Steroid Psychosis Stories
Story One – Naked Lady Alert on Three-West
One of the administrative assistants rushed into my office midafternoon. “Get up to Three-West right away,” she said, near-panic in her voice. As I leapt from behind my desk and headed out, she said the floor called. The internist for a Mrs. Graham, Dr. Phillips, had ordered an emergency psychiatry consultation to be done immediately. I ran past the bank of elevators and headed for the stairs. The nurses knew my habits. Shani, one of the RNs on Three-West, was waiting for me at the stairway door as I burst through. She filled me in as I headed for the nurses station. Mrs. Graham, a sedate, dignified, older lady, was running through the halls with no clothes on. She’s saying, “You’re out to get me!” She won’t let anyone near her and said she took off her hospital gown when “they” tried to light it on fire.
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Start at the Beginning – Diagnosis and History
The patient, Mrs. Virginia Graham, had psoriatic arthritis, a form of inflammatory arthritis. In psoriatic arthritis the individual’s immune system goes awry and attacks their joints, inflaming them, causing joint pain, swelling, and stiffness. It can at times be a difficult disease to treat. This current arthritic flare was severe enough that her internist, Dr. Phillips, had admitted her to the hospital for treatment. She complained of swollen joints, back aches, and fatigue that stopped her in her tracks, that she could not overcome. Given the severity of the flare Dr. Phillips elected to give her a brief course of systemic steroids in addition to increasing her dose of methotrexate. Or, maybe switch her to apremilast, a newer disease modifying antirheumatic drugs that’s just as effective as methotrexate and might cause fewer side effects.
The Best Laid Schemes O’ Mice An’ Men. Gang Aft A-gley
Dr. Phillips admitted Mrs. Ginny Graham to the hospital, to Three-West, and started a brief course of steroid to quickly shut down the joint inflammation while he consulted with one of the rheumatologists about whether to just increase her methotrexate or switch her to apremilast. He started a prednisone bolus and taper at 40 mg on day one, 30 mg on day two, but that’s as far as Mrs. Graham got. A few hours after the 30 mg dose she tore off her hospital gown and, clutching it in her hands, began running down the hallway in her birthday suit, looking afraid. The Three-West nurses called Dr. Phillips who ordered the emergency psychiatry consult.
Plan A for Mrs. Graham – Calm and Clothes
So, back to me bursting through the stairway door and toward the nurses station. I asked one of the nurses to grab a clean large bedsheet, and she and another nurse and I went searching for Mrs. Graham. We found her sitting on the floor in a corner, looking terrified and clutching her hospital gown in her hands but making no attempt to put it back on. Being in a corner was an advantage for us in that she couldn’t go anywhere, we had her “surrounded”, and we didn’t have to keep chasing her down hospital hallways. I huddled with the two nurses, working out a plan. While the two nurses stood by with the still-folded sheet, I sat on the floor a few yards from her and began talking to her calmly about “nothing to fear”, “we’re here to help”, and so on. But calm words had no effect.
Plan B for Mrs. Graham – One Sheet to the Wind
One of the nurses went back to the nursing station and filled a syringe for intramuscular injection with haloperidol (Haldol®) 5 mg and lorazepam (Ativan®) 1 mg while the other stayed with me, still holding the sheet. While there were just two of us we didn’t provoke Mrs. Graham, just waited calmly and talked to her softly. When the other nurse joined us we again tried to encourage Mrs. Graham not to be afraid. We asked one of the nursing assistants to bring us three chairs so that we could appear more relaxed and friendly and less confrontational. It didn’t work. When she arrived with the first chair it spooked Mrs. Graham. She leapt up to run from her corner. As she started to run past us the two nurses quickly unfurled the sheet and, each grabbing a side of the sheet, ran on opposite sides of the lady.
Plan B Worked – One Calm, Sleeping Mrs. Graham
In a practiced move from the hospital safety protocol the two nurses swept around Mrs. Graham and snugged the sheet around her, trapping her arms and legs, trapping her, in the sheet. She was in the sheet cocoon and the three of us laid her gently to the floor while the nurse with the syringe pulled it from her pocket and gave Mrs. Graham the haloperidol / lorazepam injection. We continued to hold her in the sheet for a few minutes and tried to calm her, talking to her softly, until the medication took effect. Within a few minutes she relaxed and, when she was almost asleep, I left her in the immediate care of the two nurses. Within thirty minutes she was back in her hospital gown, back in her bed in her room, and, for the moment, asleep.
The Calm After the Storm – All’s Well
I called Dr. Phillips to confirm that he was willing to discontinue the steroid use. He agree and had consulted with a rheumatologist on increasing the dose of methotrexate while other medications were considered. I left orders with the nurses on repeat dosage and timing of the haloperidol / lorazepam if she was still fearful when she awoke in a few hours. Later that evening I visited Mrs. Graham. She was calm, smiling, with no signs of psychosis. She didn’t remember much of what happened to her except that something was really frightening for a while.
One of our Readers in wrote in the say:
Steroids are so awful and haloperidol is terrible. You doctors really beat up on people with drugs.
Physicians don’t use a steroid medication unless it’s really necessary because, you’re right, they can be awful for some people. And, we’ve moved away from using any steroid medications long-term. They’re used for brief intervals to save a life or save an organ. But they will continue to be a valuable tool in the medical toolbox because they work well and work quickly. They can pull a person back from the brink of death or disability when a disease flares or there are surprise severe complications. Also, there are some disorders where there are no other choices.
Physicians are always looking for other options than using steroids. That’s one reason why the family of medications called disease-modifying antirheumatic drugs became popular so quickly. As Dr. Phillips did with Mrs. Graham above, doctors use steroids to bring an individual in crisis under control quickly, with the intent to keep them at the lowest possible doses for the shortest possible time. Then start a disease-modifying antirheumatic drug to control the disorder long-term.
You’re also correct that haloperidol is terrible. There are better choices except in emergency situations, like Mrs. Graham’s steroid psychosis. There have been many studies of haloperidol use in emergencies for agitated, threatening, or violent behavior. As in this case, the haloperidol is usually given by intramuscular injection in these situations so that the person in crisis does not have to cooperate. Usually, within thirty minutes the individual is calm and the disruptive behavior is gone. Thus, haloperidol is considered to be a safe and effective medication for use with out-of-control people, and, in addition, it can be useful to manage agitation in many situations.
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Story Two – Mrs. Melville’s Rheumatoid Arthritis
Most people are familiar with rheumatoid arthritis. It’s a chronic disease, chronic meaning that once it appears it’s life long, like diabetes, or asthma, or heart disease. Though it lasts for years, it’s not always at the same intensity as time goes by. There are times when it becomes more active and worsens quickly. That is, the disease flares. A flare starts with routine activities feeling a bit more difficult, then clear muscle tightness and soreness starts. Lethargy sets in and sleep becomes less restful. Twinges of stabbing pain start to evolve into more severe, constant, aching pain. The lethargy worsens to feeling sick and active inflammation starts, causing swollen joints, feverish feelings, and chills. Thus was the course for Mrs. Anne Melville, and at its peak the pain and illness was so bad that her physician admitted her to the hospital for treatment.
Getting Mrs. Melville’s Rheumatoid Arthritis Flare Treated Quickly
Once it gets rolling a flare of rheumatoid arthritis can last a long time, weeks or even months. And stopping it quickly is really important beyond the matter of the individual’s comfort. Arthritic activity can actually physically damage the joints’ cartilage and bone. The usual treatment is a brief course of steroids, which stops the inflammation quickly. The steroid is started along with an increase in the patient’s disease-modifying antirheumatic drug. The steroid stops the inflammation quickly and the disease-modifying antirheumatic drug works to protect the joints and organ from permanent damage. Just as Dr. Phillips did with Mrs. Graham above, Anne Melville’s physician started a prednisone bolus and taper: 40 mg, then 30, then 20, and so on. By day 5 Mrs. Melville was down to 5 mg and was feeling much less ill.
Just When It Seemed That Anne Melville’s Health Had Arrived
Her physician was getting ready to send her home. She had done well and certainly no longer needed to be in the hospital. But when the social worker went into her room to discuss discharge planning she did not look well. The social worker asked a nurse to evaluate her. Mrs. Melville had a strange look on her face, some mixture of scared and anxious, and she told the nurse something was wrong. She seemed kind of frozen, as if she couldn’t move much or didn’t want to. The nurse called her physician and she ordered, you guessed it, an emergency psychiatry consultation. The call came into the department and I was “on call” for the group. Mrs. Melville was also on Three-West, the usual floor for rheumatology patients. Since this consult did not say “to be done immediately” I went up about an hour later.
A Really Nice Lady With a Big Concern
I went into her room and she appeared to be just as the nurse and the social worker had described, looking scared and frozen. She didn’t look at me as I walked into her room. I introduced myself and started talking. After a few minutes she moved her eyes to look at me without moving her head. I told her that it did seem that something was clearly wrong but that it was not apparent what it was. Then she said, “So, you don’t see it”. I looked in the direction she was looking and saw nothing, just a typical hospital room picture hanging on the wall. “No, I don’t see it,” I told her, and asked her what she saw. Then she just looked fretful and said, “So, it’s not really there?” “No, I’m sure it’s not,” I told her. She seemed to relax just a bit.
From Big Something to Little Rabbits
I told her that I thought the prednisone had caused her to imagine she saw things that weren’t there. I didn’t use the term steroid psychosis, which can sound pretty scary to some people. I explained that today’s prednisone 5 mg was the last dose, so she would not get any more. I asked her what she had seen and she refused to say. “I don’t want to tell anyone. They’ll think I’m crazy.” I again explained that the prednisone can do funny things to one’s mind. To this she replied, “So, I guess the little rabbits in that picture on the wall aren’t really moving and hopping around.” I looked at the picture, standard bland hospital art, and smiled. “Mrs. Melville, there aren’t any rabbits in that picture.” She smiled, and I smiled back. Then she laughed. “Too bad,” she said, “They’re such cute little rabbits.”
Homeward Bound for Mrs. Anne Melville
I called her rheumatologist and explained the day’s events in response to his request for a consult. Mrs. Melville seemed fine. I left an order on the chart for risperidone 1 mg if needed, with one repeat six hours later if needed. I recommended he keep her in the hospital that night but that he could discharge her tomorrow if he wished. He agreed with this plan and thanked me. I checked on her the next morning before she went home. She was fine, with a big smile on her face. She still didn’t say what she saw that frightened her, and I didn’t ask. She did again comment that it was too bad that the cute little rabbits hopping about weren’t real.
Helpful links:
Baylor University Medical Center Proceedings on Steroid-induced Psychosis
The Rheumatologist – When Steroids Cause Psychosis
The Journal of Pharmacy Technology on Pharmacological Management of Steroid-Induced Psychosis: A Review of Patient Cases