Background: Synthetic corticosteroids are commonly utilized in interventional pain management procedures. These substances have potential side-effects including psychological adverse events. Objective: We describe a case of substance-induced psychotic disorder resulting from corticosteroids administration. Design: Case Report Methods: We describe a 67-year-old male that, six months prior to being consulted at our center, received a cervical epidural, 4 level medial branch blocks, 4 trigger point injections and a tendon injection in the shoulder all including corticosteroids all in one treatment session. Results: Approximately 7 days following the multiple injections, the patient developed psychotic episodes including racing thoughts, anger, agitation, pressured hyperverbal speech and paranoia. The symptoms spontaneously resolved in approximately 7-10 days. Discussion: Although well known as a potential complication, corticosteroid induced psychosis secondary to interventional pain procedures have never been reported. We further discuss this potential side effect of utilizing corticosteroids and emphasize the need for guidelines regarding steroid utilization. Key words: Steroid, corticosteroid, psychosis, psychotic disorder Results: Approximately 7 days following the multiple injections, the patient devel - oped psychotic episodes including racing thoughts, anger, agitation, pressured hyper- verbal speech and paranoia. The symptoms spontaneously resolved in approximately 7-10 days. Discussion: Although well known as a potential complication, corticosteroid induced psychosis secondary to interventional pain procedures have never been reported. We further discuss this potential side effect of utilizing corticosteroids and emphasize the need for guidelines regarding steroid utilization. Key words: Steroid, corticosteroid, psychosis, psychotic disorder Pain Physician 2008; 11:6:917-920 Despite the lack of reports in the pain literature, the current case emphasizes the potential of corticosteroid induced psychosis following multiple interventional pain procedures performed in one session. A 67-year-old, Caucasian male was referred to our pain center for evaluation and management of chronic neck pain as a result of a fall 7 years prior. His Pain Physician: November/December 2008:11:917-920 918 www.painphysicianjournal.com wife. His mental status examination well after the episode was within normal limits, with no evidence of cognitive impairment and no evidence of mood problems, anxiety, or psychosis. The time course of pain relief is consistent with reported onset of corticosteroid induced psychiatric symptoms (8,10,14), although the onset seems to be quite variable between patients (3–11 days; 86% show symptoms within 7 days). The Boston Collaborative Drug Surveillance Pro - gram demonstrated a dose related corticosteroid in - duced incidence of psychiatric disturbances with an upward onset in 18.6% patients receiving > 80 mg prednisone (approximately the same dose equivalence of methylprednisolone), 4.6% when the dose was 41- 80 mg/day and 1.3% when dose was 40 mg or less per day (15). It seems that higher doses of steroid predis - pose individuals to suffer from psychiatric episodes, although it is unclear if the dose impacts the develop- ment of psychosis specifically. From available evidence, the dose does not seem to affect the rate of onset, duration, or severity (16,17). This case would suggest that dose did play a role since the patient was already taking 5 mg oral corticosteroid prior to the interven - tional procedures without developing psychosis. Addi- tionally, the total dose reported for this patient was in past medical history was significant for hypertension treated with nifedipine and polymylagia rheumatica treated with 5 mg daily dose of oral prednisone. The patient is now back living with his www.painphysicianjournal.com 919 Corticosteroid Induced Psychosis in the Pain Management Setting the high range compared to the previously published data linking corticosteroids and psychotic episodes (15). In the current case, the patient was not taking any other medications that could possibly trigger a psychotic episode (the patient was on a stable dose of prednisone without psychosis). Moreover, the lack of manic symptoms despite taking duloxetine further shows a lack of primary psychiatric disorder. There have been reports of corticosteroid induced psychosis following both single (hip; 80 mg depome - drone) and multiple intraarticular (bilateral shoulders; 40 mg methylprednisolone each) injections. In both cases, patients suffered delusional and disorienting episodes (18,19). These doses were slightly less than the total dose the patient in the current report re - ceived, however one should take into account dose equivalents when comparing total absolute doses of corticosteroids (2,3,20). Similar doses of corticoste - roids are reported in interventional pain procedures such as epidural injections, facet joint injections, and sacroiliac joint injections (1,21). Preliminary observations on mental disturbanc - es occurring in patients under therapy with cortisone and ACTH. N Engl J Med 1952; 246:205-216. 17. Glaser GH. Psychotic reactions induced by corticotropin (ACTH) cortisone. Psy- chosom Med 1953; 15:280-291. 18. Baloch N. ‘Steroid psychosis’: A case re- port. Br J Psychiatry 1974; 124:545-546. 19. Robinson DE, Harrison-Hansley E, Spencer RF. Steroid psychosis after an intra-articular injection. Ann Rheum Dis 2000; 59:927. 20. Manchikanti L. Role of neuraxial ste - roids in interventional pain manage - ment. Pain Physician 2002; 5:182-199. 21. Spine J 2005; 5:191-201. 14. Wada K, Yamada N, Suzuki H, Lee Y, Kuroda S. Recurrent cases of cortico - steroid-induced mood disorder: Clini - cal characteristics and treatment. J Clin Psychiatry 2000; 61:261-267. 15. Program BCDS Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther 1972; 13:694-698