Paging Oliver Sacks. This was awful.
October 17, 2014 1:00 PM   Subscribe

My partner had a significant mental health event in the past that nobody (neurologists or psych people) have been able to explain. It's never reappeared and there was no history beforehand, but it's a significant source of worry for both of us. Blizzard within.

You are not my, his or our doctor or shrink. We've dealt with this event in therapy a lot, to the point that it's no longer the lynchpin of whether we stay together or a source of shame and blame. But the question of how it happened persists. His psychiatrists have referred to it as a manic episode, a psychotic episode or even questioned whether it happened.

My partner had a breakdown in 2009 that defies the usual bounds. He is mid to late 40's. I am 40ish. We have been together almost a decade. In 2009, he very suddenly became very agitated and began destroying furniture (he broke apart a whole dining room set with his bare hands, nonsensical), ranting at me and our friends in an incomprehensible way, tearing up everything in the kitchen (there were bags of granola, rice and pasta all over the floor when I came home one day) and throwing away sentimental possessions. He was hostile to his therapist and psychiatrist (who were treating him for depression) and refused to go in. They were alarmed -- my partner is usually a VERY acquiescent person -- and his psychiatrist prescribed klonipan (a sedative) and seroquel (an antipsychotic).

Things darkened over the week: he began to be so suicidal that he threatened to run into the (rather busy) street we lived on and was very verbally aggressive (and slightly physically aggressive) when I stopped him, so I called the police. He was just as verbally aggressive in the same way with the police (which was equally out of character -- he'd never even had a speeding ticket before), earning him a trip to the ER. Unfortunately, our city had a perpetual psych bed shortage. He ended up being kept in the ER for less than 24 hours, even though he was very up front about his suicidal intentions. When he returned, friends helped me "babysit" him. He was out of character with them as well, burning some bridges permanently with hostility and weirdness, talking constantly of suicide, sleeping constantly, trying to keep destroying things in the apartment. Friends taking him to the movies seemed to help most. I only interacted with him to make sure he took his medications -- and they did not really help, except to sedate him. He was upset that I was "drugging" him and he talked about hallucinations in front of me and others. He once left and called a friend of mine to discuss how he felt that I should leave our home because he might kill me, which initiated trip #2 to the ER and me staying with friends. All of this was very out of character - people could not believe it and knew something was wrong.

He was in the ER for two days the next time, given no new meds, but sobered up. He was horrified about the past week when I came to meet with the social worker to see if he should come home. We have no idea what happened. He does not remember any of this. He has amnesia for the whole week. I believe him - some of the social fallout has seemed totally mysterious to him and I've had to explain that he interacted with that person during that week.

The immediate diagnosis was that this was a manic episode, but subsequent psychiatrists have questioned that, given that this happened post-40 and he'd never shown bipolar symptoms before then -- and they've taken him off the lithium and depakote prescribed. No more episodes have happened. On the other end of the spectrum, one of his counselors suggested that tearing up your house and having amnesia is a normal response to stress, which we both find hard to believe.

Possibly relevant info:

1. He had a cortisone shot in his foot just days before this happened.
2. He was also put on Tramadol for his foot at the time of his cortisone injection
3. His amnesia is total - he has blacked out the whole week
4. He was taking some sort of SSRI antidepressant at the time, which he also takes now - he is treated for depression
5. He was also just put on Androgel (testosterone cream) by an endocrinologist just prior

A few doctors have waved their hands and said, "oh, that must have been a medication interaction!" but, really? It's hard to accept a pat answer about that, for both of us. Do you think so, hive mind? I'd really appreciate only medical speculation about why this might have happened, not inquiries into my reasons for asking or philosophical reflections on whether there's an answer. We're ok with it being history, but we'd really like to have an explanation some day and nobody has ever ventured anything that sounds plausible. throwaway:
posted by anonymous to Health & Fitness (34 answers total) 6 users marked this as a favorite
Tramadol + SSRI, possibly serotonin syndrome? Were there any physical signs?
posted by morganw at 1:09 PM on October 17, 2014

Why is that explanation hard for you to accept?

I'm not a medical professional, but looking at the meds he was on, I could totally believe it was some kind of weird interaction. Especially since there's been no recurrence.
posted by ottereroticist at 1:10 PM on October 17, 2014 [10 favorites]

The only thing I can think of is something related to the steroids, although it seems unlikely from a single cortisone shot, I guess? I am in no way a doctor, but my dad had a very serious psychotic break from prednisone treatment, which included suicide attempts and disassociation and paranoia.
posted by poffin boffin at 1:11 PM on October 17, 2014 [2 favorites]

Tramadol is no joke.
posted by empath at 1:16 PM on October 17, 2014 [3 favorites]

Do you have poisonous plants in your home? (This is a total stretch, btw)

Accidental ingestion of something like angel trumpet seeds can cause hallucinations, blackouts, agitation, etc.
posted by unixrat at 1:19 PM on October 17, 2014
Steroids can be a trigger (cortisone) as can opiate medications (tramadol). This is a pretty extreme reaction for a (presumably) healthy young man but I've seen similar things happen.
Also, can you be absolutely sure he wasn't using any other drugs at the time (even herbals or OTCs)?
posted by arrmatie at 1:19 PM on October 17, 2014 [5 favorites]

So basically any of the three drugs by themselves can cause severe psychological reactions -- seems reasonable that the combination of them would make a reaction even more likely.
posted by empath at 1:20 PM on October 17, 2014 [5 favorites]

Tramadol: Seizures, Serotonin Syndrome, and Coadministered Antidepressants

Also, this sound terrifying and shitty, and I'm so sorry that there was social fallout from something that seems so obviously like a medical problem. That sucks.
posted by showbiz_liz at 1:23 PM on October 17, 2014 [10 favorites]

We just learned about something called anti-NMDA receptor encephalitis in our neurobiology class and your partner's symptoms sound similar to this. It was only recently formalized as a pathology recently which is why many practitioners haven't heard about it. it was previously thought to be associated with uterine teratomas but newer research indicates that most cases are idiopathic.

There was a book written recently about one woman's experience called Brain on Fire by Susannah Cahalan. I'm halfway done and it sounds very similar to what you experienced.
posted by ghostpony at 1:25 PM on October 17, 2014 [2 favorites]

Case reports show that tramadol, SSRIs, cortisone, and testosterone-boosters can have dramatic adverse reactions in some people. Taking all four drugs at the same time might have been the "perfect storm" that pushed your partner over the edge.

I am not a doctor.
posted by alex1965 at 1:25 PM on October 17, 2014 [3 favorites]

You may want to reach out to people he interacted with and explain what happened just to stop the rumor mill before it gets revved up.
posted by empath at 1:26 PM on October 17, 2014

You may want to reach out to people he interacted with and explain what happened just to stop the rumor mill before it gets revved up.

This happened five years ago.
posted by showbiz_liz at 1:27 PM on October 17, 2014

See also: Can the Crowd Solve Medical Mysteries?
posted by alex1965 at 1:33 PM on October 17, 2014 [2 favorites]

You know what's a hoot is tick-born illnesses that cause cognitive failures, I.e. Lyme disease, and a host of others.

During the time period in question, did he have any other physical symptoms?

Maybe an initial episode of cognitive distress brought on by ??? followed by a severe bout in reaction to the drugs?

Either way, I'd get a complete and comprehensive copy of his medical records.

Everything's anecdotal on the internet, you know that --so really people's little stories are junk, but my little story is my husband became unhinged following a course of steroids following a course of antibiotics while being treated for Lyme Disease. It was, indeed, a real treat.

Are you looking for assurance this will never happen again? Is that why you want the causality nailed down? I'd start with detailed medical records, and then try to find a doctor who you can trust. And then I'd Google each of those medications like crazy.

After five years, I think you could relax a little, but given what you're describing, I understand why it would be hard.
posted by A Terrible Llama at 1:45 PM on October 17, 2014

"oh, that must have been a medication interaction!" but, really? It's hard to accept a pat answer about that, for both of us. Do you think so, hive mind?

I'd guess the reason that answer burns is that 'a medication interaction' could be absolutely anything and is in fact not actually an explanation.
posted by A Terrible Llama at 1:46 PM on October 17, 2014 [2 favorites]

The mix of drugs seems like an excellent recipe for a psychotic break to me. I'm not sure why you are reluctant to accept that. I sure would.
posted by DarlingBri at 1:47 PM on October 17, 2014 [10 favorites]

This is anecdotal and I am not a doctor, but I have seen opiate drugs, even tramadol which is often considered a milder alternative to stronger opiates, have a variety of odd side effects in people. The situation you describe is obviously extreme but mood swings are a known and relatively common side effect of tramadol (in ~1-10% of patients) and it's reasonable to believe that there might have been drug interactions.

Again anecdotal, but I have also seen the combination of opiate drugs and sleep disorders lead to really weird behavior, including hallucinations. Did your partner have trouble sleeping before the episode in question? Could be another factor.
posted by Wretch729 at 1:58 PM on October 17, 2014

The software tester in me wants to know if the symptom is reproducible but that's not practical or humane. Seconding your doing some research on the drugs in question to arrive at a more informed judgment about how plausible an explanation drug interaction is. Even if you don't identify any medical testing that may add some confidence, you may be surprised how quickly you can arrive at the peace of mind you seek through that line of inquiry.
posted by maniabug at 2:01 PM on October 17, 2014 [1 favorite]

As I was reading through the top half of your question, I was asking myself "If I scroll down to the bottom, I wonder if I'll find mention of steroid medication usage." And bam, there it was: cortisone. Steroid psychosis is definitely a thing. A scary thing.
posted by drlith at 2:20 PM on October 17, 2014 [7 favorites]

Like many others here, the strength of my reactions to opioid painkillers and steroids individually is strong enough that I can imagine going to a very bad place if I had them in combination, and I'm sure testosterone cream couldn't help, either. To the extent that I'm on £10k a year of antibody therapies to make sure I don't have to take steroids for flare ups.
posted by ambrosen at 3:16 PM on October 17, 2014 [2 favorites]

From an anonymous commenter:
I am an RN with a lot of hospital bedside care experience. I have personally witnessed people - all elderly, but have read it's possible in middle age as well - develop severe psychosis after ONE dose of steroid medication (orally and by injection).

"Steroids" was one of my first thoughts as I started to read your question.

I'd certainly be very cautious if he was ever prescribed any steroid meds again, and if the drug was medically critical, expect that he be closely monitored.
posted by mathowie at 5:30 PM on October 17, 2014 [3 favorites]

I was prescribed Tramadol for dental pain 3 times. 1st time I took it, I began crying for no reason. I felt that the world was too sad & thought about not being in it any more/suicide. I've NEVER been suicidal. 2nd time I took it I was violently ill, vomiting, etc. 3rd & final time I thought I was going to die, I was violently sick again but so much worse, for hours on end. It felt like my scalp was peeling off, it was just horrible. I will never take Tramadol again no matter what, it's like poison to my body.

My dentist implied I was depressed but I have never had symptoms like this before or since. I think she also thought I was seeking opiates-I wasn't, just didn't want Tramadol again. I'm not saying that's what happened to your SO but my experience was terrible.
posted by RichardHenryYarbo at 5:49 PM on October 17, 2014

So this is more of a zebras when you're hearing hoof beats (the steroids or other meds are much more likely), but has he been worked up for any metabolic conditions? Maybe something like porphyria?
posted by goggie at 6:19 PM on October 17, 2014 [1 favorite]

I was wondering about porphyria too. But the Tramadol reaction seems more likely.
posted by brianogilvie at 6:45 PM on October 17, 2014

I had Valium years ago for a routine outpatient procedure and screamed so loud they had to take people out of the waiting room and restrain me because I began hallucinating and panicked violently. I have very very vague to no memories of that afternoon, but the people there looked horrified. I make sure to always warn doctors that I can't take Valium or other benzo drugs. This was like a single tiny Valium and a very rare side effect, but bam straight into nightmareville. Your partner just needs to avoid or closely monitor those meds moving forward.
posted by viggorlijah at 6:48 PM on October 17, 2014 [2 favorites]

With the switch to electronic medical records, you might want to verify that he has some notes on file about bad reactions to those drugs.
posted by yohko at 9:20 PM on October 17, 2014

Another vote for medication-induced psychosis, from someone who's been there, as have friends and relatives. Sometimes people just have unexpected scary reactions to medications and even more commonly, combinations of medications.
posted by MuChao at 9:58 PM on October 17, 2014

A few doctors have waved their hands and said, "oh, that must have been a medication interaction!" but, really? It's hard to accept a pat answer about that, for both of us..

Yes really, although it does seem like your doctors haven't really explained this to you very well. Steroid-induced psychosis can be AMAZING. It's usually dose-dependent, and comes on 3-4 days after starting the steroids which sounds about right for your husband. I'd say the episode went on a bit too long to be the tramadol (hallucinations usually last a day or so), but steroid psychosis can hang around for weeks after just a single dose. The treatment is stopping the steroids (hard to do after an injection, but if he was on tablets you would stop them) and giving sedatives/antipsychotics to keep him calm until it wears off, so it sounds like he was treated appropriately. In the UK he would get admitted under Gen Med if he was that confused (not psych because this is an organic illness not a psychiatric one), but things are probably different in the US. I agree with previous commenters that it is important people know about this in case he gets given steroids again.

Other differentials would be some kind of encephalopathy (but given the time that's elapsed there's no chance of diagnosing that retrospectively), or some kind of illegal drug intoxication or alcohol withdrawal (but presumably anything like that would have become more evident over the past five years).
posted by tinkletown at 8:28 AM on October 18, 2014 [1 favorite]

I've taken a lot of medications for orthopedic pain, but even though Tramadol is a milder-seeming go to for some docs, I'll never take it again. Oy, the mania, the nightmares. And it doesn't even relieve my pain. I can't imagine taking it on top of two different steroids. The medication interaction explanation seems totally plausible to me.
posted by ImproviseOrDie at 9:34 AM on October 18, 2014

At this point, I'd say the avalanche is pretty clear, but if I can add one more data point on the pile: over New Year's this past year, Tamiflu gave my wife a psychotic break complete with suicidal ideation and deep, scary, burning anger. Yes, Tamiflu (go Google Tamiflu psychosis, heh.) It's rare and apparently more common in kids, but it happens,. The only reason she avoided a 4 day stay where she didn't want to be is that we figured out what was going on pretty quickly and Tamiflu has a pretty quick half life; she spent weekend at home on the condition that someone be with her at all times and if things were't improving 4 days later (when most of the Tamiflu was out of her system) then they'd book her into the psych ward.

It was scary and hard, but she's pretty self aware (she's been down this road before, though it wasn't Tamiflu induced) and we're okay. She's okay.

You're looking for another explanation because this seems arbitrary and frightening and scary, and it is in fact scary and most importantly, arbitrary. Human bodies are complicated, weird, messed up machines. I pop hives if I take Dayquil or Nyquil. I have a friend whose sister's psych meds and birth control meds interacted badly, and she passed away. My mom swells up if she wears Bandaids (which makes hospital stays fun, whee.) My point is, bodies are just flat weird, and the ways in which human bodies can react to their environments are numerous and really scary.

I am sorry that the medical professionals you all trusted seem blithe about the whole thing; that's exceedingly not great patient care. But while "medication interaction" may not seem like an explanation, it is likely all they have. Doctors prescribe medications (generally) in good faith, and sometimes our bodies react in ways that we can't explain. I'd love to blame the urgent care doc last winter, but how were they supposed to know that my wife was going to be one of the very few adults to react to Tamiflu like that? They couldn't possibly.

You're ok, your husband is ok, and it sounds like your relationship is okay (one last bit of advice, though I'm sure your therapists have dealt with this one extensively: don't hold anything he said while he was 'out' against him. You just can't. That wasn't him talking.) You all know what to look out for and know to say no if a doctor tries to prescribe those drugs to him again. If nothing like this has happened since, 'drug interaction' is almost assuredly the explanation.
posted by joycehealy at 12:36 PM on October 18, 2014 [2 favorites]

I'm an ER doctor who has encountered many people with psychiatric/psychotic reactions to steroids, typically to oral steroids. I've never seen or heard of a case of steroid psychosis after an intra-articular injection, but hey, that's what PubMed is for. I found a case report citing 2 cases of psychosis after intra-articular injections. Very uncommon, yes, but possible!
posted by treehorn+bunny at 4:38 PM on October 18, 2014 [3 favorites]

I got pretty manic when I was on oral prednisone. I have no idea how I didn't get murdered, arrested, or fired from my job. I lived alone, had recently split from my ex, and didn't have close friends or family nearby, so I was basically unsupervised and behaving like a lunatic around town with no one but my job to pick up on the drastic change in behavior. My mother was horrified, just hearing me on the phone, and she didn't know half of what was going on.

Apparently, my dad also reacts very poorly to prednisone.
posted by nobejen at 7:25 PM on October 18, 2014 [1 favorite]

My father recently had a week-long psychotic episode which his doctors thought was probably a reaction to Tramadol (he was also on an SSRI). It was very frightening for all of us and I can see that a brief explanation of medication interaction could seem too pat, but for us it fitted with the circumstances of no previous history of anything like that and ending once he was off Tramadol.
posted by paduasoy at 8:03 AM on October 19, 2014

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