Could the word-finding difficulty and occasional word repetition in a patient taking bupropion (Wellbutrin) 200 mg daily for three months be a medication side effect, and what is the appropriate management?

Word-Finding Difficulty and Repetition on Bupropion: Assessment and Management

This patient's word-finding difficulty and word repetition after 2 months on bupropion 200 mg daily is unlikely to be a direct medication side effect, and you should evaluate for other causes before attributing symptoms to the drug.

Why Bupropion Is Unlikely the Primary Cause

Bupropion has been used safely for 17 years with a well-established side-effect profile that does not include speech or language impairment as a recognized adverse effect 1. The most common side effects are nervousness, insomnia, dry mouth, and agitation—not cognitive or language dysfunction 1, 2, 3.

Critical timing consideration: The patient tolerated bupropion without issues for the first 2 months, then developed symptoms in month 3. Medication-related adverse effects typically emerge within the first 1–2 weeks of initiation or dose escalation, not after 2 months of stable dosing 4, 5.

Differential Diagnosis to Evaluate

Functional Neurological Disorder

Word-finding difficulties and speech hesitations can occur as functional cognitive symptoms, often reflecting inefficient allocation of attentional resources 6. These symptoms:

• Show significant internal inconsistency compared to lesion-based aphasia patterns 6
• May improve once other functional symptoms are treated 6
• Can be accompanied by subjective memory and concentration difficulties 6

Progressive Neurological Conditions

Screen for red flags suggesting a progressive aphasic syndrome:

• True anomia (word-finding difficulty) is a core feature of logopenic variant primary progressive aphasia, usually caused by Alzheimer's disease 6
• Impaired repetition due to auditory-verbal working memory deficits 6
• Progressive course over weeks to months 6

Anxiety or Stress-Related Cognitive Symptoms

Bupropion can cause agitation in 8.2% of patients, even at therapeutic doses 5. If the patient has developed increased anxiety or agitation, this could manifest as:

• Difficulty with word retrieval under stress
• Speech hesitations
• Subjective cognitive complaints 6

Immediate Management Steps

1. Confirm the Dose and Formulation

Verify the patient is taking bupropion SR 200 mg (not a standard dose—typical dosing is 150 mg once or twice daily) 7. If this is actually 150 mg twice daily (300 mg total), confirm:

• The second dose is taken before 3 PM to minimize insomnia 7
• No recent dose escalation occurred 7

2. Rule Out Acute Dystonia

Although rare, bupropion can cause dose-related dystonic reactions affecting jaw and neck muscles within 24–48 hours of dose increases 4. Examine for:

• Jaw muscle tightness or trismus
• Neck stiffness or inability to rotate head
• TMJ pain or subluxation 4

If dystonia is present: Reduce bupropion to 150 mg once daily immediately 4.

3. Assess for Neuropsychiatric Changes

Monitor for agitation, irritability, or behavioral changes that emerged around the same time as speech symptoms 7, 5. Agitation is the most common reason for bupropion discontinuation (9.1% of patients) 3.

4. Evaluate for Seizure Activity

Bupropion lowers the seizure threshold, with a risk of approximately 0.1% at doses ≤300 mg/day 7, 2. Word repetition (palilalia) can be a subtle seizure manifestation. Ask about:

• Brief lapses in awareness
• Automatisms
• Post-event confusion 2

If seizure is suspected: Discontinue bupropion immediately and refer for neurology evaluation 7, 2.

Recommended Action Plan

Step 1: Obtain a detailed timeline of symptom onset relative to any medication changes, life stressors, or intercurrent illnesses.

Step 2: Perform a focused neurological examination including:

• Cranial nerve testing
• Motor and sensory exam
• Assessment for dystonia (jaw, neck) 4
• Cognitive screening with attention to language fluency, naming, and repetition 6

Step 3: If examination is normal and symptoms are mild, continue bupropion at the current dose and reassess in 1–2 weeks. Many functional cognitive symptoms resolve spontaneously 6.

Step 4: If symptoms persist beyond 2 weeks or worsen, consider:

• Reducing bupropion to 150 mg once daily to test for dose-response relationship 4
• Referral to speech-language pathology for formal language assessment 6
• Neurology consultation if progressive aphasia is suspected 6

When to Discontinue Bupropion

Discontinue immediately if:

• Seizure activity is confirmed or strongly suspected 7, 2
• Acute dystonia develops 4
• Symptoms progress to include impaired comprehension, reading, or writing (suggesting true aphasia) 6

Consider discontinuation if:

• Symptoms persist after dose reduction to 150 mg once daily 4
• Patient develops significant agitation or behavioral changes 3, 5

Critical Pitfalls to Avoid

• Do not assume speech symptoms are medication-related without ruling out functional, neurological, or psychiatric causes 6
• Do not abruptly discontinue bupropion without a clear indication, as this may worsen underlying depression 7
• Do not exceed 450 mg/day total if considering dose adjustment upward, as seizure risk increases markedly 7, 2
• Do not miss a progressive neurodegenerative process by prematurely attributing symptoms to medication 6