Ajayi, OA

Dada, MU

Obadeji, A

Oluwole, MU

English

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SCIENTIFIC LETTER |  http://dx.doi.org/10.4314/ajpsy.v14i4.10 Afr J Psychiatry 2011;14:316-318African Journal of Psychiatry • September 2011 316Catatonia is a complex condition characterized by thepresence of various motor signs and symptoms. It remainsa poorly understood, poorly studied, and poorly recognizedsyndrome.1 Catatonic features are seen in a range ofpsychiatric conditions including psychotic disorders, mooddisorders, conversion disorder and dementia.2 Studies havealso identified over 35 medical and neurological illnessesassociated with catatonia including corticosteroidsexposure, central nervous system (CNS) structural damage,encephalitis and other CNS infections, seizures, metabolicdisturbances, phencyclidine exposure, neurolepticexposure, lupus cerebritis, disulfuram, porphyria, and otherconditions. These medical causes of catatonia account forbetween 20% to 30% of such cases.3Whilst various authors have reported several cases ofpsychiatric illnesses such as mood disorders, psychoticdisorders, delirium and anxiety disorders due to use ofcorticosteroids, there are however, few reported cases ofcatatonia due to steroids. A literature search revealed veryfew articles written on catatonia due to steroids. We report acase of apparent dexamethasone induced psychosispresenting with features of catatonia.B.O, a 20year old female undergraduate in Nigeria, wasbrought to the hospital by her elder sister (who was theinformant). She started using dexamethasone withoutprescription six months prior to presentation because shewanted to increase her body weight. She was introduced tothe drug by the elder sister who was also using it for thesame purpose. She initially started with a dose of 4mg daily(an unused sachet of the drug was brought to the hospitalby the informant) but later increased this to 4mg twice dailyabout two months before presentation. Her reason for theincrement was that she had observed that the drug causesinsomnia and since her exams were approaching, she feltthe need to take something that would keep her awake atnight to study. About two days before presentation, she was observedby the elder sister to have been staying awake almostthroughout the night and was also behaving abnormally, forexample trying to strip herself naked in public. She wasalso observed to be withdrawn and refusing to talkgenerally but at times murmuring the same wordsrepeatedly. Based on these features, she was brought to thehospital. Detailed history from the informant did not revealany abnormalities in the patient before she commenced thedrugs and there was also no family history of anypsychiatric illness. On admission, she was observed to beuncooperative as she refused to obey any instruction. Shewas also mute and maintained abnormal postures. Physicalexamination showed she had high grade fever, muscularrigidity (though some of these features may be suggestiveof neuroleptic malignant syndrome, this patient howeverhad no previous exposure to antipsychotics). She also had acopious whitish vaginal discharge and widespread hypopigmented macular lesions on her body. Various laboratorytests done including a full blood count, electrolytes, ureaand creatinine and retroviral screening did not reveal anyabnormalities. Cortisol levels could however not be donedue to unavailability of facilities to do this. She was commenced on a parenteral benzodiazepine(diazepam) to which she responded favourably. She waslater observed to be speaking irrelevantly with auditoryand visual hallucinations, whilst in clear consciousness.Based on these psychotic symptoms, she was commencedon risperidone. She responded favourably to this and wasdischarged after two weeks on the ward, mentally stablewith no evidence of thought disorder or hallucinations.This case demonstrates that dexamethasone canprecipitate psychotic symptoms with catatonic features(catatonic stupor) in previously well individuals. Theprominent catatonic features seen in this patient weremutism, posturing, withdrawal, rigidity, immobility(assessed using the 14-item Bush-Francis catatoniascreening instrument4).The evidence suggesting causationis that the patient was functioning well even while using thedexamethasone at the initial dose but shortly after sheincreased the dose the psychiatric complications began.Such causation has not been noted in the literature, withonly one of such publications reporting a case ofprednisolone induced mood disorder with catatonicfeatures.5Catatonia has been described by various authors asa"common functional final pathway" in expression of severeneuropsychiatric illness.6 Based on this, it is probable thatthe catatonia occurring due to use of corticosteroids is asevere manifestation of a possible dexamethasone inducedpsychotic disorder in this patient. Probable theories for thiscausation include: • The report by various researchers such as Wolkowitzthat high levels of glucocorticoids cause an increase indopamine levels which consequently leads to variouspsychiatric consequences.7 The effect of theseglucocorticoids have been shown to be mediated by theDexamethasone induced psychosispresenting with catatonic featuresCorrespondenceDr MU Dada email: bu_dada@yahoo.com SCIENTIFIC LETTER |  http://dx.doi.org/10.4314/ajpsy.v14i4.10 Afr J Psychiatry 2011;14:316-318African Journal of Psychiatry • September 2011 318presence of glucocorticoid receptors (GR) in the brainwhich mediate feed back action of steroids.8• That in catatonic patients, as Northoff hypothesizes,there is modulation of cortical and sub corticalstructures due to various conditions. The resultanthyperdopaminergic mesolimbic system may attempt arestitutive down regulation of dopamine to ward offpsychosis, thus affecting other systems and producingmotor symptoms seen in catatonia via the nigrostriatalpathway.9 Hence, corticosteroids which have beenknown to affect cortical and sub cortical structures caninvariably cause catatonic features.The catatonic features observed in this patient weremanaged successfully with a parenteral benzodiazepinewhile the psychotic symptoms were managed withrisperidone. The choice of benzodiazepines was due tothe unavailability of ECT. Benzodiazepines have also beenused successfully in the management of catatoniaassociated with a range of disorders.10 Also, the choice ofrisperidone in the management of psychosis due tocorticosteroids has been reported.11This case report illustrates that psychotic symptomswith catatonic features can be a complication ofcorticosteroid use with parenteral benzodiazepines andoral antipsychotics beneficial in the management of suchpresentations. MU Dada, L Oluwole, A Obadeji, OA AjayiUniversity Teaching Hospital, Ado-Ekiti, Ekiti State, NigeriaReferences 1. Penland HR, Weder N, Tampi RR. The catatonic dilemma expanded.Annals of General Psychiatry 2006; 5(14):1-9.2. Caroff SN, Mann SC, Campbell EC, Sullivan KA. Epidemiology. InCatatonia: from psychopathology to neurobiology. Edited by: CaroffSN, Mann SC, Francis A, Fricchione GL. Washington, DC: AmericanPsychiatric publishing, 2004: 15-31.3. Carroll BT, Goforth HW. Medical catatonia. In Catatonia: frompsychopathology to neurobiology Edited by: Caroff SN, Mann SC,Francis A, Fricchione GL. Washington, DC: American PsychiatricPublishing, 2004:121-127.4. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia, I: rating scaleand standardized examination. Acta Psychiatr Scand 1996; 93:129-136.5. Grigg JR. Prednisolone induced mood disorder with associated catatonia.Journal of Geriatric Psychiatry and Neurology 1989; 2(1): 41-44.6. Northoff G. What catatonia can tell us about "top-down modulation": aneuropsychiatric hypothesis. Behav Brain Sci 2002; 25:555-604.7. Wolkowitz O, Sutton M, Koulo M. Chronic corticosteroneadministration in rats: behavioural and biochemical evidence ofincreased central dopaminergic activity. Eur J Pharmacol 1996; 122:329–338.8. De Kloet ER, Reul JMH. Feedback action and tonic influence ofcorticosteroids on brain receptor systems arising from theheterogeneity of brain. Psychoneuroendo 1987; 12:83-105.9. Northoff G, Kotter R, Baumgart F, Danos P, Boeker H, Schlagenhauf F, etal. Orbitofrontal cortical dysfunction in akinetic catatonia: a functionalmagnetic resonance imaging study during negative emotionalstimulation. Schizophr Bull 2004; 30:405-427.10. Weder ND, Muralee S, Penland H, Tampi RR. Catatonia: a review. AnnClin Psychiatry. 2008; 20(2):97-107.11. Karmer B, Cottingham E. Risperidone in the treatment of steroidinduced psychosis. Journal of Child and AdolescentPsychopharmacology 1999; 9(4):315–316.Mental Health Review Boards (MHRBs) are regarded as thewatch dog structures to protect the human rights of mentalhealth care users and to generally uphold the principles of theMental Health Care Act (MHCA).1 According to the MHCA,MHRB’s have to: consider assisted and involuntary admissions;consider ongoing admission (more frequent periodicalreports); respond to appeals; consider transfer of patients tomaximum security facilities (including state patients); andconsider periodic reports of mentally ill prisoners. Proceduresof admission and discharge are described by the MHCA forvoluntary users (Section 25, Chapter 5), for whom no legalapplication is required. Non-voluntary users include assistedusers (Sections 26 to 31), with an impaired capacity to makean informed decision about own mental health care due tomental illness, and involuntary users (Sections 33 to 38) who, inaddition, also refuse treatment. Helen Joseph Hospital (HJH) in Auckland Park(Johannesburg, South Africa) in southern Gauteng, is a 480-bed regional hospital in an urban setting. The psychiatric unitof the hospital is designated as a 72-hour assessment unit. It isa 30-bed acute adult unit providing inpatient, outpatient, andconsultation/liaison services. After initial assessment andTracking the legal status of a cohortof inpatients on discharge from a 72-hour assessment unitSCIENTIFIC LETTER |  http://dx.doi.org/10.4314/ajpsy.v14i4.11 Afr J Psychiatry 2011;14:318-320

Dexamethasone induced psychosis presenting with catatonic features

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Dexamethasone induced psychosis presenting with catatonic features

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