Case Vignette Tatiana Ramage, MD PGY2. 3/24/18 Northern California Psychiatric Society Annual Meeting
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1 Case Vignette Tatiana Ramage, MD PGY2 3/24/18 Northern California Psychiatric Society Annual Meeting
2 HPI 70 yo woman with history of wellcontrolled schizophrenia Erratic behavior, confused Previously stable > 10 years 2 San Mateo Behavioral Health and Recovery Services March 24, 2018
3 Patient History Psychiatric Hx: Schizophrenia; last saw psychiatrist 1 year ago Meds: 2mg Stelazine, L-Thyroxine Substance use hx: none Family hx: mother with dementia Social Hx: never married, lives alone, worked as a transcriber PMH/Surg Hx: HTN, DM, thryoidectomy Allergies: PCN 3 San Mateo Behavioral Health and Recovery Services March 24, 2018
4 Examination Vitals: Afebrile. BP 137/110, HR 70, RR 10, O2 95% on RA MSE: disoriented, no pmr/pma, affect anxious, TP: tangential, TC: +notable for mild paranoia. No SI/HI/AVH. Judgment/insight: impaired Physical Exam: Revealed dry skin with dry hair, facial puffiness. Heart and lung unremarkable. MOCA: unable to participate 4 San Mateo Behavioral Health and Recovery Services March 24, 2018
5 Differential Diagnosis Schizophrenia Dementia (likely vascular 2/2 DM, frontotemporal) Delirium (2/2..) Substance use Hypothyroidism induced psychosis 5 San Mateo Behavioral Health and Recovery Services March 24, 2018
6 Diagnostic Testing Imaging: CTH negative Labs: CBC nl CMP K+ 3.2 Glucose 130 Lipid panel wnl UA, UCx neg No UDS TSH >125 uiu/ml; T4 <0.1 ng/dl 6 San Mateo Behavioral Health and Recovery Services March 24, 2018
7 Neuropsychiatric Manifestations Of Hypothyroidism 7 San Mateo Behavioral Health and Recovery Services March 24, 2018
8 Brief Review of Thyroid T4 T3 20% T4 T3 80% T3 B rain B one Effects B eta-adrenergic B asal metabolic rate 8 San Mateo Behavioral Health and Recovery Services March 24, 2018
9 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition 1888 Committee on Myxedema of the Clinical Society of London 1949 Asher myxoedematous madness Multiple case reports 9 San Mateo Behavioral Health and Recovery Services March 24, 2018
10 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition 1888 Committee on Myxedema of the Clinical 50% Society of London 1949 Asher myxoedematous madness Multiple case reports 10 San Mateo Behavioral Health and Recovery Services March 24, 2018
11 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition 1888 Committee on Myxedema of the Clinical 50% Society of London 1949 Asher myxoedematous madness Asher R., 1949; Br Med J Multiple case reports 11 San Mateo Behavioral Health and Recovery Services March 24, 2018
12 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition 1888 Committee on Myxedema of the Clinical 50% Society of London 1949 Asher myxoedematous madness 1970s - present Multiple case reports 5-15% 12 San Mateo Behavioral Health and Recovery Services March 24, 2018 Hall, RC. 1983; Psychosomatics Granite RB., 1978; J Clin Psychiatry McGaffee J., 1981; Am Fam Physician. Madakasira S., 1981; Am J Psychiatry Davis AT., 1989; Int J Psychiatry Med Shiykov MA., 2016; BMJ
13 Psychosis and Hypothyroidism Pathophysiology Sato T., 1986; Acta Endocrinol 13 San Mateo Behavioral Health and Recovery Services March 24, 2018
14 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition 1888 Committee on Myxedema of the Clinical Society of London 1949 Asher myxoedematous madness Multiple case reports 14 San Mateo Behavioral Health and Recovery Services March 24, 2018
15 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition 40% Depressed Ordas DM., 1995; Ann Clin Psychiatry Howland RH., 1993; J Clin Psychiatry Heinrich TW., 2003; Prim Care Companion J Clin Psychiatry 15 San Mateo Behavioral Health and Recovery Services March 24, 2018
16 Affective Disorders and Hypothyroidism Pathophysiology central serotonergic deficiency? relative cerebral hypothyroidism? Clear AJ., 1995; Clin Endocrinol Joff RT., 1990; Can J Psychiatry 16 San Mateo Behavioral Health and Recovery Services March 24, 2018
17 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition Dementia sx: 66-90% Possibly irreversible 17 San Mateo Behavioral Health and Recovery Services March 24, 2018
18 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition Dementia sx: 66-90% Leigh H., 1984; Adv Int Med Haggerty JJ Jr., 1986; Am J Psychiatry Clarnette, RM., 1994; Geriatr Psychiatry Neurol. Possibly irreversible 18 San Mateo Behavioral Health and Recovery Services March 24, 2018
19 Hypothyroidism and Neuropsychiatric Symptoms Psychosis Mood Cognition Dementia sx: 66-90% Leigh H., 1984; Adv Int Med Haggerty JJ Jr., 1986; Am J Psychiatry Clarnette, RM., 1994; Geriatr Psychiatry Neurol. Possibly irreversible 19 San Mateo Behavioral Health and Recovery Services March 24, 2018
20 Cognitive Disorders and Hypothyroidism Pathophysiology mediated by depression? decreased cerebral blood flow? 20 San Mateo Behavioral Health and Recovery Services March 24, 2018
21 So what about Maxine? Psychosis Mood Cognition Suspicious, delusions anxious Executive functionin g Attention 21 San Mateo Behavioral Health and Recovery Services March 24, 2018
22 Treatment 1. Levothyroxine 2. Antipsychotics 3. Dose low, go slow 4. Treatment goal: normalize TSH and T4 and address hypothyroid s/sx 5. Usually resolve over weeks to months 22 San Mateo Behavioral Health and Recovery Services March 24, 2018
23 Pearls Hypothyroidism may affect psychosis, mood, and cognition Keep on differential, especially for new-onset psychosis or previously stable patient Combo therapy of L-T4 and antipsychotics Recovery can take weeks to months 23 San Mateo Behavioral Health and Recovery Services March 24, 2018
24 Acknowledgements San Mateo Behavioral Health and Recovery Services Zachary Plaut, MD 24 San Mateo Behavioral Health and Recovery Services March 24, 2018
25 Extra Slides 25 San Mateo Behavioral Health and Recovery Services March 24, 2018
26 Question: What is the correlation between thyroid dysfunction and psychiatric symptoms? 26 San Mateo Behavioral Health and Recovery Services March 24, 2018 Jain VK., 1971; Br J Psychiatry Lehrmann, JA., 2002; Gen Hospital Psychiatry
27 Clinical Features of Hypothyroidism SYMPTOMS Cold intolerance Weight gain Hair loss Hypoactivity, lethargy, fatigue, weakness Constipation Menstrual irregularities Myxedema (facial, periorbital) Hoarse voice Muscle cramps Carpal tunnel syndrome (25-33%) Dyspnea on exertion Neuropsychiatric symptoms Luboshitzky R., 1996; Isr J Med Sci Endocrine practice 2002; 8: San Mateo Behavioral Health and Recovery Services March 24, 2018
28 Clinical Features of Hypothyroidism SIGNS LAB FINDINGS HEENT Reflexes Hair loss Periorbital/facial edema Enlarged tongue Dec. relaxation phase of DTR TSH Free T3, T4 Cholesterol Vitals Bradycardia Diastolic hypertension Hypothermia ECG Blunted ECG voltages 28 San Mateo Behavioral Health and Recovery Services March 24, 2018 Luboshitzky R., 1996; Isr J Med Sci Endocrine practice 2002; 8:
29 Epidemiology of Hypothyroidism Prevalence: 0.5% to 18% 10x more common in women Increases with age Usually autoimmune 29 Luboshitzky R., 1996; Isr J Med Sci
30 Brief Review of Hypothyroidism Hypothyroidism Subclinical hypothyroidism TSH Level FREE T4 Level Primary Hypothyroidism Elevated Low Secondary Hypothyroidism Normal or low Low Subclinical hypothyroidism Elevated Normal 30 San Mateo Behavioral Health and Recovery Services March 24, 2018
31 Neurospychiatric Sx of Hypothyroidism Presentation? Onset of sx? Highly variable AH to Capgras syndrome Psychosis, Affective, Cognitive Months to years after physical sx (older literature) 31 Any correlation between degree of thyroid dysfunction and psychiatric symptoms? Nope Logothetis J., 1963; J Nerv Ment Dis Jain VK., 1971; Br J Psychiatry Lehrmann JA., 2002; Gen Hosp Psychiatry Heinrich TW., 2003; Prim Care Companion J Clin Psychiatry
32 Bipolar Disorder and Hypothyroidism - Lower FT4 and higher TSH (both within the normal range) significantly associated with slower response to treatment (Cole DP., 2002; Am J Psychiatry) - Hypothyroidism may be risk factor for development of rapidcycling - Antithyroid antibody titers found in 50% of rapid-cycling bipolar patients (Hennesy, JV., 1996; Endocrinologist) 32 San Mateo Behavioral Health and Recovery Services March 24, 2018
33 Myxedema Coma Clinical features of myxedema coma Decreased mental status Hypothermia Bradycardia Hyponatremia Hypoglycemia Hypotension Precipitating illness 33 San Mateo Behavioral Health and Recovery Services March 24, 2018
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