Jump to content
westcoast

Cortes and Radhakrishnan, 2013. A Case of Amelioration of Venlafaxine-Discontinuation “Brain Shivers” With Atomoxetine

Recommended Posts

westcoast
My Comment: This is the complete letter. The references can be seen via the link.
I was interested in what they say about the mechanism, at the end.
AFAIK, atomoxetine is an SNRI. It gave me the most horrendous evil feeling in the muscles of my legs that I went to emergency after a few days and almost got locked up. It wasn't pain per se. It was like "expectancy." These novel drugs give us sensations we can't describe, so the doctors describe us as crazy, you know?
 
Prim Care Companion CNS Disord. 2013; 15(2): PCC.12l01427. Published online 2013 Mar 21. doi:  10.4088/PCC.12l01427

A Case of Amelioration of Venlafaxine-Discontinuation “Brain Shivers” With Atomoxetine
Jose A. Cortes, PhD and Rajiv Radhakrishnan, MD
 

Full text at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733524/

To the Editor: Antidepressant discontinuation syndrome is a common syndrome seen following abrupt termination of treatment with a serotonin reuptake inhibitor.1 It occurs at rates ranging from 17.2% to as high as 78% with venlafaxine.2,3 There is, however, little literature on “brain shivers,”4,5 a common antidepressant-discontinuation symptom described by patients taking venlafaxine, duloxetine, citalopram, and paroxetine. Much of the information comes from Internet blogs and Web sites.6–8 The symptom is described variously as “an electrical shock–like sensation in the brain,” “the sensation of the brain shivering,” “brain zaps,” “brain shocks,” “brain shivers,” “head shocks,” or “cranial zings.” The etiology of the symptom is not known, and there is no known treatment for this distressing symptom.
 
We describe a case in which “brain shivers” occurred as part of venlafaxine discontinuation syndrome and abated with atomoxetine treatment. ["we made this man miserable for nothing"]
 
Case report. Mr A, a 34-year-old man, presented with DSM-IV major depressive disorder (MDD) that responded well to venlafaxine (300 mg/d). He achieved remission except for seasonal exacerbations during autumn during the next 4 years. In view of a family history of bipolar disorder, it was decided to add lamotrigine and taper venlafaxine. [idiots] Mr A maintained remission on venlafaxine (37.5 mg/d) and lamotrigine (200 mg/d) without seasonal exacerbations. Mr A abruptly discontinued venlafaxine 37.5 mg/d. On the second day following discontinuation, he reported feeling an unpleasant sensation of “electricity in the head” that “felt like the brain was shaking inside the skull.”
 
Mr A was also noticed to demonstrate emotional incontinence and complained of anhedonia, anxiety, tinnitus, headache, nausea, and increased sensitivity to noise.
 
Since the “brain shivers” were the most distressing symptom, a trial of atomoxetine 40 mg/d was attempted based on the hypothesis that the symptom was a result of noradrenergic imbalance.9 An immediate improvement in “brain shivers” was reported within 2 or 3 hours of taking the first dose.
 
Over the next 3 days, Mr A reported further improvement in “brain shivers” and anhedonia although emotional incontinence and increased sensitivity to noise persisted.
 
Given the severity of other withdrawal symptoms, venlafaxine (37.5 mg/d) was reinstated and atomoxetine was stopped. All withdrawal symptoms disappeared during the next day. [chalk one up for Effexor!]
 
The case adds to the interesting speculation about the noradrenergic imbalance as the basis of “brain shivers.”9 “Brain shivers,” conceptually related to Lhermitte’s phenomenon,10 have also been reported with the noradrenergic drug 3,4-methylenedioxy-N-methylamphetamine (MDMA).
 
The psychotropic effects of MDMA are mediated via norepinephrine transporter11 and results in an increase in synaptic norepinephrine levels.
 
Venlafaxine’s affinity for norepinephrine transporter (K = 2,984 nM),12 is 103-fold lower than that of atomoxetine (K = 5 nM),13 yet venlafaxine causes an increase (242%)14 in synaptic norepinephrine levels comparable to that by atomoxetine (290% ± 33%).13 Curiously, chronic treatment with venlafaxine does not reduce norepinephrine transporter binding sites.15 These facts point to the possibility that increases in synaptic norepinephrine are due to norepinephrine transporter reversal, akin to dopamine transporter reversal associated with amphetamine.16
 
Abrupt withdrawal of venlafaxine would hence result in paradoxical increase in synaptic norepinephrine via efflux through norepinephrine transporter channels, which is normalized by atomoxetine’s norepinephrine transporter blockade. This speculation of the noradrenergic basis of “brain shivers” warrants further study.

Edited by Altostrata
refined format

Share this post


Link to post
Share on other sites
Altostrata

Good job on the format.

 

If the doctors were able to recognize withdrawal symptoms, they would have found the "brain shivers" would have abated with Effexor reinstatement. The atomoxetine (Strattera) step was unnecessary, but resulted in their pondering whether "noradrenergic imbalance" caused the "brain shivers."

 

Frankly, I don't think this adds anything to the understanding of withdrawal symptoms, but at least the patient isn't still in withdrawal.

Share this post


Link to post
Share on other sites
Altostrata

Drs. Cortes and Radhakrishnan —

I read with interest your 2013 paper A Case of Amelioration of Venlafaxine-Discontinuation “Brain Shivers” With Atomoxetine http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733524/

You should be aware that doctors overlook withdrawal symptoms, including “brain shivers”, every day. In fact, there are dozens of peer support Web sites and hundreds of thousands of patient postings all over the Web about the difficulties of quitting psychiatric medication, even under a doctor's supervision.

Patients are having a very hard time finding clinicians who are aware of gradual tapering procedures tailored to individual tolerance and fail to recognize even obvious signs of withdrawal syndrome, such as “brain shivers."

I am very concerned about the vacuum of knowledge in medicine regarding discontinuing all types of psychiatric medications. I founded SurvivingAntidepressants.org to provide peer support for tapering and post-acute withdrawal syndrome. You may read thousands of case histories here http://tinyurl.com/3o4k3j5

For what it’s worth, I doubt that “brain shivers” have a specifically noradrenergic cause. They occur in all types of psychiatric drug withdrawal, not just SSRIs or SNRIs. In your case report, the alleviation of the symptom by atomoxetine was most likely idiosyncratic. What was needed was reinstatement of Effexor, as recommended in all medical guidelines, including the Effexor package insert, regarding the emergence of withdrawal symptoms.

On SurvivingAntidepressants.org, we have several topics regarding brain zaps, brain shivers, and other neurological manifestations of withdrawal syndrome, such as

http://survivingantidepressants.org/index.php?/topic/288-brain-zaps/

http://survivingantidepressants.org/index.php?/topic/6118-constant-low-level-jolts-in-entire-body/

http://survivingantidepressants.org/index.php?/topic/6548-paresthesia-pins-needles-numbness-tingling-burning-sensations/

http://survivingantidepressants.org/index.php?/topic/2133-exploding-head-syndrome-or-ssri-withdrawal/

http://survivingantidepressants.org/index.php?/topic/2016-tremors-shaking-body-vibration/

Skaehill, 1997 SSRI Withdrawal Syndrome http://survivingantidepressants.org/index.php?/topic/1511-skaehill-1997-ssri-withdrawal-syndrome/suggests brain zaps are a form of Lhermitte’s sign, a low-level epilepsy. Having experienced them myself for 6 months, this makes sense to me. (It took 9 years for my nervous system to recover from Paxil withdrawal syndrome.)

Contrary to popular belief, withdrawal symptoms do not always emerge immediately and resolve within a few weeks or months. Some people suffer debilitating neurological damage from too-fast withdrawal for years, as I did.

The misdiagnosis of withdrawal syndrome may have confounded all studies of relapse after discontinuation of psychiatric drugs.

These iatrogenic symptoms are usually misdiagnosed as relapse or emergence of a psychiatric illness. This can result in drastic over-medication as doctors try to quell withdrawal symptoms.

What's shown up on patient-run Web sites is that some people require very, very gradual decrements in dosage, sometimes 5% or less per month, to minimize withdrawal symptoms. Some can tolerate decreases of only a fraction of a milligram at a time.

We have found such very gradual reductions in dosage can be successful in avoiding neurological destabiization.

We are always looking for people with prescription privileges anywhere in the world who are knowledgeable about very gradual, individualized tapering of antidepressants and antipsychotics as well as benzos, and who can recognize withdrawal symptoms and know what to do if they show up.

This would be for the purpose of local referrals.

Can you offer this service? Can you recommend any prescriber colleagues who are knowledgeable about tapering? Do you know of any who treat post-acute withdrawal syndrome?

Thank you,

Altostrata
Administrator
SurvivingAntidepressants.org

PS For the information of the general public, I have accumulated probably the best collection of documentation about tapering and withdrawal syndrome available:

- Journal articles about withdrawal syndrome here http://survivingantidepressants.org/index.php?/forum/16-from-journals-and-scientific-sources/
- About tapering techniques here http://survivingantidepressants.org/index.php?/topic/300-important-topics-in-the-tapering-forum-and-faq/

Share this post


Link to post
Share on other sites
nz11

Wow Alto what a great piece of writing.

 

" vacuum of knowledge "

Awesome!

Share this post


Link to post
Share on other sites
Altostrata

Thanks, nz. I send these letters out frequently.

Share this post


Link to post
Share on other sites
nz11

You're welcome

Well its certainly a masterly lesson in a tactful diplomatic effort.

Be interesting to hear the reply.

Share this post


Link to post
Share on other sites
dalsaan

Alto, I just enjoy your existence in the world. This gave me cause to smile

Share this post


Link to post
Share on other sites
Altostrata

:wub: !!!

Share this post


Link to post
Share on other sites
westcoast

Let's keep bumping this so if they visit the site it'll be visible as the top post in Journals, and they can enjoy the bold blue editorializing.

 

It's interesting that Atomoxetine :(:o helped with a couple of the symptoms but not all. I'm just glad the patient wasn't an elderly man. It makes me too sad when innocent trusting old people are subject to these cruel chemicals.

Share this post


Link to post
Share on other sites
manymoretodays

Glad it was bumped.  I missed it the first time around.

 

I don't know whether to salute you guys or hug you or maybe I will just cry...........

 

Thank you.

Share this post


Link to post
Share on other sites
Altostrata

I doubt they'll look here. You might send your editorializing to the authors in an e-mail.

Share this post


Link to post
Share on other sites
manymoretodays

That I might. :) Thank you Altostrata.  With you and Amy Schumer as role models how can I go wrong?

Share this post


Link to post
Share on other sites
JanCarol

I think the phrase that struck me the most from their report was: "emotional incontinence."  First I'd ever heard of such a symptom - is it one of the new DSM V ones?

 

GREAT work Alto!   I love the way you balance between the diplomatic and the technical!  Our Champion! 

Share this post


Link to post
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.


×
×
  • Create New...

Important Information

Terms of Use Privacy Policy