Influence of paroxetine and cognitive/behavioral strategies in neurocardiogenic syncope and depression: a case report

doi:10.4236/ojpsych.2011.13011

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Open Journal of Psychiatry, 2011, 1, 75-78 OJPsych

doi:10.4236/ojpsych.2011.13011 Published Online October 2011 (http://www.SciRP.org/journal/OJPsych/).

Published Online October 2011 in SciRes. http://www.scirp.org/journal/OJPsych

Influence of paroxetine and cognitive/behavioral strategies in

neurocardiogenic syncope and depression: a case report

Reg Arthur Williams1*, Juan F. Lopez2

1School of Nursing and Psychiatry, Medical School, University of Michigan, Ann Arbor, USA;

2Psychiatry, Medical School, University of Michigan, Ann Arbor, USA.

Email: *[email protected]

Received 21 June 2011; revised 15 July 2011; accepted 24 July 2011.

ABSTRACT

Objective: Neurocardiogenic syncope (NCS) is a con-

dition where the patient has a temporary loss of con-

sciousness or feelings of weakness and fatigue. There

are triggers such as prolonged sitting or standing,

pain, and heavy exercise, but often episodes are ran-

dom. Treatments are limited and the use of specific

serotonin reuptake inhibitors (SSRI) have had mixed

results, but a limited number of studies have sug-

gested that paroxetine may be effective in improving

the symptoms of NCS. Methods: This is a single case

report of a 20 year old female who was diagnosed with

NCS by a tilt test and treated conservatively with in-

creased fluid and salt intake, and counter-pressure

maneuvers. She was given one dose of sertraline, but

immediately experienced disturbing visual images.

She presented at the Depression Center with moder-

ate depressive symptoms and was started on par-

oxetine and given cognitive/behavioral strategies to

manage the NCS. Results: Since the patient had a

negative experience with a prior SSRI, she was

started on a low dose of paroxetine and omega-3 fatty

acids. She also was given a detailed explanation of

NCS and a number of cognitive/behavioral strategies

such as deep breathing, progressive relaxation, im-

agery, and sleep. Conclusion: After 2 weeks of the

multi-faceted treatment approach, she had a signifi-

cant decrease in her depressive symptoms. After 6

months, the patient had no episodes of syncope and

no depressive symptoms. She was able to stand for

long periods and exercise without feelings of weak-

ness and fatigue. A multimodal approach may offer

the best treatment strategy to achieve full remission

in patients with NCS.

Keywords: Neurocardiogenic; Paroxetine; Depression;

Cognitive/Behavioral; Syncope; Case Report

1. INTRODUCTION

Neurocardiogenic syncope (NCS) is a condition often

associated with a temporary loss of consciousness or

feeling of weakness and fatigue. There is an abrupt drop

in arterial blood pressure and followed rapidly with bra-

dycardia. Often vasovagal syncope (VS) and neurally

mediated syncope are terms used interchangeably with

NCS [1,2]. The incident of NCS has been estimated to

range from 1.3 to 2.7 events per thousand of the popula-

tion [3,4]. Common symptoms associated with NCS,

which usually occur while standing, include fatigue,

weakness, nausea, perspiring, pallor, visual disturbances,

abdominal discomfort, headache, tingling, lightheaded-

ness or vertigo [5]. It is usually triggered by prolonged

sitting or standing, pain, sight of blood or medical pro-

cedures, heavy exercise, and rising or chang ing positions

abruptly [6]. From episode to episode the symptoms will

vary and can be estimated by a simple risk score [7]. The

hypotension is thought to be caused by a reduction in

peripheral sympathetic neural outflow, which leads to

venous pooling and vasodepression. Yet, the exact centr-

al neurophysiology is not known [8]. The majority of

cases of syncope in young people are not typically asso -

ciated with risk of mortality [9], bu t physical and psych-

osocial function can be seriously impaired in patients

suffering from recurrent syncope [10].

A number of treatments have been proposed for NCS

[e.g., 1,2], but only one focused review of therapies with

structured recommendations was found. Most patients

can be managed conservatively and the recommended

treatments included liberalized fluid and salt intake, pa-

tients being taught counter-pressure maneuvers and Mi-

dodrine to manage hypotension. Beta blockers, specific

serotonin reuptake inhibitors (SSRI), fludrocortisones,

and pacemakers have had mixed results, and were there-

fore discourag ed f o r use [8].

Specifically for SSRI treatment, there were only two

R. A. W illiams et al. / Open Journal of Psychiatry 1 (2011) 75-78

randomized double-bind placebo-controlled study found

using paroxetine in 68 patients (mean age 44.7, SD =

16.5) with recurrent syncope and positive head-up tilt

test [11] and 41 young patients (aged less than 30 years

old) with recurrent syncope [12]. The conclusion in both

studies was that paroxetine significantly improved sym-

ptoms of patients with vasovagal syncope not respond-

ing well with more traditional medications and treat-

ments. Of note, although paroxetine treatment was sig-

nificantly superior to placebo, more than one-third of

patients remained symptomatic. Another randomized,

placebo-controlled study using fluoxetine, propranolol,

and placebo showed no differences between treatment

groups [13], therefore, it is possible that not all SSRI are

effective in treating recurrent vasovagal syncope. Addi-

tionally others have argued for the importance of ad-

dressing the psychological distress in these patients [14,

15]. The purpose of this paper is to present a case of a

young woman who was treated with a combination of

paroxetine and cognitiv e/behavioral strategies to address

her recurr ent NCS symptoms.

2. METHODS

Case Report

While the patient was in high school at the age of 17 she

developed feelings of malaise, what she thought was

fever and chills, but was not febrile. She had periods of

feelings of weakness and fatigue, experienced diaphore-

sis, diminished appetite, oversleeping, and hypotension.

During high school, she had one period of syncope for

approximately one minute that occurred after a band

practice. Since that time she had not experienced true

syncope, but rather ataxia, nausea, extreme fatigue, and

vertigo where she would need to lie on the ground to

stop the vertigo. She also was placed on Ethinyl Estra-

diol and Norgestimate (Ortho Tri-Cyclen) for dysmen-

orrhea.

The syncope symptoms continued and she was seen

by an internist. At one point her symptoms were sugges-

tive of malaria since she ha d been in Honduras and upon

returning had developed uticaria, which later was deter-

mined to be eczema. Blood results ruled out malaria,

mononucleosis, West Nile virus, and Lyme disease. She

then was tested for demyelinating disease by an MRI

brain scan, which provided evidence of a normal brain

MRI, without and with contrast. She further was tested

with a two-dimensional transthoracic echocardiogram

(ECG) with M-mode and color flow Doppler. The results

were deemed normal. The diagnosis of NCS was sug-

gested when a tilt test was performed where her resting

heart rate and blood pressure were normal. Her health

record indicated, “She was maintained in an 80-degree

upright tilt position and within 15 minutes, she devel-

oped sinus tachycardia with a sudden loss of palpable

blood pressure with near syncope.” She was then re-

turned to a supine position where her abnormal vital

signs resolved.

The patient was treated conservatively and was en-

couraged to increase her salt intake, use counter-pressure

measures, and rest when she experienced fatigue and

dizziness. According to her health record, she was s tarted

on metoprolol 25 mg. a beta-blocker with mixed results

in several studies (8). However, her response was blood

pressure of 98/50 and pulse 64, so the treating physician

was reluctant to increase the dosage due to the border-

line blood pressure and heart rate. The beta-blocker was

discontinued since there was not a significant decrease

of her syncope symptoms. Because of her history of de-

pressive symptoms she was started on 14.5 mg. of ser-

traline to increase to 25 mg., however immediately after

taking one dosage of sertraline she had a serious episode

with extreme fatigue, near syncope and disturbing visual

images so the treating physician was reluctant to have

her continue with the medication. Because of her history

of depression and treatment strategies had not decreased

the number of episodes; the patient, at age 20, was re-

ferred to the Depression Center at University of Michi-

gan by her sister, a nurse practitioner.

In her evaluation, she reported that she first experi-

enced depressive symptoms at the age of 14, but while in

her junior year of high school (age of 17) she had de-

pressive symptoms including depressed mood, feelings

of fatigue, trouble concentrating, insomnia, feelings of

worthlessness, overeating, but not gaining weight, and

thoughts of suicide. She had approximately a week of

feeling suicidal and had developed a plan for suicide by

causing a car accident. She had made a specific plan, but

a friend called her and ask ed her how she was doing. At

that moment she realized she did not want to die. The

symptoms diminished and she did not seek treatment nor

diagnosed with depression at the time. At evaluation, she

described her symptoms of depression as mild depressed

mood, anhedonia, loss of appetite, trouble concentrating,

feeling restless, moderate insomnia, and lack of energy.

She denied suicidal ideations. She scored 10 on the Pa-

tient Health Questionnaire (PHQ-9) indicating moderate

depression, and 19 on the clinician administered Hamil-

ton Rating Scale for Depression (HAM-D). She met cri-

teria for a diagnosis of Major Depressive Disorder

(MDD). Moreover, she scored 11 on the Sleep Assess-

ment Questionnaire (SAQ), indicating a potential sleep

problem. Her score on the Penn State Worry Question-

naire (PSWQ) was 33, indicating likely sub-clinical

anxiety.

Most concerning was her description of vivid visual

images where her heart would pound, feelings of panic,

and where she described the images as “hallucinations.”

R. A. W illiams et al. / Open Journal of Psychiatry 1 (2011) 75-78 77

She became tearful as she described that these visual

images could occur 3 or 4 times a week and could last up

to 20 minutes but often shorter, where she would vi-

sualize “dead babies” and see “killing” herself. She

noted that after these episodes it would often take her a

week or more to recover since she experienced a depre-

ssed mood, anhedonia, and extreme fatigue. Since her

depression in high school she also described experiences

where she “wanted to crawl in small spaces.” As exam-

ples, she sat in a closet or under a desk. This was espe-

cially noteworthy in her junior year at high school where

she was entering the closet or under the desk about 2 or

3 times a week. During college she would get the feeling,

but acted on it only a few times.

3. RESULTS

Because of the possibility that the previous SSRI might

have triggered the disturbing visual images, the patient

was provided scientific evidence [11,12] that paroxetine

was promising as an effective treatment for depression in

NCS. The theoretical mechanism of how paroxetine

would work in her brain was explained with a drawing

and the typical side effects of the medication also were

presented. Since the patient appeared to be sensitive to

medications, she was started at only 5 mg. of paroxetine

each day in the morning. Also, she was recommended to

start 2000 mg. of omega-3 fatty acid based on the evi-

dence it can also help to boost mood and vagal tone [16].

She was recommended to purchase omega-3 that con-

tained 1000 mg. of eicosapentaenoic acid (EPA) and

docosahexaenoic acid (DHA), where EPA is considerd to

be the ingred ient with the most therapeutic effect.

She was educated about the physiology of NCS in lay

terms. After several days after starting treatment, she

was called at home to check if she had any side effects

or any disturbing images. She only experienced a slight

headache and nausea for a day from the paroxetine. After

one week, her PHQ-9 score decreased to 8 indicating

mild depressive symptoms, which was lower than her

initial evaluation. Attributable to a slight decrease in

depressive symptoms was the several cognitive/behav-

ioral strategies she was given. She noted that when she

would experience fatigue she had a tendency to get in-

creasingly concerned that another episode would occur.

She was taught thought-stopping and thought-substitu-

tion. We identified an experience that gave her “nothing

but warm feelings” and she identified the experience as

the moment when her fiancé asked her to marry him.

Therefore, during the first week of treatment, if she ex-

perienced fatigue or weakness, she used this imagery

strategy reporting that it was helpful.

Since the patient had minimal side-effects from par-

oxetine her dosage was increased to 10 mg. In the ses-

sion she identified a pattern that she noticed when she

drove from her college to see her fiancé (approximately

a 3-hour drive). She would tense grip the steering wheel

and would experience fatigue and weakness after the

drive. She was taught deep-breathing by taking a deep

breath and letting it out over a 10-second period and

progressive relaxation by tensing a muscle group and

relax it over a 10-second period. Since she had to hold

the steering wheel, she was instructed to relax one arm

and hand at a time and shake out the tension about every

15 minutes while driving. She also was encouraged to

use progressive relaxation when she occasionally would

experience early insomnia. At the next session a week

later, she reported that these strategies were helpful and

her PHQ-9 score was reduced to 4 indicating minimal

depressive symptoms. She also noted that the treatment

had helped with her dysmenorrhea symptoms.

After six-months from initial treatment the patient had

no syncope and depressive symptoms. Most indicative of

her progress was that several weeks before her appoint-

ment she was the Maiden-of-Honor for her sister’s wed-

ding. Her family was concerned that she would not be

able to stand through the entire ceremony. She reported

that she had no periods of weakness or vertigo and da n c e d

late into the evening. Her fiancé also reported that she

was able to play a full set of tennis where before she

would need to take breaks to play.

4. DISCUSSION

There is limited evidence as to the most effective treat-

ments for NCS. Some conservative strategies have been

suggested [1,2,5,8], but only one research team provided

randomized controlled studies [11,12] suggesting par-

oxetine as an effective treatment for at least some pa-

tients with NCS. Yet, another randomized control study

using fluoxetine did not demonstrate effectiveness [13].

This conflicting evidence led some researchers [8] to

conclude that SSRIs are not effective in treating NCS.

Also, one study found that paroxetine did not prevent the

presyncope associated with lower body negative pres-

sure in healthy volunteers [17]. These mixed results may

suggest that SSRIs are not effective in individuals with

NCS, yet the specific use of paroxetine with patients

having NCS and depression may be more effective than

treating patients with other SSRIs.

There is evidence that co-morbid mood disorders are

present in a significant proportion of patients with syn-

cope [18]. Studies have shown that a combination of

antidepressants and psychotherapy are more effective at

achieving remission in chronic depression that either

treatment alone [e.g., 19]. In this case report a multi-

faceted approach was used to address the NCS and de-

pressive symptoms. Using paroxetine in conjunction

with omega-3 fatty acids, counter-pressure techniques,

and cognitive/behavioral strategies to address the distre-

R. A. W illiams et al. / Open Journal of Psychiatry 1 (2011) 75-78

ssing events [14,15] was ultimately successful. The use

of progressive relaxation, imagery, sleep strategies, and

exercise helped with the life altering experience. Prior to

treatment, the patient often experienced fatigue, weak-

ness, vertigo, disturbing images, and depressed mood.

Now, the patient is able to take part in normal and pro-

ductive activities and not have concern about NCS and

the concomitant symptoms. This report suggests that a

combination treatment may be most effective to ach-

ieve remission in patients suffering from NCS, particu-

larly in the context of depressive symptoms, and that

these strategies should be evaluated in future random-

ized clinical trials.

5. ACKNOWLEDGEMENTS

This article was made available as Open Access with the support of the

University of Michigan COPE Fund, http://lib.umich.edu/cope.

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