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Procedia - Social and Behavioral Sciences 84 (2013) 1050 – 1052

3rd World Conference on Psychology, Counselling and Guidance (WCPCG-2012)

Delusional type psychosis associated with hypothyroidism: A case

report
Ghasem Dastjerdi a *
a
Department of psychiatry, shaheed Sadoughi University of medical sciences, Yazd, Iran

Abstract

INTRODUCTION: The association between hypothyroidism and psychiatric disorders especially psychosis well described in
some studies and treatment options of this situation is controversy. The aim of this work is implication the role of early diagnosis
and treatment of hypothyroidism with psychotic manifestation.CASE PRESENTATION: the patient is 53 years old man was
admitted in psychiatric ward because of his jealousy and persecution delusions and some behavioral problems (agitation.
Aggression .insomnia and obsessions).he was history of hyperthyroidism 6 month before admission with TSH lower than 0.1 that
was treated with radioactive Iodine.6 month after this treatment he referred to psychiatrist with psychosis and behavioral
problems that mentioned above and in thyroid function tests his TSH was 57.4 (range: 0.1-5) and T3 and T4 was very lower than
ded
optimally to a combination of levothyroxine (150 microgram daily), haloperidol (15 mg daily) and biperidine. He was
hospitalized tree times after first admission over two year later with psychosis and in every admission he was thyroid
dysfunctions with high TSH (57.4, 19.6, and 32.5) and almost all of symptoms treated with levothyroxine and antipsychotic
drugs.CONCLUSIONS: this case shows the importance of ascertaining the thyroid status in patients with psychotic disorders and
the need to consider hypothyroidism in the differential diagnosis of new onset psychosis. This case illustrates combination
therapy with levothyroxine and antipsychotics are choice option in such situation.
© 2013 The Authors. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
© 2013 Published
Selection by Elsevier
and peer-review Ltd.responsibility
under Selection and of
peer review
Prof. Dr. under theUzunboylu
Huseyin responsibility
&ofDr.Dr. Melehat Halat
Mukaddes Demirok, Near East University, Cyprus
Keywords: delusion, psychosis, hypothyroidism, myxedema , madness

Introduction

The prevalence of overt, or clinical, hypothyroidism is approximately 2 percent in women and less than 0.1
percent in men. Subclinical hypothyroidism also predominates in women, occurring in approximately 7.5 percent of
women and 3 percent in men. Antibodies against the thyroid are the most prevalent cause of hypothyroidism.
Hypothyroidism additionally is associated with reduced central serotonin (5-HT) activity and Brain synthesis of 5-
HT is reduced. Also, serum 5-HT levels correlate positively with serum T3 levels. Symptoms of hypothyroidism
tend to develop when TSH levels increase to 8 to 12 mIU/L or greater. Psychiatric symptoms include depressed
mood, apathy, impaired memory and concentration. Psychotic symptoms, including paranoid ideas,
misidentification, visual and auditory hallucinations, and thought disorder, were originally thought to be common

Corresponding author name: * Ghasem Dastjerdi. Tel.: +98-352-6232005

E-mail address: ghasemdastgerdi@yahoo.com

1877-0428 © 2013 The Authors. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
Selection and peer-review under responsibility of Prof. Dr. Huseyin Uzunboylu & Dr. Mukaddes Demirok, Near East University, Cyprus
doi:10.1016/j.sbspro.2013.06.697
 Ghasem Dastjerdi / Procedia - Social and Behavioral Sciences 84 (2013) 1050 – 1052 1051

(and described as myxedematous madness), but likely occur in 4)less than 5 percent of all patients with
hypothyroidism and tend to emerge after the onset of physical symptoms.( Ashok Chandra Rao R, Bhat V.K
etal,1990).
In one paper a clinical case of thyroid insufficiency who was 63 years old man was admitted in a psychiatric
ward because of his persecutive delusions and behavioral disorders (agitation, aggression) was reported(Boilet D,
Szoke A, 1998). in the other case a 13-year-old boy presented with psychosis(new-onset auditory hallucinations,
severe obsessions) resulting from hypothyroidism(Sadock BJ, Kaplan HI etal ,2009). Although these symptoms also
respond to appropriate thyroid hormone treatment, rapid titration of hormone doses may exacerbate psychosis.
Careful addition of a low dose of antipsychotic to thyroxin has been reported to be well tolerated and results in an
earlier remission of psychosis. TSH testing is the most sensitive assay for hypothyroidism. TSH levels are high and
Level of T4 are low, whereas levels of T3 are low or normal. The physical and mental symptoms in adults are
usually reversible with thyroid replacement. However, long-standing hypothyroidism may produce permanent
cognitive deficits, possibly from neuronal death resulting from thyroid deficiency in the brain (Ashok Chandra Rao
R, Bhat V.K etal, 1990).

Case Presentation:

The patient is 53 years old man was admitted in psychiatric ward because of his jealousy and persecution
delusions and some behavioral problems (agitation. Aggression .insomnia and obsessions).he was history of
hyperthyroidism 6 month before admission with TSH lower than 0.1 that was treated with radioactive Iodine.6
month after this treatment he referred to psychiatrist with psychosis and behavioral problems that mentioned above
and in thyroid function tests his TSH was 57.4 (normal range: 0.1-5) and T3 and T4 was very lower than normal
range. On examination patient has nonpitting edema of the feet and legs. Skin was dry , and voice hoarse ,there was

history and family history of psychosis or other psychiatric disorders. The patient responded optimally to a
combination of levothyroxine( 150 microgram daily), haloperidol (15 mg daily) and biperidin.he was likely
symptom free for 6 months and that time he was hospitalized with control delusion, persecution, restlessness and
insomnia. In TFT his TSH was 19.6. Almost all of symptom treated with levothyroxine and antipsychotic drugs and

admitted because of jealousy delusions,. Self-talking, persecution, insomnia, doubt and washing compulsions and
TSH=32.5, T4=8, T3=73. After 2 weeks he discharged with acceptable state. overall He was hospitalized tree times
after first admission over two year later with psychosis and in every admission he was thyroid dysfunctions with
high TSH (57.4, 19.6, and 32.5) and almost all of symptoms treated with levothyroxine and antipsychotic drugs.

Conclusion and discussion:

In 1888, the Committee on Myxedema of the Clinical Society of London first linked hypothyroidism with

1949, R i c h a r d Asher, for the firsttime used the term ''myxedematous

madness" to describe the psychotic illness .he observed in 14 patients of overt hypothyroidism He described this as
one of the most frequently missed causes of organic psychosis.( Thomas W. Heinrich,, Garth Grahm, 2003).
Myxedematous madness is an acute or chronic organic brain syndrome occurring in cases of severe
hypothyroidism. Publication of this case may call attention to the very important fact that hypothyroidism causes
psychosis. Possibly there are many cases in mental hospitals which have not been diagnosed. There is no specific
psychosis, but paranoid ideas are common. Their potential subtle manifestations of hypothyroidism make it a
diagnosis that is easy to miss. Behavioral changes may occur in the absence of the classical physical signs and
symptoms of the disorder. As a result, it is imperative to remember that many patients presenting with psychiatric
disorders may have alterations in endocrine function. Since psychiatric complaints may be one of the earliest
1052 Ghasem Dastjerdi / Procedia - Social and Behavioral Sciences 84 (2013) 1050 – 1052

manifestations of hypothyroidism, they are often misdiagnosed as functional psychiatric disorders, rather than a
psychiatric disorder due to a general medical condition. This confusion leads to delayed treatment and a high
likelihood of increased morbidity. Treatment of this condition is controversy, thyroid hormone alone or combination
of antipsychotics and levothyroxine? More documents and papers recommend the second choice (combination
therapy). (Ashok Chandra Rao R, Bhat V.K eta,1990). This case illustrates combination therapy with levothyroxine
and antipsychotics are probably choice option in such situations and shows the importance of ascertaining the
thyroid status in patients with psychotic disorders and the need to consider hypothyroidism in the differential
diagnosis of new onset psychosis.

References

Ashok Chandra Rao R, Bhat V.K ,Satish K. . (1990).Myxoedema presenting with psychosis . Indain journal psychiatry,32(3), 287 289

Boilet D, Szoke A.( 1998). Psychiatric manifestations as the only clinical sign of hypothyroidism. Apropos of a case,Encephale,24(1):65-8.

Sadock BJ, Kaplan HI, Sadock VA,Ruiz P. (2009). Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th Edition. Lippinco tt Williams
& Wilkins . chapter 24.7

Thomas W. Heinrich,, Garth Grahm. (2003) . Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited. Prim Care Companion J
Clin Psychiatry, 5(6): 260 266

Tor PC,Lee HY , Fones Cs.(2003) . Late-onset mania with psychosis associated with hypothyroidism in an elderly Chinese lady. Singapore Med
J,48(4):354-7