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Mental Health (Expert Forum)
Serotonin Syndrome
Answered by
Roger Gould, M.D. - Mental Health, Wellness
Questions posted in the Mental Health forum are being answered by Dr. Roger L. Gould, author of the Mastering Stress and Depression program and affiliated with the UCLA. Department of Psychiatry. Topics covered include anger, attention deficit disorder (ADD) , bipolar disorder , dementia , electroconvulsive therapy (ECT) , learning disabilities, memory, obsessive compulsive disorder (OCD) , panic , personality disorders, phobias , post-traumatic stress disorder (PTSD) , schizophrenia , stress , transitions, and work problems.
Serotonin Syndrome
by arnp, Jul 11, 2001 12:00AM
I had a case with the following presentation:
38 year old woman who has been on Paxil 40 mg for 2 years for OCD and depression. She has had good success with it, and decides to taper back to see how she feels. She tapered down slowly to 10 mg but did had recurrence of her Obsessions and depression so tapered back up to 30 mg and had been back on that dose for approximately one month.
She went to work one day and after work went home and ate supper. She usually takes her Paxil in the morning (after experimenting with when it works best for her) but that day took it on an empty stomach at about 5 pm (she has taken it at varying times of the day when she has forgotten her morning dose without problems). After going right home and eating supper, she took her kids up to the pool and was sitting on a beach chair watching her kids swim and chatting with a friend. The sun was quite hot and she states she felt like the sun started bothering her eyes. She then suddenly became terribly dizzy where she felt like the clouds in the sky were spinning around her at a very fast speed. She tried to get up and walk but could not without falling. Ambulance was called.
When ambulance arrived, the paramedics said she was having marked rotational nystagmus. She was alert and oriented but kept complaining she couldn't walk due to dizziness. BP was slightly elevated. Other vitals stable. Skin warm and dry. However, blood sugar was checked and found to be 35 (no history of hypoglycemia). She had eaten a high carb meal one hour prior. The ambulance squirted the glucose gel in her mouth. In about 15 minutes, blood sugar was 48. By the time she was loaded in the ambulance, blood sugar was 60. However, the dizziness had not abated at all. An IV was started and on arrival to the hospital, she was given a bolus of D5 and then it ran at 125 cc/hour. Due to nausea, she was given Phenergan 25 mg IV (which abated the nausea and it never returned). She was fed and at midnight blood sugar was 100 (about 2 hours after a peanut butter sandwich and the D5 still running). At 4 am, blood sugar had come up to 160 but she was still terribly dizzy. With D5 still going, blood sugar dropped to 105 by 6 am. She was fed breakfast (combo of high protein and high carbs) and an hour later, blood sugar was 96. She was still terribly dizzy. She ended up being discharged later that day and could walk only with assistance. It took a full week for dizziness to clear (most of the way) and she did not drive until that time. This happened two weeks ago. Also, CAT scan and MRI of brain were normal. Fasting and serial insulins were normal. 5 hour glucose tolerance test done one week later was slightly abnormal. She tapered off the Paxil and has now been off it one week.
Could this have been Serotonin syndrome? The other doctors have felt that the Paxil could not be responsible. There have been mixed opinions about her going off it due to her OCD and depression (she has never been so depressed that she is suicidal). I am a family nurse practitioner in a rural practice and we are all quite puzzled. What do you think? Thank you in advance.
38 year old woman who has been on Paxil 40 mg for 2 years for OCD and depression. She has had good success with it, and decides to taper back to see how she feels. She tapered down slowly to 10 mg but did had recurrence of her Obsessions and depression so tapered back up to 30 mg and had been back on that dose for approximately one month.
She went to work one day and after work went home and ate supper. She usually takes her Paxil in the morning (after experimenting with when it works best for her) but that day took it on an empty stomach at about 5 pm (she has taken it at varying times of the day when she has forgotten her morning dose without problems). After going right home and eating supper, she took her kids up to the pool and was sitting on a beach chair watching her kids swim and chatting with a friend. The sun was quite hot and she states she felt like the sun started bothering her eyes. She then suddenly became terribly dizzy where she felt like the clouds in the sky were spinning around her at a very fast speed. She tried to get up and walk but could not without falling. Ambulance was called.
When ambulance arrived, the paramedics said she was having marked rotational nystagmus. She was alert and oriented but kept complaining she couldn't walk due to dizziness. BP was slightly elevated. Other vitals stable. Skin warm and dry. However, blood sugar was checked and found to be 35 (no history of hypoglycemia). She had eaten a high carb meal one hour prior. The ambulance squirted the glucose gel in her mouth. In about 15 minutes, blood sugar was 48. By the time she was loaded in the ambulance, blood sugar was 60. However, the dizziness had not abated at all. An IV was started and on arrival to the hospital, she was given a bolus of D5 and then it ran at 125 cc/hour. Due to nausea, she was given Phenergan 25 mg IV (which abated the nausea and it never returned). She was fed and at midnight blood sugar was 100 (about 2 hours after a peanut butter sandwich and the D5 still running). At 4 am, blood sugar had come up to 160 but she was still terribly dizzy. With D5 still going, blood sugar dropped to 105 by 6 am. She was fed breakfast (combo of high protein and high carbs) and an hour later, blood sugar was 96. She was still terribly dizzy. She ended up being discharged later that day and could walk only with assistance. It took a full week for dizziness to clear (most of the way) and she did not drive until that time. This happened two weeks ago. Also, CAT scan and MRI of brain were normal. Fasting and serial insulins were normal. 5 hour glucose tolerance test done one week later was slightly abnormal. She tapered off the Paxil and has now been off it one week.
Could this have been Serotonin syndrome? The other doctors have felt that the Paxil could not be responsible. There have been mixed opinions about her going off it due to her OCD and depression (she has never been so depressed that she is suicidal). I am a family nurse practitioner in a rural practice and we are all quite puzzled. What do you think? Thank you in advance.
Doctor's Answer
by Roger Gould, M.D., Jul 14, 2001 12:00AM
, Jul 14, 2001 12:00AM
Dr. Gould will return next wed.and answer your question at that time.
Member Comments (3)
by advocate53, Jul 11, 2001 12:00AM
I am currently involved in research efforts in the area of antidepressants. Much is widely unknown by the medical community at large concerning the true risks involved in the use of these drugs but also the phenomenon of SSRI withdrawal syndrome, now recognized by the World Health Organization. A very important site to go to for more in depth and crucial information is http://www.drugawareness.org
by Roger Gould, M.D., Jul 24, 2001 12:00AM
, Jul 24, 2001 12:00AM
I have checked this out with some of my colleagues who have more direct experience and they say that this is defintely a possible withdrawal syndrome, and that it frequently occurs more often with Paxil because it is shorter acting. Some people, after missing only one dose,call and say they feel like they are having a stroke. Hope this helps..sorry for the delay.
