Fluoxetine-induced extrapyramidal symptoms in an adolescent: a case report.

Abstract

We present a 15-year-old girl with depression, an obsessive compulsive disorder and conduct disorder, who developed EPS (torticollis, bradykinesia and cogwheel rigidity) while on fluoxetine. No other cause of EPS was present. The patient responded well to benztropine but re-experienced EPS when benztropine was stopped. Fluoxetine and benztropine were used concomitantly for 21.2 months and the patient has been off medication for 2 months without EPS. This case report shows that EPS can and does occur in youth with SSRI. Clinicians should be aware of the SSRIs as a potential causative factor for EPS.

Full text

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Fluoxetine-induced extrapyramidal symptoms
in an adolescent: a case report
Rasim Somer Diler, Aysegul Yolga, Ayse Avci
Department of Child and Adolescent Psychiatry, Cukurova University,
Faculty of Medicine, Adana, Turkey
As in adults, selective serotonin reuptake in-
hibitors (SSRIs) have been increasingly used in the
treatment of children and adolescents [1, 2]. Be-
cause of this wide use even low-frequency adverse
effects are becoming more prevalent [3], and re-
ports of extrapyramidal symptoms (e.g. dystonia,
dyskinesia, akathisia, parkinsonism and neurolep-
tic malignant syndrome) associated with SSRI use
have been accumulating in the literature [3, 4].
Epidemiological studies suggest that EPS occur in
about 1 per 1000 adult patients treated with SSRIs
[5, 6].
A literature review on children and adolescents
revealed only one EPS report in which paroxetine-
induced oculogyric crisis was described in a
9-year-old girl with compulsivity and attention-
deficit hyperactivity disorder [7]. Symptoms of
ocular pain and a sustained upward gaze occurred
approximately 3 days after the addition of paroxe-
tine 10 mg/day to a regimen of pimozide [7].
In this report we present a 15-year-old girl
who developed EPS while using fluoxetine. We
discuss the clinical features, aetiology and signifi-
cance of this rare clinical condition.
We present a 15-year-old girl with depression,
an obsessive compulsive disorder and conduct dis-
order, who developed EPS (torticollis, bradykine-
sia and cogwheel rigidity) while on fluoxetine. No
other cause of EPS was present. The patient re-
sponded well to benztropine but re-experienced
EPS when benztropine was stopped. Fluoxetine
and benztropine were used concomitantly for 21⁄2
months and the patient has been off medication for
2 months without EPS. This case report shows that
EPS can and does occur in youth with SSRI. Clin-
icians should be aware of the SSRIs as a potential
causative factor for EPS.
Key words: selective serotonin reuptake inhibitor;
fluoxetine; children; extrapyramidal symptom
125
Short communication
SWISS MED WKLY 2002;132:125–126 · www.smw.ch
Peer reviewed article
Summary
Introduction
Case report
“A” was a 15-year-old female in whom a major de-
pressive disorder, OCD (washing, cleaning and checking)
and CD according to DSM-IV were diagnosed at age 14
[8]. There was no family neuropsychiatric history and ini-
tial medical work-up including whole blood count, blood
chemistry panel, liver function tests, ECG, thyroid function
tests and child neurology consult revealed no significance.
Fluoxetine 20 mg PO qd was started and then in-
creased to 40 mg in six weeks due to slow response to the
treatment. We also used 25–50 mg/day quatiapine (an
atypical serotonin-dopamine receptor antagonist) be-
tween 21⁄2 and 81⁄2 months of fluoxetine treatment when
OCD symptoms markedly diminished and CD symptoms
were improved. After three more months of 20 mg/day
fluoxetine monotherapy (after 121⁄2 months of fluoxetine
introduction) A developed “cogwheel rigidity”, “bradyki-
nesia”, and “episodic torticollis lasting 5–10 minutes three
to four times a day”. A was seen with torticollis, which
looked similar to that seen in patients on typical antipsy-
chotics. The physical and neurological examination was
normal except for “cogwheel rigidity and bradikinesia”.
No physical findings or abnormal movements were ob-
seved in A. Benztropine 2 mg IV resulted in rapid relief of
Abbreviations
EPSExtrapyramidal symptoms
SSRISelective serotonin reuptake inhibitor
OCDObsessive compulsive disorder
CDConduct disorder
PD Parkinson’s disease
No financial
support declared.

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torticollis. Whole blood count, blood chemistry panel,
liver function tests, ECG and creatine phosphokinase level
were normal.
Given the effectiveness of fluoxetine treatment, A and
A’s parents were unwilling to stop fluoxetine, and benz-
tropine 1 mg PO tid was prescribed along with fluoxetine.
A received no EPS for 10 days and benztropine was grad-
ually withdrawn over a week. She re-experienced mild
bradykinesia and cogwheel rigidity, but no torticollis, one
day after cessation of benztropine. Benztropine 1 mg PO
tid was restarted and EPS were resolved within two days.
Benztropine and fluoxetine were used for a further 2
months. A has not experienced EPS since cessation of
medication 2 months ago.
Fluoxetine-induced extrapyramidal symptoms in an adolescent: a case report
126
Discussion
Given the absence of a drug-related cause for
EPS (quatiapine poses a relatively low risk for EPS
and our patient had not taken quatiapine for three
months) [4] and the rapid and time-related re-
sponse to benztropine, we conclude that A experi-
enced parkinsonian symptoms (bradykinesia and
cogwheel rigidity) and an acute dystonic reaction
(episodic torticollis) related to fluoxetine. This
case report adds to the accumulating literature and
is evidence that EPS can and do occur in young pa-
tients on SSRI.
The majority of SSRI-related reactions oc-
curred within the first month of treatment, but
they have also been reported to occur within a
number of months [4]. Our case was a female ado-
lescent on a long-term moderate fluoxetine dose
without rapid dose adjustment. The literature of-
fers no supporting evidence for a consistent risk
factor, although total daily dose of SSRI, rapid dose
escalations, increased age, female gender, concur-
rent psychotropics known to precipitate EPS, and
concurrent disease states such as Parkinson’s dis-
ease are cited [3–6].
As in our report, fluoxetine is the biggest of-
fender in the literature on adults and acute dysto-
nia is the most frequent EPS finding [3, 4, 9]. EPS
is usually reversible and conveniently managed
by discontinuing the responsible agent, lowering
its dose or using drugs similar to those employed
in neuroleptic-induced EPS [9]. On the other
hand, co-prescribing of SSRIs and neuroleptics
may increase neuroleptic plasma levels (due to
P-450.2D6 system blockage), increasing the like-
lihood of EPS [10, 11].
Conclusions
Clinicians should be aware of the SSRIs as a
potential causative factor for EPS. Greater aware-
ness of this potential role could lead to more fre-
quent recognition and help to decrease morbidity.
The emergence of SSRI-induced EPS in children
and adolescents should be the subject of further
research in large clinical samples.
Correspondence:
Rasim Somer Diler, M.D.
Asisstant Professor
Child and Adolescent Psychiatry Dept.
Faculty of Medicine
Cukurova University
Balcali, Adana, Turkey 01330
E-Mail: dilerrs@yahoo.com
References
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3 Goldberg R. Selective serotonin reuptake inhibitors: Infrequent
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4 Caley CF. Extrapyramidal reactions and the selective serotonin
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5 Choo V. Paroxetine and extrapyramidal reactions. Lancet 1993;
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6 Coulter D, Pillans P. Fluoxetine and extrapyramidal side effects.
Am J Psychiatry 1995;152:122–5.
7 Horrigan JP, Barnhill LJ. Paroxetine-pimozede drug inter-
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