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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 233-235

A unique case of myxedema madness with suicidal attempts


Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Puducherry, India

Date of Submission08-Jun-2020
Date of Decision18-Jul-2020
Date of Acceptance05-Aug-2020
Date of Web Publication25-Nov-2020

Correspondence Address:
Dr. Harsh Avinash Thappa
Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Madagadipet - 605 107, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_42_20

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  Abstract 


Hypothyroidism has been associated with mood disorders, sometimes with acute psychosis, hence this report. A 45-year-old married female, working as a daily-wage laborer, was brought with marked irritability, suspiciousness, wandering about, decreased sleep, appetite, and personal care for the past 1½ years. She had attempted suicide three times in the initial 6 months of illness. She had an asthenic body type; dry, hairless skin; hoarse voice; and nonpitting pedal edema. Deep tendon reflexes were delayed. High thyroid-stimulating hormone levels and positive anti-thyroid peroxidase antibody led to the diagnosis of severe hypothyroidism. Based on her psychiatric evaluation, a diagnosis of organic schizophrenia-like disorder (myxedema madness) was made. She was managed with olanzapine and haloperidol along with thyroxine supplement. The patient improved significantly following thyroxine supplementation and modified electroconvulsive therapy sessions. Herewith, we present this unique case of myxedema madness with suicidal attempts for its uniqueness and rarity.

Keywords: Hypothyroidism, myxedema madness, suicidal attempts


How to cite this article:
Thappa HA, Selvaraj A, Dass VK. A unique case of myxedema madness with suicidal attempts. Ann Indian Psychiatry 2020;4:233-5

How to cite this URL:
Thappa HA, Selvaraj A, Dass VK. A unique case of myxedema madness with suicidal attempts. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Apr 20];4:233-5. Available from: https://www.anip.co.in/text.asp?2020/4/2/233/301432




  Introduction Top


As such, no specific type of psychosis characterizes the myxedematous patient.[1],[2] However, possible presentations include delusions, auditory and visual hallucinations, perseveration, and paranoia. Physical symptoms of hypothyroidism usually precede the onset of psychosis by several months or years.[3]

Mood disorders, particularly depression, are commonly associated with hypothyroidism, but a few cases of acute psychosis have also been reported in such settings.[4] Suicidal behaviors have been described rarely in these patients. We know that suicide may result from several factors including psychosocial stressors, psychiatric symptoms, and hormonal disturbance.[4] Herewith, we present a unique and rare case of myxedema madness with suicidal attempts in a 45-year-old married female who needed modified electroconvulsive therapy (MECT) along with antipsychotics and thyroxine replacement for its management.


  Case Report Top


A 45-year-old married female, educated up to 3rd standard, working as a daily-wage laborer, was brought to us with marked irritability; suspiciousness toward everyone, especially toward the husband; wandering about; and decreased sleep, appetite, and personal care for the past 1½ years. She had an insidious onset, progressively deteriorating course. There was a history of decreased interaction with others, muttering to self, and decreased routine activities including taking care of children and going for daily works. She had attempted suicide three times in the initial 6 months of illness.

She was threatening and abusive toward others, occasionally resorting to assault. She had received magico-religious treatment for the past 1 year. There was a failure to attain restitutio ad integrum. In the past, she had febrile illness at the age of 12 years, following which she became hard of hearing. She was diagnosed as a case of hypothyroidism 4 years prior to presenting with psychiatric illness, however, she did not take any therapy for the same. She had no other systemic illness. There was no family history of similar disorder.

Her examination revealed an asthenic body type; dry, hairless skin; hoarse voice; and nonpitting pedal edema. Her pulse, respiratory rate, and blood pressure were within normal limits. Deep tendon reflexes were delayed.

Mental status examination revealed a minimally kempt and groomed female in shabby condition. Eye contact was made but not maintained, established rapport with difficulty, had indifferent and uncooperative attitude toward the examiner, and most of the time withdrawn. Her psychomotor activity had reduced and speech was irrelevant and incoherent with decreased rate, rhythm, volume, and tone, with delayed reaction time, and was not spontaneous. Neologisms were present. Her affect was irritable with a narrow range, minimal reactivity, and low communicability. Lability of mood was present but was appropriate for speech.

By Kirby's method, the patient was found to be irritable, was physically and verbally abusive with an incoherent speech; and was muttering to self, and her neologisms were notable. Hallucinatory behavior and paranoid ideas were present, suggestive of delusion of persecution and reference.

Her routine baseline investigations such as hemogram and biochemical profile of renal and liver function were within normal limits. High thyroid-stimulating hormone (TSH) levels (TSH >150 mIU/ml) and positive anti-thyroid peroxidase (TPO) antibody (anti-TPO >500 IU/ml, suggestive of autoimmune thyroiditis) led to the diagnosis of severe hypothyroidism. Brief Psychiatric Rating Scale (BPRS) score was 46. Based on the above, a diagnosis of Axis I – organic schizophrenia-like disorder (myxedema madness); Axis II – severe impairment in personal, familial, occupational, and social domains; and Axis III – severe hypothyroidism; hearing impairment; and suicidal attempts was made.

The patient was treated with up to 20 mg/day of olanzapine and 10 mg/day of haloperidol orally to ameliorate the psychotic symptoms. She was found to have severe hypothyroidism, which was managed as per the advice of internists. Thyroxine was started at 150 μg/day orally, which was escalated to 300 μg based on TSH levels, and gradually tapered to 100 μg.

The patient was then planned to receive MECT, but MECT was postponed till TSH is brought to <10 mIU/ml. Bitemporal MECT of 6 V/1 s was delivered.

The patient improved significantly following MECT sessions and thyroxine replacement therapy, and TSH normalized as well. BPRS score at discharge was 24. Her husband was psychoeducated regarding the nature of illness and the need for regular treatment.


  Discussion Top


The term “myxedematous madness” was introduced by Richard Asher in 1949.[1] He had reported 14 cases of hypothyroidism with psychotic illness. In those times, myxedema was one of the least known, frequently missed causes of organic psychosis. Hypothyroidism is a common disease with an estimated prevalence of 3.6%.[5] Neuropsychiatric features are known to occur in hypothyroidism. The mechanism of hypothyroid-induced neuropsychiatric manifestations is unclear in humans. It is speculated that triiodothyronine (T3) receptors concentrate heavily in the amygdala and hippocampus. Emotional and behavioral integration is carried by amygdala. Furthermore, there is a significant increase in the transformation rate of thyroxine to T3 in cases of hypothyroidism. There are increased cerebral neurotransmitter dopamine and adrenal catecholamine activities in hypothyroid patients, which may be responsible for the neuropsychiatric manifestations.[5]

The slowing of metabolic processes and accumulation of matrix glycosaminoglycans in tissues characteristic of hypothyroidism leads to well-known signs and symptoms including depression, apathy, and attention deficits and less commonly psychosis, delusion, and disorientation.[6] Psychosis secondary to hypothyroidism is historically termed as “myxedema madness.”

Hashimoto's thyroiditis is the most common cause of hypothyroidism in adults characterized by antibodies against the thyroid, as seen in our case. The signs and symptoms of hypothyroidism are varied and include cold intolerance; constipation; puffy subcutaneous swelling of the eyes, face, and extremities; hearing reduction; brittle and thinning hair; hoarse voice; slowed deep tendon reflexes; bradycardia; and cardiomegaly.[7],[8]

Thyroid hormone plays a major role in the regulation of mood, cognition, and behavior. In hypothyroidism, there is a change in milieu of neurotransmitters and their receptors, hence resulting in neuropsychiatric manifestations.[7] Neuropsychiatric symptoms are classically associated with overt hypothyroidism.[8] Depressed mood, apathy, psychomotor retardation, and slowed cognition with memory and concentration complaints occur. Psychosis, “myxedema madness,” is though now rare, the presentation is varied. Its manifestations include delusions, auditory and visual hallucinations, thought disorders, and paranoia. In severe cases, there may be diminished blood flow with subsequent coma or death.[8] “The Clinical Society of London” first linked myxedema with psychosis in the latter half of the 19th century. The relationship between myxedema (severe hypothyroidism) and psychosis was strengthened by the works of “Asher” who coined the term “myxedema madness” in the latter half of the 20th century.[1]

The onset of hypothyroidism is usually gradual, except in cases of surgical or chemical thyroid ablation.[8] The physical and mental symptoms in adults are usually reversible with thyroid replacement. However, long-standing hypothyroidism may produce permanent cognitive deficits, possibly from neuronal death resulting from thyroid deficiency in the brain.

Myxedema psychosis can respond as quickly as within days to a few weeks to thyroxine replacement.[9] TSH level should be monitored and dosage should be adjusted accordingly. If thyroxine replacement is started at a too high dose or titrated too rapidly, an acute confusional state or exacerbation of psychosis can occur. Some physicians use antipsychotic treatment for a short period to control the psychosis symptoms at the beginning of the illness; these medications can be safely discontinued on follow-up after ensuring that there is no recurrence of symptoms.[9]

Delay in replacement of thyroid hormone may cause failure of symptoms to resolve completely or progress to a more severe condition, such as myxedema coma.[10] The mortality rate for myxedema coma is reported to be 30%–60% despite aggressive treatment. Once euthyroid state is achieved and if the patient continues to have comorbid primary psychiatric disorders, appropriate antidepressants, mood-stabilizing, or antipsychotic medications should be added.[10]


  Conclusion Top


Neuropsychiatric features are known to occur in hypothyroidism, but the occurrence of myxedema madness with suicidal attempts was a unique and rare event in our case.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Asher R. Myxoedematous madness. Br Med J 1949;2:555-62.  Back to cited text no. 1
    
2.
Davis AT. Psychotic states associated with disorders of thyroid function. Int J Psychiatry Med 1989;19:47-56.  Back to cited text no. 2
    
3.
Logothetis JA. Psychotic behavior as the indicator of adult myxoedema. J Nerv Ment Dis 1963;136:561-8.  Back to cited text no. 3
    
4.
Todorov L, Boudaoud AA, de Raykeer RP, Radu A, Lahlou-Laforet K, Limosin F, et al. A case of violent. suicide attempt in context of myxedema psychosis following radioiodine treatment in a patient with Graves' disease. Hindawi Case Rep Psychiatry 2019;2019:3.  Back to cited text no. 4
    
5.
Mohamed MFH, Mahgrab AB, Sardar S, Elzaki AN, Acute psychosis and concurrent rhabdomyolysis unveiling diagnosis of hypothyroidism. BMJ Case Rep 2019;12:E 231579.  Back to cited text no. 5
    
6.
Shlykov MA, Rath S, Badger A, Winder GS. 'Myxoedema madness' with Capgras syndrome and catatonic features responsive to combination olanzapine and levothyroxine. BMJ Case Rep 2016;2016:bcr2016215957.  Back to cited text no. 6
    
7.
Parikh N, Sharma P, Parmar C. A case report on myxedema madness: Curable psychosis. Indian J Psychol Med 2014;36:80-1.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Williams KE, Rasgon NL. Endocrine and metabolic disorders, In: Sadok BI, Sadock VA, Ruiz P, editors. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, Vol II, 10th ed. Philadelphia: Wolters Kluwer; 2017. p. 2239-42.  Back to cited text no. 8
    
9.
Mohamed MF, Mahgoub AB, Sardar S, Elzouki AN. Acute psychosis and concurrent rhabdomyolysis unveiling diagnosis of hypothyroidism. BMJ Case Rep 2019;12:e231579.  Back to cited text no. 9
    
10.
Maududi T, Mall SK, Mall GD. A 50- year- old woman who hears voices. Psychiatry Ann 2009;39:11:936-40.  Back to cited text no. 10
    




 

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