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The study of Psychiatric Disorders in patients with Thyroid Disorder at the
tertiary care centre in Western Region of Nepal
Article in Journal of Psychiatrists Association of Nepal · December 2013
DOI: 10.3126/jpan.v2i2.9723
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J Psychiatrists’ Association of Nepal Vol .2, No.2, 2013
Original Article
The study of Psychiatric Disorders in patients with Thyroid
Disorder at the tertiary care centre in Western Region of Nepal
Thapa DK1Upadhyaya TL2lamichhaneN3 Subedi S4
1. Assistant Professor, Department of Psychiatry, GMC, Pokhara, Nepal, 2. Assistant Professor, Internal
Medicine, GMC, Pokhara, Nepal, 3. Associate Professor, Department of Psychiatry, GMC, Pokhara, Nepal 4.
Assistant Professor, Department of Psychiatry, UCMS, Bhairahawa, Nepal
Abstract
Background:Recent advances in biotechnology have led to an improved understanding of the impact of thyroid functions
on the adult, mature brain. This development has been particularly helpful in elucidating the role of thyroid hormones in the
pathophysiology of psychiatric disorders. The aim of the study was to evaluate the occurrence of various psychiatric
disorders in adult patients affected by different thyroid disorders.
Methods and materials:This was a descriptive, cross- sectional, hospital based and a collaborative study between the
internal medicine and the psychiatry department at Gandaki Medical College, Pokhara, Nepal. Based on the ICD- 10
psychiatric diagnosis, 60 consecutive consenting subjects of any gender above 18 years of age were included in the study.
The duration of the study was 6 months.
Results:The total numbers of subjects enrolled in the study were 60. The female consisted of 81.7% (49). The mean age was
39.62 ± 12.85 years. Regarding the thyroid disorder; 76.7% (46) had hypothyroidism, 15% (9) had sub clinical
hypothyroidism, and both the hyperthyroidism and Hashimoto thyroiditis were found in 3.3% (2) of the cases while
papillary carcinoma was found in 1.7% (1) case. Determination of psychiatric co-morbidity showed that; greater numbers of
the subjects i.e. 48.3% (29) had neurotic, stress- related and somatoform disorders (F40- F48), 26.7% (16) had mood
(affective) disorder (F30- F39), 13.3% (8) had simultaneously two psychiatric disorder, 10% (6) had headache and only
1.7% (1) had lack or loss of sexual desire (F52.0).
Conclusion: Compared to males, Females are more likely to have thyroid disorder. Clinician has to be alert to the possible
underlying psychiatric disorder in subjects with any thyroid disorder.
Keywords: Female, Thyroid disorder, Psychiatric disorder
INTRODUCTION
For more than a century, science has recognized
Thyroid gland is essential for normal human the connection between the thyroid axis and
development and maintenance.1Recent studies several commonly experienced psychiatric
suggest that thyroid hormones have direct and disorders. Small changes in thyroid hormone
important effect on mature brain function.2During levels, within the normal range, may have
brain development, iodine deficiency, maternal significant effects on cerebral thyroid function.
thyroid dysfunction, and neonatal thyroid This may manifest as alterations in mood,
malformations together with genetic factors may behavior and cognition.2
cause permanent neurological deficits with severe
mental retardation and cretinism.3
Thapa DK. Psychiatric Disorder in Thyroid disorder….
29
J Psychiatrists’ Association of Nepal Vol .2, No.2, 2013
Unlike in children, in adults, the effects of thyroid diagnosed with any thyroid disorder, who were
hormones on mental functioning are said to be suspected to have suffered from psychiatric
less striking. Most psychiatric patients may not ailments, were referred by the physician to
have overt thyroid dysfunction. If a thyroid psychiatry outpatient department. Those patients
abnormality is present, it is usually mild and may were thoroughly interviewed and examined by
be considered as a risk factor for mental disorder the psychiatrists and the psychiatric diagnoses
rather than as a causal factor.3 were based on the ICD- 10. The results were then
interpreted. The duration of the study was 6
But the recent advances in biotechnology have led months, from March to August 2013. The
to an improved understanding of the impact of consecutive consenting subjects of any gender
thyroid functions on the adult, mature brain. This above 18 years of age were included in the study.
development has been particularly helpful in Patients with other multiple medical co-
elucidating the role of thyroid hormones in the morbidities were excluded from the study.
pathophysiology of psychiatric disorders.4
RESULTS
Now the several studies have underlined the high
prevalence of psychiatric symptoms and The total numbers of subjects enrolled in the
disorders in thyroid diseases. 5 study were 60. Female consisted of 81.7% (49)
while 18.3% (11) were the males. The mean age
Slowly progressive changes in thyroid hormone was 39.62 ± 12.85 years while the age ranged from
levels are more likely to be associated with a 20 years to 70 years. The 86.7% (52) of the subjects
picture of chronic anxiety, increased fatigability were married while 13.3% (8) were single.
and psychomotor slowing. The severity of mental Regarding the thyroid disorder; 76.7% (46) had
symptoms is greater in elderly patients and, as hypothyroidism, 15% (9) had sub clinical
noted, in patients with rapidly changing thyroid hypothyroidism, both the hyperthyroidism and
hormone levels. 6 Hashimoto thyroiditis were found in 3.3% (2) of
the cases while papillary carcinoma was found in
1.7% (1) patient(See Table 1)
Psychiatric disorders, loss of consciousness,
movement disorders and weakness may all be Table 1: Showing the distribution of thyroid
manifestations of primary thyroid disease. 1In disorder (n=60):
adult patients with frank thyroid disease, mental
symptoms are usually limited to depression, Thyroid disorder Frequency Percentage
(n=60) (%)
anxiety, or reversible cognitive decline.3 Rapid
Hypothyroidism 46 76.7
cycling and other refractory forms of bipolar
Subclinical 9 15
disorder have been particularly highlighted, since Hypothyroidism
the prevalence of thyroid dysfunction appears to Hyperthyroidism 2 3.3
be greater in such forms of the disorder. 4Some Hashimoto 2 3.3
patients may not meet the full criteria of a specific thyroiditis
mental disorder, but they will not be free of Papillary Carcinoma 1 1.7
mental symptoms such as tension, hyperactivity, Total 60 100
or autonomic symptoms.3
Determination of psychiatric co-morbidity
METHOD
showed that; greater numbers of the subjects i.e.
This was a descriptive, cross- sectional, hospital 48.3% (29) had neurotic, stress- related and
based and a collaborative study between the somatoform disorders (F40- F48), 26.7% (16) had
internal medicine and the psychiatry department mood (affective) disorder (F30- F39), 13.3% (8)
at Gandaki Medical College, Pokhara, Nepal. The had simultaneously two psychiatric disorders,
aim of this study was to evaluate the occurrence 10% (6) had headache and only 1.7% (1) had lack
of psychiatric disorders in adult patients affected or loss of sexual desire (F52.0). (See Table 2)
by different thyroid diseases. The patients
30 Thapa DK. Psychiatric Disorder in Thyroid disorder….
J Psychiatrists’ Association of Nepal Vol .2, No.2, 2013
Table 2: Showing the distribution of psychiatric comorbidity in subjects with thyroid disorder (n=60):
Category of psychiatric Types of psychiatric disorder Frequency Percentage
comorbidity (n=60) (%)
Anxiety disorder unspecified 17
Somatization disorder 5
Mixed anxiety depressive disorder 2
Panic disorder 2
Neurotic, stress- related Obsessive compulsive disorder 1
and somatoform Persistent somatoform pain disorder 1
disorders (F40- F48) Neuroasthenia 1
Total 29 48.3
Recurrent depressive disorder 6
Bipolar affective disorder 4
Depressive episode 3
Mood (affective) disorder Dysthymia 2
(F30- F39) Mania 1
Total 16 26.7
Migraine headache with Somatization 2
disorder
Bipolar affective disorder with Harmful use 2
of alcohol
Migraine headache with Anxiety disorder 2
unspecified
Simultaneously occurring Migraine headache with Depressive 1
psychiatric disorder episode
Migraine headache with Recurrent 1
depressive disorder
Total 8 13.3
Migraine Headache 5
Headache cases Mixed Headache 1
Total 6 10
F52.0 Lack or loss of sexual desire 1 1.7
Overall total 60 100
Among 48.3% (29) cases of neurotic, stress- disorders were; 2 cases of migraine headache with
related and somatoform disorders i.e. (F40- F48) somatization disorder, 2 cases of bipolar affective
category, the distributions of disorders were; 17 disorder with harmful use of alcohol, 2 cases of
cases of anxiety disorder unspecified, 5 cases of migraine headache with anxiety disorder
somatization disorder, 2 cases of mixed anxiety unspecified, a single case of migraine headache
disorder and panic disorder each and a single case with depressive episode and a single case of
of obsessive- compulsive disorder, persistent migraine headache with recurrent depressive
somatoform pain disorder and neurasthenia. disorder. The diagnosis of headache was based on
criteria of set forth by International Headache
Among 26.7% (16) cases of mood (affective) Society (IHS).
disorder i.e. (F30 – F39) category, the distribution
of disorders were; 6 cases of recurrent depressive Among 10% (6) cases of headache, 5 cases were of
disorder, 4 cases of bipolar affective disorder, 3 migraine headache and the remaining single case
cases of depressive episode, 2 cases of dysthymia was of mixed headache.
and a single case of mania. Out of the 60 subjects, medical co- morbidity was
Among 13.3% (8) cases of simultaneously found in 10% (6) of the cases only. Those being, 2
occurring psychiatric disorder, the distribution of cases of iron deficiency anemia, and each case of
Thapa DK. Psychiatric Disorder in Thyroid disorder….
31
J Psychiatrists’ Association of Nepal Vol .2, No.2, 2013
ischemic heart disease, irritable bowel syndrome, and the least was cancer, 1.7%. At least 13 million
diabetes mellitus and carpel tunnel syndrome. Americans suffer from thyroid disorders, and in
Evaluation of the family history of thyroid more than 80% of cases, the problem is an
disorder revealed that, majority of the subjects i.e. underactive thyroid gland — hypothyroidism.
93.3% (56) had no family history. In remaining 7Likewise, other study have showed that
6.7% (4) of the cases, there was a positive history hypothyroidism is such a common problem with
of hypothyroidism. (See Table 3) an incidence of 410/100000/yearin women and
Table 3: Showing the family history of thyroid 60/100000/year in men, increasing with age).1 In
and mental disorder: the general population,the prevalence of
subclinical hypothyroidism is about 4 to 8.5
Family history of thyroid disorder percent, and may be as high as up to 20 percent in
Positive Hypothyroidism: 4 (6.7%) women older than 60 years. 8, 2Other thyroid
disorders are comparatively less in incidence.
Negative 56 (93.3%)
Evaluation of psychiatric co-morbidity among the
Total 60 (100%) subjects with thyroid disorder showed that;
greater numbers of the subjects i.e. 48.3% (29) had
Family history of mental disorder neurotic, stress- related and somatoform
Anxiety disorder unspecified: 3(5%) disorders (F40- F48) followed by 26.7% (16) of
Positive Bipolar affective disorder: 3 (5%) mood (affective) disorder (F30- F39). Others co-
Depression: 2 (3.3%) morbidities were headache and lack or loss of
Migraine headache: 2 (3.3%) sexual desire. Few had two simultaneously
Negative 50 (83.3%) occurring psychiatric disorders.
Total 60 (100%) Among the neurotic, stress- related and
somatoform disorders i.e. (F40- F48) category;
anxiety disorder unspecified=17; somatization
About 83.3% (50) did not have family history of disorder=5; mixed anxiety disorder=2; panic
mental disorder. Among the detected cases, disorder=2. There were patients a single diagnosis
anxiety disorder unspecified and bipolar affective of obsessive- compulsive disorder, persistent
disorder were found both in 5% (3) of the cases somatoform pain disorder and neuroasthenia.
while depression and migraine headache were
found both in 3.3% (2) of the cases. Psychiatric presentations are often the first sign of
DISCUSSION thyroid disorders. Anxiety and progressive
mental slowing associated with diminished recent
Thyroid disorder can present with variety of
memory, speech deficits and diminished learning
symptoms including the psychiatric symptoms.
The current study was to determine the ability are the characteristic initial progression of
distribution of various thyroid disorder and the symptoms that occur in hypothyroidism. Rogers
presenting comorbid psychiatric conditions et al examined the prevalence and characteristics
among the patients attending Gandaki Medical of medical illness in 711 patients who were
College, a tertiary care centre at Pokhara, Nepal. enrolled in the Harvard-Brown Anxiety Disorders
As shown in other studies, thyroid disorder is Research Program (HARP), a multi-center,
more common in female gender, and the rate rises longitudinal study of anxiety disorders. The study
with age, specially reaching 20% in women over noted that patients who suffered from panic
65.7 Among the thyroid disorder our study shows disorder were more likely to have an underlying
that; hypothyroidism was the most common medical illness causing their anxiety, particularly
occurrence (76.7%), followed by sub clinical thyroid disease in women. 6
hypothyroidism (15%), hyperthyroidism and
The vast majority of patients with
Hashimoto thyroiditis, each consisting of 3.3%
hyperthyroidism will display a psychiatric
32 Thapa DK. Psychiatric Disorder in Thyroid disorder….
J Psychiatrists’ Association of Nepal Vol .2, No.2, 2013
disorder such as anxiety, mania, or depression. 3 subclinical hypothyroidism may lower the
Between 30% and 40% present with conspicuous threshold for the occurrence of depression. 9Only
complaints of anxiety, nervousness, a few instances of mania or hypomania associated
apprehension, dread, depression, restlessness,
with hypothyroidism have been reported in the
diminished concentration, forced thinking,
emotional lability, and hyperkinesia. 6 The literature. Underlying mechanisms are less clear;
occurrence of anxiety as a symptom of they could include dysregulation of CNS
hyperthyroidism is well recognized. In one study, catecholamine receptor
29 patients were prospectively followed and sensitivity,associatedthyroditis and
found that 23 of them were diagnosed with thyrotoxicosis, or a disruption of circadian
generalized anxiety disorder and/or panic rhythms.4The relationship between
disorder. 2 Similarly, Trepacz et al report a
hyperthyroidism and depression is less clear.
highprevalence of general anxiety disorder in a
series of patients with untreated Graves' disease. However, prolonged hyperthyroidism might
In a study of patients with Hashimoto's exhaust noradrenergic transmission and thus
thyroiditis, anxiety was a prominent initial contribute to depression. Noradrenergic
symptom at the time the condition was exhaustion might well occur in patients with
diagnosed. Popkin and MacKenzie note that the hyperthyroidism who have bipolar disorder. In
behavioral changes of hyperthyroidism are the initial phase of hyperthyroidism, thyroid
numerous and useful in differentiating it from a
hormone stimulation of the noradrenergic system
primary anxiety neurosis or a neurasthenia.
Patients with hyperthyroidism are differentiated may cause mania; later, when noradrenergic
from primary anxiety states as "in thyroid neurotransmission is exhausted, it may contribute
dysfunction, sleeping pulse will remain to depression.3 Accumulating evidence suggests
accelerated; sedated pulse will exceed 80; palms that hypothalamo-pituitary-thyroid (HPT) axis
will be dry and warm, not cold and clammy; dysfunction is relevant to the pathophysiology
fatigue will be accomplished by a desire to be
and clinical course of bipolar affective disorder.
active; and cognitive dysfunction is more
prominent than in neurasthenia." 6 Hypothyroidism, either overt or more commonly
subclinical, appears to the commonest
Whybrow et al noted the elevation of abnormality found in bipolar disorder. The
schizophrenia and paranoid scales on the MMPI prevalence of thyroid dysfunction is also likely to
when patients are hyperthyroid and psychotic. be greater among patients with rapid cycling and
MacCrimmon et al noted MMPI changes in other refractory forms of the disorder. 10
hyperthyroid patients suggestive of hysterical
somatization. They suggested that the behavioral, Even though thyroid disorders are associated
neurotic and psychotic manifestations of
with psychiatric symptoms in clinical
hyperthyroidism were related more to disease
induced biochemical abnormalities than to the populations, existence of a similar association in
patient's previous personality pattern. 6Psychiatric general population is less certain. 4Data from
symptoms of anxiety in hyperthyroidism appears epidemiological studies provide conflicting
to be mediated by beta-adrenergic hyperactivity. 4, evidence as to associations between thyroid
3
disorders and mental symptoms.3
Among the mood (affective) disorder i.e. (F30 – In one such survey, Canadian researchers found
F39) category; recurrent depressive disorder=6; that the only psychiatric disorder associated with
bipolar affective disorder=4, depressive thyroid disease was social anxiety disorder (social
episode=3; dysthymia=2 and mania=1. phobia). In a study of more than 300 people over
Depression is usually linked to hypothyroidism. 3 age 60 who came to internal medicine and
The lifetime frequency of depression was psychiatry clinics, some of them for depression
significantly higher in the subjects who met the and others for symptoms suggesting abnormal
criteria for subclinical hypothyroidism (56%) than thyroid activity, researchers found a high rate of
in those who did not (20%), suggesting that depression among those with subclinical
Thapa DK. Psychiatric Disorder in Thyroid disorder….
33
J Psychiatrists’ Association of Nepal Vol .2, No.2, 2013
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