LETTERS

Punding Behavior in Bipolar Disorder Type 1: Case Report

To the Editor: Punding is a stereotyped behavior characterized by intense fascination with complex, excessive, non–goal-oriented, and repetitive activity, such as manipulation of technical equipment; handling, examining, or sorting through common objects; grooming; hoarding; and engagement in extended monologues devoid of content.1 Patients’ awareness of punding might be poor, therefore underreporting it.2 The most common causes of punding currently are dopaminergic replacement therapy in patients with Parkinson’s disease and cocaine/amphetamine use.1 Case Report The present case concerned a 64year-old woman, who was unemployed and diagnosed with bipolar disorder type I at age 25, according to DSM-IV-TR criteria. She also reported several manic/mixed episodes, during which she developed impulsive compulsive behaviors (i.e., pathological shopping).3 She was admitted to the psychiatric ward of the clinic because of the persistence of a severe mixed state. On admission, the patient underwent thorough psychiatric, medical, and physical examination. Her father was diagnosed with Parkinson’s disease. On admission, she had been taking quetiapine 200 mg/day, alprazolam 1.5 mg/day, and clotiapine 20 mg/day for 6 months. She had recently discontinued sertraline. She was experiencing a mixed state, characterized by dysphoria, irritability, less

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TABLE 1.

Psychiatric Assessment and Punding Rating Scale1 at Baseline and Follow-Up T0 (baseline)

T1 (3 months)

Phase of illness Mixed state Euthymia Brief Psychiatric 56 45 Rating Scale Global 35 50 Assessment of Functioning Young Mania 19 4 Rating Scale Hamilton 16 6 Depression Rating Scale 24 22 Punding Rating Scale1 Pharmacological Quetiapine (200) Quetiapine (300) treatment (mg) Alprazolam (1.5) Valproate (900) Clotiapine (20) Alprazolam (0.75)

need for sleep, racing thoughts and speech, overactivity, and suicidal ideation. The patient reported lavish spending and severe debts. The patient’s daughter reported that she spent most of her day tying scarves. The patient actually continuously purchased numerous scarves and stored them in plastic bags. Daily these scarves were repeatedly folded along oblique lines, knotted, or jointed, without a purpose. When asked about this behavior, she responded with denial and minimization. Throughout her hospitalization, she was repeatedly observed fiddling with a glove over and over again and continued to spend most of her day folding scarves. The onset of this behavior was reported to be 3 years ago, and no association with psychopharmacological treatments was observed. No change in the severity of the behavior was reported after the administration of quetiapine4 and clotiapine. To exclude an association between the occurrence of punding and a possible Parkinson’s disease diagnosis, the patient underwent a thorough neurological examination, which ruled out signs

T2 (6 months) Euthymia 42

T3 (12 months) Depression 47

55

40

3

0

4

16

23

21

Quetiapine (200) Quetiapine (200) Valproate (900) Valproate (900) Alprazolam (0.75) Alprazolam (1.25)

of parkinsonism; in addition, she was not under treatment with dopaminergic agents. The patient was administered the Punding Rating Scale1; item 1, specific for PD patients/addicts and relative to dopaminergic medication, was modified. The patient was followed up for 1 year and assessed at T0 (baseline), T1 (3 months), T2 (6 months), and T3 (12 months). Table 1 shows the scores the patient obtained at baseline and during follow-up. During the follow-up, punding behaviors did not vary in relation to pharmacological treatments, and no changes were observed across the different mood phases. Discussion This case suggests that punding may occur during the course of bipolar disorder. A case report cannot quantify a clinical association. Specific studies are needed to investigate the real proportions of punding behaviors in bipolar disorder and to clarify the pathophysiology and possible treatment strategies5 for this condition.

J Neuropsychiatry Clin Neurosci 26:4, Fall 2014

PETTORRUSO et al. Mauro Pettorruso, M.D. Marco Di Nicola, M.D., Ph.D. Luisa De Risio, M.D. Alfonso Fasano, M.D., Ph.D. Giovanni Martinotti, M.D., Ph.D. Gianluigi Conte, M.D. Anna Rita Bentivoglio, M.D., Ph.D. Luigi Janiri, M.D. Institute of Psychiatry and Psychology, Catholic University of Sacred Heart, Rome, Italy (MP, MDN, LDR, GC, LJ); Movement Disorders Center, Toronto Western Hospital, Krembil Neurosciences Program, Division of Neurology, University of

Toronto, Toronto, Ontario, Canada (AF); Department of Neurosciences and Imaging, University “G. D’Annunzio”, Chieti, Italy (GM); and Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy (ARB) Correspondence: Mauro Pettorruso; e-mail: [email protected]

References 1. Fasano A, Petrovic I: Insights into pathophysiology of punding reveal possible treatment strategies. Mol Psychiatry 2010; 15:560–573

J Neuropsychiatry Clin Neurosci 26:4, Fall 2014

2. Fasano A, Pettorruso M, Ricciardi L, et al: Punding in Parkinson’s disease: the impact of patient’s awareness on diagnosis. Mov Disord 2010; 25:1297–1299 3. Di Nicola M, Tedeschi D, Mazza M, et al: Behavioural addictions in bipolar disorder patients: role of impulsivity and personality dimensions. J Affect Disord 2010; 125:82–88 4. Miwa H, Morita S, Nakanishi I, et al: Stereotyped behaviors or punding after quetiapine administration in Parkinson’s disease. Parkinsonism Relat Disord 2004; 10:177–180 5. Fasano A, Ricciardi L, Pettorruso M, et al: Management of punding in Parkinson’s disease: an open-label prospective study. J Neurol 2011; 258:656–660

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Punding behavior in bipolar disorder type 1: case report.

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