Psychoses associated with thyrotoxicosis - 'thyrotoxic psychosis.' A report of 18 cases, with statistical analysis of incidence

Abstract

Objective: To report a series of newly diagnosed thyrotoxic patients with concurrent acute psychosis, and to assess the association between the two disorders. Design: Retrospective study of thyrotoxic patients with associated psychosis ('thyrotoxic psychosis'; TP) requiring inpatient psychiatric care. New Zealand thyrotoxicosis annual incidence figures and first psychiatric admission rates for affective psychosis were utilised to statistically assess the co-occurrence of thyrotoxicosis and affective psychosis. Patients and Methods: During the 20-year study period, 18 inpatients (16 women and 2 men), mean age 54 years, with TP were identified. No patient had a past history of thyrotoxicosis, but four had required psychiatric inpatient care many years earlier. Thyrotoxicosis was documented by radioimmunoassay of thyroid hormone levels, and thyroid scintiscan. Psychiatric manifestations were classified using ICD9 criteria. Results: Thyroid hormone levels were markedly elevated in more than half of our TP patients. All younger patients had Graves' disease, and most older patients toxic nodular goitre. All patients were treated with antithyroid drugs, and all but one subsequently received 131 I therapy. Two patients were not mentally ill when thyrotoxicosis was diagnosed, but suffered major mood swings when thyroid hormone levels were falling. There was no specific psychiatric clinical picture but affective psychoses were commonest -seven depression, seven mania. The other diagnoses were two schizophreniform, one paranoid, and one delirium. Initially, neuroleptic medication was used in all but one patient, and during long-term follow-up (median 11 years) more than half our series had remained well with no further psychiatric problems. Statistical analysis was restricted to thyrotoxic patients with first psychiatric hospital admission for affective psychosis. During the 20-year period, there were nine thyrotoxic patients (95% confidence interval 4.5-17.1) with concurrent affective psychosis requiring first admission, and the calculated expected number was only 0.36. These findings indicate a clear association well above chance co-occurrence. Conclusion: TP is not a specific clinical picture, but affective psychoses are commonest. Statistical analysis of thyrotoxic patients with concurrent affective psychoses showed an incidence well above chance co-occurrence. It appears that thyrotoxicosis may be a precipitant of acute affective psychosis.

Steroid-Induced Psychosis Treated With Valproic Acid and Risperidone in a Patient With Systemic Lupus Erythematosus

“…7 In severe cases, serious manifestations, including impairment in memory, orientation, and judgment; manic excitement; delusions; and hallucinations have been reported. 8 As reported in this case, the most likely etiology of psychosis appears to be manifestation of psychosis secondary to uncontrolled hyperthyroidism. In the present case, effective management of the underlying endocrine disorder resulted in rapid resolution of psychotic manifestations.…”

“…4,5 Although a primary psychotic disorder should be strongly considered in the differential diagnoses, in the absence of substance abuse history (patients can present with acute psychosis with substance abuse), patients with abrupt and unusual onset of psychotic symptoms or manifestations such as nervousness, excitability, irritability, or pressured speech should be screened for thyroid or other underlying endocrine abnormalities. 2,3,[8][9][10] The presence of physical manifestations such as heat intolerance, excessive sweating, weight loss, palpitations, and gastrointestinal symptoms of vomiting and diarrhea along with the above-mentioned symptoms should give rise to a suspicion of hyperthyroidism. No significant psychiatric history, good premorbid functioning, and sudden onset of neuropsychiatric symptoms warrant an investigation for underlying pathology.…”

Psychosis associated with methimazole-induced hypothyroidism: a case report

“…That is thought to happen regardless of whether thyroid function remains high or is moving downward. In the retrospective study of thyrotoxic patients with associated psychosis, sixteen cases occurred in untreated thyrotoxicosis and two developed psychosis within weeks of commencing antithyroid medication when thyroid hormone levels were falling 9 . Bewsher et al describes a patient who developed mental illness at a time when she was euthyroid 7 .…”

Subacute Thyroiditis Presenting as Acute Psychosis: A Case Report and a Literature Review

“…In 1840, Basedow provided the first description of associated psychosis, but it was not until 1886 that a thyrotoxic syndrome of endocrine origin was clearly distinguished from a group of neuroses [6]. Brownlie et al [7] reported a series of newly diagnosed thyrotoxic patients with concurrent acute psychosis which included 11 cases of Graves' disease, six cases of toxic multinodular goiter, and one case of toxic adenoma. They suggested that thyrotoxicosis is a precipitant of acute affective psychosis.…”