Psychiatric and neuropsychological response to propranolol in Graves' disease

Impact of hyperthyroidism and its treatment on the outcome of mental health, occupational functioning, and quality of life: A naturalistic, prospective study

Context Background

Hyperthyroidism has a major impact on mental health.

Aims

We intended to determine the magnitude of the unmet need for mental health support in patients with hyperthyroidism attending an endocrinology clinic.

Settings and Design

General Hospital Endocrine Department, Prospective Study.

Methods and Material

In a naturalistic, prospective study, consecutive (n = 176) hyperthyroid patients were assessed for anxiety (generalized anxiety disorder, GAD-7), depression (Patient Health Questionnaire PHQ-9), functional impairment (work and social adjustment scale, WSAS), and quality of life (EuroQol ED5D) using standardized instruments.

Statistical Analysis Used

Percentages, mean and standard deviation (SD), Chi-square, Student's t-test, ANOVA, Spearman's correlation.

Results

A considerable proportion (40.5%) of patients had moderate and severe anxiety, around half (50.6%) had moderate or severe depression, and 20.8% had severe functional impairment at presentation. Mean EQ5D score was 59.6 ± 23.5. The scores of anxiety, depression, and functional impairment were significantly correlated with each other and negatively correlated with QOL. Following treatment of hyperthyroidism, improvement in psychiatric symptoms was noted which could be correlated with the lowering of T4. However, a significant proportion of patients continued to have psychiatric symptoms and functional impairment despite achieving euthyroidism. There was no correlation between the severity of hyperthyroidism to persistence of mental health parameters.

Conclusions

Our findings of high prevalence and persistence of impairment of mental health and functional status of patients with hyperthyroidism have highlighted the unmet needs for these patients.

Graves' disease and mental disorders

Mental disorders merge highly with thyroid diseases. Because of its regulatory effects on serotonin and noradrenalin, T3 has been linked closely to depression and anxiety. It has known that in many cases, the mental symptoms persist even after normalization of thyroid function by treatment. Psychosocial factors including stress have been associated with mental symptoms even after thyroid function normalization in Graves’ disease and a combination of mental disorders have been related to the exacerbation of hyperthyroidism. These findings suggest that psychosomatic approaches based on the bio-psycho-social medical model are important for the treatment of mental disorders associated with Graves’ disease.

Thyroid Storm Presenting as Psychosis

Thyroid storm is a life-threatening endocrine emergency with an incidence rate of 1% to 2%. It is a systemic condition of excessive thyroid hormone production and release leading to thermoregulatory, adrenergic, neuropsychiatric, cardiovascular, and abdominal manifestations. Although it is a rare condition, it carries a significant mortality rate. Hence, knowing the common and uncommon presentations of thyroid storm is important for its prompt diagnosis and treatment. In this article, we present an unusual case of a young woman who presented with psychosis as the manifesting symptom of thyroid storm. She did not respond adequately to conventional medical treatment, requiring plasmapheresis and a definitive thyroidectomy, which ultimately led to the return of patient’s baseline mental status and a dramatic recovery.

2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition)

Thyroid storm is an endocrine emergency which is characterized by multiple organ failure due to severe thyrotoxicosis, often associated with triggering illnesses. Early suspicion, prompt diagnosis and intensive treatment will improve survival in thyroid storm patients. Because of its rarity and high mortality, prospective intervention studies for the treatment of thyroid storm are difficult to carry out. We, the Japan Thyroid Association and Japan Endocrine Society taskforce committee, previously developed new diagnostic criteria and conducted nationwide surveys for thyroid storm in Japan. Detailed analyses of clinical data from 356 patients revealed that the mortality in Japan was still high (∼11%) and that multiple organ failure and acute heart failure were common causes of death. In addition, multimodal treatment with antithyroid drugs, inorganic iodide, corticosteroids and beta-adrenergic antagonists has been suggested to improve mortality of these patients. Based on the evidence obtained by nationwide surveys and additional literature searches, we herein established clinical guidelines for the management of thyroid storm. The present guideline includes 15 recommendations for the treatment of thyrotoxicosis and organ failure in the central nervous system, cardiovascular system, and hepato-gastrointestinal tract, admission criteria for the intensive care unit, and prognostic evaluation. We also proposed preventive approaches to thyroid storm, roles of definitive therapy, and future prospective trial plans for the treatment of thyroid storm. We hope that this guideline will be useful for many physicians all over the world as well as in Japan in the management of thyroid storm and the improvement of its outcome.

Withdrawal From Chronic Nicotine Reduces Thyroid Hormone Levels and Levothyroxine Treatment Ameliorates Nicotine Withdrawal-Induced Deficits in Hippocampus-Dependent Learning in C57BL/6J Mice

INTRODUCTION

Cigarette smoking alters a variety of endocrine systems including thyroid hormones. Altered thyroid hormone signaling may lead to a subclinical or overt hypothyroid condition that could contribute to nicotine withdrawal-related symptoms, such as cognitive deficits. Thus, normalizing thyroid hormone levels may represent a novel therapeutic target for ameliorating nicotine withdrawal-associated cognitive deficits.

METHODS

The current studies conducted an analysis of serum thyroid hormone levels after chronic and withdrawal from chronic nicotine treatment in C57BL/6J mice using an enzyme-linked immunosorbent assay. The present studies also evaluated the effect of synthetic thyroid hormone (levothyroxine) on contextual and cued memory.

RESULTS

The current studies found that nicotine withdrawal reduces secreted thyroid hormone levels by 9% in C57BL/6J mice. Further, supplemental thyroid hormone not only enhanced memory in naïve animals, but also ameliorated deficits in hippocampus-dependent learning associated with nicotine withdrawal.

CONCLUSIONS

These results suggest that smokers attempting to quit should be monitored closely for changes in thyroid function. If successfully treated, normalization of thyroid hormone levels may ameliorate some deficits associated with nicotine withdrawal and this may lead to higher rates of successful abstinence.

Anxiety and depression are more prevalent in patients with graves' disease than in patients with nodular goitre

BACKGROUND AND OBJECTIVE

Graves' disease has been associated with an increased psychiatric morbidity. It is unclarified whether this relates to Graves' disease or chronic disease per se. The aim of our study was to estimate the prevalence of anxiety and depression symptoms in patients with Graves' disease compared to patients with another chronic thyroid disease, nodular goitre, and to investigate determinants of anxiety and depression in Graves' disease.

METHODS

157 cross-sectionally sampled patients with Graves' disease, 17 newly diagnosed, 140 treated, and 251 controls with nodular goitre completed the Hospital Anxiety and Depression Scale (HADS). The differences in the mean HADS scores between the groups were analysed using multiple linear regression, controlling for socio-demographic variables. HADS scores were also analysed dichotomized: a score >10 indicating probable 'anxiety'/probable 'depression'. Determinants of anxiety and depression symptoms in Graves' disease were examined using multiple linear regression.

RESULTS

In Graves' disease levels of anxiety (p = 0.008) and depression (p = 0.014) were significantly higher than in controls. The prevalence of depression was 10% in Graves' disease versus 4% in nodular goitre (p = 0.038), anxiety was 18 versus 13% (p = 0.131). Symptoms of anxiety (p = 0.04) and depression (p = 0.01) increased with comorbidity. Anxiety symptoms increased with duration of Graves' disease (p = 0.04). Neither thyroid function nor autoantibody levels were associated with anxiety and depression symptoms.

CONCLUSIONS

Anxiety and depression symptoms were more severe in Graves' disease than in nodular goitre. Symptoms were positively correlated to comorbidity and duration of Graves' disease but neither to thyroid function nor thyroid autoimmunity.

Thyroid disease and cognition

Overt hypothyroidism and thyrotoxicosis are associated with significant decrements in mood and cognitive function, and therapy usually leads to improvement in these symptoms. In contrast, major affective or cognitive dysfunction is not typical of subclinical thyroid disease. Subtle deficits in specific cognitive domains (primarily working memory and executive function) likely exist in subclinical hypothyroidism and thyrotoxicosis, but these are unlikely to cause major problems in most patients. Patients with mild thyroid disease and significant distress related to mood or cognition most likely have independent diagnoses that should be evaluated and treated separately.

Bladder pain syndrome/interstitial cystitis is associated with hyperthyroidism

BACKGROUND

Although the etiology of bladder pain syndrome/interstitial cystitis (BPS/IC) is still unclear, a common theme with BPS/IC patients is comorbid disorders which are related to the autonomic nervous system that connects the nervous system to end-organs. Nevertheless, no study to date has reported the association between hyperthyroidism and BPS/IC. In this study, we examined the association of IC/BPS with having previously been diagnosed with hyperthyroidism in Taiwan.

DESIGN

Data in this study were retrieved from the Longitudinal Health Insurance Database. Our study consisted of 736 female cases with BPS/IC and 2208 randomly selected female controls. We performed a conditional logistic regression to calculate the odds ratio (OR) for having previously been diagnosed with hyperthyroidism between cases and controls.

RESULTS

Of the 2944 sampled subjects, there was a significant difference in the prevalence of prior hyperthyroidism between cases and controls (3.3% vs. 1.5%, p<0.001). The conditional logistic regression analysis revealed that compared to controls, the OR for prior hyperthyroidism among cases was 2.16 (95% confidence interval (CI): 1.27∼3.66). Furthermore, the OR for prior hyperthyroidism among cases was 2.01 (95% CI: 1.15∼3.53) compared to controls after adjusting for diabetes, coronary heart disease, obesity, hyperlipidemia, chronic pelvic pain, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, depression, panic disorder, migraines, sicca syndrome, allergies, endometriosis, and asthma.

CONCLUSIONS

Our study results indicated an association between hyperthyroidism and BPS/IC. We suggest that clinicians treating female subjects with hyperthyroidism be alert to urinary complaints in this population.

The thyroid function of Graves' disease patients is aggravated by depressive personality during antithyroid drug treatment

Background

We previously reported that depressive personality (the scores of hypochondriasis, depression and psychasthenia determined by the Minnesota Multiphasic Personality Inventory (MMPI)) and daily hassles of Graves' disease (GD) patients treated long trem with antithyroid drug (ATD) were significantly higher in a relapsed group than in a remitted group, even in the euthyroid state. The present study aims to examine the relationship among depressive personality, emotional stresses, thyroid function and the prognosis of hyperthyroidism in newly diagnosed GD patients.

Methods

Sixty-four untreated GD patients responded to the MMPI for personality traits, the Natsume's Stress Inventory for major life events, and the Hayashi's Daily Life Stress Inventory for daily life stresses before and during ATD treatment.

Results

In the untreated thyrotoxic state, depressive personality (T-scores of hypochondriasis, depression or psychasthenia greater than 60 points in MMPI) were found for 44 patients (69%). For 15 (23%) of these patients, the scores decreased to the normal range after treatment. However, depressive personality persisted after treatment in the remaining 29 patients (46%). Normal scores before treatment were found for 20 patients (31%), and the scores were persistently normal for 15 patients (23%). The remaining 5 patients (8%) had higher depressive personality after treatment. Such depressive personality was not associated with the severity of hyperthyroidism. Serum TSH receptor antibody activity at three years after treatment was significantly (p = 0.0351) greater in the depression group than in the non- depression group. The remission rate at four years after treatment was significantly (p = 0.0305) lower in the depression group than in the non- depression group (22% vs 52%).

Conclusion

The data indicate that in GD patients treated with ATD, depressive personality during treatment reflects the effect of emotional stress more than that of thyrotoxicosis and that it aggravates hyperthyroidism. Psychosomatic therapeutic approaches including antipsychiatric drugs and/or psychotherapy appears to be useful for improving the prognosis of hyperthyroidism.

Thyroid disease and mental disorders: cause and effect or only comorbidity?

PURPOSE OF REVIEW

To discuss the effects of thyroid dysfunction and thyroid autoimmunity on mental symptoms and disorders in patients with thyroid disease with reference to recent epidemiological, clinical, and genetic findings.

RECENT FINDINGS

During brain development, iodine deficiency, maternal thyroid dysfunction, and neonatal thyroid malformations together with genetic factors contribute to neurological deficit. Most adults with thyroid dysfunction will develop mental symptoms. In hyperthyroidism, adrenergic hyperactivity is a major cause of psychiatric symptoms, and beta-adrenergic antagonists are effective treatment. Most patients with severe hypothyroidism will also demonstrate mental symptoms; however, causality is not so evident as in hyperthyroidism. Polymorphism in deiodinase genes and in transporter genes appears to make an important contribution to the presentation of mental symptoms as well as to the outcome of treatment of hypothyroidism. A thyroid autoimmunity process may by itself contribute to mental symptoms in vulnerable patients. Data from epidemiological studies provide conflicting evidence as to associations between thyroid disorders and mental symptoms.

SUMMARY

In the adult brain, compared with the developing brain, brain-thyroid relationships are less apparent but still important. Adrenergic hyperactivity is a major cause of psychiatric symptoms in hyperthyroidism. Genetic factors contribute to the development and treatment outcome of mental disorder in hypothyroidism.

Thyroid Function and Cognition during Aging

We summarize here the studies examining the association between thyroid function and cognitive performance from an aging perspective. The available data suggest that there may be a continuum in which cognitive dysfunction can result from increased or decreased concentrations of thyroid hormones. Clinical and subclinical hypothyroidism as well as hyperthyroidism in middle-aged and elderly adults are both associated with decreased cognitive functioning, especially memory, visuospatial organization, attention, and reaction time. Mild variations of thyroid function, even within normal limits, can have significant consequences for cognitive function in the elderly. Different cognitive deficits possibly related to thyroid failure do not necessarily follow a consistent pattern, and L-thyroxine treatment may not always completely restore normal functioning in patients with hypothyroidism. There is little or no consensus in the literature regarding how thyroid function is associated with cognitive performance in the elderly.

Affective symptoms and cognitive functions in the acute phase of Graves' thyrotoxicosis

In the acute phase of Graves' thyrotoxicosis patients often have subjective cognitive complaints. Continuing controversy exists about the nature of these symptoms and whether they persist after treatment. This prospective study included 31 consecutively referred, newly diagnosed, and untreated patients with Graves' thyrotoxicosis. A control group of 34 individuals matched for age, education and premorbid intelligence was also included. At baseline all patients and control subjects were examined with psychiatric rating scales and a comprehensive neuropsychological battery. The effect of treatment on affective symptomatology was examined in the patient group after reaching euthyroidism and 1 year after treatment initiation. At initial examination patients had significantly higher scores on psychiatric rating scales as compared with controls, and the majority reported memory and concentration problems. No significant differences between the patient and the control group on neuropsychological test performances were found. Thyroid levels did not correlate with the neuropsychological test performances or psychiatric ratings. After reaching euthyroidism the level of affective symptoms (including reports of cognitive deficits) had decreased significantly, with further normalisation 1-year after treatment initiation. In conclusion, patients had subjective reports of cognitive deficits in the toxic phase of Graves' thyrotoxicosis but comprehensive neuropsychological testing revealed no cognitive impairment. Reports of cognitive dysfunction may reflect affective and somatic manifestations of thyrotoxicosis and in most patients these symptoms disappear after treatment of Graves' thyrotoxicosis.

Cortical activation during finger tapping in thyroid dysfunction: A functional magnetic resonance imaging study

Thyroid dysfunction is associated with attention deficit and impairment of the motor system (muscle weakness and fatigue). This paper investigates possible motor function deficit in thyroid patients,compared to the controls. Functional MRI studies (fMRI)were carried out in five hypo and five hyperthyroid patients and six healthy volunteers. Whole brain imaging was performed using echo planar imaging (EPI)technique, on a 1.5T whole body MR system (Siemens Magnetom Vision). The task paradigm consisted of 8 cycles of active and reference phases of 6 measurements each, with right index finger tapping at a rate of 120 taps/min. Post-processing was performed using statistical parametric mapping on a voxel-by-voxel basis using SPM99. Clusters of activation were found in the contralateral hemisphere in primary somatomotor area (M1), supplementary motor area (SMA), somatosensory,auditory receptive and integration areas, inferior temporal lobe, thalamus and cerebellum. Increased clusters of activation were observed in M1 in thyroid subjects as compared to controls and with bilateral activation of the primary motor cortex in two hyperthyroid patients. The results are explained in terms of increased functional demands in thyroid patients compared to volunteers for the execution of the same task.

Graves' disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery

The effects of treatment modality for Graves' disease (GD) were studied with respect to long-term quality of life and present health status. A total of 179 patients with GD were randomized during the period 1983-1990 for treatment with antithyroid drugs, radioiodine, or surgery. A 36-item Short Form Health Status Survey questionnaire and specific questions for GD were sent to patients 14-21 years after randomization. Present medical records, and clinical and laboratory status were recorded. No major significant differences in quality of life among the three treatments were observed. Compared to a large Swedish reference group, all treatment groups had significantly lower scores for vitality (p < 0.05). The Mental Component Summary was lower for both the young medical, young surgical, and the older medical group (p < 0.05). Radioiodine-treated patients had a lower General Health score. Young medical patients (<35 years) had lower Mental Health scores (p < 0.05). There was also a strong trend, which barely met statistically significance, for older surgical and radioiodine groups for lower Mental Component Summary. GD patients have, compared with a large Swedish reference population, diminished vital and mental quality of life aspects even many years after treatment. The quality-of-life scores were not different among the three treatment modalities.

Increased risk of affective disorder following hospitalisation with hyperthyroidism - a register-based study

OBJECTIVE

The pattern of comorbidity between thyroid disorders and affective disorder is not fully known. We assessed whether hospitalisation with hyperthyroidism was a risk factor for hospitalisation with affective disorder and evaluated the temporal relationship between these events.

DESIGN

A historical prospective cohort study comparing patients with hyperthyroidism with patients with non-toxic goitre or osteoarthritis, using existing data from Danish registers. The observational period was from 1 January 1977 to 31 December 1999.

METHODS

Three study cohorts were identified by their International Classification of Diseases (ICD) diagnoses at discharge from hospital and consisted of all patients with a first hospital admission with the index diagnoses of hyperthyroidism, osteoarthritis, or non-toxic goitre. Later admissions to psychiatric hospital wards with discharge ICD diagnoses of affective disorder were used as events of interest. Rates of re-admission were estimated using competing risks models in survival analyses. Age, sex, substance abuse, and calendar time were included as co-variables.

RESULTS

A study sample of 183 647 patients discharged with an index diagnosis was identified. In total 1374 events occurred in the observational period. An index diagnosis of hyperthyroidism was associated with an increased risk of hospitalisation with affective disorder for both sexes and for all age-bands investigated, compared with the other index diagnoses. The risk was greatest in the first six months after index hospitalisation (rate ratio, 95% confidence interval: 3.60 (2.58-5.04)).

CONCLUSIONS

Patients hospitalised with hyperthyroidism are at greater risk of re-admission with depressive disorder or bipolar disorder than control patients. This suggests that hyperthyroidism is associated with long-term mood disturbances.

Mood and anxiety disorders in women with treated hyperthyroidism and ophthalmopathy caused by Graves' disease

OBJECTIVE

To evaluate the prevalence of mood and anxiety disorders in women with treated hyperthyroidism caused by Graves' disease and to compare them with the prevalence of such findings in women without past or present thyroid disease.

METHODS

Thirty inpatient women with treated hyperthyroidism and ophthalmopathy caused by Graves' disease and 45 women hospitalized for treatment of gynecologic disorders such as abnormal vaginal bleeding, benign tumors or infertility were evaluated for the prevalence of mood and anxiety diagnoses using a standard Mini-International Neuropsychiatric Interview and for mood and anxiety ratings using the Profile of Mood States (POMS). At the time of assessment, it was discovered that 14 of 30 women with treated hyperthyroidism caused by Graves' disease were still hyperthyroid, while 16 women were euthyroid.

RESULTS

Significantly greater prevalence of social anxiety disorder, generalized anxiety disorder, major depression and total mood and anxiety disorders, as well as higher symptom scores on the POMS, was found in hyperthyroid women with Graves' disease in comparison with the control group. A prevalence of total anxiety disorder, as well as history of mania or hypomania and lifetime bipolar disorder, but not lifetime unipolar depression, was more frequent in both the euthyroid and the hyperthyroid subgroups of study women in comparison with the control group.

CONCLUSIONS

These results confirm a high prevalence of mood and anxiety disorders in women with treated hyperthyroidism and ophthalmopathy caused by Graves' disease. Hyperthyroidism plays a major role in psychiatric morbidity in Graves' disease.

Cognitive and neuropsychiatric aspects of subclinical hypothyroidism: significance in the elderly

The effects of overt hypothyroidism (HO) on cognition and mood are well established, and HO is considered a common cause of reversible dementia. There is now increasing evidence to suggest that subclinical hypothyroidism (ie, elevated thyroid stimulating hormone in the presence of normal thyroxine concentrations) may be a predisposing factor for depression, cognitive impairment, and dementia. Subclinical hypothyroidism is more common than HO and is most prevalent in the elderly, particularly in women. Older adults may be more vulnerable to the effects of subclinical hypothyroidism, given age-related changes to the hypothalamic-pituitary-thyroid axis, and there is an association between thyroid status and cognitive decline and dementia in the elderly. The purpose of this review is to summarize existing data on the cognitive and neuropsychiatric consequences of subclinical hypothyroidism, benefits of treatment, and recommendations for screening and monitoring in older adults.

Depression and anxiety in hyperthyroidism

BACKGROUND

Our objective was to determine symptomatology of depression and anxiety in patients with untreated hyperthyroidism and compare with euthyroid patients.

METHODS

Thirty-two patients with hyperthyroidism (high free T3 and free T4, and suppressed TSH) and 30 euthyroid (normal free T3, free T4, and TSH) controls attending the Endocrinology Out-Patient Department at Celal Bayar University Hospital in Manisa, Turkey were included in the study. Hormonal screening was performed by immunoassay and hemagglutination method. For psychiatric assessment, Hospital Anxiety and Depression Scale [HAD], Hamilton Depression Rating Scale [HAM-D], and Hamilton Anxiety Rating Scale [HAM-A] were used. There was no difference between the two groups in terms of demographic features.

RESULTS

Total scores obtained both from HAM-D and HAM-A were significantly greater in the hyperthyroidism group than that of the euthyroid group (p <0.05); there was no difference in terms of HAD. When compared in terms of symptomatology, early insomnia (HAM-D#6), work and activities (HAM-D#7), psychic anxiety (HAM-D#10), weight loss (HAM-D#16), insomnia (HAM-A#4), and cardiovascular symptoms (HAM-A#8) were significantly more frequent in the hyperthyroidism group. By Wilks lambda discriminant analysis, psychomotor agitation (HAM-D#9), weight loss (HAM-D#16), and insomnia (HAM-A#4) were found as the discriminating symptoms for the hyperthyroidism group, whereas somatic anxiety (HAM-A#11) and loss of interest (HAD#14) were distinguishing symptoms of the euthyroidism group.

CONCLUSIONS

Hyperthyroidism and syndromal depression-anxiety have overlapping features that can cause misdiagnosis during acute phase. For differential diagnosis, one should follow-up patients with hyperthyroidism with specific hormonal treatment and evaluate persisting symptoms thereafter. In addition to specific symptoms of hyperthyroidism, psychomotor retardation, guilt, muscle pain, energy loss, and fatigue seem to appear more frequently in patients with comorbid depression and hyperthyroidism; thus, presence of these symptoms should be a warning sign to nonpsychiatric professionals for the need for psychiatric consultation.

Hormones and cognition: current concepts and issues in neuropsychology

This article provides an extensive and comprehensive review of the effects of hormones on cognition. Studies detailing specific neurocognitive functions affected by variation in hormone levels across the life span are presented. Dysregulation of hormone levels is considered from models of both normal and diseased functioning. Patterns of cognitive dysfunction are described for a range of syndromes involving the neuroendocrine system, and evidence of specific neurophysiological mechanisms that can account for these findings is outlined. This review includes discussion of treatment outcomes and the permanency of endocrine-related cognitive dysfunction. The authors present a set of guidelines for clinical neuropsychologists to use for assessment of patients with neuroendocrine system dysfunction. Clinical and methodological issues in research and treatment settings are discussed.

Frontal lobe proton magnetic-resonance spectroscopy in Graves' disease: a pilot study

Patients with hyperthyroidism may show impaired performance on several neuropsychological tests that require complex visual discrimination, conceptualization, mental flexibility or organization. These neurocognitive impairments appear to be consistent with prefrontal lobe dysfunction. This pilot study was undertaken to characterize the metabolite profile in the right prefrontal cortex in six patients with untreated Graves' disease by using in vivo proton magnetic-resonance spectroscopy (1H-MRS). For comparison, 1H-MRS was also carried out in seven healthy controls. The choline/creatine (Cho/Cr) and N-acetyl aspartate/creatine (Naa/Cr) ratios were determined. Cho/Cr ratios of the hyperthyroid patients were significantly lower than that of controls (means +/- SD = 0.61 +/- 0.09 vs. 0.90 +/- 0.18, p = .05). The two groups did not differ in their Naa/Cr ratios. Follow-up data after antithyroid treatment were available in three patients: Cho/Cr ratios were higher after treatment (euthyroidism) than before treatment (1.06 vs. 0.55; 0.82 vs. 0.54; 1.15 vs. 0.76). Tentatively, these preliminary data are most consistent with reversible reductions in the concentrations of choline-containing compounds (especially glycerophosphocholine and phosphocholine) in the prefrontal area during hyperthyroidism. However, these findings await confirmation by a definitive study with a larger sample size. A possible explanation of the findings is an altered brain cholinergic-adrenergic balance in hyperthyroidism.

Subclinical hyperthyroidism: physical and mental state of patients

We investigated whether subclinical hyperthyroidism [subnormal basal thyroid-stimulating hormone (TSH) level, attenuated TSH response to thyrotropin-releasing hormone (TRH) stimulation, peripheral thyroid hormones within normal range] is accompanied by physical and mental changes. Thirty-five subclinically hyperthyroid patients (27 female, 8 male) were compared with 60 overtly hyperthyroid patients (51 female, 9 male) and with 28 euthyroid control patients (18 female, 10 male) with respect to physical symptoms, affective state, short-term memory, ability to concentrate and psychomotor performance. Patients with subclinical hyperthyroidism ranged between the other two groups. The major difference between controls and subclinically hyperthyroid patients was an increase in frequency of nervous symptoms and symptoms due to an increase of metabolic rate and thermal regulation changes. The major differences between subclinically hyperthyroid and overtly hyperthyroid patients were psychomotor impairment and symptoms of increased metabolic rate. Self-ratings of affective state tended to be similar in patients with subclinical and overt hyperthyroidism. The ability to concentrate and short-term memory were not impaired in any group. Symptoms in patients with subclinical hyperthyroidism probably result from central changes which lead to attenuated TSH responses to TRH, or from elevated but still normal thyroxine levels, which possibly enhance the effect of catecholamines.

Hyperthyroid myopathy and the response to treatment

Hyperthyroidism is accompanied by significant dysfunction of both proximal and distal skeletal muscles. The purpose of this study was to quantitate the degree of muscle weakness in newly diagnosed patients with Graves' disease and to assess the response to treatment. Ten patients were prospectively studied with objective measures of strength and endurance of proximal and distal muscles while hyperthyroid (stage I), after 2 weeks of propranolol (stage II), and about 6 months later when euthyroid (stage III). Propranolol treatment for 2 weeks resulted in a subjective decrease in weakness, which was accompanied by a statistically significant improvement in grip strength (P less than 0.01), shoulder strength (P less than 0.02), and grip endurance (P less than 0.01) but not shoulder endurance. Muscle function further improved and attained control levels when the patients were chemically and clinically euthyroid. In contrast, a control group subjected to the same muscle testing protocol before and after 1 week of propranolol treatment showed no improvement in grip, shoulder strength, or shoulder endurance but had decreased grip endurance (P less than 0.01) and increased subjective weakness. These results confirm that muscle weakness commonly is associated with hyperthyroidism and can be quantitatively profound. In contrast to the effects of beta-blockade in normal controls, propranolol partially improves muscle weakness in thyrotoxic patients. We conclude that thyroid hormone and catecholamines in concert mediate the muscle dysfunction of hyperthyroidism.

Sequential psychological testing during the course of autoimmune hyperthyroidism

Although the psychological disturbances accompanying Graves' disease are well known, the time required for normalisation of these disturbances during antithyroid drug treatment is not known. Therefore sequential psychological testing during the course of Graves' disease was done. There are also contradictory results concerning the possible correlation of neurophysiological and psychological test results during the course of Graves' disease with thyroid hormone values. Finally, psychological disturbances have been proposed as possible etiologic factors in Graves' disease. In our study, a significant decrease in anxiety and irritability could be observed at the time euthyroidism was achieved. Self-evaluations of depressivity, activity, exhaustion, well-being, extraversion, introversion, and the ability to concentrate changed 1 or 2 months after euthyroidism was induced. Similar test results could be observed after induction of euthyroidism by antithyroid drugs and subtotal thyroid resection. Therefore the mode of therapy does not seem to influence the course of normalisation of psychological parameters. In contrast to other investigations there was hardly any correlation between thyroid hormone values and psychological test results or the ability to concentrate. Nontheless, patients with Graves' disease showing high scores for depression and anxiety exhibit abnormal peripheral helper/suppressor T-lymphocyte relations. Furthermore, patients suffering from Graves' disease tend to be more anxious than controls. It remains to be determined whether an increased susceptibility to psychological disturbances has led to these alterations of lymphocyte subsets in Graves' disease patients with severe depression and anxiety.

Catecholamine-thyroid hormone interactions and the cardiovascular manifestations of hyperthyroidism

The spectrum of classic symptoms of hyperthyroidism suggests that in addition to the effects of increased thyroid hormone, affecting various organ systems, there is also a hyperadrenergic state. Despite this clinical impression, direct measures of serum levels of catecholamines and their urinary metabolites demonstrate values that are equal to or less than normal. In contrast, the hypothyroid patient who clinically manifests signs of decreased adrenergic stimulation can be expected to have increased levels of epinephrine, norepinephrine, and its metabolites. This review discusses possible mechanisms to explain this seeming paradox. Treatment of hyperthyroidism includes the rapid reversal of many of the adrenergic symptoms with use of beta-blocking drugs. Return to a clinically and chemically euthyroid state, however, requires antithyroid therapy accomplished over a longer period of time. A knowledge of the interaction of the cardiovascular and extracardiovascular manifestations of hyperthyroidism and the role of the adrenergic nervous system is important in the rational management of these patients.

Psychiatric aspects of hyperthyroidism

This article reviews the psychiatric aspects of hyperthyroidism. The psychosomatic theory in the aetiology of thyrotoxicosis is first reviewed in relation to pre-morbid personality and stress. The nature of hyperthyroidism is briefly analysed, as it has direct relevance to the integral psychiatric manifestations of the disorder. Psychiatric manifestations are then described: firstly, those that are an integral part of hyperthyroidism and; secondly, those which have been reported to occur in association with hyperthyroidism. The psychosocial impact of the disease is also considered. There follows a discussion of the antecedents of psychiatric disorder in relation to mediating psychological and biological factors. The article reviews past and present evidence concerning the nature of the association between hyperthyroidism and other psychiatric disorders. Course and outcome of psychiatric disorder in hyperthyroidism are reviewed and, lastly, an appraisal is made of implications for management.

Graves' disease: an analysis of thyroid hormone levels and hyperthyroid signs and symptoms

PURPOSE

Assessment of disease severity for patients with hyperthyroidism involves clinical evaluation and laboratory testing. To determine if there is a correlation between symptoms and thyroid function test results, we prospectively studied hyperthyroid patients using a standardized symptom rating scale and serum thyroid function parameters.

PATIENTS AND METHODS

We examined 25 patients with untreated, newly diagnosed Graves' disease using the Hyperthyroid Symptom Scale (HSS) and serum levels of thyroxine (T4), triiodothyronine (T3) relative insulin area (RIA), and estimates of free thyroxine index (FTI). In addition, we compared thyroid hormone levels with standard measures of depression and anxiety in these patients.

RESULTS

When regression analyses controlling for age were performed, none of these symptom ratings were associated with FTI or T3 RIA. The HSS was correlated with goiter size and anxiety ratings and was inversely correlated with age.

CONCLUSION

The present study suggests that there is no relationship between the clinical assessment of disease severity and serum levels of thyroid hormone in untreated Graves' disease.