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Thyroid dysfunction psych aspects
- 1. MEDICAL AND PSYCHIATRIC MANIFESTATIONS OF THYROID DYSFUNCTION Gibson george First year msc nursing
- 2. INTRODUCTION - Thelargest endocrine gland - 20-25 g (adults) - purple brown, two lateral lobes, isthmus - lies in front upper trachea (2nd/3rd rings) - Posterior – 2 pairs of parathyroid glands
- 3. 3 The Thyroxines Tri Iodo Thyronine – T3 Tetra Iodo Thyronine – T4
- 4. Actions of thyroidHormones - Increase BMR ( oxygen consumption & heat production – body temperature) - Growth/development= all tissues - Carbohydrate metabolism= hyperglycemia. Increase glycogenolysis, gluconeogenesis - Fat metabolism= enhance lipolysis, increase plasma FFA, decrease serum cholesterol.
- 5. Actions of thyroidHormones - Protein metabolism – mainly catabolic. Also increase some protein synthesis. - Bone turnover is increased - Cardiovascular - increase HR, cardiac contractility, cardiac output. - GI tract - increase appetite, GI motility. - CNS - essential for normal brain development : memory, mentation, reflexes, tremor - Gonadal function
- 6. Hypothalamus-Pituitary-Thyroid axis Stimulifrom Central nervous system Hypothalamus -ve Releasing (TRH)/inhibitory hormones(somatostatin) Pituitary gland (anterior lobe) Thyrotropin (TSH) -ve T3, T4 hormones Thyroid gland
- 7. 7 Thyroid FunctionTests 1. TSH 2. Free T4 3. Free T3
- 8. Definitions of ThyroidStatus TTSSHH Low Normal High <0.3 mIU/mL 0.3–4.0 mIU/mL1 >4.0 mIU/mL HHyyppeerrtthhyyrrooiidd EEuutthhyyrrooiidd HHyyppootthhyyrrooiidd 11Demers Demers LM, Spencer CA, eds. Laboratory Medicine Practice Guidelines: Laboratory Support for tthhee DDiiaaggnnoossiiss aanndd MMoonniittoorriinngg ooff TThhyyrrooiidd DDiisseeaassee.. FFrroomm tthhee TThhee NNaattiioonnaall AAccaaddeemmyy ooff CClliinniiccaall BBiioocchheemmiissttrryy.. AAvvaaiillaabbllee aatt:: wwwwww..nnaaccbb..oorrgg//tthhyyrrooiidd__llmmppgg..hhttmm.. AAcccceesssseedd MMaarrcchh 1122,, 22000022..
- 9. Thyroid Disease Spectrum OOvveerrtt HHyyppootthhyyrrooiiddiissmm TTSSHH >>44..00 mIIUU//mmLL MMiilldd TThhyyrrooiidd FFaaiilluurree TTSSHH >> 44..00 mIIUU//mmLL FFTT44 nnoorrmmaall 00 55 ³1100 TTSSHH ((mIIUU//mmLL)) FFTT44 llooww EEuutthhyyrrooiidd TTSSHH 00..33––44..00 mIIUU//mmLL FFTT44 nnoorrmmaall HHyyppeerrtthhyyrrooiiddiissmm TTSSHH <<00..33 mIIUU//mmLL FFTT44 eelleevvaatteedd
- 10.
- 11. Hypothyroidism Hypothyroidism isa disorder of diverse causes in which the thyroid fails to secrete an adequate amount of thyroid hormone.
- 12. Hypothyroidism • Epidemiology – Most common endocrine disease – Females > Males • Presentation – Often unsuspected and grossly under diagnosed – 90 % of the cases are Primary Hypothyroidism – Low free T4 and High TSH – Easily treatable with oral Levo-thyroxine 12
- 13. Primary hypothyroidism •Results from diseases or treatments that destroy thyroid tissue or interfere with thyroid hormone synthesis Central or “secondary” hypothyroidism • Results from hypothalamic or pituitary disease
- 14. Primary Hypothyroidism: UnderlyingCauses • Congenital thyroid disorder – Agenesis – Defective thyroid hormone biosynthesis • Thyroid tissue destruction as a result of: – Chronic autoimmune thyroiditis – Radiation – Subtotal and total thyroidectomy – Infiltrative diseases of thyroid • Drugs with anti-thyroid actions (eg, lithium, iodine, iodine-containing drugs, radiographic contrast agents, interferon alpha)
- 15. 15 Multi systemeffects - Hypothyroidism General Neuromuscular •Lethargy, Somnalence •Aches and pains •Weight gain, Goitre •Muscle stiffness •Cold Intolerence •Carpel tunnel syndrome Cardiovascular •Deafness, Hoarseness •Bradycardia, Angina •Cerebellar ataxia •CHF, Pericardial Effusion •Depression, Psychosis •HyperlipIdemia, Xanthelsma Gastro-intestinal Haematological •Constipation, Ileus, Ascites Iron def. Anaemia, Dermatological Normo cytic /chromic Anaemia •Dry flaky skin and hair Reproductive system •Myxoedema, •Infertility, Menorrhagia •Vitiligo, Alopecia •Impotence, Inc. Prolactin
- 16. 16 Clinical Signsof Hypothyroidism Coarse Hair; Dry cool and pale skin Hoarseness of voice Non-pitting oedema (myxoedema) Puffiness of eyes and face Delayed relaxation of DTR Slow hoarse speech and slow movements Thinning of lateral 1/3 of eye brows Bradycardia, pericardial effusion
- 17. Fatigue Forgetfulness/Slower Thinking Nervousness/Irritability Depression Poor Mental Concentration and Memory Thinning Hair/Hair Loss Anemia Dry, Patchy Skin (Pilaris) Brittle Nails Cold Intolerance Elevated Cholesterol and Other Hyperlipidemias Effusion Personal History Endocrine/Autoimmune Disorders Eyelid Edema/Puffy Eyes Swelling (Goiter) Thyroiditis Throat Pain Dysphagia Diastolic Hypertension Hoarseness/Deepening of Voice Bradycardia Weight Gain Constipation Muscle Weakness/Cramps Infertility Menstrual Irregularities, Menometrorrhagia
- 18. Thyroid Failure -Organ Systems Cardiovascular • Decreased ventricular contractility • Increased diastolic blood pressure • Decreased heart rate Central Nervous • Decreased concentration • General lack of interest • Depression Gastro-instestinal • Decreased GI motility • Constipation 18
- 19. Thyroid Failure -Organ Systems Musculoskeletal Muscle stiffness, cramps, pain, weakness, myalgia Slow muscle-stretch reflexes, muscle enlargement, atrophy 19 Renal Fluid retention and oedema Decreased glomerular filtration
- 20. Thyroid Failure -Organ Systems Reproductive • Arrest of pubertal development • Reduced growth velocity • Menorrhagia, Amenorrhea • Anovulation, Infertility Hepatic • Increased LDL / TC • Elevated LDL + triglycerides 20
- 21. Thyroid Failure -Organ Systems 21 Skin and Hair Thickening and dryness of skin Dry, coarse hair, Alopecia Loss of scalp hair and / or lateral eyebrow hair
- 22. 22 Order forTSH alone as a screen • Psychiatric patients • Elderly women / men • Hypercholesterolemia • Lithium, • Postpartum women Other Autoimmune disease Rx. Grave’s Ophthalmopathy Family H/o thyroid disease Neck irradiation therapy Previous Rx for thyrotoxicosis Autoimmune Thyroiditis
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- 29. Xanthomata 29 Xanthelasma Tuberous Xanthoma
- 30.
- 31. • Thyrotoxicosis isdefined as the state of thyroid hormone excess and is not synonymous with hyperthyroidism, which is the result of excessive thyroid function. • The major etiologies of thyrotoxicosis are hyperthyroidism caused by Graves' disease, toxic MNG, and toxic adenomas. • Subclinical hyperthyroidism describes a condition in which circulating thyroid hormone concentrations are normal but the TSH response to TRH is blunted or absent. Patients may experience symptoms of hyperthyroidism such as nervousness, irritability, fatigue, and tachycardia. Subclinical hyperthyroidism may progress to overt hyperthyroidism.
- 32. PREVALENCE .5% annualincidence 1-10 per 1000 Women to men 4 : 1 Peak age 4th-5th decade
- 33. CAUSES Graves’ disease(60-85%) Hashimoto’s thyroiditis Solitary toxic adenoma (2-10%)
- 34. Thyrotoxicosis without hyperthyroidism • Subacute thyroiditis • Silent thyroiditis • Other causes of thyroid destruction: amiodarone, radiation, infarction of adenoma • Ingestion of excess thyroid hormone (thyrotoxicosis factitia) or thyroid tissue
- 35. CLINICAL MANIFESTATIONS OF HYPERTHYROIDISM: Symptoms • Nervousness • Increased sweating • Heat intolerance • palpitations • Dyspnea • Fatigue/weakness • Weight loss • Hyperactivity • Irritability • Polyuria • Oligomenorrhea • Loss of libido • Increased appetite • Diarrhoea
- 36. CLINICAL MANIFESTATIONS OF HYPERTHYROIDISM: Signs • Thyr. enlargement • Lid retraction • Hyperactivity • Tremor • Tachycardia • AF • Warm, moist skin • Muscle weakness, proximal myopathy • Gynecomastia
- 37. Figure 10-4. Classicsevere Graves' ophthalmopathy demonstrating a widened palpebral fissure, periorbital edema, proptosis, chemosis, and conjunctival injection.
- 38. Figure 12-6. Acase of severe pretibial myxedema showing the coarsened, nodular, infiltrated, pigmented lesions on the lower extremities.
- 39. Thyroid Dysfunction and Mental Disorders
- 40. The relationship betweenpsychiatry and thyroid dysfunction has attracted a good deal of attention for the following reasons: 1. Thyroid disorders, such as hyperthyroidism or hypothyroidism, can be accompanied by prominent mental abnormalities. 2. Thyroid hormones have been used in the treatment of certain psychiatric conditions. 3. Some drugs used for the treatment of mental illness can have an effect on the thyroid gland.
- 41. PSYCHIATRIC MANIFESTATIONS OF HYPOTHYROIDISM
- 42. • Patients diagnosedwith mental illnesses (especially those with a mood component) are more likely to have involvement of a thyroid hormone imbalance than the general population. • Symptoms of hypothyroidism can mimic, or be intertwined with, schizophrenia, bipolar disorder, anxiety and depression. Treating an underlying thyroid problem is critical to alleviating the associated psychiatric symptoms.
- 43. Patients with thyroiddisturbance and psychiatric symptoms are most often diagnosed with one of the following: • atypical depression (which may present as dysthymia) • bipolar spectrum syndrome (including manic-depression, mixed mania, bipolar depression, rapid-cycling bipolar disorder, cyclothymia, and premenstrual syndromes) • borderline personality disorder • psychotic disorder (typically paranoid psychosis)
- 44. Psychiatric symptoms of hypothyroidism include • depression • mood instability • Mania • Psychosis • Anxiety • Delirium • hypersomnia • apathy • anergia • impaired memory • psychomotor slowing • attentional problems • dementia
- 45. Other symptoms (suchas hypersomnia and lethargy), as well as laboratory findings such as hypercholesterolemia, galactorrhea, hyperprolactinemia, menstrual irregularities, and sexual dysfunction could be misconstrued as resulting from the psychotropic medications being given to alleviate the psychiatric symptoms.
- 46. Hypothyroidism and Depression • Depressive symptoms are common in hypothyroidism • Many hypothyroid patients fulfill DSM-IV criteria for a depressive disorder • Depressed patients may be more likely than normal individuals to be hypothyroid • All depressed patients should be evaluated for thyroid dysfunction 46
- 47. Hypothyroidism and Depression Have Many Common Features DDeepprreessssiioonn HHyyppootthhyyrrooiiddiissmm •Sleep decrease • Suicidal ideation • Weight loss • Appetite increase/ decrease • Bradycardia • Cardiac and lipid abnormalities • Cold intolerance • Delayed reflexes • Goiter • Hair and skin changes • Constipation • Appetite decrease • Decreased concentration • Decreased libido • Delusions • Depressed mood • Diminished interest •Sleep increase • Weight increase • Fatigue
- 48. Hypothyroidism, Depression, andOlder Patients • Hypothyroidism can mimic or coexist with depression at any age • Older patients are at increased risk for hypothyroidism as well as for depression • TSH analysis is warranted in at-risk patients: – Women – Patients with history of: • Autoimmune thyroid disease (including a family history of disease) • Goiter • Bipolar disorder treated with lithium • Dementia
- 49. Thyroxine in Depression 1. Thyroxine therapy is recommended for patients with depression who have persistently elevated serum TSH 2. Antidepressants may be less effective if thyroid function not normalized 49
- 50. • Anxiety disordersoccur in between 30% and 40% of patients developing acute hypothyroidism. • The most characteristic picture of patients with rapidly developing myxedema is one of progressive anxiety with generalized agitation.
- 51. • Patients mayexperience a progressive disorientation, persecutory delusions, hallucinations, and bouts of lethargy alternating with periods of extreme restlessness. • They are often extremely irritable, delusional, and paranoid and may complain of auditory and visual hallucinations. • Hypersexuality, irritability, suspicion, delusions, inability to concentrate, and failing memory are all conspicuous signs of rapidly developing thyroid disease.
- 52. • A psychoticsyndrome of auditory hallucinations and paranoia, named “myxedema madness,” has been described in some patients. Patients with severe cases may exhibit diminished cerebral blood flow, with subsequent coma or death. • Slowly progressive changes in thyroid hormone levels are more likely to be associated with a picture of chronic anxiety, increased fatiguability and psychomotor slowing.
- 53. Hypothyroidism and dementia • One of most important treatable and reversible cause of dementia. • Accounts for less than 1% of dementias. • Prompt identification and treatment can reverse the dementing process.
- 54. PSYCHIATRIC MANIFESTATIONS OF HYPERTHYROIDISM
- 55. • Between 1%and 20% of hyperthyroid patients have been reported to present with psychosis. • Between 30% and 40% present with conspicuous complaints of anxiety, nervousness, apprehension, dread, depression, restlessness, diminished concentration, forced thinking, emotional lability, and hyperkinesia.
- 56. Psychological disturbances common with Hyperthyroidism include: • marked anxiety and tension • emotional lability • irritability and impatience • distractible overactivity • exaggerated sensitivity to noise • fluctuating depression
- 57. • Speech maybe pressured, and patients may demonstrate a heightened activity level. • Cognitive symptoms include a short attention span, impaired recent memory, and an exaggerated startle response. • Patients with severe cases may exhibit visual hallucinations, paranoid ideation, and delirium. • While some symptoms of hyperthyroidism resemble those of a manic episode, an association between hyperthyroidism and mania has rarely been observed.
- 58. • More seriousmental disturbances which used to accompany "thyroid crisis", such as acute psychotic episodes, delirium and fever are rarely seen these days as a result of the improved detection of the illness and availability of effective treatment.
- 59. Effects of PsychiatricDrugs on the Thyroid Gland
- 60. LITHIUM • The“antithyroid” effect of lithium is one of the most common side effects. • This underscores the importance of regular monitoring of thyroid function during long-term lithium therapy.
- 61. • Lithium inhibitsthe secretion of T4 and T3 • Lithium induced hypothyroidism usually responds well to replacement therapy and lithium therapy can continue with thyroxine.
- 62. • One ofthe most common abnormality in thyroid function test findings in acute psychiatric admissions is an elevation of FTI (7-9% of patients). • This is secondary to a transient increase in T4, which is rare in other diseases. Elevated total T4 and FTI normalize after treatment.
- 63.
Editor's Notes
- #7 Slide 1. The probability that a patient has GH deficiency (GHD) increases with the number of other pituitary hormone deficiencies.
- #9 The most current guideline1 for the definition of thyroid status has changed the recommended serum TSH cutoff between euthyroid and hypothyroid from 5.1 IU/mL to 4.0 IU/mL. This change is an acknowledgment of the growing database showing that elevated serum TSH values are associated with health consequences. Reference Demers LM, Spencer CA, eds. Laboratory Medicine Practice Guidelines: Laboratory Support for the Diagnosis and Monitoring of Thyroid Disease. From the The National Academy of Clinical Biochemistry Available at: www.nacb.org/thyroid_lmpg.htm. Accessed March 12, 2002.
- #10 Hyperthyroidism corresponds with sustained increases in thyroid hormone biosynthesis and secretion. On the other end of the spectrum, hypothyroidism is associated with decreases in thyroid hormone production and is associated with a wide range of clinical manifestations. Overt hypothyroidism is defined as the triad of classical signs and symptoms of hypothyroidism, elevated serum thyroid-stimulating hormone (TSH), and abnormally low free thyroxine (T4). Mild thyroid failure is less often associated with the classical signs and symptoms of hypothyroidism. Serum TSH levels are elevated, but to a lesser extent than with overt hypothyroidism. Unlike overt disease, the serum free T4 concentration is typically in the normal range. The focus on mild thyroid failure throughout this series of slides is for two reasons: (1) mild thyroid failure is associated with health consequences (eg, unhealthy changes in lipid profiles)2 and (2) untreated, 35% of patients with mild thyroid failure progress to overt disease.1-3 References Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000;160:526-534. Bemben DA, Hamm RM, Morgan L, Winn P, Davis A, Barton E. Thyroid disease in the elderly. Part 2. Predictability of subclinical hypothyroidism. J Fam Pract. 1994;38:583-588. Vanderpump MP, Tunbridge WM, French JM, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf). 1995;43:55-68.
- #12 Most cases of hypothyroidism fall under the category of primary hypothyroidism with only 5% or less classified as central (formerly called secondary).1 Despite the low prevalence, central hypothyroidism should be ruled out because treatment approaches will differ. From a clinical standpoint, it is important to recognize central hypothyroidism because it is often associated with defects of other pituitary hormones.2 When central hypothyroidism is present, thyroid replacement therapy alone can precipitate acute adrenal insufficiency. References Braverman LE, Utiger RD. Introduction to hypothyroidism. In: Braverman LE, Utiger RD, eds. Werner & Ingbar&apos;s The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott Williams & Wiklins; 2000:719-720. Martino E, Bartalena L, Pinchera A. Central hypothyroidism. In: Braverman LE, Utiger RE, eds. Werner & Ingbar&apos;s The Thyroid. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:763-773.
- #15 The underlying causes of hypothyroidism are listed in this slide.1-4 In 70% to 80% of cases of congenital thyroid disorder, some form of developmental abnormality is involved.1 The underlying causes of hypothyroidism that are of the greatest importance in adults (probably representing 95% of the cases) fall under the category of thyroid tissue destruction. In a small percentage of cases, primary hypothyroidism results from actions that interfere with thyroid hormone biosynthesis.4 Primary hypothyroidism has also been implicated as a side effect of a number of drugs (eg, lithium, anti-thyroid drugs used to treat hyperthyroidism, iodine-containing drugs, some radiographic contrast agents, and interferon alpha).4 References Vijlder JJM, Vulsma T. Causes of hypothyroidism: hereditary metaboalic disorders causing hypothyroidism. In: Braverman LE, Utiger RD, eds. Werner & Ingbar&apos;s The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadephia, Pa: Lippincott Williams & Wilkins; 2000:733-742. Weetman AP. Causes of hypothyroidism: chronic autoimmune thyroiditis. In: Braverman LE, Utiger RD, eds. Werner & Ingbar&apos;s The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:721-732. Delance FM. Endemic cretinism. In: Braverman LE, Utiger RD, eds. Werner & Ingbar&apos;s The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadephia, Pa: Lippincott Williams & Wilkins; 2000:743-754. Singer PA. Primary hypothyroidism due to other causes. In: Braverman LE, Utiger RD, eds. Werner & Ingbar&apos;s The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:755-761.
- #18 The extensive list of signs and symptoms associated with hypothyroidism are shown above. Although the graphic depicts a female figure, hypothyroidism is not limited to women. Hypothyroidism may be less prevalent in young and middle-aged men, but its occurrence increases after the age of 60 years and becomes almost equivalent.1-4 References Tunbridge WM, Evered DC, Hall R, et al. The spectrum of thyroid disease in a community: the Whickham survey. Clin Endocrinol (Oxf). 1977;7:481-493. Vanderpump MP, Tunbridge WM, French JM, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf). 1995;43:55-68. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000;160:526-534. Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002;87:489-499.
- #48 Overlap between major depression and thyroid disease has been recognized for a long time based on three major findings1: Patients with thyroid disease, particularly primary hypothyroidism, frequently exhibit prominent depressive symptoms, and many actually fulfill criteria for major depression. Many patients with affective disorders, specifically depression, have demonstrable abnormalities in thyroid function. Thyroid hormones have been successfully used to treat depression and to accelerate and/or potentiate the effects of the tricyclic antidepressants. In a review of the topic, Charles Nemeroff, describes the overlapping signs and symptoms shown above.1 Dr. Nemeroff, in agreement with others who have studied the relationship between hypothyroidism and depression,2 recommends that all patients being considered for antidepressant therapy should first be checked for thyroid function. References Nemeroff CB. Clinical significance of psychoneuroendocrinology in psychiatry: focus on the thyroid and adrenal. J Clin Psychiatry. 1989;50(suppl):13-20. Gold MS, Pottash A, Extein I. Hypothyroidism and depression: evidence from complete thyroid evaluation. JAMA. 1981;245:1919-1921.
- #49 The symptoms of depression and hypothyroidism can mimic one another or coexist at any age. Older patients are at increased risks for both disorders, which should heighten awareness for either potential diagnosis. Therefore, to facilitate the differential diagnosis of patients at risk for either depression or hypothyroidism, TSH measurements are crucial.
- #64 THANK YOU