A 58-year-old man is brought to the emergency department by his wife for "unusual behavior." She says that since last night, the patient has been afraid to go into their bedroom because he sees "evil children" there. He spent most of the night pacing back and forth in the living room and got minimal sleep. Five days ago, when the patient had an asthma exacerbation, his primary care physician added a new oral medication to his regimen. Medical history also includes hypertension and non-insulin-dependent diabetes mellitus. The patient does not drink alcohol but has used marijuana as recently as last week. Vital signs and physical examination are within normal limits. The patient is alert and aware of his surroundings. He reports hearing children laughing at him and frequently covers his ears with his hands. The patient has no suicidal ideation. Which of the following is the most likely diagnosis?

Question

A 58-year-old man is brought to the emergency department by his wife for "unusual behavior."  She says that since last night, the patient has been afraid to go into their bedroom because he sees "evil children" there.  He spent most of the night pacing back and forth in the living room and got minimal sleep.  Five days ago, when the patient had an asthma exacerbation, his primary care physician added a new oral medication to his regimen.  Medical history also includes hypertension and non-insulin-dependent diabetes mellitus.  The patient does not drink alcohol but has used marijuana as recently as last week.  Vital signs and physical examination are within normal limits.  The patient is alert and aware of his surroundings.  He reports hearing children laughing at him and frequently covers his ears with his hands.  The patient has no suicidal ideation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient exhibits the acute onset of psychosis (hallucinations) that is temporally associated with the introduction of a new medication, most likely high-dose glucocorticoid for his asthma exacerbation. His psychosis does not appear to be associated with delirium (he is alert and oriented) or any other psychiatric or medical illness. High-dose glucocorticoids, often given for allergic, inflammatory, or autoimmune conditions, may cause glucocorticoid-induced psychosis, an example of medication-induced psychotic disorder. Psychotic symptoms typically occur during the first week of glucocorticoid treatment but can occur at any time. Glucocorticoids can also cause manic or depressive symptoms. (Choice A) Brief psychotic disorder is characterized by psychotic symptoms lasting ≥1 day but <1 month. This diagnosis is excluded if the symptoms are better explained by the effects of a medication or medical illness. (Choice B) Cannabis (marijuana) use may cause euphoria, perceptual changes, increased appetite, red eyes, slowed reflexes, dizziness, and impaired coordination. Paranoia may occur during acute use but is unlikely to be persistent. (Choice C) The core feature of delirium is fluctuating cognitive impairment, characterized by poor attention and disorientation; psychotic features may be present secondarily. This patient is alert and oriented, making delirium less likely. (Choice E) This diagnosis would be appropriate if the patient's history, examination, or laboratory results suggested that psychosis was a direct pathophysiological consequence of another medical condition (eg, CNS tumor causing psychosis). Educational objective: Medication-induced psychotic disorder is characterized by the acute onset of delusions and/or hallucinations that are temporally associated with the use of a new medication. Glucocorticoids, particularly at high doses, are often implicated in new-onset psychotic symptoms in patients who may have no current underlying psychiatric illness. References: The neuropsychiatric complications of glucocorticoid use: steroid psychosis revisited. (http://www.ncbi.nlm.nih.gov/pubmed/22424158) Sustained corticosteroid-induced mania and psychosis despite cessation: a case study and brief literature review. (http://www.ncbi.nlm.nih.gov/pubmed/26644319)

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