“Thyroid Storm Presenting as Psychosis”: Article Analysis Essay

Introduction

Hyperthyroidism is a medical condition that occurs when the thyroid gland becomes overactive and produces abnormal amount of the thyroid hormone. Thyroid gland is located in the front of the human neck and functions by releasing hormones that control multiple processes and systems, such as metabolism, nervous system, body temperature, and weight. Considerably, hyperthyroidism could emerge in various clinical diagnoses and signs, including unintentional weight loss, rapid heartbeat, abnormally increased appetite, nervousness and anxiety, sweating, tremor, difficulty sleeping, and changes in menstrual patterns among females. The complexity with hyperthyroidism in this case is also explained by mimicking the symptoms of other diseases, which could be hard to clinically differentiate, eventually leading to the inappropriate diagnoses. Henceforth, it is further considered that biostatistical analysis is required to determine how specific methods and approaches could be utilized to address the issues of hyperthyroidism, using the evidence proposed in an academic article and associated analysis of recent healthcare interventions. Specific theoretical consideration and methods are further described below to lay down the ground for relevant conclusions on the subject.

Clinically, hyperthyroidism is diagnosed when the thyroid gland produces too much of thyroxine and triiodothyronine hormones that are important for the human body function. Most commonly, hyperthyroidism is caused by the autoimmune disorder known as Graves’ disease (Fukao et al., 2020). Under conditions of such disorder, human body produces a specific antibody protein defined as thyroid-stimulating immunoglobulin (TSI) that provokes thyroid gland to produce more hormones. Another clinical reason of hyperthyroidism is known as toxic multinodular goiter, which denotes the nodules existing in the thyroid gland that also cause excessive amount of the hormone production. This syndrome could be also enhanced through the thyroid gland inflammation as a consequence of a virus or the immune system issues, temporarily causing the increased hormone output. Finally, hyperthyroidism is frequently observed among patients who consume too much iodine either from food or supplements, or take medications that contain iodine as a part of regular treatment.

Hyperthyroidism also has some outstanding clinical representations pertinent to specific populations and comorbidity effects. First, hyperthyroidism is more frequently observed among females rather than males within the 5:1 ratio, with 2-5% of all females affected by the condition during the lifetime (Adedarian et al., 2018). Most frequently, females are affected by hyperthyroidism during the pregnancy period, which is explained by hyperactivity of other body systems and changes in metabolism. Second, hyperthyroidism in some cases is supplemented with the comorbidity syndrome known as the Graves’ ophthalmology often observed among smokers. Graves’ ophthalmology is a disorder that makes human eyeballs to protrude beyond the protective orbits, causing the problems with dry eyes, eye tearing, and light sensitivity among the patients. Finally, hyperthyroidism is mostly diagnosed among adolescents aged between 20 and 40, while in some outstanding cases hyperthyroidism could be observed among specific populations such as African-American children.

The biostatistical article chosen for this analysis is the one published by Desai et al. (2018) In this article, pathogenesis of hyperthyroidism as the main case of psychosis is theoretically explained by modulating beta-receptor density in human brain, which is sensitive to catecholamines and hence could cause neuropsychiatric syndromes under the condition of adrenergic activity (Desai et al., 2018). Thyroid-stimulating hormone receptors are largely present in the various sectors of the human brain, primarily in hippocampus. In patients with Graves’ disease, these receptors are increasingly stimulated by the produced antibodies, which leads to the excessive production of T3, which further contributes to manifestation of psychiatric syndromes since T3 also stimulates higher production of serotonin and noradrenalin. Continuous stimulation of beta-receptors could result into thyroid storms, that could have abnormal psychosis effects such as delusions, suicidal thoughts, and severe hallucinations. Administering medications and plasmapheresis could curate the effects, while in patients with Graves’ disease a regular follow-up with endocrinologists is required after the discharge. It means that patients who have a diagnose hyperthyroidism and past medical or family history of medical disorders are under a high risk of repetitive cases of psychosis caused by the T3 and T4 outbursts (Dzierlenga et al., 2019). These patients should be subjected to a teaching intervention by nurses and medical staff both during the pre- and post-discharge to develop cognitive abilities of controlling the signs of psychosis and immediately reporting to the nearest medical facility.

The baseline laboratory analyses reveal that there is a need to conduct consecutive tests related to the thyroid functioning. Endocrinologic investigations identified that elevated free levels of both T3 and T4 hormones produced by the thyroid gland, in line with markedly elevated thyroid peroxidase antibodies, allow diagnosing Graves’ disease as the underlying reason for the psychiatric condition of the patient. A standard treatment with propranolol and methimazole is typically prescribed; however, for the psychosis manifestations antipsychotic medications are also administered (Sutton et al., 2018). However, in some severe cases patients could be resistant to take psychotropic medications from personal reasons or elevated sense of fear. Hence, the key learning point is that psychiatric conditions under the diagnosed hyperthyroidism are manifold and require extensive analysis of the underlying state and cause of hyperthyroidism prior to administering psychotropic medications.

The educational intervention will be undertaken among females in North Miami area, targeting to increase their awareness about the sign and symptoms of psychosis. Self-reporting questionnaires will be used to evaluate the level of awareness among research participants before and after the intervention, and the variety of educational approaches within the traditional treatment and ACT framework will be utilized as a part of intervention. Table 1 summarizes essential details that characterize the study

Table 1. Key characteristics of the study.

Teaching Intervention

The following teaching interventions were identified as the most appropriate educational efforts that could be delivered by nurses and medical staff to the patients with signs of psychoses under the diagnosed condition of hyperthyroidism.

To determine the level of awareness about the signs of psychosis among the study participants. This intervention assumed conducting initial interviews with patients recruited for the experiment regarding the basic knowledge they have about the symptoms of psychosis relevant to their feeling or behaviors. Interviewees were asked to a series of questions, such as whether they found themselves withdrawn from their friends or favorite activities, whether they have had any hostile thoughts for no particular reason, or whether they feel hard to concentrate on specific though or having problems with self-expression to others. The objective of this intervention was to determine the initial condition of each participants in order to eventually customize further interventions between the pre- and post-trial.

To determine the level of past knowledge about the psychosis manifestations (pre-test). This intervention was aimed to evaluate the existing level of knowledge among participants about the manifestations of psychosis in a form of self-assessment report. Participants were supplied with a protocol that included ten statements describing a condition that either relevant or not relevant to the manifestation of psychosis. Each statement should have been evaluated as true or false. The correct answer was score as ‘2’, and the incorrect answer was scored as ‘1’. The cut-off interpretations were assigned as indicated in Table 2.

Table 2. Questionnaire rating scale.

To conduct therapy session in small groups. This intervention was aimed to enable patients to speak openly about the past occurrences of psychosis in small groups of 4-5 participants. This intervention follows the principles of ACT and namely it commitment component, which teaches patients to engage more in valued deemed to be important and accurately reflect on them (Vaessen et al., 2019). The group approach was used to decrease the tension among the participants to speak openly, asserting that in a group of co-thinkers having the same disorders patients would be more prone to socialize and learn about alternative experiences of their peers. Consequently, it was expected to make them feeling more comfortable to accept negative thoughts and emotions and educate themselves about possible manifestations of psychosis and accurately reflect on individual experiences.

To motivate employee writing diaries. This intervention emerges from the aspect of psychosis treatment that reinforces the importance of regular reflections on moods, feelings, level of mental and physical activity, and visual associations to make sure that there is a documented reflection on whether treatment is effective or not effective. Considering the educational stance of the interventions in general, patients were asked to write diary entries each two-three days, where they reflected on new experiences about signs and syndromes of psychosis they learned as a part of group therapy sessions or individual inquiries. Patients were not restricted in either writing diaries by hand or using the software. Diaries were further used by nurses to track whether patients are making any progress in enriching their knowledge about manifestations of psychosis.

To communicate with nurses online using telemedicine tools. This intervention was applied to the discharged patients who undergone treatment at home under the close supervision of endocrinologist, psychiatrist, and registered nurse. Patients were prompted with so-called ‘office hours’, when any of the supervising bodies was available to connect with the patient online using telemedicine tools and talk about their feelings, mood, or potential repetitive manifestations of psychosis. Online sessions could have been also initiated by nurses if those felt that the patients require assistance in expressing one’s feelings about the treatment effect, or there was a recent observation of worsening condition related to sporadic signs of fever, anxiety, or depression.

To engage family members and significant others as caregivers through education and training. This intervention was aimed at people who play significant roles in the life of the patient. The objective of the intervention is to ensure that discharged patient could receive the same level of care at home as they have in the hospital or medical center, assuming that prepared friends, relatives or spouses could assist the patient in educating oneself about the manifestations of psychosis. Hence, this intervention was implemented by conducting a group training for the caregivers identified through interviews with patients and analysis of family history to identify people who would fit the most to undertake the role of caregivers. During the training, caregivers were briefly introduced to the severity of hyperthyroidism for the intense manifestations of psychosis, instructed about the appropriate medications and recommended diet, as well as about the most common stressors that could affect the condition of the patient. Caregivers were also advised about potential sources of information they can use themselves to help the patient being better educated about the potential causes and manifestations of psychosis depending on the situational context.

To decrease the amount of external and internal stressors. This intervention was realized by educating patients about the potential stress factors that could provoke the abnormal activity of thyroid gland and associated brain activity. Specifically, patients were recommended to watch a series of educational programs that communicate the advantages of treatment in a soft, friendly manner, as well as a number of movies that trigger positive feelings and do not create negative associations. Patients were also advised to avoid watching specific TV programs that create abnormal cortex activities and movies rated as violent or scary.

To promote healthy lifestyle using printed materials. This intervention assumed that each patient should be equipped with a quick pocket reference that recommends the appropriate diet, describes the most common exercises that should be done by the patient on the daily basis, and recommendations for the first actions that should be done if the emergency psychosis manifestation is felt or observed. The same pocket books were supplied for the caregivers. The content of the pocket books included the list of products that are recommended to be consumed daily and their benefits for decreasing the risk of particular diagnosis, visual tips for memorizing the main recommendations, and friendly illustrations that call for socialization and communication made in a form of cartoon.

To determine the level of acquired knowledge about the psychosis manifestations (post-test). This intervention was aimed to measure the effectiveness of the previous interventions based on administering the same questionnaire developed for the pre-test stage. Participants were asked to evaluate the same statements with the same scoring principle applied. The magnitude of change was considered as the indicator of the intervention success or failure.

Pre- and Post-Test Results

The experiment was initiated among fourteen females who agreed to participate in teaching intervention and met the inclusion criteria. The experiment was conducted on a ‘pre-test – intervention – post-test’ format, using the same survey instrument at the pre-test and post-test stages. The questionnaire was distributed among participants after the first week of the experiment considering the importance to conduct initial interviews for evaluation of the group dynamics. Survey scores and survey summary for the pre-test stage are summarized under Tables 3 and 4.

Table 3. Pre-test survey results.

Table 4. Pre-test survey summary

Pre-test data analysis suggests that the majority of respondents demonstrated medium awareness about psychosis signs and syndromes (57.1%), followed by participants with low awareness (28.6%), and high awareness (14.3%). Among the research participants, 35.7% of females were pregnant at the start of the experiment. The prevalence of respondents had family record of mental disorders (42.9%), followed by respondents with personal record of mental disorders (35.7%), and respondents with both manifestations (21.4%). By the beginning of the experiment, 78.6% of participants had elevated thyroid function test indicators.

Teaching intervention lasted for five weeks. By the end of the sixth week, participants were requested to complete the questionnaire once again in order to evaluate the effect of intervention. Survey scores and survey summary for the post-test stage are summarized under Tables 5 and 6.

Table 5. Post-test survey results.

Table 6. Post-test survey summary.

Post-test data analysis suggests that the majority of respondents demonstrated medium awareness about psychosis signs and syndromes (50%), while after intervention it followed by participants with high awareness (35.7%), leaving the participants with low awareness in minority (14.3%). Among the research participants, 28.6% of females were pregnant at the end of the experiment since one of the participants gave birth to a child. By the end of the experiment, the percentage of participants with elevated thyroid function test indicators also dropped to 50%.

Outcomes

Based on the comparison of awareness scores for the pre- and post-test stages, we can conclude that teaching intervention was successful, since the percentage of participants with high awareness increased from 14.3% to 35.7%. There was also a decrease in the percentage of participants with elevated thyroid function test results, while this aspect should be rather researched with respect to medications intake and overall mental condition of the individual rather than teaching intervention alone. However, it is worth admitting that the effect of the intervention was not uniform for all participants. For instance, when comparing Tables 3 and 5, it is evident that the awareness score either changed very slightly or even dropped, like for the case of participants 12, 13, and 14. It implies that intervention was not useful for some individuals because of the reluctance to the subject, lack or follow-up, or worsening mental condition that could eventually lead to the continuous episodes of psychosis and need of alternative treatment interventions. Hence, it could not be concluded that proposed teaching intervention would fit any chosen cohort of patients with hyperthyroidism and tendency mental disorders.

Policy Considerations

• The Congress should not only encourage but empower the states to synchronize laws related to the Medicaid program coverage, which would enable states to develop local statutes for APRN training and education.
• Meanwhile, APRNs should be prepared for the increasing requirements and job responsibilities, which partially constraints the IOM in removing the scope-of-service barriers and the need of revision compensation plans.
• The Congress might eventually need to focus on evaluation of specialty designations per state, which will bring additional insights on training and education depending on the healthcare issues predominant in the state healthcare system. It will certainly affect the effectiveness of educational systems foe future APRNs and change of the core curriculum scope of educational deliverables.
• Physicians might demonstrate resistance to the newly proposed changes, which will require further cooperation with personnel management authorities to revise motivation and compensation plans.

Conclusions and Recommendations

Overall, experimental results of teaching intervention among patients with hyperthyroidism confirm that patient education is essential to increase awareness about signs and symptoms of psychosis as a symptomatic case of thyroid gland hyperactivity. During the course of five weeks, it was possible to increase the total percentage of participants with medium to high awareness by 85.7% of the total research sample, which provides significant foundations for the patient autonomy in self-management of psychosis manifestations without severe behavioral consequences (Masih et al., 2019). However, considering that research sample is relatively small, this study should be further expanded in scope to recruit the valid number of research participants for a consistent quantitative inquiry using extended questionnaire that assesses past history of the patient against one’s current mental condition and results of the thyroid function tests. Larger populations would also allow to refine methodological approach by including statistical tests that would measure association between the variables and allow to determine the strength of various factors that could predict the level of awareness about psychosis manifestations. Hence, it is proposed to continue current research with larger group of participants in the future, also bearing in mind the importance of contribution to the academic research which explores complex relationship between mental disorders and thyroid diseases.

At this point, the following recommendations stemming from the results of the proposed intervention could be made. First, teaching interventions aimed to prevent psychosis in patients with hyperthyroidism should be delivered based on the extensive landscape analysis that defines categories of patient who would or would not benefit from education. Based on the cases reviewed in the literature, severe cases such as thyroid storms are unlikely to be resolved with teaching intervention until patient condition is reverted to the baseline, since the severity of psychosis side effects in such cases is very high and could not be cured using approaches such as group therapy or caregiver training. Apparently, if there is a large population cohort, teaching intervention is likely to be customized per severity of psychosis manifestations by including or excluding certain parts of teaching curriculum. Second, teaching intervention requires regular follow-up to ensure that patients participate in intervention rather than pretend participating, which was partially observed for the case of conducted experiment after the post-test. One of the proposed methods for such effort is the use of diaries, which could be submitted electronically on a weekly basis to program coordinators and nurses in order to establish corrective measures if some deviations or abnormal mood reflections are noticed in diary entries. Finally, it is important to integrate ACT principles in teaching intervention to reduce patient anxiety about his mental condition while also to increase self-confidence in admitting the need of treatment and self-control. Systematic application of ACT principles will positively influence patient’s intentions to discuss personal issues with family members and medical staff, providing more opportunities to explore changes in mental conditions and compare those to the occurrences of hyperthyroidism.

References

Adediran, K.I., Alapati, D., & Rasimas, J.J. (2018). Delusional psychosis in Graves’ disease. The Primary Care Companion for CNS Disorders, 25(1), pii: 17I02145.

Desai, D., Anaraki, S.Z., Reddy, N., Epstein, E., & Tabatabaie, V. (2018). Thyroid storm presenting as psychosis. Journal of Investigative Medicine High Impact Case Reports, 6, 1-5.

Dzierlenga, M.W., Allen, B.C., Ward, P.L., Clewell III, H.J., & Longnecker, M.P. (2019). A model of functional thyroid disease over the lifetime. PLoS One, 14(7), e0219769. Web.

Fukao, A., Takamatsu, J., Arishima, T., Tanaka, M., Kawai, T., Okamoto, Y., Miyachi, A., & Imagava, A. (2020). Graves’ disease and mental disorders.Journal of Clinical & Translational Endocrinology, 19, 100207. Web.

Masih, J., Belshak, J.M.I., & Verbeke, W. (2019). Mood configurations and their relationship to immune system responses: Exploring the relationship between moods, immune system responses, thyroid hormones, and social support. PLoS One, 14(5), e0216232. Web.

Sutton, M., O’Keeffe, D., Frawley, T., Madigan, K., Fanning, F., Lawlor, E., Roche, E., Kelly, A., Turner, N., Horenstein, A., O’Callaghan, E., & Clarke, M. (2018). Feasibility of a psychosis information intervention to improve mental health literacy for professional groups in contact with young people.Early Intervention in Psychiatry, 12(2), 234-239. Web.

Vaessen, T., Steinhart, H., Batnik, T., Klippel, A., van Nierop, M., Reininghaus, U., & Myin-Germeys, I. (2019). ACT in daily life in early psychosis: An ecological momentary intervention approach. Psychosis, 11(2), 93-104. Web.