Punding - What is it?
Submitted by Michael C LaFerney RN, PMHCNS, BC
Tags: adhd medication ocd parkinsons patients
Punding -What is it?
Johann, who has Parkinson's disease, likes to take apart his bedroom clock and put it back together .Once done he starts the process all over again. He will then store it for easy access so he can touch it and examine it frequently. He used to be a mechanic so at first this behavior was not seen as unusual. Now it occurs frequently and has no real purpose. Anxiety doesn't appear to be driving this behavior. He gets no real pleasure from this activity and at times interferes with useful tasks he could be doing. He appears fascinated with his alarm clock and gets upset when his wife tries to get him to stop this behavior, What is behind this unusual behavior?
What is Punding?
Punding is a chronic, unusual, repetitive, stereotyped purposeless behavior. It can include excessive handling and touching of common objects, excessive grooming, sorting objects, lining up things in order, doodling, writing, blogging and excessive monologues with no real audience. The cause is thought to be related to dopaminergic action but other neurotransmitters as Serotonin may also be involved. Structural brain changes have been observed. It is seen in patients with dementia, Parkinson's disease, ADHD, cocaine users and other stimulant users. It was first seen in amphetamine and cocaine addicts. It is now more commonly seen in patients with Parkinson' disease. High doses of Levodopa and other dopamine agonists have been implicated as a precipitating factor. Punding may occur in 1-14 per cent of patients on anti-parkinsonism drugs.
Punding has also been observed in patients with dementing disorders. It can be a sign of impending dementia if unusual to a patient's normal behavior. It has also been observed in patients with Bipolar disorder and patients who have suffered a brainstem stroke. It can be seen in patients who have Restless Legs syndrome who are treated with dopaminergic therapy as Requip.
Diagnosis
Punding is often under-diagnosed. Many patients punding behaviors may be related to their past hobbies and occupation as a mechanic who now disassembles and puts things back together or a writer who now obsessively blogs. Until it becomes problematic it might not be noticed. It is not OCD although patient with Punding often have other psychiatric symptoms and impulsive behaviors. It is diagnosed by history and observation.
Treatment
Since it is thought to be caused by excessive dopamine avoiding medications and drugs that increase it or cutting down the dose will help. This includes stimulants like Ritalin, Adderal and cocaine.
For patients with Restless Legs syndrome switching to medications such as Gabapentin and benzodiazepines instead of dopamine agonists may be effective. For patients with Parkinson's disease reducing the daily dose of levodopa is the best treatment for punding. If this cannot be done as it may increase the symptoms of Parkinson's disease other medication can be added. Atypical antipsychotic medication as Quetipind and Clozapine have been helpful in treating punding. Antidepressants as SSRIs have not been seen as effective in aiding punding. There is some evidence Cognitive Behavioral Therapy (CBT) might be helpful but more research is needed.
Conclusion
Punding is in many cases a iatrogenic condition. There is no definitive way to prevent punding as the medications that cause it are needed to treat other conditions. Monitoring for it in patients who use this medication will aid for early intervention to reduce or stop it as dose reductions or changing medications.