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SSRI Discontinuation Syndrome

Confusing Neurological Presentation? Consider This Possibility…

Sometimes a patient presents with a range of neurological symptoms that would make even the most clinically capable osteopath shudder and return to the books (or Google!). However, as well as considering pathological aetiologies, it is wise to be aware of the following issues should your patient also be withdrawing from or reducing their medication:

The group of antidepressants know as Selective Serotonin Reuptake Inhibitors (SSRIs) are known to be an effective option for people suffering with depressive symptoms, and a range of other indications. However, withdrawal or reduction of dosage can in some circumstances lead to a disturbing secondary condition known as SSRI Discontinuation Syndrome.

“dizziness, light-headedness, vertigo or feeling faint; shock-like sensations or paresthesia; anxiety; diarrhoea; fatigue; gait instability; headache; insomnia; irritability; nausea or emesis; tremor; and visual disturbance”

Early studies of case reports that suggested a wide range of symptoms attributable to withdrawal were followed up with a number of controlled studies, and many showed that paroxetine is most likely to cause SSRI discontinuation syndrome of all the SSRI varieties.

double-blind placebo controlled trials demonstrate statistically and clinically significant indications of difficulties with the discontinuing of SSRIs”

 

Unusual Symptoms, Unknown pathology…

As you can see above, the symptoms of this condition are many and varied. However, to date there is no evidence to suggest that the length of SSRI treatment is associated with the development of more symptoms or with the severity of the the symptoms.

Moreover, many aspects of the neurobiology of the SSRI discontinuation syndrome remain unresolved, and so a 2013 paper discusses the underlying pathophysiology of the SSRI discontinuation syndrome to better understand this condition.

Obviously if there is a suspicion that your patient may be suffering with this, referral to their GP would be most prudent. Osteopaths’ awareness of some of the more unusual symptoms of this syndrome, such as dizziness and shock-like sensations, should prevent the unnecessary medical investigations described in some cases. In the mean time, the studies suggest the following advice:

“The best route of action for cessation of SSRI treatment is to taper down the dose of the medication rather than abrupt termination, as tapering is likely to decrease the possibility of the occurrence of discontinuation symptoms”

 

 

REFERENCES

1. Michelson, D.; Fava, M.; Amsterdam, J. et al. (April 2000). “Interruption of selective serotonin reuptake inhibitor treatment. Double-blind, placebo-controlled trial“. Br J Psychiatry 176 (4): 363–8. doi:10.1192/bjp.176.4.363. PMID 10827885.

2. Renoir, T. Selective serotonin reuptake inhibitor antidepressant treatment discontinuation syndrome: a review of the clinical evidence and the possible mechanisms involved. Front. Pharmacol. 4, 45 (2013).

3. Black, K., Chb, M. B., Shea, C., Dursun, S. & Kutcher, S. reuptake inhibitor discontinuation. (2000).

5. Wikipedia contributors, “SSRI discontinuation syndrome” Wikipedia, The Free Encyclopedia,

6. ‘Antidepressants’ image by DMedina @ Morguefile.com

The Evolution of Head Pain

Headache In Children and Adolescents

Headache and migraine sufferers frequently seek osteopathic intervention to help prevent, alleviate and manage their pain episodes. Headache is a complex clinical presentation, which requires – among other things – that the practitioner is able to take an appropriate case history, and then test for and discover signs such as raised ICP (e.g. papilloedema), ocular anomalies, CN signs and other red-flags that may require referral.

If dealing with children and adolescents who have headache and migraine, it is also important to be aware of physical and psychopathological co-morbidities and the expected prognoses of these conditions. Thus, the case-history, examination, treatment and management of these cases can be improved.

The following three papers, from many available online, form only a starting point to help the Osteopath to understand the bigger clinical picture when dealing with headache in childhood and adolescence, and should also lead to further study.
(See references for links to papers)

 

Headache Co-morbidities in Children and Adolescents

In 2013, Bellini et al reviewed studies that dealt with comorbid features of juvenile headache, in order to understand the risk-factors surrounding a child with this presentation. This interesting, but initially poorly-translated (!) paper particularly focusses on association with depression and anxiety, epilepsy, sleep disorders, ADHD, stroke and patent foramen ovale.

This is worthwhile reading for the osteopathic practitioner who might wish to fully understand the risks involved in both assessment and treatment of child patients. In conclusion the study states:

“Primary headaches in childhood and adolescence are often associated with, and deeply influenced by, many comorbid situations. …it is fundamental to take care of any kind of comorbidity to establish the most effective treatment strategy”

 

The Evolution of Headache

A 2014 study by Antonaci et al looked at the evolution of the clinical features of primary headache and migraine in the transition from childhood to adulthood by systematically reviewing available data from over 25 years. In discussion of these studies, the paper states:

“There is a large consensus that the natural temporal pattern of migraine may change over time: as attack frequency increases, the number of migraine features diminishes during the transformation period.”

Importantly, the paper also underlines the need for awareness of poor reporting in the paediatric case, given that some discrepancies are shown when interpreting variance in the studies’ results:

“Paediatric cases are often diagnosed as child hood periodic syndromes because children might not focus on their head pain, but rather on abdominal symptoms or vertigo. As they grow older their ability to describe their head pain improves and the description of the clinical picture of migraine becomes more detailed and accurate”.

When communicating with parents of children with recurrent headache, the following might also be of some reassurance in terms of expected length of treatment and the objective being pain management as well as improvement of the condition:

“When patients were followed up for 10 years or less, headaches were shown to improve or remit in 60-80% of cases. Persistence of primary headache at 10-year follow-up appears to be more predictive of headache persistence into adulthood, particularly if the primary headache is migraine.”

Given that headache is a major factor contributing to school absenteeism and poorer quality of life not only in childhood but also in adolescence, understanding the natural history during the management of the different headache forms is vital.

The Head-Pain Case History

In this extremely comprehensive paper, Donald Lewis M.D. provides the practitioner with an overview of the spectrum of primary headaches and a practical and rational approach to the evaluation and management of children with these recurring headache syndromes.

The article also uses clinical scenarios to illustrate diagnostic reasoning, explains relevant clinical methods, describes the pathophysiology of migraine in detail (from previous work) and common medications and their side-effects. Needless to say, this takes some investment in reading-time, but again highly informative and relevant to practice (CPD!!).

 

The Osteopathic Approach

It is of course, outside of the scope of this post to fully discuss the osteopathic approach to headache. However, our need to align our palpatory findings with the case history often requires us to ask further questions when discussing, for example, a physically traumatic event. Directionality of impact forces, previous injury or treatment and birth history (among many other factors) can all inform what is eventually palpated in the patient’s tissues.

Future courses from the Rollin E. Becker Institute will specifically address the osteopathic approach to the head pain patient, but more information can also be found on our upcoming 5-day Cranial Course in Swindon (see info here)

 

 

REFERENCES

1. Bellini, B. et al. Headache and comorbidity in children and adolescents. J. Headache Pain 14, 79 (2013).

2. Antonaci, F. et al. The evolution of headache from childhood to adulthood: a review of the literature. J. Headache Pain 15, 15 (2014).

3. Lewis, D. W. Headaches in children and adolescents. Curr. Probl. Pediatr. Adolesc. Health Care 37, 207–46 (2007).