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Hashimoto's encephalopathy presenting with psychotic symptoms

 Department of Psychiatry, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, New Delhi, India

Date of Submission24-Nov-2021
Date of Acceptance16-Aug-2022
Date of Web Publication04-Jan-2023

Correspondence Address:
Raj K Sahu,
Room G-11, Hostel-1, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, New Delhi - 110 095
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_242_21

How to cite this URL:
Sahu RK, Rana A. Hashimoto's encephalopathy presenting with psychotic symptoms. Ind Psychiatry J [Epub ahead of print] [cited 2023 Jan 27]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=367030

Hypothyroidism is the most common hormonal disorder. Commonly recognized signs of this disease include hoarse voice, bradycardia, nonpitting edema, facial puffiness, slow speech, fatigue, cold intolerance, menstrual abnormalities, decreased appetite, and constipation.[1] Hypothyroidism can present with psychiatric symptoms in some cases. "Myxedema madness" was quoted first in the year 1949 to describe the psychotic symptoms of hypothyroidism.[2],[3]

Hashimoto's encephalopathy (HE) is a rare autoimmune disorder. It associates encephalopathy with autoimmune thyroiditis, presenting a high serum level of antithyroglobulin antibody (TG Ab) and/or antithyroid peroxidase antibody (TPO Ab).[4] It was first described by Brain et al. in 1966.[5] The pathophysiology of HE is still unknown. However, it is considered as an autoimmune disease due to the autoantibodies against the antigens shared by the thyroid and the brain, resulting in either vasculitis or damage to the brain cells.[6],[7],[8] HE has an estimated prevalence of 2/100,000.[4] The authors report the case of a male patient whose clinical presentation was dominated by multiple psychotic symptoms caused by HE.

A 56-year-old male patient with a history of diabetes mellitus type 2, no psychiatric history and a family history of hypothyroidism in sister presented with complaints of aggressive and violent behaviour, muttering to self, wandering behaviour, suspiciousness, inadequate self-care and reduced sleep from past 7 months. The patient was initially having poor social interaction with neighbors and family members and gradually became irritable most of the times with several incidents of unprovoked aggression. Patient would wander out of his house without telling anyone. Many a times he was seen muttering to himself. On general physical examination there was coarse dry skin, brittle hair, bradycardia. There was no palpable goiter. He had impaired immediate and recent memory. He had a perplexed affect- often reporting that he is confused and not able to understand things, delusion of persecution- was suspicious of family members that they will mix something in his food to poison him, delusion of reference, somatic passivity- someone is strangulating him with his hands, sometimes feels as if someone has caught his neck from behind and not letting him move although not able to see him and second person auditory hallucinations- can hear the voice of two or three people abusing him while no one is around. Brief Psychiatric Rating Scale (BPRS) = 37 on day 1 of hospitalization.

Investigations include hemoglobin—8.3 g/dL. TFT report revealed T3 = 0.76 pg/mL (N = 2.0–4.4 pg/mL), T4 = 0.12 ng/dL (N = 0.93–1.73 ng/dL), TSH = 254 μIU/mL (N = 0.27–4.2 μIU/mL). Auto antibodies reveals raised level of thyroid peroxidase antibody (TPO) Ab = >1,000 IU/mL (N = <5.61 IU/mL). 2D ECHO- Grade 1 left ventricular diastolic dysfunction. EEG revealed background slowing. NCCT Head was done which showed mild generalized cerebral atrophy with frontal predominance and exvacuo predominance of ventricular system.

Diagnosis of Hashimoto's encephalopathy presenting as psychosis, ICD10- F06.2 Other mental disorders due to brain damage and dysfunction and to physical disease-Organic delusional disorder was made. Patient was started on T. Risperidone 2 mg/day and gradually titrated up to 6 mg/day and Thyroxine 25 mcg/day which was titrated up to 75 mcg/day. The patient was admitted for around 30 days and had no verbal or physical aggression, took adequate self-care and had normal sleep and appetite on discharge. Patient's BPRS dropped to 23 by the end of 4 weeks of treatment. Patient was discharged with medications in a stable condition.

As per research adding an antipsychotic with thyroid hormone replacement may fasten the remission of psychosis.[9] Through this case it seems pertinent to start both treatment of hypothyroidism and antipsychotics to achieve a faster therapeutic recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Gaitonde DY, Rowley KD, Sweeney LB. Hypothyroidism: An update. Am Fam Physician 2012;54:384-90.  Back to cited text no. 1
Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: Myxedema madness revisited. Prim Care Companion J Clin Psychiatry 2003;5:260-6.  Back to cited text no. 2
Asher R. Myxoedematous madness. Br Med J 1949;2:555-62.  Back to cited text no. 3
Crotty GF, Doherty C, Solomon IH, Berry JD, Samuels MA. Learning from history: Lord Brain and Hashimoto's encephalopathy. Pract Neurol 2019;19:316-20.  Back to cited text no. 4
Brain L, Jellinek EH, Ball K. Hashimoto's disease and encephalopathy. Lancet 1966;2:512-4.  Back to cited text no. 5
Laurent C, Capron J, Quillerou B, Thomas G, Alamowitch S, Fain O, et al. Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT): Characteristics, treatment and outcome in 251 cases from the literature. Autoimmun Rev 2016;15:1129-33.  Back to cited text no. 6
Olmez I, Moses H, Sriram S, Kirshner H, Lagrange AH, Pawate S. Diagnostic and therapeutic aspects of Hashimoto's encephalopathy. J Neurol Sci 2013;331:67-71.  Back to cited text no. 7
Shaw P, Walls T, Newman P, Cleland P, Cartlidge N. Hashirnoto's encephalopathy: A steroid-responsive disorder associated with high anti-thyroid antibody titers—report of 5 cases. Neurology 1991;41:228-33.  Back to cited text no. 8
Chari S. The lesson from a yellow psychotic patient. Hosp Med 2002;63:370-1.  Back to cited text no. 9


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