Hypothyroid psychosis

[nexus73]

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Recent call from the ED. 60 yr old lady with new onset psychosis (Paranoid delusions regarding neighbors plus both audio and visual hallucinations) increasing over 2 months. She is oriented and spelled world correctly backwards. 3 word recall 0/3. Negative head imaging. Normal physical exam. No history of psych dx. Labs normal except tsh 120 and mildly low free t4. Patient says off synthroid only over the last month. Negative drug screen. No edema, lethargy, or abnormal vitals. I suggested medical admit and was getting push back from the hospitalist.

Am I wrong to be worried this could be a manifestation of her hypothyroidism? If she was on the correct dose of synthroid previously, how long would she need to be off it for tsh to get this high? I suspect she’s been off it longer than 1 month.

 

[thepoopologist]

Random thoughts since its late
She's probably been off much longer than a month with a a TSH like that.
Medical history? She on any other meds?
If it is what you think it is - its kind of uncommon isn't it? - then I wonder if the hospitalist really wants to admit someone and wait the inordinate amount of time it would take for Synthroid to take effect. The problem is how impairing the psychosis is and whether you could also treat it at the same time.

 

[thepoopologist]

I read it again. I mean this is someone who is alert? and oriented, unremarkable physical exam, unremarkable labs apart from the TSH. Would this really require a medical floor admit? You didn't mention vitals? Oh wait you did. I need to sleep

 

[PikminOC]

Recent call from the ED. 60 yr old lady with new onset psychosis (Paranoid delusions regarding neighbors plus both audio and visual hallucinations) increasing over 2 months. She is oriented and spelled world correctly backwards. 3 word recall 0/3. Negative head imaging. Normal physical exam. No history of psych dx. Labs normal except tsh 120 and mildly low free t4. Patient says off synthroid only over the last month. Negative drug screen. No edema, lethargy, or abnormal vitals. I suggested medical admit and was getting push back from the hospitalist.

Am I wrong to be worried this could be a manifestation of her hypothyroidism? If she was on the correct dose of synthroid previously, how long would she need to be off it for tsh to get this high? I suspect she’s been off it longer than 1 month.

Was she admitted?

 

[splik]

with TSH >100 you can definitely see "myxedema madness". However in patients with known hypothyroidism, it is usually the psychosis causing non-adherence to synthroid and the high TSH rather than the TSH causing psychosis. I would still recommend a good workup for other causes of psychosis but if this is hypothyroid-related, there should be significant improvement within 8 weeks of resuming synthroid. does not necessarily warrant medical admission presuming she was loading on IV thyroxine in the ED and is not too weak to be managed on inpatient psychiatry or at as an outpatient and has no hypoglycemia, hypothermia, or hypotension.

 

[tr]

Off Synthroid only 1 month, FT4 'mildly' low (how low?), asymptomatic other than psychosis, and TSH 120? Those don't fit together. But also, new onset psychosis in a 60 yo is medical until proven otherwise. (Urine clean presumably?) Is hospitalist pushing for psych admission or discharge? I wouldn't discharge a psychotic elderly person and she won't get the right workup on psych, they'll just snow her with Seroquel and ship her home when she's too zonked to talk about the voices anymore.

 

[WisNeuro]

Any collateral from family/friends who know her well? Oftentimes we'll get cases of "new onset" symptoms of psychosis popping up in the ED after a confusional episode, only to find out that the symptoms have been present, albeit in milder forms for years. Such as hallucinations in LBD. Usually in our less well-to-do patients who don't have a lot of social supports, so it takes us a while to track down someone to get a valid history.

 

[nexus73]

She was admitted to medicine, awaiting cog screening and some other lab results. Another psychiatrist on duty is going to consult today. Additionally, she’s having visual hallucinations of “little people” and the auditory hallucinations are less frequent vague “popping sounds”, no voices. Maybe a dementia process like LBD that is progressing? If dementia, would she be more sensitive to aberrations in thyroid hormone level.

 

[WisNeuro]

She was admitted to medicine, awaiting cog screening and some other lab results. Another psychiatrist on duty is going to consult today. Additionally, she’s having visual hallucinations of “little people” and the auditory hallucinations are less frequent vague “popping sounds”, no voices. Maybe a dementia process like LBD that is progressing? If dementia, would she be more sensitive to aberrations in thyroid hormone level.

Lilliputian hallucinations are very common in LBD, though also common in other diagnoses, so somewhat non-specific. If LBD, I'd also be looking at discrete periods of confusion and some parkinsonism and/or postural instability. If she has one or two of those and REM sleep disorder, it's looking more likely. As for the hormone level, there is a decent amount of research coming out that is suggesting that while fluctuating hormone level does not set off psychosis, it may exacerbate already existing psychotic symptoms. I'll take a look when I have time, I saw some articles on this several months ago.

 

[nowaysanjose]

Any collateral from family/friends who know her well? Oftentimes we'll get cases of "new onset" symptoms of psychosis popping up in the ED after a confusional episode, only to find out that the symptoms have been present, albeit in milder forms for years. Such as hallucinations in LBD. Usually in our less well-to-do patients who don't have a lot of social supports, so it takes us a while to track down someone to get a valid history.

Don’t want to sound ignorant but they have psychologists in the ED now?

 

[WisNeuro]

Don’t want to sound ignorant but they have psychologists in the ED now?

Depends on the settings. Many places I've been, we've had SW and psychologists in the ED. The VA has employed psychologists in the ED for some time, they had people in there back when I was an intern. I, personally, do not work in the ED. I get consulted after ED admits them to a medical or psychiatric ward.

 

[tr]

Little people = get neuro in there

 

[Crayola227]

with TSH >100 you can definitely see "myxedema madness". However in patients with known hypothyroidism, it is usually the psychosis causing non-adherence to synthroid and the high TSH rather than the TSH causing psychosis. I would still recommend a good workup for other causes of psychosis but if this is hypothyroid-related, there should be significant improvement within 8 weeks of resuming synthroid. does not necessarily warrant medical admission presuming she was loading on IV thyroxine in the ED and is not too weak to be managed on inpatient psychiatry or at as an outpatient and has no hypoglycemia, hypothermia, or hypotension.

Every time I read this I just don't get it.

When you say it it isn't the TSH causing psychosis, you don't mean to say that high TSH itself is ever a cause of psychosis, do you? I read this at 3 in the afternoon and 3 am, I must need more naps.

 

[michaelrack]

Cortisol/adrenal status should also be assessed in severe hypothyroidism ( and often a few doses of IV hydrocortisone are given). However, once the patient is felt stable enough to be on oral medications, there's no reason to be on an inpatient medical service

 

[calvnandhobbs68]

Yeah hopefully they’re gonna get a brain MRI on medicine for this lady who developed new onset psychotic sx at 60.

 

[Mass Effect]

Yeah hopefully they’re gonna get a brain MRI on medicine for this lady who developed new onset psychotic sx at 60.

I was just going to ask. Surely there's been head imaging? If not, that's step 1.

This sounds like delirium to me (and if that's what it is, she should stay on medicine until symptoms are stable enough for discharge, then she can follow up outpatient). As was said above, with a TSH that high, you can see psychotic symptoms. But why is the TSH that high? Why did she stop taking Synthroid? I'm wondering if she had symptoms that made her stop taking it. Has she been on any new meds recently? Has she been ill?

 

[tr]

Negative head imaging in first post. Was that just CT though?

 

[calvnandhobbs68]

Negative head imaging in first post. Was that just CT though?

Just a CT was my impression...which is basically useless unless you suspect trauma, a bleed or massive tumor (which you'd probably pick up on neuro exam or some reported sx anyway...)

 

[Alemo]

Just a CT was my impression...which is basically useless unless you suspect trauma, a bleed or massive tumor (which you'd probably pick up on neuro exam or some reported sx anyway...)

The MRI will say “chronic microangiopathic changes.”

 

[WisNeuro]

The MRI will say “chronic microangiopathic changes.”

Pt is 60, you forgot to add the obligatory "mild generalized atrophy." Remember, the more nonspecific, the better in neuroradiology reports.

 

[Ceke2002]

I'm assuming you've checked calcium levels and considered the possibility of hyperparathyroidism as a contributing factor? Just that the situation with this patient sounds awfully similar to my Mum's just before she was diagnosed with early(ish) stage mixed dementia. She also had hypothyroid issues, but on top of the dementia was also diagnosed with primary hyperparathyroidism after blood tests showed hypercalcaemia, which in turn made her psychotic symptoms a lot worse. Symptomatic treatment for the high calcium levels didn't stop the dementia related psychosis completely, but it definitely dialled it down a lot (at least until she progressed to later dementia stages).

 

[nexus73]

The anticlimactic conclusion after I was able to meet her face to face:

The patient is under extreme stress due to recent legal charges. She recently moved to the area and has limited support. Her hallucinations and delusions rapidly resolved the day after admission (following 1 dose of synthroid which clearly is not the reason they stopped). No medical cause could be found. After I met with her, she has obvious borderline/histrionic personality disorder and as best I can tell, was having pseudo-hallucinations and possibly some dissociation given her stress. She may have been factitious, with possible outright malingering given legal charges. We'll see if her lawyer tries to subpoena one of the doctors to testify about her "psychosis" affecting her intent/culpability for charges.

 

[WisNeuro]

Is it bad that I'm disappointed when someone doesn't have an interesting neurological condition and instead just has some boring Axis II?

 

[splik]

The anticlimactic conclusion after I was able to meet her face to face:

The patient is under extreme stress due to recent legal charges. She recently moved to the area and has limited support. Her hallucinations and delusions rapidly resolved the day after admission (following 1 dose of synthroid which clearly is not the reason they stopped). No medical cause could be found. After I met with her, she has obvious borderline/histrionic personality disorder and as best I can tell, was having pseudo-hallucinations and possibly some dissociation given her stress. She may have been factitious, with possible outright malingering given legal charges. We'll see if her lawyer tries to subpoena one of the doctors to testify about her "psychosis" affecting her intent/culpability for charges.

strong work. I dont see where the factitious would come in but always good to consider. case illustrative of how important to think about hysterical diagnoses even if older patients. We would still recommend followup with repeat imaging in a year + neuropsych testing at that time as still possible a neurodegenerative disease is playing out here, though pre-test probability is now lower.

 

[Alemo]

I’m always amazed when other specialties take complaints of hallucinations at face value. I get that everyone is not actively psychotic and responding to internal stimuli on exam, but if you dig into the content a bit it’s pretty obvious what is “trauma based” (I see my own body lying in a puddle of blood”) or psychotic (I haven’t been able to get out of bed for two weeks and I’m hearing a whisper to kill myself and I see shadows on my room) or neurologic (I’ve been having headaches and now there are bright flashes of green in my visual field) or toxic (I’m in the ICU withdrawing from 1 handle a day of vodka and there’s a man in my room also my blood pressure is 220/100)

 

[splik]

I’m always amazed when other specialties take complaints of hallucinations at face value. I get that everyone is not actively psychotic and responding to internal stimuli on exam, but if you dig into the content a bit it’s pretty obvious what is “trauma based” (I see my own body lying in a puddle of blood”) or malingering (I haven’t been able to get out of bed for two weeks and I’m hearing a whisper to kill myself and I see shadows on my room) or neurologic (I’ve been having headaches and now there are bright flashes of green in my visual field) or toxic (I’m in the ICU withdrawing from 1 handle a day of vodka and there’s a man in my room also my blood pressure is 220/100)

fixed that for you

 

[Alemo]

meh ok I suppose it’s just as likely. The point is we wouldn’t call cardiology after hearing a patient say “my chest hurts”

 

[calvnandhobbs68]

meh ok I suppose it’s just as likely. The point is we wouldn’t call cardiology after hearing a patient say “my chest hurts”

Ive tried to explain that analogy to the ER more than once

 

[michaelrack]

meh ok I suppose it’s just as likely. The point is we wouldn’t call cardiology after hearing a patient say “my chest hurts”

In most psych hospitals the call would go to IM or Family medicine

 

[NickNaylor]

Ive tried to explain that analogy to the ER more than once

Our ED is worse in that they seem to have a policy that they will simply refuse to refill home psychiatric medications, even if the patient is completely asymptomatic. Any psychiatric medication refills require a psych consult. Doesn't matter if they follow in the same hospital system, were seen recently, and their psychotropic regimen is in the chart. Doesn't matter if it's an SSRI that the patient has been stable on for months.

Absolutely asinine.