Serotonin Syndrome - What You Need to Know

You are taking antidepressants (SSRI, SNRI, Tricyclic, St. John's Wort) or migraine medications (Triptans) or maybe treating a terrible cough with an over-the-counter cough syrup (dextromethorphan). Maybe you are taking a combination of drugs such as medication for a cough while taking your daily antidepressant. At first, you may think that the dizziness, chronic agitation, and fast heart rate are signs you just need to rest. But soon you develop seizure-like muscular twitches and jerks and perhaps uncontrollable shaking in the form of tremors that come and go. Perhaps you feel electrical-like jolts in your spine or head. You may have trouble sleeping and concentrating. When you see a health professional, it is concluded you are having severe anxiety, panic attacks, and/or [insert some psychological cause]. In reality, you may be suffering from Serotonin Syndrome - a poorly understood, potentially life threatening syndrome that is caused by excessive effects of serotonin on the nervous system and it is being missed by many health professionals.

A lot times, health professionals do not recognize the mild and moderate cases of this syndrome. When asked, emergency room professionals tend to dismiss the symptoms remarking that the patient is not “sick enough” to have serotonin syndrome basing this on the idea that patients must present with severe life-threatening symptoms for diagnosis. A study in 2013 by Cooper and Sejnowki found that 85% of physicians were unaware of this syndrome as a potential clinical diagnosis.

To help educate yourself about this syndrome, see Table 1 below for the symptoms.

Who is at risk?

Anyone who takes a drug that could elevate the amount of serotonin in the bloodstream is at risk. In the recent past, this syndrome was mostly associated with the class of drugs known as selective serotonin reuptake inhibitors, commonly known as SSRIs (Cooper & Sejnowski, 2013). Zoloft, Prozac, and Paxil are some of the most common brand names but there are many more. However this syndrome is not limited to these drugs which is part of the diagnostic problem; many other drugs used to treat depression, anxiety, nausea, migraine headaches, pain, and even over the counter common-cold remedies can cause this syndrome (Cooper & Sejnowski, 2013). See Table 2 below for a list of drugs that have been implicated in serotonin syndrome.

A little history

As far back as the mid 1950s, it was found that taking a certain prescription drugs could cause this syndrome. It is a little cloudy as which kinds of drugs were implicated first. One study implicates drugs in a class called HT3 receptor antagonists (Gillman, 1998). Drugs such as Zofran (ondansetron) are used today to treat nausea in a variety of disorders, including cancer, fall into this class. Another points to older medications used to treat depression - the monoamine oxidase inhibitors (MAOIs) like Nardil (phenelzine) (Cooper & Sejnowski, 2013). More recently, it was believed that only overdoses and combinations of high doses of these drugs could cause it. It is understandable why there is so much confusion in the field; the information about the syndrome continues to evolve.

What should I do?

If you are experiencing the mild symptoms of serotonin syndrome, see your doctor as soon as possible to discuss potential treatment options. DO NOT STOP MEDICATION WITHOUT THE HELP OF A MEDICAL PROFESSIONAL! ABRUPTLY STOPPING A MEDICATION CAN CAUSE OTHER POTENTIALLY SEVERE HEALTH PROBLEMS! Your doctor may discuss other medication options and begin a weaning process or even just reduce the dose of your medications to alleviate symptoms. If you are experiencing moderate symptoms, you need to seek treatment immediately – especially if you have a fever. Be sure to bring a list of all medications, including over the counter and herbal/vitamins you may be taking.

I am a firm believer in Western medicine. I don't particularly love our current fee for service health care reimbursement system and the inequalities that result but that has nothing to do with this story. What I do believe is that the West generally has some of the best medical research and providers of medicine in the world. Everyday we see new innovative ways to treat and prevent diseases that once were death sentences for our ancestors. But with the cutting edge of innovation in real-time, comes risk. We need a better system of information flow because too many people are getting sick and not enough professionals understand the cause.

Table 1 Symptoms

Mild symptoms include (Cooper & Sejnowski, 2013):

Tachycardia – an abnormally fast heart rate while at rest (not exercising or exerting oneself). For adults a heart rate > 100 beats per minute (BPM), in adolescents > 90 BPM Shivering Excessive sweating Dilated pupils Body tremors (uncontrollable shaking) or clonus (spasmodic jerky contraction of groups of muscles). twitching or spastic muscles Agitation

Moderate symptoms include all the mild symptoms plus (Cooper & Sejnowski, 2013):

Fever of 104° F (40 ° C) Hyperactive bowel sounds More severe twitching and inducible clonus (can actually bring the episodes on with stress or by just thinking about them) Ocular clonus – eye ball twitching or involuntary movements

Severe life-threatening symptoms include all mild and moderate plus (Cooper & Sejnowski, 2013):

Hypertension – High blood pressure Delirium – a confused mental state Muscle rigidity – muscles are involuntarily tensed Hypertonicity – resistance to muscles being stretched High Fever > 105.8° F (41 ° C) Metabolic acidosis – too much acid in the bloodstream (found through lab workup) Rhabdomyolysis - death of muscle fibers and release of their contents into the bloodstream (found through lab workup) Elevation of serum aminotransaminases and creatinine (found through lab workup) Seizure Disseminated intravascular coagulopathy – widespread coagulation of blood clots

Note. Adapted from Serotonin syndrome: recognition and treatment. AACN advanced critical care, 24(1), 15-20, by Cooper & Sejnowski, 2013.

Table 2 Drugs That Have the Potential to Cause Serotonin Syndrome
SSRIs	Miscellaneous
Citalopram	Buspirone
Fluoxetine	Carbamazepine
Fluvoxamine	Cocaine
Olanzapine/fluoxetine	Cyclobenzaprine
Paroxetine	Dextromethorphan
	Ergot alkaloids
SNRIs	Fentanyl
Duloxetine	5-Hydroxytryptophan
Sibutramine	Linezolid
Venlafaxine	Lithium
	L-Tryptophan
Triptans	Meperidine
Almotriptan	Methadone
Eletriptan	Methamphetamine
Frovatriptan	Methylene blue
Naratriptan	Metoclopramide
Rizatriptan	Mirtazapine
Sumatriptan	Ondansetron
Zolmitriptan	Phenelzine
	Selegiline
	St. John's wort
	Tramadol
	Tranylcypromine
	Trazodone
	Tricyclic antidepressants
	Valproic acid
SNRI: serotonin norepinephrine reuptake inhibitor; SS: serotonin syndrome; SSRI: selective serotonin reuptake inhibitor. Note. Adapted from Drug-Induced Serotonin Syndrome. U.S. Pharmacist, 35(11) by C. Brown, 2010, http://www.uspharmacist.com/content/d/feature/c/23707/

Works Cited

Brown, C. (2010). Drug-Induced Serotonin Syndrome. U.S. Pharmacist, 35(11). Retrieved from http://www.uspharmacist.com/content/d/feature/c/23707/

Cooper, B. E., & Sejnowski, C. A. (2013). Serotonin syndrome: recognition and treatment. AACN advanced critical care, 24(1), 15-20.

Gillman, P. (1998), Serotonin syndrome: history and risk. Fundamental & Clinical Pharmacology, 12: 482–491. doi: 10.1111/j.1472-8206.1998.tb00976.x

Abusive and Murderous Care-taking does not Evoke Compassion

A simple Google News search will turn up hundreds of results of abuse, neglect, and filicide (the murder of a child by a parent). Doing this search is not for the faint of heart. If you want to feel real pain for the suffering of children, by all means search away. The following are some snippets for which I am issuing a huge trigger warning; the details are highly disturbing.

• Rachel Ball pleaded guilty to criminally negligent homicide, two felony drug counts and a misdemeanor of endangering the welfare of a child after her toddler, Kayleigh, died from drug exposure to cocaine and heroin in February 2015. Ball admitted to watching her boyfriend physically abuse Kayleigh, even leaving him alone with Kayleigh at times to do so.
• In December 2014, Lindsey Nicole Blansett waited until midnight to enter her 10-year-old son Caleb's room with a rock and a knife. She hit him over the head with a rock and stabbed him seven times until he was dead.
• In what is considered a family effort, Mary C. Rader and her parents Deanna and Dennis Beighley nearly starved her 7-year-old son to death. Children's Hospital of Pittsburgh staff was quoted as saying this was the worst case of child neglect they had ever encountered. He was less than 20 pounds when authorities rescued him. He also suffered injuries from beatings he incurred and was held prisoner in the family home. His three siblings all were healthy and attended school regularly.

Are you sick yet? Are you angry yet?

• In January 2014, 17-month old Lucas Ruiz was poisoned to death by his mother who injected hand sanitizer into his tiny body causing acute alcohol poisoning. His father, who had also been feeding the tiny babe rum, was quoted as saying their son "would be better off dead, and that he wished he (the child) would die…".
• In 2013, 14-year-old Alex Spourdalakis was murdered by his mother and godmother. First they forced sleeping pills down his throat and when that didn't work his mother stabbed the teenage boy multiple times in the chest as he lay in bed. She then slashed his wrist, nearly cutting off his hand while the godmother killed the family cat.
• In April of 2012, 4-year-old Daniel Corby was drowned in a bathtub by his mother. She filled the tub, put him in the bath and held him under until he was dead. She then wrapped him in a blanket and put him the backseat of her car.

Do you feel compassion for the murderers?

You must be shaking by now. I know I am. As a parent I cannot fathom how anyone could ever think to hurt a child, let alone their own. The last three examples, Lucas's, Alex's, and Daniel's stories are often met with public sympathy for the murders, however. I hope after reading these awful crime snippets you are complete aghast at how one could feel any sort of compassion or sorrow for the murderer. I hope that you instead are feeling compassion and sorrow for the victim and the people who truly loved and mourn that victim; not the selfish murderous parent.

But society has given some leniency to killing people who are different than themselves. You see, these boys all had some form of a disability. And so it is with ease that you will find articles that dismiss the murders as “mercy killings.” There is no mercy in murder. There is no compassion evoked by these stories. By accepting the mercy killing ideal, society promotes that  people who have disabilities, who are different, are worthless and burdens. 

This is unacceptable.

A list of murdered disabled people can be found here:
https://sites.google.com/site/pwddayofmourning2014/the-list
and
http://autism-memorial.livejournal.com/

Defending Yourself (How Not to Apologize)

Backpedaling would almost be acceptable. I wish I could say that the Autism Daily Newscast backpedaled when editor Roberta Hill went on to [non]apologize for the pro-bullying article by Karen Kabaki Sisto last week. Instead, Ms. Hill issued a statement defending the article while only apologizing for the wording used. In other words, the Autism Daily Newscast apparently stands by the idea that bullying is good for autistic children because it is a great learning experience. Apparently autistic people and those of us who actual give a damn about them just need not be so sensitive about it all. You know, lighten up, people! How dare we suggest that our children and friends be treated like human beings - with dignity and respect? According to Ms. Hill,

"No matter how much energy and resources we put into making it a safe place for ourselves and our children, Shit Happens." ~Roberta Hill

So there you have it folks. Shit happens. And it seems then that there is no need to discuss that the "shit" must stop, or that the "shit" is unacceptable or that the "shit" causes irreparable psychological damage. In fact, no. We need to accept the "shit" and not only deal with it, but turn the "shit" into something good. At least Ms. Kabaki Sisto alluded to turning lemons into lemonade; Ms. Hill expects autistic people and their families to magically turn "shit" into a sweet smelling life experience.

[addenda @8:55 pm ET] This apparently is not the first time Ms. Hill has misrepresented or offended the autism community. In February, she ran an editorial misrepresenting the views of the Autistic Self Advocacy Network. When called on her mistake, she denied any wrongdoing and refused to change the article. You can read the story here.

Ms. Hill needs to check her allistic privilege and the Autism Daily Newscast needs a new editor.



Hill, R. (2015). My Response to the Outrage from the Autistic Community Regarding a Published Article - Autism Daily Newscast.

Trash Talk: Bullying Edition

When you search for data in a garbage can you're bound to get, well garbage. This idea is, not surprisingly, common knowledge among pretty much anyone who deals with any type of information processing. Programmers have for years used the adage “garbage in, garbage out” when referring to code. It makes a lot of sense then when science progresses and casts away old ideas to the scientific trash bin, that we file this old information and replace it with the shiny new, more correct data. After all, science's ultimate goal is to get as close to the truth as possible. But then there are those who are seemingly stuck in the past. This week, a garish example of such garbage reared its ugly head at the Autism Daily Newscast.

This past week, the Autism Daily Newscast published a pro-bullying article by speech and language pathologist and self proclaimed behaviorist Karen Kabaki Sisto, M.S., CCC-SLP. In her article, Ms. Kabaki-Sisto outlined the perks of bullying an autistic child; that is, the benefits the autistic child and a family get when the child is bullied at school. If that were not enough, she went on to defend her article on Twitter and Facebook (though she carefully never linked to her own article on these personal sites) by basically saying it was all about turning lemons into lemonade. How...um...refreshing?

By her logic, we just cannot stop the bullies so we might as well get used to it and try to make the best of it; bullying is a learning experience. Since, there have been many analogies thrown at this scenario: rape, incest, murder, domestic abuse. One wonders if Ms. Kabaki-Sisto also feels these equally disturbing issues should be accepted as empowering experiences. You know, victims should actually be thanking their abusers for the PTSD. Really. In any case, you can read lots of responses as to why her dangerous assumptions are wrong at these links:

https://silencebreakingsound.wordpress.com/2015/10/15/bullying-is-abuse-and-abuse-has-no-perks/
https://autloveaccept.wordpress.com/2015/10/15/there-are-no-perks-to-being-bullied/
https://thedigitalhyperlexic.wordpress.com/2015/10/15/ten-things-this-autistic-kid-learned-from-being-bullied/
http://autisticacademic.com/2015/10/15/ten-things-autistic-kids-pick-up-faster-better-and-with-less-trauma-if-they-arent-bullied-into-learning-them/

I began to wonder where Ms. Kabaki-Sisto got this very warped idea in the first place. I decided to do a little digging and ended up at her blog where I found numerous extremely outdated ideas about autistic people. One in particular was the idea that autistic adults had the minds of children.

“At the core of this argument is that for people of all ages with autism, the chronological or physical age of the person does not match the ‘mental age’ of their language, cognition (IQ; thought
processes), and/or emotional development.”

This is an extremely outdated view (like 1950s view) and in fact just wrong. It is now known that being autistic is not synonymous with having a low IQ. People on the spectrum tend to present with various levels of intelligence much like the rest of the population (Pickles, Simonoff, Chandler, Loucas & Baird, 2010). This timewarp does not seem to phase her, however. Throughout a lot of her writing, Ms. Kabaki-Sisto seems to want to infantilize autistic adults; that is, deny them the opportunity to be treated as adults.

Ms. Kabaki-Sisto also goes on to talk about forcing, physically if necessary, eye contact from autistic people. Not only is this known to be unnecessary, it can also be physically and psychologically painful for an autistic person. She defends her forced eye contact position stating that

“...true feelings and intentions can only be seen when one looks at another’s face and body.”

One might have guessed by now that Ms. Kabaki-Sisto has not been updating her research shelves because the latest data shows that eye contact can actually be detrimental to a conversation, especially if one is trying to be persuasive (Chen, Minson, Schone & Heinrichs, 2012).

So where is she getting all this old data from? This brings me back to my original thought of garbage in -garbage out. Ms. Kabaki-Sisto apparently gets her information from the garbage can. At the site where you can purchase her non-evidence based program (no efficacy testing has been done to date on her wares), you can find this little gem of a quote on her “Meet Karen” page:

“My persistence lead me to my speech-language department’s library. Of all the valuable information available there, the most influential item I found was - surprisingly - in the garbage can!”

Yes folks, you read it correctly – her information comes from the trash - old information that is no longer relevant. Concepts such like “Theory of Mind” deficits which has since become an extremely controversial subject and no longer presumed a deficit in autism spectrum disorders (Peterson, 2014), the idea that people on the spectrum also have severe cognitive delays or prefer child-like things from the early Kanner's autism years among many more questionable bits of misinformation. Oh, and of course lest we forget that bullying is a good learning experience for autistic children.

Science may not have all the answers, but I can guarantee you that using garbage as the basis for your “program” is not going to get good results.

Charman, T., Pickles, A., Simonoff, E., Chandler, S., Loucas, T., & Baird, G. (2010). IQ in children with autism spectrum disorders: Data from the Special Needs and Autism Project (SNAP). Psychological Medicine Psychol. Med., 619-627.

Chen, F., Minson, J., Schone, M., & Heinrichs, M. (2013). In the Eye of the Beholder: Eye Contact Increases Resistance to Persuasion. Psychological Science, 2254-2261. 

Karen's Straight-Talk. (n.d.). Retrieved October 16, 2015.

Peterson, C. (2014). Theory of mind understanding and empathic behavior in children with autism spectrum disorders. International Journal of Developmental Neuroscience, 16-21.

Language Matters

Stomp out…Combat...Fight against…Beat…Battle…these are the words of aggression and war. These are the words also commonly used to rally support to overcome illness. When we think of pervasive diseases such as cancer or diabetes, most do not question combating these deadly diseases. In these examples, aggressive and fear-based language such as dangerous, serve to motivate; fearful people are likely to contribute to research funding and hopefully engage in prevention activities. Here the use of aggressive language potentially helps makes positive change. When aggressive language is used to represent disabilities including mental health, the situation changes dramatically. 

When we use language that says we must fight against a dangerous mental illness or a disability we are telling the uninformed public that people who have these labels are dangerous. We are telling them that these disorders must be beaten and battled against in order to prevent vicious behaviors and violent crime. And when society cannot beat or overcome via a cure, it must find ways of preventing the public from the dangerously ill people. This is how the asylums began in the late 1700s. Most would agree we do not want to repeat this history.

This is not to say that disabilities and mental illnesses do not present difficulties to those who wear the labels. Clinical depression can be debilitating. Many anxiety disorders when left unsupported can lead to clinical depression which can lead to suicidal behavior. Other times, unsupported these issues can lead to substance abuse. In most cases, however, the danger is truly to the person experiencing the mental health issue. More troubling is that the person with the label is more likely to experience violence by the hands of someone not considered disabled. According to recent studies, people with disabilities are at a considerably higher risk of violent abuse than the general public. This means that it is more likely that a non-disabled person will act violently against a person with the disability label than vise versa. It is not hard to believe that our use of fear-based, aggressive language has a part to play in this trend. After all, what better way to beat dangerous mental illness than to start at home.

Language matters. There is a difference between “Fight to End Mental Illness” and “End Stigma about Mental Illness.”  There is a difference between “Mental Illness is Dangerous” and “Misinformation about Mental Health is Dangerous.” What we say and how we say it can be the difference between what the public believes and inevitably how people wearing these labels are treated.


http://www.pbs.org/wgbh/amex/nash/timeline/

http://www.apa.org/pi/disability/resources/publications/newsletter/2012/12/disabilities-violence.aspx