Can persistent anxiety, paresthesias, facial flushing, memory loss, and dizziness in a female patient, following discontinuation of her psychiatric medications, including selective serotonin reuptake inhibitors (SSRIs), be symptoms of a brain tumor?

SSRI Discontinuation Syndrome is the Most Likely Explanation

The symptoms described—persistent anxiety, paresthesias, facial flushing, memory loss, and dizziness following SSRI discontinuation—are classic manifestations of SSRI discontinuation syndrome rather than a brain tumor. While brain tumors can rarely present with isolated psychiatric symptoms, the temporal relationship to medication cessation and the specific symptom constellation strongly point to withdrawal effects.

SSRI Discontinuation Syndrome: The Primary Diagnosis

The FDA explicitly warns that discontinuation of SSRIs, particularly when abrupt, causes dysphoric mood, irritability, agitation, dizziness, sensory disturbances (specifically paresthesias such as electric shock sensations), anxiety, confusion, headache, and emotional lability 1. These symptoms typically emerge within 24-48 hours of dose reduction or cessation 2.

Key distinguishing features of SSRI withdrawal:

• Temporal relationship: Symptoms begin within 24-48 hours after stopping medication 2
• Paresthesias: The "electric shock" sensations are pathognomonic for SSRI discontinuation 1
• Autonomic symptoms: Flushing and dizziness are consistent with serotonergic withdrawal 1
• Self-limiting course: Most withdrawal symptoms improve gradually over 1-2 weeks 2

When to Consider Brain Tumor Imaging

While SSRI withdrawal is the likely culprit, certain red flags would warrant neuroimaging to exclude a brain tumor:

Indications for urgent brain imaging:

• Abrupt onset of psychiatric symptoms in a patient with no prior psychiatric history 3, 4, 5
• Progressive cognitive decline or personality changes over weeks to months 3, 6
• New-onset seizures 7
• Focal neurological deficits (weakness, visual changes, speech difficulties) 3, 4
• Treatment-resistant psychiatric symptoms that fail to respond to appropriate interventions 6
• Headaches with features of raised intracranial pressure (worse in morning, with vomiting, positional) 6

Important caveat: Brain tumors can be "neurologically silent" and present with only psychiatric manifestations, particularly frontal and temporal lobe lesions 3, 4, 5, 8, 6. However, this is uncommon, and the temporal relationship to medication discontinuation in this case is highly suggestive of withdrawal.

Recommended Management Algorithm

Step 1: Assess withdrawal syndrome severity

• Monitor closely for symptom evolution over the first 1-2 weeks 2
• Document the specific timeline of symptom onset relative to medication cessation 1

Step 2: Consider medication reinitiation

• If symptoms are intolerable, resume the previously prescribed SSRI dose 1
• Subsequently taper more gradually with smaller dose reductions (2.5-5 mg at a time) over 2-4 week intervals 2

Step 3: Neuroimaging indications

• Order brain MRI if symptoms persist beyond 2 weeks without improvement 2
• Image immediately if any focal neurological signs develop 3, 4, 6
• Consider imaging if symptoms worsen progressively rather than stabilize 6
• Image if new symptoms emerge that are atypical for withdrawal (e.g., personality changes, severe memory impairment beyond expected withdrawal effects) 3, 4, 5

Critical Pitfalls to Avoid

Do not assume all psychiatric symptoms are withdrawal-related in patients with abrupt symptom onset, no prior psychiatric history, or treatment-resistant presentations 6. Brain tumors, particularly meningiomas and frontal lobe lesions, can present with isolated psychiatric symptoms including anxiety, depression, personality changes, and memory difficulties without focal neurological signs 3, 4, 5, 8.

Do not delay imaging in atypical presentations: If the patient has never had psychiatric symptoms before medication initiation, or if symptoms are qualitatively different from the original indication for SSRI treatment, maintain a lower threshold for neuroimaging 3, 4, 6.

Recognize that memory loss is less typical of pure SSRI withdrawal: While confusion can occur with discontinuation 1, progressive memory impairment warrants closer evaluation and potentially earlier imaging 3, 5.

Practical Next Steps

For this specific patient, the most appropriate initial approach is:

• Reassure that symptoms are likely self-limiting withdrawal effects 2, 1
• Monitor symptom trajectory over 1-2 weeks 2
• Consider gradual SSRI reinitiation and slower taper if symptoms are intolerable 2, 1
• Obtain brain MRI if symptoms persist beyond 2 weeks, worsen, or if any focal neurological signs develop 3, 4, 6