Thread by @hyderabaddoctor

An elderly woman who would repeatedly count her dresses

1. 69-yr old lady was brought with 1-month history of repeated & excessive arranging and counting of dresses. Patient spent a lot of time searching for clothes & dresses and meticulously arranging them as per their sizes.

2. She would repeatedly count them. She would get up from sleep and repeat this act for several hours. On questioning, the patient agreed that this act of hers was irrational and unproductive, however, she expressed an inability to control her from doing so.
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3. She had been diagnosed to have #Parkinsonsdisease 13 yrs ago. She was taking various medications including levodopa.
She had no prior history of psychiatric illness.
She was unable to sleep well, as she used to get up multiple times at nights to count her dresses.

4. Her family consulted a psychiatrist, who did not find any psychopathology. Her act was found to be an impulsive act & she did not fulfill the criteria for diagnosis of obsessive compulsive disorder (OCD).
Counting dresses & rearranging them gave her mental peace & soothed her.

5. She was brought to me for second opinion. I reanalyzed her clinical details and investigations (all normal).
She was on levodopa, the dose had been gradually increased to 1000 mg per day. It was discovered that she was taking an additional dose of 500 mg per day on her own.

6. The duration of levodopa effect had gradually decreased from initial six hours to one-two hours at the time of presentation.
Medication history gave me the clue to the diagnosis, which was obvious now.
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7. A possible diagnosis of punding related to high-dose levodopa was made. Levodopa dose was reduced to 750 mg daily and amantadine was added. She had a good response and punding subsided within three days.
She stopped counting and rearranging her dresses.

8. Punding is a stereotypical motor behavior in which there is an intense fascination with repetitive handling and examining of mechanical objects, such as picking at oneself or taking apart watches and radios or sorting and arranging of common objects, such as lining up pebbles+

9. rocks, or other small objects. Punding differs from compulsions in that performance of these activities is not distressing to patients and it is only if the act is interrupted that any compulsive urge becomes apparent.

10. Punding is well known to occur in association with addiction to central stimulant drugs such as amphetamine or cocaine.
Punding on levodopa therapy was initially reported by Friedman about 25 years ago. However, there is not much data available on this topic yet.

11. Punding in PD is not a specific problem related to levodopa, as cases with punding have been described in association with quetiapine (an atypical antipsychotic) used for treating psychosis in PD.

(Special on the occasion of World Parkinson Day today)

I had published this patient's report in Neurology India, official publication of Neurological Society of India, in 2005.
doi.org/10.4103/0028-3…