Serotonin Syndrome Too Much of a Good Thing Part 3/3

March 1, 20140 Comments

In part three I demonstrate the point prescription I used with remarkable success. First let’s go over the signs and symptoms (SSx) of SS. Keep in mind there can be other additional SSx’s as in the case I present below.

The symptoms of the serotonin syndrome are (from The Serotonin Syndrome, AM J PSYCHIATRY, June 1991):

1. Euphoria

2. Drowsiness

3. Sustained rapid eye movement

4. Overreaction of the reflexes

5. Rapid muscle contraction and relaxation in the ankle causing abnormal movements of the foot

6. Clumsiness

7. Restlessness

8. Feeling drunk and dizzy

9. Muscle contraction and relaxation in the jaw

10. Sweating

11. Intoxication

12. Muscle twitching

13. Rigidity

14. High body temperature

15. Mental status changes were frequent (including confusion and hypomania – a “happy drunk” state)

16. Shivering

17. Diarrhea

18. Loss of consciousness and death.

There is an additional and unique 19th symptom in which the patient experiences intense, deep, brain pain which is not like a headache, it’s a totally different type of pain.

Note that if the patient has no history of serotonergic drug use, think of a different cause.

Note that if the patient has no history of serotonergic drug use, think of a different cause for agitation. Click to enlarge diagram.

I have made this diagnosis before and it isn’t pretty. In fact I see it as yet another form of malpractice. Why malpractice? Because it usually takes a deliberate attempt to induce this syndrome by adding in one serotonergic drug after another like you would when experimenting on a lab rat. In the case where I saw it, this person was slowly being driven mad. Yet, astonishingly, it could have easily been prevented if his psychiatrist hadn’t been so apathetic. When he finally became toxic he was taking 5 serotonergic agents every day, five! Had I not been there when this patient came in I fear he would have died in the next day or two before anyone could figure out what was happening.

Number 1. If you suspect that your patient has SS, immediately go to the medication list that a patient usually has in her purse or wallet. Or get the list from the patient if coherent-you must find out what they are taking. Keep in mind that the syndrome can still occur with only one antidepressant. A good history is key. Often times the medication was just added or the dose increased. There are many classes of meds that can contribute so be sure that you are familiar with each class (see below for a list).

MY CASE: In the case detailed here we had a middle aged, white male with a history of CVD, hypertension and diabetes. His medications included:

  1. Trazodone (often prescribed to help patients sleep)
  2. Paxil
  3. Seroquel (this is a push-me-pull-you drug: it antagonizes the 5HT (serotonin) receptor)
  4. Prozac
  5. Amphetamine

Number 2. Compare signs and symptoms provided from this discussion and get a set of vital signs including temperature. This is where an automatic cuff is peachy and using your new, cool pulse oximeter even peachier (see previous blog “what you gunna do when your patient passes out on you.”) The patient can have a dangerously elevated body temperature which can be fatal.

DO NOT forget to obtain an accurate temperature. Should you encounter extreme changes in vitals such as a temperature over 102, severe tachycardia and hypertension or hypotension and bradycardia or if in shock (the hallmarks of shock: systolic BP < 90 torr and HR > 100 BPM) you need to call an ambulance immediately. Assess the patient for orientation times three: person, place and time. If disoriented times three it’s best to call an ambulance in that setting as well. Lastly, you can needle the patient as, or right after, you call an ambulance. This would be very helpful for the EMT’s too. More than likely you will not see a case as bad as this one. Most will probably present as HYPO-mania which gives you a little more wiggle room to comfortably proceed with the prescription provided. Mild tachycardia and mild hypertension is part of the syndrome which you can safely treat.

DO NOT miss simple hypoglycemia which can look very similar to this syndrome. Keep orange juice in the refrigerator or something sugary for just such a time. Neurolept Malignant Syndrome (NMS) is another syndrome that can look like SS. In NMS the temperature climbs rapidly and can be fatal. This is brought on by another dangerous class of psychiatric drugs the antipsychotics.

The serotonin syndrome is generally caused by a combination of two or more drugs, one of which is often a selective serotonergic medication. The drugs which we know…most frequently contribute to this condition are the combining of MAOIs with Prozac (this should also include the other SSRIs) or other drugs that have a powerful effect upon serotonin, ie., clomipramine (Anafranil), trazadone (Deseryl), etc. The combination of lithium with these selective serotonergic agents has been implicated in enhancing the serotonin syndrome. The tricyclic antidepressants, lithium, MAOIs, SSRIs, ECT (electric shock treatment), tryptophan, and the serotonin agonists (fenfluramine) all enhance serotonin neurotransmission and can contribute to this syndrome. Anything which will raise the level of serotonin can bring on this hyperserotonergic condition. [Note be sure to enquire on the use of St John’s Wort or Valerian too] The optimal treatment for the serotonin syndrome is discontinuation of the offending medication or medications, offer supportive measures, and wait for the symptoms to resolve. If the offending medication is discontinued, the condition will often resolve on its own within a 24 hour period. If the medication is not discontinued the condition can progress rapidly to a more serious state and become fatal. It should be apparent that the greater the enhancement of serotonin levels, the greater the chances of producing the serotonin syndrome. Therefore it is recommended that Zoloft, Prozac, Paxil, Luvox, Serzone, etc. not be used concurrently with each other or any other serotonergic drugs and that these serious adverse reactions should be expected with these combinations (Callahan, 1993).[1]

Number three. For the LAc contact the patient’s MD or whomever is listed on the medication bottle (if available) or get the information from the patient if it’s possible. Inform him or her what the situation looks like. Start with the patient’s name and age and describe the vital signs first followed by the other SSx’s from the list. Tell the physician the drugs your patient appears to be taking as well.

MY CASE (cont.). My patient’s presentation was of marked “fight or flight” activation: sweating, tachycardia, hypertension, dilated pupils. He was crying one minute, laughing the next. He complained of lightning bolts in his head which would come and go starting in the spine and shooting into his brain. Restlessness and confusion were also present. He appeared as if he had just finished a tumultuous roller coaster ride at 120 miles per hour, without a lap belt. He was not disoriented however. Vital signs: HR 95. BP 150/98, Temp 100.5, RR 23. Deep tendon reflexes were increased but no muscle rigidity was seen.

Number four. Proceed with the point prescription that has worked for over a thousand years: For Mania SUN SI MIAO. DU26, LU11, SP1, P7, BL62, DU16, ST6, REN24, P8, DU23, REN1, LI11, SHEXIA (TWO VEINS UNDER TONGUE), P5, SI3.

NEEDLE ONE BY ONE IN THE ORDER WRITTEN WITH NO RETENTION OF NEEDLES, REDUCE STRONGLY (for about one min) THEN REMOVE. I ALSO ADDED SSC AT THE BEGINNING. BLEED THE VEINS AND NEEDLE OR BLEED THE JING WELL POINTS. (I DIDN’T DO REN1 FOR SEVERAL REASONS).

The effect of this treatment was pretty amazing. No sooner was I half way through the series and he already started calming down. The entire treatment took no more than 15 minutes and in the end produced a calm, quiet, and totally different patient. Mania scale before treatment 9/10, after treatment 3/10. His Shen cleared and he became lucent. I instructed him to STOP ALL MEDICATIONS and called his doctor. I saw him every day for three days with the same treatment protocol. Each time it had more powerful and lasting results. Along with the discontinuance of the serotonergic offenders he was nearly normal in 48 hours.

I cannot stress enough how important it is to be as familiar as possible with this syndrome. Why? Because people die from this and MOST prescribing physicians will prescribe more drugs or higher doses of existing ones because they are not aware of the signs and symptoms of SS as a possible culprit. 99/100 times the physician will blame the patient-typically they will claim that his “mania” surfaced as he was being treated. We all need to be more aware of the terrible consequences of serotonergic polypharmacy. If you examine the tragedies like school shootings you will see a similar picture, only it’s not SS it’s simply mania emerging from the ashes of serotonergic drugs. The doc doesn’t recognize the emerging mania as a consequence of over-medication so he or she prescribes more or adds another drug. In a small minority of patients the consequences are disastrous. This is precisely what has happened time and again in cases of murder, mayhem, and suicide.

The big difference is that mania is not a maniac. Mania produces a cool, somewhat calm picture of a person who can plot and plan a mass murder for weeks on end in a disturbingly efficient way. That’s at least one way, the worst way, mania can present. SS on the other hand looks more like your “Hollywood” maniac: up and down and all over the place-sweating, and delirious. For additional reading I suggest three books by Dr Peter Breggin. Toxic Psychiatry, The SSRI Handbook and Medication Madness. Below I provide a chart on the differential diagnosis of several very similar syndromes. Familiarize yourself with SS, NMS, and the anticholinergic toxidrome. Malignant Hyperthermia is an anesthesia disease which I have had the (mis)fortune of seeing while in private practice. I always had very good intuition when it came to possible “bad outcome” cases and this one was no different. A 6 yo scheduled for tonsillectomy with no medical Hx. After I put him to sleep he did a weird hiccup (the best way I could describe it) and showed some unusual activity on EKG-a couple PVC’s (extra beats). With my powerful and trustworthy sense of intuition I immediately cancelled the case, woke him up, and noticed the temperature rising. By the time we got to the recovery room his body temperature had already reached 104. Before his muscles could liquify (they break down quickly) I administered Dantrolene IV which puts a stop to the muscle contractions which are fatal if not addressed. Had I not paid attention to my gut feeling I would have had a dead kid on my hands. The oddest thing about it was my indications for cancelling the case, in the surgeon’s eyes, were ridiculous-I had no (physical) reason. Yes, indeed! My point? Trust your intuition. If you think a patient is going south he or she probably is.

Cheers!

Chris

SEROTONIN SYN DDX

SEROTONIN SYN DDX



[1] (Tracy, PROZAC: PANACEA OR PANDORA? p. 88.)

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About the Author ()

Christopher Rasmussen MD, MS is Founder and Professor at AdaptiveTCM where helps Traditional Chinese Medicine Practitioners treat complex patients with confidence through providing online CEUs and research. Dr. Rasmussen is currently writing a comprehensive, preventive medicine book, with an emphasis on inflammatory components of disease prevalent in today's patients.

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