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Psychosomatic symptoms and borderline hyperthyroidism
PSYCHOSOMATIC SYMPTOMS AND BORDERLINE HYPERTHYROIDISM BERNARD J. FICARRA, M.D. Fellowin Surgery,Lahey Clinic, BOSTON, MASSACHUSETTS
T
HE
surgeon of yesteryear IittIe realized that posterity wouId demand a psychiatric knowIedge in modern surgery. In the diagnosis and care of hyperthyroid patients the surgeon trespasses on the confines of the psychiatrist. AIthough he does not enter his domain, it cannot be denied that in the care of the borderIine hyperthyroid patient the surgeon pierces the outskirts of this reaIm. Psychosomatic medicine concerns itseIf with those patients who are neither physicaIIy iI nor have an organic menta1 derangement. These patients are cate“ functiona iIInesses.” gorized as having Most of these patients have a nervous disposition. A tremor may be present with palpitation occasionaIIy noted. This triad of symptoms IabeIs the patient a hyperthyroid. A basa1 metaboIic rate is taken on the nervous patient. It is usually elevated. FaiIure to repeat this study does not reveal the error. The diagnosis is apparentIy correct and the patient is sent to the surgeon for thyroid surgery. The surgeon now assumes the responsibiIity. Unless he is aIert he wiI1 perform a subtota1 thyroidectomy on a patient whose symptoms wiI1 persist or become more marked folIowing surgica1 intervention. NeurocircuIatory asthenia is the most common disorder confused with hyperthyroidism. These individuaIs have paIpitation, tachycardia, tremor, weight Ioss and a sIightIy eIevated basa1 metaboIism. Such patients, however, have no eye signs, no increase in pulse pressure or puIse rate, poor appetite, cold extremities and they demonstrate no manifestations of chronic anxiety. Psychoneurotic states produced by psychic trauma simuIate hyperthyroidism. 363
A patient may have witnessed or was a party to a frightening experience. This factor may precipitate symptoms cIoseIy paraIIeIing toxic goiter. This cIass of patients perhaps have a pre-existing hyperadrenaIism. The physica examination of such persons may not confirm the history of tremor, sweating and tachycardia. The gIand may be normal to inspection and paIpation without any audibIe bruit. The vaIue of the pulse rate which is increased in hyperthyroidism, is noteworthy. Psychic factors may cause a temporaryeIevation whereas hyperthyroidism maintains a constant eIevation of the puIse rate. A fact to remember is that the toxic goiter patient is usuaIIy oIder than the neurotic individual. We have observed that patients with true hyperthyroidism have a tendency to cry spontaneousIy without apparent cause. When the basa1 metaboIism has been eIevated on the initia1 reading, technica inaccuracies may be the cause. The nervous individua1 shouId be informed of the procedure and his cooperation obtained. As a generality it may be stated that cooperation and relaxation are Iess frequentIy obtained with psychoneurotic patients than with hyperthyroids. Repetition of the test each morning unti1 a satisfactory technical reading is obtained may reward the observer with a norma basa1 metabolic recording. Another important differentiating observation is the apparent improvement when these functionaIIy disturbed patients are hospitalized. When these persons are liberated from famiIia1 entangIements relief occurs within a few days. Freedom from noxious menta1 stimuIi eradicates the tach,vcardia and nervous symptoms.
364
American Journal
ofSurgery
Ficarra-Hyperthyroidism
When persons with mentaI unrest have been convinced of the functiona nature of their compIaints and are assisted by competent heIpfu1 psychiatric suggestions, improvement is noted. With the aid of a psychiatrist the so-caIIed hyperthyroid patient undergoes a compIete metamorphosis. AI1 patients suspected of miId hyperthyroidism do not faI1 into the category stressed, even as the diagnosis between a functiona disorder and borderIine hyperthyroidism is not as faciIe as outIined Each individua1 is a singuIar above. probIem. There is no one diagnostic pattern appIicabIe to a11 patients. Caution is advised against the other extreme of faiIing to recognize a true borderIine hyperthyroid patient. To brand such a patient a hypochondriac, a maIingerer or a neurotic may produce deIeterious resuIts. It must also be reaIized that hyperthyroidism is a constitutiona disease and as such may dispIay unusua1 psychic reactions. AIthough no characteristic psy-
MARCH, 1946
chic reaction is indigenous of hyperthyroidism, many of these patients. have acute deIirium. Some patients with Iong standing hyperthyrbidism may manifest toxic exhaustion psychosis and others a manic depressive reaction. True menta1 disease may occur in the hyperthyroid individua1 as in others. In such instances it is diffkuIt to sift the menta1 cIass of symptoms from the hyperthyroid group. This type of patient, however, presents many signs of hyperthyroidism which categorize the disease. Thus even if the menta1 compIaints are attributed to hyperthyroidism, at Ieast the major underIying pathoIogica1 condition has been identified. Upon the thyroid surgeon rests the burden of separating borderIine hyperthyroidism from functiona disorders. His perspicuity and decision wiI1 save the neurotic from a needIess thyroidectomy, even as he can eradicate hypochondriasis from a patient with miId hyperthyroidism.
T
HE
surgeon of yesteryear IittIe realized that posterity wouId demand a psychiatric knowIedge in modern surgery. In the diagnosis and care of hyperthyroid patients the surgeon trespasses on the confines of the psychiatrist. AIthough he does not enter his domain, it cannot be denied that in the care of the borderIine hyperthyroid patient the surgeon pierces the outskirts of this reaIm. Psychosomatic medicine concerns itseIf with those patients who are neither physicaIIy iI nor have an organic menta1 derangement. These patients are cate“ functiona iIInesses.” gorized as having Most of these patients have a nervous disposition. A tremor may be present with palpitation occasionaIIy noted. This triad of symptoms IabeIs the patient a hyperthyroid. A basa1 metaboIic rate is taken on the nervous patient. It is usually elevated. FaiIure to repeat this study does not reveal the error. The diagnosis is apparentIy correct and the patient is sent to the surgeon for thyroid surgery. The surgeon now assumes the responsibiIity. Unless he is aIert he wiI1 perform a subtota1 thyroidectomy on a patient whose symptoms wiI1 persist or become more marked folIowing surgica1 intervention. NeurocircuIatory asthenia is the most common disorder confused with hyperthyroidism. These individuaIs have paIpitation, tachycardia, tremor, weight Ioss and a sIightIy eIevated basa1 metaboIism. Such patients, however, have no eye signs, no increase in pulse pressure or puIse rate, poor appetite, cold extremities and they demonstrate no manifestations of chronic anxiety. Psychoneurotic states produced by psychic trauma simuIate hyperthyroidism. 363
A patient may have witnessed or was a party to a frightening experience. This factor may precipitate symptoms cIoseIy paraIIeIing toxic goiter. This cIass of patients perhaps have a pre-existing hyperadrenaIism. The physica examination of such persons may not confirm the history of tremor, sweating and tachycardia. The gIand may be normal to inspection and paIpation without any audibIe bruit. The vaIue of the pulse rate which is increased in hyperthyroidism, is noteworthy. Psychic factors may cause a temporaryeIevation whereas hyperthyroidism maintains a constant eIevation of the puIse rate. A fact to remember is that the toxic goiter patient is usuaIIy oIder than the neurotic individual. We have observed that patients with true hyperthyroidism have a tendency to cry spontaneousIy without apparent cause. When the basa1 metaboIism has been eIevated on the initia1 reading, technica inaccuracies may be the cause. The nervous individua1 shouId be informed of the procedure and his cooperation obtained. As a generality it may be stated that cooperation and relaxation are Iess frequentIy obtained with psychoneurotic patients than with hyperthyroids. Repetition of the test each morning unti1 a satisfactory technical reading is obtained may reward the observer with a norma basa1 metabolic recording. Another important differentiating observation is the apparent improvement when these functionaIIy disturbed patients are hospitalized. When these persons are liberated from famiIia1 entangIements relief occurs within a few days. Freedom from noxious menta1 stimuIi eradicates the tach,vcardia and nervous symptoms.
364
American Journal
ofSurgery
Ficarra-Hyperthyroidism
When persons with mentaI unrest have been convinced of the functiona nature of their compIaints and are assisted by competent heIpfu1 psychiatric suggestions, improvement is noted. With the aid of a psychiatrist the so-caIIed hyperthyroid patient undergoes a compIete metamorphosis. AI1 patients suspected of miId hyperthyroidism do not faI1 into the category stressed, even as the diagnosis between a functiona disorder and borderIine hyperthyroidism is not as faciIe as outIined Each individua1 is a singuIar above. probIem. There is no one diagnostic pattern appIicabIe to a11 patients. Caution is advised against the other extreme of faiIing to recognize a true borderIine hyperthyroid patient. To brand such a patient a hypochondriac, a maIingerer or a neurotic may produce deIeterious resuIts. It must also be reaIized that hyperthyroidism is a constitutiona disease and as such may dispIay unusua1 psychic reactions. AIthough no characteristic psy-
MARCH, 1946
chic reaction is indigenous of hyperthyroidism, many of these patients. have acute deIirium. Some patients with Iong standing hyperthyrbidism may manifest toxic exhaustion psychosis and others a manic depressive reaction. True menta1 disease may occur in the hyperthyroid individua1 as in others. In such instances it is diffkuIt to sift the menta1 cIass of symptoms from the hyperthyroid group. This type of patient, however, presents many signs of hyperthyroidism which categorize the disease. Thus even if the menta1 compIaints are attributed to hyperthyroidism, at Ieast the major underIying pathoIogica1 condition has been identified. Upon the thyroid surgeon rests the burden of separating borderIine hyperthyroidism from functiona disorders. His perspicuity and decision wiI1 save the neurotic from a needIess thyroidectomy, even as he can eradicate hypochondriasis from a patient with miId hyperthyroidism.