Graves’ disease presenting with hypomania and paranoia: BMJ
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A 32-year-old woman was brought to the accident and emergency (A&E) department by her husband, as she had demonstrated increasingly erratic behaviour over the previous 6 months.

In the 4 months prior to presentation, she had been sleeping for only 2–3 hours per night on the family sofa and eating only one meal per day. She had lost 15 kg in weight and had developed palpitations. Her thoughts were racing, and while she spent long hours working, she was unfocused and less productive than normal. She had developed paranoid ideas, reporting to her husband that she was receiving messages from her mobile telephone directly into her brain, despite it being turned off. She had been feeling increasingly anxious, which was attributed to ‘stress’ and financial difficulties. She was finding it more difficult to look after her 16-month-old child; at the peak of her symptoms, her husband found her wandering around the kitchen and placing spoons in the fridge.

The situation reached a crisis point 3 days prior to attendance, when she was asked to leave work. Her husband arranged an appointment with their general practitioner the next day. The patient was suspicious of her husband’s insistence that she see a doctor and asked him to wait outside during her consultation with the general practitioner (GP). Symptoms were initially diagnosed as ‘anxiety’, but as symptoms progressed she was referred to acute psychiatry services and was seen in the A&E department.

When assessed by the liaison psychiatry nurse, the patient was easily distracted, with intermittent eye contact and was agitated, pacing around the room. There was pressure of speech, but no hallucinations or thoughts of self-harm. The patient expressed paranoid ideas, but these were not held with delusional intensity. Blood tests were performed to help exclude biological causes of acute psychosis: she was referred to the medical team on call as blood tests revealed that she was markedly thyrotoxic.

When she was assessed by the medical team, routine observations found her to be apyrexial at 36.7°C, and tachycardic at 120 beats per minute. She was hypertensive with blood pressure 162/85 mm Hg and had a slightly elevated respiratory rate of 23 breaths per minute. She had a visible and palpable smooth goitre; there was no tremor and she had lid lag but no evidence of thyroid eye disease, nail disease or skin changes of Graves’ disease.

After starting treatment with carbimazole and propranolol, symptoms resolved without the use of antipsychotic drugs. Close liaison between psychiatry and endocrinology services was essential.

Learning points:
- Psychosis can occur as a significant or presenting feature in both thyrotoxicosis and hypothyroidism.

- In the assessment of patients with either a newly diagnosed psychosis or relapse of a psychiatric condition, ask about symptoms of thyrotoxicosis or hypothyroidism.

- When screening patients with agitation, delirium or psychotic symptoms for organic disease, always include a thyroid function test.

- Patients with psychiatric complications of thyrotoxicosis may be managed without antipsychotic medication. Treatment with a thionamide and beta-blocker may be sufficient, but this needs careful assessment on a case-by-case basis in close liaison with the psychiatry team.