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Nortriptyline-Induced “Room Tilt Illusion”: A Rare Adverse Event of Antidepressants (2024 Case Report)

Room Tilt Illusion (RTI) presents a perplexing challenge to both patients and physicians, transforming the familiar into the surreal as surroundings appear rotated or flipped.

This rare condition, often linked to neurological or vestibular disorders, has recently been observed as an adverse effect of the antidepressant nortriptyline, used in treatment-resistant depression.

A case report highlights the intricate balance of our sensory processing and the unexpected consequences medication can have on our perception of reality.


  1. RTI is a rare perceptual disturbance where individuals perceive their environment as being rotated or tilted, often at extreme angles.
  2. The condition is commonly associated with vestibular disorders and neurological lesions but has recently been connected to nortriptyline use.
  3. The case of nortriptyline-induced RTI underscores the potential impact of tricyclic antidepressants on the vestibulo-thalamo-cortical system and visual-vestibular integration.
  4. Understanding RTI induced by medications like nortriptyline is crucial for clinicians, particularly in the differential diagnosis of elderly patients with comorbidities.

Source: Cureus (2024)

What is Room Tilt Illusion?

RTI involves a temporary but dramatic alteration in how the brain interprets sensory information, leading to the perception that the room or surrounding environment has been tilted or flipped upside down.

Unlike vertigo, which is a sensation of spinning or moving, RTI specifically alters the perceived orientation of static objects and spaces.


The exact mechanisms behind RTI are not fully understood, but it is believed to result from disruptions in the integration of vestibular, visual, and proprioceptive inputs within the brain.

Commonly associated causes include:

  • Vestibular Disorders: Conditions affecting the inner ear and balance, such as labyrinthitis or vestibular neuritis, can trigger RTI by disrupting the normal vestibular inputs to the brain.
  • Neurological Lesions: Strokes, particularly those affecting the posterior circulation of the brain, tumors, and multiple sclerosis lesions in areas responsible for processing spatial orientation, can lead to RTI.
  • Migraines: Some individuals experience RTI as part of a complex migraine aura.
  • Epilepsy: Seizure activity, especially in regions of the brain involved in processing visual and vestibular information, may cause RTI.


Due to its transient nature and the rarity of reported cases, the prevalence of RTI is difficult to ascertain.

It is considered a rare condition, with literature mainly consisting of case reports and small case series.

Risk Factors

Risk factors for RTI are generally related to the underlying causes of the illusion. These can include:

  • Age: Older adults may be at higher risk due to the higher prevalence of strokes and vestibular disorders in this population.
  • Existing Neurological Conditions: Individuals with a history of migraines, epilepsy, or other neurological conditions affecting the brain’s ability to process sensory information may be more susceptible to RTI.
  • Medication Use: Certain medications, particularly those affecting the central nervous system or those with anticholinergic effects, can increase the risk of RTI.
  • Vestibular Disorders: People with a history of inner ear disorders or balance issues are at an elevated risk.

Diagnosis & Management

Diagnosing RTI involves a thorough clinical evaluation to rule out other causes of altered perception, such as vertigo or psychiatric disorders.

Detailed history taking, focusing on the nature of the perceptual disturbances and any associated symptoms, is crucial.

Neuroimaging and vestibular testing may be employed to identify or rule out potential underlying causes.

Management of RTI is primarily directed towards treating the underlying cause, if identified.

This might involve managing vestibular disorders, adjusting medications, or treating neurological conditions.

In cases where RTI occurs as a side effect of medication, altering or discontinuing the offending drug may resolve the symptoms.

(Related: Nortriptyline May Help People Quit Smoking)

Notriptyline & Room Tilt Illusion: Case Report (2024)

Sarmiento et al. presented a case of Room Tilt Illusion (RTI) induced by the tricyclic antidepressant “nortriptyline” – below are some of the details.

Patient Background

  • Demographics: 77-year-old male
  • Psychiatric History: Worsening depression with psychotic features for several months, diagnosed with generalized anxiety disorder (GAD) two years prior following his wife’s death. Initial treatments with anxiolytics and supportive counseling were unsuccessful.
  • Symptoms Prior to RTI Onset: Escalating depression and anxiety, significant weight loss (40 pounds), diminished motivation, hopelessness, anhedonia, active suicidal ideation, auditory hallucinations, and delusional ideas of reference.
  • Medical History: Atrial flutter, hypertension, obstructive sleep apnea.
  • Medications Prior to Nortriptyline: Venlafaxine (150 mg daily), aripiprazole (10 mg daily), mirtazapine (30 mg nightly), trazodone (25 mg as needed).

Room Tilt Illusion Onset

  • Nortriptyline Initiation: Started at a tertiary academic center for treatment-refractory depression, with a dose initiation of 25 mg daily, gradually titrated to 50 mg daily over five days.
  • RTI Symptoms: On the sixth day after starting nortriptyline, the patient described a peculiar visual disturbance, perceiving his surroundings as if tilted by 90 degrees, resembling standing on the wall and looking downwards. These episodes were intermittent, lasting between 2 to 30 seconds, and persisted for the four weeks he was on nortriptyline.
  • Other Medications During RTI: Lithium carbonate (initiated after 12 days on nortriptyline, titrated to 600 mg nightly) and an increased dose of aripiprazole (to 15 mg daily).

Diagnostic Workup

  • Neurocognitive Evaluation: Mini-mental state examination score of 26 of 30, ruling out cognitive impairment from delirium or dementia.
  • Medical and Neurological Examination: Comprehensive physical exam and laboratory testing including complete blood count, comprehensive metabolic panel, vitamin D, thyroid functioning, and urinalysis were unremarkable.
  • Imaging: Computed tomography (CT) and magnetic resonance imaging (MRI) of the head showed no abnormalities.

Treatment & Outcome

  • Medication Adjustment: Due to profound dysphoria and lack of mood improvement with augmentation, nortriptyline was discontinued after four weeks.
  • Post-Nortriptyline Monitoring: The patient did not experience a recurrence of RTI in the two months following discontinuation. He was discharged four months after admission and two months post-nortriptyline trial, with improved depressive symptoms and minimal mood-congruent delusions of guilt.
  • Discharge Medications: Phenelzine 15 mg twice daily, trazodone 25 mg as needed.

(Related: Nortriptyline for Migraines)

Did Notriptyline Really Cause Room Tilt Illusion in this Patient?

In the case of the 77-year-old male patient experiencing Room Tilt Illusion (RTI) after starting nortriptyline for treatment-refractory depression, the timing of symptom onset relative to medication initiation strongly suggests nortriptyline as the likely cause.

However, the question of whether nortriptyline was the sole contributor or if other variables played a role is complex and warrants consideration of several factors.

  • Medication History & Changes: The patient underwent significant changes in his medication regimen around the time nortriptyline was introduced, including discontinuation of venlafaxine and mirtazapine, and later, the addition of lithium carbonate. These adjustments could potentially influence neurological and vestibular systems, either through withdrawal effects or new drug interactions.
  • Underlying Psychiatric & Medical Conditions: The patient’s complex medical history, including severe depression with psychotic features, generalized anxiety disorder, and a history of significant anorexia and weight loss, could contribute to vulnerability to perceptual disturbances. Additionally, the presence of medical conditions such as atrial flutter and hypertension, as well as the treatments for these conditions, could have indirect effects on cerebral perfusion and vestibular function.
  • Age-Related Sensory Vulnerability: Older adults may have a reduced capacity to compensate for disruptions in sensory integration due to age-related changes in the brain and sensory organs. This factor could make the patient more susceptible to experiencing RTI in response to changes in medication that might be better tolerated in a younger or healthier population.

Antidepressants & Room Tilt Illusion (Potential Mechanisms)

The occurrence of Room Tilt Illusion (RTI) as a side effect of antidepressant medication is a rare but documented phenomenon that sheds light on the complex interactions between pharmacological agents and the brain’s sensory processing systems.

Understanding how antidepressants may cause RTI involves delving into the mechanisms by which these drugs interact with the central nervous system, particularly in areas involved in spatial orientation and sensory integration.


  1. Neurotransmitter Modulation: Antidepressants, including tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), alter the levels of neurotransmitters in the brain, notably serotonin and norepinephrine. These neurotransmitters play critical roles in regulating mood and cognitive functions but also influence the neural circuits involved in processing vestibular information. Alterations in their levels can disrupt the normal integration of sensory inputs necessary for maintaining spatial orientation.
  2. Anticholinergic Effects: Some antidepressants, particularly TCAs, have anticholinergic properties that can affect the vestibular system. By blocking acetylcholine receptors, these medications can impair the transmission of signals related to balance and spatial orientation, potentially leading to RTI.
  3. Histamine Receptor Blockade: Many antidepressants also block histamine H1 receptors, which can influence vestibular function and contribute to disturbances in spatial perception, including RTI.

Signs of Antidepressant-Induced RTI

Recognizing the signs of RTI induced by antidepressant use is crucial for managing this disorienting side effect. Symptoms to watch for include:

  • A sudden perception that the environment is tilted or flipped, often described as seeing the room turned by 90 or 180 degrees.
  • These episodes may be transient, lasting from seconds to several minutes, and can occur without any changes in consciousness or other neurological symptoms.

If you or someone you know experiences RTI while on antidepressants, the following steps are recommended:

  1. Seek Medical Attention: Contact a healthcare provider to report the symptoms and receive a proper evaluation. It’s essential to rule out other causes of RTI, such as vestibular disorders or neurological conditions.
  2. Review Medication Use: The healthcare provider will review the current medication regimen to identify the antidepressant that may be causing RTI. A detailed medication history is crucial, as interactions between drugs can also contribute to side effects.
  3. Adjustment of Medication: Under the guidance of a healthcare professional, adjusting the dose or switching to an alternative antidepressant may be necessary. The goal is to manage the underlying condition effectively while minimizing the risk of RTI.
  4. Monitoring & Support: Continuous monitoring for any recurrence of RTI symptoms is important after any medication adjustment. Providing support and reassurance can help manage the anxiety and distress that may accompany RTI episodes.

Room Tilt Illusion Treatments

The treatment for Room Tilt Illusion (RTI) largely depends on identifying and addressing its underlying cause, given its association with a variety of vestibular, neurological, and sometimes pharmacological factors.

Since RTI is a symptom rather than a standalone condition, the most common interventions are targeted toward the etiological factors contributing to the distorted perception.

1. Management of Vestibular Disorders

Since many cases of RTI are linked to vestibular dysfunctions, treatments focusing on vestibular rehabilitation can be effective. These may include:

  • Vestibular Rehabilitation Therapy (VRT): A specialized form of therapy designed to alleviate both the primary and secondary problems caused by vestibular disorders. VRT aims to restore normal vestibular function or teach the brain to compensate for abnormalities.
  • Medications: In some cases, medications that reduce vertigo and dizziness, such as meclizine, can be helpful in managing symptoms associated with vestibular disorders.

2. Neurological Treatments

For RTI episodes triggered by neurological conditions, treatments are more specific to the underlying cause:

  • Stroke Management: In cases where RTI is linked to strokes, particularly in the posterior circulation, treatment focuses on stroke management, including the use of antiplatelet drugs, statins, and, in some cases, surgical interventions to prevent further cerebrovascular events.
  • Multiple Sclerosis (MS) Management: For patients with MS, treatment may involve disease-modifying therapies aimed at slowing disease progression and managing acute relapses with corticosteroids.
  • Epilepsy Treatment: If RTI is associated with seizure activity, antiepileptic drugs (AEDs) are the cornerstone of treatment, tailored to the type of epilepsy and the individual’s response to medication.

3. Migraine Management

In individuals for whom RTI is part of a migraine aura, managing the migraines can reduce the occurrence of RTI episodes:

  • Preventive Medication: Medications such as beta-blockers, calcium channel blockers, and certain antidepressants can be effective in reducing the frequency and severity of migraines.
  • Acute Treatment: For managing acute migraine attacks, triptans and nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective. In some cases, anti-nausea medication may also be necessary.

4. Medication Adjustment

If RTI is suspected to be a side effect of medication, especially those with anticholinergic properties or other central nervous system effects, a review and adjustment of the patient’s medication regimen may be necessary.

  • Discontinuing the Offending Medication: Under medical supervision, gradually discontinuing or switching the medication suspected of causing RTI.
  • Medication Substitution: Replacing the offending medication with an alternative that does not have the same side effects but provides similar therapeutic benefits.

5. Psychological Support

Though RTI is not a psychological condition, the disorienting nature of the episodes can cause distress and anxiety. Supportive counseling or therapy can help individuals cope with the stress and anxiety associated with RTI episodes.

Cognitive-behavioral therapy (CBT) may be particularly helpful in managing any resultant phobias or anxiety disorders.

Conclusion: Nortriptyline-Induced Room Tilt Illusion

The case report of nortriptyline-induced Room Tilt Illusion (RTI) provides a rare glimpse into the complex interplay between pharmacological treatment for depression and perceptual disturbances.

This phenomenon underscores the importance of understanding the potential side effects of antidepressants, particularly those with significant anticholinergic properties, which may impact the vestibulo-thalamo-cortical pathway and disrupt sensory integration.

The resolution of RTI symptoms upon discontinuation of the medication highlights the reversible nature of the condition when the causative agent is identified and appropriately managed.

This case serves as a crucial reminder for clinicians to maintain a high index of suspicion for medication-induced perceptual disturbances, especially in patients with complex psychiatric and neurological histories.

It emphasizes the need for thorough patient education about possible side effects and the importance of prompt reporting of any unusual sensory experiences.

Overall, this case contributes to the broader understanding of the potential neurological impacts of tricyclic antidepressants and underscores the need for careful medication selection and monitoring in treating psychiatric conditions.


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