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Guest Editorial
Highlighting Bipolar II Disorder
Gordon Parker, MD, PhD, DSc, FRANZCP
(PDF)

In Review
Neurobiological Findings in Bipolar II Disorder Compared With Findings in Bipolar I Disorder
Brent M McGrath, BSc, MSc, Phillip H Wessels, MD, FRCPC, Emily C Bell, BSc, MSc, Michele Ulrich, BSc, Peter H Silverstone, MB, BS, MD, MRCPsych, FRCPC
(PDF)

Bipolar II Disorder: An Overview of Recent Developments
George Hadjipavlou, MA, MD, Hiram Mok, MA, MB, BCh, BAO, FRCPC, Lakshmi N Yatham, MBBS, MRCPsych, FRCPC3 (PDF)

Review Paper
Bipolar Disorder: It’s All in Your Mind? The Neuropsychological Profile of a Biological Disorder
Gin S Malhi, BSc, MB, ChB, MRCPsych, FRANZCP, Belinda Ivanovski, Ssc Psychol, M Clin Psychol, Viktoria Szekeres, BSc,Psychol
(PDF)

Original Research
Impact of Culture on Depressive Symptoms of Elderly Chinese Immigrants
Glenda MacQueen, MD, PhD, FRCPC
Daniel WL Lai, PhD
(PDF)

Development and Reliability of a Pictorial Mental Disorders Screen for Young Adolescents
Nicole Smolla, PhD, Jean-Pierre Valla, MD, MSc, Lise Bergeron, PhD, Claude Berthiaume, MSc, Marie St-Georges, MPs
(PDF)

Command Hallucinations Among Asian Patients With Schizophrenia
Theresa MY Lee, MBBS, MMed, Siow Ann Chong, MBBS, MMed, Yiong Huat Chan, PhD, Gangaharan Sathyadevan, MBBS, MRCPsych
(PDF)

The Centre for Addiction and Mental Health Concurrent Disorders Screener
Juan C Negrete, MD, FRCPC, Jane Collins, MSc, Nigel E Turner, PhD, Wayne Skinner, MSW
(PDF)

Validation de la version française du questionnaire de Sociotropie-Autonomie de Beck et collègues
Mathilde M Husky, MSc, Olivier S Grondin, MSc, Philippe D Compagnone, PhD
(PDF)

Brief Communication
Depressive Symptoms and Alcohol Consumption Among Nonalcoholic Depression Patients Treated With Desipramine
Benjamin I Goldstein, MD, PhD, Ayal Schaffer, MD, FRCPC, Anthony Levitt, MD, FRCPC, Ari Zaretsky, MD, FRCPC, Russell T Joffe, MD, FRCPC, Virginia Wesson, MD, R Michael Bagby, PhD
Pierre Bleau, MD, FRCPC
(PDF)

Letters to the Editor
(PDF)

Safety of Clozapine in 2 Successive Pregnancies

Revisiting the Diagnostic Challenges of Secondary Mania and Bipolar Disorder in a Patient With Borderline Hyperthyroidism

Dyslipidaemia and Psychiatric Patients

Dream Contents in Patients With Major Depressive Disorder

Sensory Deprivation and Disorders of Perception

Re: The Internet’s Impact on the Practice of Psychiatry

Response: The Internet’s Impact on the Practice of Psychiatry

Denial and Avoidance in an Unusual Case of Death From Breast Cancer

Interferon-Induced Mania

Drug-Induced Psychosis After Long-Term Treatment With Levetiracetam

Priapism

An Ounce of Prevention: “COPEing with Toddler Behaviour”

Internet Gaming Addiction

Letters to the Editor

Revisiting the Diagnostic Challenges of Secondary Mania and Bipolar Disorder in a Patient With Borderline Hyperthyroidism

Dear Editor:
It can be a challenge to differentiate between a manic episode in bipolar disorder (BD) and a manic episode owing to a general medical condition. There are few case reports of BD associated with hyperthyroidism, despite the fact that symptoms of a manic episode overlap with those of hyperthyroidism (1–6). This may be attributed to problems in establishing etiology because of past psychiatric history and previous treatment with lithium, which can have antithyroid effects (7). There are few studies in the literature carried out with lithium-naive patients regarding thyroid dysfunction and BD (8), and the role of a borderline hyperthyroid state in patients is not well described. Therefore, we report on a drug-naïve patient who presented with a manic episode and was found to have borderline hyperthyroidism.

Case Report

A woman, aged 54 years, presented at a university hospital with a 3-week history of elevated mood, grandiosity, incessant activity, and decreased sleep. There was no psychiatric history, and she had otherwise been functioning well. Her medical and family histories were unremarkable, and she was not on any medications. Her mental status exam revealed pressured speech and flight of ideas. On admission, her thyroid profile revealed the following: thyroid-stimulating hormone (TSH) 0.11 mU/L (0.35 to 5.5), free triiodothyronine (T3) 5.2 (3.5 to 6.5), free thyroxine (T4) 18 (11 to 23), and thyroglobulin 25.5 (< 43). Other routine blood tests and computed tomography imaging of her head were normal. Given the suppressed TSH, she was diagnosed with borderline hyperthyroidism.

While in hospital, the patient received olanzapine dissolvable 5 to 7.5 mg once daily, and her manic symptoms abated over a week-long hospital stay. After discharge, she did not continue taking medications. On follow-up a month later, the patient had resumed her usual activities and was euthymic. At this time, lab tests were done and showed a normal thyroid profile.

In the case of borderline hyperthyroidism, it may be difficult to establish whether the hyperthyroid state is the etiologic cause, a contributing factor to the manic episode, or simply comorbid with BD. In this case, it is reasonable to postulate that the hyperthyroid state contributed to the manic episode or precipitated a manic episode in a patient predisposed to BD. This is further supported by the fact that the patient’s symptoms resolved without further medications and were coincident with normalization of her thyroid profile. This reinforces the concept that perturbations in the thyroid function may be tied to manic symptomatology. At this time, the patient’s preliminary diagnosis is secondary mania, and longitudinal follow-up of her mood symptoms and thyroid function may lead to a more definitive diagnosis. If she had another manic episode without clinical or laboratory indicators of hyperthyroidism, primary BD would be the diagnosis. Notwithstanding the diagnostic dilemma, we suggest that monitoring TSH is appropriate for patients with BD. For patients with recurrent or poorly controlled manic symptoms, it may be informative to see whether the manic symptoms coincide with changes in thyroid function. In conclusion, this case underscores the importance of monitoring TSH in patients with manic episodes.

References

1. Hendrick V, Altshuler L, Whybrow P. Psychoneuroendocrinology of mood disorders: the hypothalamic–pituitary–thyroid axis. Psychiatr Clin North Am 1998;21:277–92.

2. Villani S, Weitel WD. Secondary mania. Arch Gen Psychiatry 1979;36:1031.

3. Corn TH, Checkley SA. A case of recurrent mania with recurrent hyperthyroidism. Br J Psychiatry 1983;143:74–6.

4. HR Khouzam, Hat V, Boyer J, Hardy W. Rapid cycling in a patient with bipolar mood disorder secondary to graves’ disease. Am J Psychiatry 1991;148:1272–3.

5. Lee S, Chow CC, Wing YK, Leung CM, Chiu H, and Chen C. Mania secondary to thyrotoxicosis. Br J Psychiat 1991;159:712–3.

6. Nath J, Sagar R. Late-onset bipolar disorder due to hyperthyroidism. Acta Psychiatr Scand 2001;104:72–5.

7. Spaulding SW, Burrow GN, Bermudez F, Himmelhoch JM. The inhibitory effect of lithium on thyroid hormone release in both euthyroid and thyrotoxic patients. J Clin Endocrinol Metab 1972;35:905–11.

8.Valle J, Ayuso-Gutierrez JL, Abril A, Ayuso-Mateos JL. Evaluation of thyroid function in lithium-naïve bipolar patients Eur Psychiatry 1999;14:341–5.

Emiko Moniwa, Burnaby,
British Columbia;
T Warren Lee, MD,
New Haven, Conneticut;
Jodi Lofchy, MD, FRCPC,
Toronto, Ontario