Tuesday, 31 December 2013

Is this punding? You decide

While I appreciate that starting any blog with the word Wagner is usually enough to have readers abandoning the page like lemmings, you might want to stick around for this one. Trust me, it will make sense -- well, inasmuch as anything I write makes sense.

Because dear reader, and you may already be in the singular rather than plural, I want to tell you how the music of Richard Wagner has alerted me to possible new developments in my Parkinson's. And no, despite the man's overwhelming sense of self-importance, not even he claimed to be a neurologist. Pretty much everything besides -- musician, composer, poet, political activist, author and general philanderer. But not a neurologist.

Let me backtrack a little.

As many of you who know me would be the first to acknowledge, I like music. And my tastes are catholic, albeit with a few gaping holes. I can't imagine the day dawning when I will buy my first Eminem record for instance. And Lady Gaga should probably not rely on me to bolster sales in the post-Christmas lull. But other than a few egregious examples, I like most music. And some music, I absolutely adore. Many of you will already be hearing the possible direction this is taking. But bear with me.

Anyway, to cut a long story short (and when have I ever), I discovered that, over some 30 years of purchasing, I have amassed just over 3500 classical CDs. Leaving aside the fact that this amounts to a cash outlay of somewhere in the region of a year's salary, it also represents a substantial listening time commitment. People often ask me how I find time to listen to them all. Well, the answer is of course that I don't. Assuming a conservative estimate of 60 minutes per disc, and an average listening day of say 10 hours (just to make the mathematics easy), I could start at Albinoni at 9 AM on January 1, 2014 and only reach the closing bars of Zemlinsky's Sinfonietta at around supper time on 14 December.

I would have put Beethoven behind me in late February, before hearing Delius's 'First Cuckoo in Spring' appropriately enough in mid-March. April would be spent wading through the deep waters of Elgar oratorios before summer marched in around June with Mahler's hymn to nature, the mighty 3rd Symphony. By August, we are humming 'O Mio Babbino Caro' and ''Nessun Dorma' with a glass of Barolo in hand, before Sibelius's Tapiola accompanies a distinct nip in the September air. As we rummage for jumpers in October, Stravinsky's Rite of Spring seems a world away. Slippers by the fireside in November can only mean the whoop of Valkyries, before Walton invites us to Belshazar's Feast, just as the office Christmas bashes gets underway.

I f I took an hour off for lunch each day, we would be into 2015 before I had popped the cork on Strauss's Champagne Gallop. And if I allowed myself music free weekends, we would be surrounded by Sugar Plum fairies until well after Easter 2015. And if the restriction was a mere one hour per day (and I have to concede that there are some people out there who listen to as little Wagner as this), we would have changed presidents not once but twice during the course of my classical record collection. In fact it's not beyond the realms of possibility that, by the time Wagner reaches the end of the world in Gotterdammerung, the world could actually have ended. Now that would be a production worth seeing ...

Of course these calculations make the assumption that I do not buy a single CD between now and the election of Obama's successor's successor (or the end of the world, whichever comes first). And let's face it, that's not going to happen.

For many of you, the prospect of listening to my record collection for the next decade would be about as popular as eight years of Republican government. And probably about as productive.

Okay, enough of these diversions. Let's get down to the serious business of what I have to say. Amusing though the above may be (I hope it made you laugh), the very detail of it reveals the number of important aspects of Parkinson's. How a record collection can be indicative of symptom progression is something that many of you may find puzzling. But in amongst all those fripperies, are some key facts.

1) I have an abnormally large number of CDs.

2) I have expended significant time and energy counting them

3) I have arranged them in alphabetical order

4) I have performed several unnecessary (if amusing) calculations on these CDs.

From a neurological stance, these activities are evidently pointless. It really doesn't matter how many CDs I have nor the length of time the music would play for. Not one of these mental exercises has the slightest value. These are essentially repetitive and unproductive behaviour elements. And there is a word for this behaviour.

It's called punding.

Punding is essentially the unproductive repetition of small behavioural components, to the exclusion of other behaviours. Typical examples might be the collection and sorting of objects according to size or shape for instance. Taking things to pieces and reassembling them might be another example, particularly amongst men. Women will often repeatedly sort through their handbags or tidy continuously. Many people with Parkinson's who exhibit punding find it comforting, rewarding or in some way enjoyable and are frustrated when diverted from the activity. Most who pund retain insight into their behaviour.

On the face of it, and in the absence of any other information, you would reasonably suppose that I was showing signs of punding. Collecting and sorting are hallmarks of punding. So, were I to present myself to an uninitiated neurologist -- a trainee for instance -- they might draw that conclusion and treat accordingly.

We know that this is a dopaminergic behaviour as it was first observed in amphetamine and cocaine users, both of which drugs release dopamine in the brain. A recent paper (Fasano & Petrovic, 2010) appeared to implicate the dopamine agonists in general and those with actions on D1 and D2 receptors particularly.

But am I actually punding? If the hypothetical neurologist trainee knew me a little better, might they draw a different conclusion?

The key thing here is the premorbid personality. What was the patient (me) like before I had Parkinson's? Is this apparent punding a new behaviour, entirely out of character, or is it merely an exaggeration of the behaviour I exhibited before Parkinson's? Is it even exaggeration at all?

So, to help answer this question, let me take you back more than 40 years. A 10-year-old Jon has a bedroom at the end of a long corridor. Sharing his bedroom are 4 floor-to-ceiling industrial shelf units. And covering (literally covering) every inch of space are model aeroplanes of every shape or form. More than 200 as I recall, and here memory fails me. And these planes were divided up thematically. Two shelves were occupied by First World War aircraft -- Sopwiths, Fokkers, Spads and so on, surrounding the pride of my collection, a Handley Page bomber. And so it went on, each shelf organised according to nationality or time period (e.g. Second World War American bombers). On those four shelves was an entire Airfix airforce. Were these planes real, they would have amounted to a significant strategic deterrent.

So my point is this. The 10-year-old Jon did not have Parkinson's and did not take any medication beyond the usual aspirin or paracetamol. Juvenile Jon was nonetheless of a rather obsessive persuasion and although I did not wash my hands hundreds of times a day, I always avoided the cracks in pavements.

I would submit, your honour, that what at first sight looks like an open and shut case of punding is rather more complex. I don't rule punding out but I do believe that it is important to take into account the patient's own personality, however quirky!

Finally, before I subject my case to you for scrutiny, I should just like to respond to each of the points I enumerated above:

1) 3500 CDs is not unique. David Mellor has more.

2) It’s only a ballpark figure, accurate to ~50 or so.

3) Well, since they occupy 8 metres of shelf space, how would you find any CD otherwise

4) Actually only once - for the amusement of readers of this blog.

Over to you -- am I punding?
Fasano A, Petrovic I (2010) Insights into pathophysiology of punding reveal possible treatment strategies. Mol Psychiatry. 15: 560-73.

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