Repetition compulsion

An equally important assumption is that conflict and anxiety are ubiquitous, ongoing, and recurrent not so much because of an unconscious repetitive compulsion, but rather because life is always a competitive and uncertain interaction of unknowably complex variables. In that sense, therapy is indeed interminable if one expects to rid the world and the brain-mind of its intrinsic chaotic properties. Rather than vainly hoping to get to the bottom of it, we should try our best to stay on top of it while fully realizing that despite our most nimble balancing efforts we will all get out of whack from time to time. 

The repetitive involvement in apparently aversive or abusive relationships (sometimes called the repetition compulsion) may be related to hypersensitivity of the separation-stress center in the brain (see the discussion in chapter 7), which has been shown to respond favorably to treatment with antidepressants, especially MAO inhibitors. 

Pathological skin picking is characterized by repetitive compulsive picking of the skin, causing tissue damage. In a 12-week doubleblind, randomized, placebo-controlled trial of lamotrigine as monotherapy with doses of 12.5-300 mg/day in 32 subjects, the incidence and severity of adverse experiences... 

In addition, patients with body dysmorphic disorder experience a preoccupation with an imagined defect in appearance that leads to repetitive checking behaviors to assess their appearance. The symptoms of body dysmorphic disorder, essentially equivalent to the obsessions and compulsions of OCD, have led some to propose that the former syndrome is not a distinct disorder but a subtype of the latter. Again, a key distinguishing factor is that OCD will typically have been associated with some other nonsomatic obsession during the course of the illness. 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

McDougle, C.J., Kresch, I.E., Goodman, W.K., Naylor, S.T, Volk-mar, F.R., Cohen, D.J., and Price L.H. (1995) A case-controlled study of repetitive thoughts and behavior in adults with autistic disorder and obsessive-compulsive disorder. Am J Psychiatry 152 772-777. 

Obsessions are defined as intrusive, repetitive thoughts, ideas, images, or impulses that are anxiety provoking and unwanted ( worries ). They are typically recognized as being unwanted and excessive (ego dystonic), even in very young children, and the anxiety they cause leads to the performance of compulsive behaviors that serve to reduce anxiety ( rituals ), thus setting up a... 

Obsessive-compulsive disorder (OCD) is characterized by recurrent, intrusive, and distressing thoughts, images, or impulses (obsessions) and repetitive, seemingly purposeful behaviors that a person feels driven to perform (compulsions). 

Compulsions are repetitive, purposeful, intentional behaviors performed in response to an obsession, typically according to certain rules or in a stereotyped fashion. These behaviors are designed to neutralize obsessions, but again, the individual recognizes them as unreasonable or excessive. Typical compulsive behaviors include the following ... 

Although many schizophrenic patients demonstrate obsessive-compulsive symptoms, this problem has received little systematic investigation. There are conflicting case reports of patients with obsessive-compulsive symptoms who failed to benefit when given an antiobsessional drug in addition to an antipsychotic, and other cases in which this strategy was beneficial (176). There are also reports of certain repetitive behaviors that mimic OCD that are benefited by the addition of clomipramine (177,178 and 179). Schulz has proposed the term schizo-obsessive to describe this clinical presentation ( 180). 

OCD is known to respond to serotonergic antidepressants. It is characterized by repetitive anxiety-provoking thoughts (obsessions) or repetitive behaviors aimed at reducing anxiety (compulsions). Clomipramine and several of the SSRIs are approved for the treatment of OCD, and they are moderately effective. Behavior therapy is usually combined with the antidepressant for additional benefits. 

Drugs are abused (used in ways that are not medically approved) because they cause strong feelings of euphoria or alter perception. However, repetitive exposure induces widespread adaptive changes in the brain. As a consequence drug use may become compulsive—the hallmark of addiction. 

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