A 58-year-old man is brought to the office by his daughter for evaluation of "abnormal behavior." The patient has been anxious and irritable for the past several days, and over the past 2 days, he has repeatedly said that "bad men" are following him. He has no history of psychiatric illness but was diagnosed with polymyositis 2 weeks ago. The patient has been taking high-dose prednisone with improvement in muscle weakness. He has no other medical conditions and takes no other medications. Vital signs are within normal limits. Physical examination shows mild symmetric, proximal muscle weakness. During the examination, the patient frequently looks around the room and startles easily when the nurse knocks on the door. He reports no suicidal ideation or hallucinations. Based on the patient's responses to questions, his memory and recall are intact. Which of the following is the most appropriate first step in the management of this patient's current symptoms?

Question

A 58-year-old man is brought to the office by his daughter for evaluation of "abnormal behavior."  The patient has been anxious and irritable for the past several days, and over the past 2 days, he has repeatedly said that "bad men" are following him.  He has no history of psychiatric illness but was diagnosed with polymyositis 2 weeks ago.  The patient has been taking high-dose prednisone with improvement in muscle weakness.  He has no other medical conditions and takes no other medications.  Vital signs are within normal limits.  Physical examination shows mild symmetric, proximal muscle weakness.  During the examination, the patient frequently looks around the room and startles easily when the nurse knocks on the door.  He reports no suicidal ideation or hallucinations.  Based on the patient's responses to questions, his memory and recall are intact.  Which of the following is the most appropriate first step in the management of this patient's current symptoms?

Quizplus · Accepted Answer

The acute onset of behavioral changes with paranoia in this patient with no psychiatric history is most likely due to high-dose prednisone used to treat his polymyositis. Psychosis following initiation of a new medication (eg, glucocorticoids) capable of producing these symptoms indicates a medication-induced psychotic disorder. Although psychiatric symptoms secondary to corticosteroids may begin at any time during treatment, they are more likely to manifest when high doses are used for longer periods of time. Therefore, because this patient's physical symptoms have improved, reducing or, if possible, discontinuing his prednisone dosage would be the most appropriate first step in managing the patient's psychiatric symptoms. Other neuropsychiatric symptoms that may occur in patients taking glucocorticoids include mood and anxiety symptoms, sleep disturbances, restlessness, and memory loss. (Choices A and B) When feasible, the primary intervention for medication-induced psychosis is reduction of the causative agent. Antipsychotics, such as haloperidol or quetiapine, may be needed when the medication-induced psychosis is very severe or persistent. (Choices D and E) The patient's memory and recall appear to be intact, and there are no acute neurological symptoms. Further diagnostic studies, such as a brain MRI or lumbar puncture, are not indicated at this time. (Choice F) Reassurance alone is unlikely to resolve psychiatric symptoms with continued exposure to high-dose prednisone. Educational objective: Glucocorticoid therapy may cause psychosis, anxiety, and mood symptoms. Restlessness, sleep disturbances, and memory loss may also occur. Glucocorticoid dose reduction, or discontinuation, is indicated whenever possible. References: The neuropsychiatric complications of glucocorticoid use: steroid psychosis revisited. (http://www.ncbi.nlm.nih.gov/pubmed/22424158)

A 58-Year-Old Man Is Brought to the Office by His