Adrenal insufficiency presenting with psychosis

Primary adrenal insufficiency (PAI) often presents with nonspecific symptoms; neuropsychiatric features such as psychosis or catatonia are uncommon and easily misattributed. We describe a man in his mid-20s with hallucinations, delusions and catatonia, accompanied by anorexia, vomiting, weight loss and persistent diarrhoea. Examination revealed generalised hyperpigmentation and hypotension with hyponatraemia–hyperkalaemia. Endocrine testing confirmed autoimmune PAI, and corticosteroid plus mineralocorticoid replacement led to rapid resolution of psychiatric and systemic features. Recognising bedside clues such as hyperpigmentation, weight loss, anorexia and salt craving should prompt early endocrine work-up in psychiatric presentations, allowing swift diagnosis and obviating extensive investigations.