A Case of Violent Suicide Attempt in a Context of Myxedema Psychosis following Radioiodine Treatment in a Patient with Graves' Disease

This is a quite extraordinary case report.

The full paper says:

She had been treated for Grave's disease by carbimazole for six years. Almost four months before the suicide attempt, she received radioiodine therapy. Because of a misunderstanding, carbimazole was not switched by the patient for levothyroxine but had been continued until one week before admission.

Later it says:

Here, the patient had seen her general practitioner twice the week before her admission.

So this poor person had their thyroid treated with radio-active iodine, continued to take carbimazole for four months, even saw her doctor. Yet no-one seemed to notice her severe hypothyroidism! OK, so there were other issues going on, but the case history should have been like a flashing motorway sign saying "Hypothyroidism ahead!"

We have seen so many patients on this forum who have pitched from hyperthyroidism to hypothyroidism - whether due to an antithyroid medicine like carbimazole, radio-active iodine or surgery. And the reaction of the medics has so many times appeared to be surprise.

Case Rep Psychiatry. 2019 Jan 9;2019:4972760. doi: 10.1155/2019/4972760. eCollection 2019.

A Case of Violent Suicide Attempt in a Context of Myxedema Psychosis following Radioiodine Treatment in a Patient with Graves' Disease.

Todorov L1, Ait Boudaoud A2,3, Pascal de Raykeer R1, Radu A2, Lahlou-Laforêt K1, Limosin F1,3,4, Lemogne C1,3,4, Czernichow S2,3.

Author information

1 AP-HP, Hôpitaux Universitaires Paris Ouest, Service de Psychiatrie de l'Adulte et du Sujet Âgé, Paris, France.

2 AP-HP, Hôpitaux Universitaires Paris Ouest, Service de Nutrition, UF Endocrinologie-Diabétologie, Paris, France.

3 Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.

4 Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France.

Abstract

Introduction:

Hypothyroidism has been associated with mood disorders but some cases of acute psychosis have also been reported. However, less attention has been paid to suicidal behavior in these patients.

Case Report:

We report a case of suicide attempt by self-stabbing in a 43-year-old woman without past psychiatric history, four months after radioiodine therapy for Graves' disease. On clinical examination remarkable signs of myxedema were found and blood investigations showed hypothyroidism with an extremely high thyroid stimulating hormone (TSH) level (152 mUI/L; reference range 0.20-5.10). The patient presented delirium symptoms at the time of self-stabbing, which was associated with persecutory delusions and auditory harm command hallucinations. A rapid physical and psychiatric improvement was observed after the initiation of an oral thyroid replacement therapy without relapse after early discontinuation of the antipsychotic treatment.

Discussion:

The most distinctive feature of our case is that the violent suicide attempt could be attributed to the myxedema psychosis. Suicide may result from several factors, including psychosocial stressors, psychiatric symptoms, and hormonal disturbance. This unique presentation should remind clinicians to systematically consider ordering additional tests in patients with atypical psychiatric presentation, even when serious behavioral disorders (such as violent suicide attempts) are present and may result in premature transfer to psychiatric units.

PMID: 30729057

PMCID: PMC6343151

DOI: 10.1155/2019/4972760

ncbi.nlm.nih.gov/pubmed/307...

Full paper freely available here:

ncbi.nlm.nih.gov/pmc/articl...

81 Replies

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MaisieGray

8 days ago

I'd want to see much more detail before commenting. I've worked with people in the past, presenting with the same sort of psychiatric disturbances, and indeed was held in their respective flats by two of them, on separate occasions, one of whom was on licensed released having followed his own auditory harm command hallucinations to kill a policeman walking by. And even when initiating sectioning proceedings at various times, I can't recall anyone raising the issue of hypothyroidism as the first thing coming to either of the two practitioners' mind. We don't know what physical evidence, if any, of her myxoedemic state, had developed in the four months - whilst I wasn't in myxoedema trauma at the time of my diagnosis, I was however told I was so ill that I had one foot in the grave - yet looked and felt perfectly well. So I don't think there's sufficient facts available to us, to apportion blame in this case.

SilverAvocado

in reply to MaisieGray

I was going to say something kind of similar, but I think the advice should be less "When seeing atypical psychiatric symptoms be more alert...", and more, "When a patient is having powerful anti thyroid treatments be more alert..."

During my thyroidectomy and RAI treatment, I and almost everyone I saw looked absolutely wretched, hanging off their bones and moving in slow motion. I think it's pretty unlikely there weren't visual clues that her body was slowed to a standstill. Four months of it, as well, it's just such a long time to be so extremely hypo.

I think part of the explanation will be that doctors consider thyroid illness to be rather trivial, and they forget that with surgical and other interventions it is really turbo charged!

in reply to helvella

I did not reference my comment to this person or case, I said quite clearly and in a general sense, that it reinforces the importance of retaining responsibility for our health. We are all aware of the all too frequent scenario of people not even asking what tests are being carried out, or what the results were, when they are perfectly compos mentis and able to do so. I neither inferred not stated that someone in a myxodoema crisis could do so. I suppose I could have said "and this case also reminds me how important it is to ask questions or have someone speak on our behalf if we can't do so ourselves" if that makes my intent more clear. However, there is NO evidence from what we can read here, that at the point of completing her hyperthyroid treatment, and due to stop antithyroid meds and begin taking thyroid hormones, that she wasn't anything other than of sound mind, and presumably no reason to believe she wouldn't be. She presumably was rational and focused on that day when someone supposedly or allegedly instructed her to stop taking one med and start taking another. It is reasonable to infer that the mania developed incrementally at whatever rate over those 4 weeks, and that it wasn't present on the day she was medically declared hypothyroid. If this case evidences the possibility that someone can instantly experience a psychotic state immediately following such treatment, I would assume that it would be commented on, but in the 'discussion' aspect of the abstract you posted, the converse is stated viz that if someone presents with atypically psychiatrical symptoms, a thyroid cause should be considered. No reference is made that patients undergoing the radioactive treatment should be routinely assessed for psychiatric disturbance, and as I say, no reference in the above, that this woman was disturbed at the point immediately following her own.

StitchFairy

I have been following this thread with great interest, being someone who suffered awful mental illness due to thyroid hormone issues. Until now, I've refrained from commenting.

I find this comment of yours very upsetting:

"We are all aware of the all too frequent scenario of people not even asking what tests are being carried out, or what the results were, when they are perfectly compos mentis and able to do so."

A few years back, I was for a while under the - so called - care of a private endo at a BMI hospital who ordered blood tests. When I asked the nurse there for the details of tests ordered and the results, she categorically stated that I couldn't have this information as it was only for the doctor to know, and anyway, I wouldn't understand it. She had no idea who I was, and presumably made the assumption that because I was a patient I couldn't possibly be an intelligent human being.

This sort of thing happened regularly at my GP surgery too. Receptionists assuming patients were far too stupid to understand such things. It has only very recently been acknowledged (GDPR etc) that we patients have a right to this info, regardless of whether or not we understand it.

TSH110

in reply to StitchFairy

7 days ago

Or too ill. I had told doctor after doctor that there was a family history of thyroid disorder and could all the problems I was experiencing be thyroid related. I was repeatedly told it was irrelevant and nothing to do with my menopausal symptoms. Only one thyroid function test was done which I was told was normal - I now wonder how it could possibly have been normal but my medical notes were lost so I will never know. I believed I was just a hypochondriac imagining all these problems that were a normal part of a woman’s rotten lot in life. But I got worse and worse even deteriorating long after my menopause had ended. I had to demand a thyroid function test in the end even then I was offered antidepressants initially 🙄 Had it been left much longer I do not think I’d be here today. I was in a shocking state by this juncture but must have still looked ok. It took me a very long time to be able to start to be able comprehend the illness/tests etc although I did get the role of TSH in regulating hormone levels as my life saver doc explained it clearly. Even now I am still learning about hypothyroidism. It is my experience that the majority of doctors I saw, a not insignificant number, had very poor knowledge of the disorder and lacked the ability to diagnose it even when compelling evidence was under their very nose, all bar the two GPS who ran a thyroid function test. I feel it is the medical profession who need to pull up their socks, not patients who are too sick to function after having repeatedly sought medical help and have found effective and appropriate care severely wanting. It is a pattern of inadequacy revealed on this forum again and again

MiniMum97

That sounds like patient blaming to me! Some people simply do not have the capability to keep an eye on their own health the way a large number of people on this forum do. Most people still trust their and don’t question their treatment.

The responsibility is firmly on the doctor to monitor patients who have had RAI. If they were doing this the severe hypothyroidism and the mistake with the medication would have been picked up before the patient got to a place where they started stabbing themselves.

I have to monitor my own health and research and self diagnose. I am thankfully capable of doing this. If I just followed the doctors lead I dread to think where I would be now. That is not OK. We should be able to trust in our doctors that they will listen to our concerns, and act and treat accordingly and with accurate and up to date expert knowledge but that does not seem to be the case the majority of the time.

Umm I wasn’t listening I was reading and sometimes opinions in writing don’t always come across as intended. Emails being a good example of this. No need to be offended and make rude comments. The assumption that any confusion couldn’t possibly be due to your part of the communication is quite interesting!!

I have just reread your post however and have come to the same conclusions. It reads like you are saying that the patient should have taken “responsibility for [her] health” and should have asked various questions etc etc. You have clarified that you did not mean this but that is certainly how your post reads. And along with your other posts, your overall message seems to be: “we don’t know enough to blame the doctor and the patient should have asked more questions”.

Perhaps you could clarify your position further as having reread your posts I can’t discern another possible meaning?

Raventhorpe

This doesn't surprise me at all as when I had RAI for graves desease I was told by my endo to come back in six months time for blood test, in the mean time I became very ill was feeling dizzy, face was puffy, became very depressed was having panic attacks I went to the GP many times and was given antidepressants, water tablets at no time was it mentioned to have my thyroid levels checked, I went on to have a cycotic breakdown, I was put in mental ward and it was there they realised that it was due to my thyroid, TSH of over a hundred and was taken to hospital where I was put on levo and had someone sit by my bed 24/7 for the next week as they were worried I would hurt myself or someone else, it took me two years to recover from this nobody ever apologized just had letter from endo saying she had never seen anybody become so hypo so quickly after RAI.

holyshedballs

in reply to Tugun

In my experience, when things go wrong, the sufferer wants an apology and reassurances that the error will not be repeated. Most sufferers don't want a financial penalty. The NHS is trying very slowly (and really not very successfully) to adopt an environment where mistakes can be acknowledged and learned from.

Nevertheless, the doctors code of practice is very clear about apologies.

In Good Medical Practice at paragraph 55 the General Medical Council say:

You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should:

>put matters right (if that is possible)

>offer an apology

>explain fully and promptly what has happened and the likely short-term and long-term effects

I think that if doctors were familiar with this important guidance and implemented it, patients would be unlikely to take the time and expense of pursuing formal action to rectify a poor situation. But the reality is that doctors often don't apologise and often blame the patient. This frustrates the patient and sours the patient/doctor relationship.

in reply to Cica77

This happened 9yrs ago so now I am fully recovered it took me along time to come off all the medication they had put me on antidepressants, anti cycotic drugs, and tranquilliser, but this could all have been avoided if they had just done a simple thyroid function test when they should have at 6to8 weeks and again at 3 months then six months. I was too trusting of the Doc's and left my health in their hands but was so ill at the time hardly knew my own name let alone trying to fight to get the right treatment. To be honest I didn't know anything about thyroid desease till I came across this site 2yrs ago and thanks to members on here have learnt so much and now question everything to do with my health and fight tooth and nail hence I'm on T3/t4 combo meds now thou for how much longer that will last I don't know, and that's a big problem for us all .

MissGrace

A terrible case. I understand the lack of detail makes us cautious to comment, but in terms of the prescribing, some people totally trust their doctors and the tablets. If told to take something, they take it without question. My sister is like that - she takes pills like smarties and never bothers to look at the side effects or into the condition she has. It drives me nutty!

Also, not everyone can take responsibility for managing their own care, especially with some kinds of mental health issues.

The lack of blood testing following the RAI is negligent. Although there may have been other issues that exacerbated the reaction, having a TSH so high cannot have helped. Although not in this country, we know there are people on this site who feel after RAI or thyroidectomy they are left to go it alone.

I wonder if they gave the patient T3 as well as T4 to help with recovery?

It’s so sad that thyroid patients seem to get such poor treatment or face so many misunderstandings in so many countries.

🤸🏿‍♀️

helvellaAdministrator

in reply to MissGrace

The lack of blood testing following the RAI is negligent.

I cannot come to any other conclusion. I would, however, include the way in which all too many hyperthyroid patients are catapulted into hypothyroidism by anti-thyroid medicines.

That we see so many who seem utterly unaware that is likely to happen, and do not know what to do, compounds the negligence.

Although in itself insufficient, anyone post-RAI or on anti-thyroid medicine should have an "open" blood test form which they can use anywhere in the UK to get tested when they notice changes. They should not have to wonder what is happening, arrange a GP appointment, arrange a blood test appointment, and eventually get tested.

(Imagine, if you will: Sometime in the next few months, you will break a leg. When that happens get an appointment for an X-ray... It is predictable that it it will, or is at least likely, to happen.)

RockyPath

Thank you for sharing this link. It is chilling to consider how easily what was learned over a century ago has been abbreviated down to black-and-white, zero-or-one logic for healthcare providers: it isn't myxedema unless one is on death's door with a symptom that could never be attributed to anything else; otherwise, all of the symptoms are quite invisible to the trained eyes of people who have been through nearly a decade of medical training.

And the surgeon who treated me for a hernia recently had the ignorance to suggest I should never investigate my health condition to better understand it, but should leave it to his expertise. He said this while I was being prepared for surgery. When I next saw him, he had to admit that he had misjudged and had to poke around after he had sliced me open, dissecting my groin, to find where the problem really was, so that he could finally repair the tear. And I attribute the hernia to the hypothyroidism that went untreated at first and then became more profound as the levothyroxine treatment caused me to become profoundly hypothyroid.

Life can be a hard teacher, and what doesn't kill us can ultimately make us stronger, if we learn our lessons well.

posthinking01

Here is some more historical data

J Neurol Neurosurg Psychiatry. May 2006; 77(5): 639.

doi: 10.1136/jnnp.2005.082198

PMCID: PMC2117466

Myxoedema and Sir William Withey Gull (1816–1890)

J M S Pearce

Author information ► Article notes ► Copyright and License information ►

This is a brief history of hypothyroidism and the contribution of Sir William Withey Gull. Hypothyroidism and its complications provide many clinical puzzles for neurologists.

The thyroid had no known function until the end of the 19th century. In the wake of the term coined by Claude Bernard (1813–1878) in 1855, "internal secretion", and his concept of the milieu interieur, Sir William Withey Gull in 1873 was one of the first to understand that the cause of myxoedema is atrophy of the thyroid gland.

Gull's seminal paper1 related the changed appearance of a Miss B:

“after the cessation of the catamenial period, became insensibly more and more languid, with general increase of bulk… Her face altering from oval to round, …the tongue broad and thick, voice guttural, and the pronunciation as if the tongue were too large for the mouth (cretinoid)… In the cretinoid condition in adults which I have seen, the thyroid was not enlarged. …

There had been a distinct change in the mental state. The mind, which had previously been active and inquisitive, assumed a gentle, placid indifference, corresponding to the muscular languor, but the intellect was unimpaired… The change in the skin is remarkable. The texture being peculiarly smooth and fine, and the complexion fair, at a first hasty glance there might be supposed to be a general slight oedema of it… The beautiful delicate rose‐purple tint on the cheek is entirely different from what one sees in the bloated face of renal anasarca.”

Four years later, William Miller Ord (1834–1902)2 introduced the term myxoedema. Like Graves' disease, it was generally considered an affliction of the nervous system, which shows how little was known of the thyroid. William Smith Greenfield (1846–1919) of Edinburgh, who examined pathologically one of Ord's myxoedema patients observed that it was the antithesis to exophthalmic goitre. In his Bradshaw Lecture (1893):

‘In thus discussing Graves' disease, even provisionally as a disease of the thyroid gland rather than of the nervous system, I am aware that I am opposed to nearly all English and American physicians of eminence.'

but Kocher even 10 years later observed:

“Surgeons had simply assumed that the thyroid gland has no function whatever…”;

And Jaques‐Louis Reverdin asked in 1882:

“Can it be that the thyroid body whose functions are still obscure plays a part in haematopoiesis so important that its ablation produces such profound trouble?”

George Redmayne Murray(1865–1939) of Newcastle, stimulated by his mentor Victor Horsley (1857–1916), introduced in Britain the successful treatment of myxoedema in 1891, with injections of sheep thyroid extract.3 A similar success in Lisbon reported in 1890,4 but reported in Portuguese, was overlooked.

The discovery of autoimmune thyroid disease5,6 had to await the 20th century.

Go to:

Footnotes

Competing interests: none declared

References

1. Gull W W. On a cretinoid state supervening in adult life in women. Trans Clin Soc Lond. 1873– 1874. 7180–185.185

2. Ord W M. Report of a committee of the Clinical Society of London nominated December 14, 1883, to investigate the subject of myxoedema. Trans Clin Soc Lond 1888. 21 (supp)

3. Murray G R. Note on the treatment of myxoedema by hypodermic injections of an extract of the thyroid gland of a sheep. Brit Med J 1891. 2796 [PMC free article] [PubMed]

4. Un cas de myxoedème traité par la greffe hypodermique du corps thyroïde d'un mouton. Sem Medicale 1890. 10294

5. Weetman A. Autoimmune thyroiditis: predisposition and pathogenesis. Clin Endocrinol 1992. 36307–323.323 [PubMed]

6. Vaidya B, Kendall‐Taylor P, Pearce S H S. The genetics of autoimmune thyroid disease. J Clin Endocrinol Metab 2002. 875385–5397.5397 [PubMed]

in reply to jgelliss

From an article about 8 years old in Huffington Post about Pete Seeger: When Will They Ever Learn?:

I tell everybody a little parable about the ‘teaspoon brigades.’ Imagine a big seesaw. One end of the seesaw is on the ground because it has a big basket half full of rocks in it. The other end of the seesaw is up in the air because it’s got a basket one-quarter full of sand. Some of us have teaspoons, and we are trying to fill it up. Most people are scoffing at us. They say, ‘People like you have been trying for thousands of years, but it is leaking out of that basket as fast as you are putting it in.’ Our answer is that we are getting more people with teaspoons every day. And we believe that one of these days or years — who knows — that basket of sand is going to be so full that you are going to see that whole seesaw going zoop! in the other direction. Then people are going to say, ‘How did it happen so suddenly?’ And we answer, ‘Us and our little teaspoons over thousands of years.’

huffingtonpost.com/john-w-w...

leftbehind

Poor lady. This is what happens if you don't know enough about your thyroid to question everything the doctors do. I went to a "endocrinologist" ARNP who LOWERED my dosage of Naturethroid when she saw all my labs were too low! I was thrown into terrible diahrrea for three months. She told me she knew all about Graves Disease but she didn't know any of the symptoms or how to read the labs. I have now changed to NP Thyroid and raised my dosage to 1 grain, formerly 3/4 grain which she lowered. I kept telling her I have no thyroid. WHY CAN'T THEY LEARN ABOUT THYROID AND ALL THE ORGANS IN YOUR BODY IT IS CONTROLLING? I am so tired of their bad attitude and treating one like a hypochondriac. I have been very depressed and doctors just want to give you an antidepressant which doesn't do anything to help because it's all about the thyroid!

sally1976

I had RAI treatment September last year. Prior to having it done I was told by the Endo to stop taking the carbimazole the day before having the RAI treatment. I was also told by the nurse just before having the RAI about stopping my thyroid medication. I was also on steriods for 6 weeks. I had horrendous indigestion for a couple of weeks and had a phone consultation with my GP, who did ask if I'd stopped my carbimazole and if I had been put on sterioids. I saw the Endo 4 weeks later and was told the blood tests were OK and put on thyroxine - 50mg a day. Told to come back in 2 months. Blood test for that visit said my readings were low, so dosage upped to 125mg a day. Back in 3 months time.

The only cock up I had was when collecting my 2nd prescription the pharmacist said my dosage had been reduced, I said it hadn't, turned out he was translating carbimazole and thyroxine as the same medication !!

At last visit Endo gave a prescription of 75mg of thyroxine as I'd just collected 2 months supply of 50mg from my GP. I had a copy of the letter sent to my GP stating that they've given me 50mg extra thyroxine to cover me for 2 months and can GP up my next prescription to 125mg. Had a phone call from the surgery saying that my prescription is there for the additional thyroxine requested by the hospital. Obviously GP hasn't read the letter correctly !!

I do have other health issue, lupus, coealic, Sjogrens, rheumatoid arthritis. When one GP asked if I had any health issues - why don't they glance through my notes - and I started reeling them off, he said 'Oh I think that's enough to be going on with' I just continued and said that obviously he needed to know my medical history to offer a diagnosis.

It is a minefield out there !!

vajra2

6 days ago

It rings so many bells.

My sense is that the profession is if not uncaring is at least utterly unaware of the misery and ultimately the risk that severe hypothyroidism creates.

That they tend to be blinded by one size fits all practices designed to minimise testing/resource usage which result result in symptoms being almost entirely discounted.

Especially after procedures such as this lady had - they rationalise people's complaints of feeling awful as being down to whinging, and such situations as being only temporary.

My personal experience of this scenario followed a partial thyroidectomy about 14 yrs ago while already severely hypothyroid (due to subsequently proven secondary hypothyroidism which required T3 to resolve) - I was placed on a ridiculously low (50mcg) maintenance dose of T4 for several months pending a completion thyroidectomy.

I was in hell within a matter of weeks, but my consultant refused to act - passing the whole deal off as a bit of temporary discomfort, and claiming I didn't need more hormone.

My then GP wouldn't engage either - but she was already in denial, playing the 'depression, card, and backed into the bunker'. She had despite repeated briefings on the existence of secondary hypothyroidism for many years denied all possibility of hypothyroidism. (ie the reality that many making enough hormone, but unable to use it properly due to downstream problems are hypothyroid and likely need T3)

This much like the consultant by ignoring symptoms, and relying entirely on the stock T4/TSH tests. 'Your thyroid is perfectly normal'. 'Yes, but I can't use the hormone....'

I ended up traveling to the UK to see Dr. Skinner in Birmingham the following week - who immediately based on symptoms diagnosed severe hypothyroidism and placed me on a massively increased (x4) dose of T4 - with the possibility of trialing T3 if it wasn't effective.

It since I needed T3 didn't resolve the situation, but it did return me to where I had been prior to the partial thyroidectomy - hypothyroid, but just about coping.

I never made it back to Dr. Skinner since the pathology report identified a Hurthle cell thyroid cancer, and a completion thyroidectomy was scheduled for a few weeks later.

Even then (despite my handing him Dr. Skinner's report) the consultant flat refused to up my dose or to prescribe T3. I got by only because I still had Dr. S's prescription.

I switched immediately to a young consultant who after considerable pressure finally agreed to trial me with T3 (magic results - a clear head within a few hours, and an upwards profile which continued for over a year) - and the rest as they say is history.

Even that guy I'm pretty certain would never have trialed the T3 except that I had been diagnosed with a dangerous thyroid cancer. So he was keen to see my TSH suppressed, and presumably wasn't going to risk liability in the event of a return of the cancer since I'd also briefed him in writing on the likelihood that I suffered from secondary hypothyroidism.

He was to be fair to aware of the possibility of secondary hypothyroidism, but acted as though he was hog tied by norms...

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