General Hospital Psychiatry xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Postpartum psychosis in a woman with Graves' disease: a case report Ajit Bhalchandra Dahale, M.D. a, Prabha S. Chandra, M.D., FRCPsych a,⁎, Linda Sherine, M.B.B.S. a, Harish Thippeswamy, M.D., D.N.B., P.G.D.M.L.E. a, Geetha Desai, M.D., D.N.B. a, Dharma Reddy, M.Phil. b a b
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, (NIMHANS) Bangalore-560029, India Department of Psychiatric Social Work, National Institute of Mental Health and, Neuro Sciences (NIMHANS) Bangalore-560029, India
a r t i c l e
i n f o
Article history: Received 25 December 2013 Revised 11 July 2014 Accepted 15 July 2014 Available online xxxx Keywords: Hyperthyroidism Graves' disease Postpartum psychosis Psychosis Catatonia
a b s t r a c t Objective: Thyroid dysfunction is common during pregnancy and the postpartum period and is known to cause psychiatric disturbances. A woman with Graves' disease and psychosis in the postpartum period is described. Methods: A 22-year-old woman with Graves' disease developed fluctuating orientation, catatonia, delusions of persecution and auditory hallucinations 3 days following childbirth. Results: The report discusses the clinical presentation. Treatment of both conditions led to the resolution of symptoms. Conclusion: Graves' disease with postpartum psychosis may present with delirium, catatonia and prominent auditory hallucinations and responds well to a combination of psychotropic and antithyroid drugs. Thyroid dysfunction should be assessed for and managed adequately in postpartum psychosis. © 2014 Published by Elsevier Inc.
Graves' disease is an autoimmune disease causing hyperthyroidism and is common in women compared to men [1]. Anxiety, depression and affective psychoses have been associated with this condition [2,3]. Paranoid schizophrenia and other psychoses have also been reported in patients with Graves' disease and other hyperthyroid states [4–13]. Catatonia has also been reported in association with Graves' disease [14–16]. Thyroid disorders commonly occur during the perinatal period and may be associated with psychiatric disturbances [17]. This case illustrates the association between Graves' disease and postpartum psychosis.
Her obstetric history revealed poor antenatal care and full-term normal delivery of a healthy baby. There was no past or family history of psychiatric illness. Physical examination revealed moist cold skin, exophthalmos, tachycardia, tachypnea and a diffuse thyroid swelling. There were no neurologic deficits. Mental status examination revealed several features of catatonia such as immobility, mutism, passive negativism and posturing. She also appeared anxious and was found muttering to herself. Family members reported that she was on medications for hyperthyroidism which she had discontinued before becoming pregnant (10 months earlier) due to poor economic conditions. A clinical diagnosis of Graves' disease with organic psychosis was considered.
1. Case report 2. Investigations and treatment A 22-year-old multiparous woman in her 12th day postpartum presented with a history of behavior change noticed 3 days after delivery. She initially reported sudden fear that her husband had been assaulted by someone and that he would leave her. She also reported of auditory hallucinations and was noticed to be laughing to herself. She became suspicious toward her in-laws, and her social interaction reduced markedly with decline in sleep and food intake. From the eighth day onwards, there was minimal speech; she stopped eating and had posturing and immobility for long periods. Mother–Infant interaction was significantly impaired. Occasionally, she would not identify family members, and there were two episodes of incontinence. ⁎ Corresponding author. Tel.: +91-80-26995272, +91-9880383057 (mobile). E-mail address: [email protected] (P.S. Chandra).
Thyroid function tests confirmed presence of current hyperthyroidism [thyroid stimulating hormones (TSH)b0.008 uIU/ml; serumfree T3 of 243.53 ng/dl and T4 19.86 ng/dl—free T4 of 1.83 ng/dl]. Serum anti-thyroid peroxidase antibody level was 377.1 U/ml (normal range: 28–60 U/ml). Thyroid technetium scan showed increased tracer uptake in a Grave's Disease pattern. All other metabolic and hematological tests were normal. Computed tomography scan of brain was also normal. The infant was evaluated for thyroid dysfunction and was found to be euthyroid. The patient was started on lorazepam 2 mg intravenous thrice a day for catatonia which was changed to oral lorazepam on the third day. She was also started on tablet propranolol 40 mg twice a day and tablet Carbimazole 30 mg on the fifth day of admission based on advice by the endocrinologist. Her food intake and immobility
http://dx.doi.org/10.1016/j.genhosppsych.2014.07.003 0163-8343/© 2014 Published by Elsevier Inc.
Please cite this article as: Dahale A.B., et al, Postpartum psychosis in a woman with Graves' disease: a case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.07.003
2
A.B. Dahale et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
improved gradually, and she began to care for and breastfeed the baby within 8 days of admission. Lorazepam was then tapered and stopped within 10 days. However, once her catatonia resolved, she continued to report anxiety, had weeping spells and reported fearfulness. She reported auditory hallucinations on multiple occasions. These included voices of a woman who claimed that the baby was not hers and had been swapped at birth. She also reported hearing voices of men in the ward even when no men were around. In view of the psychotic symptoms, she was started on olanzapine 2.5 mg per day orally on the 10th day of admission. Tachypnea, tachycardia and excessive sweating improved significantly after 2 weeks of treatment with propranolol and Carbimazole. The anxiety and weeping spells resolved over 2 weeks of olanzapine treatment. However, the auditory hallucinations and fearfulness continued for which the olanzapine was increased up to 10 mg per day on the 20th day of admission. After 10 days of treatment with olanzapine 10 mg, she was found to be euthymic and did not report any fear or auditory hallucinations. At the time of discharge, she was breast feeding, bonding well with her infant and was able to manage her maternal duties. She was discharged after 35 days of inpatient care and referred to her local general practitioner. At the time of discharge her serum-free T3 was 96.08 ng/dl; serum free T4 was 9.6 mcg/dl, and TSH was 0.05 IU/ml (all within the normal range except TSH, which was still low). The team has been reviewing her condition over the phone, and she appears to have no psychotic symptoms while continuing her antithyroid medication and 2.5 mg of olanzapine. 3. Discussion This case describes the importance of assessing thyroid dysfunction in postpartum psychosis. Thyrotoxicosis leading to postpartum psychosis often manifests with delirium, catatonia and transient psychotic symptoms [17,20]. Autoimmune thyroid dysfunction is likely to worsen during the postpartum period [18], and the postpartum state by itself is a risk factor for occurrence or relapse of psychiatric illnesses [19]. In hyperthyroidism, adrenergic hyperactivity is considered as a major cause of psychiatric symptoms, and beta blockers are effective in ameliorating symptoms [20]. Women with postpartum psychosis are also at higher risk of autoimmune thyroiditis which could be a possible etiological factor [21]. Antithyroid drugs are the mainstay of treatment in psychiatric problems in Graves' disease [22]. Antipsychotics are advised only when psychotic symptoms are prominent [12,22,23]. Both Carbimazole and propranolol are safe in lactation and, hence, can be used in postpartum psychosis without disruption of breast feeding [24,25]. This is particularly important in low-resource countries where artificial feeding may not be an option for many mothers. In our case, lorazepam was the first drug of choice as it is the preferred treatment for catatonia and is a relatively safe benzodiazepine during lactation [26]. Olanzapine was used in view of its relative safety profile in breastfeeding and reports of severe dystonia and potentiation of neurotoxicity with typical drugs such as haloperidol in cases of hyperthyroidism [27–29]. Methimazole (the active form of Carbimazole) is the preferred medication during pregnancy and is known to be safe [30].
The complete improvement within a month of this highly symptomatic and distressed patient with use of a combination of antithyroid drugs and olanzapine reiterates the need to be alert to the presence of thyroid dysfunction in women with postpartum psychosis.
References [1] Weetman AP. Graves' disease. N Engl J Med 2000;343:1236–48. [2] Kathol RG, Delahunt JW. The relationship of anxiety and depression to symptoms of hyperthyroidism using operational criteria. Gen Hosp Psychiatry 1986;8:23–8. [3] Trazepacz PT, McCue M, Klein I, Levey GS, Greenhouse J. A psychiatric and neuropsychological study of patients with untreated Graves' disease. Gen Hosp Psychiatry 1988;10:49–55. [4] Knauer. Uber Puerperale psychosen,fur practische Arzte. Berlin: Karger; 1897. [5] Sivadon. Les Psychoses Puerperales. Paris: These; 1933. [6] Abely. Considerations endocrine-biologiques a proposdes nevroses et des psychoses de la puerperalite. AMP 1947;105:560–5. [7] Butts. Psychodynamic and endocrine factors in postpartum psychoses. J Natl Med Assoc 1968;60:224–7. [8] Mahmood A, Ashton AK, Hina FH. Psychotic symptoms with underlying Graves disease: a case report. Prim Care Companion J Clin Psychiatry 2005;7:311–2. [9] Ogah OS, Timeyin AO, Kayode OA, et al. Graves' disease presenting as paranoid schizophrenia in a Nigerian woman: a case report. Cases J 2009;2:6708–9. [10] Snabboon T, Khemkha A, Chaiyaumporn C, Lalitanantpong D, Sridama V. Psychosis as the first presentation of hyperthyroidism. Intern Emerg Med 2009;4:359–60. [11] Katsigiannopoulos K, Georgiadou E, Pazarlis P, et al. Psychotic disorder as a manifestation of Graves' disease. Psychosomatics 2010;51:449–50. [12] Macedo LR, Marino J, Bradshaw B, Henry J. Graves' hyperthyroidism-induced psychosis treated with aripiprazole–a case report. J Pharm Pract 2013;26:59–61. [13] Chen TS, Wen MJ, Hung YJ, Hsieh CH, Hsiao FC. A rare storm in a psychiatric ward: thyroid storm. Gen Hosp Psychiatry 2012;34:210.e1–4. [14] Rudolf J, Grond M, Neveling M, Heiss WD. Catatonia in Graves' disease. Eur Psychiatry 1998;13:419–20. [15] Saito T, Saito R, Suwa H, et al. Differences in the treatment response to antithyroid drugs versus electroconvulsive therapy in a case of recurrent catatonia due to Graves' disease. Case Rep Psychiatry 2012;2012:868490. [16] Bharadwaj B, Sugaparaneetharan A, Rajkumar RP. Graves' disease presenting with catatonia: a probable case of encephalopathy associated with autoimmune thyroid disease. Acta Neuropsychiatr 2012;24:374–9. [17] Brockington IF. Incidental psychoses. In: Brockington I, editor. Eileithyia's mischief: the organic psychoses of pregnancy, parturition and the puerperium. I. Brockington; 2006. p. 301–16. [18] Adams Waldorf KM, Nelson JL. Autoimmune disease during pregnancy and the microchimerism legacy of pregnancy. Immunol Invest 2008;37:631–44. [19] Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. J Womens Health (Larchmt) 2006;15:352–68. [20] Bunevicius R, Arthur J. Prange Jr. Thyroid Disease and Mental Disorders: cause and effect or only comorbidity? Curr Opin Psychiatry 2010;23(4):363–8. [21] Bergink V, Kushner SA, Pop V, et al. Prevalence of autoimmune thyroid dysfunction in postpartum psychosis. Br J Psychiatry 2011;198(4):264–8. [22] Bunevicius R, Prange Jr AJ. Psychiatric manifestations of Graves' hyperthyroidism: pathophysiology and treatment options. CNS Drugs 2006;20:897–909. [23] Brownlie BE, Rae AM, Walshe JW, Wells JE. Psychoses associated with thyrotoxicosis - 'thyrotoxic psychosis'. A report of 18 cases, with statistical analysis of incidence. Eur J Endocrinol 2000;142:438–44. [24] Cooper DS. Antithyroid drugs. N Engl J Med 2005;352:905–17. [25] Ghuman N, Rheiner J, Tendler BE, White WB. Hypertension in the postpartum woman: clinical update for the hypertension specialist. J Clin Hypertens (Greenwich) 2009;11:726–33. [26] Fortinguerra F, Clavenna A, Bonati M. Psychotropic drug use during breastfeeding: a review of the evidence. Pediatrics 2009;124:e547–56. [27] Penland HR, Weder N, Tampi RR. The catatonic dilemma expanded. Ann Gen Psychiatry 2006;5:14–5. [28] Weiner MF. Haloperidol, hyperthyroidism, and sudden death. Am J Psychiatry 1979;136:717–8. [29] Chu H, Lin JC, Hsu YD. Potentiation of haloperidol neurotoxicity in acute hyperthyroidism: report of a case. Acta Neurol Taiwan 2004;13:126–30. [30] Azizi F, Amouzegar A. Management of hyperthyroidism during pregnancy and lactation. Eur J Endocrinol 2011;164:871–6.
Please cite this article as: Dahale A.B., et al, Postpartum psychosis in a woman with Graves' disease: a case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.07.003
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Postpartum psychosis in a woman with Graves' disease: a case report Ajit Bhalchandra Dahale, M.D. a, Prabha S. Chandra, M.D., FRCPsych a,⁎, Linda Sherine, M.B.B.S. a, Harish Thippeswamy, M.D., D.N.B., P.G.D.M.L.E. a, Geetha Desai, M.D., D.N.B. a, Dharma Reddy, M.Phil. b a b
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, (NIMHANS) Bangalore-560029, India Department of Psychiatric Social Work, National Institute of Mental Health and, Neuro Sciences (NIMHANS) Bangalore-560029, India
a r t i c l e
i n f o
Article history: Received 25 December 2013 Revised 11 July 2014 Accepted 15 July 2014 Available online xxxx Keywords: Hyperthyroidism Graves' disease Postpartum psychosis Psychosis Catatonia
a b s t r a c t Objective: Thyroid dysfunction is common during pregnancy and the postpartum period and is known to cause psychiatric disturbances. A woman with Graves' disease and psychosis in the postpartum period is described. Methods: A 22-year-old woman with Graves' disease developed fluctuating orientation, catatonia, delusions of persecution and auditory hallucinations 3 days following childbirth. Results: The report discusses the clinical presentation. Treatment of both conditions led to the resolution of symptoms. Conclusion: Graves' disease with postpartum psychosis may present with delirium, catatonia and prominent auditory hallucinations and responds well to a combination of psychotropic and antithyroid drugs. Thyroid dysfunction should be assessed for and managed adequately in postpartum psychosis. © 2014 Published by Elsevier Inc.
Graves' disease is an autoimmune disease causing hyperthyroidism and is common in women compared to men [1]. Anxiety, depression and affective psychoses have been associated with this condition [2,3]. Paranoid schizophrenia and other psychoses have also been reported in patients with Graves' disease and other hyperthyroid states [4–13]. Catatonia has also been reported in association with Graves' disease [14–16]. Thyroid disorders commonly occur during the perinatal period and may be associated with psychiatric disturbances [17]. This case illustrates the association between Graves' disease and postpartum psychosis.
Her obstetric history revealed poor antenatal care and full-term normal delivery of a healthy baby. There was no past or family history of psychiatric illness. Physical examination revealed moist cold skin, exophthalmos, tachycardia, tachypnea and a diffuse thyroid swelling. There were no neurologic deficits. Mental status examination revealed several features of catatonia such as immobility, mutism, passive negativism and posturing. She also appeared anxious and was found muttering to herself. Family members reported that she was on medications for hyperthyroidism which she had discontinued before becoming pregnant (10 months earlier) due to poor economic conditions. A clinical diagnosis of Graves' disease with organic psychosis was considered.
1. Case report 2. Investigations and treatment A 22-year-old multiparous woman in her 12th day postpartum presented with a history of behavior change noticed 3 days after delivery. She initially reported sudden fear that her husband had been assaulted by someone and that he would leave her. She also reported of auditory hallucinations and was noticed to be laughing to herself. She became suspicious toward her in-laws, and her social interaction reduced markedly with decline in sleep and food intake. From the eighth day onwards, there was minimal speech; she stopped eating and had posturing and immobility for long periods. Mother–Infant interaction was significantly impaired. Occasionally, she would not identify family members, and there were two episodes of incontinence. ⁎ Corresponding author. Tel.: +91-80-26995272, +91-9880383057 (mobile). E-mail address: [email protected] (P.S. Chandra).
Thyroid function tests confirmed presence of current hyperthyroidism [thyroid stimulating hormones (TSH)b0.008 uIU/ml; serumfree T3 of 243.53 ng/dl and T4 19.86 ng/dl—free T4 of 1.83 ng/dl]. Serum anti-thyroid peroxidase antibody level was 377.1 U/ml (normal range: 28–60 U/ml). Thyroid technetium scan showed increased tracer uptake in a Grave's Disease pattern. All other metabolic and hematological tests were normal. Computed tomography scan of brain was also normal. The infant was evaluated for thyroid dysfunction and was found to be euthyroid. The patient was started on lorazepam 2 mg intravenous thrice a day for catatonia which was changed to oral lorazepam on the third day. She was also started on tablet propranolol 40 mg twice a day and tablet Carbimazole 30 mg on the fifth day of admission based on advice by the endocrinologist. Her food intake and immobility
http://dx.doi.org/10.1016/j.genhosppsych.2014.07.003 0163-8343/© 2014 Published by Elsevier Inc.
Please cite this article as: Dahale A.B., et al, Postpartum psychosis in a woman with Graves' disease: a case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.07.003
2
A.B. Dahale et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
improved gradually, and she began to care for and breastfeed the baby within 8 days of admission. Lorazepam was then tapered and stopped within 10 days. However, once her catatonia resolved, she continued to report anxiety, had weeping spells and reported fearfulness. She reported auditory hallucinations on multiple occasions. These included voices of a woman who claimed that the baby was not hers and had been swapped at birth. She also reported hearing voices of men in the ward even when no men were around. In view of the psychotic symptoms, she was started on olanzapine 2.5 mg per day orally on the 10th day of admission. Tachypnea, tachycardia and excessive sweating improved significantly after 2 weeks of treatment with propranolol and Carbimazole. The anxiety and weeping spells resolved over 2 weeks of olanzapine treatment. However, the auditory hallucinations and fearfulness continued for which the olanzapine was increased up to 10 mg per day on the 20th day of admission. After 10 days of treatment with olanzapine 10 mg, she was found to be euthymic and did not report any fear or auditory hallucinations. At the time of discharge, she was breast feeding, bonding well with her infant and was able to manage her maternal duties. She was discharged after 35 days of inpatient care and referred to her local general practitioner. At the time of discharge her serum-free T3 was 96.08 ng/dl; serum free T4 was 9.6 mcg/dl, and TSH was 0.05 IU/ml (all within the normal range except TSH, which was still low). The team has been reviewing her condition over the phone, and she appears to have no psychotic symptoms while continuing her antithyroid medication and 2.5 mg of olanzapine. 3. Discussion This case describes the importance of assessing thyroid dysfunction in postpartum psychosis. Thyrotoxicosis leading to postpartum psychosis often manifests with delirium, catatonia and transient psychotic symptoms [17,20]. Autoimmune thyroid dysfunction is likely to worsen during the postpartum period [18], and the postpartum state by itself is a risk factor for occurrence or relapse of psychiatric illnesses [19]. In hyperthyroidism, adrenergic hyperactivity is considered as a major cause of psychiatric symptoms, and beta blockers are effective in ameliorating symptoms [20]. Women with postpartum psychosis are also at higher risk of autoimmune thyroiditis which could be a possible etiological factor [21]. Antithyroid drugs are the mainstay of treatment in psychiatric problems in Graves' disease [22]. Antipsychotics are advised only when psychotic symptoms are prominent [12,22,23]. Both Carbimazole and propranolol are safe in lactation and, hence, can be used in postpartum psychosis without disruption of breast feeding [24,25]. This is particularly important in low-resource countries where artificial feeding may not be an option for many mothers. In our case, lorazepam was the first drug of choice as it is the preferred treatment for catatonia and is a relatively safe benzodiazepine during lactation [26]. Olanzapine was used in view of its relative safety profile in breastfeeding and reports of severe dystonia and potentiation of neurotoxicity with typical drugs such as haloperidol in cases of hyperthyroidism [27–29]. Methimazole (the active form of Carbimazole) is the preferred medication during pregnancy and is known to be safe [30].
The complete improvement within a month of this highly symptomatic and distressed patient with use of a combination of antithyroid drugs and olanzapine reiterates the need to be alert to the presence of thyroid dysfunction in women with postpartum psychosis.
References [1] Weetman AP. Graves' disease. N Engl J Med 2000;343:1236–48. [2] Kathol RG, Delahunt JW. The relationship of anxiety and depression to symptoms of hyperthyroidism using operational criteria. Gen Hosp Psychiatry 1986;8:23–8. [3] Trazepacz PT, McCue M, Klein I, Levey GS, Greenhouse J. A psychiatric and neuropsychological study of patients with untreated Graves' disease. Gen Hosp Psychiatry 1988;10:49–55. [4] Knauer. Uber Puerperale psychosen,fur practische Arzte. Berlin: Karger; 1897. [5] Sivadon. Les Psychoses Puerperales. Paris: These; 1933. [6] Abely. Considerations endocrine-biologiques a proposdes nevroses et des psychoses de la puerperalite. AMP 1947;105:560–5. [7] Butts. Psychodynamic and endocrine factors in postpartum psychoses. J Natl Med Assoc 1968;60:224–7. [8] Mahmood A, Ashton AK, Hina FH. Psychotic symptoms with underlying Graves disease: a case report. Prim Care Companion J Clin Psychiatry 2005;7:311–2. [9] Ogah OS, Timeyin AO, Kayode OA, et al. Graves' disease presenting as paranoid schizophrenia in a Nigerian woman: a case report. Cases J 2009;2:6708–9. [10] Snabboon T, Khemkha A, Chaiyaumporn C, Lalitanantpong D, Sridama V. Psychosis as the first presentation of hyperthyroidism. Intern Emerg Med 2009;4:359–60. [11] Katsigiannopoulos K, Georgiadou E, Pazarlis P, et al. Psychotic disorder as a manifestation of Graves' disease. Psychosomatics 2010;51:449–50. [12] Macedo LR, Marino J, Bradshaw B, Henry J. Graves' hyperthyroidism-induced psychosis treated with aripiprazole–a case report. J Pharm Pract 2013;26:59–61. [13] Chen TS, Wen MJ, Hung YJ, Hsieh CH, Hsiao FC. A rare storm in a psychiatric ward: thyroid storm. Gen Hosp Psychiatry 2012;34:210.e1–4. [14] Rudolf J, Grond M, Neveling M, Heiss WD. Catatonia in Graves' disease. Eur Psychiatry 1998;13:419–20. [15] Saito T, Saito R, Suwa H, et al. Differences in the treatment response to antithyroid drugs versus electroconvulsive therapy in a case of recurrent catatonia due to Graves' disease. Case Rep Psychiatry 2012;2012:868490. [16] Bharadwaj B, Sugaparaneetharan A, Rajkumar RP. Graves' disease presenting with catatonia: a probable case of encephalopathy associated with autoimmune thyroid disease. Acta Neuropsychiatr 2012;24:374–9. [17] Brockington IF. Incidental psychoses. In: Brockington I, editor. Eileithyia's mischief: the organic psychoses of pregnancy, parturition and the puerperium. I. Brockington; 2006. p. 301–16. [18] Adams Waldorf KM, Nelson JL. Autoimmune disease during pregnancy and the microchimerism legacy of pregnancy. Immunol Invest 2008;37:631–44. [19] Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. J Womens Health (Larchmt) 2006;15:352–68. [20] Bunevicius R, Arthur J. Prange Jr. Thyroid Disease and Mental Disorders: cause and effect or only comorbidity? Curr Opin Psychiatry 2010;23(4):363–8. [21] Bergink V, Kushner SA, Pop V, et al. Prevalence of autoimmune thyroid dysfunction in postpartum psychosis. Br J Psychiatry 2011;198(4):264–8. [22] Bunevicius R, Prange Jr AJ. Psychiatric manifestations of Graves' hyperthyroidism: pathophysiology and treatment options. CNS Drugs 2006;20:897–909. [23] Brownlie BE, Rae AM, Walshe JW, Wells JE. Psychoses associated with thyrotoxicosis - 'thyrotoxic psychosis'. A report of 18 cases, with statistical analysis of incidence. Eur J Endocrinol 2000;142:438–44. [24] Cooper DS. Antithyroid drugs. N Engl J Med 2005;352:905–17. [25] Ghuman N, Rheiner J, Tendler BE, White WB. Hypertension in the postpartum woman: clinical update for the hypertension specialist. J Clin Hypertens (Greenwich) 2009;11:726–33. [26] Fortinguerra F, Clavenna A, Bonati M. Psychotropic drug use during breastfeeding: a review of the evidence. Pediatrics 2009;124:e547–56. [27] Penland HR, Weder N, Tampi RR. The catatonic dilemma expanded. Ann Gen Psychiatry 2006;5:14–5. [28] Weiner MF. Haloperidol, hyperthyroidism, and sudden death. Am J Psychiatry 1979;136:717–8. [29] Chu H, Lin JC, Hsu YD. Potentiation of haloperidol neurotoxicity in acute hyperthyroidism: report of a case. Acta Neurol Taiwan 2004;13:126–30. [30] Azizi F, Amouzegar A. Management of hyperthyroidism during pregnancy and lactation. Eur J Endocrinol 2011;164:871–6.
Please cite this article as: Dahale A.B., et al, Postpartum psychosis in a woman with Graves' disease: a case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.07.003
