Sibutramine and panic attacks.

To the Editor: St John’s wort (Hypericum perforatum L) is one of the oldest and best investigated medicinal herbs.1 Hypericum extracts have been shown to be significantly effective in treating mild-to-moderate depression.2 To the best of our knowledge, we report the first case of panic attack induced by a single dose of St John’s wort extract. Case report. Mr A, an otherwise healthy 35-year-old man, was admitted to the hospital for gradually increased trembling and fear of dying. He stated that, 2 hours after he drank a glass of St John’s wort extract (because of difficulty falling asleep), he became restless, anxious, and agitated. He also reported palpitations, sweating, chest discomfort, shortness of breath, nausea, blurred vision, and feelings of derealization. The patient denied hallucinations or delusions. An electrocardiogram showed tachycardia. Vital signs were remarkable for a pulse of 110 bpm and respiratory rate of 22 breaths/min. Improvement was seen in the panic state, and vital signs returned to normal within 25 minutes after oral alprazolam 1 mg was administered. He denied any psychiatric history (apart from difficulty falling asleep 1 or 2 days a week), current stressors, or use of alcohol. Family history was noncontributory. When questioned, Mr A reported a similar episode after drinking a glass of St John’s wort extract approximately 2 months previously. The patient met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for panic attack. According to the Naranjo Adverse Drug Reaction Probability Scale,3 there was a probable association between St John’s wort and panic attack. After being discharged, Mr A denied any further panic attacks at his 1- and 3-month visits. Although the exact mechanism of action is not known, there is good evidence from in vitro experiments that St John’s wort extracts are potent but nonspecific inhibitors of the synaptosomal reuptake of serotonin, norepinephrine, and dopamine.4 In vivo studies have shown that Hypericum extracts lead to a down-regulation of β-adrenergic receptors and an up-regulation of 5-HT2 receptors.4 The most important risk associated with Hypericum extracts is reported to be the interactions with other drugs.5 However, as reported here, a single dose of St John’s wort extract can induce a panic attack. It is crucial to investigate herbal drug use in patients presenting with psychiatric complaints. It is important that clinicians become aware of the potential psychiatric adverse effects associated with St John’s wort, which is a widely used medicinal herb, and explain these effects to their patients.

Lichenoid drug eruption (LDE) is an uncommon cutaneous adverse drug reaction, where a variety of drugs used in day-to-day clinical practice have been implicated. To describe the clinico-demographic characteristics of patients with LDE and to identify the most likely drugs involved. In this prospective, observational study, consecutive patients with LDE presenting to the dermatology department of a tertiary teaching hospital were included. The clinico-demographic profile of patients with LDE and implicated drugs was noted. Treatment of drug reaction along with outcome was also documented. Naranjo adverse drug reaction probability scale was used for causality assessment of the drug reactions. A thorough literature review on LDE was also undertaken due to the paucity of existing literature. A total of 15 patients (11 males and 4 females) with LDE were evaluated. Their age ranged from 37 to 61 years, with a mean of 51.53 ± 7.59 years. Anti-hypertensive medications (40%) were the most common culprit agent, followed by antitubercular drugs (33.4%), anti-diabetic agents (13.3%), and others (13.3%). The latent period (time from drug initiation to the appearance of a cutaneous eruption) varied from 15 days to 6 months (mean 2.2 months). Cutaneous involvement was generalized in 73.4% and photo-distributed lesions in 26.6%. Drug provocation test was done to identify the culprit drug. According to the Naranjo adverse drug reaction probability scale, one-third of LDEs were "definite," whereas two-thirds were designated as "probable." LDE is more common in the elderly population. The latent period is comparatively longer in LDE than in other common drug reactions. Prompt recognition and withdrawal of suspected drug are essential to minimize disease morbidity.

Disclosure: C.M. Barrera: None. Background: The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) has anxiety and panic attacks among the most common psychiatric disorders. Previously published cases have shown multiple thyroid nodules associated with chronic anxiety and panic attacks despite normal thyroid function and uptake scan. A low-dose methimazole trial resolved their anxiety (1). Case 1: A 58-year-old Latin female is referred for thyroid nodule evaluation. The thyroid ultrasound demonstrated three left-side nodules of 33x28, 43x35, and 10x7 mm. An I123-Thyroid Scan showed an uptake of 17.7% (High is >35%) with a left inferior hot nodule. No cold nodules were reported. The echotexture was homogeneous, with no reported suppression. The patient had a history of chronic anxiety and panic attacks, with an elevated heart rate of 93 bpm on the initial visit. She was referred for a right hemithyroidectomy. Pre-surgery TSH was 0.51 mIU/L (0.40-4.5 mIU/L), and T4 was 7.7 mcg/dL (5.1-11.9 mcg/L). Post-surgery TSH was 4.49 mIU/L (0.40-4.5 mIU/L) and T4 6.7 mcg/dl (5.1-11.9 mcg/dl). A PROMIS short form anxiety scale total was 27 pre-surgery and 13, 2 months post-surgery. Case 2: A 59-year-old Latin female is referred for thyroid nodule evaluation. The thyroid ultrasound demonstrated two right mid-pole nodules measuring 26x13 and 24x18 mm and two on the left measuring 30x21 and 20x10 mm. The I123-Thyroid Scan had an uptake of 36.4% (within the normal margin of error, High is >35%). The patient had a history of chronic anxiety and panic attacks. The patient was sent for a thyroid biopsy, but the surgeon decided to do a total thyroidectomy. Her pre-surgery TSH was 0.43 mIU/L (0.40-4.5 mIU/L) and free T4 1.2 ng/dl (0.8-1.8 ng /dl). Post-surgery, on 2 months of levothyroxine 100 mcg daily, TSH was 4.5 mIU/L and T4 8.7 mcg/dl. The PROMIS short form anxiety scale was 31 pre-surgery and 10, 2 months post-surgery. Conclusion: Two more cases are presented, demonstrating that anxiety/panic attacks can be resolved not just with low-dose methimazole (1) but with surgical removal of the thyroid nodules. Learning Points: These cases demonstrate that some chronic anxiety disorders have autonomous thyroid nodules as their underlying cause despite normal thyroid function tests and uptake scans. This strengthens the case for a new diagnostic category: Subclinical toxic multinodular goiter. 1. Thyroid Nodules, Normal Thyroid Levels, and Chronic Anxiety: A Case for Sub-Clinical Toxic Multinodular Goiter. CM Barrera. J Endocr Soc, Vol 8, Supplement 1, Oct-Nov 2024, bvae163.2103, https://doi.org/10.1210/jendso/bvae163.2103 2. Teresi JA, Ocepek-Welikson K, Kleinman M, Ramirez M, Kim G. Measurement equivalence of the patient-reported outcomes measurement information system®(PROMIS®) anxiety short forms in ethnically diverse groups. Psychol Test Assess Model. 2016;58(1):183-219. Presentation: Monday, July 14, 2025

Responses to false physiological feedback in individuals with panic attacks and elevated anxiety sensitivity

Agoraphobia between panic and phobias: clinical epidemiology from the Sesto Fiorentino Study

Back to table of contents Previous article Next article LettersFull AccessSertraline-Induced Akathisia and Dystonia Misinterpreted as a Panic AttackLisa Walker, M.D.Lisa WalkerSearch for more papers by this author, M.D.Published Online:1 Nov 2002https://doi.org/10.1176/appi.ps.53.11.1477AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: The selective serotonin reuptake inhibitors (SSRIs) are widely prescribed to treat a variety of psychiatric disorders. About 60 percent of patients with psychiatric disorders receive diagnosis and treatment in primary care clinics, where SSRIs are used routinely as first-line agents because of their tolerability, efficacy, and safety (1). The common side effects—nausea, hyperarousal, and sexual dysfunction—are well known and familiar to general practitioners, but the extrapyramidal reactions associated with the SSRIs are less well known. This letter describes a case in which a patient with depressive symptoms was initially treated in a primary care setting with sertraline. He developed akathisia and dystonia, which were misinterpreted as symptoms of a panic attack.Mr. A, a healthy 21-year-old single male with no history of a mood or anxiety disorder, was seen in a primary care setting for complaints of a two-week history of depressed mood, apathy, loss of appetite, insomnia, poor concentration, and significant anhedonia and anergia. Sertraline was prescribed at a dosage of 50 mg a day. During his second week on the medication, he visited an emergency department with complaints of awakening from sleep with what he described as "tightening in my chest and throat" and daytime tremulousness, restlessness, and a feeling that his skin was crawling. He was assessed as having anxiety attacks and advised to return to his primary care provider.Mr. A did so and was instructed to double his sertraline dosage to 100 mg a day to address his anxiety attacks. His discomfort increased significantly after two days with the higher dosage, and he returned to the primary care clinic with greater muscle stiffness in his thorax and neck, severe motor restlessness, and bilateral hand tremor. He saw a different provider, who prescribed alprazolam for anxiety and instructed him to stop taking sertraline and to begin paroxetine at 20 mg a day.Three days later Mr. A was seen for the first time in the psychiatry clinic on referral from his primary care provider. On evaluation, he was found to have a history consistent with a major depressive disorder and no history of panic attacks. He was able to clearly describe his feeling that the muscles in his neck, shoulders, and thorax were tight and stiff and that he felt as if he wanted to "jump out of my skin."Mr. A was given a diagnosis of a medication-induced movement disorder not otherwise specified—akathisia and dystonia—and a major depressive disorder, single episode. Paroxetine was tapered off, and diphenhydramine was prescribed for dystonia and insomnia at 50 mg a day.Mr. A's akathisia resolved completely five days after he stopped taking paroxetine. After eight days, he was started on buproprion SR at 150 mg a day. Five days later the daily dosage was increased to 300. He tolerated the higher dosage without side effects. After three weeks his symptoms of anhedonia and anergia were less severe, and he demonstrated a brighter affect.It is thought that SSRI-induced extrapyramidal symptoms result from the inhibitory effect of serotonergic input to the dopaminergic pathways in the basal ganglia (2). Theoretically, sertraline may offer a lower risk of extrapyramidal symptoms because of its dopamine reuptake inhibition, which would mitigate the effects of the serotonin. However, a review of case reports of SSRI-induced movement disorders from 1979 to 1996 found that eight of the 71 cases of extrapyramidal symptoms documented in the literature were associated with sertraline use. The side effects included neck stiffness, akathisia, and general body stiffness (3).Another consideration in the etiology of movement disorders associated with pharmacological agents is the rekindling effect that the agents may have on neurons that have suffered a previous insult, such as a poststreptococcal illness with chorea or previous exposure to neuroleptics (4). In a study of patients in a lithium clinic, Merikangas and Himmelhoch (5) found that among patients treated with a combination of lithium and antidepressants, those who were taking the more serotonergic agents were more likely to experience serious myoclonic jerks.However, Mr. A. had no history of a childhood poststreptococcal illness, such as rheumatic fever with chorea or glomerulonephritis, and he had no previous exposure to neuroleptics.This case demonstrates that the extrapyramidal side effects of akathisia nd dystonia may occur among young males who are given moderate dosages of sertraline. Many clinicians prescribe SSRIs because of their ease of use. However, a greater awareness among clinicians of the possible adverse reactions would increase their recognition of extrapyramidal symptoms and allow for appropriate treatment.Dr. Walker is affiliated with the Naval Medical Clinic in Pearl Harbor, Hawaii.

Panic disorder, which is found in about 1.5 percent of the population at some time in their lives, includes recurrent episodes of sudden, unpredictable, intense fear accompanied by symptoms such as palpitations, chest pain, and faintness. Panic attacks, which do not meet these diagnostic criteria fully, are two to three times more prevalent. Since panic symptoms can mimic those of other medical disorders, patients with these symptoms use medical services frequently. To determine the risk of suicidal ideation and suicide attempts in panic disorder and attacks, we studied a random sample of 18,011 adults drawn from five U.S. communities. Subjects who had panic disorder, as compared with other psychiatric disorders, had more suicidal ideation and suicide attempts, with an adjusted odds ratio for suicide attempts of 2.62 (95 percent confidence interval, 1.83 to 3.74). The odds ratio was 17.99 (95 percent confidence interval, 12.18 to 26.58) when the group with panic disorder was compared with subjects who had no psychiatric disorder. Twenty percent of the subjects with panic disorder and 12 percent of those with panic attacks had made suicide attempts. These results could not be explained by the coexistence of major depression or of alcohol or drug abuse. We conclude that panic disorder and attacks are associated with an increased risk of suicidal ideation and suicide attempts. Physicians working in general medical settings and emergency departments should be alert to this problem.

Cefdinir is an extended-spectrum, third-generation cephalosporin that may be used for treatment of acute otitis media in patients allergic to penicillin. When administered with iron-containing products, including infant formulas, cefdinir or one of its metabolites may bind to ferric ions, forming a nonabsorbable complex that imparts a reddish color to the stool. We describe a 9-month-old infant with failure to thrive and acute otitis media who developed an erythematous maculopapular rash during treatment with amoxicillin-clavulanate. His antibiotic therapy was changed to cefdinir. Five days into a 10-day course of therapy, the infant's mother brought him to the pediatric clinic and reported the appearance of red stools. He had no associated gastrointestinal symptoms (vomiting, abdominal pain, or diarrhea). His hematocrit and hemoglobin level were normal, and Clostridium difficile antigen studies and tests for species of Shigella, Salmonella, and Camphylobacter as well as ova and parasites were all negative. Cefdinir was discontinued, and his stools returned to normal within 48 hours. Three weeks later, he again received cefdinir for recurrent otitis media. Red stools reappeared 48 hours later, were determined to be guaiac negative, and resolved within hours of drug discontinuation. During both occurrences of red stools, the infant had been breastfed and was receiving supplemental feedings with an iron-containing infant formula. In the product labeling of cefdinir, this adverse event is described as a consequence of the drug-drug interaction; however, it is not listed in the adverse drug reaction section of the labeling. As such, one may miss the association between cefdinir and reddish stools when investigating this event as a potential adverse reaction to cefdinir. When using the Naranjo adverse drug reaction probability scale to assess causality in our patient's case, this adverse drug reaction was determined as highly probable. As this infant had been breastfed, the use of a supplemental iron-containing infant formula was not identified as a potential contributing factor until the second occurrence of red stools. Health care professionals should review the entire product labeling, including the drug-drug interaction section, when investigating a potential adverse drug reaction. With the recent approval of generic formulations of cefdinir, clinicians should be aware of this drug-drug interaction with iron-containing products to prevent unnecessary alarm by parents and caregivers, as well as costly medical evaluations for gastrointestinal bleeding.

To describe three cases of pericarditis probably related to azacitidine administration in a span of 3 years at our center. Case series. Comprehensive cancer center within a large, academic medical center. Three patients with high-grade myelodysplastic syndrome or acute myeloid leukemia who received azacitidine. None. None. Patient 1 presented with pericarditis after cycle 2 of azacitidine, patient 3 presented 3 weeks after completing cycle 5, and patient 2 presented during cycle 1. All patients were treated symptomatically and responded to corticosteroids. None of the patients were re-challenged with hypomethylating agents. Use of the Naranjo adverse drug reaction probability scale indicated a probable adverse drug reaction (score of 6) for patients 1 and 3 and a possible adverse drug reaction (score of 3) for patient 2. With the exclusion of other common causes of pericarditis, we believe it is likely that azacitidine was responsible for the findings in our patients. Providers caring for patients receiving hypomethylating agents should consider this potential adverse drug reaction in the setting of unexplained chest pain or other clinical signs consistent with cardiotoxicity.

A 65-year-old male with a history of hypertension and chronic obstructive pulmonary disease (COPD) was admitted with complaints of cough, shortness of breath, fever, and fatigue. Initial treatment included multiple medications, among which Monocef (Ceftriaxone) was suspected to cause adverse drug reactions, specifically loose stools. Two days into treatment, the patient developed loose stools, which resolved after the discontinuation of Monocef(Ceftriaxone ). Using the Naranjo Adverse Drug Reaction Probability Scale, the reaction was determined to be probable (score of 6). The patient’s condition improved over the course of four days, and he was discharged in stable condition on the fifth day. This case highlights the importance of monitoring for adverse drug reactions in elderly patients with comorbidities, as well as adjusting treatment based on observed symptoms.

Evaluating emotional sensitivity and tolerance factors in the prediction of panic-relevant responding to a biological challenge

Reversal of refractory sulfasalazine-related renal failure after treatment with corticosteroids

Acute pancreatitis has numerous etiologies, with the most common including gallstones, alcohol abuse, and medications such as angiotensin-converting enzyme (ACE) inhibitors, statins, and diuretics. Mirtazapine has been associated with increased serum cholesterol and serum triglyceride levels. However, few studies have reported dangerously elevated triglyceride levels resulting in acute pancreatitis. This report discusses a case of mirtazapine-induced pancreatitis in a 46-year-old African American female. The patient presented to the emergency department with pancreatitis, presumably alcohol-induced as with a prior admission, but she denied any recent alcohol use. Mirtazapine then became the suspected cause of her hypertriglyceridemia-induced pancreatitis and was discontinued. After discontinuing mirtazapine, and utilizing an insulin infusion, her triglyceride levels normalized and symptoms of pancreatitis resolved. Using the Naranjo Adverse Drug Reaction Probability Scale, a total score of 5 was calculated indicating a probable adverse drug reaction of acute pancreatitis from mirtazapine.

Azithromycin-Induced Agitation and Choreoathetosis

Background: Lithium is a cornerstone therapy for Bipolar I Disorder, yet its use necessitates vigilant monitoring for adverse drug reactions (ADRs). While lithium-induced hypothyroidism is a well-documented complication, the emergence of thyrotoxicosis secondary to destructive thyroiditis is a rare and diagnostically challenging event. This report presents a systematic analysis of a case of suspected lithium-induced thyroiditis notable for its paradoxical clinical presentation as a severe depressive episode. Case presentation: A 33-year-old female with a 10-year history of Bipolar I Disorder, stable on lithium for two years, was admitted with a severe depressive episode and active suicidal ideation. The onset of her psychiatric decompensation was temporally correlated with a diagnosis of thyrotoxicosis (suppressed TSH <0.005 uIU/mL; elevated FT4 >7.77 ng/dL). A formal causality assessment using the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 6, indicating a "probable" relationship between lithium and the thyroiditis. Critically, the thyrotoxic state, which conventionally mimics mania, presented atypically as severe depression. Conclusion: This case of probable lithium-induced destructive thyroiditis, presenting paradoxically with severe depression, underscores the critical need for a high index of suspicion for iatrogenic endocrinopathies in patients on lithium who exhibit any mood destabilization. A systematic approach to ADR assessment is essential to guide appropriate clinical management in such complex presentations.