Dissociative disorder due to associated with Graves’ hyperthyroidism: a case report Kaoru Mizutani M.D., Katsuji Nishimura M.D., Ph.D., Atsuhiro Ichihara M.D., Ph.D., Ishigooka Jun M.D., Ph.D. PII: DOI: Reference:
S0163-8343(14)00073-5 doi: 10.1016/j.genhosppsych.2014.03.010 GHP 6846
To appear in:
General Hospital Psychiatry
Received date: Revised date: Accepted date:
20 July 2013 11 March 2014 11 March 2014
Please cite this article as: Mizutani Kaoru, Nishimura Katsuji, Ichihara Atsuhiro, Jun Ishigooka, Dissociative disorder due to associated with Graves’ hyperthyroidism: a case report, General Hospital Psychiatry (2014), doi: 10.1016/j.genhosppsych.2014.03.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 1
RI P
T
Dissociative disorder due to associated with Graves’ hyperthyroidism: a case report
Kaoru Mizutani, M.D.1), Katsuji Nishimura, M.D., Ph.D. 1), Atsuhiro Ichihara, M.D., Ph.D.2),
SC
Jun Ishigooka, M.D., Ph.D.1)
MA NU
1) Department of Psychiatry, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan. 2) Department of Medicine II, Endocrinology and Hypertension, Tokyo Women’s Medical
ED
University School of Medicine, Tokyo, Japan
PT
Address correspondence and reprint requests to:
CE
Katsuji Nishimura, M.D., Ph.D., Department of Psychiatry, Tokyo Women’s Medical University, School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
AC
Tel.: +81-3-3353-8111
Fax: +81-3-3351-8979 E-mail: [email protected]
Keywords: Dissociative disorder, Graves’ disease, Hyperthyroidism
Running title: Dissociative disorder and Graves’ Disease
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 2
RI P
T
Abstract
We report the case of a 20-year-old Japanese woman with no prior psychiatric history
SC
with apparent dissociative symptoms. These consisted of amnesia for episodes of
MA NU
shoplifting behaviors and a suicide attempt, developing together with an exacerbation of Graves’ hyperthyroidism. Patients with Graves’ disease frequently manifest various psychiatric disorders; however, very few reports have described dissociative disorder due
ED
to this disease. Along with other possible causes, for example, encephalopathy associated
1. Introduction
CE
PT
with autoimmune thyroid disease, clinicians should be aware of this possibility.
AC
It is well known that patients with Graves’ disease may manifest various psychiatric disorders such as depression, mania, anxiety disorders or, sometimes, cognitive dysfunction [1], [2]. Despite the historical case description by Graves himself [3], of a young woman with repeated “fits of hysteria” accompanied with globus hystericus (although the temporal association between the onset, exacerbation, or resolution of the disease and of her psychiatric symptoms was unclear), dissociative/conversion disorders have been rarely reported.
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 3
To our knowledge, only one case report has described a dissociative disorder in a young
RI P
T
woman with Graves' disease with a previous history of domestic violence from her father [4]. She developed puerilism together with an exacerbation of hyperthyroidism and the
SC
puerilism disappeared completely together with an amelioration of the hyperthyroidism.
and
a
suicide attempt
MA NU
Here we report a case presenting dissociative amnesia for episodes of shoplifting behaviors developing
with
an exacerbation
of
Graves’
ED
hyperthyroidism.
together
PT
2. Case report
CE
The patient, a 20-year-old Japanese woman, had no previous history of psychiatric or neurologic illness. Her premorbid personality was serious, eager and active. She had
AC
moderate anankastic traits, but had neither a tendency to overreact to bad news, nor an inability to confront and handle conflicted situations, nor a lack of psychological self-awareness. She was an honor student and a cheerleader in high school, and wished to be a medical doctor. In January 2010 she visited our hospital because of goiter, palpitations and excessive sweating. Laboratory investigation showed the following: thyroid stimulating hormone (TSH) < 0.005 μU/ml (normal range: 0.38-4.30 μU/ml); free T3-II > 32.55 pg/ml (2.40-4.00); free T4 > 7.77 ng/dl (0.94-1.60); TSH-receptor antibody (TRAb) 84.0
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 4
IU/L (≤ 2.0); and anti-thyroid peroxydase antibody (anti-TPO Ab) 49.5 U/ml (≤ 0.3). Thyroid
RI P
T
scintigraphy demonstrated diffuse and remarkably elevated 123I uptake. She was diagnosed as having Graves’ disease, which her father also had. Administration of thiamazole 15
SC
mg/day and propranolol 30 mg/day were started. One month later, propranolol was
MA NU
discontinued because the palpitations disappeared. Her disease gradually improved and her thyroid function was within normal limits from October 2010 under the maintenance of thiamazole 5 mg/day.
ED
Meanwhile, in March 2010 she graduated from high school, but failed an entrance
PT
examination for medical school. After that, she spent one year preparing for the next
CE
entrance examination. However, she failed the entrance examination again and entered the department of education of a university in April 2011.
AC
In September 2011, she took time off from the department and began to go to a cram school after deciding to take the medical school exam again in the next season. However, beginning at the same time, she experienced palpitations, excessive sweating, insomnia, fatigability, decreased concentration, and irritability. She experienced significant difficulties in preparing for the exam and became agitated and depressed. Her disease worsened (TSH 0.006 μU/ml; free T3-II 7.34 pg/ml; free T4 2.35 ng/dl; TRAb 7.6 IU/L). Thiamazole was increased from 5 mg/day to 15 mg/day and propranolol 30 mg/day was restarted. At the
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 5
beginning of October 2011 she shoplifted a toothbrush, the first such behavior in her life,
RI P
T
followed by a second similar incident. At the beginning of December 2011, her third shoplifting act (comic books) was discovered by a salesclerk. Afterwards, in the restroom of
SC
the shop, she wound a string around her neck and lost consciousness. She was conveyed to
MA NU
the emergency hospital, but regained consciousness immediately. One week after that episode, she was admitted to hospital for treatment of Graves’ disease as well as psychiatric care. Her thyroid hormone level had increased further (TSH
ED
0.006 μU/ml; free T3-II 13.85 pg/ml; free T4 3.86 ng/dl; TRAb 20.6 IU/L). The thyroid storm
PT
score of Burch & Wartofsky [5] was 15/140 (< 25 makes thyroid storm unlikely). Thiamazole
CE
was increased up to 30 mg/day. On the third day after admission, we were asked to perform a psychiatric evaluation. She was cooperative and answered questions honestly
AC
and appropriately. The classical La belle indifference was not observed. The Mini-mental State Examination score was 29/30. She did not express any suicidal ideation at that time. She explained her medical history in detail and her frustration over her health issues around preparing for the exam. She had not had any other stressors, such as in her family, or in her relationships. She showed memory impairment limited to her shoplifting behaviors and her suicide attempt. She could only remember fragments of her shoplifting behaviors (“I remember I noticed that I had just brought out a toothbrush or a comic book, but cannot
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 6
remember how and why I did so.”), and could not recall her suicide attempt at all. She was
RI P
T
diagnosed as having Graves’ hyperthyroidism-associated dissociative disorder. Because these symptoms had improved at the time of our interview and her thyroid hormone level
SC
had decreased, we did not prescribe psychotropic drugs for her and advised recuperation.
MA NU
She left our hospital a week after admission. After radioiodine therapy in January 2012, her thyroid function returned to within normal limits (TSH 0.196 μU/ml; free T3-II 2.36 pg/ml; free T4 0.79 ng/dl; TRAb 19.2 IU/L). She gave up trying to enter medical school and
ED
returned to the department of education in April 2012. Since then, she has shown no
3. Discussion
CE
PT
dissociative symptoms through June 2013.
AC
This case presented dissociative symptoms consisting of amnesia for episodes of shoplifting behavior and a suicide attempt, developing together with an exacerbation of Graves’ hyperthyroidism. We cannot completely preclude the possibility that the complete amnesia for her suicide attempt following loss of consciousness was retrograde amnesia that occurred as a result of hypoxic encephalopathy from strangulation. Several studies have demonstrated a higher prevalence of emotional symptoms including depression and anxiety in hyperthyroidism [6], [7], [8]. In some studies [9], [10],
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 7
significant worsening of cognitive functions such as concentration or attention in
RI P
T
hyperthyroid patients compared with healthy subjects have been reported. Although this patient experienced major depression-like episode at the same time, most symptoms of the
SC
episode, e.g., insomnia, fatigability, agitation and decreased concentration, were
MA NU
attributable to her hyperthyroidism. Because of a temporal association between the exacerbation/amelioration of hyperthyroidism and those of her dissociative symptoms, this patient’s
dissociative
behaviors
may
have
been
a
consequence
of
her
ED
hyperthyroidism-induced psychosomatic symptoms including emotional and cognitive
PT
disturbances, even in light of her chronic academic stress. Therefore, we diagnosed her
CE
with dissociative disorder due to Graves' hyperthyroidism, as in the above-mentioned case [4]. However, we should note that it has been reported that the psychiatric symptoms in
AC
patients with Graves' disease are not necessarily dependent on the activity of the Graves' disease itself [11].
Other possible causes of the dissociative disorder in this patient were hyperthyroid encephalopathy as well as encephalopathy associated with autoimmune thyroid disease, which may also occur in patients with Graves’ disease. The former was unlikely because there was not a complete clinical presentation of thyroid storm. The possibility of the latter could not be ruled out completely because there was no information available in the
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 8
cerebrospinal fluid findings or electroencephalogram that could have supported this
RI P
T
diagnosis[12]. Encephalopathy associated with autoimmune thyroid disease generally occurs in patients with normal, or slightly abnormal, thyroid hormone levels. Further
SC
careful observation for psychiatric conditions in this patient is warranted.
MA NU
This case highlights the possibility that dissociative disorders can develop as a result of Graves’ hyperthyroidism.
Grabe HJ, Völzke H, Lüdemann J, et al. Mental and physical complaints in thyroid
PT
1.
ED
References
2.
CE
disorders in the general population. Acta Psychiatr Scand 2005;112:286-93. Bunevicius R, Prange AJ Jr. Psychiatric manifestations of Graves' hyperthyroidism:
AC
pathophysiology and treatment options. CNS Drugs 2006;20:897-909. 3.
Graves RJ: Clinical lectures. Medical Classics 1940;5:22-43.
4.
Kawakami M, Masumo H, Nakamura K, Ushijima S. A case of Basedow’s disease accompanied by dissociative symptom [in Japanese]. Jap J Clin Psychiatry 2003;32:81-84.
5.
Burch HB, Wartofsky L: Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77.
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 9
6.
Iacovides A, Fountoulakis KN, Grammaticos P, et al. Difference in symptom profile
RI P
T
between generalized anxiety disorder and anxiety secondary to hyperthyroidism. Int J Psychiatry Med 2000;30:71-81.
Demet MM, Ozmen B, Deveci A, et al. Depression and anxiety in hyperthyroidism.
SC
7.
8.
MA NU
Arch Med Res 2002;33:552-6.
Gulseren S, Gulseren L, Hekimsoy Z, et al. Depression, anxiety, health-related quality of life, and disability in patients with overt and subclinical thyroid dysfunction. Arch
Rockel M, Teuber J, Schmidt R, et al. Correlation of "latent hyperthyroidism” with
PT
9.
ED
Med Res 2006;37:133-9.
CE
psychological and somatic changes [in German]. Klin Wochenschr 1987;65:264-73. 10. Alvarez MA, Gomez A, Alavez E, et al. Attention disturbance in Graves’ disease.
AC
Psychoneuroendocrinology 1983;8:451-4. 11. Engum A, Bjøro T, Mykletun A, Dahl AA. An association between depression, anxiety and thyroid function--a clinical fact or an artefact? Acta Psychiatr Scand 2002;106:27-34. 12. Tamagno G, Celik Y, Simó R, et al. Encephalopathy associated with autoimmune thyroid disease in patients with Graves' disease: clinical manifestations, follow-up, and outcomes. BMC Neurology 2010:10;27.
S0163-8343(14)00073-5 doi: 10.1016/j.genhosppsych.2014.03.010 GHP 6846
To appear in:
General Hospital Psychiatry
Received date: Revised date: Accepted date:
20 July 2013 11 March 2014 11 March 2014
Please cite this article as: Mizutani Kaoru, Nishimura Katsuji, Ichihara Atsuhiro, Jun Ishigooka, Dissociative disorder due to associated with Graves’ hyperthyroidism: a case report, General Hospital Psychiatry (2014), doi: 10.1016/j.genhosppsych.2014.03.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 1
RI P
T
Dissociative disorder due to associated with Graves’ hyperthyroidism: a case report
Kaoru Mizutani, M.D.1), Katsuji Nishimura, M.D., Ph.D. 1), Atsuhiro Ichihara, M.D., Ph.D.2),
SC
Jun Ishigooka, M.D., Ph.D.1)
MA NU
1) Department of Psychiatry, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan. 2) Department of Medicine II, Endocrinology and Hypertension, Tokyo Women’s Medical
ED
University School of Medicine, Tokyo, Japan
PT
Address correspondence and reprint requests to:
CE
Katsuji Nishimura, M.D., Ph.D., Department of Psychiatry, Tokyo Women’s Medical University, School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
AC
Tel.: +81-3-3353-8111
Fax: +81-3-3351-8979 E-mail: [email protected]
Keywords: Dissociative disorder, Graves’ disease, Hyperthyroidism
Running title: Dissociative disorder and Graves’ Disease
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 2
RI P
T
Abstract
We report the case of a 20-year-old Japanese woman with no prior psychiatric history
SC
with apparent dissociative symptoms. These consisted of amnesia for episodes of
MA NU
shoplifting behaviors and a suicide attempt, developing together with an exacerbation of Graves’ hyperthyroidism. Patients with Graves’ disease frequently manifest various psychiatric disorders; however, very few reports have described dissociative disorder due
ED
to this disease. Along with other possible causes, for example, encephalopathy associated
1. Introduction
CE
PT
with autoimmune thyroid disease, clinicians should be aware of this possibility.
AC
It is well known that patients with Graves’ disease may manifest various psychiatric disorders such as depression, mania, anxiety disorders or, sometimes, cognitive dysfunction [1], [2]. Despite the historical case description by Graves himself [3], of a young woman with repeated “fits of hysteria” accompanied with globus hystericus (although the temporal association between the onset, exacerbation, or resolution of the disease and of her psychiatric symptoms was unclear), dissociative/conversion disorders have been rarely reported.
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 3
To our knowledge, only one case report has described a dissociative disorder in a young
RI P
T
woman with Graves' disease with a previous history of domestic violence from her father [4]. She developed puerilism together with an exacerbation of hyperthyroidism and the
SC
puerilism disappeared completely together with an amelioration of the hyperthyroidism.
and
a
suicide attempt
MA NU
Here we report a case presenting dissociative amnesia for episodes of shoplifting behaviors developing
with
an exacerbation
of
Graves’
ED
hyperthyroidism.
together
PT
2. Case report
CE
The patient, a 20-year-old Japanese woman, had no previous history of psychiatric or neurologic illness. Her premorbid personality was serious, eager and active. She had
AC
moderate anankastic traits, but had neither a tendency to overreact to bad news, nor an inability to confront and handle conflicted situations, nor a lack of psychological self-awareness. She was an honor student and a cheerleader in high school, and wished to be a medical doctor. In January 2010 she visited our hospital because of goiter, palpitations and excessive sweating. Laboratory investigation showed the following: thyroid stimulating hormone (TSH) < 0.005 μU/ml (normal range: 0.38-4.30 μU/ml); free T3-II > 32.55 pg/ml (2.40-4.00); free T4 > 7.77 ng/dl (0.94-1.60); TSH-receptor antibody (TRAb) 84.0
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 4
IU/L (≤ 2.0); and anti-thyroid peroxydase antibody (anti-TPO Ab) 49.5 U/ml (≤ 0.3). Thyroid
RI P
T
scintigraphy demonstrated diffuse and remarkably elevated 123I uptake. She was diagnosed as having Graves’ disease, which her father also had. Administration of thiamazole 15
SC
mg/day and propranolol 30 mg/day were started. One month later, propranolol was
MA NU
discontinued because the palpitations disappeared. Her disease gradually improved and her thyroid function was within normal limits from October 2010 under the maintenance of thiamazole 5 mg/day.
ED
Meanwhile, in March 2010 she graduated from high school, but failed an entrance
PT
examination for medical school. After that, she spent one year preparing for the next
CE
entrance examination. However, she failed the entrance examination again and entered the department of education of a university in April 2011.
AC
In September 2011, she took time off from the department and began to go to a cram school after deciding to take the medical school exam again in the next season. However, beginning at the same time, she experienced palpitations, excessive sweating, insomnia, fatigability, decreased concentration, and irritability. She experienced significant difficulties in preparing for the exam and became agitated and depressed. Her disease worsened (TSH 0.006 μU/ml; free T3-II 7.34 pg/ml; free T4 2.35 ng/dl; TRAb 7.6 IU/L). Thiamazole was increased from 5 mg/day to 15 mg/day and propranolol 30 mg/day was restarted. At the
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 5
beginning of October 2011 she shoplifted a toothbrush, the first such behavior in her life,
RI P
T
followed by a second similar incident. At the beginning of December 2011, her third shoplifting act (comic books) was discovered by a salesclerk. Afterwards, in the restroom of
SC
the shop, she wound a string around her neck and lost consciousness. She was conveyed to
MA NU
the emergency hospital, but regained consciousness immediately. One week after that episode, she was admitted to hospital for treatment of Graves’ disease as well as psychiatric care. Her thyroid hormone level had increased further (TSH
ED
0.006 μU/ml; free T3-II 13.85 pg/ml; free T4 3.86 ng/dl; TRAb 20.6 IU/L). The thyroid storm
PT
score of Burch & Wartofsky [5] was 15/140 (< 25 makes thyroid storm unlikely). Thiamazole
CE
was increased up to 30 mg/day. On the third day after admission, we were asked to perform a psychiatric evaluation. She was cooperative and answered questions honestly
AC
and appropriately. The classical La belle indifference was not observed. The Mini-mental State Examination score was 29/30. She did not express any suicidal ideation at that time. She explained her medical history in detail and her frustration over her health issues around preparing for the exam. She had not had any other stressors, such as in her family, or in her relationships. She showed memory impairment limited to her shoplifting behaviors and her suicide attempt. She could only remember fragments of her shoplifting behaviors (“I remember I noticed that I had just brought out a toothbrush or a comic book, but cannot
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 6
remember how and why I did so.”), and could not recall her suicide attempt at all. She was
RI P
T
diagnosed as having Graves’ hyperthyroidism-associated dissociative disorder. Because these symptoms had improved at the time of our interview and her thyroid hormone level
SC
had decreased, we did not prescribe psychotropic drugs for her and advised recuperation.
MA NU
She left our hospital a week after admission. After radioiodine therapy in January 2012, her thyroid function returned to within normal limits (TSH 0.196 μU/ml; free T3-II 2.36 pg/ml; free T4 0.79 ng/dl; TRAb 19.2 IU/L). She gave up trying to enter medical school and
ED
returned to the department of education in April 2012. Since then, she has shown no
3. Discussion
CE
PT
dissociative symptoms through June 2013.
AC
This case presented dissociative symptoms consisting of amnesia for episodes of shoplifting behavior and a suicide attempt, developing together with an exacerbation of Graves’ hyperthyroidism. We cannot completely preclude the possibility that the complete amnesia for her suicide attempt following loss of consciousness was retrograde amnesia that occurred as a result of hypoxic encephalopathy from strangulation. Several studies have demonstrated a higher prevalence of emotional symptoms including depression and anxiety in hyperthyroidism [6], [7], [8]. In some studies [9], [10],
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 7
significant worsening of cognitive functions such as concentration or attention in
RI P
T
hyperthyroid patients compared with healthy subjects have been reported. Although this patient experienced major depression-like episode at the same time, most symptoms of the
SC
episode, e.g., insomnia, fatigability, agitation and decreased concentration, were
MA NU
attributable to her hyperthyroidism. Because of a temporal association between the exacerbation/amelioration of hyperthyroidism and those of her dissociative symptoms, this patient’s
dissociative
behaviors
may
have
been
a
consequence
of
her
ED
hyperthyroidism-induced psychosomatic symptoms including emotional and cognitive
PT
disturbances, even in light of her chronic academic stress. Therefore, we diagnosed her
CE
with dissociative disorder due to Graves' hyperthyroidism, as in the above-mentioned case [4]. However, we should note that it has been reported that the psychiatric symptoms in
AC
patients with Graves' disease are not necessarily dependent on the activity of the Graves' disease itself [11].
Other possible causes of the dissociative disorder in this patient were hyperthyroid encephalopathy as well as encephalopathy associated with autoimmune thyroid disease, which may also occur in patients with Graves’ disease. The former was unlikely because there was not a complete clinical presentation of thyroid storm. The possibility of the latter could not be ruled out completely because there was no information available in the
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 8
cerebrospinal fluid findings or electroencephalogram that could have supported this
RI P
T
diagnosis[12]. Encephalopathy associated with autoimmune thyroid disease generally occurs in patients with normal, or slightly abnormal, thyroid hormone levels. Further
SC
careful observation for psychiatric conditions in this patient is warranted.
MA NU
This case highlights the possibility that dissociative disorders can develop as a result of Graves’ hyperthyroidism.
Grabe HJ, Völzke H, Lüdemann J, et al. Mental and physical complaints in thyroid
PT
1.
ED
References
2.
CE
disorders in the general population. Acta Psychiatr Scand 2005;112:286-93. Bunevicius R, Prange AJ Jr. Psychiatric manifestations of Graves' hyperthyroidism:
AC
pathophysiology and treatment options. CNS Drugs 2006;20:897-909. 3.
Graves RJ: Clinical lectures. Medical Classics 1940;5:22-43.
4.
Kawakami M, Masumo H, Nakamura K, Ushijima S. A case of Basedow’s disease accompanied by dissociative symptom [in Japanese]. Jap J Clin Psychiatry 2003;32:81-84.
5.
Burch HB, Wartofsky L: Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77.
ACCEPTED MANUSCRIPT Dissociative disorder and Graves’ Disease 9
6.
Iacovides A, Fountoulakis KN, Grammaticos P, et al. Difference in symptom profile
RI P
T
between generalized anxiety disorder and anxiety secondary to hyperthyroidism. Int J Psychiatry Med 2000;30:71-81.
Demet MM, Ozmen B, Deveci A, et al. Depression and anxiety in hyperthyroidism.
SC
7.
8.
MA NU
Arch Med Res 2002;33:552-6.
Gulseren S, Gulseren L, Hekimsoy Z, et al. Depression, anxiety, health-related quality of life, and disability in patients with overt and subclinical thyroid dysfunction. Arch
Rockel M, Teuber J, Schmidt R, et al. Correlation of "latent hyperthyroidism” with
PT
9.
ED
Med Res 2006;37:133-9.
CE
psychological and somatic changes [in German]. Klin Wochenschr 1987;65:264-73. 10. Alvarez MA, Gomez A, Alavez E, et al. Attention disturbance in Graves’ disease.
AC
Psychoneuroendocrinology 1983;8:451-4. 11. Engum A, Bjøro T, Mykletun A, Dahl AA. An association between depression, anxiety and thyroid function--a clinical fact or an artefact? Acta Psychiatr Scand 2002;106:27-34. 12. Tamagno G, Celik Y, Simó R, et al. Encephalopathy associated with autoimmune thyroid disease in patients with Graves' disease: clinical manifestations, follow-up, and outcomes. BMC Neurology 2010:10;27.
