Psychotic states associated with disorders of thyroid function

Prevalence and clinical correlates of psychotic symptoms in first-episode untreated female chinese patients with major depressive disorder

BACKGROUND

Recent studies have reported that psychotic symptoms are common in patients with major depressive disorder (MDD). However, few studies have reported the relationship between thyroid function, lipid metabolism and clinical profiles in female MDD patients. Thus, this study aimed to investigate the prevalence of psychotic depression (PD) and its risk factors in first-episode and drug naive (FEDN) depression among the female population in China.

METHODS

This was a cross-sectional study involving a representative probability sample of 1,130 FEDN female outpatients with MDD (aged 18 years or older) in China. We collected information relating to socio-demographic characteristics, clinical data and blood samples. The Hamilton Depression Rating Scale 17-item version (HAMD-17), Hamilton Anxiety Rating Scale 14-item version (HAMA-14), and Positive and Negative Syndrome Scale (PANSS) were used to evaluate depressive, anxiety, and psychotic symptoms.

RESULTS

The prevalence of psychotic symptoms in female MDD patients was 10.97%. The findings revealed significant differences between MDD female patients with psychotic symptoms and non-PD female patients in the following areas: higher HAMD scores, higher HAMA scores, more severe anxiety and an increased risk of suicide attempts. Further logistic regression analysis showed that psychotic symptoms were associated with higher thyroid-stimulating hormone (TSH) levels and an odds ratio of 1.168.

CONCLUSIONS

Our findings supported the hypothesis that higher TSH levels were correlated with psychotic symptoms in female MDD patients. Therefore, serum TSH levels may be a potential biomarker of PD in female MDD patients. In addition, we found that PD was closely associated with suicide attempts and lipid levels, but did not reach statistical significance.

Myxedema Madness - Systematic literature review of published case reports

Myxedema Madness is a rare but easily treatable cause of psychosis. Since Myxedema Madness was first described the question of a specific psychopathological symptom complex caused by severe hypothyroidism was raised in the literature. The present review of 52 published cases indicates that there are no specific somatic and psychopathological findings to diagnose a myxedema psychosis. It is diagnosed through the measurement of thyroid stimulating hormone and treated by application of L-thyroxine. Due to its excellent prognosis, myxedema madness should always be considered a differential diagnosis in new onset psychosis.

Myxedema Psychosis: Systematic Review and Pooled Analysis

BACKGROUND AND OBJECTIVE

The term myxedema psychosis (MP) was introduced to describe the occurrence of psychotic symptoms in patients with untreated hypothyroidism, but the optimal assessment and treatment of this condition are unclear. We aimed to synthesize data from the literature to characterize the clinical presentation and management of MP.

METHODS

We performed a systematic review according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines in PubMed (Medline), Embase, Google Scholar, and Cochrane databases, including observational studies, case series, and case reports published from 1/1/1980 to 31/12/2019 in the English language. Descriptive statistics along with univariate and multivariate analysis were used for data synthesis.

RESULTS

Out of 1583 articles screened, 71 case reports met our inclusion criteria providing data on 75 MP cases. The median age at diagnosis was 42 years [32-56]. About 53% had no prior hypothyroidism diagnosis. Delusions occurred in 91%, with a predominance of persecutory ideas (84%), while hallucinations occurred in 78%. Physical symptoms and signs of hypothyroidism were absent in 37% and 26%, respectively. If symptoms occurred, nonspecific fatigue was seen most frequently (63%). The median thyroid-stimulating hormone value was 93 mIU/L [60-139]. Thyroid peroxidase antibodies were found positive in 75% (23/33) of reported cases. Creatinine kinase was reported abnormal in seven cases. Cranial imaging (CT or MRI) and electroencephalogram were normal in 89%, 75%, and 73% of the cases reported. The majority of patients were treated orally with thyroxine in combination with short-term antipsychotics. More than 90% of them showed complete recovery. Univariate analysis revealed a trend towards a shorter duration of psychosis with IV thyroid hormone therapy (p= 0.0502), but the effect was not consistent in a multivariate analysis.

CONCLUSION

While we identified a substantial lack of published research on MP, our pooled analysis of case observations suggests that the condition presents a broad spectrum of psychiatric and physical symptoms lending support to the value of screening for thyroid dysfunction in patients with first-ever psychosis.

PROSPERO REGISTRATION NUMBER

CRD42020160310.

Hallucinations: A Systematic Review of Points of Similarity and Difference Across Diagnostic Classes

Hallucinations constitute one of the 5 symptom domains of psychotic disorders in DSM-5, suggesting diagnostic significance for that group of disorders. Although specific featural properties of hallucinations (negative voices, talking in the third person, and location in external space) are no longer highlighted in DSM, there is likely a residual assumption that hallucinations in schizophrenia can be identified based on these candidate features. We investigated whether certain featural properties of hallucinations are specifically indicative of schizophrenia by conducting a systematic review of studies showing direct comparisons of the featural and clinical characteristics of (auditory and visual) hallucinations among 2 or more population groups (one of which included schizophrenia). A total of 43 articles were reviewed, which included hallucinations in 4 major groups (nonclinical groups, drug- and alcohol-related conditions, medical and neurological conditions, and psychiatric disorders). The results showed that no single hallucination feature or characteristic uniquely indicated a diagnosis of schizophrenia, with the sole exception of an age of onset in late adolescence. Among the 21 features of hallucinations in schizophrenia considered here, 95% were shared with other psychiatric disorders, 85% with medical/neurological conditions, 66% with drugs and alcohol conditions, and 52% with the nonclinical groups. Additional differences rendered the nonclinical groups somewhat distinctive from clinical disorders. Overall, when considering hallucinations, it is inadvisable to give weight to the presence of any featural properties alone in making a schizophrenia diagnosis. It is more important to focus instead on the co-occurrence of other symptoms and the value of hallucinations as an indicator of vulnerability.

Myxoedema madness

A 59-year-old man was referred for Mental Health Act Assessment following several months of 'odd behaviour' and self-neglect reported by his neighbours. He presented as unkempt and expressed delusional ideas with respect to age, employment and identity of family members. He was fully oriented but lacked insight into his mental state and capacity for self-care. Physical examination revealed dry skin and slow relaxing reflexes. Blood investigations revealed a raised thyroid stimulating hormone and free T4 with positive thyroid peroxidise antibodies. MRI of the brain revealed frontal lobe and cerebellar atrophy, while neuropsychological assessment identified deficit in memory processing and executive functions. Despite appropriate correction of primary hypothyroidism with levothyroxine, the patient remained delusional with respect to age and employment although he showed some improvement in memory. Capacity for self-care remained poor; thus, he was eventually transferred to sheltered housing with rehabilitation.

Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited

Hypothyroidism is a medical condition commonly encountered in a variety of clinical settings. The clinical presentations of thyroid hormone deficiency are diverse, complicated, and often overlooked. Hypothyroidism is a potential etiology for multiple somatic complaints and a variety of psychological disturbances. The physical complaints are primarily related to metabolic slowing secondary to lack of thyroid hormone. Psychiatric presentations include cognitive dysfunction, affective disorders, and psychosis. The realization that hypothyroidism might be the potential etiology of an assortment of symptoms is critical in the identification and treatment of the hypothyroid patient. Once hypothyroidism is identified, symptoms usually respond to appropriate thyroid hormone supplementation. This article presents a case of clinical hypothyroidism that came to clinical attention due to psychotic symptoms consisting of auditory and visual hallucinations. The case is followed by a brief discussion of the literature describing the relationship of hypothyroidism and psychiatric symptomatology. References were identified with an English language-based MEDLINE search (1966-2003) using the terms thyroid, hypothyroid, depression, dementia, delirium, mania, bipolar disorder, psychosis, and myxedema and utilization of referenced articles.

Child psychosis due to hypothyroidism

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Utility of thyroid function screening in adolescent psychiatric inpatients

OBJECTIVE

Thyroid function abnormalities have been associated with psychiatric symptoms. This study examines the utility of thyroid screening among adolescent psychiatric inpatients.

METHOD

A retrospective chart review of 196 first-time admissions to an adolescent psychiatric unit was conducted. Charts were screened for demographics, presence/absence of thyroid function testing, history of thyroid disease, medication/illicit substance use, and other factors of influence on thyroid testing. Thyroid test results were reviewed for abnormalities.

RESULTS

Thyroid function testing was conducted in 150 of the 196 admissions. Fifty-two patients had abnormalities, most of which were isolated abnormalities of thyroxine (T4) or triiodothyronine uptake (T3U). Laboratory diagnosis of hyperthyroidism and mild hypothyroidism was met by two and eight patients, respectively; five had profiles that were normal upon subsequent testing 1 week later. None of the patients was symptomatic, and none required thyroid supplementation or antithyroid medications. Gender differences in T4 and T3U were noted, and age was positively correlated with T3U.

CONCLUSIONS

Thyroid function tests may be spuriously abnormal in routine screening of newly admitted psychiatric patients. Routine thyroid screening among adolescent psychiatric inpatients is unwarranted except in patients who display physical signs or symptoms suggestive of thyroid disease.

Diagnostic utility of endocrine and neuroimaging screening tests in first-onset adolescent psychosis

OBJECTIVE

To determine the diagnostic utility of endocrine and neuroimaging screening tests in first-onset adolescent psychosis.

METHOD

111 consecutively admitted adolescents (aged 13 through 19 years) who presented with a first-onset psychosis and who had an unremarkable medical history and normal physical examination were given a battery of endocrine and neuroimaging screening tests. Diagnostic utility of a screening test was defined as an abnormal result (a positive test) that either led to a previously unknown or unsuspected medical diagnosis or played an important role in the clinical care of the patient.

RESULTS

15.4% of the endocrine screening tests and 11.0% of the neuroimaging screening tests were identified as positive. However, no endocrine and no neuroimaging tests met criteria for diagnostic utility. The direct cost of this screening battery was $636.95 per patient.

CONCLUSION

Routine endocrine and neuroimaging screening tests in first-onset adolescent psychosis provide no diagnostic utility and are not cost-effective. Selective use of appropriate endocrine and neuroimaging diagnostic tests in populations with symptoms suggestive of organic disorders should replace routine screening procedures.