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A case of a suicide attempt associated with hyperthyroidism
General Hospital Psychiatry 35 (2013) 576.e9–576.e10
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
A case of a suicide attempt associated with hyperthyroidism Christine E. Petrich, M.D. a,⁎, Melissa P. Bui, M.D. a, Helen M. Farrell, M.D. b a b
Harvard Longwood Psychiatry Residency Training Program, Brookline, MA 02215 Beth Israel Deaconess Medical Center
a r t i c l e
i n f o
Article history: Received 26 October 2012 Revised 17 December 2012 Accepted 19 December 2012 Keywords: Graves’ disease Hyperthyroidism Suicide
a b s t r a c t Hyperthyroidism has profound effects on mental health. The literature is sparse, however, with regard to suicide attempts related to untreated hyperthyroidism. This case report illustrates the presentation of a patient in the intensive care unit after a life-threatening Tylenol overdose presumed to be secondary to adjustment disorder. During the patient's hospitalization, she experienced anxiety, heart palpitations, tachycardia and diaphoresis. The psychiatric consultant, endocrinology consultant and inpatient psychiatry teams helped to diagnose Graves’ disease, significantly changing her treatment and trajectory. © 2013 Elsevier Inc. All rights reserved.
1. Case “Ms. A,” a 24-year-old Caucasian woman, presented to the emergency department of a general hospital after ingesting 100 tablets of Tylenol PM over a 2-day period. She was admitted to the Transplant Surgery Intensive Care Unit (ICU) given the concern that her condition could necessitate liver transplant, for management of an acetaminophen level N 400 μg/ml, critical liver function tests and coagulopathy. Vital signs on admission were as follows: temperature 97.8°F, heart rate 110 beats/min, blood pressure 152/85 mmHg and respiratory rate 20 breaths per minute. Labs were notable for a white count of 17.2 K/μl, alanine aminotransferase of 966 IU/L, aspartate aminotransferase of 1046 IU/L, prothrombin time international normalized ratio (PT-INR) of 2.3, PT of 26 s, serum total bilirubin (TBili) of 6.1 mg/dl and lactate of 3.2 mmol/L. The ICU team administered N-acetylcysteine 8200 mg iv (150 mg/kg) and 1 L of normal saline. Over the next 48 h, her liver function test (LFTs) rose to the 12,000s IU/L, TBili to 7.2 mg/dl and INR to 4.0. The psychiatric consultant was called to assess Ms. A's safety and to advise regarding her candidacy to receive a liver transplant, specifically in order to assess psychosocial factors making her more or less able to tolerate the immediate and long-term demands of liver transplantation. Psychiatry's initial assessment of Ms. A's mental status was remarkable for delirium, presumed due to hepatic encephalopathy, so the initial history was limited and obtained in part from collateral sources. Ms. A had no psychiatric history but for the last year had felt overwhelming anxiety. She often experienced ⁎ Corresponding author. Tel.: +1 617 667 2300x14231. E-mail address: [email protected] (C.E. Petrich). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2012.12.006
chest pain, palpitations, diaphoresis, numbness and tingling. She had started to avoid social functions and limited her activities to time spent with her fiancé, with whom she lived. She continued to maintain an overnight job where she did not have to interact with many other people. Three days into her ICU admission, Ms. A's delirium resolved, her LFTs began to trend down, and her INR normalized. She was no longer in danger of needing a liver transplant and was transferred to a medical step-down unit. The consultant psychiatrist then gained further history, learning that, 5 days prior to Ms. A's overdose, she had argued with her fiancé, and he had called off their engagement. Since then, she had experienced worsened anxiety, depressed mood, poor sleep, poor appetite, poor concentration and feelings of hopelessness. Ms. A was diagnosed with an adjustment disorder with depressed mood and anxiety, and it was decided that she would benefit from psychiatric admission once she medically stabilized. During this time, the psychiatric consultant was managing Ms. A's overwhelming anxiety, which was manifesting as a sinus tachycardia with rate in the 160s beats/min. After she failed to respond to successive doses of lorazepam, the psychiatric consultant recommended thyroid function testing. Ms A's results were as follows: thyroid stimulating hormone undetectable; thyroxine (T4) 11.8 μg/dl (normal 4.6–12 μg/dl); triiodothyronine (T3) 126 ng/dl (normal 80– 200 ng/dl). She was started on propranolol 10 mg three times daily with improvement of heart rate, and endocrinology was consulted. Ms. A gave further history to the endocrinology consultant about her hands being constantly warm and moist. She complained of palpitations when changing position and a few months of chest pain and dyspnea lasting for a few minutes and resolving on their own. She reported alternating constipation and loose stools. Ms. A also said her eyes had been “different” for quite a while and said people had told
576.e10
C.E. Petrich et al. / General Hospital Psychiatry 35 (2013) 576.e9–576.e10
her they “bulge out.” On exam, Ms. A had fine tremor, rapid reflex relaxation and proptosis. Ms. A was further tested for Graves’ disease. T3 uptake ratio was 1.12, and free T4 was 35 mg/dl (normal 0.8–2.7 ng/dl). Thyroid stimulating immunoglobulins were 248% of reference range, antithyroglobulin antibodies were 123 IU/ml (normal 0–40 IU/ml), and anti-thyroid peroxidase antibodies were 175 IU/ml (normal 0–35 IU/ ml). A technetium-99 thyroid scan showed very high homogeneous tracer trapping in the thyroid, consistent with Graves’ disease. Ms. A was treated with methimazole 20 mg daily and atenolol 50 mg daily. She was transferred to the inpatient psychiatry unit. She was not given any psychiatric medication and stayed for 7 days. Her anxiety and suicidal thoughts resolved despite the continuation of life stressors. A 6-month psychiatric follow-up confirmed that she remained free from anxiety without psychiatric medication. 2. Discussion Ms. A's case suggests a biopsychosocial interplay between her Graves’ disease and her psychiatric symptoms, leading to her suicide attempt. She described that severe anxiety mounted over a year along with her physical disease manifestations, a time course suggestive that both were related to hyperthyroidism of Graves’ disease. Her anxiety had left her increasingly dependent on her fiancé. In this predisposing milieu of anxiety and social withdrawal, the loss of her engagement preceded her suicide attempt. The stress itself of the loss may have exacerbated her hyperthyroidism, thus worsening her anxiety both directly and indirectly. This profound anxiety, in turn, likely overwhelmed her coping abilities and contributed to her suicide attempt. Notably, her psychiatric symptoms have not returned since initiation of antithyroid treatment, so she has not required psychotropic management. Originally the medical team attributed Ms. A's tachycardia to an exacerbation of her anxiety. When her tachycardia persisted, the psychiatric consultant recommended evaluation of medical causes, including hyperthyroidism, which in collaboration with the endocrinology consultant led to the diagnosis of Graves’ disease. Ms. A met the criteria for thyroid storm (TS) according to the TS1 criteria proposed by Akamizu and colleagues due to her thyrotoxicosis, psychiatric symptoms, tachycardia and serum bilirubin N3 mg/dl [1]. Patients with psychiatric disorders have elevated rates of thyroid disease [2,3]. Aside from physical symptoms including sweating, fatigue, heat intolerance, hair thinning, gastrointestinal hypermotility, weight loss and muscle weakness, patients with Graves’ disease often present with anxiety, hypomania, depression, cognitive difficulties and personality changes. In younger patients and the elderly, hyperthyroidism can typically manifest either as hyperactivity or as apathy and depression [4–7]. There has not previously been shown to be a clear link between Graves’ disease and attempted or completed suicide [8,9]. On the other hand, stress is associated with the onset of Graves’ disease [10–13]. Both major life events and daily stressors worsen the prognosis of antithyroid treatment [14]. Hyperthyroid symptoms typically resolve with antithyroid therapy or with the use of beta-blockers such as propranolol [15]. However,
long-term neuropsychiatric symptoms following hyperthyroidism have been shown even in many patients who have been appropriately treated [16–18]. Presence of these symptoms when euthyroid aggravates hyperthyroidism, though they are themselves due to emotional stress and not thyrotoxicosis [19]. 3. Conclusion This case illustrates a rare event which is Graves’ disease leading to excessive anxiety and contributing to a suicide attempt. Psychosocial stressors faced by patients can mislead providers into an inaccurate psychiatric diagnosis of adjustment disorder with depressed mood and anxiety. As this case illustrates, even in patients with marked risk factors for self-harm, evaluation for other medical illnesses must occur. The psychiatric consultant can be pivotal in general medical hospitals with regard to accurate diagnosis and treatment. References [1] Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012;22: 661–79. [2] Farmer A, Korszun A, Owen MJ, et al. Medical disorders in people with recurrent depression. Br J Psychiatry 2008;192:351–5. [3] Lobo-Escolar A, Saz P, Marcos G, et al. Somatic and psychiatric co-morbidity in the general elderly population. J Psychosom Res 2008;65:347–55. [4] Boxall E, Lauener R, McIntosh H. Atypical manifestations of hyperthyroidism. Can Med Assoc J 1964;1:204–11. [5] Kathol RG, Turner R, Delahunt J. Depression and anxiety associated with hyperthyroidism: response to antithyroid therapy. Psychosomatics 1986;27: 501–5. [6] Bhatara VS, Sankar R. Neuropsychiatric aspects of pediatric thyrotoxicosis. Indian J Pediatr 1999;66:277–84. [7] Mooradian AD. Asymptomatic hyperthyroidism in older adults: is it a distinct clinical and laboratory entity? Drugs Aging 2008;25:371–80. [8] Drummond L, Lodrick M, Hallstrom C. Thyroid abnormalities and violent suicide. Br J Psychiatry 1984;144:213. [9] Abraham-Nordling M, Lönn S, Wallin G, et al. Hyperthyroidism and suicide: a retrospective cohort study in Sweden. Eur J Endocrinol 2009;160:437–41. [10] Kung AW. Life events, daily stresses and coping in patients with Graves’ disease. Clin Endocrinol 1995;42:303–8. [11] Sonino N, Girelli ME, Boscaro M, et al. Life events in the pathogenesis of Graves’ disease: a controlled study. Acta Endocrinol 1993;128:293–6. [12] Winsa B, Adami H-O, Bergström R, et al. Stressful life events and Graves’ disease. Lancet 1991;338:1475–9. [13] Yoshiuchi K, Kumano H, Nomura S, et al. Stressful life events and smoking were associated with Graves’ disease in women, but not in men. Psychosom Med 1998;60:182–5. [14] Fukao A, Takamatsu J, Murakami Y, et al. The relationship of psychological factors to the prognosis of hyperthyroidism in antithyroid drug-treated patients with Graves’ disease. Clin Endocrinol 2003;58:550–5. [15] Kathman N, Kuisle U, Bommer M, et al. Effects of elevated tri-iodothyronine on cognitive performance and mood in healthy subjects. Neuropsychobiology 1994;29:136–42. [16] Elberling TV, Rasmussen AK, Feldt-Rasmussen U, et al. Impaired health-related quality of life in Graves’ disease. A prospective study. Eur J Endocrinol 2004;151: 549–55. [17] Trzepacz PT, McCue M, Klein I, et al. A psychiatric and neuropsychological study of patients with untreated Graves’ disease. Gen Hosp Psychiatry 1988;10:49–55. [18] Bunevicius R, Velickiene D, Prange AJ. Mood and anxiety disorders in women with treated hyperthyroidism and ophthalmopathy caused by Graves’ disease. Gen Hosp Psychiatry 2005;27:133–9. [19] Fukao A, Takamatsu J, Kubota S, Miyauchi A, Hanafusa T. The thyroid function of Graves’ disease patients is aggravated by depressive personality during antithyroid drug treatment. Biopsychosoc Med 2011;5:9.
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
A case of a suicide attempt associated with hyperthyroidism Christine E. Petrich, M.D. a,⁎, Melissa P. Bui, M.D. a, Helen M. Farrell, M.D. b a b
Harvard Longwood Psychiatry Residency Training Program, Brookline, MA 02215 Beth Israel Deaconess Medical Center
a r t i c l e
i n f o
Article history: Received 26 October 2012 Revised 17 December 2012 Accepted 19 December 2012 Keywords: Graves’ disease Hyperthyroidism Suicide
a b s t r a c t Hyperthyroidism has profound effects on mental health. The literature is sparse, however, with regard to suicide attempts related to untreated hyperthyroidism. This case report illustrates the presentation of a patient in the intensive care unit after a life-threatening Tylenol overdose presumed to be secondary to adjustment disorder. During the patient's hospitalization, she experienced anxiety, heart palpitations, tachycardia and diaphoresis. The psychiatric consultant, endocrinology consultant and inpatient psychiatry teams helped to diagnose Graves’ disease, significantly changing her treatment and trajectory. © 2013 Elsevier Inc. All rights reserved.
1. Case “Ms. A,” a 24-year-old Caucasian woman, presented to the emergency department of a general hospital after ingesting 100 tablets of Tylenol PM over a 2-day period. She was admitted to the Transplant Surgery Intensive Care Unit (ICU) given the concern that her condition could necessitate liver transplant, for management of an acetaminophen level N 400 μg/ml, critical liver function tests and coagulopathy. Vital signs on admission were as follows: temperature 97.8°F, heart rate 110 beats/min, blood pressure 152/85 mmHg and respiratory rate 20 breaths per minute. Labs were notable for a white count of 17.2 K/μl, alanine aminotransferase of 966 IU/L, aspartate aminotransferase of 1046 IU/L, prothrombin time international normalized ratio (PT-INR) of 2.3, PT of 26 s, serum total bilirubin (TBili) of 6.1 mg/dl and lactate of 3.2 mmol/L. The ICU team administered N-acetylcysteine 8200 mg iv (150 mg/kg) and 1 L of normal saline. Over the next 48 h, her liver function test (LFTs) rose to the 12,000s IU/L, TBili to 7.2 mg/dl and INR to 4.0. The psychiatric consultant was called to assess Ms. A's safety and to advise regarding her candidacy to receive a liver transplant, specifically in order to assess psychosocial factors making her more or less able to tolerate the immediate and long-term demands of liver transplantation. Psychiatry's initial assessment of Ms. A's mental status was remarkable for delirium, presumed due to hepatic encephalopathy, so the initial history was limited and obtained in part from collateral sources. Ms. A had no psychiatric history but for the last year had felt overwhelming anxiety. She often experienced ⁎ Corresponding author. Tel.: +1 617 667 2300x14231. E-mail address: [email protected] (C.E. Petrich). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2012.12.006
chest pain, palpitations, diaphoresis, numbness and tingling. She had started to avoid social functions and limited her activities to time spent with her fiancé, with whom she lived. She continued to maintain an overnight job where she did not have to interact with many other people. Three days into her ICU admission, Ms. A's delirium resolved, her LFTs began to trend down, and her INR normalized. She was no longer in danger of needing a liver transplant and was transferred to a medical step-down unit. The consultant psychiatrist then gained further history, learning that, 5 days prior to Ms. A's overdose, she had argued with her fiancé, and he had called off their engagement. Since then, she had experienced worsened anxiety, depressed mood, poor sleep, poor appetite, poor concentration and feelings of hopelessness. Ms. A was diagnosed with an adjustment disorder with depressed mood and anxiety, and it was decided that she would benefit from psychiatric admission once she medically stabilized. During this time, the psychiatric consultant was managing Ms. A's overwhelming anxiety, which was manifesting as a sinus tachycardia with rate in the 160s beats/min. After she failed to respond to successive doses of lorazepam, the psychiatric consultant recommended thyroid function testing. Ms A's results were as follows: thyroid stimulating hormone undetectable; thyroxine (T4) 11.8 μg/dl (normal 4.6–12 μg/dl); triiodothyronine (T3) 126 ng/dl (normal 80– 200 ng/dl). She was started on propranolol 10 mg three times daily with improvement of heart rate, and endocrinology was consulted. Ms. A gave further history to the endocrinology consultant about her hands being constantly warm and moist. She complained of palpitations when changing position and a few months of chest pain and dyspnea lasting for a few minutes and resolving on their own. She reported alternating constipation and loose stools. Ms. A also said her eyes had been “different” for quite a while and said people had told
576.e10
C.E. Petrich et al. / General Hospital Psychiatry 35 (2013) 576.e9–576.e10
her they “bulge out.” On exam, Ms. A had fine tremor, rapid reflex relaxation and proptosis. Ms. A was further tested for Graves’ disease. T3 uptake ratio was 1.12, and free T4 was 35 mg/dl (normal 0.8–2.7 ng/dl). Thyroid stimulating immunoglobulins were 248% of reference range, antithyroglobulin antibodies were 123 IU/ml (normal 0–40 IU/ml), and anti-thyroid peroxidase antibodies were 175 IU/ml (normal 0–35 IU/ ml). A technetium-99 thyroid scan showed very high homogeneous tracer trapping in the thyroid, consistent with Graves’ disease. Ms. A was treated with methimazole 20 mg daily and atenolol 50 mg daily. She was transferred to the inpatient psychiatry unit. She was not given any psychiatric medication and stayed for 7 days. Her anxiety and suicidal thoughts resolved despite the continuation of life stressors. A 6-month psychiatric follow-up confirmed that she remained free from anxiety without psychiatric medication. 2. Discussion Ms. A's case suggests a biopsychosocial interplay between her Graves’ disease and her psychiatric symptoms, leading to her suicide attempt. She described that severe anxiety mounted over a year along with her physical disease manifestations, a time course suggestive that both were related to hyperthyroidism of Graves’ disease. Her anxiety had left her increasingly dependent on her fiancé. In this predisposing milieu of anxiety and social withdrawal, the loss of her engagement preceded her suicide attempt. The stress itself of the loss may have exacerbated her hyperthyroidism, thus worsening her anxiety both directly and indirectly. This profound anxiety, in turn, likely overwhelmed her coping abilities and contributed to her suicide attempt. Notably, her psychiatric symptoms have not returned since initiation of antithyroid treatment, so she has not required psychotropic management. Originally the medical team attributed Ms. A's tachycardia to an exacerbation of her anxiety. When her tachycardia persisted, the psychiatric consultant recommended evaluation of medical causes, including hyperthyroidism, which in collaboration with the endocrinology consultant led to the diagnosis of Graves’ disease. Ms. A met the criteria for thyroid storm (TS) according to the TS1 criteria proposed by Akamizu and colleagues due to her thyrotoxicosis, psychiatric symptoms, tachycardia and serum bilirubin N3 mg/dl [1]. Patients with psychiatric disorders have elevated rates of thyroid disease [2,3]. Aside from physical symptoms including sweating, fatigue, heat intolerance, hair thinning, gastrointestinal hypermotility, weight loss and muscle weakness, patients with Graves’ disease often present with anxiety, hypomania, depression, cognitive difficulties and personality changes. In younger patients and the elderly, hyperthyroidism can typically manifest either as hyperactivity or as apathy and depression [4–7]. There has not previously been shown to be a clear link between Graves’ disease and attempted or completed suicide [8,9]. On the other hand, stress is associated with the onset of Graves’ disease [10–13]. Both major life events and daily stressors worsen the prognosis of antithyroid treatment [14]. Hyperthyroid symptoms typically resolve with antithyroid therapy or with the use of beta-blockers such as propranolol [15]. However,
long-term neuropsychiatric symptoms following hyperthyroidism have been shown even in many patients who have been appropriately treated [16–18]. Presence of these symptoms when euthyroid aggravates hyperthyroidism, though they are themselves due to emotional stress and not thyrotoxicosis [19]. 3. Conclusion This case illustrates a rare event which is Graves’ disease leading to excessive anxiety and contributing to a suicide attempt. Psychosocial stressors faced by patients can mislead providers into an inaccurate psychiatric diagnosis of adjustment disorder with depressed mood and anxiety. As this case illustrates, even in patients with marked risk factors for self-harm, evaluation for other medical illnesses must occur. The psychiatric consultant can be pivotal in general medical hospitals with regard to accurate diagnosis and treatment. References [1] Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012;22: 661–79. [2] Farmer A, Korszun A, Owen MJ, et al. Medical disorders in people with recurrent depression. Br J Psychiatry 2008;192:351–5. [3] Lobo-Escolar A, Saz P, Marcos G, et al. Somatic and psychiatric co-morbidity in the general elderly population. J Psychosom Res 2008;65:347–55. [4] Boxall E, Lauener R, McIntosh H. Atypical manifestations of hyperthyroidism. Can Med Assoc J 1964;1:204–11. [5] Kathol RG, Turner R, Delahunt J. Depression and anxiety associated with hyperthyroidism: response to antithyroid therapy. Psychosomatics 1986;27: 501–5. [6] Bhatara VS, Sankar R. Neuropsychiatric aspects of pediatric thyrotoxicosis. Indian J Pediatr 1999;66:277–84. [7] Mooradian AD. Asymptomatic hyperthyroidism in older adults: is it a distinct clinical and laboratory entity? Drugs Aging 2008;25:371–80. [8] Drummond L, Lodrick M, Hallstrom C. Thyroid abnormalities and violent suicide. Br J Psychiatry 1984;144:213. [9] Abraham-Nordling M, Lönn S, Wallin G, et al. Hyperthyroidism and suicide: a retrospective cohort study in Sweden. Eur J Endocrinol 2009;160:437–41. [10] Kung AW. Life events, daily stresses and coping in patients with Graves’ disease. Clin Endocrinol 1995;42:303–8. [11] Sonino N, Girelli ME, Boscaro M, et al. Life events in the pathogenesis of Graves’ disease: a controlled study. Acta Endocrinol 1993;128:293–6. [12] Winsa B, Adami H-O, Bergström R, et al. Stressful life events and Graves’ disease. Lancet 1991;338:1475–9. [13] Yoshiuchi K, Kumano H, Nomura S, et al. Stressful life events and smoking were associated with Graves’ disease in women, but not in men. Psychosom Med 1998;60:182–5. [14] Fukao A, Takamatsu J, Murakami Y, et al. The relationship of psychological factors to the prognosis of hyperthyroidism in antithyroid drug-treated patients with Graves’ disease. Clin Endocrinol 2003;58:550–5. [15] Kathman N, Kuisle U, Bommer M, et al. Effects of elevated tri-iodothyronine on cognitive performance and mood in healthy subjects. Neuropsychobiology 1994;29:136–42. [16] Elberling TV, Rasmussen AK, Feldt-Rasmussen U, et al. Impaired health-related quality of life in Graves’ disease. A prospective study. Eur J Endocrinol 2004;151: 549–55. [17] Trzepacz PT, McCue M, Klein I, et al. A psychiatric and neuropsychological study of patients with untreated Graves’ disease. Gen Hosp Psychiatry 1988;10:49–55. [18] Bunevicius R, Velickiene D, Prange AJ. Mood and anxiety disorders in women with treated hyperthyroidism and ophthalmopathy caused by Graves’ disease. Gen Hosp Psychiatry 2005;27:133–9. [19] Fukao A, Takamatsu J, Kubota S, Miyauchi A, Hanafusa T. The thyroid function of Graves’ disease patients is aggravated by depressive personality during antithyroid drug treatment. Biopsychosoc Med 2011;5:9.