Steroid-induced psychosis

Background

• In 718 hospitalized patients, 4.6% of patients on 40 mg or higher per day of prednisone had psychiatric symptoms
  • Incidence rises to 18.4% for patients receiving more than 80 mg per day
• Mechanism unproven but thought to be increased dopamine due to induction of tyrosin hydroxylase by corticosteroids

Clinical Features

• Wide range of possible psychiatric symptoms
  • Delusions or hallucinations
  • Euphoria
  • Mania, depression, anxiety
  • Severe cases may present with suicidal ideation, violence, aggression

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

• Hypoxic encephalopathy
• Acute toxic-metabolic encephalopathy (Delirium)
  • Hypoglycemia
  • Hyperosmolar state (e.g., hyperglycemia)
  • Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
  • Organ system failure
  • Hepatic Encephalopathy
  • Uremia/Renal Failure
  • Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
  • Hypoxia
  • CO2 narcosis
• Hypertensive Encephalopathy
• Toxins
• TTP / Thrombotic thrombocytopenic purpura
• Alcohol withdrawal
• Drug reactions (NMS, Serotonin Syndrome)
• Environmental causes
  • Hypothermia
  • Hyperthermia
• Deficiency state
  • Wernicke encephalopathy
  • Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
  • Vitamin D Deficiency
  • Zinc Deficiency
• Sepsis
• Osmotic demyelination syndrome (central pontine myelinolysis)
• Limbic encephalitis

Primary CNS disease or trauma

• Direct CNS trauma
  • Diffuse axonal injury
  • Subdural/epidural hematoma
• Vascular disease
  • Intraparenchymal hemorrhage
• SAH
• Stroke
  • Hemispheric, brainstem
• CNS infections
  • Encephalitis
  • Anti-NMDA receptor encephalitis
  • Meningitis
• Neoplasms
  • Paraneoplastic Limbic encephalitis
  • Malignant Meningitis
  • Pancreatic Insulinoma
• Seizures
  • Nonconvulsive status epilepticus
  • Postictal state
• Dementia
  • Alzheimer's
  • Lewy Body Dementia
  • Frontotemporal Dementia

Psychiatric

• Acute psychosis
• Catatonia
• Excited delirium
• Malingering
• Steroid induced psychosis

Evaluation

Workup

• Diagnosis of exclusion

Diagnosis

• Consider AMS workup

Management

• Cease offending agent or taper depending on clinical need for corticosteroids vs psychiatric complications
  • Onset of relief of symptoms vary widely, with some improving within 24 hours or as long as 8 weeks at the longest
  • Discontinuing immediately, as opposed to tapering, contributed to quicker resolution of symptoms

Disposition

• Admission for severe cases
• Possible discharge for mild cases, consider short supply atypical antipsychotics and close follow up