Antidepressives-induced persisting perception disorder

Depression is by far the most frequent psychiatric disorder and may occur in everyone (see here).

Escitalopram Oxalate

In his first post to the Ezboard forum Visual snow or static, the 20-year-old American male wrote:

"Hey guys I've been reading for the past few days because I've been having what I consider symptoms similar to yours. Now, I'll be the first to admit that my vision isn't 100 percent grainy. Not even 50 percent. But I feel what I'm getting is the start of visual snow.

Here's a little background:

I started taking Lexapro [Escitalopram Oxalate] 2 weeks and 2 days ago [April 10, 2006]. A few days in I noticed my first floater ever and quick flashes of light. I went to the ophthalmologist; perfect eye pressure, no tears, etc. etc. Gradually, I've noticed more dots and flashing lights. Last night [April 25, 2006] was the worst I'd ever experienced; lots of dots and squiggly lines.

I am getting off the Lexapro and probably anxiety meds altogether. It's done nothing but make me more anxious than I already am. I am hoping that coming off this will stop my symptoms, but, if not, I know I will have a place to go for comfort."

(Who Del [subject #94], Ezboard forum Visual snow or static – Discussion – New here, April 26, 2006)

"I was taking Lexapro and it began to really screw with my eyes; I experienced floaters and flashes of light. Sometimes, when I look at bright lights I can see sparks of light... I haven't taken Lexapro for a week [since April 26, 2006] and I've noticed some improvement. As of now I do not have visual snow, but if it does happen I have a feeling the Lexapro could be to blame. "

(Who Del [subject #94], Email to Klaus Podoll, May 2, 2006)

"It's no problem at all. As far as the VS is concerned my symptoms have slowly gotten better since I stopped taking the Lexapro (which was a week ago today actually). I had never noticed any of the symptoms I had until I started on the Lexapro. I had never even noticed a floater on a rare occasion it came into my visual field. When I was on the Lexapro I had kaleidoscope-like visuals (only once or twice). Ever since I've been off it those symptoms have vanished.

I have no history of migraines or migraine aura. I have never done any drugs other than drink alcohol occasionally and smoke marijuana a few times in my life; definitely not regularly though. In my case I believe it was the Lexapro because I was never that anxious to begin with. I had a virus in my stomach called H Pylori that can cause GERD and chest pain. That had me worried. My doc prescribed Lexapro to calm me down.

Thankfully I am off it now and things seem to be getting better. I will definitely keep in touch though."

(Who Del [subject #94], Email to Klaus Podoll, May 3, 2006)

"Discontinuing the Lexapro seems to have helped. Maybe in my mind there is still 'something'. I think a lot of it has to do with the fact that I keep staring at walls looking for it. I only really notice anything when I'm outside. What they call Scheerer's phenomenon. That can be quite annoying! Let me ask you something: I honestly don't believe I have 'VS' but I know for sure I have Scheerer's phenomenon. Will that ever go away? Or am I to deal with that forever?"

(Who Del [subject #94], Email to Klaus Podoll, May 6, 2006)

Scheerer's phenomenon (Scheerer, 1924) is the appearance of tiny bright dots moving quickly along squiggly lines in the visual field, especially when looking into blue light (such as the sky). These dots are due to the white blood cells that move in the capillaries in front of the retina of the eye, near the macula. This is a physiological phenomenon, so it should not worsen in intensity and change in quality, as has been Who Del's experience with "the start of visual snow" a few days after the begin of pharmacotherapy with Escitalopram Oxalate. Scheerer's phenomenon is characterised by the appearance of multiple, identical-looking bright dots that follow each other rapidly along the same path, moving somewhat in sync with the heart beat. In contrast to this phenomenon, visual snow is more variable in its form, colour and movement dimensions, as illustrated by Who Del's description of "the start of visual snow" that featured not only "lots of dots", but also "squiggly lines" and "floaters"-shaped forms. As regards the prognosis of Who Del's persisting perception disorder, its immediate improvement after the discontinuation of the medication Escitalopram Oxalate suggests that there is good reason to expect a full recovery.

"I guess the good news is that it will probably go away since I've discontinued the Lexapro. I've only been off it for about a week and a half, so I'm not sure how long before I really start seeing some vast improvement. I've only seen improvement little by little, and sometimes the symptoms just stay the same. So we'll see. Thanks for the encouragement though.

Really, I only see things when it's extremely bright. That's the only time I see anything. At night I'm not affected. Unless I close my eyes then I see what looks like a kaleidoscope effect sometimes.

Is there any research into why antidepressants can cause this sort of thing? And why it can stop afterwards? I find it interesting that this isn't getting more research."

(Who Del [subject #94], Email to Klaus Podoll, May 6, 2006)

"Just wanted to update you on myself. I can't really tell what's going on to be honest. Some days I think it's worse and other days I think it's better. I'm actually worried that it will never go away. I've read some people got these symptoms from SSRIs, and had them for a while before they went away so I am holding out hope."

(Who Del [subject #94], Email to Klaus Podoll, June 2, 2006)

"Yeah. Some days it's better. Some days it's worse. I've read some people have it from one to three months, some longer. I'm trying not to think about it, but it's very hard. I don't want this permanently and I will do anything I can to stop it. I will not be taking any medications for the time being for this. Trust me. I don't want any more crap coming my way. I search online all the time but it's impossible to find answers for this. I can't even find people who have been on antidepressants then have had visual disturbances for a while after. So I guess I will wait and see what happens to my eyes."

(Who Del [subject #94], Email to Klaus Podoll, June 2, 2006)

Paroxetine

Subject #43

In subject #43 from Sofia Greene's internet survey, a then 14-year-old girl who later got a diagnosis of Lyme disease, persisting VS occurred after a week of treatment with paroxetine, a selective-serotonin reuptake inhibitor (SSRI) commonly prescribed as an antidepressant.

"My 14-year-old daughter's visual problems... started after taking Paxil [in December 2004]. She was on it for only 6 days before experiencing hallucinations and vertigo. The worst passed a day or so after we stopped the Paxil, but she was left with shimmering VS", reported her mother.

(leahester [mother of subject #43], Ezboard forum Visual snow or static - Archive - JulesJubie's advice on Epsom salts - it's working, June 5, 2005; additions in square brackets by Klaus Podoll)

"While I was sitting on her bed, she saw my head turn from green to black and then she saw just my skull. She was terrified. She has afterimages, trails, distortions in her peripheral vision (things appear much bigger than they actually are) and things appear to move although she knows they're not."

(leahester [mother of subject #43], Email to Sofia Greene, July 15, 2005)

"She reports that her visual disturbances are continuous. She reports seeing shimmering white lights, especially in the dark, 24 hours a day, 7 days a week, even in her sleep. She also complains of occasional trails, halos around objects and squiggles of color. She has other visual problems that seem more related to her orthostatic intolerance; i.e. tunnel vision and, at times, black-outs of her visual field when she stands up. Her visual problems initially seemed to be triggered by 7 days of Paxil, at which time she developed frank hallucinations. The hallucinations passed and she was left with the disturbances I described. She had a normal MRI, EEG, SPECT scan and eye exams."

(leahester [mother of subject #43], Email to Sofia Greene, February 23, 2006)

"Sara, my 14-year-old, complains of VS being present in her dreams. Not trails or afterimages, that I can recall, but she frequently says the white spots are always there, even in her dreams."

(leahester [mother of subject #43], Ezboard forum Visual snow or static - Archive – my soap box, May 31, 2005)

"SSRIs do seem to be associated with palinopsia and other visual phenomena so, with such a clear temporal link, I would have to say yes, paroxetine (Paxil) may have precipitated the symptoms", commented Dr. Dominic ffyttche on this case (subject #43). "Why they should persist after the medication was stopped is unclear. However, we are entirely happy that 'trails' and 'snow' can persist long after exposure to another 5HT-related drug, namely LSD. Perhaps we should be thinking of SSRI-related visual perceptual pathology as iatrogenic flashbacks!"

(Dr. Dominic ffytche, Email to Klaus Podoll, February 16, 2006)

Henry David Abraham, MD. © 2006 Henry David Abraham

This notion is confirmed by clinical observations of Dr. Abraham who recorded: "I have seen several cases of HPPD associated with SSRIs... without prior use of hallucinogenic drugs. The largest number of cases in the medical literature relates to the use of LSD for the most part, but in medicine we never say never."

(Dr. Henry David Abraham, Email to jacob, undated [2005]; cited by jacob, Ezboard forum Visual snow or static, hppd vs visual snow - [validation of VS], June 30, 2005)

Subject #360

In subject #360, a 29-year-old male, persistent visual snow and increased afterimages were brought on by paroxetine withdrawal syndrome following the decrease and then discontinuation of the selective serotonin reuptake inhibitor.

"I noticed VS symptoms a couple months after I weened myself off Paxil. I took it for 4 years prior, and did not see any VS symptoms then. I may have had the symptoms longer, but were so mild, I simply did not take notice. I no longer take the drug.

I believe Paxil could be the culprit in my case as I see no other reason for vs to be induced (or awoken if you will...) upon myself other than a toxic, ill suited, poorly researched, oft-litigated, anti depressant entering my bloodstream for 4 years.

I have witnessed others stating that Paxil has been, or is in, their lives. Therefore I see a connection.

I cannot write Paxil off as the sole reason for my symptoms, as my mother has suffered from migraines (I never have had an actual 'migraine' per say), therefore a genetic disposition my be a viable reason. I have also experimented with drugs in my past, all which were long behind me before the weening process started.

BTW, this is my first post on the site and I appreciate the knowledge I've learned about my VS symptoms, and I am very grateful."

(minimum [subject #360], Ezboard forum Visual snow or static - Discussion - hi, May 20, 2007)

"My weening process took around 6 months, with 5 mg intervals every 1.5-2 months. I was on 20 mg for the better part of the 4 years. The GP who prescribed this drug to me told me to do it in 2 weeks. Boy, I'm glad I didnt listen to him, as it's the worst way to come off Paxil.

I won't get into specifics too much, but I was in a depressive situation, and being the naive patient and I went to a clinic and asked for help from an ill mannered prescribe-drugs-on-a-whim kind of doctor. At the end of year three, I then decided to get off Paxil, it was at the middle duration mark of the weening process, that I felt I should have never been on the drug in the first place. My family agreed, as did my friends; therefore we all felt I was misdiagnosed. When I came off the drug I started to realize why the hell I was on the drug in the first place. After my first dosage drop I felt amazing and even better after the subsequent dosage decreases. I became me again, a broken me, but a me that would become stronger than ever. What doesn't kill you makes you stronger.

The withdrawl symptoms were horrible. The dizzy spells, stuttering, memory, the anger, the feelings like you're gonna lose it, the induced OCD, all were the toughest things I had to battle in my life, but I prevailed. I can say I'm still recovering from the drug, as I stopped late last year and withdrawl can last for up to a year.

If it helped you, then that's great. I'm strongly against the drug, but if it works for you, then so be it, but please do the research on what it CAN do.

(minimum [subject #360], Ezboard forum Visual snow or static - Discussion - hi, May 20, 2007)

"Perhaps I phrased myself incorrectly, I started experiencing VS a couple months after I STARTED to ween off Paxil. The VS intensified slowly as I decreased dosages. It hasn't changed since."

(minimum [subject #360], Ezboard forum Visual snow or static - Discussion - hi, May 21, 2007)

"Did I feel terrible? Sometimes I felt the worst.

My mind so was in such a whirlwind at the time but no, I did not have any 'migraine attacks' while weening off Paxil. Bad headaches, yes, but they were the least of worries at the time. I don't disagree with that theory, but Paxil is a drug above the rest when it comes to its unstability. Look at Paxil's homepage, its comprised of a short blurb about the drug, when before, it was a full, somewhat informative advertising styled website. Why? GSK (makers of the drug) is getting sued by the hundreds every year. It's been labeled the worst AD, SSRI, etc to stop and many can't. It is just too unstable of a drug to class it with other AD and SSRIs. I've seen it labeled as highly toxic by some."

(minimum [subject #360], Ezboard forum Visual snow or static - Discussion - hi, May 21, 2007)

"1. Name or screen name (optional): minimum

2. Email (optional): N/A.

3. Location (optional): Canada

4. Age: 29

5. Sex: M

6. Nationality and Race (optional): Canadian/E. Euro

7. Do you have classic migraine (migraine with aura) or common migraine (migraine without aura)? When did it begin?

8. What do you take for your classic or common migraine and does it help?

Nothing.

9. Have you been diagnosed with persistent aura (prolonged migraine aura status)?

Have not been diagnosed.

10. What is your visual problem and how long does it last?

Visual snow became noticable September 06. I believe VS may have started a couple months prior, but not that noticable, but I can't distinguish if it was my mind playing a trick on me.

VS - static in vision (worst at night), floaters (a couple darks ones, 3-5 in both eyes of cobweb style ones, and retinal white blood cells), unconventional dizzy spells (depth perception, wooziness), starburst and halos, increased negative afterimages, a bit of tinnitus

11. Any other problems that you think might be related?

Three of them: (1.) My mother is a migraine suffer and was diagnosed as having migraines with aura when shes was 23. She had some similar symptoms but did not have visual snow. (2.) Paxil. On a 20 mg dosage for 4 years, started weening 5 mg at a time over a 4.5 month duration around end of year 4. Very stressful time on both mind and body. Three days after I started to ween, the dizzy spells came about. I still have these spells, but I can't tell if they're from the VS, paxil or past ear infection (had infection around same time). I also had sinusitis 3-4 times in 2006. When I first started Paxil I had jaw tremors and developed bruxism (clenching/grinding of teeth). I now wear a night guard and has aleaviated tension from my temple area and may be helping (to early to tell yet). (3.) I had lasik 2 months prior to my onset. I thought my VS was a side effect from lasik and surgeon said me that knew of nothing relating to VS. It's until my discovery of this website that I started to rule out lasik as the sole reason. I had a enhancment surgery last week on one of my eyes as I seem to have lost some contrast and been having night time problems (I came back to -1.00 astigmatism in both syes).

Timeline: May: (started paxil ween to 15 mg ) July: (weened to 10 mg) (sinusitis) (lasik) August: (N/A) Sept: (ween to 5mg) (Static became very noticable) Oct: (stop paxil) (sinusitis) Nov: (Zyban to stop smoking, could only tolerate 3 weeks, VS intensified greatly, felt pains shooting down my left arm, heart palpatations,stress was at its peak) Dec - now (no change in VS, still have dizzy spells)

12. What do you take or do for your vision problem and does it help?

I supplement with multivitamins for an unrelated reasons, but i feel do they do sharpen my vision up a bit and help with some of the floaters.

13. Have you found a trigger for your vision problem?

No, I wish I could, although I have the continuous form. It doesn't get any better or worse.

14. What tests have you had and the results?

No tests. I'm having a CT done for the dizziness.

15. Drug history (pre VS)

Paxil 20mg, various anti biotics for sinusitis, bupropion for smoking cessation, narcotics: late teens-mid twenties, occasional. Haven't done or tried in a long time. I looked at the HPPD site and I dont apply to most of the HPPD sufferer's criteria.

16. Drug history (post VS - effect on VS - negative, positive, not at all)

Weening Paxil: got worse. Bupropion: at its peak.

17. Other information you want to provide?

Does persistant migraine aura without infarction apply to my case? I believe a genetic disposition and SSRIs are the probable cause of my onset."

(minimum [subject #360], Ezboard forum Visual snow or static - Discussion - hi, May 22, 2007)

"I've always had astigmatism; therefore halos/starbursts were not foreign to me. Unconventional dizzy spells started day 3 after starting to ween off paxil. Unconventional dizzy spells are said to me #1 withdrawal symptom, so thought of VS did not clue in. Floaters came after lasik. Snow, increased floaters, increased startbursts and afterimages came around paxil ween to 5 mg. As for tinnitus, it's minor and can't tell you when it started. I've been to too many concerts.

I have consumed all of the above (LSD, Ecstasy, mushrooms) no more times that the fingers on my hand. I did not experience any VS symptoms right after taking these per say, latency between time I tried to VS onset was greater than year.

I wanted to add something, I have POSITIVE after images, I must have understood the meaning. After I look at a light source, an afterimage is provided when I close my eyes."

(minimum [subject #359], Ezboard forum Visual snow or static - Discussion - hi, May 24, 2007)

Withdrawal syndrome after decreasing or discontinuing serotonin re-uptake inhibitors, especially paroxetine, is largely unknown to most physicians (Belloeuf et al., 2000). The main signs are dizziness, vertigo, headache, nausea, and flu-like symptoms as well as anxiety, confusion, irritability, excessive dreaming and insomnia, most of which have been described by minimum (subject #360) in the above report on his serotonin re-uptake inhibitor withdrawal syndrome which brought on persistent visual snow and increased afterimages, echoing a case vignette by Terao (2002) who reported palinopsia in a patient with paroxetine withdrawal.

Maprotiline

Hori et al. (2000) reported the case of a 56-year-old depressive man who suffered from visual perseveration during maprotiline therapy. The visual perseveration was dose-related and disappeared with reduction and cessation of the therapy.

Mirtazapine

Ihde-Scholl and Jefferson (2001) described a case of mirtazapine-associated palinopsia (see here for a full reprint of the case history).

Nefazodone

Kraus (1996) reported visual trails and Schwartz (1997) and Faber and Benzick (2000) palinopsia in each one patient treated with nefazodone. Horton and Trobe (1999) observed visual trails and polyopia of moving objets in each one patient treated with nefadozone. In the last mentioned patient, moving objects were followed by a trail of multiple "freeze-frame" images, which dissipated promptly when motion ceased

Trazodone

Hughes and Lessell (1990) reported three patients who experienced palinopsia as an isolated symptom, apparently as a side effect of trazodone hydrochloride therapy for depression. The palinopsia was dose related and disappeared with reduction or cessation of therapy.

References

Belloeuf L, Le Jeunne C, Hugues FC. [Paroxetine withdrawal syndrome] [Article in French] Ann Med Interne (Paris) 2000; 151 Suppl A: A52-53.
Cancelli I, Marcou G, Balestrieri M. Factors associated with complex visual hallucinations during antidepressant treatment. Hum Psychopharmacol 2004; 19: 577-584.
Faber RA, Benzick JM. Nafazodone-induced palinopsia. J Clin Psychopharmacol 2000; 20: 275-276.
Hori H, Terao T, Nakamura J. Visual perseveration: a new side effect of maprotiline. Acta Psychiatr Scand 2000; 101: 476-477.
Horton JC, Trobe JD. Akinetopsia from nefazodone toxicity. Am J Ophthalmol 1999; 128: 530-531.
Hughes MS, Lessell S. Trazodone-induced palinopsia. Arch Ophthalmol 1990; 108:399-400.
Ihde-Scholl T, Jefferson JW. Mirtazapine-associated palinopsia. J Clin Psychiatry 2001; 62: 373. (See here for a full reprint.)
Kraus RP. Visual "trails" with nefazodone treatment. Am J Psychiatry 1996; 153: 1365-1366.
Scheerer R. Die entoptische Sichtbarkeit der Blutbewegungen im Auge und ihre klinische Bedeutung. Klinisches Monatsblatt Augenheilkunde 1924; 73: 67-107.
Schwartz K. Nefazodone and visual side effects [letter]. Am J Psychiatry 1997; 154: 1038.
Terao T. Palinopsia and paroxetine withdrawal. J Clin Psychiatry 2002; 63: 368.

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