IAJPS 2018, 05 (02), 1280-1284 Muhammad Iqbal et al ISSN 2349-7750

CODEN [USA]: IAJPBB ISSN: 2349-7750

INDO AMERICAN JOURNAL OF

PHARMACEUTICAL SCIENCES
http://doi.org/10.5281/zenodo.1194803

Available online at: http://www.iajps.com Research Article

EVALUATION OF FREQUENCY AND SEVERITY OF

ANXIETY AND MOOD DISORDERS
AMONG PATIENTS WITH GRAVES' DISEASE.
Muhammad Iqbal1, Atif Ahmed2, Sohail Baig3, Hamid Nawaz Ali Memon4 and
Aatir H. Rajput5
1
Department of Medicine - Liaquat University of Medical & Health Sciences, Jamshoro
2
Department of Medicine – Bilawal Medical College, Jamshoro
3
Department of Medicine - Liaquat University Hospital, Hyderabad
4
Zulekha Hospital – United Arab Emirates
5
Department of Psychiatry – Liaqua University of Medical & health Sciences, Jamshoro
Abstract:
Objective: Graves' disease has been associated with an increased psychiatric morbidity. It is unclarified whether
this relates to Graves' disease or chronic disease per se. The aim of our study was to evaluate the frequency and
severity of anxiety and mood disorders in patients with Graves' disease.
Methodology: This cross-sectional analysis was conducted upon a total of 341 patients presenting to the medical
out-patient department of Liaquat University Hospital, Hyderabad. Data was collected using a structured, interview
based questionnaire comprising of 2 factions. One derived from the DAS-42 scale for anxiety and the standard
Profile of Mood States (POMS) for mood disorders, after taking written informed consent. The data obtained was
analyzed using MS. Excel 2017 and SPSS v. 21.0.
Results: Significantly greater frequency of social anxiety disorder, generalized anxiety disorder, total mood and
anxiety disorders, as well as major depression and higher symptom scores on the POMS and DAS-42 scale, was
found in the subjects. The difference in severity however, when gauged against published controls, was found non-
significant.
Conclusion: The results confirm, without any doubt, that frequency of anxiety and mood disorders among patients
of Graves’ disease is greater than any found in other chronic disease (as per published evidence).
Keywords: Graves’ disease, Social Anxiety, General Anxiety Disorder, Major Depression and Cghronic Illness.
Corresponding author:
Dr. Muhammad Iqbal, QR code
Associate Professor of Medicine,
Liaquat University, Jamshoro
Email: muhammadiqbalshah22 @gmail.com
Phone: +92-300-3034963

Please cite this article in press as Muhammad Iqbal et al., Evaluation of Frequency and Severity of Anxiety and
Mood Disorders among Patients with Graves ‘disease, Indo Am. J. P. Sci, 2018; 05(02).

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 IAJPS 2018, 05 (02), 1280-1284 Muhammad Iqbal et al ISSN 2349-7750

INTRODUCTION: ratings and not with the prevalence of discrete

Graves’ disease, an expression of an autoimmune psychiatric entities. The studies cited above have
process, is the most common cause of taken patients with hyperthyroidism as their index
hyperthyroidism. [1] It is associated with various populations. Many other studies have taken at their
mental signs and symptoms, including anxiety, index populations patients with psychiatric disorders.
depression, mania and cognitive dysfunction and with Although strictly outside the purview of the present
discrete psychiatrtic disorders, including (but not study, two such studies seem relevant. In patients
limited to) mood disorders [2]. Increased prevalence with anxiety disorders, a history of hyperthyroidism
of mood and anxiety disorders, diagnosed using was found unusually often [17, 18].
psychiatric diagnostic criteria [3–5], as well as
increased scores on depression and anxiety self-rating The aim of our study was to evaluate the frequency
scales [4,6–8], has been consistently reported in and severity of anxiety and mood disorders in un-
untreated hyperthyroid patients. treated patients with Graves' disease presenting at our
Mood scores tended to be similar in patients with study setting.
subclinical and overt hyperthyroidism [9]. Trzepacz
et al. [10] found no associations between scores of METHODOLOGY:
anxiety or depression and serum concentrations of This cross-sectional analysis was conducted upon a
thyroid hormones in Graves’ disease. In a similar total of 341 patients presenting to the medical out-
way, no strict relationship was found between patient department of Liaquat University Hospital,
severity of symptoms of hyperthyroidism and degree Hyderabad. Data was collected using a structured,
of elevation in thyroid hormone concentration [11]. interview based questionnaire comprising of 2
The effects of treatment of hyperthyroidism on factions. One derived from the DAS-42 scale for
mental symptoms also have been examined. In the anxiety and the standard Profile of Mood States
short term, treatment was found to produce a parallel (POMS) for mood disorders, after taking written
decrease in endocrine symptoms and in psychiatric informed consent. The data obtained was analyzed
symptoms [6, 12]. using MS. Excel 2017 and SPSS v. 21.0.

When prolonged treatment normalizes thyroid RESULTS:

function some psychiatric symptoms and somatic Significantly greater frequency of social anxiety
complaints may persist [13–15]. Nevertheless, a disorder, generalized anxiety disorder, total mood
recent study showed that remitted Graves’ disease and anxiety disorders, as well as major depression
patients, in contrast to relapsed Graves’ disease and higher symptom scores on the POMS and DAS-
patients, showed no significant differences from 42 scale, was found in the subjects. The difference in
healthy controls on standard psychometric tests [16]. severity however, when gauged against published
controls, was found non-significant.
These studies of treatment effects have been
concerned only with the measurement of mood

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The thyroid status of the subjects was as tabulated below:

Euthyroidism Hyperthyroidism All Normal Range

Thyroid Stimulating 1.84 0.07 1.22 0.17 – 4
Hormone (mU/L)
Free T4 17.8 34.7 26.22 11.5 – 23
(pmol/L)

A main faction of the subjects comprised of females. Male subjects were scarce.

DISSCUSION: such as orbital muscle and brain. Stimulation of the

In Graves’ disease, presumably as a result of some TSH receptor in brain increases type II deiodinase
failure of autoimmune regulation, the TSH receptor, a activity, which is responsible for local
normal element of the HPT axis, becomes an antigen. triiodothyronine production. Cortex and hippocampus
Its excessive stimulation in thyroid gland by TSH are rich in TSH receptors and play an important role
receptor antibodies results in hyperthyroidism. The in mood regulation and cognition.
TSH receptor is also found in extrathyroidal tissues

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Thus, the excessive production of triiodothyronine in The results confirm, without any doubt, that
these regions may occur in Graves’ disease and may frequency of anxiety and mood disorders among
contribute to its typical mental symptoms. A full patients of Graves’ disease is greater than any found
understanding, however, of the causes of mental in other chronic disease (as per published evidence).
disability in Graves’ disease awaits a full description
of the effects on neural tissue of thyroid hormones as REFERENCES:
well as of the underlying autoimmune process. 1.Vanderpump MPJ, Tunbridge WMG. The
epidemiology of thyroid diseases. In: Braverman LE,
The results of this study demonstrate a high Utiger RD, editors. Werner & Ingbar’s thyroid: a
prevalence of mood and anxiety disorders in subjects fundamental and clinical text. 8th ed. Philadelphia7
as assessed by our research tools. Mental disorders Lippincott Williams & Wilkins; 2000. p. 465–73.
among women with Graves’ disease were 2.Whybrow PC, Bauer M. Behavioral and psychiatric
significantly more frequent than among men. It aspects of thyrotoxicosis. In: Braverman LE, Utiger
should be noted, however, that prevalence of mental RD, editors. Werner & Ingbar’s thyroid: a
disorder among women with gynecologic disease was fundamental and clinical text. 8th ed. Philadelphia7
also quite high. This observation is consistent with Lippincott Williams & Wilkins; 2000. p. 673–8.
the findings of other studies [19, 20]. 3.Kathol RG, Delahunt JW. The relationship of
Hyperthyroid study subjects demonstrated a anxiety and depression to symptoms of
significantly higher prevalence of current mood hyperthyroidism using operational criteria. Gen Hosp
episodes and specific anxiety disorders in comparison Psychiatry 1986;8:23–8.
with the euthyroid patients. These findings are 4.Trzepacz PT, McCue M, Klein I, Levey GS,
consistent with reports concerning psychiatric Greenhouse J. A psychiatric and neuropsychological
morbidity in studies, such as that conducted by study of patients with untreated Graves’ disease. Gen
Kathol and Delahunt. [3] These studies, like many Hosp Psychiatry 1988;10:49–55.
others, however, of their era, failed to employ 5.Placidi GPA, Boldrni M, Patronelli A, et al.
standard psychiatric diagnostic criteria. Prevalence of psychiatric disorders in thyroid
Despite these limitations, there was general diseased patients. Neuropsychobiology 1998;38:
agreement that hyperthyroid patients tend to show a 222–5.
high rate of anxiety. The later studies, using standard 6.Whybrow PC, Prange Jr AJ, Treadway CR. Mental
psychiatric diagnostic criteria, confirmed earlier changes accompanying thyroid gland dysfunction.
findings. Trzepacz et al. [4] studied 13 patients with Arch Gen Psychiatry 1969;20:48–63.
untreated Graves’ disease, using the Schedule for 7.MacCrimmon DJ, Wallace JE, Goldberg WM,
Affective Disorders and Schizophrenia and applying Streiner DL. Emotional disturbance and cognitive
Research Diagnostic Criteria. They found that every deficits in hyperthyroidism. Psychosom Med
patient met Research Diagnostic Criteria for at least 1979;41:331–40.
one psychiatric diagnosis, most often anxiety. Placidi 8.Demet MM, Ozmen B, Deveci A, et al. Depression
et al. [5] studied 93 hyperthyroid patients, using a and anxiety in hyperthyroidism. Arch Med Res
version of the Structured Clinical Interview for DSM, 2002;33:552–6.
Revised Third Edition criteria (SCID). They found 9.Schlote B, Nowotny B, Schaaf L, et al. Subclinical
that one third of patients suffered from panic disorder hyperthyroidism: physical and mental state of
and nearly as many from generalized anxiety patients. Eur Arch Psychiatry Clin Neurosci
disorder. Brownlie et al. [21] studied 18 patients who, 1992;241:357–64.
over the course of 20 years, had been considered to 10.Trzepacz PT, Klein I, Roberts M, Greenhouse J,
be thyrotoxic and, at some time, psychotic. Levey GS. Graves’ disease: an analysis of thyroid
hormone levels and hyperthyroid signs and
Scores on only one mood factor, the subscale of symptoms. Am J Med 1989;87:558–61.
confusion and bewilderment, were significantly 11.Larsen PR. Thyroid–pituitary interaction:
higher in hyperthyroid subjects with treated Graves’ feedback regulation of thyrotropin secretion by
disease. This finding corresponds to data from thyroid hormones. N Engl J Med 1982;306: 23–32.
Whybrow et al. [6], showing prominent confusion in 12.Trzepacz PT, McCue M, Klein I, Greenhouse J,
patients with hyperthyroidism. Scores of other Levey GS. Psychiatric and neuropsychological
subscales of the POMS may have been blunted by the response to propranolol in Graves’ disease. Biol
drugs in use; Propranolol, benzodiazepines and Psychiatry 1988;23:678–88.
antidepressants. [13, 15] 13.Bommer M, Eversmann T, Pickardt R, Leonhardt
A, Naber D. Psychopathological and
CONCLUSION: neuropsychological symptoms in patients with

www.iajps.com Page 1283

 IAJPS 2018, 05 (02), 1280-1284 Muhammad Iqbal et al ISSN 2349-7750

subclinical and remitted hyperthyroidism. Klin

Wochenschr 1990;68:552–8.
14.Stern RA, Robinson B, Thorner AR, et al. A
survey study of neuropsychiatric complaints in
patients with Graves’ disease. J Neuropsychiatry Clin
Neurosci 1996;8:181–5
15.Fahrenfort JJ, Wilterdink AM, van der Veen EA.
Long-term residual complaints and psychosocial
sequel after remission of hyperthyroidism.
Psychoneuroendocrinology 2000;25:201–11.
16.Fukao A, Takamatsu J, Murakami Y, et al. The
relationship of psychological factors to the prognosis
of hyperthyroidism in antithyroid drug-treated
patients with Graves’ disease. Clin Endocrinol
2003;58:550–5.
17.Orenstein H, Peskind A, Raskind MA. Thyroid
disorders in female psychiatric patients with panic
disorder or agoraphobia. Am J Psychiatry
1988;145:1428–30.
18.Simon NM, Blacker D, Korbly NB, et al.
Hypothyroidism and hyperthyroidism in anxiety
disorders revisited: new data and literature review. J
Affect Disord 2002;69:209–17.
19.Sundstrom IM, Bixo M, Bjorn I, Astrom M.
Prevalence of psychiatric disorders in gynecologic
outpatients. Am J Obstet Gynecol 2001;184:8–13.
20.Scholle SH, Haskett RF, Hanusa BH, Pincus HA,
Kupfer DJ. Addressing depression in
obstetrics/gynecology practice. Gen Hosp Psychiatry
2003;25:83–90.
21.Brownlie BEW, Rae AM, Walshe JWB, Wells JE.
Psychoses associated with thyrotoxicoses —
bthyrotoxic psychosesQ. A report of 18 cases, with
statistical analysis of incidence. Eur J Endocrinol
2000;142:438–44.

www.iajps.com Page 1284