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Reply to Drs. Kurlan, Fasano, and Evans: A clinically useful definition of stereotypies

motor behaviors are ‘‘identical with those of normal acts’’ and are ‘‘resembling intentional or professional acts,’’ analogous to the behaviors of punders, whose activities frequently originate from prepotent idiosyncratic behaviors. We propose that punding should not be considered as a psychiatric side effect of dopaminergic drugs but as a motor behavior firmly within the rubric of stereotypies (Table 1). Accordingly, we agree with Edwards and colleagues not to include the complexity of movements in the definitions of stereotypy, similar to the situation with tics. Nevertheless, in analogy with the Jankovic’s classification of stereotypies, punding might still be viewed as a complex (not rhythmic) stereotypy. Another important feature shared by both stereotypies and punding is that movements are carried out at the expense of other motor activities (with a narrowing of the individual’s behavioral repertoire), distinguishing it from complex tics. Furthermore, an important source of analogy comes from the literature on animal and amphetamine effects (as also referenced in the review by Edwards and colleagues), which inspired a part of the current speculation on the pathophysiology of either stereotypies or punding. More complex is the relationship between punding and stereotypies with respect to the ‘‘non-goal-directed’’ feature of the behavior. The basal ganglia have been shown to contribute to various forms of learning and behaviors that have the property of slow acquisition and can occur with or without conscious awareness. Punding behaviors by nature originate from goal-directed behaviors, and their phenomenology typically reflects a global sensitization to appetitive behaviors. Indeed, PD patients may experience a hobbyistic increase in goal-directed activity before losing control of the activity (thus becoming ‘‘non-goal-directed’’). This evidence would suggest that punding is strongly mediated by bottomup brain processes. So, the proposal that stereotypies should be typically distractible would also seem arbitrary. In conclusion, we appreciate the contribution of a new definition of stereotypies to clinical practice and welcome debate on the subject. However, we would propose that the concept of stereotypy should include and potentially be informed by the example of punding.