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Steroid induced rare bipolar mood disorder
Case reports
264
paraphilias (Cames, 1989; Prentky et al, 1989). Our first case presented with voyeurism but has a strong secondary component of compulsive masturbation. There has been suggestion that these two conditions lie on the same continuum with PA on the severe end and NPSA on the mild end. Researchers of both sexual disorders and obsessive compulsive disorders (OCD) (Hollander, 1991) have suggested that this spectrum includes sexual behaviours such as compulsive masturbation and repetitive promiscuity. OCD patients frequently have obsessions with a sexual content and may be plagued by religious and moral concerns about sexual issues. Furthermore, OCD patients do not always experience their symptoms as senseless and may obtain a sense of relief from completion of rituals. Conversely, patients with paraphilias and sexual addictions may experience their sexual urges as alien to their self-image and while enactment of fantasies may be anxiety relieving, it may also lead to discomfort. Besides this, both the conditions share the same psychological and social sequelae eg depression, feelings of loss of control, inability to maintain a romantic relationship, sexual activity jeopardizing the well being of family, difficulty in maintaining a desired level of social or recreational activity, interference with work studies, sexual activity during work hours and decreased work productivity and financial problems. Paraphilic behaviours are currently characterized as impulse disorders; non-paraphilic sexual behaviours as “addiction” or compulsions. Serotonin reuptake blockers are useful both in OCD and in impulsive patients. As such they should be useful in PA and NPSA as well. They are also effective for the depressive symptoms
Steroid
induced
PK Mazumdar,
rare bipolar
mood disorder
MA Najib, SL Varma
Department of Psychiatry, siti Sains Malaysia, 16150,
School &bang
of Medical Sciences, UniverKerian, Kelantan Malaysia
(Received 25 October 1994; accepted 15 November 1994) Summary - A patient with multiple psychosomatic disorder developed a steroid induced rare bipolar mood disorder (both mania and depression). The “unmasking effect” of steroids and a positive family history of psychiatric disorder as a possible risk factor, hitherto undocumented, is suggested in steroid induced
psychosis.
bipolar mood disorder
/ steroid
/ psychosomatic
disorder
Introduction Corticosteroids have established themselves as a treatment for various medical illness. The incidence of steroid induced psychiatric syndromes varies from .5.7-50% (Lewis and Smith, 1983). The common psychiatric manifestations are depressive syndrome (40%), manic syndrome (31%), both manic and depressive syndrome
accompanying these conditions. Both patients improved after treatment with clomipramine. However this was not a clinical trial and there were no controls. It may be possible that the antidepressant merely reduced sexual desire as a side effect. However, it is well known that antidepressants are far more likely to improve sexual interest and increase sexual desire in depressed men. In conclusion the use of clomipramine in the treatments of sexual
deviation
and
addiction
merits
attention
and
needs more systematic research.
References Barth RJ, Kinder BN. The mislabelling of sexual impulsivity. J Sex Marital Ther 1987;13:15-23 Cames P. Out of the shadows: understanding sexual addiction. Minneapolis: Compcare, 1983 Carnes P. Contrary to love: helping the sexual addict. Mmncapolis, MN: Compcare, 1989 Colemen E. The obsessive-compulsive model for describing compulsive sexual behaviour. Am J Prev Psychiatry Neural 1990;2:9-13 Hollander E. Serotonergic drugs and the treatment of disorders related to obsessive compulsive disorder. In: Pato M, Zohar J, eds. Current treatments of obsessive compulsive disorder. Washington DC: American Psychiatric Press, 1991;173-92 Kafka MP. Successful antidepressent treatment of NPSA and PA men. J Clin Psychiatry 1991;52:&5 Prentky RA, Burgess AW, Rokous F. The presumptive role of fantasy in serial sexual homicide. Am J Psychiatry 1989;146:887-91 Quadland MC. Compulsive sexual behaviour: definition of a problem and an approach to treatment. J Sex Marital Ther 1985;11:121-32
combined (11%) and acute psychotic reaction (16%) (Ling et al, 1981). They usually occur in the early course of treatment with no convincing evidence of past history of psychiatric illness and premorbid personality being risk factors. The prognosis is generally favourable with over 50% of cases recovering within two weeks and over 90% are well within 6 weeks (Lewis and Smith, 1983).
Case report MC, a 34 year old Siamese housewife, with a family history of depression (mother and sister), was a known case of thyrotoxicosis since 1984 (on carbimazole), psoriasis since 1985 and mitral valve prolapse since early 1994. She presented with a two month history of ulcerative colitis with concurrent erythema nodosum and polyarthritis and was put on prednisolone 40 mg daily. She showed rapid improvement with this treatment and was subsequently discharged with prednisolone 30 mg daily. Four weeks later, she presented to the medical clinic with extravagant dressing, euphoria, excessive talking, mega planning, unrealistic ambitions and claimed to have a sixth sense. Detailed history revealed that during this period she was very friendly and social with strangers, irritable with frequent anger outbursts, sleepless and
Case reports
highly charitable with multiple business misadventures. A mental state examination revealed pressure of speech, elated affect, grandiose delusions and distractibility. A diagnosis of bipolar mood disorder, currently in manic state, was made and she was put on haloperidol, initially 10 mg and subsequently increased to 30 mg daily in divided dosage along with benzhexol 4 mg daily. Prednisolone was gradually reduced and stopped by the consulting physician. The patient showed remarkable improvement within one week of treatment and maintained such improvement for one month following which she developed features of major depression. Haloperidol was stopped and dothiepin hydrochloride was started. At present, she has been on 125 mg for seven weeks and on regular follow-up.
Discussion The cardinal features of this case are presence of multiple psychosomatic disorder like psoriasis, ulcerative colitis and thyrotoxicosis. She also has a strong family history of depression both in mother and sister and steroid induced mood disorder. The classical features of steroid induced psychosis evident in this case are her sex which is known to be at higher risk than males (Lewis and Smith, 1983), the development of abnormal behaviour within one month of steroid treatment (Lewis and Smith, 1983; Smyllie and Connolly, 1968). remarkable improvement of mania within a short period of treatment (Lewis and Smith, 1983) ie one week in this case and the relative non-responsiveness of the depression with the conventional antidepressants (Hall et al, 1979). The rare and other interesting highlights of the case are the occurrence of both mania and depression in the same case which account for only 11% of the total steroid induced psychiatric disorders (Lewis and Smith, 1983) and its
265
evolution in a genetically predisposed but otherwise (psychiatrically) normal female and the possible contributory role of psychosomatic disorders with bipolar mood disorder. Both these phenomena may be explained by an “unmasking” effect of steroids in a genetically predisposed patient. The same logic leads to a suggestion of positive family history as a potential risk factor for steroid induced psychosis. This finding of family history as a possible risk factor is not reported as yet, although the past history of psychiatric illness and premorbid personality as possible risk factors is discussed (Lewis and Smith, 1983; Hall er al, 1979). The other possibility is that it is a purely rare steroid induced independent syndrome (Ling et al, 1981). The role of psychosomatic disorder in the genesis of a mood disorder in this case is uncertain. It might have played a synergistic role and so is another risk factor either alone or in conjunction with positive family history in the evolution of steroid induced psychosis. It might also be just a coincidental finding. So an undescribed “unmasking effect” of corticosteroid is postulated in this case along with the suggestion of two possible new risk factors of family history of psychiatric illness and presence of psychosomatic factor. Further studies are needed to confirm this finding.
References Hall
RCW, Popkin MK, Kirkpatrick B. Tricyclic exacerbation of steroid psychosis. J Nerv Ment Dis 1979;167:229-36 Lewis DA, Smith RE. Steroid induced psychiatric syndromes. JAffective Disord 1983;5:319-32 Ling MHM, Perly PJ, Tsuang MT. Side-effects of corticosteroid therapy-psychiatric aspects. Arch Gen Psychiatry 1981;38:471-7 Smyllie HC, Connolly CK. Incidence of serious complications of corticosteroid therapy in respiratory disease. Thorax 1968;23:571-81
264
paraphilias (Cames, 1989; Prentky et al, 1989). Our first case presented with voyeurism but has a strong secondary component of compulsive masturbation. There has been suggestion that these two conditions lie on the same continuum with PA on the severe end and NPSA on the mild end. Researchers of both sexual disorders and obsessive compulsive disorders (OCD) (Hollander, 1991) have suggested that this spectrum includes sexual behaviours such as compulsive masturbation and repetitive promiscuity. OCD patients frequently have obsessions with a sexual content and may be plagued by religious and moral concerns about sexual issues. Furthermore, OCD patients do not always experience their symptoms as senseless and may obtain a sense of relief from completion of rituals. Conversely, patients with paraphilias and sexual addictions may experience their sexual urges as alien to their self-image and while enactment of fantasies may be anxiety relieving, it may also lead to discomfort. Besides this, both the conditions share the same psychological and social sequelae eg depression, feelings of loss of control, inability to maintain a romantic relationship, sexual activity jeopardizing the well being of family, difficulty in maintaining a desired level of social or recreational activity, interference with work studies, sexual activity during work hours and decreased work productivity and financial problems. Paraphilic behaviours are currently characterized as impulse disorders; non-paraphilic sexual behaviours as “addiction” or compulsions. Serotonin reuptake blockers are useful both in OCD and in impulsive patients. As such they should be useful in PA and NPSA as well. They are also effective for the depressive symptoms
Steroid
induced
PK Mazumdar,
rare bipolar
mood disorder
MA Najib, SL Varma
Department of Psychiatry, siti Sains Malaysia, 16150,
School &bang
of Medical Sciences, UniverKerian, Kelantan Malaysia
(Received 25 October 1994; accepted 15 November 1994) Summary - A patient with multiple psychosomatic disorder developed a steroid induced rare bipolar mood disorder (both mania and depression). The “unmasking effect” of steroids and a positive family history of psychiatric disorder as a possible risk factor, hitherto undocumented, is suggested in steroid induced
psychosis.
bipolar mood disorder
/ steroid
/ psychosomatic
disorder
Introduction Corticosteroids have established themselves as a treatment for various medical illness. The incidence of steroid induced psychiatric syndromes varies from .5.7-50% (Lewis and Smith, 1983). The common psychiatric manifestations are depressive syndrome (40%), manic syndrome (31%), both manic and depressive syndrome
accompanying these conditions. Both patients improved after treatment with clomipramine. However this was not a clinical trial and there were no controls. It may be possible that the antidepressant merely reduced sexual desire as a side effect. However, it is well known that antidepressants are far more likely to improve sexual interest and increase sexual desire in depressed men. In conclusion the use of clomipramine in the treatments of sexual
deviation
and
addiction
merits
attention
and
needs more systematic research.
References Barth RJ, Kinder BN. The mislabelling of sexual impulsivity. J Sex Marital Ther 1987;13:15-23 Cames P. Out of the shadows: understanding sexual addiction. Minneapolis: Compcare, 1983 Carnes P. Contrary to love: helping the sexual addict. Mmncapolis, MN: Compcare, 1989 Colemen E. The obsessive-compulsive model for describing compulsive sexual behaviour. Am J Prev Psychiatry Neural 1990;2:9-13 Hollander E. Serotonergic drugs and the treatment of disorders related to obsessive compulsive disorder. In: Pato M, Zohar J, eds. Current treatments of obsessive compulsive disorder. Washington DC: American Psychiatric Press, 1991;173-92 Kafka MP. Successful antidepressent treatment of NPSA and PA men. J Clin Psychiatry 1991;52:&5 Prentky RA, Burgess AW, Rokous F. The presumptive role of fantasy in serial sexual homicide. Am J Psychiatry 1989;146:887-91 Quadland MC. Compulsive sexual behaviour: definition of a problem and an approach to treatment. J Sex Marital Ther 1985;11:121-32
combined (11%) and acute psychotic reaction (16%) (Ling et al, 1981). They usually occur in the early course of treatment with no convincing evidence of past history of psychiatric illness and premorbid personality being risk factors. The prognosis is generally favourable with over 50% of cases recovering within two weeks and over 90% are well within 6 weeks (Lewis and Smith, 1983).
Case report MC, a 34 year old Siamese housewife, with a family history of depression (mother and sister), was a known case of thyrotoxicosis since 1984 (on carbimazole), psoriasis since 1985 and mitral valve prolapse since early 1994. She presented with a two month history of ulcerative colitis with concurrent erythema nodosum and polyarthritis and was put on prednisolone 40 mg daily. She showed rapid improvement with this treatment and was subsequently discharged with prednisolone 30 mg daily. Four weeks later, she presented to the medical clinic with extravagant dressing, euphoria, excessive talking, mega planning, unrealistic ambitions and claimed to have a sixth sense. Detailed history revealed that during this period she was very friendly and social with strangers, irritable with frequent anger outbursts, sleepless and
Case reports
highly charitable with multiple business misadventures. A mental state examination revealed pressure of speech, elated affect, grandiose delusions and distractibility. A diagnosis of bipolar mood disorder, currently in manic state, was made and she was put on haloperidol, initially 10 mg and subsequently increased to 30 mg daily in divided dosage along with benzhexol 4 mg daily. Prednisolone was gradually reduced and stopped by the consulting physician. The patient showed remarkable improvement within one week of treatment and maintained such improvement for one month following which she developed features of major depression. Haloperidol was stopped and dothiepin hydrochloride was started. At present, she has been on 125 mg for seven weeks and on regular follow-up.
Discussion The cardinal features of this case are presence of multiple psychosomatic disorder like psoriasis, ulcerative colitis and thyrotoxicosis. She also has a strong family history of depression both in mother and sister and steroid induced mood disorder. The classical features of steroid induced psychosis evident in this case are her sex which is known to be at higher risk than males (Lewis and Smith, 1983), the development of abnormal behaviour within one month of steroid treatment (Lewis and Smith, 1983; Smyllie and Connolly, 1968). remarkable improvement of mania within a short period of treatment (Lewis and Smith, 1983) ie one week in this case and the relative non-responsiveness of the depression with the conventional antidepressants (Hall et al, 1979). The rare and other interesting highlights of the case are the occurrence of both mania and depression in the same case which account for only 11% of the total steroid induced psychiatric disorders (Lewis and Smith, 1983) and its
265
evolution in a genetically predisposed but otherwise (psychiatrically) normal female and the possible contributory role of psychosomatic disorders with bipolar mood disorder. Both these phenomena may be explained by an “unmasking” effect of steroids in a genetically predisposed patient. The same logic leads to a suggestion of positive family history as a potential risk factor for steroid induced psychosis. This finding of family history as a possible risk factor is not reported as yet, although the past history of psychiatric illness and premorbid personality as possible risk factors is discussed (Lewis and Smith, 1983; Hall er al, 1979). The other possibility is that it is a purely rare steroid induced independent syndrome (Ling et al, 1981). The role of psychosomatic disorder in the genesis of a mood disorder in this case is uncertain. It might have played a synergistic role and so is another risk factor either alone or in conjunction with positive family history in the evolution of steroid induced psychosis. It might also be just a coincidental finding. So an undescribed “unmasking effect” of corticosteroid is postulated in this case along with the suggestion of two possible new risk factors of family history of psychiatric illness and presence of psychosomatic factor. Further studies are needed to confirm this finding.
References Hall
RCW, Popkin MK, Kirkpatrick B. Tricyclic exacerbation of steroid psychosis. J Nerv Ment Dis 1979;167:229-36 Lewis DA, Smith RE. Steroid induced psychiatric syndromes. JAffective Disord 1983;5:319-32 Ling MHM, Perly PJ, Tsuang MT. Side-effects of corticosteroid therapy-psychiatric aspects. Arch Gen Psychiatry 1981;38:471-7 Smyllie HC, Connolly CK. Incidence of serious complications of corticosteroid therapy in respiratory disease. Thorax 1968;23:571-81