“Mr. A,” a 35-year-old man diagnosed with obsessive-compulsive disorder for 13 years with predominant obsessions of contamination and washing compulsions, was receiving a combination of sertraline 200 mg/day, clomipramine 225 mg/day, lithium carbonate 800 mg/day, and risperidone 2 mg/day. He experienced inadequate symptomatic improvement despite being on this regime for more than 8 weeks, and he was almost housebound. Disappointed, he decided to try a higher dosage of medications, and increased the dose of sertraline to 400 mg/day on his own. After 2 weeks, he presented to us with complaints of hearing voices, difficulty in walking, and occasional twitching of face and body. There was no history of past medical illness or substance use. Family history and personal history was unremarkable.
Physical examination revealed increased sweating, blood pressure of 130/90 mm Hg, coarse tremors of extremities, occasional myoclonic jerks, and ataxic gait. On mental status examination, he was conscious, oriented, and had florid functional auditory hallucinations. He reported hearing music from a fan or tap water along with their sounds and was highly distressed. The findings from history and physical examination met Sternbach’s criteria3 for serotonin syndrome. The dose of sertraline was reduced to 200 mg/day, and the symptoms and signs of serotonin syndrome resolved within 3 days, including complete disappearance of functional auditory hallucinations.