Psychoses associated with thyrotoxicosis - 'thyrotoxic psychosis.' A report of 18 cases, with statistical analysis of incidence.

OBJECTIVE: To report a series of newly diagnosed thyrotoxic patients with concurrent acute psychosis, and to assess the association between the two disorders. DESIGN: Retrospective study of thyrotoxic patients with associated psychosis ('thyrotoxic psychosis'; TP) requiring inpatient psychiatric care. New Zealand thyrotoxicosis annual incidence figures and first psychiatric admission rates for affective psychosis were utilised to statistically assess the co-occurrence of thyrotoxicosis and affective psychosis. PATIENTS AND METHODS: During the 20-year study period, 18 inpatients (16 women and 2 men), mean age 54 years, with TP were identified. No patient had a past history of thyrotoxicosis, but four had required psychiatric inpatient care many years earlier. Thyrotoxicosis was documented by radioimmunoassay of thyroid hormone levels, and thyroid scintiscan. Psychiatric manifestations were classified using ICD9 criteria. RESULTS: Thyroid hormone levels were markedly elevated in more than half of our TP patients. All younger patients had Graves' disease, and most older patients toxic nodular goitre. All patients were treated with antithyroid drugs, and all but one subsequently received (131)I therapy. Two patients were not mentally ill when thyrotoxicosis was diagnosed, but suffered major mood swings when thyroid hormone levels were falling. There was no specific psychiatric clinical picture but affective psychoses were commonest - seven depression, seven mania. The other diagnoses were two schizophreniform, one paranoid, and one delirium. Initially, neuroleptic medication was used in all but one patient, and during long-term follow-up (median 11 years) more than half our series had remained well with no further psychiatric problems. Statistical analysis was restricted to thyrotoxic patients with first psychiatric hospital admission for affective psychosis. During the 20-year period, there were nine thyrotoxic patients (95% confidence interval 4.5-17.1) with concurrent affective psychosis requiring first admission, and the calculated expected number was only 0.36. These findings indicate a clear association well above chance co-occurrence. CONCLUSION: TP is not a specific clinical picture, but affective psychoses are commonest. Statistical analysis of thyrotoxic patients with concurrent affective psychoses showed an incidence well above chance co-occurrence. It appears that thyrotoxicosis may be a precipitant of acute affective psychosis.

Abnormal illness behaviour and anxiety in acute non-organic abdominal pain.

Of 105 patients admitted to a surgical ward with acute abdominal pain, 18 were considered to be without evidence of any organic aetiology for this symptom. These 'non-organic' patients were almost all female and differed from the 'organic' patients in state anxiety and in the illness behaviour questionnaire scales of psychological versus somatic perception, denial and affective disturbance. The two groups of patients could be differentiated on the basis of scores derived from the Illness Behaviour Questionnaire, and the State-Trait Anxiety Inventory.

Readmissions to hospital ater appendicectomy for non-specific abdominal pain.

Appendicitis is the most common cause of acute abdominal pain, but in ten per cent of appendicectomies the appendix is normal. Follow up of 54 patients having a normal appendix removed reveals that in only two cases was a physical diagnosis missed and yet these patients were more likely to be readmitted with suicidal behaviour or further unexplained pain than patients who had an inflamed appendix removed. Psychological factors may be of aetiological importance in patients having a normal appendix removed, and although none of these patients had multiple admissions or further abdominal surgery it is suggested that patients be told that their appendix was normal.

Benzodiazepine dependence: a general practice survey.

This study aims to evaluate the dependence potential of benzodiazepines in general practice. Amongst a sample of 1079 current general practice patients 87 (8.1 percent) were using benzodiazepines. Most of the users were middle to old age females and had chronic physical illnesses. The drug history was extensive (mean--3 years 7 months) and about 39 percent (34/87) of users were currently on a higher dose than the first prescribed dose. Interview of a selected group (40) of benzodiazepine users showed 75 percent (30/40) to be from a lower socio-economic class and 17 percent (7/40) of these reported past experiences consisting of withdrawal phenomena of varying severity. Benzodiazepines appear to have replaced barbiturates in the general practice setting.

A family with abdominal pain.

We present the case history of a middle-aged woman with a "battle scarred" abdomen who has had abdominal pain for over 20 years and more than 36 hospital admissions in this time. Her children have also had 25 hospital admissions for abdominal pain and three normal appendices removed. This complaint of recurrent abdominal pain not due to a physical disorder is conceptualised in terms of abnormal illness behaviour rather than in traditional terms such as hysteria and hypochondriasis.