Aubrey had few complaints until, with no history of trauma or clinical anxiety, she suddenly found herself experiencing full blown panic attacks almost daily, complete with heart palpitations, breathlessness and trembling hands. After several weeks, she sought help from both a psychiatrist, who prescribed Klonopin, Effexor and Lexapro, and me. My initial experience of Aubrey was that, while she was not someone who immediately presented with a long-standing mood disorder, she was definitely confronting some pressing family issues that made sense of her symptoms.
I introduced her to some breathing techniques to help with her general anxiety and frequent teariness. We also worked with various Buddhist-based practices for accepting, releasing and allowing, helping her to manage her current familial upheaval and the issue driving that upheaval, her father's impending incarceration.
After about 4 months the panic attacks and crying jags had diminished, and Aubrey's overall mood improved; although she recalls, "I still felt like I was living in a fog—sort of there, but not there." To my eyes, she remained somewhat restless, edgy and preoccupied. She continued to improve, struggling at times in fits and starts, until, toward the end of the following year, those fits and starts changed into something altogether different.
Aubrey became plagued by debilitating fatigue. She lost interest in just about everything, from sex to her work to her martial arts practice. Her eating habits and sleeping patterns became erratic. Her weight dropped precipitously, then rebounded and began to rise sharply. She was constantly cranky, irritable and feeling overwhelmed; and she began to display cognitive deficits—trouble concentrating, failings in short term memory, gaps in remembering and a general sense of confusion.
One of the most significant ways that these symptoms manifested themselves was in her martial arts practice. Aubrey, an accomplished martial artist, says, "I was in a state of massive confusion—completely in a fog. I couldn't remember my forms, or keep my footwork straight. I felt awkward and weak. I couldn't hold onto my weapons—not dropping them, you know, but they kept, sort of, popping out of my hands. And words—I couldn't remember words. I would say to my fiancé, "The thing, you know the thing ...the pink thing", and I'd be talking about a hairbrush. It was really frustrating and scary, and it was right about then I started to think I was losing my mind."
I began to consider a long-cycling bi-polar disorder, but the extremity of Aubrey's cognitive symptoms had me a bit baffled. Could a mild traumatic brain injury have been overlooked? Could it be her allergies? How about ergot poisoning? I was reaching, yes, but I was also becoming gradually more perplexed—and maybe just a little afraid for Aubrey.
I expanded the scope of the tools with which we were working to include some Dialectical Behavioral Therapy exercises, helping Aubrey to become more engaged, and address her ever-increasing irritation and impatience. She leveled out some, but I could see that she was still just managing. Making dinner, not tearing up at work or getting to the dojo became small victories, while not losing a day to the couch was an accomplishment. Those lost days were quickly turning into lost months for Aubrey, and, frustrated, I continued to cast about for something more.
I then had an off-hand conversation with a colleague about a bi-polar patient whose inexplicable decompensation into paralyzing depression turned out to be a case of mono, and that conversation got me thinking. I was reminded of a handful of cases I had seen involving endocrine imbalance. It wasn't something that had previously occurred to me because, at 30, Aubrey was so young, and, to the best of my knowledge, she'd never been pregnant. I suggested to her that she get some blood work—a simple test that measures the levels of thyroxine and thyroid-stimulating hormone (TSH), or thyrotropin—and that test confirmed what I had begun to suspect—hyperthyroidism.
Hyperthyroidism, or thyrotoxicosis, occurs when the thyroid gland, which regulates the body's metabolism, overproduces one or both of two important thyroid hormones, Triiodothyronine (T3) and Thyroxine (T4). This imbalance, typically referred to as Grave's disease, ramps up the metabolism and produces symptoms that include heart palpitations, shortness of breath, chest pain, hand tremors, irritability and/or oversensitivity, fatigue, weight fluctuation, muscle weakness and sleeplessness, which are almost identical to those of anxiety and depression. Pseudo-psychiatric symptoms are reported as the first sign of hyperthyroidism in somewhere between 2% and 12% of cases.
Asked about the psychiatric symptoms associated with hyperthyroidism, Dr. Jeff Garber, Immediate Past President of the American Association of Clinical Endocrinologists (AACE), says that he most often encounters a presentation of anxiety with no underlying psychiatric condition, "I've actually seen an occasional person whose presentation was depression, but that's been the exception for me. I've seen anxiety and depression, and really severe depression resolved without any chronic anti-thyroid therapy. I've seen anxiety, black and white, just gone." He points to several studies that detail the behavioral and psychiatric aspects of hyperthyroidism, and the symptom parallels described there read like a script for Aubrey's experience.
The AACE reports that hyperthyroidism presents fairly frequently, occurring in close to 1% of the U.S. population and affecting about 300,000 people annually. Women are 5 to 10 times more likely to develop the disorder, and, while it typically occurs in those over the age of 60, a smaller percentage presents in the 40-60 age range, and sometimes younger.
Overall risk factors include an iodine rich diet, Type 1 Diabetes, pernicious anemia, primary adrenal insufficiency, a history of autoimmune disease, or additional, unrelated thyroid issues. One risk factor that is especially significant for younger women is a recent pregnancy, or delivery of a child. Pregnancy induces a pseudo-hyperthyroid state through a naturally occurring increase of the T3 and T4 hormones. In the majority of women, this corrects itself within 1 to 4 months after pregnancy. For some women, however, the T3 and T4 hormones do not return to their normal levels, and the result is an on-going hyperthyroid condition, which can very often be mistaken for post-partum depression.
For Aubrey, her medical diagnosis was a revelation. "I felt totally amazed and empowered. Everything was suddenly big and bright and clear again, even more than before." she says, "I realized that I wasn't crazy."
Her endocrinologist put her on the beta-blocker Toprol XL, a short term intervention to treat the high blood pressure that accompanied her skyrocketing metabolism, as well as Tapazole, an anti-thyroid medication that prevents the thyroid gland from over-producing thyroid hormone, but does not interfere with its action in the body.
Anti-thyroid medications are typically administered for about a year to a year-and-a-half in an attempt to bring the thyroid back into a normal range of functioning. If during that time the hyperthyroid state does not go into remission, this treatment may continue, or a more aggressive form of intervention—surgical removal of the thyroid gland, or its destruction using radioactive iodine—may be pursued. In both of these cases, the result is a life-long reliance on synthroid (levothyroxine) as a thyroid replacement therapy.
With treatment, Aubrey began to feel better immediately. Her psychiatric symptoms all but vanished, and, she says, "I felt human again." Her eyes clear and her skin no longer splotchy, Aubrey appeared to me as the woman whom I had seen previously only in flashes; vibrant, alive and quite literally shimmering with vitality. No longer feeling overwhelmed, or plagued by the sense that everything was closing in on her, she felt that she had gotten her life back, and she was again intent on living it.
Aubrey taught me that things are not always as they seem, and just because we presume to know something does not mean that we actually do; we need to ask the questions that may not, at first, seem so obvious.
Today Aubrey's reply to the question "How are you?" garners a response that is all sparkling eyes and cherubic smile—"I'm great. Everything is just great."
© 2011 Michael J. Formica, All Rights Reserved
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