Steroid-induced psychosis: Difference between revisions
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===Workup=== | ===Workup=== | ||
*Diagnosis of exclusion | *Diagnosis of exclusion | ||
*DSM 5 diagnostic criteria | |||
**Must include hallucinations or delusions after steroid exposure<ref>American Psychiatric Association. Schizophrenia Spectrum and Other Psychotic Disorders: Substance/Medication-Induced Psychotic Disorder. DSM-5-TR. Published 2022.</ref> | |||
**Other causes cannot explain symptoms | |||
===Diagnosis=== | ===Diagnosis=== | ||
Revision as of 13:09, 13 March 2024
Background
- In 718 hospitalized patients, 4.6% of patients on 40 mg or higher per day of prednisone had psychiatric symptoms[1]
- 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[2]
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
- 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
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Evaluation
Workup
- Diagnosis of exclusion
- DSM 5 diagnostic criteria
- Must include hallucinations or delusions after steroid exposure[3]
- Other causes cannot explain symptoms
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
See Also
External Links
References
- ↑ Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther. 1972;13:694-698.
- ↑ J Pharm Technol. 2021 Apr; 37(2): 120–126. Published online 2020 Dec 2.
- ↑ American Psychiatric Association. Schizophrenia Spectrum and Other Psychotic Disorders: Substance/Medication-Induced Psychotic Disorder. DSM-5-TR. Published 2022.