Corticosteroids PMHNP Exam

### **Corticosteroids in the PMHNP Exam**

**Corticosteroids** are **anti-inflammatory medications** that **affect mood, cognition, and behavior** by **altering neurotransmitter activity and the hypothalamic-pituitary-adrenal (HPA) axis**. They are frequently tested on the **PMHNP-BC exam**, especially in relation to **steroid-induced psychiatric symptoms, withdrawal effects, and long-term complications**.

## **1. Commonly Used Corticosteroids**
- **Prednisone**
- **Dexamethasone**
- **Methylprednisolone**
- **Hydrocortisone**
- **Fludrocortisone** (mineralocorticoid)

Used to treat **asthma, autoimmune diseases, allergies, inflammation, and adrenal insufficiency**.

## **2. Psychiatric Effects of Corticosteroids**
| **Effect** | **Symptoms** | **Risk Factors** |
|-----------|------------|----------------|
| **Mood Changes** | **Irritability, euphoria, mania, depression** | **High doses (over 40 mg/day), long-term use** |
| **Psychosis** | **Hallucinations, paranoia, delusions** | **High-dose steroids, rapid dose increase** |
| **Cognitive Impairment** | **Memory loss, difficulty concentrating** | **Long-term use, older adults** |
| **Insomnia** | **Restlessness, difficulty sleeping** | **Higher doses, nighttime dosing** |
| **Anxiety & Agitation** | **Panic-like symptoms, restlessness** | **Dose-dependent risk** |

- **High doses (over 40 mg/day) or long-term use increase risk of psychiatric symptoms.**
- **Mood symptoms can occur within days of starting steroids.**
- **Steroid-induced psychosis is more common in patients with a history of mental illness.**

## **3. Corticosteroid Withdrawal & Adrenal Insufficiency**
- **Abrupt discontinuation of corticosteroids can cause adrenal insufficiency:**
- **Fatigue, depression, hypotension, nausea, joint pain, dizziness**
- **Can mimic major depressive disorder or medical illness**
- **Gradual tapering is necessary to prevent withdrawal effects.**
- **Long-term corticosteroid use suppresses the HPA axis → Sudden discontinuation can be fatal.**

## **4. Corticosteroids & Comorbid Psychiatric Disorders**
| **Psychiatric Disorder** | **Steroid Effect** | **Clinical Concern** |
|----------------|----------------|----------------|
| **Depression** | Can **worsen depressive symptoms** | Higher risk of **steroid-induced mood instability** |
| **Bipolar Disorder** | Can **trigger mania or psychosis** | Avoid in **patients with mood instability** |
| **Anxiety Disorders** | Can cause **agitation, panic-like symptoms** | Consider **lower doses or evening dosing** |
| **Schizophrenia** | May **exacerbate psychotic symptoms** | Monitor for **hallucinations, paranoia** |
| **PTSD** | Can increase **hyperarousal, anxiety** | Avoid prolonged use |

## **5. Treatment of Steroid-Induced Psychiatric Symptoms**
- **For mood symptoms:**
- **First-line:** **Reduce dose or taper steroids if possible**
- **Second-line:** **Mood stabilizers (Lithium, Valproate), Atypical antipsychotics (Quetiapine, Olanzapine)**
- **For psychosis:**
- **Atypical antipsychotics (Risperidone, Quetiapine)**
- **For insomnia & anxiety:**
- **Benzodiazepines (Lorazepam, Clonazepam)** – Short-term use only
- **For adrenal insufficiency:**
- **Gradual steroid tapering, stress-dose steroids if needed**

## **6. PMHNP Exam Key Takeaways**
- **Corticosteroids can cause mood instability (mania, depression), psychosis, anxiety, and cognitive impairment.**
- **High doses (over 40 mg/day) increase risk of psychiatric symptoms.**
- **Long-term use can lead to HPA axis suppression and adrenal insufficiency.**
- **Steroid withdrawal can mimic depression or medical illness (fatigue, hypotension, nausea).**
- **Avoid steroids in patients with bipolar disorder due to mania risk.**
- **Treat steroid-induced psychosis with dose reduction + atypical antipsychotics.**
- **Taper steroids gradually to prevent adrenal crisis.**

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