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Mental disorders associated with hyperthyroidism
MENTAL
DISORDERS ASSOCIATED
WITH
HYPERTHYROIDISM ELBERT T. RULISON, JR., M.D., Resident House Offbzer, HighIand HospitaI
JOHN D. WHITE, M.D. Resident House Officer, HighIand HospitaI AND
LEONARD K.STALKER, M.D. On Surgical Staff, Highland HospitaI ROCHESTER, NEW YORK
P
SYCHOSIS is not a common complication of hyperthyroidism. Johnson onIy twenty-four instances reported of psychosis in 2,000 patients with hyperthyroidism. Foss and Jackson studied 800 patients with hyperthyroidism and found evidence of mentaI disorder in two cases. ConverseIy, a goiter was present in fifty of I ,700 psychotic patients studied. Parker states that less than 2 per cent of patients with exophthaImic goiter present evidence of menta1 derangement. In view of the rather infrequent association of these two conditions and because of the unusual results obtained, we feIt justified in presenting our case and discussing the nature and reIationship of this association in general. A variance of opinion has been expressed regarding the r8Ie of the thyroid as an etioIogica1 factor in the production of psychosis. Hammes beIieves that psychoses encountered with thyrotoxicosis can be cIassified with, and have the usual characteristics of, ordinary psychoses. He considers the hyperthyroidism an associated rather than etioIogic condition. On the other hand, WaIker considers the thyrotoxicosis as etioIogica1. KatzeneIbogen and Luton beIieved that the thyroid dysfunction was a precipitating or aggravating factor in their cases. Thyroid malfunction is accompanied by deviations from the average norma menta1 and motor activity; as for exampIe, retardation is a concomittant of myxedema and cretinism, and menta1 and motor overactivity with hyperthyroidism. If this is true, one would expect some possibIe
etioIogic relationship between thyroid disease and psychoses in certain cases. Hyperthyroidism, however, has not been associated with any one type of psychosis. In Jameson and WaII’s series each case exhibited a different psychoIogica1 response and psychotic manifestation. They beIieved that given a favorable background, incIuding famiIia1 and personaIity propensities, and such factors as proIonged physica and emotiona stress that a Iatent thyroid disease might be precipitated with an associated psychosis of any type. DunIap and Moersch cIassified their cases according to the psychic manifestations and the thyroid pathoIogica1 condition present. The predominant types of menta1 reactions were (I) toxic exhaustion, (2) acute delirium, and (3) manic-depressive psychosis, gr per cent of the series being made up of the first two groups. Toxic exhaustive psychoses were present onIy in cases of thyrotoxicosis, due to either exophthalmic or adenomatous goiter. The majority gave a reIativeIy short history of menta1 disturbance and under medica care showed marked and rapid improvement. Acute delirium, Iikewise, was seen only in association with hyperthyroid states. The terms acute deIirium, thyroid crisis, hyperthyroid reaction and thyroid storm are used to designate more or less the same condition. These cases are regarded as presenting the one possibIe definite relationship between hyperthyroidism and mental disturbances, for no instance of famiIia1 history of psychosis or of a previous menta1 disturbance occurred in this group.
$00
American
Journnl
Rulison
of Surgery
et al.-----Mental
AI1 these patients presented a severe degree of hyperthyroidism, but the severity of the hyperthyroidism was found to be no index to the severity of the mentaI reaction. TypicaI acute delirium, or thyroid crisis, is seen infrequently since the introduction of compound solution of iodine in the treatment of thyrotoxicosis. When it occurs, however, the psychosis is in proportion to the severity of the hyperthyroid reaction and disappears The third
most
Moersch’s found
when the crisis
manic-depressive common series.
compIicating
cases group
Since cases
is controlled. made
up the
in DunIap
this
and
psychosis
of goiter
is
without
hyperfunction,
as we11 as those with thyrotoxicosis, the hyperthyroid&m cannot be considered responsibIe for the development of the manic-depressive reaction. We have seen an interesting case of hyperthyroidism which was comphcated by the deveIopment of a mentaI disorder. CASE
REPORT
A hfty-one year oId white, married woman was admitted to the hospital with a chief compIaint of nervousness and increasing weakness of one year’s duration. One year prior to admission, because of increasing asthenia, nervousness, irritability, tremor, crying speIls, increased appetite and diaphoresis, the patient consuIted her physician. Two months prior to her admission she deveIoped edema of the ankIes, dyspnea on moderate exertion, orthopnea and a nonproductive cough. Ten days before admission she was toId that her heart was “beating 200 beats too fast” and was confined to bed. She had Iost eighty pounds in weight during the last three years. Her past history was essentially negative. PhysicaI examination revealed an undernourished woman who was alert, co-operative but very apprehensive and nervous. The bIood pressure was 165 mm. of mercury systolic, and 85 mm. of mercury diastolic. The pulse rate was 136 beats per minute and respiration 28 per minute. Moderate exophthalmous and slight Iid lag were present. The thyroid was diffuseIy enIarged to a size approximateIy six to eight times normaI. A bruit was present over both lobes. The heart was enIarged to the Ieft and a faint apica systolic murmur was present. There
Disorders
Novn~et.~.
lg.+,
was pitting edema of the ankIes and muscular strength of the extremities was poor. A marked tremor of the hands was present. UrinaIysis showed a moderate amount of albumin. The concentration of nonprotein nitrogen was within norma Iimits and the bIood cholestero1 I 18 mg. per cent. HemogIobin was 72 per cent, Ieukocyte count 5,200, and erythrocyte count 4,71o,ooo per cubic miIIimeter of blood. The serologic reaction for syphilis was negative. BasaI metaboIic rate was plus 69 per cent. Roentgenographic examination of the chest showed a widening of the aortic arch and shght cardiac enlargement. An eIectrocardiogram reveaIed nothing unusual. The patient responded poorly to the usua1 methods of preoperative preparation and for this reason was given two treatments with x-ray at five week intervaIs. She showed some improvement, and on her fifty-third hospita1 day, three weeks foIlowing the first x-ray treatment, the basa1 metaboIism rate was pIus 40 per cent and she had gained five pounds. Despite the general improvement, surgery was deIayed because of the presence of an acute foIIicular tonsiIIitis. During the hospita1 stay the patient’s mental status showed gradua1 deterioration, so that by the sixty-sixth day doubt was expressed as to the advisabiIity of, or benefit to be expected from, thyroidectomy. She was disoriented as to time, place, and person, and showed in genera1 marked motor depression. She wept when spoken to and could not remember her visitors from day to day. She exhibited occasiona deIusions and halIucinations, hearing or seeing people outside her room who had come to kil1 her or to take her to the operating room. For transient periods her orientation and genera1 menta1 reaction seemed improved. These episodes were usuaIIy associated with some improvement in the genera1 toxic status as indicated by lowering and steadying of her puIse and temperature levels. We assumed care of this patient on her seventy-ninth hospita1 day and after consuItation with her previous physicians decided that a more radica1 program must be instituted. ConsequentIy, after two weeks of vigorous thyroidectomy was performed. preparation, PathoIogical examination confirmed the cIinica1 diagnosis of exophthaImic goiter. The patient made an uncomplicated convaIescence and by
NEW
SERIES VOL.LIV, No. z
Rulison
et aI.-MentaI
the fifth postoperative day was walking about, was well oriented and conversed rationaIIy. She was dismissed from the hospita1 ten days foIIowing the operation. Three months following the operation the patient had gained thirty pounds, was doing her own housework and manifested no evidence of mental disturbance. Nine months folIowing operation she had gained fifty pounds and was in the best of health. COMMENT
We believe that this patient had marked hyperthyroidism due to an exophthaImic goiter and in addition deveIoped a toxic exhaustive type of psychosis. The increase in the toxic and psychotic symptoms, in spite of adequate medica care, was unusual. It is possibIe that the tonsiIIitis and the consequent foci of infection aggravated this condition. The most unusua1 feature presented by this case is the fact that the psychosis of this severity cleared foIIowing thyroidectomy. It was our opinion, and this was substantiated by discussion with Pemberton, that it is very unusua1 for such a patient to be materiaIIy improved from the menta1 viewpoint foIlowing contro1 of the hyperthyroidism. On the other hand, occasionaIIy the psychotic symptoms of a shorter duration, and usuaIIy those associated with a crisis of the disease, disappear with contro1 of the thyroid hyperfunction. Certainly one shouId not consider the presence of a mental condition a definite contraindication to surgery, and in seIected cases indicated surgery is advised.
Disorders
A me&an
Journ:llof Surgery
301
SUMMARY
Hyperthyroidism is not specificaIIy associated with one type of psychosis. Toxic exhaustive reactions and acute delirium are probabIy the most common mentaI disturbances compIicating thyroid hyperfunction. The content of the psychoses does not differ essentiaIIy from that of simiIar types of psychoses in individuals without hyperthyroidism. When a psychosis occurs in the presence of hyperthyroidism it shouId not be considered a definite contraindication to surgery. The prognosis of the psychosis probabIy depends upon the ratio of thyroid toxicity to the underIying mentaI instabiIity of the patient. REFERENCES I.
2.
DUNLAP, H. F. and MOERSCH, F. P. Psychic manifestations associated with hyperthyroidism. Am. J. Psycbiat., 91: 1215, 1935. Foss, H. L. and JACKSON, J. A. The relationship of goiter to mental disorders. Am. J. M. SC., 167: 724,
1924. disorders and 3. HAMMES, E. M. Neuropsychiatric hyperthyroidism. JournaLLancet, 48: 43, 1928. 4. JAMEISON. G. R. and WALL. J. H. Psvchoses associated with hyperthyroidism. Psych&. Quart., I 0 : 464, 1936. 5. JOHNSON, W. 0. Psychosis and hyperthyroidism. J. New. &+Ment. Dis., 67: 558, 1928. 6. KATZENELBOGEN, S. and LUTON, F. H. IIyperthyroidism and psychobiologica1 reactions. Am. J. Psycbiat., 91: 969, 1935. 7. PARKER, R. M. Disastrous possibiIities in thyroidectomy. Illinois M. J., 33: 317, 1918. 8. PEMBERTON,JOHN DEJ. Personal communication to the author, 1941. and mental dis9. WALKER, W. K. Hyperthyroidism orders. New York State J. Med., 107: 391, 1918.
DISORDERS ASSOCIATED
WITH
HYPERTHYROIDISM ELBERT T. RULISON, JR., M.D., Resident House Offbzer, HighIand HospitaI
JOHN D. WHITE, M.D. Resident House Officer, HighIand HospitaI AND
LEONARD K.STALKER, M.D. On Surgical Staff, Highland HospitaI ROCHESTER, NEW YORK
P
SYCHOSIS is not a common complication of hyperthyroidism. Johnson onIy twenty-four instances reported of psychosis in 2,000 patients with hyperthyroidism. Foss and Jackson studied 800 patients with hyperthyroidism and found evidence of mentaI disorder in two cases. ConverseIy, a goiter was present in fifty of I ,700 psychotic patients studied. Parker states that less than 2 per cent of patients with exophthaImic goiter present evidence of menta1 derangement. In view of the rather infrequent association of these two conditions and because of the unusual results obtained, we feIt justified in presenting our case and discussing the nature and reIationship of this association in general. A variance of opinion has been expressed regarding the r8Ie of the thyroid as an etioIogica1 factor in the production of psychosis. Hammes beIieves that psychoses encountered with thyrotoxicosis can be cIassified with, and have the usual characteristics of, ordinary psychoses. He considers the hyperthyroidism an associated rather than etioIogic condition. On the other hand, WaIker considers the thyrotoxicosis as etioIogica1. KatzeneIbogen and Luton beIieved that the thyroid dysfunction was a precipitating or aggravating factor in their cases. Thyroid malfunction is accompanied by deviations from the average norma menta1 and motor activity; as for exampIe, retardation is a concomittant of myxedema and cretinism, and menta1 and motor overactivity with hyperthyroidism. If this is true, one would expect some possibIe
etioIogic relationship between thyroid disease and psychoses in certain cases. Hyperthyroidism, however, has not been associated with any one type of psychosis. In Jameson and WaII’s series each case exhibited a different psychoIogica1 response and psychotic manifestation. They beIieved that given a favorable background, incIuding famiIia1 and personaIity propensities, and such factors as proIonged physica and emotiona stress that a Iatent thyroid disease might be precipitated with an associated psychosis of any type. DunIap and Moersch cIassified their cases according to the psychic manifestations and the thyroid pathoIogica1 condition present. The predominant types of menta1 reactions were (I) toxic exhaustion, (2) acute delirium, and (3) manic-depressive psychosis, gr per cent of the series being made up of the first two groups. Toxic exhaustive psychoses were present onIy in cases of thyrotoxicosis, due to either exophthalmic or adenomatous goiter. The majority gave a reIativeIy short history of menta1 disturbance and under medica care showed marked and rapid improvement. Acute delirium, Iikewise, was seen only in association with hyperthyroid states. The terms acute deIirium, thyroid crisis, hyperthyroid reaction and thyroid storm are used to designate more or less the same condition. These cases are regarded as presenting the one possibIe definite relationship between hyperthyroidism and mental disturbances, for no instance of famiIia1 history of psychosis or of a previous menta1 disturbance occurred in this group.
$00
American
Journnl
Rulison
of Surgery
et al.-----Mental
AI1 these patients presented a severe degree of hyperthyroidism, but the severity of the hyperthyroidism was found to be no index to the severity of the mentaI reaction. TypicaI acute delirium, or thyroid crisis, is seen infrequently since the introduction of compound solution of iodine in the treatment of thyrotoxicosis. When it occurs, however, the psychosis is in proportion to the severity of the hyperthyroid reaction and disappears The third
most
Moersch’s found
when the crisis
manic-depressive common series.
compIicating
cases group
Since cases
is controlled. made
up the
in DunIap
this
and
psychosis
of goiter
is
without
hyperfunction,
as we11 as those with thyrotoxicosis, the hyperthyroid&m cannot be considered responsibIe for the development of the manic-depressive reaction. We have seen an interesting case of hyperthyroidism which was comphcated by the deveIopment of a mentaI disorder. CASE
REPORT
A hfty-one year oId white, married woman was admitted to the hospital with a chief compIaint of nervousness and increasing weakness of one year’s duration. One year prior to admission, because of increasing asthenia, nervousness, irritability, tremor, crying speIls, increased appetite and diaphoresis, the patient consuIted her physician. Two months prior to her admission she deveIoped edema of the ankIes, dyspnea on moderate exertion, orthopnea and a nonproductive cough. Ten days before admission she was toId that her heart was “beating 200 beats too fast” and was confined to bed. She had Iost eighty pounds in weight during the last three years. Her past history was essentially negative. PhysicaI examination revealed an undernourished woman who was alert, co-operative but very apprehensive and nervous. The bIood pressure was 165 mm. of mercury systolic, and 85 mm. of mercury diastolic. The pulse rate was 136 beats per minute and respiration 28 per minute. Moderate exophthalmous and slight Iid lag were present. The thyroid was diffuseIy enIarged to a size approximateIy six to eight times normaI. A bruit was present over both lobes. The heart was enIarged to the Ieft and a faint apica systolic murmur was present. There
Disorders
Novn~et.~.
lg.+,
was pitting edema of the ankIes and muscular strength of the extremities was poor. A marked tremor of the hands was present. UrinaIysis showed a moderate amount of albumin. The concentration of nonprotein nitrogen was within norma Iimits and the bIood cholestero1 I 18 mg. per cent. HemogIobin was 72 per cent, Ieukocyte count 5,200, and erythrocyte count 4,71o,ooo per cubic miIIimeter of blood. The serologic reaction for syphilis was negative. BasaI metaboIic rate was plus 69 per cent. Roentgenographic examination of the chest showed a widening of the aortic arch and shght cardiac enlargement. An eIectrocardiogram reveaIed nothing unusual. The patient responded poorly to the usua1 methods of preoperative preparation and for this reason was given two treatments with x-ray at five week intervaIs. She showed some improvement, and on her fifty-third hospita1 day, three weeks foIlowing the first x-ray treatment, the basa1 metaboIism rate was pIus 40 per cent and she had gained five pounds. Despite the general improvement, surgery was deIayed because of the presence of an acute foIIicular tonsiIIitis. During the hospita1 stay the patient’s mental status showed gradua1 deterioration, so that by the sixty-sixth day doubt was expressed as to the advisabiIity of, or benefit to be expected from, thyroidectomy. She was disoriented as to time, place, and person, and showed in genera1 marked motor depression. She wept when spoken to and could not remember her visitors from day to day. She exhibited occasiona deIusions and halIucinations, hearing or seeing people outside her room who had come to kil1 her or to take her to the operating room. For transient periods her orientation and genera1 menta1 reaction seemed improved. These episodes were usuaIIy associated with some improvement in the genera1 toxic status as indicated by lowering and steadying of her puIse and temperature levels. We assumed care of this patient on her seventy-ninth hospita1 day and after consuItation with her previous physicians decided that a more radica1 program must be instituted. ConsequentIy, after two weeks of vigorous thyroidectomy was performed. preparation, PathoIogical examination confirmed the cIinica1 diagnosis of exophthaImic goiter. The patient made an uncomplicated convaIescence and by
NEW
SERIES VOL.LIV, No. z
Rulison
et aI.-MentaI
the fifth postoperative day was walking about, was well oriented and conversed rationaIIy. She was dismissed from the hospita1 ten days foIIowing the operation. Three months following the operation the patient had gained thirty pounds, was doing her own housework and manifested no evidence of mental disturbance. Nine months folIowing operation she had gained fifty pounds and was in the best of health. COMMENT
We believe that this patient had marked hyperthyroidism due to an exophthaImic goiter and in addition deveIoped a toxic exhaustive type of psychosis. The increase in the toxic and psychotic symptoms, in spite of adequate medica care, was unusual. It is possibIe that the tonsiIIitis and the consequent foci of infection aggravated this condition. The most unusua1 feature presented by this case is the fact that the psychosis of this severity cleared foIIowing thyroidectomy. It was our opinion, and this was substantiated by discussion with Pemberton, that it is very unusua1 for such a patient to be materiaIIy improved from the menta1 viewpoint foIlowing contro1 of the hyperthyroidism. On the other hand, occasionaIIy the psychotic symptoms of a shorter duration, and usuaIIy those associated with a crisis of the disease, disappear with contro1 of the thyroid hyperfunction. Certainly one shouId not consider the presence of a mental condition a definite contraindication to surgery, and in seIected cases indicated surgery is advised.
Disorders
A me&an
Journ:llof Surgery
301
SUMMARY
Hyperthyroidism is not specificaIIy associated with one type of psychosis. Toxic exhaustive reactions and acute delirium are probabIy the most common mentaI disturbances compIicating thyroid hyperfunction. The content of the psychoses does not differ essentiaIIy from that of simiIar types of psychoses in individuals without hyperthyroidism. When a psychosis occurs in the presence of hyperthyroidism it shouId not be considered a definite contraindication to surgery. The prognosis of the psychosis probabIy depends upon the ratio of thyroid toxicity to the underIying mentaI instabiIity of the patient. REFERENCES I.
2.
DUNLAP, H. F. and MOERSCH, F. P. Psychic manifestations associated with hyperthyroidism. Am. J. Psycbiat., 91: 1215, 1935. Foss, H. L. and JACKSON, J. A. The relationship of goiter to mental disorders. Am. J. M. SC., 167: 724,
1924. disorders and 3. HAMMES, E. M. Neuropsychiatric hyperthyroidism. JournaLLancet, 48: 43, 1928. 4. JAMEISON. G. R. and WALL. J. H. Psvchoses associated with hyperthyroidism. Psych&. Quart., I 0 : 464, 1936. 5. JOHNSON, W. 0. Psychosis and hyperthyroidism. J. New. &+Ment. Dis., 67: 558, 1928. 6. KATZENELBOGEN, S. and LUTON, F. H. IIyperthyroidism and psychobiologica1 reactions. Am. J. Psycbiat., 91: 969, 1935. 7. PARKER, R. M. Disastrous possibiIities in thyroidectomy. Illinois M. J., 33: 317, 1918. 8. PEMBERTON,JOHN DEJ. Personal communication to the author, 1941. and mental dis9. WALKER, W. K. Hyperthyroidism orders. New York State J. Med., 107: 391, 1918.