Association of Psychosis and Hyperthyroid Goiter

Abstract

Sir: Psychiatric symptoms have been reported, not infrequently, with disorders of the thyroid gland,1 most commonly with hypothyroidism. Additionally, psychosis is quite a rare occurrence,2,3 with hyperthyroxinemia being considered a potential cause.4 We present a case of a young man with preceding symptoms of hyperthyroidism and an acute psychotic state. Case report. Mr. A, a 31-year-old married man, was brought to the psychiatry outpatient clinic by his family in March 2003. Around January 2003, he had started reporting subtle complaints in the form of gradually increasing appetite and thirst, loss of weight, mild tremors, and occasional nervousness without any apparent reason. Around February 2003, he started remaining tense, preoccupied, irritable, and restless, complaining of lack of confidence with poor concentration. Subsequent worsening led to additional features of irrelevant speech, inappropriate affect, paranoid ideas, and auditory hallucinations. Mr. A was premorbidly well-adjusted, with no significant medical or surgical history or any history of substance abuse. There was family history of hypothyroidism in the mother and bipolar affective disorder in the father. Physical examination showed moist palms, fine tremors of fingers, and exaggerated deep tendon reflexes in all the limbs. Mr. A had a soft, diffusely enlarged thyroid gland. Investigations found high triiodothyronine/thyroxine levels, low thyroid-stimulating hormone levels, and high radioactive iodine uptake at 4 hours that became low at both 24 and 48 hours. Ultrasound of the thyroid revealed bilateral symmetrical enlargement of both lobes and isthmus, with multiple tiny nodules. Test for thyroid microsomal antibody was positive. The endocrinologist made a diagnosis of diffuse toxic goiter and advised nonsurgical treatment. Initially, Mr. A was treated with risperidone, clonazepam, and trihexiphenidyl as an outpatient. However, due to nonre-sponse he had to be managed as an inpatient. Olanzapine (10–20 mg/day), lorazepam (4–8 mg/day intravenously/oral), and zolpidem (10 mg nocte) were used for treating psychosis, with carbimazole (40 mg daily) and atenolol (50 mg daily) for hyperthyroidism. Mr. A showed improvement in all the symptoms over the next 7 to 10 days, and the symptoms were negligible after around 4 weeks, except for occasional apprehension regarding his office work. Mr. A was discharged in a stable condition with recommendations to visit psychiatric and endocrinology outpatient clinics and to continue with medicines. His diagnosis at that time was organic delusional (schizophrenia-like) disorder (ICD-10 criteria).5 After discharge, Mr. A maintained euthyroid status (with medication). He was followed up in the psychiatry outpatient clinic. There was no emergence of psychosis; his antipsychotic was tapered and stopped after 6 months. Mr. A was asymptomatic at last follow-up (8 months post-discharge). Patients with elevated thyroid hormonal levels frequently have psychological symptoms and sometimes have well-defined psychotic syndromes, as described above in our index patient. The pattern and association of onset and resolution of symptoms with treatment response in our patient point to the likelihood that the psychosis was secondary to the hyperthyroid state. Case reports refer to certain manifestations, i.e., thyrotoxic psychosis,2 organic schizophreniform disorder in autoimmune thyroiditis,6 and psychosis following acute alteration of thyroid status.7 It is important to distinguish these cases from the transient hyperthyroxinemia that may accompany acute exacerbations of certain psychiatric disorders,8 as the distinction can have important implications for management. As in our index case, most people with a psychotic illness induced by hyperthyroxinemia may respond well to a combination of short-term antipsychotic treatment and management of the underlying thyroid illness.3,9 Other researchers have put forward a case for studying neuropsychiatric aspects of thyroid disorders.3,9 We affirm this suggestion, highlighting the need for a close liaison between psychiatrists and endocrinologists.