies in laboratory rodents following the administration of L-dopa, cocaine or amphetamine.
The prevalence of disabling punding in Parkinson’s disease is probably less than 5%.
Treatment strategies in Parkinson’s disease consist of gradual, carefully supervised reduction in dopaminergic medications with active involvement of the patient’s family; in refractory cases quetiapine may be required.
REFERENCES
Evans AH, Katzenschlager R, Paviour D, et al. Punding in Parkinson’s disease: its relation to the dopamine dysregulation syndrome. Mov Disord 2004; 19: 397–405.[Medline]
Rylander G. Psychoses and the punding and choreiform syndromes in addiction to central stimulant drugs. Psychiatr Neurol Neurochir 1972; 75: 203–12.[Medline]
Schiorring E. Psychopathology induced by "speed drugs". Pharmacol Biochem Behav 1981; 14(Suppl 1): 109–22.[Medline]
Friedman JH. Punding on levodopa. Biol Psychiatry 1994; 36: 350–1.[Medline]
Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. Mov Disord 2006; 21: 524–9.[Medline]
Miwa H, Morita S, Nakanishi I, et al. Stereotyped behaviors or punding after quetiapine administration in Parkinson’s disease. Parkinsonism Relat Disord 2004; 10: 177–80.[Medline]
Miyasaki JM, Al Hassan K, Lang AE, et al. Punding prevalence in Parkinson’s disease. Mov Disord 2007; 22: 1179–81.[Medline]
Silveira-Moriyama L, Evans AH, Katzenschlager R, et al. Punding and dyskinesias. Mov Disord 2006; 21: 2214–17.[Medline]