Endocrine Abstracts

A 24-year-old female make-up artist presented with a 6 months history of emotional lability, heat intolerance, weight loss and shaking of the hands. She described a deteriorating relationship with her spouse and increasing difficulties performing her professional role. On examination, she demonstrated marked agitation, tremor, sweating and tachycardia. Biochemistry confirmed severe thyrotoxicosis (fT₄ 84 pmol/l, TSH<0.01 mU/l). Subsequent clinic attendance and compliance with carbimazole were extremely poor. After 6 months, the patient’s thyroid function tests were unchanged. She had been made redundant (her employer assumed she was abusing illegal substances) and she reported that several friendships had broken down irretrievably. The frequency of contact between the patient and the thyroid specialist nurse was subsequently increased significantly. A combination of ‘carrot and stick’ strategies were employed including daily reassurance, reminders and encouragement as well as frank consideration and discussion of the evident deleterious medical and psychosocial effects of uncontrolled thyrotoxicosis. This resulted in improved medication compliance and facilitated the completion of definitive treatment (a total thyroidectomy). Post-operatively, the patient’s partner reported that in the months prior to treatment adherence, the patient had been increasingly abusive towards him: verbal abuse had escalated to threatening behaviour and had culminated in an attempt to inflict severe physical injury. There was no preceding history of violent behaviour, which stopped following restoration of euthyroidism.

Psychiatric symptoms may occur in up to 10% of patients with thyrotoxicosis. Features include anxiety, depression, mixed mood disorders, mania and cognitive impairment. Paranoid and schizophreniform manifestations are less common. The frequency of violent behaviour against a spouse, precipitated by thyrotoxicosis, is unknown and likely to be under-reported. Asking open questions regarding changes in behaviour in the presence of attending family members may encourage the provision of this highly sensitive information and inform more timely planning of treatment.