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A 42-year-old female with systemic lupus erythematosus is referred for urgent psychiatric evaluation by her rheumatologist. She was started on prednisone 60 mg daily twelve days ago for a severe lupus flare involving nephritis. Over the past five days, her husband reports she has become increasingly irritable, has been sleeping only two to three hours per night without feeling tired, has started three home renovation projects simultaneously, has made several large online purchases, and has been talking rapidly with pressured speech. She has no prior psychiatric history, no family history of bipolar disorder, and no history of substance use. Her SLE disease activity has improved on the corticosteroid course. Mental status examination reveals an elevated, expansive mood with flight of ideas, grandiosity about her renovation abilities, psychomotor agitation, and distractibility. Which assessment approach most accurately characterizes this psychiatric presentation?
Explanation
Corticosteroid-induced psychiatric symptoms follow a dose-dependent pattern with increased risk at prednisone doses above 40 mg/day. Mania is the most common psychiatric presentation at higher doses, typically emerging within the first one to two weeks of therapy. The combination of high-dose corticosteroid exposure, onset within the expected temporal window, no prior psychiatric history, and classic manic symptomatology establishes the substance-induced etiology.
Key Takeaway
Corticosteroid-induced mania occurs in a dose-dependent fashion, most commonly with prednisone doses above 40 mg/day, typically within the first one to two weeks of therapy, and should be the primary diagnostic consideration when manic symptoms emerge in this temporal and pharmacological context in a patient without psychiatric history.