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Letters to the Editor   |    
Compulsions in Depression: Stalking by Text Message
OLIVER D. HOWES
Am J Psychiatry 2006;163:1642-1642.

To the Editor: The ubiquitous nature of text messaging may result in compulsive text messaging as a clinical problem. The case below highlights the affect of compulsive text messaging and suggests that trazodone and behavioral therapy might be effective treatment, although the effect of natural recovery cannot be excluded.

A 32-year-old woman compulsively sent her ex-boyfriend text messages (repeatedly asking him to meet her, chastising him for leaving her, and expressing love for him) after he ended their relationship. He told her to stop contacting him because he wanted no communication with her. Her messages were alarming and disrupted his life. She continued, however, despite his attorney threatening legal action against her. Any effort to resist sending a message resulted in increased tension until she sent a message, which was followed by a short period of relief that “a link [between her and her ex-boyfriend] was maintained.” Her growing tensions were only relieved by sending messages. Her text messages continued to increase until she spent 4 hours per day sending 30 to 40 messages, resulting in phone bills of £100 per month, and disciplinary procedures were issued by her employer for her poor work performance. Subsequently, she made no other attempts to contact her ex-boyfriend.

The patient had no personal or family history of psychiatric illness, substance misuse, obsessive compulsive disorder, or habit disorders, but her parents were very distant throughout her life. Her two previous relationships, both heterosexual, ended mutually with no difficulties.

After 6 months, her general practitioner treated her with fluoxetine, 20 mg/day. The doses were increased to 40 mg/ day. In addition, she attended six sessions of Rogerian counseling concerning adjustment to relationship loss. Since there was little response after 4 months of treatment, she was referred to psychiatric services. Trazodone, which is reportedly beneficial for compulsive behaviors (1), was substituted for fluoxetine, and a behavioral program was started (charting her text messaging, prescribing relaxation techniques to reduce tension, and scheduling time to send messages). The time between sending text messages was gradually increased. Over a period of 3 months, her compulsive text messaging gradually resolved, and she has not sent her ex-boyfriend a text message for more than 1 year.

To our knowledge, this is the first report of compulsive text messaging. Compulsive text messaging can be conceptualized as stalking—a pattern of repeated, intrusive, distressing behavior focussed on one individual that persists despite clear indications that it is unwanted (2, 3); for example, in the context of maladjustment to the termination of a relationship. Cyber stalking—using technology, including e-mail, fax, text messages, and pagers as part of stalking behavior (2)—is becoming an increasingly recognized behavior (see http://www.mincava.umn.edu/documents/commissioned/stalkingandtech/stalkingandtech.pdf). Stalking behavior has been categorized as the perpetrator following the victim (e.g., keeping a vigil outside the victim’s home); the perpetrator communicating with the victim via phone, letters, and other media; and, ultimately, the perpetrator using aggression toward the victim (2). Studies of stalkers report that they are more likely to be men with female victims than vice versa (2, 3). The simple obsessional group, a classification in which there is a prior relationship between the victim and the stalker, such as in the case above, is the most common type of stalking and most likely to resort to violence (2). Disturbed childhood attachment is also commonly reported in such cases (3).

1.Khouzam HR, Mayo-Smith MF, Bernard DR, Mahdasian JA: Treatment of crack-cocaine-induced compulsive behavior with trazodone. J Subst Abuse Treat 1995; 12:85–88
 
2.Nadkarni R, Grubin D: Stalking: why do people do it? BMJ 2000; 320:1486–1487
 
3.Kamphuis JH, Emmelkamp PM: Stalking: a contemporary challenge for forensic and clinical psychiatry. Br J Psychiatry 2000; 176:206–209
 
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References

1.Khouzam HR, Mayo-Smith MF, Bernard DR, Mahdasian JA: Treatment of crack-cocaine-induced compulsive behavior with trazodone. J Subst Abuse Treat 1995; 12:85–88
 
2.Nadkarni R, Grubin D: Stalking: why do people do it? BMJ 2000; 320:1486–1487
 
3.Kamphuis JH, Emmelkamp PM: Stalking: a contemporary challenge for forensic and clinical psychiatry. Br J Psychiatry 2000; 176:206–209
 
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