Could a patient with tingling sensations in their legs and arms, memory issues, and anxiety 3 months after discontinuing their medication have a brain tumor?

Could This Patient Have a Brain Tumor?

While brain tumors can rarely present with psychiatric symptoms alone, the constellation of tingling sensations (paresthesias), memory issues, and anxiety occurring 3 months after medication discontinuation is far more consistent with medication withdrawal syndrome than a brain tumor. 1, 2

Why This Is Most Likely Medication Withdrawal

The timing and symptom pattern strongly suggest withdrawal rather than tumor:

• Withdrawal symptoms from medications like SSRIs/SNRIs (such as Pristiq) typically emerge within 24-48 hours but can persist for months to years, particularly in patients with psychiatric comorbidities 1
• Paresthesias (tingling in arms and legs) are classic withdrawal symptoms from antidepressants, not typical presenting features of brain tumors 3
• Anxiety and memory impairment are well-documented withdrawal symptoms that can persist long after discontinuation 3, 1
• The American Academy of Child and Adolescent Psychiatry notes that mood and anxiety disorder patients may experience symptom return weeks to months after medication discontinuation 3

When Brain Tumors Actually Present With These Symptoms

Brain tumors presenting with purely psychiatric symptoms without focal neurological signs are exceedingly rare:

• There is no consistent association between psychiatric symptoms and specific tumor locations or histological types 2

• When brain tumors do cause psychiatric symptoms, they typically present with additional "red flag" features: 2, 4

  • New-onset symptoms (not recurrence after medication change)
  • Progressive worsening over days to weeks
  • Focal neurological deficits (weakness, vision changes, coordination problems)
  • Headaches that worsen with position or Valsalva
  • Seizures (occur in 10-20% of brain tumor presentations) 3
  • Signs of increased intracranial pressure

• Paresthesias from brain tumors would typically be unilateral and associated with other focal signs, not bilateral symmetric tingling 4

Clinical Decision Algorithm

Proceed with this evaluation sequence:

1. First, obtain detailed medication history: 3

   • Which specific medication was discontinued
   • Whether it was tapered or stopped abruptly
   • Previous psychiatric history and baseline symptoms
   • Whether symptoms are new or represent return of prior condition

2. Distinguish withdrawal from relapse: 1

   • Withdrawal: Prominent physical symptoms (paresthesias, dizziness), emerged within days to weeks of discontinuation, may include "brain zaps"
   • Relapse: Primarily mood/anxiety symptoms matching original presentation, typically emerges weeks to months later

3. Assess for brain tumor "red flags" requiring urgent neuroimaging: 2, 4

   • Progressive focal neurological deficits
   • New-onset seizures
   • Severe headaches with concerning features
   • Cognitive decline beyond memory complaints
   • Atypical psychiatric presentation with treatment resistance
   • If none present: Brain tumor is highly unlikely

Management Approach

For medication withdrawal syndrome:

• Consider medication reinitiation at low dose followed by slower taper, as this is the most evidence-based approach for established withdrawal 1
• Symptomatic management alone has limited evidence for protracted withdrawal 1
• The American Academy of Child and Adolescent Psychiatry recommends gradual tapering to avoid withdrawal symptoms, particularly with SSRIs and benzodiazepines 3

Neuroimaging is NOT indicated unless red flag features develop, as the pretest probability of brain tumor in this clinical scenario is extremely low. 2

Critical Pitfall to Avoid

Do not mistake withdrawal symptoms for disease relapse and inappropriately escalate to neuroimaging or add new medications. The key distinguishing feature is that withdrawal includes prominent physical symptoms (especially paresthesias) that resolve with medication reinitiation, whereas relapse primarily involves return of the original psychiatric symptoms. 1