MEDICAL AND PSYCHIATRIC MANIFESTATIONS OF

THYROID DYSFUNCTION

Gibson george

First year msc nursing

INTRODUCTION

- The largest 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

The Thyroxines

Tri Iodo Thyronine – T3

Tetra Iodo Thyronine – T4

Actions of thyroid Hormones

- 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.

Actions of thyroid Hormones

- 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

Hypothalamus-Pituitary-Thyroid axis

Stimuli from Central nervous system

Hypothalamus

Releasing (TRH)/inhibitory hormones(somatostatin)

Pituitary gland (anterior lobe)

Thyrotropin (TSH)

Thyroid glandT3, T4 hormones

-ve

-ve

7

Thyroid Function Tests

1. TSH

2. Free T4

3. Free T3

11Demers LM, Spencer CA, eds. Laboratory Medicine Practice Guidelines: Laboratory Support for the Diagnosis 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. 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.Available at: www.nacb.org/thyroid_lmpg.htm. Accessed March 12, 2002.

Low Normal High

HyperthyroidHyperthyroid HypothyroidHypothyroidEuthyroidEuthyroid

TSHTSH

0.3–4.0 µ IU/mL1 >4.0 µIU/mL<0.3 µIU/mL

Definitions of Thyroid Status

Thyroid Disease Spectrum

00 ≥≥101055

TSH (TSH (µµIU/mL)IU/mL)

Mild Thyroid FailureMild Thyroid FailureTSH > 4.0 TSH > 4.0 µµ IU/mLIU/mL FTFT44 normalnormal

Overt HypothyroidismOvert HypothyroidismTSH >4.0 TSH >4.0 µµ IU/mLIU/mL FTFT44 lowlow

EuthyroidEuthyroidTSH 0.3TSH 0.3–4.0 –4.0 µµ IU/mLIU/mL FTFT4 4 normalnormal

HyperthyroidismHyperthyroidismTSH <0.3 TSH <0.3 µµ IU/mLIU/mLFTFT44 elevatedelevated

HYPOTHYROIDISM

Hypothyroidism

Hypothyroidism is a disorder of diverse causes in which the thyroid fails to secrete an adequate amount of thyroid hormone.

12

• 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

Hypothyroidism

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

Primary Hypothyroidism: Underlying Causes

• 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

Multi system effects - Hypothyroidism

General•Lethargy, Somnalence•Weight gain, Goitre•Cold IntolerenceCardiovascular•Bradycardia, Angina•CHF, Pericardial Effusion•HyperlipIdemia, XanthelsmaHaematologicalIron def. Anaemia, Normo cytic /chromic AnaemiaReproductive system•Infertility, Menorrhagia•Impotence, Inc. Prolactin

Neuromuscular•Aches and pains•Muscle stiffness•Carpel tunnel syndrome•Deafness, Hoarseness•Cerebellar ataxia•Depression, PsychosisGastro-intestinal•Constipation, Ileus, AscitesDermatological•Dry flaky skin and hair•Myxoedema, •Vitiligo, Alopecia

16

Clinical Signs of 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

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 Cholesteroland Other Hyperlipidemias

Effusion

Personal HistoryEndocrine/Autoimmune Disorders

Hoarseness/Deepening of Voice

Eyelid Edema/Puffy Eyes

Swelling (Goiter)Thyroiditis

Throat Pain

Dysphagia

Diastolic Hypertension

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 rateCentral Nervous• Decreased concentration• General lack of interest• DepressionGastro-instestinal• Decreased GI motility• Constipation

19

Thyroid Failure - Organ Systems

Musculoskeletal Muscle stiffness, cramps,

pain, weakness, myalgia Slow muscle-stretch

reflexes, muscle enlargement, atrophy

Renal

Fluid retention and oedema

Decreased glomerular filtration

20

Reproductive• Arrest of pubertal development• Reduced growth velocity• Menorrhagia, Amenorrhea• Anovulation, Infertility

Hepatic• Increased LDL / TC

• Elevated LDL + triglycerides

Thyroid Failure - Organ Systems

21

Thyroid Failure - Organ Systems

Skin and Hair Thickening and dryness of

skin Dry, coarse hair, Alopecia Loss of scalp hair and / or

lateral eyebrow hair

22

Order for TSH 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

23

Congenital Hypothyroidism

www.drsarma.in 24

www.drsarma.in 25

26

Endemic Goiter

27

Myxedema

28

Myxedema

29

Xanthomata

Xanthelasma

Tuberous Xanthoma

HYPERTHYROIDISM

• Thyrotoxicosis is defined 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.

PREVALENCE

.5%

annual incidence 1-10 per 1000

Women to men 4 : 1

Peak age 4th-5th decade

CAUSES

Graves’ disease (60-85%)

Hashimoto’s thyroiditis

Solitary toxic adenoma (2-10%)

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

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

CLINICAL MANIFESTATIONS OF HYPERTHYROIDISM:Signs

 • Thyr. enlargement• Lid retraction• Hyperactivity• Tremor

• Tachycardia• AF

 

• Warm, moist skin• Muscle weakness,

proximal myopathy• Gynecomastia

Figure 10-4. Classic severe Graves' ophthalmopathy demonstrating a widened palpebral fissure, periorbital edema, proptosis, chemosis, and conjunctival injection.

Figure 12-6. A case of severe pretibial myxedema showing the coarsened, nodular, infiltrated, pigmented lesions on the lower extremities.

Thyroid Dysfunction and Mental Disorders

The relationship between psychiatry 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.

PSYCHIATRIC MANIFESTATIONS OF

HYPOTHYROIDISM

• Patients diagnosed with 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.

Patients with thyroid disturbance 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) 

Psychiatric symptoms of hypothyroidism include

• depression

• mood instability • Mania• Psychosis

• Anxiety• Delirium• hypersomnia

• apathy• anergia• impaired memory• psychomotor slowing• attentional problems• dementia

Other symptoms (such as 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

Hypothyroidism and DepressionHave Many Common Features

DepressionDepression HypothyroidismHypothyroidism

•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

Hypothyroidism, Depression, and Older 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

• Anxiety disorders occur 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.

• Patients may experience 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.

• A psychotic syndrome 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.

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.

PSYCHIATRIC MANIFESTATIONS OF HYPERTHYROIDISM

• 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.

Psychological disturbances common with Hyperthyroidism include:

• marked anxiety and tension

• emotional lability

• irritability and impatience

• distractible overactivity

• exaggerated sensitivity to noise

• fluctuating depression

• Speech may be 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.

• More serious mental 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.

Effects of Psychiatric Drugs on the Thyroid Gland

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.

• Lithium inhibits the secretion of T4 and T3

• Lithium induced hypothyroidism usually responds well to replacement therapy and lithium therapy can continue with thyroxine.

• One of the 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.

THANK YOU