case vignette tatiana ramage, md pgy2 · on myxedema of the clinical society ... 1949 asher...

Case Vignette

3/24/18 Northern California Psychiatric Society – Annual Meeting

Tatiana Ramage, MD PGY2

2

HPI

• 70 yo woman with history of well-controlled schizophrenia

San Mateo Behavioral Health and Recovery Services| March 24, 2018

• Erratic behavior, confused

• Previously stable > 10 years

3

Patient History

• Psychiatric Hx: Schizophrenia; last saw psychiatrist 1 year ago

• Meds: 2mg Stelazine, L-Thyroxine

• Substance use hx: none

• Family hx: mother with dementia

• Social Hx: never married, lives alone, worked as a transcriber

• PMH/Surg Hx: HTN, DM, thryoidectomy

• Allergies: PCN

San Mateo Behavioral Health and Recovery Services | March 24, 2018

4

Examination

• Vitals: Afebrile. BP 137/110, HR 70, RR 10, O2 95% on RA

• MSE: disoriented, no pmr/pma, affect anxious, TP: tangential , TC: +notable for mild paranoia. No SI/HI/AVH. Judgment/insight: impaired

• Physical Exam: Revealed dry skin with dry hair, facial puffiness. Heart and lung unremarkable.

• MOCA: unable to participate


5

Differential Diagnosis

• Schizophrenia

• Dementia (likely vascular 2/2 DM, frontotemporal)

• Delirium (2/2…..)

• Substance use

• Hypothyroidism induced psychosis


6

Diagnostic Testing


• Imaging: CTH negative

• Labs:• CBC nl• CMP K+ 3.2 • Glucose 130• Lipid panel wnl• UA, UCx neg• No UDS• TSH >125 uIU/mL; T4 <0.1

ng/dL

7

Neuropsychiatric Manifestations

Of

Hypothyroidism


8

Brief Review of Thyroid


T4 T3 T3

EffectsB

B

B

B

rain one

eta-adrenergic asal metabolic rate

T4

T3

80%

20%

9

Hypothyroidism and Neuropsychiatric Symptoms

Psychosis

1888 Committee on Myxedema of

the Clinical Society of London

1949 Asher “myxoedematous

madness”

Multiple case reports…

Mood Cognition


10


Psychosis




madness”


Mood Cognition


1888

50%

11


Psychosis




madness”


Mood Cognition


Asher R., 1949; Br Med J

1888

50%

12


Psychosis




madness”


Mood Cognition


Hall, RC. 1983; Psychosomatics

Granite RB., 1978; J Clin Psychiatry

McGaffee J., 1981; Am Fam Physician.

Madakasira S., 1981; Am J Psychiatry

Davis AT., 1989; Int J Psychiatry Med

Shiykov MA., 2016; BMJ

1888

50%

1970s - present

5-15%

13

Psychosis and Hypothyroidism


Pathophysiology

Sato T., 1986; Acta

Endocrinol

14


Psychosis




madness”


Mood Cognition


15


Psychosis Mood

40% Depressed

Cognition


Ordas DM., 1995; Ann

Clin Psychiatry

Howland RH., 1993; J

Clin Psychiatry

Heinrich TW., 2003; Prim

Care Companion J Clin

Psychiatry

16

Affective Disorders and Hypothyroidism


Clear AJ., 1995; Clin

Endocrinol

Joff RT., 1990; Can J

Psychiatry

Pathophysiology

• central serotonergic deficiency?

• relative cerebral hypothyroidism?

17


Psychosis Mood Cognition

Dementia sx: 66-90%

Possibly irreversible


18



Dementia sx: 66-90%



Leigh H., 1984; Adv Int MedHaggerty JJ Jr., 1986; Am J PsychiatryClarnette, RM., 1994; Geriatr Psychiatry Neurol.

19



Dementia sx: 66-90%



Leigh H., 1984; Adv Int MedHaggerty JJ Jr., 1986; Am J PsychiatryClarnette, RM., 1994; Geriatr Psychiatry Neurol.

20

Cognitive Disorders and Hypothyroidism


Pathophysiology

• mediated by depression?

• decreased cerebral blood flow?

21

So what about Maxine?

Psychosis

Suspicious, delusions

Mood

anxious

Cognition

Executive functionin

g

Attention


22

Treatment

1. Levothyroxine

2. Antipsychotics

3. Dose low, go slow

4. Treatment goal: normalize TSH and T4 and address hypothyroid s/sx

5. Usually resolve over weeks to months


23

Pearls

• Hypothyroidism may affect psychosis, mood, and cognition• Keep on differential, especially for new-onset psychosis or previously

stable patient

• Combo therapy of L-T4 and antipsychotics

• Recovery can take weeks to months


24

Acknowledgements

• San Mateo Behavioral Health and Recovery Services

• Zachary Plaut, MD


25

Extra Slides


26

Question:

What is the correlation between thyroid dysfunction and psychiatric

symptoms?


Jain VK., 1971; Br

J Psychiatry

Lehrmann, JA.,

2002; Gen Hospital

Psychiatry

27

Clinical Features of Hypothyroidism


• Cold intolerance

• Weight gain

• Hair loss

• Hypoactivity, lethargy, fatigue, weakness

• Constipation

• Menstrual irregularities

• Myxedema (facial, periorbital)

• Hoarse voice

• Muscle cramps

• Carpal tunnel syndrome (25-33%)

• Dyspnea on exertion

• Neuropsychiatric symptoms

Luboshitzky R., 1996; Isr J Med

Sci

Endocrine practice 2002; 8: 457-

469

SYMPTOMS

28

Clinical Features of Hypothyroidism



Sci

Endocrine practice 2002; 8: 457-

469

SIGNS LAB FINDINGS

HEENT

Reflexes

Vitals

ECG

• Hair loss• Periorbital/facial edema• Enlarged tongue

Dec. relaxation phase of DTR

• Bradycardia• Diastolic hypertension• Hypothermia

Blunted ECG voltages

TSH

Free T3, T4

Cholesterol

29

Epidemiology of Hypothyroidism

• Prevalence:

0.5% to 18%

• 10x more common in women

• Increases with age

• Usually autoimmune


Sci

30

Brief Review of Hypothyroidism


TSH Level FREE T4 Level

Primary Hypothyroidism Elevated Low

Secondary Hypothyroidism Normal or low Low

Subclinical hypothyroidism Elevated Normal

• Hypothyroidism

• Subclinical hypothyroidism

31

Neurospychiatric Sx of Hypothyroidism

Presentation?

Logothetis J., 1963; J Nerv Ment Dis

Jain VK., 1971; Br J Psychiatry

Lehrmann JA., 2002; Gen Hosp

Psychiatry

Heinrich TW., 2003; Prim Care Companion

J Clin Psychiatry

Highly variable – AH to Capgras syndromePsychosis, Affective, Cognitive

Months to years after physical sx(older literature)

Nope

Onset of sx?

Any correlation

between degree

of thyroid

dysfunction and

psychiatric

symptoms?

32

Bipolar Disorder and Hypothyroidism

- Lower FT4 and higher TSH (both within the normal range) significantly associated with slower response to treatment (Cole DP., 2002; Am J Psychiatry)

- Hypothyroidism may be risk factor for development of rapid-cycling- Antithyroid antibody titers found in 50% of rapid-cycling bipolar

patients (Hennesy, JV., 1996; Endocrinologist)


33

Myxedema Coma


Clinical features of myxedema coma

Decreased mental status

Hypothermia

Bradycardia

Hyponatremia

Hypoglycemia

Hypotension

Precipitating illness

case vignette tatiana ramage, md pgy2 · on myxedema of the clinical society ... 1949 asher...

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