Copyright Ó Blackwell Munksgaard 2004
Ephedra alkaloids and brief relapse inEMDR-treated obsessive compulsivedisorder
Fluvoxamine with no compulsive hand washing and no mooddisturbance.
In his review of the adverse effects of some herbal medicines,
While there is still debate about the mechanism of action of
Ernst (1) draws attention to reports that ma-huang, a herbal
EMDR in post-traumatic stress disorder, the use of eye
preparation containing ephedra alkaloids, has been associated
movements or alternating bilateral auditory stimulation deliv-
with psychiatric and neurological complications. We here
ered through headphones may enhance attentional focus (6) in
report the case of a patient who was effectively treated for
a way which allows accelerated information processing (2). In
severe obsessive compulsive disorder but relapsed briefly
this case, the key component appeared to be a fast processing
following ingestion of herbal products containing ephedra
of anxiety provoked by imaginal exposure to the usual triggers
alkaloids that she bought to facilitate weight loss. The patient
while resisting the urge to obtain relief through compulsive
was a 29-year-old woman with a 10-year history of obsessive
compulsive disorder who was referred for Eye Movement
That reprocessing of the childhood trauma in this case had
Desensitisation and Reprocessing (EMDR) (2) when her
not occurred (an attempt to target it specifically had not
condition had not responded to CBT nor to various medica-
elicited any significant emotional memories) is also suggested
tions including Fluoxetine, Paroxetine, Clomipramine and
by the re-emergence of the presenting clinical picture when the
Amitriptyline. At the time of referral she was taking Fluvox-
patient had a sudden and unexpected increase in anxiety.
Perhaps treatment would have been more conclusive if the
Most distress was occasioned by hand washing: up to 50
memories of the childhood events had been more emotionally
times a day in multiples of 5. There were various triggers, some
charged and therefore more responsive to reprocessing. Nev-
of which related to thoughts about an incident of non-
ertheless, it is of interest that this longstanding treatment-
penetrative sexual molestation when she was a child. Her
resistant obsessive–compulsive disorder responded well to
score on the Dissociative Experiences Scale (3) was low and
EMDR but relapsed briefly with ephedra alkaloids, which
there was nothing in the clinical history to suggest major
are known to stimulate catecholamine release.
dissociative disorder, so after preparation with mindfulness,relaxation and safe place imagery she proceeded to treatment
Unfortunately she felt so much better after two sessions
that she stopped Fluvoxamine completely without a titrated
withdrawal, became depressed, and treatment was delayed
until she was re-established on 100 mg nocte and brighter in
mood. After a further five sessions she was completelysymptom-free despite reduction of Fluvoxamine to 50 mg
Nine months later she reported a relapse into increased
1. Ernst E. Serious psychiatric and neurological adverse effects
anxiety with a partial return to compulsive thoughts and
of herbal medicines – a systematic review. Acta Psychiatr
behaviours after she had obtained a herbal health product sold
2. Shapiro F. Eye movement desensitization and reprocessing.
to promote weight loss. Each capsule contained 200 mg
caffeine, 50 mg capsicum and 3 mg ephedra alkaloids obtained
3. Carlson EB, Putnam FW. An update on the dissociative
from Sida Cordifolia (Therma Pro; Pro Lab Nutrition,
experiences scale. Dissociation 1993;6:16–27.
Bloomfield, CT, USA). According to the manufacturer, Sida
4. Haller CA, Benowitz NL. Adverse cardiovascular and
Cordifolia is essentially similar to but weaker than ma-huang, a
central nervous system events associated with dietary sup-
herbal remedy that has been associated with adverse events
plements containing ephedra alkaloids. N Engl J Med
including death (4) and psychosis (5).
In this patient one capsule had been sufficient to trigger a
5. Doyle H, Kargin M. Herbal stimulant containing ephedrine
partial relapse into hand washing. This cleared with immediate
has also caused psychosis. BMJ 1996;313:756.
cessation of the herbal health product, a temporary increase in
6. Corrigan FM. Mindfulness, dissociation, EMDR and the
Fluvoxamine and a session of hypnosis to reduce baseline
anterior cingulate cortex – a hypothesis. Contemp Hypn
anxiety. Six months later the patient was again well on 50 mg
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Pharmacokinetic Study of Bupropion Hydrochloride Products with Different Release Patt. Page 1 of 3 Pharmacokinetic Study of Bupropion Hydrochloride Products with Different Release Patterns Solicitation Number: 1116087 Agency: Department of Health and Human Services Office: Food and Drug Administration Location: Office of Acquisitions and Grants Services Notice Type: Posted Date:
