Tiagabine in the Treatment of Nervios

Sir: Nervios or ataque de nervios is a condition seen primarily in Hispanic women.¹ It has been described in the anthropological as well as the psychiatric literature for many years.² Symptoms of nervios may overlap with symptoms of affective disorders and those within the anxiety disorders.¹ The following case describes a Hispanic woman diagnosed with nervios, in her country of origin, successfully treated with tiagabine after trials with more traditional agents utilized in anxiety disorders were not tolerated.

Case report

Ms. A was a 26-year-old Hispanic woman who arrived for consultation referred by her primary care physician. At the initial evaluation, she described a 5-year history of feeling anxious most days with an infrequent overwhelming sense of restlessness. She had practiced purging in her late adolescence, but denied any other psychiatric problems. She was in excellent medical condition and took no medications except for alprazolam, 8–10 mg/day, for 3 years. Ms. A did not use alcohol, illicit substances, or nicotine products; drank occasional coffee; but did not use herbal medications. At this time, she was diagnosed with nervios, which does not clearly fit DSM-IV criteria for either panic disorder or generalized anxiety disorder, but would best be described as anxiety disorder NOS. Ms. A requested to discontinue the alprazolam, after encouragement from a close friend, because she did not want to continue with a dependency on the drug. Pharmacologic alternative treatments to alprazolam were explained to Ms. A who agreed to taper alprazolam and add citalopram starting at 10 mg/day. The alprazolam was tapered over 9 weeks' time without any untoward effects.

Ms. A did well on citalopram treatment increased to 20 mg/day, and at 1 month's time taking citalopram as a stand-alone agent, felt her anxiety was well controlled. She complained of anorgasmia, however, which had not existed prior to initiating treatment with citalopram. She was in a stable relationship with no known relationship difficulties. Encouraged by the work of Nurnberg et al.,³ a trial of sildenafil, 50 mg, 1 hour prior to sexual activity, was initiated. Unfortunately for Ms. A, this did not alleviate her anorgasmia despite following the instructions and increasing the dose to 100 mg/day over a 5-day trial. She requested an alternative adjunctive agent to treat the anorgasmia. Bupropion was considered, but because Ms. A had a history of purging, it was decided to try another agent. Mirtazapine, 15 mg at bedtime, was initiated. Within 1 week, she began to experience orgasms as per her subjective "normal" functioning, with no return of the anxiety. Unfortunately, she also noted an increase in appetite and a 7-lb (3-kg) weight gain within 2 weeks.

The patient discontinued the mirtazapine and agreed to a trial of tiagabine, 2 mg by mouth, 2 times/day. Prior to initiating the tiagabine, it was explained to Ms. A that this was an off-label use of the medication; she understood and agreed to a trial. The tiagabine was increased at the end of week 1 to 4 mg b.i.d. without any untoward effects. At this dose, she experienced control of her anxiety, no sexual dysfunction, and no increase in weight. After 6 months, she is doing well and has been able to return to her studies.

Tiagabine, approved by the U.S. Food and Drug Administration, is an adjunct anticonvulsant for the treatment of partial seizures.⁴ It purportedly exerts its action by inhibiting γ-aminobutyric acid (GABA) reuptake from the synaptic cleft.^5,6 Ms. A's sustained improvement on tiagabine treatment, may be due to this GABAergic mechanism. Although citalopram controlled Ms. A's anxiety, its use was associated with sexual dysfunction. Mirtazapine use resulted in symptomatic improvement as well, but weight gain limited its tolerability. Long-term benzodiazepine use in such conditions is associated with a risk of addiction, albeit a low risk. Tiagabine was a reasonable choice, therefore, in treating nervios in this case based on its mechanism of action. Controlled studies will be required to adequately assess the efficacy of tiagabine in patients with anxiety disorders.