Punding Prevalence in Parkinson’s Disease Janis M. Miyasaki, MD, MEd, FRCPC, * Khalid Al Hassan, MB, BCh, BAO, Anthony E. Lang, MD, FRCPC, and Valerie Voon, MD, FRCPC Movement Disorders Centre, Toronto Western Hospital, University Health Network, Krembil Neuroscience Centre, University of Toronto, Toronto, Canada Abstract: The purpose of this study was to determine pund- ing prevalence in an ambulatory Parkinson’s disease (PD) population. We conducted a patient-and-caregiver– com- pleted punding survey in 373 consecutive patients in an academic ambulatory center. Completion rate was 78%. Only four patients were identified as punding. Patients did not retain insight to their behavior. Forty patients with high-dose levodopa monotherapy or levodopa and dopa- mine agonist treatment had physician-administered inter- view. None had punding. Punding incidence was low in this patient group (1.4%) in contrast with previous reports of 14%. Despite the low incidence, this behavior is disruptive and should be carefully elicited by physicians caring for Parkinson’s disease patients. © 2007 Movement Disorder Society Key words: Parkinson’s disease; punding; dopaminergic therapy Giovannoni and colleagues 1 first described “hedonistic homeostatic dysregulation” in 2000. This designation has been subsequently revised to the “dopamine dysregula- tion syndrome” (DDS) and is characterized by compul- sive gambling, shopping, hyperphagia or binge eating, hypersexuality, and punding. Punding was first described in amphetamine and cocaine users. 2 The term itself comes from Swedish slang translating to “blockhead” and consists of repetitive, aimless activity. 3 Examples include sorting and resorting objects, doodling without producing artwork, and dismantling objects without be- ing able to complete the task. Punders will neglect food, hygiene, medications, and sleep to engage in their chosen activity. Attempts to stop the activity by others results in resistance and irritability. Insight into the disruptive or senseless nature of the behavior is often absent. They do admit that the activity does not bring them joy or satis- faction, yet they persist in the activity. Friedman 4 first described punding in Parkinson’s dis- ease (PD) with levodopa use. Evans and colleagues 5 surveyed patients with high-dose therapy and found an incidence of 14%. We sought to determine the incidence of punding in nonselected PD patients. PATIENTS AND METHODS Study Population Consecutive patients (n = 373) with Parkinson’s dis- ease (U.K. Brain Bank criteria 6 ) from the Toronto West- ern Hospital Movement Disorders Centre were given a survey to complete at their clinic appointment. The pop- ulation included a spectrum of patients from early- to late-stage illness. Referral sources included family phy- sicians as well as neurologists. Survey Instrument Evans and colleagues 5 conducted interviews using 26 questions. We modified the questionnaire, simplifying the language to allow patients and caregivers to complete the survey (Table 1). Patients were identified as punders if behavior was repetitive, nonproductive, and disruptive to normal activities as defined by the patients or care- givers. Those responding affirmatively to the survey were further interviewed in person or by telephone by the investigators. In order to compare the yield of the patient-completed questionnaire and the clinician interview, 40 patients receiving more than 800 mg levodopa alone or levodopa equivalent daily dose (LEDD) were interviewed by a physician (J.M.M.) for punding behavior. Levodopa equivalent dose 6 for each patient was cal- culated in mg as follows: levodopa/carbidopa regular + (levodopa/carbidopa CR  0.75) + ([levodopa/carbi- dopa regular + levodopa carbidopa CR  0.75])  0.25 if on tolcapone or entacapone + (pramipexole  67.5) + (pergolide  100) + (ropinirole  16.67) + bromocrip- tine  10). RESULTS Survey completion rate was 78% (291 of 373). Pund- ing was present in 4 of 291 patients (2 female, 2 male), confirmed by subsequent in-person or telephone inter- view. Two patients reported computer gaming more than 4 hours each day, one tidied for more than 3 hours each day, and one dismantled and tried unsuccessfully to build objects endlessly. The incidence of punding was there- fore 1.4%. Duration of illness was 8.7 years (range, 5–15) for punders versus 9.1 years (range, 1–33) for *Correspondence to: Dr. Janis M. Miyasaki, Movement Disorders Cen- tre, Toronto Western Hospital, 399 Bathurst Street, 7 McL, Toronto, Ontario, M5T 2S8, Canada. E-mail: miyasaki@uhnres.utoronto.ca Received 22 March 2006; Revised 6 September 2006; Accepted 14 September 2006 Published online 17 January 2007 in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/mds.21296 PUNDING AND PD 1179 Movement Disorders, Vol. 22, No. 8, 2007