Open Journal of Psychiatry, 2011, 1, 75-78 OJPsych
doi:10.4236/ojpsych.2011.13011 Published Online October 2011 (
Published Online October 2011 in SciRes.
Influence of paroxetine and cognitive/behavioral strategies in
neurocardiogenic syncope and depression: a case report
Reg Arthur Williams1*, Juan F. Lopez2
1School of Nursing and Psychiatry, Medical School, University of Michigan, Ann Arbor, USA;
2Psychiatry, Medical School, University of Michigan, Ann Arbor, USA.
Email: *
Received 21 June 2011; revised 15 July 2011; accepted 24 July 2011.
Objective: Neurocardiogenic syncope (NCS) is a con-
dition where the patient has a temporary loss of con-
sciousness or feelings of weakness and fatigue. There
are triggers such as prolonged sitting or standing,
pain, and heavy exercise, but often episodes are ran-
dom. Treatments are limited and the use of specific
serotonin reuptake inhibitors (SSRI) have had mixed
results, but a limited number of studies have sug-
gested that paroxetine may be effective in improving
the symptoms of NCS. Methods: This is a single case
report of a 20 year old female who was diagnosed with
NCS by a tilt test and treated conservatively with in-
creased fluid and salt intake, and counter-pressure
maneuvers. She was given one dose of sertraline, but
immediately experienced disturbing visual images.
She presented at the Depression Center with moder-
ate depressive symptoms and was started on par-
oxetine and given cognitive/behavioral strategies to
manage the NCS. Results: Since the patient had a
negative experience with a prior SSRI, she was
started on a low dose of paroxetine and omega-3 fatty
acids. She also was given a detailed explanation of
NCS and a number of cognitive/behavioral strategies
such as deep breathing, progressive relaxation, im-
agery, and sleep. Conclusion: After 2 weeks of the
multi-faceted treatment approach, she had a signifi-
cant decrease in her depressive symptoms. After 6
months, the patient had no episodes of syncope and
no depressive symptoms. She was able to stand for
long periods and exercise without feelings of weak-
ness and fatigue. A multimodal approach may offer
the best treatment strategy to achieve full remission
in patients with NCS.
Keywords: Neurocardiogenic; Paroxetine; Depression;
Cognitive/Behavioral; Syncope; Case Report
Neurocardiogenic syncope (NCS) is a condition often
associated with a temporary loss of consciousness or
feeling of weakness and fatigue. There is an abrupt drop
in arterial blood pressure and followed rapidly with bra-
dycardia. Often vasovagal syncope (VS) and neurally
mediated syncope are terms used interchangeably with
NCS [1,2]. The incident of NCS has been estimated to
range from 1.3 to 2.7 events per thousand of the popula-
tion [3,4]. Common symptoms associated with NCS,
which usually occur while standing, include fatigue,
weakness, nausea, perspiring, pallor, visual disturbances,
abdominal discomfort, headache, tingling, lightheaded-
ness or vertigo [5]. It is usually triggered by prolonged
sitting or standing, pain, sight of blood or medical pro-
cedures, heavy exercise, and rising or chang ing positions
abruptly [6]. From episode to episode the symptoms will
vary and can be estimated by a simple risk score [7]. The
hypotension is thought to be caused by a reduction in
peripheral sympathetic neural outflow, which leads to
venous pooling and vasodepression. Yet, the exact centr-
al neurophysiology is not known [8]. The majority of
cases of syncope in young people are not typically asso -
ciated with risk of mortality [9], bu t physical and psych-
osocial function can be seriously impaired in patients
suffering from recurrent syncope [10].
A number of treatments have been proposed for NCS
[e.g., 1,2], but only one focused review of therapies with
structured recommendations was found. Most patients
can be managed conservatively and the recommended
treatments included liberalized fluid and salt intake, pa-
tients being taught counter-pressure maneuvers and Mi-
dodrine to manage hypotension. Beta blockers, specific
serotonin reuptake inhibitors (SSRI), fludrocortisones,
and pacemakers have had mixed results, and were there-
fore discourag ed f o r use [8].
Specifically for SSRI treatment, there were only two
R. A. W illiams et al. / Open Journal of Psychiatry 1 (2011) 75-78
randomized double-bind placebo-controlled study found
using paroxetine in 68 patients (mean age 44.7, SD =
16.5) with recurrent syncope and positive head-up tilt
test [11] and 41 young patients (aged less than 30 years
old) with recurrent syncope [12]. The conclusion in both
studies was that paroxetine significantly improved sym-
ptoms of patients with vasovagal syncope not respond-
ing well with more traditional medications and treat-
ments. Of note, although paroxetine treatment was sig-
nificantly superior to placebo, more than one-third of
patients remained symptomatic. Another randomized,
placebo-controlled study using fluoxetine, propranolol,
and placebo showed no differences between treatment
groups [13], therefore, it is possible that not all SSRI are
effective in treating recurrent vasovagal syncope. Addi-
tionally others have argued for the importance of ad-
dressing the psychological distress in these patients [14,
15]. The purpose of this paper is to present a case of a
young woman who was treated with a combination of
paroxetine and cognitiv e/behavioral strategies to address
her recurr ent NCS symptoms.
Case Report
While the patient was in high school at the age of 17 she
developed feelings of malaise, what she thought was
fever and chills, but was not febrile. She had periods of
feelings of weakness and fatigue, experienced diaphore-
sis, diminished appetite, oversleeping, and hypotension.
During high school, she had one period of syncope for
approximately one minute that occurred after a band
practice. Since that time she had not experienced true
syncope, but rather ataxia, nausea, extreme fatigue, and
vertigo where she would need to lie on the ground to
stop the vertigo. She also was placed on Ethinyl Estra-
diol and Norgestimate (Ortho Tri-Cyclen) for dysmen-
The syncope symptoms continued and she was seen
by an internist. At one point her symptoms were sugges-
tive of malaria since she ha d been in Honduras and upon
returning had developed uticaria, which later was deter-
mined to be eczema. Blood results ruled out malaria,
mononucleosis, West Nile virus, and Lyme disease. She
then was tested for demyelinating disease by an MRI
brain scan, which provided evidence of a normal brain
MRI, without and with contrast. She further was tested
with a two-dimensional transthoracic echocardiogram
(ECG) with M-mode and color flow Doppler. The results
were deemed normal. The diagnosis of NCS was sug-
gested when a tilt test was performed where her resting
heart rate and blood pressure were normal. Her health
record indicated, “She was maintained in an 80-degree
upright tilt position and within 15 minutes, she devel-
oped sinus tachycardia with a sudden loss of palpable
blood pressure with near syncope.” She was then re-
turned to a supine position where her abnormal vital
signs resolved.
The patient was treated conservatively and was en-
couraged to increase her salt intake, use counter-pressure
measures, and rest when she experienced fatigue and
dizziness. According to her health record, she was s tarted
on metoprolol 25 mg. a beta-blocker with mixed results
in several studies (8). However, her response was blood
pressure of 98/50 and pulse 64, so the treating physician
was reluctant to increase the dosage due to the border-
line blood pressure and heart rate. The beta-blocker was
discontinued since there was not a significant decrease
of her syncope symptoms. Because of her history of de-
pressive symptoms she was started on 14.5 mg. of ser-
traline to increase to 25 mg., however immediately after
taking one dosage of sertraline she had a serious episode
with extreme fatigue, near syncope and disturbing visual
images so the treating physician was reluctant to have
her continue with the medication. Because of her history
of depression and treatment strategies had not decreased
the number of episodes; the patient, at age 20, was re-
ferred to the Depression Center at University of Michi-
gan by her sister, a nurse practitioner.
In her evaluation, she reported that she first experi-
enced depressive symptoms at the age of 14, but while in
her junior year of high school (age of 17) she had de-
pressive symptoms including depressed mood, feelings
of fatigue, trouble concentrating, insomnia, feelings of
worthlessness, overeating, but not gaining weight, and
thoughts of suicide. She had approximately a week of
feeling suicidal and had developed a plan for suicide by
causing a car accident. She had made a specific plan, but
a friend called her and ask ed her how she was doing. At
that moment she realized she did not want to die. The
symptoms diminished and she did not seek treatment nor
diagnosed with depression at the time. At evaluation, she
described her symptoms of depression as mild depressed
mood, anhedonia, loss of appetite, trouble concentrating,
feeling restless, moderate insomnia, and lack of energy.
She denied suicidal ideations. She scored 10 on the Pa-
tient Health Questionnaire (PHQ-9) indicating moderate
depression, and 19 on the clinician administered Hamil-
ton Rating Scale for Depression (HAM-D). She met cri-
teria for a diagnosis of Major Depressive Disorder
(MDD). Moreover, she scored 11 on the Sleep Assess-
ment Questionnaire (SAQ), indicating a potential sleep
problem. Her score on the Penn State Worry Question-
naire (PSWQ) was 33, indicating likely sub-clinical
Most concerning was her description of vivid visual
images where her heart would pound, feelings of panic,
and where she described the images as “hallucinations.”
Copyright © 2011 SciRes. OJPsych
R. A. W illiams et al. / Open Journal of Psychiatry 1 (2011) 75-78 77
She became tearful as she described that these visual
images could occur 3 or 4 times a week and could last up
to 20 minutes but often shorter, where she would vi-
sualize “dead babies” and see “killing” herself. She
noted that after these episodes it would often take her a
week or more to recover since she experienced a depre-
ssed mood, anhedonia, and extreme fatigue. Since her
depression in high school she also described experiences
where she “wanted to crawl in small spaces.” As exam-
ples, she sat in a closet or under a desk. This was espe-
cially noteworthy in her junior year at high school where
she was entering the closet or under the desk about 2 or
3 times a week. During college she would get the feeling,
but acted on it only a few times.
Because of the possibility that the previous SSRI might
have triggered the disturbing visual images, the patient
was provided scientific evidence [11,12] that paroxetine
was promising as an effective treatment for depression in
NCS. The theoretical mechanism of how paroxetine
would work in her brain was explained with a drawing
and the typical side effects of the medication also were
presented. Since the patient appeared to be sensitive to
medications, she was started at only 5 mg. of paroxetine
each day in the morning. Also, she was recommended to
start 2000 mg. of omega-3 fatty acid based on the evi-
dence it can also help to boost mood and vagal tone [16].
She was recommended to purchase omega-3 that con-
tained 1000 mg. of eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), where EPA is considerd to
be the ingred ient with the most therapeutic effect.
She was educated about the physiology of NCS in lay
terms. After several days after starting treatment, she
was called at home to check if she had any side effects
or any disturbing images. She only experienced a slight
headache and nausea for a day from the paroxetine. After
one week, her PHQ-9 score decreased to 8 indicating
mild depressive symptoms, which was lower than her
initial evaluation. Attributable to a slight decrease in
depressive symptoms was the several cognitive/behav-
ioral strategies she was given. She noted that when she
would experience fatigue she had a tendency to get in-
creasingly concerned that another episode would occur.
She was taught thought-stopping and thought-substitu-
tion. We identified an experience that gave her “nothing
but warm feelings” and she identified the experience as
the moment when her fiancé asked her to marry him.
Therefore, during the first week of treatment, if she ex-
perienced fatigue or weakness, she used this imagery
strategy reporting that it was helpful.
Since the patient had minimal side-effects from par-
oxetine her dosage was increased to 10 mg. In the ses-
sion she identified a pattern that she noticed when she
drove from her college to see her fiancé (approximately
a 3-hour drive). She would tense grip the steering wheel
and would experience fatigue and weakness after the
drive. She was taught deep-breathing by taking a deep
breath and letting it out over a 10-second period and
progressive relaxation by tensing a muscle group and
relax it over a 10-second period. Since she had to hold
the steering wheel, she was instructed to relax one arm
and hand at a time and shake out the tension about every
15 minutes while driving. She also was encouraged to
use progressive relaxation when she occasionally would
experience early insomnia. At the next session a week
later, she reported that these strategies were helpful and
her PHQ-9 score was reduced to 4 indicating minimal
depressive symptoms. She also noted that the treatment
had helped with her dysmenorrhea symptoms.
After six-months from initial treatment the patient had
no syncope and depressive symptoms. Most indicative of
her progress was that several weeks before her appoint-
ment she was the Maiden-of-Honor for her sister’s wed-
ding. Her family was concerned that she would not be
able to stand through the entire ceremony. She reported
that she had no periods of weakness or vertigo and da n c e d
late into the evening. Her fiancé also reported that she
was able to play a full set of tennis where before she
would need to take breaks to play.
There is limited evidence as to the most effective treat-
ments for NCS. Some conservative strategies have been
suggested [1,2,5,8], but only one research team provided
randomized controlled studies [11,12] suggesting par-
oxetine as an effective treatment for at least some pa-
tients with NCS. Yet, another randomized control study
using fluoxetine did not demonstrate effectiveness [13].
This conflicting evidence led some researchers [8] to
conclude that SSRIs are not effective in treating NCS.
Also, one study found that paroxetine did not prevent the
presyncope associated with lower body negative pres-
sure in healthy volunteers [17]. These mixed results may
suggest that SSRIs are not effective in individuals with
NCS, yet the specific use of paroxetine with patients
having NCS and depression may be more effective than
treating patients with other SSRIs.
There is evidence that co-morbid mood disorders are
present in a significant proportion of patients with syn-
cope [18]. Studies have shown that a combination of
antidepressants and psychotherapy are more effective at
achieving remission in chronic depression that either
treatment alone [e.g., 19]. In this case report a multi-
faceted approach was used to address the NCS and de-
pressive symptoms. Using paroxetine in conjunction
with omega-3 fatty acids, counter-pressure techniques,
and cognitive/behavioral strategies to address the distre-
opyright © 2011 SciRes. OJPsych
R. A. W illiams et al. / Open Journal of Psychiatry 1 (2011) 75-78
Copyright © 2011 SciRes. OJPsych
ssing events [14,15] was ultimately successful. The use
of progressive relaxation, imagery, sleep strategies, and
exercise helped with the life altering experience. Prior to
treatment, the patient often experienced fatigue, weak-
ness, vertigo, disturbing images, and depressed mood.
Now, the patient is able to take part in normal and pro-
ductive activities and not have concern about NCS and
the concomitant symptoms. This report suggests that a
combination treatment may be most effective to ach-
ieve remission in patients suffering from NCS, particu-
larly in the context of depressive symptoms, and that
these strategies should be evaluated in future random-
ized clinical trials.
This article was made available as Open Access with the support of the
University of Michigan COPE Fund,
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