Bupropion-Induced Claustrophobia

Abstract

Sir: Although emergent anxiety can occur with bupropion therapy (5%–6% per the package insert1), to date there are no reports of claustrophobia associated with the drug. We present a case of new-onset claustrophobia related to bupropion therapy. Case report. Mr. A, a 59-year-old man with no prior psychiatric history, was prescribed bupropion in May of 2005 for a major depressive episode (DSM-IV criteria). Target symptoms included decreased energy, feelings of worthlessness, decreased appetite, and restlessness. Past treatment consisted of sertraline (taken from December 2004 to January 2005), discontinued due to sexual side effects, and citalopram (prescribed once in March 2005), discontinued for lack of efficacy. The patient was administered bupropion SR, titrated to 150 mg twice daily. Soon after, he self-decreased his dose to 150 mg daily because of irritability and “claustrophobia,” described as an intense feeling that the walls were closing in. He also reported increased heart rate, diaphoresis, and difficulty breathing while in rooms with closed doors, in elevators, in the shower, and in the back seat of compact cars. These symptoms were not present in situations that did not involve enclosed spaces. In clinic, he insisted the office door be left open. Bupropion was subsequently discontinued (June 29, 2005) and venlafaxine was initiated on the same day. After 1 month, his claustrophobic symptoms resolved. Nine months after bupropion therapy was terminated, anxiety symptoms have not recurred. Claustrophobia is an anxiety disorder that involves the fear of confined or enclosed spaces.2 Although one of the most prevalent specific phobias in the general population, only 20% of those affected will seek medical attention.3 Thus, the disorder often goes undiagnosed. Although the exact pathophysiology of claustrophobia is unknown, there is compelling evidence that supports the role of the noradrenergic system in anxiety disorders. The activation of brain noradrenergic neurotransmission in the presence of acute stress results in neuroendocrine, autonomic, behavioral, and cognitive responses.4,5 Unlike other agents, bupropion exerts its therapeutic effects by inhibiting norepinephrine and dopamine reuptake. Because of its actions on the noradrenergic system, it is reasonable that bupropion may worsen anxiety. In a study by Ashton and Rosen,6 15% of patients treated with bupropion for sexual side effects associated with selective serotonin reuptake inhibitors discontinued therapy due to anxiety or tremor. Additionally, Young7 reported a case of panic occurring following the addition of bupropion to fluoxetine. To our knowledge this is the first report of bupropion-induced claustrophobia. We recommend caution with the use of bupropion in patients with primary anxiety disorders.