Discussions By Condition: I cannot get a diagnosis.


Posted In: I cannot get a diagnosis. 8 Replies
  • Posted By: Christa Bernadette
  • August 2, 2009
  • 07:21 PM

Dr Cottle (or anyone else who can help!),

I noticed that you posted information about "brain shocks" for another member. Please help me figure out what is happening to my mother. She is a very healthy 70 year old. Her doctor doubled her dose of Diovan about 11 days ago because her blood pressure went up. A few days later, she took one of her regular water pills as part of her blood pressure regimen, and went to sleep. She said as she fell asleep, she had a powerful "brain shock" at the top of head. She had three smaller ones each time she drifted to sleep. She went to the emergency room the next day and they could not explain it. The next night, she had the shocks again (she stopped the water pill) and she has had them every night for the past five nights. The worst part is that she cannot sleep afterward because she is so wired, like her brain is hyperactive. She saw a neurologist just this past Friday (an osteopath) and the neurologist had no real explanation. She has no symptoms of seizures. The shocks now are moving all over her body. They only happen when she sleeps.

A couple of weeks ago, she was taking Librax to relax her color (irritable bowel) and Tranxene because she was anxious about a colonoscopy she had about a month ago (she was sure it would show she had cancer, but it was fine). Her doctor took her off those abruptly last week because he thought it was causing her nausea. Could this be drug withdrawal? Or is it the Diovan? She suffers from anxiety, but now she is worse than ever. No appetite, no sleep, shocks to the brain, constipation, depression setting in. I am sorry this is so long but I am praying you will have an answer. Thank you.

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8 Replies:

  • Okay, the symptoms described sound like withdrawal and if she was taking either the librax, tranxene or both medications for a period longer than about 4 weeks, then it's likely contributing to her symptoms. Although tranxene is considered to be in the long-acting class of benzodiazapines, withdrawal can still occur with abrupt cessation. The problem in your mother's case may well be the synergism with a component of the librax called chlordiazepoxide, also a benzodiazapine. It is not a good idea to abruptly cease use of any of the benzodiazapines if they've been used regularly for more than 2 weeks. This is particularly the case with elderly patients, who common respond poorly to cessation from both short and long-acting variants in this class of drug. Diovan is an angiotensin II inhibitor and it can cause anxiety and insomnia in some patients. In the presence of benzodiazapine cessation, this may be demonstrating a compound effect. The typical approach to cessation of extended benzodiazepine use is the administration of buspirone along with the long-term benzodiazepines already being taken and then gradually reduce the the long-term medications by about 25% per week to termination of the drugs altogether. This would, however, be a decision strictly to be made by her doctor. The second issue is whether a more conventional anti-hypertensive may be more appropriate under the circumstances until the benzodiazepine issue has been resolved. The "shock" sensations are common in certain medications which act on the central nervous system, particularly those that influence serotonin regulation or other neurotransmitter activity. Although not harmful, the sensations are quite dramatic in some instances. Because of her age, her doctors simply need to re-evaluate her sensitivity to withdrawal potential and determine whether the present course is most appropriate. She does not need to be taking either the librax or the tranxene and my suggestion is to not try and reconstitute them unless the withdrawal is producing seizure-like activity. The use of an antihypertensive with less side-effect potential for anxiety and insomnia might also prove beneficial. Again, however, these are clinical decisions that must rest with her doctors. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • Dear Dr Cottle,I cannot tell you how much I appreciate your insights. You have my deepest and most sincere gratitude. For the first time, I feel like someone truly understands what my mother is going through.Also, could you recommend a good neurologist in Orange County, California? I wish you were still practicing, at that you were here!A final question: her neurologist put her on a single milligram of Lunesta at night. Another one (the er doc) gave her a single mill of Ativan to calm her down yesterday. What do you think of those two meds?Again, THANK YOU! Your response is such a gift!
    Anonymous 42,789 Replies Flag this Response
  • Dr. Cottle,Oh, I cannot tell you how much you have helped! For the first time, someone understands what is happening to my mother. Thank you so much. You have our deepest and most sincere appreciation.Please allow us a few more questions:Do you have a neurologist you would recommend in Orange County, CA?Do you agree that my mother should take Lunesta at bedtime (one mg)?Do you think it is ok for her to take Ativan (one mg) to calm nerves?Finally, what blood pressure med should replace the Diovan?Again, I do not mean to bombard you, but we are spinning our wheels over here. We saw four docs last week and none of them could give us the kind of answers you did. I know my mother's own doctors will make the final decisions, but we would so appreciate your input.THANK YOU, THANK YOU!:)
    Christa Bernadette 8 Replies Flag this Response
  • Well, I'm afraid that I can't refer you to anyone in Orange County. Jeffrey Cummings is an outstanding neurologist, but his specialty is more directed toward neurodegenerative diseases such as Alzheimer's. Regardless, I'm of the opinion that neurology may not be the most suitable specialist since her tests do not reveal the presence of any type of cerebrovascular event. Other than her labile hypertension, I'm naturally unaware of any other risk factors which would warrant following by a neurologist. As for her hypertensive episodes, it is rare that monotherapy is sufficient or deemed most appropriate in the elderly patient. If she is experiencing rather dramatic spikes in her blood pressure that occur during elevated anxiety or stress, then it can sometimes be difficult to obtain a ceiling. A calcium channel blocker such as cardizem or verapamil works very well to gain quick control over hypertensive episodes. They can be combined with a smaller dose of beta blockers like atenolol, which also have a mild anxiolytic effect that can reduce her anxiety while helping to control the hypertension. This kind of therapy is best directed by internal medicine or geriatric medicine. You should seek one specialist and stick with them to make certain that dosing and any side-effects are being addressed through close monitoring and to avoid polypharmacy. If you haven't already done so, you should purchase a sphygmomanometer so that blood pressure can be measured twice daily. It should be monitored at the same intervals each day and after she has sat calmly for about 20 minutes or so. A record should be maintained and presented to her doctor for evaluation, together with any complaints of orthostatic hypotension (dizziness when standing or rising quickly from a seated or lying position) or other unfamiliar effects. The ativan won't necessarily make matters worse, but it's questionable whether adding the Lunesta in the midst of trying to determine the nature of her symptoms would be advisable. You don't make mention of how long she had been taking both the Librax and Tranxene, but any abrupt cessation can potentially cause a rebound effect or withdrawal in a patient her age. Also, since the Diovan can cause anxiety and insomnia, change in her antihypertensive therapy may produce the desired result, or at least a potential reduction in symptoms in that regard. I naturally don't have the value of direct evaluation or past medical history to base my comments, but her anxiety seems to be somewhat health-related and I wonder whether any significant event has occurred, ie death in the family, loss of spouse or close friend may have precipitated or exacerbated her anxiety. Also realize that as much as 50% of geriatric patients demonstrate some form of mild clinical depression and this should be investigated to determine its presence and potential role with respect to symptoms or complaints. Of greatest importance here is to make certain that any decisions regarding her medications be made by a single specialist and maintain close monitoring of her blood pressure throughout any changes in antihypertensive therapy to help guide your doctor's decisions. She'll be fine. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • Dear Dr. Cottle,Well, today is my mom's 70th birthday, and she told me she did not have any brain shocks last night! What a gift! And she slept well! She chose not to take the Lunesta, so that may have helped. Also, the reassurance from your answer calmed her down and had a huge impact on her stress level. I am so grateful for your generosity and expertise.Regarding her blood pressure, the doctor has reduced the Diovan to 80 mg at night and two 80 mg pills in the morning. She goes into her doctor's office to have her bp checked three times a week (since it spiked up about three weeks ago); I conveyed to her that she needs to measure it at home, as you advised.Last week, in the midst of all these shock episodes, her doc took her off the Diovan (this past Friday) and put her on Metaprolol only. She just took one dose that Friday night with no Diovan, and that was it. What a mess! It made her feel awful, so she does not want to take it again. Perhaps, as you suggest, she would benefit from taking it in conjunction with the Diovan?Would you suggest she be in the care of a cardiologist? Her internist is a wonderful man, but he is a pulmonologist. My mother has absolutely no lung issues; she chose him for his reputation.Along with Lunesta, her neurolgist prescribed her a "brain vitamin" (forgive me for not knowing the name) and that seems to be helping her. As I said, she is so depleted from not eating well for about a month now.Your suspicion about a major stressor in her life is right on. Without getting into details, she was given some very sad and disturbing information about three weeks ago. That is when her lack of appetite, weakness, etc began and she began to sleep a lot during the day. Anyway, please know that you have made a huge difference in our lives. How wonderful that you serve people in this way! Truly, you are a God-send.With deepest gratitude,Christa
    Christa Bernadette 8 Replies Flag this Response
  • Well, I'm of the impression that a wait-n-see approach might prove most accurate. She's been though some rather dramatic responses to the various medications and it's critical to realize that intense anxiety can produce physical symptoms. Consequently, a good deal of confusion and misperception can take place relative to whether the medications, the anxiety or both are demonstrating influence. I doubt that the single dose of the beta blocker produced any ill effects and the rather dynamic nature of physical symptoms associated with stress and anxiety can cause a patient to quickly adopt a cause and effect rationale. In other words, she felt bad after taking the medicine, therefore the medicine is the cause. Once she can begin to assimilate and deal with the news or event which likely set most of her trouble in motion, her symptoms with abate for the most part. It's important for her to know that she's going to be alright and that getting past the repercussions of emotional trauma will go a long way to preserve her general health. Although the pulmonologist is not the most appropriate choice for her condition, you may do well to continue under their care for now and let some stability help smooth things over. Her medications should be adjusted based upon a broader time span and not from a purely symptomatic standpoint. She'll likely experience some good days and bad for the next few weeks, but in general her condition will likely improve to the extent she feels more normal again. Some attention to her diet and monitoring of her general emotional health will help achieve a less dramatic change in symptoms and she should not be permitted to spend idle time, during which ruminations about the emotional upset can produce a rekindling of symptoms to some extent. I think she's going to be just fine and again, I would suggest taking it slowly with any changes in medication at this point. Let me know how she progresses in the coming days and weeks. Best regards, J Cottle, MD
    JCottleMD 580 Replies Flag this Response
  • Well, I just got off the phone with my mom, and she has that "bounce" back in her voice. She's back! She sounds like her old self. She could not fall asleep last night, despite the fact that the brain shocks are gone. So in desperation, she took half of a Lunesta. She said the twitches in her arms and legs came back, so she flushed the pills down the toilet this morning!She made an appointment with a counselor for Monday. She is realizing that she must refer the people in her life who come to her with their problems to a professional, as well. (She is a great listener, but she can only take so much!) She is going to take a walk today. She sees her doc tomorrow, but will not make any changes, as you advised.In other words, she is on her way!!!!THANK YOU FOR YOUR WISDOM AND GUIDANCE!Christa
    Christa Bernadette 8 Replies Flag this Response
  • Dr. Cottle,Good morning. Just thought I would give you an update. My mom had an eeg a couple of days ago which came back normal. She saw a cardiologist yesterday who said none of her symptoms were heart-related. He reduced her Diovan back down to 80 mg in am and 80 in the pm (her old routine) because he said with Diovan, you reach a plateau where additional doses do not have an impact anymore. Her bp yesterday was 168/80 (this after 160 mg of Diovan) at the doc's office, so obviously, he was right. He put her on another med once in the morn (I do not have the name) but he said it had minimal side effects.Although he did not come out and say it, he seemed to give me a "look" when I mentioned she might be depressed (as if to say, he agreed). She had a really bad night a couple of nights ago when she twitched from 8:30 until 2:30. She was a disaster the next day. Yet, the very next night, NO twitches. She slept well. She has a constant state of intense fear in her gut and her hands still tremble a lot. My goodness, stress is a monster. She sees a psychologist next week who will confer with her neurologist regarding the appropriate med to pull her out of this.Thank you again for your interest and concern!Christa
    Christa Bernadette 8 Replies Flag this Response
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