Late Onset Psychosis and Grave's Disease: A Case Report

Abstract

<h3>Introduction</h3> Prevalence of late life psychosis is 23%, however 60% of new onset psychosis in older individuals are of secondary etiology (Cohen, 2015). Psychosis in the elderly individuals could be primarily due to Very Late Onset Schizophrenia Like Psychosis (VLOSLP) vs secondary causes (Delirium, Dementia, Drugs/illicit substances/toxin, Medical conditions including autoimmune conditions.) The apparent link between autoimmune disorders and psychotic disorders has received increased interest in the last decades (Benros, 2019). A significant positive association was observed for pernicious anemia (OR = 1.91; 95% CI, 1.29–2.84), pemphigoid (OR = 1.90; 95% CI, 1.62– 2.24), psoriasis (OR = 1.70; 95% CI, 1.51–1.91), celiac disease (OR = 1.53; 95% CI, 1.12–2.10), and Graves' disease (OR = 1.33; 95% CI, 1.03–1.72) (Cullen, 2019). In this poster, we are presenting a case of a patient with Grave's disease presenting with first episode of psychosis at late age. <h3>Methods</h3> Elmhurst Hospital Center (EHC) is uniquely placed 545 bedded Hospital having 6 psychiatric inpatient units. We are presenting a case of a patient who was admitted in one of the psychiatric inpatient units. We reviewed studies and reviews over the past 10 years using PubMed, Medline and Google Scholar. Search terms included "psychosis", "autoimmune psychosis", "grave's disease" "autoimmune disorders" "very late onset psychosis" "geriatric psychosis". We reviewed available literature with regards to first episode of psychosis in old age and psychosis in autoimmune disorders specially Grave's disease. <h3>Results</h3> Stratified analyses revealed that not only is there increased comorbidity between NNAI (Non-Neurological Autoimmune) disorders and psychosis, but also NNAI disorders increase the risk for subsequent psychosis and vice versa (Alexis E. Cullen, 2019). Graves' disease which is the most common cause of hyperthyroidism, is also known to be linked to neuropsychiatric issues, and some even present with psychotic disorders (Benros, 2019). A German study found that in a cohort of 100 patients with a schizophreniform illness, 19 had increased antithyroid autoantibodies in sera, and 13 showed signs of intrathecal synthesis hereof (Endres D, 2017). Multiple factors have been suggested to underlie the observed association between NNAI disorders and psychosis, including inflammation, shared genetic vulnerability, predisposing infections, and brain-reactive antibodies (Benros ME, 2014). Along with the abovementioned possible mechanisms, in Grave's disease or hyperthyroidism, adrenergic hyperactivity is hypothesized to be a major cause of psychiatric symptoms (Bunevic?ius, 2010). Our patient's psychotic presentation substantially subsided as pharmacological interventions were taken for both hyperthyroidism and psychotic symptoms. While there have been gradually increasing literature on the association between autoimmune disorder such as Grave's disease and psychosis, there is limited work on the treatment recommendations and prognosis. <h3>Conclusions</h3> Our case is an example of psychosis of secondary etiology (due to autoimmune condition). Research on the field of psychoimmunology is gradually evolving. Most of the available literature is on the possible mechanisms of the association between autoimmune disorders including Grave's disease and psychosis. When patients present with first episode of psychosis at late age, a thorough evaluation and examination are required to rule out possible underlying medical etiologies. Similarly, when patients are diagnosed with Grave's disease and other autoimmune disorders, careful longitudinal monitoring is warranted for the early signs of psychosis. Further expansion of studies is required for targeted treatment recommendations and overall prognosis in such cases. <h3>This research was funded by</h3> No conflict of interest. <h3>References</h3> Jeppesen R and Benros ME (2019) Autoimmune Diseases and Psychotic Disorders. Front. Psychiatry 10:131. doi: 10.3389/fpsyt.2019.00131 Endres D, Dersch R, Hochstuhl B, Fiebich B, Hottenrott T, Perlov E, et al. Intrathecal thyroid autoantibody synthesis in a subgroup of patients with schizophreniform syndromes. J Neuropsychiatry Clin Neurosci. (2017) 29:365–74. doi: 10.1176/appi.neuropsych.16110296 Benros ME, Eaton WW, Mortensen PB (2014): The epidemiologic evidence linking autoimmune diseases and psychosis. Biol Psychiatry 75:300–306. Alexis E. Cullen, S. H. (2019). Associations Between Non-neurological Autoimmune Disorders and Psychosis: A Meta-analysis. Biological Psychiatry, 85:35–48.