Fluoxetine
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Increased impulsitivity as a paradoxical reaction: case report An approximately 17-year-old girl developed increased impulsitivity as a paradoxical reaction during treatment with fluoxetine for misophonia. The girl had a history of sickle cell trait and had been treated for chronic urticaria. She underwent a surgery for paraumbilical hernia during her infancy and correction for squint (Ectropion) during her early childhood. She was diagnosed with misophonia in December 2015 at the age of 15 years. She attended psychotherapy sessions for only one month. She did not follow-up for a year and in December 2016, she revisited the clinic due to marked deterioration of her condition. At that time, she was experiencing anticipatory anxiety about people eating habits and became more isolated than before. Her social interactions were limited with her family, and she was poorly adherent to her management plan. After another seven months of unattended sessions, she presented in June 2017 (at the age of 17 years) with two weeks of untreated suicidal thoughts and depressive episode of four months. She attended two psychotherapy sessions during one month. In July 2017, she took extra pills of unspecified OTC drugs as an act of "suicide". Later, she was treated at a local hospital. She was initiated on escitalopram and continued for six weeks. Mirtazapine was added for one week, and stopped due to increase in weight. An improvement was noted in her symptoms. Her weight continued to increase, and she developed atypical bulimia nervosa characterised by several attempts to self-induce vomiting, which was limited and specific during the treatment duration. It lasted for three months and was aggravated by her obsessional concerns about the weight gains. She attended eight unstructured psychotherapy sessions. Despite the sings of resolution, escitalopram was stopped due to the concerns of the weight gain and an alternative SSRI, fluoxetine 20 mg/day was prescribed in October 2017 [route not stated]. During the subsequent visits, the misophonia and depressive symptoms were persistent. She had lost motivation in daily activities. The dose of fluoxetine was increased to 40mg daily. Bupropion 150mg daily was added to her therapy to improve her motivation. At that time, she was under severe stress from multiple arguments with her parents about her adolescent lifestyle. In December 2017, she attempted suicide for the second time by taking around 30 tablets of bupropion at an overdose. While she was hospitalised and managed medically, she convinced her father for discharge her against medical advice. It was considered that, fluoxetine might have increased her impulsivity. Her second suicide attempt was aggravated by fluoxetine paradoxical side effect, which acted as an emotionregulation behaviour for her misophonia [duration of treatment to reaction onset not stated]. After the second suicide attempt, analysis of her misophonia symptoms using Amsterdam Misophonia Scale (A-MISO) was started, and she was followed up for a year until Decembe
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