Persistent Postwithdrawal Disorders Induced by Paroxetine, a Selective Serotonin Reuptake Inhibitor, and Treated with Specific Cognitive Behavioral Therapy (original) (raw)

2014, Psychotherapy and Psychosomatics

Letter to the Editor was insensitive and detached from others, including his children, partner and relatives, and that his memory was impaired. The psychiatrist who evaluated him decided to switch paroxetine to fluvoxamine 50 mg at bedtime without tapering paroxetine. Mr. X developed more withdrawal symptoms, characterized by aggressiveness towards his partner, impulsiveness, electric sensations to the face, visual problems, sleep difficulties and severe generalized anxiety. Since these symptoms lasted more than 2 months, the psychiatrist recommended a clinical psychologist to start specific CBT described in table 1 , which was based on individualized CBT combined with well-being therapy [6] and explanatory therapy [7] including symptom interpretation according to the oppositional model of tolerance [8]. After 3 months of CBT, gambling stopped with improvement in other withdrawal-induced disorders. The patient started to remember events that had happened during paroxetine treatment. Fluvoxamine was then slowly tapered during 8 weeks and successfully discontinued. CBT lasted 6 months. The patient is now in remission and drug free after 1 year of follow-up. Mr. Y. is a 32-year-old single man diagnosed as having panic disorder with agoraphobia and treated with paroxetine 20 mg/day for 4 years. During the first 4 weeks of paroxetine, the patient reported severe emerging symptoms, nausea, headaches, panic attacks and increased irritability. After 6 weeks of paroxetine 20 mg/ day, the patient experienced a decrease in anxious symptoms, but at the same time, more appetite and a significant weight gain of 20 kg after 2 years. The patient did no longer want to continue paroxetine and self-reduced to 5 mg/day. However, he could not tolerate emerging anxiety symptoms at 5 mg/day and had to increase the dosage back to 10 mg/day. This dosage of 10 mg/day was continued for 4 years during which the patient described himself experiencing generalized anxiety symptoms, nervousness, apprehension and anticipatory anxiety. At that time, he realized that he would need to increase paroxetine back to 20 mg/day and decided to ask for help. After 6 years of paroxetine treatment, the psychiatrist who evaluated him decided to further decrease paroxetine, which was discontinued after 1 month, while giving clonazepam one 0.5-mg tablet 3 times/day. The first months of paroxetine withdrawal, including tapering and 1 month of complete discontinuation, were characterized by persistent postwithdrawal disorders consisting of continuous agitation, depersonalization, generalized anxiety, physical weakness, mood swings and sleep difficulties. Since postwithdrawal symptoms persisted, CBT, described in table 1 , was started in conjunction with clonazepam. Homework exposure focused on agoraphobia. After 5 months of CBT, 1 session every other week, the patient started to feel better, and symptoms, except for occasional anxiety attacks, subsided. The patient is now in remission after 1 year of follow-up, taking half a tablet of 0.5 mg twice a day without CBT. Mrs. Z is a 43-year-old married woman treated with paroxetine by a neurologist during 4 years for anxious depression and panic