SUBJECTIVE VERTIGO IN A
66-YEARS-OLD MAN AND ITS DISAPPEARANCE FOLLOWING AN ANTIDEPRESSANT-ANTISTRESS
DRUG THERAPY.
Renato COCCHI, a neurologist and a medical
psychologist.
Summary.
A man of 66 years was suffering since two
months from subjective vertigo by unknown cause, without any cerebellar
involvement. The stress symptom presence and a masked depression led to the
prescription of an antidepressant-antistress drug therapy ( low dosing of
amitriptyline, oxazepam, glutamine and pyridoxine). The vertigo disappeared
after three months, within a frame of a general improvement.
The author suggests that the subjective
vertigo could be a not specific symptom of stress reaction.
Key words: Subjective vertigo, aspecific
symptom, cerebellum, stress, depression, drug therapy, amitriptyline, oxazepam,
glutamine, pyridoxine.
Others
Drug modulation of stress reactions
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He arrived to consultation an elderly person
that had subjective vertigo lasting over two months. This patient got
antidepressant-antistress drug therapy for three months. He was taking a
therapy against blood hypertension with furosemide, a drug knows as one
possible cause of objective vertigo. The furosemide did not stop, at least till
now, but the patient had advice about the risk of the onset of objective
vertigo, and he continued the therapy I prescribed. I wanted to report his case
history because it leads to some considerations on an elusive and fleeing
symptom as subjective vertigo is.
Short information on the
subjective vertigo.
Vertigo is not an illness, but a symptom,
and it refers to a trouble of the equilibrium (Balance) as feeling of
environmental rotation (as objective vertigo) or of disbandment or of partial
whirling movement of the body (as subjective vertigo). Some clinicians term
even vertigo, but I think not always properly, as regard to feelings of
dizziness, lightheadedness, faintness, and unsteadiness.
The subjective vertigo has deceitful onset
and reduced intensity, continuous or partially continuous lasting, usually
without neurovegetative symptoms, without hearing troubles, but with possible
neurologic signs as creditable to the causal brain illness, if there is one.
It can be the result of a primary trouble of
the central vestibular system, that is to say vestibular nerve, brainstem,
cerebellum, as brain areas involved in the control of the coordination, of the
equilibrium, of the movement, of the blood tension and of the conscience. There
are central vestibular troubles often secondary to other affections, which can
cause subjective vertigo. They were found during:
- illnesses of the central nervous system,
as stroke or hemorrhage;
- tumors of the central vestibular system,
in particular the acoustic neurinoma;
- migraine, where 30-50% persons suffer even
suffer vertigo;
- multiple sclerosis, with the demyelinization
of the brainstem or of the cerebellum;
- heart rhythm alterations with bradycardia
or tachycardia;
- orthostatic hypotension, in diabetics, in
dehydration and in anaemia;
- systemic illnesses of the kidneys or
thyroid.
In several subjects the cause of the
subjective vertigo is fully unknown.
It can be the result of a primary trouble of
the central vestibular system, which is to say the vestibular nerve, the
brainstem, the cerebellum. These are brain areas involved in the control of the
coordination, of the equilibrium, of the movement, of the blood tension and of
the conscience. There are central vestibular troubles often secondary to other
affections, which can cause subjective vertigo. They were found during:
- Illnesses of the central nervous system,
as stroke or haemorrhage;
- Tumours of the central vestibular system,
in particular the acoustic neurinoma;
- Migraine, where 30-50% persons suffer even
suffer vertigo;
- Multiple sclerosis, with the
demyelinization of the brainstem or of the cerebellum;
- heart rhythm alterations with bradycardia
or tachycardia;
- Orthostatic hypotension, in diabetics, in
dehydration and in anaemia;
- Systemic illnesses of the kidneys or
thyroid.
In several subjects the cause of the
subjective vertigo is fully unknown.
The case history.
Male of 66 years at first consultation,
married, with adult sons, he works in the commerce.
Second ten days of September 2004: He came
here complaining of subjective vertigo since at least two months, irritability
("nervousness") and memory loss. No faintness feelings occurred.
The objective neurologic examination did not
signal any alteration, no troubles of the cerebellar function, walking went in
a normal way.
He denied systemic illnesses, but essential
blood tension, for which he takes 25mg furosemide, a tablet every day. BT
90-130 mm, with 71 pulsations per minute.
He is sleeping discreetly and dreams much,
doesn't talk in his sleep, and rarely has drooling while sleeping. A daughter
left her husband, and this is disturbing him. He does not believe to have any
depression, but he is better when he is doing something. His head is with many
thoughts, but this not gives him any bother. He bears badly the noise and the
confusion. He is indifferent to warm and cool.
At the morning he is hunger at once. He
inclines to eat sweet things, without any preference, and he tastes the meat
broth, but he does not eat milk.
Now he does not suffer from headache, but he
had it in past. His bowel function runs normally. There are not dyslalias but,
but sometimes he has difficulty in finding find the right word. He has sudden
asthenias, for no reason.
Rarely he has tachycardia, some times air
hunger, no feelings of mediastinal oppression, no lunp in the the throat. Often
he feels a riffle rasps in throat. His hair is fat. Some times he has some
difficulty to maintain the erection.
Trial drug therapy (daily doses, by the oral
via): Amitriptyline 6mg; Glutamine 125mg; 5-Hydroxitriptophan 50mg; pyridoxine
75mg; oxazepam 7.5mg.
Second ten days of October 2004, the first
checkup after 35 days of drug therapy.
He is doing better, and now he is more calm.
At the beginning of the therapy he had some nausea. The vertigo nearly missed.
The memory deficit yet persists, but he remembers some more. His penis erection
improved. His head is always full of thoughts, but he stood more both the noise
and the confusion. He doesn't know if he had more facility in finding the right
words, because he did not pay attention to that. Sudden asthenias disappeared.
Perhaps even the riffle rasps in the throat decreased. He is going out more for
his work. His sleeping improved and he stopped the need to sleep in the
afternoon.
No variation of the drug therapy.
Second ten days of December 2004, the second
checkup after 97 days from the beginning of the drug therapy.
Now, he is better. The vertigo is missing.
At home he is not more irritable, but he is yet a little more in the office.
Lately, he had an episode of rising of the blood tension. His memory seems
improved and he does less difficulty in finding the right words. His head is
less crowded of thoughts. He is always a little spiteful. He did not the need
of sleeping in the afternoon, and at night he sleeps well. Before this therapy
he was waking 2-3 times every night to urinate (nocturia), while now he goes to
the bathroom only in the morning. No more sudden asthenias appeared. The air
hunger and the riffle rasps in the throat went down very much. He doesn't go
out of his house more than in past, but for his work. His sexual life did not
change.
Therapeutic variation (daily doses, by the
oral via): Amitriptyline 8mg; oxazepam 15mg.
Discussion.
First, the vertigo is missing, he is less
irritable (less "nervous") and his memory improved. They were the three
reasons for which he came to the consultation. As a positive side-effect, the
nocturia missed, and this is the eighth case to be added to the other seven
specifically reported previously ( Cocchi, 2004 ). Here too the
antidepressant-antistress therapy reached a similar improvement within three
months.
In spite of the patient's deny, there was a
depressive base, probably due to the age. Moreover, a reactive share of it was
linked to the conjugal circumstances of the daughter, which he expressed with
irritability and a tendency to social isolation.
The trouble of the erection recommended
being cautious with the tricyclic antidepressant, used in very low dosing. Even
so, in a polytherapy with a synergistic action, acting on glutamate and GABA,
it has worked.
It is not clear if the brain condition of
glutamate and GABA were: 1. In deficit prevalence on the type A GABAergic
receptors that so lowers type A GABAergic inhibition; 2. Or, at least for some
brain areas, even an increase of type B GABAergic inhibition and retroactive
increasing of the glutamate.
There are two elements that address to the
first hypothesis.
In fact, there were two compensatory
symptoms suggesting the need to increase the synthesis of both these
neurotransmitters. The increased food introduction of sweet things to an
increased glucose destination on the Krebs' cycle, is one of two away for
increasing the glutamate synthesis, then of the GABA, its derivative.
The other was pointed out by the sudden
asthenias, as large request of brain glutamine, the other glutamate and GABA
precursor, produced in a hurry in the muscle to expenses of the APT.
In favour of the second hypothesis there is
only the thought overcrowding, besides controlled by this man. Is it a symptom
of located glutamergic hyperfunction?
However, we could even interpret it as a
compensatory reaction to a glutamergic deficit, and this could explain the no
lack of control of this trouble, in the excess of thoughts too.
Against this second hypothesis there are: 1.
Rarely the patient has drooling while he sleeps; 2. He is indifferent to warm
and cool; 3. In the morning he is hungry at once; 4. He tastes the meat broth,
which is a hydrolysed matter with glutamine and glutamic acid; 4. He had fat
hair (A peripheral deficit of pyridoxine, drained to supply an increased brain
need?) As pyridoxal-phosphate the pyridoxine is the cofactor of at least 60
brain reactions. Among them it is the cofactor of all decarboxylases,
inclusive, obviously, the glutamic acid decarboxylase (GAD) for helping its
transformation into GABA.
They could even reach this group the memory
deficit and the difficulty of the lexical choice that both improved with the
current therapy ( The criterion ex-juvantibus ).
The involvement of the inverse
GABA-glutamate pathway is expression of stress. Here its alteration seems be
limited to the deficit of type A GABAergic inhibition for poor GABA synthesis.
Antistress drugs are glutamine, pyridoxine
and oxazepam, this last such as all the benzodiazepines. (For stress and the
antistress drug therapy, see Cocchi, 1999).
Now, we need to come back to the subjective
vertigo.
We have to remember that it is an aspecific
symptom, not always correlated to known morbid causes. In this patient there
are no fainting feelings, expressly denied, and not necessarily subjective
vertigo.
By lacking the presence of cerebellar
objective symptoms in the neurologic examination, it appears that, in this
patient, we can exclude the cerebellum as an involving morbid structure, for
which vestibular nerve and brainstem rest.
There were not known morbid causes in the
case history but there were surely depression and stress, even if not heavy
ones.
For what I advised the patient of taking
care because the furosemide can be a risk factor of the development of
objective vertigo, in fact I was unable to find literature that confirms a way
in this direction from subjective vertigo. I do not believe however that this
is impossible.
The vertigo is missing following an
antidepressant-antistress drug therapy, then, always ex-juvantibus, we may
presume to have some relationship with stress, which shows itself always and
only with aspecific symptoms of reaction of the body.
Of course, this is a hypothesis that needs
substantial verifications and confirmations.
Conclusions.
In a man of 66 years suffering since two
months of subjective vertigo from unknown origin, the presence of stress
symptoms and masked depression drew to the prescription of a low-dosing
antidepressant-antistress drug therapy, with disappearance of the vertigo after
three months in the frame of a general improvement.
It suggests that the subjective vertigo
could be an aspecific symptom of stress reaction.
References.
Cocchi R. The nocturia ( or nycturia ) in elderly persons without peripheral urinary problems can be reduced or abolished with an antistress drug therapy? Preliminary report on 7 cases treated with antidepressant-antistress drugs. 2004 <www.stress-cocchi.net/Other15.htm>
Cocchi R. Drug therapy of bruxism as
modulation of stress answers. It. J. Intellect. Impair. 1999, 12: 17-21. <www.stress-cocchi.net/Drugs3-it.htm>
Posted
on Internet on 21 January 2005. Copyright by Renato Cocchi, 2005.
Author's
address: Dr Renato COCCHI, via Rabbeno, 3
42100
Reggio Emilia
renatococchi@libero.it
Others
Drug modulation of stress reactions
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