When Hashimoto’s is misdiagnosed as bipolar disorder: A patient’s story

When Hashimoto’s is misdiagnosed as bipolar disorder: A patient’s story

November 10th, 2010 | Author:

After a bipolar diagnosis, this patient was prescribed eight different psychotropic medications and received a dozen electroconvulsive treatments.

After six months of support for Hashimoto’s, her symptoms resolved and she is now drug-free, with the exception of thyroid hormone medication. Was her bipolar disorder simply misdiagnosed Hashimoto’s?

I receive many amazing stories from people around the country whose lives were turned around by proper care for their Hashimoto’s. However this story of a young woman who spent most of her thirties on psychotropic drugs and underwent more than a dozen electroconvulsive treatments while under anesthesia really struck a chord. Her story, as told by her naturopath, follows.

Could Hashimoto’s flare-ups have started her down a path of psych meds and electroshock treatments?

“My patient Jeanette, 42, had been diagnosed seven years earlier by her family physician with bipolar disorder. She had manic episodes of staying up late at night, buzzing with energy and working on various projects, and shopping to excess, spending money she and her husband didn’t have. After these energy surges she then would crash and fall into fatigue and depression. A friend suggested she might have bipolar disorder and she brought this up with her family doctor, who prescribed her two psychiatric drugs and referred her to a psychiatrist. However her diagnosis was never re-evaluated and she eventually ended up on eight different medications, including lithium and drugs for depression, anxiety, panic attacks, and insomnia.

During her seven years of treatment she had also been hospitalized six times for complications due to her medications or for manic episodes. During the last hospitalization she had her gallbladder removed and was diagnosed with high blood sugar and Hashimoto’s, an autoimmune thyroid disease, and placed on thyroid hormone medication. Prior to seeing me she received twelve or thirteen electroconvulsive treatments under anesthesia during a six-month period, as prescribed by her psychiatrist.

Uncontrollable tremors and flat affect

When Jeanette came to my office her hands and legs shook uncontrollably, the result of a tremor that had developed recently. She also had a flat affect, meaning she showed no emotion and her overall mood was dull and low. She also said she struggled with extreme fatigue.

Given the precarious nature of her mental health and that fact that she had had so many hospitalizations, I thought it prudent to start very slowly with her case management.

Going gluten-free and dietary changes

Because of her Hashimoto’s diagnosis, the first thing I did was put her on an autoimmune diet and remove gluten from her diet. I also asked her to remove dairy and sugar and add in healthy fats, lots of vegetables, and to eat more frequently to keep her blood sugar stable. I supported her nutritionally with essential fatty acids (including emulsified fish oil), emulsified vitamin D, nutrients for insulin resistance (since her blood sugar was high her last time in the hospital), and gallbladder support to give her the digestive support she needed since her gallbladder had been removed.

Gut detox and adrenal support

Immediately she started to notice improvement in how she felt. After following the diet for several months, I put her on a gut detoxification program with a hypoallergenic detox protein powder. I started her on adrenal adaptogen herbs and nutrients as her salivary adrenal panel showed an increase in cortisol and night. This means she was more awake and night when she should be tired, which indicates a dysfunction in the brain’s sleep-wake cycle. Adrenal adaptogens address this.

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Reversible dementia with psychosis: Hashimoto’s encephalopathy.

Psychiatry Clin Neurosci. 2006 Dec;60(6):761-3.

Source

Neuropsychiatry Unit, Melbourne Neuropsychiatry Center, Royal Melbourne Hospital, Melbourne, Austrailia. Ramon.Mocellin@nh.org.au

Abstract

A case of presumed Hashimoto’s encephalopathy (HE) is presented. The presentation included memory loss, delusions, functional decline and culminated in a generalized seizure. Anti-thyroid antibodies were detected and symptoms resolved with prednisolone. Patients with HE may present with prominent neuropsychiatric symptoms, attract psychiatric diagnoses and present to psychiatric services. Primarily a diagnosis of exclusion, HE should be considered in cases of encephalopathy in which standard investigations are negative.

PMID:
17109712
[PubMed – indexed for MEDLINE]

Hashimoto encephalopathy responding to risperidone.

J Child Neurol. 2007 Jul;22(7):855-7.

Source

Department of Pediatrics, Division of Pediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada. zia.bismilla@sickkids.ca

Abstract

This report describes a case of Hashimoto encephalopathy in an 11-year-old girl. She presented with features typical of this disorder including encephalopathy, seizures, and neuropsychiatric symptoms. Diagnosis was supported by an elevated thyroid-stimulating hormone level, a low levo-thyroxine level, and positive results for antithyroperoxidase antibody. Her response to typical treatment with levo-thyroxine was incomplete, requiring additional therapy with valproic acid and methylprednisone. Her course was further complicated by the development of acute psychosis. Treatment with risperidone was correlated with resolution of her psychosis and improvement in neuropsychiatric symptoms. Response to antipsychotic therapy has not previously been described in the pediatric population with Hashimoto encephalopathy. This case highlights the need for guidelines for the management of this rare disorder.

PMID:
17715278
[PubMed – indexed for MEDLINE]

Seizures, psychosis and coma: severe course of hashimoto encephalopathy in a six-year-old girl.

Neuropediatrics. 2007 Aug;38(4):197-9.

Source

University Children’s Hospital, Ludwig Maximilians University, Munich, Germany.

Abstract

Hashimoto encephalopathy (HE) is a rare steroid-responsive encephalopathy associated with elevated antithyroid antibodies and is a well recognised complication of autoimmune thyroid disease. The clinical picture is pleomorphic, presenting with variable symptoms like coma, seizures, neuropsychiatric changes (impairment of cognitive functions, behavioural and mood disturbances, hallucinations) or focal neurological deficits. HE is mainly diagnosed in adults, but also a rare differential diagnosis of encephalopathy or epilepsy in children. The diagnosis is often overlooked at presentation but is crucial as it is a treatable disease. We report on the youngest patient described up to now presenting with progressive epilepsy resistant to anticonvulsive treatment and unclear encephalopathy related to Hashimoto thyroiditis.

PMID:
18058628
[PubMed – indexed for MEDLINE]

Affective psychosis, Hashimoto’s thyroiditis, and brain perfusion abnormalities: case report

Background

It has recently become evident that circulating thyroid antibodies are found in excess among patients suffering from mood disorders. Moreover, a manic episode associated with Hashimoto’s thyroiditis has recently been reported as the first case of bipolar disorder due to Hashimoto’s encephalopathy. We report a case in which Hashimoto’s thyroiditis was suspected to be involved in the deteriorating course of mood disorder and discuss potential pathogenic mechanisms linking thyroid autoimmunity with psychopathology.

Case presentation

A 43-year-old woman, with a history of recurrent depression since the age of 31, developed manic, psychotic, and soft neurological symptoms across the last three years in concomitance with her first diagnosis of Hashimoto’s thyroiditis. The patient underwent a thorough medical and neurological workup. Circulating thyroperoxidase antibodies were highly elevated but thyroid function was adequately maintained with L-thyroxine substitution. EEG was normal and no other signs of current CNS inflammation were evidenced. However, brain magnetic resonance imaging evidenced several non-active lesions in the white matter from both hemispheres, suggestive of a non-specific past vasculitis. Brain single-photon emission computed tomography showed cortical perfusion asymmetry particularly between frontal lobes.

Conclusion

We hypothesize that abnormalities in cortical perfusion might represent a pathogenic link between thyroid autoimmunity and mood disorders, and that the rare cases of severe Hashimoto’s encephalopathy presenting with mood disorder might be only the tip of an iceberg.

Click here to read the full article.

Hashimoto’s encephalopathy masquerading as acute psychosis.

J Clin Neurosci. 2008 Nov;15(11):1301-4. Epub  2008 Mar 7.

Source

Department of Neurology, Level 2, Flinders Medical Centre, Bedford Park, Adelaide 5042, South Australia, Australia.

Abstract

Hashimoto’s encephalopathy (HE) is a relapsing, but exquisitely corticosteroid-responsive encephalopathy associated with autoimmune thyroiditis. Although a rare disease, with just over 100 cases reported, it may be under-recognised. Its presentation can be protean with prominent neuropsychiatric features, stroke-like episodes, seizures and myoclonic jerks. Prompt corticosteroid treatment usually leads to rapid recovery. Here we report a patient with HE, initially presenting with florid neuropsychiatric symptoms. Recent developments in the understanding of this condition are discussed.

PMID:
18313925
[PubMed – indexed for MEDLINE]

[Hashimoto encephalopathy: a case study].

Endokrynol Pol. 2008 Mar-Apr;59(2):168-71.
[Article in Polish]

Source

Dział Endokrynologii i Medycyny Nuklearnej, Swietokrzyskie Centrum Onkologii, Kielce, Poland. d_ss@tlen.pl

Abstract

The impact of thyroid hormones upon the proper function of central nervous system has been known for many years. The neurological symptoms and psychiatric disturbances may occur both in case of hypo- as well as hyperthyreosis. The encephalopathy Hashimoto (EH) described in this paper is a rare illness which occurs in case of patients suffering from the autoimmunological thyroid disease and increased level of antibodies in serum without any connections to the thyroid function. It is characterised by a variety of neurological symptoms and psychotic disturbances, acute state, high re-occurrence and good reaction to glicocorticosteroid treatment. Although we face encephalopathy Hashimoto extremely rarely in the clinical practice one should remember about it during the diagnostic process because when it is a long lasting untreated illness it may lead to the irreversible changes in the central nervous system.

PMID:
18465692
[PubMed – indexed for MEDLINE]

[Hashimoto encephalopathy–a difficult differential diagnosis. A case report of reversible dementia and psychosis].

Fortschr Neurol Psychiatr. 2008 Oct;76(10):610-5. Epub  2008 Oct 2.
[Article in German]

Source

Evangelisches Krankenhaus Königin Elisabeth Herzberge, Abt. für Psychiatrie, Psychotherapie und Psychosomatik, Berlin.

Abstract

INTRODUCTION:

Hashimoto encephalopathy is a rare disease that is associated with Hashimoto thyreoiditis. Dementia, disturbances of consciousness and epileptic seizures are the most common features.

CASE REPORT:

We report a case of Hashimoto encephalopathy in a 74-year-old woman who presented with psychotic episodes, visual hallucinations, dementia, tremor, rigidity and fluctuation of consciousness. After treatment with steroids, cognitive function became normal and other symptoms improved significantly.

CONCLUSION:

Hashimoto encephalopathy should be considered as a differential diagnosis of psychosis in combination with dementia and other neurological symptoms to dementia with Lewy bodies and Creutzfeldt-Jakob disease.

PMID:
18833507
[PubMed – indexed for MEDLINE]

Hashimoto encephalopathy presenting as schizophrenia-like disorder.

Cogn Behav Neurol. 2009 Sep;22(3):197-201.

Source

Department of Psychiatry, National Taiwan University Hospital and Medical College, Taiwan.

Abstract

OBJECTIVE:

Hashimoto encephalopathy (HE) is associated with numerous neuropsychiatric symptoms and responds well to steroid therapy. In the past, only a few cases were reported to present with pure psychiatric syndromes. We describe a case of HE with presenting symptoms like that of schizophrenic patients.

METHODS:

We describe a 73-year-old woman with a history of autoimmune thyroiditis. She had psychotic symptoms for 3 years that responded poorly to antipsychotic agents, and she was thus admitted in 2007.

RESULTS:

The diagnosis of HE was made, although the patient presented neurologic symptoms and signs including abnormal electroencephalography, recent memory impairment, and executive function declination. The psychotic symptoms subsided completely in a few days after high-dose intravenous steroid therapy.

CONCLUSIONS:

The neuropsychiatric manifestation of HE can be similar to typical schizophrenia. Considering the effectiveness of steroid therapy for HE, we suggested HE as an important differential diagnosis for psychotic disorders, particularly for those patients of late onset, with abnormal electroencephalography, history of autoimmune thyroiditis, or poor response to conventional psychiatric treatment, so as to provide prompt and effective treatment for these patients.

PMID:
19741331
[PubMed – indexed for MEDLINE]

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