Hypothyroidism

JULY.AUGUST, 1964

VOLUME V - NUMBER 4

PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE

Hypothyroidism A Psychoendocrinological Evaluation MARTHA SCHO:'l:,

• ~Iany definitions of personality have heen advanced throughout the years. Personality has I)('en described in tenns of heredity or as heing inHuenced by the proportions of the hody. Some believe that personality is the result of certain life experiences, while others hold that constitutional and environmental factors detennine the character structure of the individual. In the present study, we are mainly concerned with the interrelationship of honnones and personality. It is now more or less generally assumed that hormones inHuence physical and ml'lltal well being in general but their specific effect on personality and behavior has not heen studied adequately in all areas. For instance, a great deal has been written about the psychological effects of hyperthyroidism and specnlations as to its possible causes have heen proposed. Relatively little attention and systematic investigation has been devoted to the l'anse of the behavioral manifestations of hypothyroidism. The reason for this lack of attention seems to be that the hypothyroid patient asslllnedly presents little problem to his family I)('caust' of his lethargy and supposed ml:ntal dullness.'" This is in contrast to the hyperthyroid patient who creates problems hecause of his emotional instability and restFrom the J)epartm{'nt of \1{'{Heine, Neuropsychiatric Servin', \lemorial Sloan-Kettering Cann'r Center, New York, N. Y. This study was supported in part hy res{'arch grant \1 IIIH from the National Institute of \Iental Health, 0. S. PlIhlic lIealth Service,

JIlly-August,

Ph.D.

lessness and thl>reby forces the physician's attention upon him. Nevertheless, as far back as 1925 a relationship between low thyroid functioning and mental disease was noted. For instance, Bowman and Fry' have shown that the metaholic rate was below nonnal in 50% of schizophrenic patients and Hoskins and Sleeper" have found that schizophrenic patients can tolerate a high dosage of thyroid substance daily without evidence of toxicity. More recently, Reiss and his co-workers" have found that anxiety states in males were accompanied by a tendency to reduced thyroid function. In another study, Reiss'" reported in psychiatric patients treated with various forms of therapy a high correlation between mental improvement and normal thyroid activity after treatment and between activity below and ahove the nonnal range and lack of improvement regardless of diagnosis or type of treatment. Reiss believes that there is a neuroendocrine interrelationship as a result of which all psychiatric dishlrbances inHuence the endocrine system.";'''''" Recent research emphasizes specific behavioral manifestations of thyroid underfunctioning. For instance Su, Chang and Chang report"" that goiterous children are of lower intelligence, show more concrete thinking and have weaker ego strength than the nonnal control group. Stem"' c'Ompared hypothyroid patients before and after treatment with a brrouP of hyperthyroids and a group of control subjects. Result showed that in the hypothy-

1H64

II 11II1I1111111111111111111111111111111111 a92R-1FK-S9TY

~IIIII

203

psrCHOSO~IATICS

mid group after treatmt'llt speed of tapping decreased significantly while reaction times to auditory and visual stimuli and time estimation became ahout equal to those of control patients. Kenshalo' compared a group of normal female albino rats with a similar group of hyper and hypothyroid rats on tests of motivation and learning. lie found that the hypothyroid group was less motivated and made more errors in learning than the control group. This was athihuted to the greater emotionality of the hypothyroid group. The effect of stress on metaholic changes was demonstrated by Brown and Pethes." They applied various stH'SS stimuli to the conscious guinea pig and noted a (lecreased rate of release of thyroid I'''' . In view of the above studies the question must he raised as to the mechanism of the interrelationship hetwecn hyponwtaholic states and psychological manifestatiolls. Feldmesser assumes that the hypometaholic state affects mental symptoms as a resnlt of inadc
The purpose of the present study is to evaluate, in a systematic manner, the general psy204

chological manifestations of early thyroid deficiency and the changes following the administration of thyroid products. In the present study we are not <.'Oncerned with the possible biochemical basis of mental disease nor with the effects of thyroid medication on mental disturbance. This study is the out<.'Ome of a previously reported investigation on the psychological effects of hypophysectomy in humans which showed that the secondary thyroid deficiency produced was ac<.'Ompanied by certain behavioral changes. '" It was, therefore, deemed necessary to investigate the psychological effects of spontaneous hypothyroidism or thyroid deficiency following thyroidectomy."""" sUBJEcrs AND PROCEDURE

Twenty-four patients ( 21 female and 3 male) with thyroid deficiency, but with no known gross emotional disturbances were studied. Seven patients had spontaneous hypothyroidism and 17 patients had undergone total or partial thyroidectomy, for either benign or malignant tumors or thyrotoxicosis (eight for malignant, fi Ie for benign tumors and 4 for hyperthyroidism) . Their ages ranged from 27 to 73 years with a mean age of 52 years. Their prorated intelligence quotient ranged from 70 to 127 with a mean of 102. The semm protein bound iodine ( mean value 3.5 micrograms per cent), the serum cholesterol (mean value 253 milligram per cent), the basal metabolic rate (mean value minus 15 per cent) were used to classify the patients as hypothyroid. The patients were studied by means of a structured interview based on observations of previous investigators and by a series of psychological tests. The tests selected for use are the most widely used instmments for the evaluation of intellectual functioning and personality. They included parts of the WechslerBellevue Intelligence Scale"7 and the following projective tests: The Rorschach Test, The Thematic Apperception Test,1J The Drawing of the Human Figure Test" and The Thurstone's Temperament Schedule."" The projective tests have been selected to gain insight into the individual's personality. The purpose of these tests is not manifest to the subject, yet they sample individual behavVolume V

HYPOTHYROIDIS~I-SCHON

ior in a short time. More than one test was llsed because the psychological aspects of the human organism are so complex that one test might not reveal all the facets. A brief description of the Wechsler-Bellevue Intelligence Scale, the Drawing of the Human Figure Test and the Thurstone Temperament Schedule will be given here because these tests are relevant to this paper. The findings on the other tests will be reported subsequently.

The Wechsler-Bellevue Intelligence Test consists of 11 subtests. Only three of these were used for our purposes. (1) The Vocabulary Test which is an excellent tool to measure a person's general intelligence. (2) The Memory Span for Digits which is a test of retentiveness. TIle patient is asked to repeat a series of digits forward and backward. Low scores on this test are associated with attention defects. The failure to repeat digits backward often correlates with difficulties of attention and power of concentration. (3) The Block Design Test assesses the patient's perceptual processes. The patient is required to reproduce 7 designs by means of a specific number of multicolored blocks within a certain time limit. Since it is a timed test, it was also used to detennine the effect of thyroid medication on speed. The Human Figure Drawing Test is based on the assumption that the individual projects his personality into the drawing of the human figure. The subject is asked to "draw a person." When this drawing is completed the subject is instructed to draw a person of the opposite sex to the first drawing. Verbal associations to the drawings are elicited for they are an excellent method of indirect interviewing. Machover, who developed this test, suggests that the figures drawn are characteristic of the individual who draws it, like his gait, his handwriting or any other ef his expressive movements. The Thurstone Temperament Schedule2 f> is a test which appraises seven areas of temperament in a relatively short questionnaire. The areas covered are: (1) activity, (2) vigor, (3) impulsivity, (4) dominance, (5) stability, (6) sociability and (7) reflective thinking. July-August, 1964

The patients were treated with desiccated thyroid, 3:5:3' triiodothyronine or 3:5:3' triiodothyropropionic acid. The psychological evaluation was carried out before treatment and at a mean interval of five months after therapy at a time when the patients were considered euthyroid. The test data, except the drawings, were subjected to statistical analysis. T-tests were used in order to detennine the statistical significance of the difference of the means between pre- and post-treatment scores. TIle statistical formula applied took into consideration that the two sets of scores to be compared were based on the same individuals and that a rather small sample was used." The drawings were analyzed in accordance with Machover's ideas on personality projection. Pre-treatment and post-treatment comparisons of the drawings were made. Sample drawings will he shown and discussed in the text of this paper. RESULTS

Interviews revealed that the patients with thyroid deficiency complained of extreme weakness and decreased mobility. They also reported that their thinking was clouded and their memories for recent events impaired while past experiences of an unpleasant nature were vividly remembered. Insomnia, increased irritability and nervousness were noted. The patients became argumentative, emotionally explosive and showed oppositional tendencies. They were surprised at their reactions especially since they could not find any reason for their behavior. The patients regretted their behavior but were unable to control it. Speech difficulties, such as the inability to find appropriate words to express their ideas or to enunciate words properly, were widely experienced. They also complained about oversensitivity to noise. This became most ohvious to them from disagreements with their families concerning the volume of the sound from the television. Patients with hypothyroidism often experience a loss of hearing. This was also ohserved in our group. Thus, this oversensitivity to noise is contradictory to the hearing loss and therefore difficult to understand. It is possible that the undue perception of noise might be an expression of an overall sensitivity during the state of hypothyroidism. The patient~ also lamented their inability to carry on with their usual duties, 205

PSYCHOSOMATICS

household or otherwise, and were frustrated due to their helplessness. Visual disturbances were a major complaint. Feelings of having sand in the eyes, of being cross eyed, haziness, double vision, excessive tearing and reading difficulties were reported. The patients attributed these symptoms to advancing age or faulty glasses. Ophthalmological examination, however, revealed no abnormalities. The patients complained also of a

host of other somatic symptoms \arying from muscle and bone pains to prickly feelings and numbness in the extremities. Breathing difficulties, pains which would simulate cardiac attacks with feelings of impending death were reported. With regard to sexual behavior, the older patients could not be evaluated adequately because some had discontinued sexual relations for various reasons prior to the time they

TABLE I. COMPARISO:-; BETWEEN PRE-TREATMf;NT ANI> I'Oi'>T-TREATMENT SCORES 0:-; THE BLOCK DESIG:-J TEST 1:-; 24 HYPOTHYROID PATIENTS

Name

Performance Scores

No. 24

Pre

Post

A

31 IX 10 17 19

33 21 10 21 30 6 211 0 12 0 17 0 15 23 24 31 14 3 16 10 34 13 19 19

-----B C D E F G II I

:I

24 0 9 0 16 0 12 13 26 25 14

J

K L M N ()

P Q R S

:I

16 13 29 16 17 IX

T

IJ V W X

Mean Time Scores

--1---Pre

44 54 21 52 32 53 51 0 42 0 J1 0 III 52 311 59 32 40 40 52 49 24 25 25

Post

-----33 49 211 3X 70 30 41 0 36 0 X2 0 26 7X 62 35 3X 37 2X 19 46 34 22 25

~--

Diff("renn' is or confldt·nce.

si~nifi('ant

at the .05 level

Difference is not significant at ; the .05 level of confidence.

TABLE II. COMPARISON BETWEEN PRE-TREATMENT AND POST-TREATMENT SCORES OF RETE:-;TION OF DIGITS IN 24 HYPOTHYROID PATIENTS Name

I

Digil>l Forward ----Pre Post !

Digita Backward I- - -

- - - - -I- - - - - - - - - - I No. 24 A

B C D E F G H I J K L M N 0 P Q R

S T IJ

V W X

9 5 4 7 7 5 7 4 7 5 5 4 9 f; f; f;

5 5 7 5 7 4 6

5

DifferenCl' is si~nificant at the .05

206

9 5 4 9 7 7 8

4 7 5 5 6 X 5 X 7 X 4 7 6

6 7 7 6 )C'\'c1

Pre 4 3 3 4 6 3 5 0 5 3 3 3 X 4 4 4 5 4 3 4 4 4 5 4

I

Total Digita

Post

Pre

Post

7 4 3 7 4 3 5 3 4 3 4 3 X 6 5 6 6 4 4

13

16 9 7 16 J1 10 13 7 J1 X 9 9 1fi 11 13 13 14 X 11 12 10 12 14 12

6

4 5 7 6

8

7 J1 13 II 12 4 12 II II

7

17 10 10 10 10 9 10 9 J1 II 11 9

or confidence

Volume V

HYPOTHYROIDIS~I-SCHON

becanw hypothyroid. The younger patients, however, experienced a considerable decrease in sexual desire. Sexual activity was maintained, though at less frequent intervals, only in order to please their mates. One patient remarked that her husband used to go out with other women, which annoyed her greatly, but that once she became hypothyroid, she was no longer concerned about it. Another patient reported that she stayed up late at night, working or watching television in order to avoid sexual contact. During the administration of sufficient thyroid medication, most of these symptoms decreased or disappeared and the patients returJ1{'(l to a state of general well being. One patient illustrated her feelings with the words: "I feel so good, I could rip the house apart." At this time the examiner also noted a difference in time needed for the interviews. The pre-treatment interviews were lengthy, often well over one hour, because the patients were unable to answer the questions directly. They would discuss problems unrelated to the topic, or follow their own ideas. The post-treahnent interviews were short, lasting only 10 to 15 minutes. The patients were able to be concise in their replies to questions. \Vith regard to test results, the patients achieved significantly higher scores on the block design test after treatment. The time needed to carry out the tasks was, however, not affected. This indicates that though their efficiency improved, their speed remained the same. On the surface it appears that the patient's speed did not change, but if we analyze the qualitative aspects of the patient's performance on this test, which involves both synthetical and analytical ability, we will see that this is not the case. \Vhen the patients were hypothyroid, they worked impulsively and they gave up easily because of their low fmstration tolerance. After treatment, when euthyroid, they worked with deliberation, accuracy and persistence and therefore more designs were completed. Thus, if the number of completed designs increased and the mean time needed remained more or less the same, a decrease in time and an increase in speed is inherent. The patient's memory for digits improved significantly under the influence of thyroid medication, especially for "digits backward." They were able to retain more digits after July-August, 1964

treatment. This indicates an improved ability to pay attention and to do intellectual work which requires concentrated effort. Table I and II illustrate these results in detail.

L

.;?

r

b\ \~:'" . 1 ,- •\

.

'-J Figs. 1 and 2.

Analysis of the scores on the temperament schedule showed that the patients were more capable of taking initiative and responsibility, that they had a more even disposition, were less irritable, could concentrate better and were more cooperative. These changes were, however, not statistically significant. This seems to indicate that the interviews were more reliable than the test data. In analyzing the drawings, we have to consider three aspects: (1) the personality characteristics of the patient, (2) his conflicts and ( 3) the effect of the dmgs. The pre-treatment and post-treatment drawings of two hypothyroid patients are analyzed in detail (Figs. 1, 2,3 and 4). Case 1. The first patient was a 59-year-old white widowed woman. Two years prior to admission to this hospital, she had had a total thyroidectomy for carcinoma. At the time of present hospitalization, the patient was myxedematous. The protein bound iodine was 0.4 microgram per cent, the sentm cholesterol 258 milligram per cent, and the basal metabolic rate minus :23 per cent. The patient manifested the psychological symptoms of hypothyroidism as d£'scribed above. She was treated with 3:5:3' triiodothyropropionic acid. \Vhen euthyroid, her protein bound iodim' was 5.7 microgram per cent, the sentm cholestl'rol was 169 milligram per cent, but the basal metabolk ratl' fl'mained essentially unchanged. Her psychological symptoms had been greatly rt'duced by that time. Analysis of the pre-trl'atml'nt drawing shows that the female figure is incompletely drawn. It represents a frail timid woman (Fig. 1). The lim's of the drawings are light and tentative, and the figure is placed at the top of the page. It has a /loating

207

PSYCHOSOMATICS

...... ",'

Figs. 3 and 4

quality and appears as if Suspl'Jl(led in the air. These aspects rel\l'ct a genNal ft>(·ling of inst>curity, lack of insight and rt>ality orientation and more rt>liance on fantasy for the H'solution of ht'r problems. Some of tht, patit>nt's mnflicts are revealt'd in the details of tht> drawing. The whole figure is a comhination of feminim' and masculine attributes. The face has a sharp pointt'(l nos(> and chin with a masculine expression. Tht> body has a big bosom but a large masculine arm-both art> incomplete. Tht>se aspeds reflect tht> patit>nt's ft>elings of wanting to be a woman but of having to accept tht, male rolt', neither rolt' being satisfactory. It also revt>als an inability to complete actions. The manner in which certain parts of a figure are drawn H,flt>cts the individual's attitudes. For instanct', the treatment of the hair and lower part of the body is regarded as an t'xprt'ssion of spt'cillc emotional {(·t'lings and in particular of sexual attitudes. In our cast', the patient drew the female llgure with sparse hair which looks nt'vertht'lt'ss disorderly and uncontrollt'd. The lower part of the llgure appears constricted and mrseted, but has a /lared skirt with a sharp end. These a~1>ects of the drawing re/lect the prest'nce of strong emotional and sexual desire which she feels she has to curtail in line with her idea of what a woman should be. In the drawing of the male llgure, the patient projt'cts onto tht' male her thoughts and fedings which she dOl>s not dare to admit to herself (Fig. 2). The face of thl' malt' mnveys an air of freedom from responsibility, of joviality, relaxation and contact with otht'r people. In reality, sht> ht'rself was never relaxed and frt'e. She always felt hurdt'ned by responsibility and accepted this as part of heing a woman. At the same time, she exprt'SSt'S in the drawing her ideas of what ht'r concept of a male is. Aspects of the drawing which are usually associated with masculinity-the nose, the pipt" tht, cane and the lower part of the body-do not mnvey strength. The nose is just faintly indicated; the pipe is somewhat hroken. The cant' is not sturdy, and the lower part of the body is absent. The whole picture H'flects interest in bodily display which is more appropriate for a child than an adult. Thus the patit'nt perceives the male more as a child. He is a man in appearance only. The inmmpleteness of the male figure here, the

208

ahsence of the hands and the lower body again shows the patient's inability to carry out her ideas to the fullest. It also re/le<:ts her attitude of suppressing or repressing problems which are too difficult for her to deal with. For instance, to depict the person below the waist line reveals the patient's sexual con/licts. She suppresses her feelings in this respect. She permits herself only to think about it. This is hrought out in the manner in which she draws the hair on the head, disorderly and excited. In the vt'rbal associations to the drawings, the patient describes the female as 34 to 36 years old, unmarried and plain. She is walking without a purpose and "wants to lead a quiet life." Here the patient expresses the fantasy of wishing to tum back the dock (patient is now 59 years old) to an earlier stage of her life when she had less responsibilities. She also projects her desires for the future, to lead a life free of undue hurdens. Tht' patient dt'scribes the male as "30 years old, unmarried and unsettled, without an occupation." Hert' she reveals again her eoncept of the male as an immature, unst·ttll'<1 individual. This is probably based on her past experiences with male figures, eitht'r a father or husband, or both, and her dissatisfaction. The post-trt'atment dr.lwings show the effects of thyroid medication on pt'rsonality in gt'neral and on the resolution of somt' of her eon/licts in particular. Both figures are drawn with heavier and more definite lines and are located centrally on the page. This re/lects in general mort' security, reality orientation and insight (Figs. 3 and 4). The patient's eon/lict about her own role in lifemale or female-has been resolved by integrating both aspt'cts into a matriarch, an older, more mature and active woman with purpose. The facial features are still masculine, but the body is invested with female attributes. The clothes are feminine. The figure wears pearls and earrings and other adornments and carries a handbag. She is now described as a "63-year-old married woman who is going to the store. Her ambition is to be a ~~ housewife and she hopes for a better tomorrow. By ascribing to the female figure an age closer to her own, the patient shows that she is more realistic now in her (-,oncept of herself, her role, and the situation in which she finds herself. In the pretreatment drawings, she resorted to fantasy by verbalizing her wish of being 25 years younger and being carefree. The patient has aL~o resolved her mn/lict between her need to express her sexual desires and the unacceptability of these impulses. This is evidenced again by the treatment of the clothes and the hair. The dress is elaborate and attention is given to frilly details and jewelry. These are means of attracting the male. The hair is abundant, but set into place. This shows expression of abundant feelings but at the same time an application of control. Thus the patient expresses her femininity and sexual interest, but in the form of controlled and socially acceptable behavior. The post-treatment male figure also reveals the resolution of the patient's eon/licts (Fig. 4). The male has aged too, and the immature aspects of the pretreatment personality have been exchanged for religious concern and the protective behavior of an adult. The male is now described as a 50-year-old monk Volume V

HYPOTHYROIDISM-SCHON "who prays for the people for a hetter tomorrow and teachl's the children." The protective element is especially emphasized by having exchanged the unsteady cane from the pretreatment drawing for an umbrella in the post-treatment figure. Thus the patient has resolved the unacceptability of her concept of the physical sexual male as an immature boy (Fig. 2.) by divesting him of the aspects of the "man" and by turning him into an idealized "person," the guiding and protecting Father on whom one can rely. She thus expresses the feeling that if the male cannot be a man in the complete sense, he should at least serve the purpose of giving spiritual guidance and understanding. Also, by changing the man into a monk, she can free herself of any desire for him, and her conOid is thereby resoh-ed.

Figs. 6 and 7.

Fig. 5. Casl' 2. The second patient was a 49-year-old white woman who developed her first symptoms of hypothyroidism following the loss of her husband and her parents who died within one year. At the time of the pre-treatment interview, the patil'nt's protein bound iodine was 4.6 microgram per cent, serum cholesterol was 302. milligram per cent and the basal metabolic rall' minus 16 per cenl. The patient showed all the psychological concomitants of hypothyroidism described earlier. She was then treatNI with desiccated thyroid. When she was euthyroid again, her protein bound iodine was 7.3 microgram per eent, serum cholesterol 2.12. milligram per eent, the symptoms of emotional imbalance had subsided and the patient had gn'atly improved psychologically. Analysis of the patient's drawings again re8ects her basic personality, the conOiels and the effeels of thyroid medication on both aspeds. Though instruetions were given to draw each figure on a separate sheet of paper, the patient drew both figures on one p<'lge. This indicates insecurity and need for de(><'ndency and re8eds that the patient

July-August, 1964

fel,ls she cannot stand on her own but has to lean on others in order to sustain lwrself. The light and brokt·n line quality and the stance of thl' figures also expn'sses helpk'ssness (Fig. 5). There is no clear sex differentiation amI no definite identification of the Self in the drawings. Neither clothes nor anatomical attributes dilTerentiate the two figures into male and female, and the drawings arc incompll·te, empty and I·xpressionlt·ss. Th.· only differentiation is that the female figun' shows an absence of the mouth, and the ear is drawn in qucstion mark form. This indicatt's tht' patient's eonn'rn about too much talk and what is being said about lwr-a typical female quality. Both figures, however, show expression of anger and hostility but an inability to deal with these feelings. This is exhibited by thl' sharp features yet helpless posture of the figures. In the verbal associations, the patient describes the female as "40 years old. She is nothing, looks like nothing, has no ambition and would be better off dead. She wished she would become a ·person.' " The male is described as "30 years of age. lie too is nothing, docs only minimal work in order to avoid mental strain. His ambition is to be independent and equal to others." These verbalizations (~lIlvey her feelings of inferiority, of derogation of self value and dt'pression at that particular time, and her need to be like other people. It shows also her eontempt for the male. In the post-treatment drawings, the dfeets of thyroid medication are evideneed in its style. Each figure is drawn on a separate sheet of paper. They are complete, drawn with firmer lines and placed more to the right side of the page. TI1I'Y arc dressed, and details of clothing arc emphasized. Tlwse aspects reUcet that the patient can now staml alone; she fccls more secure and therefore is less dependent. A feeling of adequacy and awareness of her role in society is brought out. She has become a fum.1ioning individual

209

PSYCHOSOMATICS again. She has resolved her problem by becoming more outgoing and by relating to an objective environment instead of withdrawing to fantasy as she did before. This is also evidenced in her verbal associations to the female drawing where she described the figure as a 55-year-old woman who is active and wants to be useful (Figs. 6 and 7). Again we notice an increase in a~e. Emotional maturity is apparently equalized with increment in a~e. The patient sC('ms alo;o to have resolved her sexual problem. The drawings show a definite demarcation betwecn th<, upper and lower body in both figures. This rt'presents ddinl'ation and control of the disturbing aspl'ct of the lowcr part of the body. It is channelized into socially acceptable behavior as seen by emphasis on eosmetic aspects like eyelashes, eyebrows and lips, and on clothing, like the pleated skirt in the female and the Hying tic in the male. These are means of sexual attraction. She permits men to look at her, hut her strong impulses which she feels are unacc<,ptahle, she allows herself only to think about. She kel'ps them under her "hat," under intellectual control. This is expressed in the treatment of the hair. It is abundant and messy but nevertheless carefully delineated (Fig. 6). She also uses the defenses of minimizin~ the importance of the man in the male. She describes the male figure as "20 years old. He is still going to school and at present he is waiting to catch a ball." By reducing the man to the status of a youn~ hoy, shl' can free herself of any desire for him.

In comparing the hypothyroid with the euthyroid drawings, one notes how thyroid honnones can effect personality changes. The immature, conflict-ridden, fantasy oriented individual becomes more mature, integrated with a view toward reality. In order to dispel any misconception, a word is added to our first sample case. The question can be raised as to how thyroidectomy can effect these personality changes. Thyroidectomy does not effect a change of a personality pattern which was established over a life time. This case was chosen for presentation only because it demonstrates so clearly the integrative property of thyroid hormones, which was also obvious in other cases, no matter what the reason for the thyroid deficiency. DISCUSSION AND CONCLUSIONS

In evaluating this study, we can say that some of the findings in the literature were confinned while others could not be supported. The usual assumption that hypothyroid patients are quiet and apathetic, presenting little problems to his environment 'O could not be observed in our group. They were quite irritable and nervous, posing many problems to 210

themselves and others. Visual disturbances, which were corrected by thyroid medication could be noted. Thus thyroid deficiency does not only affect acuity of hearing, which is a well-known fact, but also the adequate functioning of other sensory organs. Though we were not primarily concerned in this study with the biochemical aspects of mental disease, we could detect in our findings a possible relationship between thyroid deficiency and disturbed emotional equilibrium. The hypothyroid patient presents symptoms similar to the neurotic patient, manifesting themselves in both instances in immature behavior. There is one main difference, however, between the neurotic and the hypothyroid. The neurotic patient blames the outside world mainly for his maladjustment while the patient with thyroid deficiency takes full responsibility for his reactions. He is keenly aware of his irrational behavior and of the detrimental influence he has on others. He would like to change it but is unable to do so and is therefore even more frustrated. The study has also shown that thyroid hormones seem to have a property which effects an integration of personality. It has a stabilizing effect on unbalanced emotions and aids in the resolution of disturbing psychological conRicts. It seems therefore that thyroid hormones might find an important place in the treabllent of certain psychiatric disorders and be a valuable adjunct to psychotherapy, especially in those patients who are inaccessible to psychotherapy because of severe depression or personality disintegration. They could assume a similar function as the psychic energizers and tranquilizers used now in general medical practice and psychiatry. Since thyroid substitution honnones are more akin to the natural products of the body, they may possibly have more natural effects. This would warrant investigation by psychological and biological methods. Sherwin and Flach~3 have used triiodothyronine in two psychotic children who showed no biochemical evidence of thyroid deficiency. As a result of the treatment, an increase of effective contact, interest in the environment, a higher frustration tolerance and an ability to learn and to confonn in group activities was observed in these withdrawn children. The need for psychotherapy and educational methVolume V

HYPOTHYROIDISM-SCHON

ods at the same time is being stressed if anything is to be gained from these hormones. This is in line with Reiss's ideasy·19 No rationale was given for the treatment with thyroid medication nor an explanation for its beneficial effects. In view of our findings, it is possible that improvement of symptoms was achieved with thyroid medication because of its integrative effect on the disintegrated personality of these autistic children. It would be of great importance to isolate the chemical detenninants in thyroid honnones which are responsihle for the integration of personality for only then can we deduct which is the chemical property of the organism responsible for the disintegration of personality in the first place. This study also gives a clue to the possible causation of hypothyroidism. The hypothyroid patients showed defects of ego structure and body image, distortion of concepts and percepts and use of unrealistic defenses in dealing with these deficiencies This resulted in the emergence of powerful emotions like hostility, aggressiveness, affection and sex. This caused arousal of disturbing conllicts hecause of the patient's inahility to coordinate the inner pressures of their emotions with the demands of society which considers expression of these feelings unacceptable. After the administration of thyroid medication, one could notice a change. The patients became more secure, effective, active and purposeful and at peace with tlll'msdves. There was again a realistic appraisal of the self and the environment and a hetter control over their emotions. Integration of personality with resolution of conflicts occurred. It was therefore concluded that the emergence of spontaneous hypothyroidism may possihly serve (1) as a protective defensive measure against the patient's inahility to manage overwhelming emotions which create conflicts at a particular time and (2) as a mechanism of delay for action until an acceptable solution is found. The lowered metabolic condition places the patient in a state of lethargy and inactivity and also creates emotional imhalance. Thus hypothyroidism helps the patient physically and psychologically to withdraw from pressures the patient is unable to cope with. Since the completion of this study, this hypothesis has been confinned in three cases. All three patients were euthyroid and the onset of July-August, 1964

hypothyroidism coincided with the arousal of emotional conflict at the particular time. They were so immobilized by its effects that they were unable to make a decision. By becoming hypometabolic, a temporary solution of their problems was achieved. This enabled them to withdraw from pressures and avoid a decision. They literally "sat it out." Since their psychological defenses were lowered they could also permit themselves to express their tme feelings which they usually kept in check and at the same time, shift responsibility for their behavior from themselves to their condition. Any conclusions reached here must he accepted with reservations, for they are hased on a relatively small sample. Nevertheless, the evidence presented from various sources, like interviews, psychological tests and drawings show a similarity of results which cannot be dismissed. Also, though all patients were hypothyroid, their thyroid deficiency was not based on the same cause and they were treated \vith various derivatives. The next step in research would be to study a group of patients with spontaneous hypothyroidism and treat them with the same thyroid product. In general, the findings of this study point more and more to the interaction hetween thyroid and personality functioning. It appears that personality characteristics are detennined by psychological factors but adequate hormonal functioning is a prerequisite for emotional stability. The interaction between hormones and hehavior has been recognized for some time, but it was usually assumed that the pituitary gland was the prime mover of personality. It seems, as far as we can detennine from this study, that it is not so much the pituitary hormones hut more their effect on proper thyroid production which in tum influences proper personality integration. SUMMARY

1. The purpose of the present study was to evaluate in a systematic manner the psychological effects of hypothyroidism and the changes following administration of thyroid honnones.

2. Twenty-four patients with thyroid deficiency were studied before and after treatment with thyroid medication. They were in211

PSYCHOSOMATICS

terviewed and series of psychological tests were administered. 3. Results indicated that patients with thyroid deficiency react psychologically like neurotic patients. After treatment with thyroid medication most of the symptoms subsided. 4. It was concluded that thyroid products have an integrative property on the personality and can therefore aid in the treatment of psychologic disorders. It also seems that the emergence of hypothyroidism may possibly be, at least in part, a protective measure against the stress of conflicting emotions. ACK1\OWLEDG:-'IENTS

Gratitude is expressed to Dr. Hulon ,V. Rawson, Chief of Medicine of tllis Institution, for suggesting this study and for his constructive criticism in discussing this paper. Many thanks are extended to Dr. Martin Sonenberg and Dr. Richard S. Benua of the Endocrine Division for making the subjects available to the investigator, and to Zoltan Hieder, M.A., of Jeshivah University, l'\ew York, for the statistical analysis of the data. The author is indebted to Karen Machover, Assistant Professor of the State University of New York, Downstate Medical Center, the originator of the use of the Human Figure drawing for personality investigation, for her assistance in analyzing and interpreting the drawings, and for her many valuable suggestions and comments. REFEHE:-':CES

1. Bowman, K. 1\1. and Fry, C. C.: Basal metabolism. Arch. Neurol. PSyclliat., 14:819, 1925. 2. Brown, G. K. and Pethes, G.: The response of the thyroid gland of the guinea pig to stress. }. Physiol., 151 :40, 1960. 3. Fcldmesser-Reiss, E. E.: The application of triiodothyronine in the treatment of mental disorder. J. Nerv. Ment. Di.v., 127 :540, 1958. 4. Flach, F. F., Celian, C. I., and Hawson, H. W.: Treatment of psychiatric disorders with triiodothyronine. Amer. J. PSYChult., 114:841, 1958. 5. Hoskins, R. G.: The Biology of Schizophrenia. P. 113. New York: W. W. Norton & Co., 1946. 6. Hoskins, R. G., and Sleeper, F. H.: Endocrine studies in dementia pral'Cox. Erulocrinology, 13:245. 19:'9. 7. Kenshalo, D. R.: The learning of albino rats as affected by altering their metabolk l'nvironment. Psychol. Rev., 8:93, 1958.

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8. Machover, K. A.: Personality Projection in the Drawing of the Human Figure. Springfield, Ill.: Charles C Thomas, 1949. 9. McNemar, Q.: Psychological Statmics, p. 226, New York: John Wiley & Sons, 1949. 10. Means, J. H.: The Thyroid and its Diseases, p. 202. Philadelphia: J. B. Lippincott Co., 1948. ll. Murray, H, A.: Thematic Apperception Test Manual. Cambridge, Mass.: Harvard University Press, 1943. 12. Pearse, J. J., and Reiss, M., II: Psyehoendocrine Aspects of Mental Retardation. Canad. Psychiat. Ass. ]., 8: 14, 1963. 13. Rawson, R. W., Koch, H., and Flach, F. F.: The thyroid hormones and their relationship to mental health. In Hudson Hoagland (Ed), Hormones, Brain Function and Behavior, p. 221. New York: Academic Press, Inc., 1957. 14. Reiss, M., Hemphill, R. E., Maggs, R., Smith, S., Haigh, C. P., and Reiss, Jean M.: Thyroid activity in mental patients. Brit. Med. J., 1: ll81, 1951. 15. Reiss, M.: CorreL'ltion between changes in mental status and thyroid activity after different forms of treatment. J. Ment. Sci., 100:687, 1954. 16. Reiss, M.: PsyehoendoerinoloID'. In Reiss, M. (Ed) Psychoendocrinalogy. New York and London: Grune and Stratton, Inc., 1958. 17. Reiss, M.: Endocrine research in psychiatry. Proc. Third World Congress of PstjchiatnJ, p. 121. Toronto, Canada: University of Toronto Press, 1962. 18. Reiss, M.: Hormones in mental disease, Chemical Pathology of the Nervous System, p. 432. New York: Pergamon Press, 1961. 19. Reiss, M., Berman, H. H., Pearse, J. J., Albert Gasorek, K., and Hillman, J. C.: Investigations into the interrelation of physical and mental retardation. J. NeurO]>sychiat., 2: 109, 1961. 20. Schon, Martha: Psychological effects of hypophysectomy in women with metastatic bn'ast cancer. Cancer, II :95, 1958. 21. Schon, Martha, Sutherland, A. ~I., and Rawson, R. W.: The psychological concomitants of thyroid deficiency. Acta Psychol., 19: 1, 1961. 22. Schon, Martha, Sutherland, A. M., and Rawson, R. W.: Hormones and Neuroses. Proc. Third World Congress of Psychiatry, p. 835. Toronto, Canada: University of Toronto Press, 1962. 23. Sherwin, A. C., Flach, F. F., and Stokes, P. E.: Treatment of psychoses in early childhood with triiodothyronine. Amer. J. Psychiat., ll5: 166, 1958. 24. Stern, Muriel H.: Thyroid function and activity, speed and timing aspects of behavior. Canad. J. Psychol., 13:43, 1959. 25. Su, H. Y., Chang, S. H., Chang, S., and Hsiao, C. L.: A study of goitrous personality from Rorschach responses. Acta Psychol. Tawanica, 1:99, 1958. 26. Thurstone, L. L.: Thurstolle Temperament Schedule. Chicago: Science Research Associates, 1949. 27. Wechsler, D.: The Measurement of Adult Intelligence (3rd ed). Baltimore: Williams and Wilkins Co., 1944. Memorial Hospital for Cancer and Allied Diseases New York 21, N. Y.

Volume V