Punding Behavior in Bipolar Disorder Type 1: Case Report

The present case concerned a 64-year-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 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 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.

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.