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Table of Contents
LETTER TO THE EDITOR
Year : 2021  |  Volume : 35  |  Issue : 4  |  Page : 212-213

Symptomatic hypothyroidism manifesting psychotic relapse in a patient with schizophrenia: A case report


Department of General Psychiatry, Yuli Hospital, Ministry of Health and Welfare, Hualien, Taiwan

Date of Submission30-May-2021
Date of Decision08-Jul-2021
Date of Acceptance10-Jul-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
M.D Chuan- Hsun Yu
No. 448, Chung-Hwa Road, Yuli Township, Hualien County 981
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TPSY.TPSY_42_21

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How to cite this article:
Ko YY, Kao YH, Lin CJ, Chang HY, Yu CH. Symptomatic hypothyroidism manifesting psychotic relapse in a patient with schizophrenia: A case report. Taiwan J Psychiatry 2021;35:212-3

How to cite this URL:
Ko YY, Kao YH, Lin CJ, Chang HY, Yu CH. Symptomatic hypothyroidism manifesting psychotic relapse in a patient with schizophrenia: A case report. Taiwan J Psychiatry [serial online] 2021 [cited 2022 Jan 27];35:212-3. Available from: http://www.e-tjp.org/text.asp?2021/35/4/212/332971



Hypothyroidism, a common endocrine disease, has been reported to have neuropsychiatric symptoms. The term “myxedema madness” was first introduced in 1949 by Asher for the relationship between hypothyroidism and psychosis [1]. The serum level of thyroid hormones influences on psychiatric manifestation and response to treatment strategies [2]. But hypothyroidism-related mental dysregulation can be masked by coexisting psychotic illness. Here, we are presenting a case of patient with schizophrenia, whose symptoms of hypothyroidism were mimicking those seen in a patient with psychotic relapse.


  Case Report Top


Ms. A, a 64-year-old divorced female patient, has been diagnosed as schizophrenia for more than 46 years. She was admitted to a psychiatric chronic ward two years ago, due to her suffering from chronic psychosis. After risperidone treatment of 4 mg per day, her condition was stabilized despite of having residual auditory hallucinations and persecutory delusion. She had a medical history of chronic renal disease and an operation history of total thyroidectomy 10 years previously with a postoperative regular thyroxin sodium supplement.

During this hospitalization, the attending psychiatrist discontinued her thyroxin supplement due to normalized thyroid profile, (serum thyroid stimulating hormone [TSH] = 1.63 μU/mL, free T4 = 0.91 ng/dL, and T3 = 0.35 ng/mL). One week later, her stream of thought became more loosening and circumstantial. She also had worsened persecutory delusion and irritability with subjective dysphoria. Her psychosis was aggravated at first. Facial puffiness and mild hand tremor were observed thereafter. The thyroid profile showed serum TSH = 25.03 μU/mL, free T4 = 0.22 ng/dL and T3 = 0.22 ng/mL, indicating overt hypothyroidism. Psychotic relapse due to hypothyroidism was strongly suggested after a thorough physical examination and laboratory confirmation.

Consequently, the patient resumed thyroxin with her previous dose of 75 μg/day and her neuropsychiatric symptoms were subsided soon after. No antipsychotic treatment dose had been changed throughout relapse and medication compliance was ensured under the supervision of medical staff. [Figure 1] shows the association between her serum thyroid hormone and rated scales of psychotic symptoms. Psychotic symptoms and mood status were measured using a brief psychiatric rating scale and brief symptom rating scale-5.
Figure 1: The correlation between thyroid stimulating hormone and BPRS, BSRS-5. thyroid stimulating hormone Unit is μU/mL. thyroid stimulating hormone, thyroid stimulating hormone; BPRS, brief psychiatric rating scale; BSRS-5, brief symptom rating scale.

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  Comments Top


This case report described an overt hypothyroidism-related psychotic exacerbation in a patient with chronic schizophrenia. Neuropsychiatric symptoms caused by general medical conditions may be similar to patients' original psychotic presentations. According to her thyroid profile, our patient was defined as primary and overt hypothyroidism.

The prevalence of overt hypothyroidism is between 0.3% and 5.3%, depending on the study population and definition [3]. In a population study, the investigators found that the schizophrenia group has a higher proportion of patients with hypothyroidism than the control group (2.01% vs. 1.25%) [4]. Antipsychotic drugs have been speculated for the abnormal serum thyroid hormone levels. In recent retrospective study, the investigators showed that the rate of hypothyroidism is higher in patients with schizophrenia patients under antipsychotic treatment [5]. In addition, the interaction between the hypothalamic–pituitary–thyroid axis and multiple neurotransmitters (involving dopaminergic, serotonergic, glutamatergic, and GABAergic) systems is also implicated in abnormal serum thyroid profile in schizophrenia [6]. We suggest that the importance of thyroid function in patients with schizophrenia should not be neglected.

The clinical symptoms of overt hypothyroidism mimic those of depression, such as fewer weight loss, more appetite changes, and sleep disturbances [2]. Without any specific psychotic characteristics in patients with hypothyroidism, paranoid symptoms, hallucinations, perseveration, and loose of associations are commonly seen [1],[2]. Although no clear diagnosing consensus of “myxoedema madness” exists, psychiatric symptoms occur earlier and more prominent in patients with hypothyroidism compared to physical symptoms [7],[8].

The most common physical symptoms in patients with hypothyroidism are fatigue, cold intolerance, and dry skin [3]. Neurological symptoms include paraesthesia, delayed relaxation of tendon reflex, and ataxia [3]. Since hypothyroidism involves in nearly all major organs [3], review of system should be done carefully. While the severity of psychotic symptoms may be unrelated to the degree of thyroid hormone deficit [9], laboratorial finding of primary hypothyroidism should demonstrate an abnormal thyroid profile [3],[10]. Imaging studies such as electroencephalography, positron emission tomography and single-photon emission computed tomography can give further clinical hints [10].

Regarding the treatment of primary hypothyroidism, oral levothyroxine 1.5–1.8 μg per kg of bodyweight is recommended. The effect of combination of T4/T3 therapy for patients with hypothyroidism is still controversial [2]. Once thyroid hormone profile has been stabilized after 4–12 weeks, repeated measurement should be scheduled every six months or annually [3]. Previous studies suggested that early recognition of thyroid deficiency is essential, and delay in effective treatment can cause irreversible metabolic change even having prolonged psychotic symptoms [8].

In summary, this is a case of a patient with symptomatic hypothyroidism, manifesting psychotic relapse in schizophrenia. Psychotic symptoms were subsided after early recognition and effective thyroxin supplement. Based on the findings of this case report and information from published papers, we suggest that physical examination, laboratory analyses, systemic review, and medical history are important in evaluating patients with psychotic or mood symptoms and should not be overlooked. (The institutional review board of Yuli Hospital approved the publication of this case report (IRB protocol number = YLH-IRB-10193 and date of approval = November 2, 2010) with the stipulation of obtaining a signed informed consent from the patient.)


  Financial Support and Sponsorship Top


None.


  Conflicts of Interest Top


The authors declare no conflicts of interest in writing this case report.



 
  References Top

1.
Asher R. Myxoedematous madness. Br Med J 1949; 2: 555-62.  Back to cited text no. 1
    
2.
Feldman AZ, Shrestha RT, Hennessey JV. Neuropsychiatric manifestations of thyroid disease. Endocrinol Metab Clin North Am 2013; 42: 453-76.  Back to cited text no. 2
    
3.
Chaker L, Bianco AC, Jonklaas J, et al.: Hypothyroidism. Lancet 2017; 390: 1550-62.  Back to cited text no. 3
    
4.
Sharif K, Tiosano S, Watad A, et al.: The link between schizophrenia and hypothyroidism: a population-based study. Immunol Res 2018; 66: 663-7.  Back to cited text no. 4
    
5.
Melamed SB, Farfel A, Gur S, et al.: Thyroid function assessment before and after diagnosis of schizophrenia: a community-based study. Psychiatry Res 2020; 293: 113356.  Back to cited text no. 5
    
6.
Santos NC, Costa P, Ruano D, et al.: Revisiting thyroid hormones in schizophrenia. J Thyroid Res 2012; 2012: 569147.  Back to cited text no. 6
    
7.
Davidoff F, Gill J: Myxedema madness: psychosis as an early manifestation of hypothyroidism. Conn Med 1977; 41: 618-21.  Back to cited text no. 7
    
8.
Azzopardi L, Murfin C, Sharda A, et al.: Myxoedema madness. BMJ Case Rep 2010; 2010: bcr0320102841.  Back to cited text no. 8
    
9.
Lehrmann JA, Jain S: Myxedema psychosis with grade II hypothyroidism. Gen Hosp Psychiatry 2002; 24: 275-7.  Back to cited text no. 9
    
10.
Heinrich TW, Grahm G: Hypothyroidism presenting as psychosis: Myxedema madness revisited. Prim Care Companion J Clin Psychiatry 2003; 5: 260-6.  Back to cited text no. 10
    


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