I Experienced Steroid-Induced Psychosis

I’m not one to take my mental health for granted. I’ve worked too hard for my emotional stability. I grew complacent once with disastrous results. After emerging from a prolonged depressive episode in 2008, in which I was hospitalized six times in eighteen months and received ECT, I returned to my chosen field of social work, first part-time, then on a full-time basis. I’d discovered my passion for writing, was participating in workshops and publishing some of my pieces. In 2013, my father passed away and all the anger and resentment I felt towards him imploded until it had no place to go and I attempted suicide.  Until the suicide attempt, I managed to stay out of the hospital for over five years, the longest since my early twenties.

I had grown complacent in therapy, talking in half-truths, lying by omission, behaviors that almost cost me my relationship with my long-time therapist and psychiatrist Dr. L. In 2014, I’d been working with her in transference focused psychotherapy (TFP) for nine years. She almost didn’t let me return to treatment, but eventually relented.

I’m vigilant now as I’ve come to realize there are no guarantees. Mental illness is hard-wired into my DNA from both sides of the family tree. Depression and addiction from my father’s side – plus some undiagnosed craziness from my paternal grandmother – and eating disorders on my mother’s side.

When the coronavirus pandemic was first making headlines in the United States, Dr. L. was on a three-week vacation in Europe. I was no longer seeing her for individual sessions, though she continued to prescribe my meds. I knew if I needed a maintenance session, her door remained open.

We’d terminated after eleven years at the end of 2016 and I was thriving. We were both thrilled.  Memorial Day weekend of 2018, I suffered a stroke, causing weakness on my left side and as I found out later, some cognitive deficits. I spent three weeks in a sub-acute rehabilitative facility receiving intensive physical, occupational and cognitive therapy. I developed a serious post-stroke depression and reached out to Dr. L.  We adjusted my medication and I started therapy again.

My future was unknown. I didn’t know if I’d be able to return to my job as a psychiatric social worker, if my brain would work at that high level of cognitive functioning. I didn’t know if I would be able to write again. I was terrified. I felt as though I’d lost myself.

I did return to work, starting with very limited hours. I worked with a rehabilitative neuropsychologist who guided my journey back to full-time and advocated for me with my organization. It took eleven months, but I’m back full-time. I have to work harder to achieve the same result, which can be disheartening and is frustrating, but I remain grateful because the stroke could have been much worse.

As the pandemic mounted and Dr. L. was away, my caseload started to increase rapidly. I turned on my computer in the morning and I’d have eight new cases. I felt overwhelmed and I was panicking. Until the stroke, I’d been stable on one antidepressant. When I experienced the post-stroke depression, it took a couple of months, but we found a new combination of meds that seemed to work: a second generation antipsychotic, working as an adjunct to my antidepressant and a different type of antidepressant, a tetracyclic as opposed to the serotonin and norepinephrine reuptake inhibitors (SNRI) I was already taking.

Don’t try this at home. Because Dr. L. and I had been working together for so long (fifteen years at this point), I was pretty sure she’d be okay with this. On my own, I increased one of the medications. I didn’t feel better, but I thought maybe it was keeping me from getting worse. When she got back we met via Zoom and she was fine with the increase, even suggested I increase the tetracyclic antidepressant as the SNRI was at the highest therapeutic dose.

After our session, I woke up feeling ill. I have moderate to severe asthma and had just started on one of the biologic medications to try and control what had been steroid dependent asthma. When I called my PCP and described my symptoms, she sent me to be tested for COVID-19. I waited anxiously for the results, but thankfully they were negative.

In the meantime, I was having difficulty breathing. I keep a hearty supply of prednisone, an oral steroid, at home. If I can’t control an asthma attack with my rescue inhaler and/or my nebulizer, then I resort to the steroids to avoid a trip to the emergency room. One of the problems with steroids is that they destroy bone and due to my past copious use of steroids, combined with prolonged course of anorexia, I’ve developed osteoporosis and lost all my teeth. Teeth are bone and they suffer the same consequences as the bones in the rest of our skeleton.

For some reason, my asthma did not ease up. I started on 60 mg of prednisone, a relatively high dose and stayed on that for two days. Walking my forty-lb. fireplug of a rescue dog, Shelby was killing me. I carry an inhaler with me on our walks and I found myself using it nearly every time we went out.

Ideally, the plan is always to taper off steroids as fast as they can be safely decreased. Steroids can’t be stopped suddenly from a high dose. I got stuck on 40 mg. For 6 days. In the middle I saw my pulmonologist who listened to my wheezy lungs and told me to stay on 40 mg for another two days. That was day six.

Day seven, I was feeling off. Not sick off, just off. I wasn’t depressed, but I was restless, irritable and I had a hard time focusing on my work. I regularly telecommute, so I usually work from home, but part of my job entails going out into the field. Now because of the COVID-19 pandemic, all field visits had been suspended.

 I stared at the screen, waiting for my various passwords to make their way to my consciousness. They didn’t come. I don’t know how much time I wasted, staring and waiting. Since the stroke, I kept cheat sheets, even though we’re not supposed to. I resorted to sneaking glances at those over and over because the passwords never stuck.

I had to get away from my desk. I felt as though prickly things were inching their way up my body, surreptitiously, under my skin. Shelby and I headed for the park, a block away. That day happened to be one of the warmest we had this past March.

When we returned, I couldn’t shake the feeling Shelby and I had been followed. I opened my laptop and I draped the cleaning cloth from my eyeglass case over the camera opening. I knew what I was thinking and doing was irrational, but I couldn’t stop my thoughts and the behaviors that followed.

I returned to my desk and tried to work, but I found it even harder to concentrate. When I got a phone call or an e-mail, I was momentarily distracted, but as soon as those tasks ended, my thoughts grew dark and paranoid again.

Earlier in the month, I’d had the opportunity to attend the Tory Burch Embrace Ambition Summit, I’d purchased a bracelet at the summit to wear so I could be remindinded of my goals each time I looked at it. Somehow I’d managed to lose it. I was convinced the bracelet was imbued with magic powers and I needed to find it. I tore the apartment apart looking for it, sure that if I didn’t find it, my life would be ruined.

I’d experienced psychosis before; in 2014, when I fell into a severe depression, it was accompanied by psychotic features. During that time, I had the insight to realize I was experiencing delusions, but that didn’t render my thoughts any less terrifying. Fortunately as my depression started to improve, the psychosis receded.

I made the connection between the high doses of steroids I’d been taking for over a week and the delusions. I felt weak, but I put in a phone call to Dr. L. She called me back within a couple of hours and through tears I told her about being followed from the park and losing my magic bracelet.

Her steady, calm voice was reassuring. She acknowledged my delusions, while offering interpretations on why I might be having those particular thoughts. Dr. L. attributed my paranoia to my feelings of inadequacy at work and my fear I was going to be let go.

I learned from the first eleven years and then the subsequent eighteen months of working with Dr. L. that she was usually right.  This explanation made sense. She suggested I temporarily increase the dosage of the second generation antipsychotic I was taking and try to taper off the steroids as quickly as I safely could. She offered me a Zoom session the next day which I quickly accepted.

That night my mind went in a million different directions. What if I got fired for not making my numbers? My organization, BWellBStrongBPD was not making any money yet. How would I support myself? I laid in bed with my laptop and started googling multiple classes and looking for jobs. There was a pandemic out there. No one was hiring.

The next day I described my franticness to Dr. L.  She said I sounded better than the day before and I agreed with her I felt calmer overall, if not slightly hypomanic and I described to her my mind going all over the place. She agreed to made sense to have a plan in place and linked the hypomania to my creativity. She reassured me that while the stroke may have left my executive functioning skills compromised, it didn’t affect my creativity, and will eventually be what supports me financially.

Dr. L. ended the session because she was scheduled to teach a class via Zoom. 

“You know where to find me.”

It was Friday afternoon and I won’t say getting through the rest of the day was easy. Time was slowed down, but I kept Dr. L.’s words in mind as well as the reassuring tone of her voice.

I kept looking for my magic bracelet, but I never found it.