Primary Hypothyroidism Associated with Acute Mania: Case Series and Literature Review

Abstract

In the evaluation of patients presenting with altered mental function searching for underlying medical conditions is necessary. Abnormal thyroid function has long been implicated in mood changes with the classic associations of depression occurring together with hypothyroidism and of mania along with hyperthyroidism. We here report 3 patients who presented with symptoms consistent with acute manic episode diagnosed using DSM IV-TR criteria and who were found to have primary hypothyroidism biochemically. This led to a review of the literature on this phenomenon resulting in the identification of 10 reports of mania and associated thyroid profiles consistent with primary hypothyroidism. All 3 of our patients improved clinically after use of levothyroxine and psychotropic medications, consistent with the literature reports. This illustrates that thyroid function abnormalities including primary hypothyroidism should be considered and screened for when evaluating patients with acute manic episodes.

Key words

hypothyroidism - psychiatric disorders - manic episodes - HPT axis - cognitive changes

References

• 1 American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders.  4th ed. Text Revision American Psychiatric Association, Washington D.C. 2000; 
• 2 Mallat M, Lima FR, Gervais A. et al . New insights into the role of thyroid hormone in the CNS: the microglial track.  Mol Psychiatry. 2002;  7 (1) 7-8
• 3 Larisch R, Ley K, Nikolaus S. et al . Depression and anxiety in different thyroid function states.  Horm Metab Res. 2004;  36 (9) 650-653
• 4 Hendrick V, Altshuler L, Whybrow P. Psychoneuroendocrinology of mood disorders. The hypothalamic-pituitary-thyroid axis.  Psychiatr Clin North Am. 1998;  21 (2) 277-292
• 5 Valle J, Ayuso-Gutierrez JL, Abril A. et al . Evaluation of thyroid function in lithium-naïve bipolar patients.  Eur Psychiatry. 1999;  14 (6) 341-345
• 6 Sato T, Imura E, Murata A. Thyroid hormone-catecholamine interrelationship during cold acclimation in rats. Compensatory role in catecholamine for altered states.  Acta Endocrinol (Copenh). 1986;  113 536-542
• 7 Asher R. Myxedematous madness.  Br Med J. 1949;  2 555-562
• 8 Sathya A, Radhika R, Mahadevan S. et al . Mania as presentation of primary hypothyroidism.  Singapore Medical Journal. 2009;  50 (2) e65-e67
• 9 Torr PC, Lee HY, Fones CS. Late-onset mania with psychosis associated with hypothyroidism in an elderly Chinese lady.  Singapore Med J. 2007;  48 (4) 354-357
• 10 Khaldi S, Dan B, Basiaux P. et al . Manic episode precipitated by withdrawal of hormone replacement therapy in severe hypothyroidism.  J Psychiatr Pract. 2006 Nov;  12 (6) 409-410
• 11 Stowell CP, Barnhill JW. Acute mania in the setting of severe hypothyroidism.  Psychosomatics. 2005;  46 (3) 259-261
• 12 Mahendran R. Hypomania in a patient with congenital familial hypothyroidism and mild mental retardation.  Singapore Medical Journal. 1999;  40 425-432
• 13 Levitte SC. Coexistent hypomania and severe hypothyroidism.  Psychosomatics. 1994;  34 96-97
• 14 Balldin J, Berggren U, Rybo E. et al . Treatment resistant mania with primary hypothyroidism: a case of recovery after thyroxine.  J Clin Psychiatry. 1987;  48 490-491
• 15 Bommer M, Naber D. Subclinical hypothyroidism in recurrent mania.  Biol Psychiatry. 1992;  31 (7) 729-734
• 16 Zolese G, Gutt R. Mania induced by biochemical imbalance resulting from low energy diet in a patient with undiagnosed myxedema.  British Medical Journal. 1987;  Volume 295 1026-1027
• 17 Cassidy F, Ahearn EP, Carroll BJ. Thyroid function in mixed and pure manic episodes.  Bipolar Disord. 2002;  4 (6) 393-397
• 18 Marcondes JA, Santomauro AT, Minanni SL. et al . Dissociated response of thyrotropin and prolactin to dopamine receptor blockade with domperidone in hypothyroid subjects.  Horm Metab Res. 1991;  23 (12) 605-608
• 19 Reddy S, Bhansali A, Sialy R. et al . Dopaminergic influence on thyrotropin secretion in primary hypothyroidism.  Horm Metab Res. 2005;  37 (5) 286-289
• 20 Goodwin G, Gary S. Bipolar disorder Oxford: Health Press; 2004: 23-24
• 21 Kennedy B, Strassman RJ, Ziegler MG. et al . Cardiovascular, catecholamine and psychological responses to TRH in four types of affective disorder patients.  Horm Metab Res. 1987;  19 (4) 164-167
• 22 Crocker AD, Overstreet DH. Modification of the behavioral effects of haloperidol and of dopamine receptor regulation by altered thyroid status.  Psychopharmacology. 1984;  82 102-106
• 23 Whybrow P C, Prange Jr AJ. A Hypothesis of Thyroid-Catecholamine-Receptor Interaction: Its Relevance to Affective Illness.  Arch Gen Psychiatry. 1981;  38 106-113
• 24 Cowdry RW, Wehr TA, Zis AP. Thyroid abnormalities associated with rapid cycling bipolar illness.  Arch Gen Psychiatry. 1983;  40 414-420
• 25 Kupka RW, Nolen WA Post. High Rate of autoimmune thyroiditis in bipolar disorder: lack of association with lithium exposure.  Biol Psychiatry. 2002;  51 305-311
• 26 Heinrich TW, Graham G. Hypothyroidism presenting as Psychosis: Myxedema Madness Revisited.  J Clin Psychiatry. 2003;  5 260-266
• 27 Hahn C-G, Friedman E. Abnormalities in protein kinase C signaling and the pathophysiology of bipolar disorder.  Bipolar Disord. 1999;  1 81-86
• 28 Nancy Diaz Granados MDMS, Carlos A, Zarate Jr MD. A Review of the Preclinical and Clinical Evidence for Protein Kinase C as a Target for Drug Development for Bipolar Disorder. Current Psychiatry Reports.  2008;  10 510-519
• 29 Iñiguez MG, Rodríguez-Peña A, Ibarrola N. Thyroid hormone regulation of RC3, a brain-specific gene encoding a protein kinase-C substrate.  Endocrinology. 1993;  133 467-473
• 30 Sawin CT, Castelli WP, Hershman JM. et al . The aging thyroid. Thyroid deficiency in the Framingham Study.  Arch Intern Med. 1985;  145 (8) 1386-1388

Correspondence