Cushing syndrome

Page most recently updated 7 September 2026

This page focuses on the reported psychiatric associations, which may be the initial presenting manifestation, and on other clinical features that may assist the psychiatrist or primary care physician in identifying the underlying diagnosis, considered through the lenses of the diagnostic lenses framework.

Cushing syndrome is an endocrine disorder characterized by prolonged exposure to excessive glucocorticoid activity, resulting in multisystemic effects.

It can present with psychiatric features such as depression, anxiety, irritability, emotional lability, sleep disturbance, cognitive impairment, mania, and, less commonly, psychosis. Psychiatric symptoms may be prominent and can occur alongside or precede recognition of the characteristic physical features of hypercortisolism.

Other characteristic features include cognitive impairment, sleep disturbance, headache, and, in severe cases, neurological complications related to metabolic and vascular effects of hypercortisolism.

From a multisystemic lens perspective, clinical features in other body systems include (but are not limited to):

  • Cardiovascular: hypertension, increased cardiovascular risk, and thromboembolic risk may occur.

  • Renal/electrolytes: hypokalaemia and metabolic alkalosis may occur, particularly with more severe cortisol excess.

  • Gastrointestinal: dyspeptic symptoms and peptic ulcer disease may occur, particularly in the presence of additional risk factors.

  • Endocrine: glucose intolerance or diabetes mellitus, menstrual irregularity, hypogonadism, and suppression of the hypothalamic–pituitary–gonadal axis may occur.

  • Hematologic: leukocytosis and a hypercoagulable state may occur.

  • Musculoskeletal: proximal muscle weakness, muscle wasting, osteoporosis, and fragility fractures are characteristic complications.

  • Dermatologic: central adiposity with relatively thin limbs, facial rounding, dorsocervical fat accumulation, skin thinning, easy bruising, wide violaceous striae, acne, and impaired wound healing are characteristic.

Early diagnosis is important to identify and treat the source of cortisol excess, reduce the risk of cardiovascular, metabolic, thromboembolic, infectious, and skeletal complications, address potentially reversible psychiatric manifestations, and improve prognosis and quality of life.

Selected references and further reading — Multisystemic lens

Cardinal RN, Bullmore ET. The diagnosis of psychosis. Cambridge: Cambridge University Press; 2011.

Sachdev PS, Keshavan MS, editors. Secondary schizophrenia. Cambridge: Cambridge University Press; 2010.

Levenson JL, editor. The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. 3rd ed. Washington (DC): American Psychiatric Association Publishing; 2019.

Stern TA, Beach SR, Smith FA, Freudenreich O, Vranceau AM, Fava M, editors. Massachusetts General Hospital handbook of general hospital psychiatry. 8th ed. Philadelphia: Elsevier; 2025.

Arciniegas DB, Yudofsky SC, Hales RE, editors. The American Psychiatric Association Publishing textbook of neuropsychiatry and clinical neurosciences. 6th ed. Washington (DC): American Psychiatric Association Publishing; 2018.

Agrawal N, Faruqui R, Bodani M, editors. Oxford textbook of neuropsychiatry. Oxford: Oxford University Press; 2020.

Boland R, Verduin M, editors. Kaplan and Sadock's comprehensive textbook of psychiatry. 11th ed. Philadelphia: Wolters Kluwer; 2024.

Loscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison's principles of internal medicine. 22nd ed. New York: McGraw Hill; 2025.