Reduction in Parkinson’s Disease Therapy Improved Punding But Not Feeling of Presence

To the Editor: There is growing evidence that dopaminergic therapy (DT) used to treat Parkinson’s disease (PD) can cause compulsive behaviors like punding and impulse-control disorders (ICDs).¹ Punding is defined as a constellation of complex, sterile, and stereotyped behaviors, including an intense fascination with repetitive manipulations of technical equipment; continual handling, examining, and sorting of common objects; excessive grooming; hoarding; incessant fidgeting at clothes or oneself; pointless driving; and the engagement in extended monologues devoid of rational content.² Feeling of presence (FP) refers to the vivid sensation that somebody is present nearby when nobody is actually there.³ FP is included in the spectrum of psychosis in PD, which has been also attributed to DT. We report a PD patient who had been experiencing punding and FP for 1 year. After reduction in DT, punding has improved, but FP persisted.

Case Report

A 51-year-old woman with a 5-year history of PD, commented that she was accumulating an amount of things at home. She invited us to visit her home, so that we could see it. She was taking levodopa/benserazide 500 mg/day, pramipexole 1.5 mg/day, amantadine 200 mg/day, and nortriptyline 25 mg/day (total levodopa-equivalent dose of 850 mg/day). Her motor and non-motor features were the following: Hoehn and Yahr: 2.0, motor UPDRS: 34, and MMSE: 28 (9 years of study). She reported anxiety, which was confirmed in clinical evaluation, and FP, feeling someone behind her at home or even when walking on the street at least twice a week. Those problems had started 1 year before, after prescription of levodopa/benserazide.

At her house, we could find a collection of small purses, some empty and others with more purses inside. We also observed small diaries in which she copied repeated notes and phone numbers (Figure 1). She was unable to throw away flyers and ads distributed in the streets. We diagnosed punding and psychosis, and decided to reduce PD medications.

Two months later, she was on levodopa/benserazide 300 mg/day, pramipexole 1.0 mg/day, and nortriptyline 25 mg/day. There was a substantial improvement in punding behavior (she donated most of the small purses and threw away diaries and flyers). On the other hand, FP persisted in the same pattern. Motor symptoms became worse, and we prescribed entacapone 600 mg/day, with partial improvement.

Discussion

Punding is a relatively rare and underrecognized condition that challenges the treating physician. In order to improve diagnostic accuracy, phenomenology of punding should be widely disclosed. Based on that, we decided to display the pictures of punding, as showed here.

In this case, we confirmed that reduction in DT might be an effective approach to treat punding.⁴ Previous studies with amantadine and quetiapine showed controversial results.⁴ On the other hand, in our case, reduction in DT and withdrawal of amantadine resulted in no improvement in feeling of presence, reinforcing that it can no longer be considered as purely drug-induced. To our knowledge, no study has focused on treatment of FP. Recent studies have correlated psychosis with REM behavior disorder, visual-processing disturbances, depression, and dementia.⁵ Punding and psychosis, as well as impulse-control disorders and dopamine dysregulation syndrome are often associated, contributing to disability and psychosocial impairment.²