Between Crisis and Clarity: Steroid-Induced Psychosis in Addison Disease

Glucocorticoids are indispensable in managing inflammatory and endocrine disorders but can cause neuropsychiatric effects ranging from mood elevation to frank psychosis. Severe psychiatric reactions occur in up to 6% of patients receiving systemic corticosteroids, with higher doses conferring greater risk.^1,2 While these effects are generally reversible after dose reduction or withdrawal, management becomes particularly challenging in patients with Addison disease, for whom corticosteroids are vital for survival.

Case Report

A 32-year-old woman with long-standing Addison disease and autoimmune hypothyroidism presented to the emergency department with pain and paresthesia over the right foot after minor trauma. She was hemodynamically stable, and investigations were normal. After orthopedic assessment, she was discharged with advice to double her usual hydrocortisone dose (10 mg–5 mg–5 mg) for 48 hours as stress coverage.

The following day, she returned with severe hyperventilation and tremulousness. Addisonian crisis was suspected, and she received hydrocortisone 100 mg intravenously, followed by 50 mg every 6 hours. Laboratory tests showed mild, transient hypocalcemia and hypophosphatemia secondary to hyperventilation. Over the next 24 hours, she developed episodes of forced eye closure, jaw stiffness, emotional lability, and intermittent jerky movements mimicking generalized seizures.

Neurologic evaluation revealed normal brain magnetic resonance imaging and cerebrospinal fluid studies. Electroencephalogram demonstrated temporal interictal epileptiform discharges without ictal correlates. Autoimmune and paraneoplastic antibody panels (N-methyl-D-aspartate, voltage-generated potassium channel, antinuclear antibody) were negative. In the absence of metabolic or structural pathology, the timing of symptom onset—within hours of steroid dose escalation—suggested steroid-induced psychosis with functional neurological manifestations (pseudoseizures). Hydrocortisone was tapered to her baseline regimen with the addition of short-term lorazepam. Her mood and behavior normalized over 3 days, and abnormal movements resolved.

Discussion

Steroid-induced psychosis is a dose-dependent, idiosyncratic adverse effect, typically arising within the first week of therapy.^3–5 Common manifestations include euphoria, irritability, insomnia, depression, mania, or psychosis.⁶ In Addison disease, physicians may hesitate to reduce steroids due to fear of adrenal crisis, but as this case illustrates, even brief supraphysiologic exposure can precipitate significant psychiatric symptoms. Judicious titration and close monitoring are therefore critical during stress dosing.

This case highlights a rare but clinically significant dilemma—balancing essential corticosteroid replacement against neuropsychiatric toxicity. Recognition of early warning signs and timely dose adjustment can prevent unnecessary investigations and improve outcomes.

Article Information

Published Online: March 24, 2026. https://doi.org/10.4088/PCC.25cr04122
© 2026 Physicians Postgraduate Press, Inc. Prim Care Companion CNS Disord 2026;28(2):25cr04122
Submitted: October 29, 2025; accepted December 23, 2025.
To Cite: Xavier V, Jos R, Salahudeen R. Between crisis and clarity: steroid-induced psychosis in Adison disease. Prim Care Companion CNS Disord 2026;28(2):25cr04122.
Author Affiliations: Department of Internal Medicine, Aster Medcity, Cochin, Kerala, India (Xavier, Jos, Salahudeen).
Corresponding Author: Vinod Xavier, DNB, Department of Internal Medicine, Aster Medcity, Cochin, Kerala, India ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Acknowledgment: The authors thank the Department of Psychiatry, Aster Medcity, for their valuable input in the evaluation and management of this patient.
Patient Consent: Written informed consent was obtained from the patient to publish the case report, and information has been de-identified to protect patient anonymity.
ORCID: Vinod Xavier: https://orcid.org/0000-0002-8883-9665; Renji Jos: https://orcid.org/0009-0005-4578-5934; Roshan Salahudeen: https://orcid.org/0009-0000-5092-4648