Commentary: considerations on the pharmacological treatment of compulsions and stereotypies with serotonin reuptake inhibitors in pervasive developmental disorders.

Abstract

Repetitive or ritualized behaviors have been considered an integral part of autistic disorder since Kanner’s original description in 1943. Presently 5 of the 13 DSM-IV criteria refer to stereotyped, repetitive, or ritualized behavior patterns of different types. Repetitive nonpurposeful motor behaviors of both involuntary (tics) and voluntary (motor stereotypies) nature are very frequently present. A desire for “sameness” and inflexible adherence to routines is combined with internal discomfort if such rituals are not closely followed in nearly all patients. Perseveration in terms of langugage use and interests is uniformly present. Finally, more typical obsessive-compulsive behaviors such as collecting, counting, and washing rituals are also frequently present. Strict and inflexible adherence to self-directed, repetitive patters of thinking and behaving and the tension, tantruming, and aggression which occur when one attempts to interfere with them impose major obstacles to learning and social development in autism. The relationship between these different types of repetitive behavior on a neurophysiological level is unclear. Nonselective and selective serotonin reuptake inhibitors and dopamine blockers (typical and atypical neuroleptic agents) have been the two classes of medications most helpful for reducing the impact of some of these behaviors on academic and social functioning. This discussion is focused on the serotonin reuptake blockers since neuroleptics are discussed elsewhere. The nonselective serotonin reuptake inhibitor, clomipramine, was shown to be differentially effective in treating autistic symptomatology with both placebo and the primarily noradrenergic tricyclic agent desipramine in a double-blind comparison in 24 children with autism and adolescents (Gordon, State, Nelson, Hamburger, & Rapoport, 1993). Clomipramine improved obsessive-compulsive symptoms as hypothesized.