Your Bipolar Disorder Could be Hypothyroidism
I am not sure how many people are aware that thyroid disorders can mimic mental illness, particularly anxiety and depressive disorders and mood disorders.
The thyroid gland is a butterfly shaped gland at the front of the throat. It secretes hormones that regulate energy needs, body temperature, growth, and metabolism.
Medical science has long known that dysfunction of the thyroid can cause psychiatric symptoms. Such include depression, anxiety, mood issues, and even psychosis. While working in the mental health field, I noticed bipolar disorder and thyroid disorder were too frequently seen together in patients’ lists of diagnoses for it be a coincidence. People with bipolar experience radical changes in energy when they shift between symptomatic episodes and periods of normalcy. Need I reiterate that the thyroid regulates energy?
None of the multiple psychiatrists and psychiatric nurse practitioners that I worked with used medical tests during patient intakes in order to rule out health problems. I had the opportunity to sit with over half a dozen psychiatric providers while they saw patients, and I can not recall a single one ordering lab tests for this purpose. What they primarily did is interview the patients about their feelings and behaviors, past and present. Medical problems were only on file if the patient previously sought medical services or reported those themselves. Sure, routine labs were drawn for patients on certain medications, such as lithium and Tegretol, but I can not recall any of the providers I worked with ordering a blood test otherwise. Perhaps more scrupulous psychiatric providers exist somewhere?
A quick overview of some relevant thyroid disorders
If you are not already familiar with thyroid disorders, a cursory knowledge of this topic will come in handy for understanding the rest of this article.
Hypothyroidism — This is a rather broad label for a person whose thyroid is under-performing and therefore slowing down the body. The underlying cause is not specified and could include a number of different conditions.
- Mental health symptoms: depression, impaired memory, and fatigue.
- Physical symptoms: weight gain, constipation, cold intolerance, menstrual irregularity, dry skin, muscle weakness, lower heart rate, and infertility.
Hashimoto’s thyroiditis— Hypothyroidism caused by a person’s immune system attacking the thyroid via thyroid antibodies. Over time, the thyroid is damaged, resulting in decreasing ability to perform its tasks for the body. Most cases of hypothyroidism in the United States are due to Hashimito’s.
Hyperthyroidism — Hyperthyroidism is a condition in which the thyroid secretes excess hormones, resulting in a revved-up body. As is the case for hypothyroidism, the cause is not specified by this label.
- Mental health symptoms: insomnia, irritability, nervousness, anxiety, and restlessness.
- Physical symptoms: hand tremors, heat intolerance, goiter, weight loss, rapid heartbeat, bulging eyes, higher metabolism, and increased bowel movements.
Graves disease — Most people with a hyperthyroid have Graves, which like Hashimoto’s is an autoimmune condition.
Thyrotoxicosis — An uncommon, more severe state of hyperthyroidism. Some may even experience psychosis in this state, and interestingly enough, euphoria and mania.
Thyroid storm — An extreme and potentially life-threatening state of thyrotoxicosis. This occurs when, all of a sudden, the thyroid floods the system with large amounts of thyroid hormone. Symptoms include confusion, diarrhea, falling unconscious, high fever, elevated heart rate.
Thyroid dysfunction can look like bipolar disorder.
People with bipolar disorder experience mood shifts as opposed to mood swings. This means that the changes in energy levels are drawn out for long periods of time. Think days, weeks, or months instead of hours. A person with bipolar typically alternates between the two extremes of hypomania/mania and depression (hence the name) with periods of normalcy.
If we look at the mental health symptoms listed above for hypothyroidism, we can see that it presents like a typical case of depression. Likewise, the mental health symptoms of hyperthyroidism can pass for an anxiety disorder or a hypomanic episode of bipolar, and thyrotoxicosis can look like mania (4).
One could argue, okay, but bipolar is called bipolar because it has both depressive and hypomanic or manic episodes, therefore no thyroid condition can look like true bipolar disorder.
Not so fast.
People with Hashimoto’s can actually experience temporary hyperthyroidism (7,8). It appears that when the immune system initially starts attacking the thyroid, the thyroid may respond by going into overdrive and releasing more hormones; this is known as hashitoxicosis. Interestingly, there is a documented case of a woman who, after failing to achieve her goal of graduating at a given date, experienced an episode of stress-induced hashitoxicosis 12 years after she was diagnosed with Hashimoto’s (10). When a person with Hashimoto’s cycles from hyperthyroid to hypothyroid, it could look just like bipolar disorder!
In his article “Thyroid Functions and Bipolar Affective Disorder,” Psychiatrist Subho Chakrabarti wrote, “Hypothyroidism, either overt or more commonly subclinical, appears to the commonest abnormality found in bipolar disorder.”
So how common is it?
Well, according to one study, thyroid antibodies were found in 28% of the bipolar patients studied, as compared with 3-18% of the control groups (6). This suggests that almost a third of bipolar patients could have an autoimmune thyroid disorder.
Dr. Chakrabarti also wrote in his article, “The prevalence of thyroid dysfunction is also likely to be greater among patients with rapid cycling and other refractory forms of the disorder.” In other words, people who experience four or more bipolar episodes a year (rapid cycling bipolar) and people who are treatment-resistant are more likely to have a thyroid condition.
Some people diagnosed with bipolar really have a thyroid problem.
It was not difficult for me to find anecdotes online of people who were diagnosed with bipolar but later discovered the real problem was a thyroid condition. Here is one such case.
In the video below, Holly talks with Dr. Michael Ruscio about her experience of being diagnosed with bipolar disorder, then discovering that the root of her symptoms was actually hyperthyroidism due to gut issues. The video is about 18 minutes long, so I will provide a synopsis of the relevant points below for convenience sake.
Holly led an active life and she owned a remodeling company. Unfortunately, her emotional and physical health deteriorated as the years passed. Due to her symptoms of increasing depression and anxiety, she was ultimately diagnosed as bipolar. Despite feeling unsure about that diagnosis, she complied with the treatment regime of psychiatric medication.
Then, in her mid-thirties, Holly was diagnosed with hyperthyroidism after developing symptoms of skin blemishes, a goiter, and even seizures. She was placed on Methimazole to treat the hyperthyroid condition. Due to a market crash, Holly dealt with a lot of work-related stress and pressure, and it appears she over-worked herself and neglected nutrition and sleep. Her seizures worsened to the point that she fell and hit her head on concrete, which put her in a temporary coma.
While she recovered from her brain injury, she tried medical marijuana and noticed she was having difficulty absorbing edibles. This was a segue into her getting interested in gut/digestive health. Holly then adjusted her diet. She went gluten-free, paleo and low FODMAP, and added probiotics and enzymes. She then experienced a remission of her bipolar and hyperthyroid symptoms. In fact, she reported she is on about a fifth of her original doze of Methimazole. Interestingly, Holly noted that before she underwent these dietary changes, she had a thyroid storm and her antidepressant was discontinued. She had experienced no withdrawal, which led her to conclude that her body had likely never even absorbed it.
Holly did not say if she had received her psychiatric diagnosis and medication from a mental health provider or a medical provider. That said, her experience reflects poorly on both sides of the equation.
Systemic problems highlighted by Holly’s experience.
Regarding the medical care she received, it should have never gotten to the point that Holly ended up in a coma and ultimately had to search elsewhere for a solution to her problems. The unfortunate reality is: most medical practitioners rely on data that is on average 17 years old rather than the latest research findings (12). I suspect not too many doctors are well-versed in gut health and elimination diets, so Holly was very fortunate to come across the book of a doctor that is (in her case, Dr. Ruscio.
What about the shortcomings of the mental health side of the equation?
Firstly, in the light that some medical problems mimic the symptoms of mental health disorders, why didn’t the party who diagnosed her with bipolar disorder check her physical health to find out if there were any medical problems that might better explain her symptoms? I know this did not happen because 1) she received her hyperthyroid diagnosis at a later date and 2) I worked in the mental health field and know that psychiatric providers do not normally order lab tests for diagnostic purposes.
Secondly, why did no one rule out the diagnosis of bipolar disorder when the reality of her thyroid condition was uncovered? The bipolar diagnosis was clearly not ruled out because she continued taking psychiatric medication until she experienced a thyroid storm. If you take a look in psychiatry’s handbook for diagnoses, the DSM-5, there is a sort of disclaimer repeated within the criteria for manic episode, hypomanic episode, and major depressive episode. This “disclaimer” basically says that what looks like a bipolar episode can not be determined as such if it was caused by something else. This takes me back to my first question: why was her thyroid not checked initially?
If you have been misdiagnosed, psychiatric medication can make things worse.
Imagine having hypothyroidism and not knowing it. You suffer from mental health symptoms and go to a psychiatrist for help. He spends about an hour asking you questions, then gives you a DSM diagnosis and puts you on Depakote, a mood stabilizer. You have already been suffering from stubborn weight gain (because of your thyroid), and now you put on an additional fifteen pounds in mere weeks (because of the psychiatric medication). Meanwhile, your thyroid condition continues in the background, undetected and untreated.
Unfortunately, this scenario is not far-fetched.
Weight gain is a problem with a number of psychiatric medications used to treat depression, up-and-down moods, anxiety, and irritability. Antipsychotic medications, which do get prescribed off-label for these mental health complaints, are the main issue here, though mood stabilizers can be problematic as well. I have even seen the antipsychotic Seroquel prescribed as a sleep aid. Zyprexa is one of the most infamous offenders in regards to weight gain; it is normal to gain 20 pounds straight away! The reason this happens is that these drugs can actually induce metabolic changes, which can over time lead to metabolic syndrome (13).
Some psychiatric medications pose another risk closer to home: damage to the thyroid. Psychiatry recognizes this risk in regards to medications like lithium, which is why the thyroid is normally monitored when a patient is on such medications. A given person has an 8.8% chance of developing hypothyroidism from lithium treatment over the span of four years (14). This may not seem like a high risk, but it is something to think about.
You could have a thyroid problem, and the lab work didn’t even catch it.
Of note, people with autoimmune thyroid conditions who take a standard thyroid blood test may not realize they have a problem simply because a number of thyroid panels do not test for the presence of antibodies. I took a look at thyroid panels from several different laboratories, and some of them only offer antibody tests as a separate purchase, apart from the standard panel. People with an autoimmune thyroid condition can have symptoms even when their thyroid hormones are within the normal range (15). As I mentioned earlier, most cases of thyroid dysfunction (at least in America) are autoimmune in origin, therefore it would seem like a good idea to make sure to screen for antibodies.
In conclusion
Clearly, not everybody with bipolar disorder, depression, or anxiety is going to have a thyroid condition. That said, if you have been given one of these psychiatric diagnoses, or something similar that has some overlap with the symptoms of thyroid dysfunction, I think it would be wise to get your thyroid thoroughly checked.
References:
1. How does the thyroid gland work? (2010, updated 2021). National Center for Biotechnology Information. ncbi.nlm.nih.gov/books/NBK279388/
2. Wallace, R., & Hobbs, H. (Updated 2023). The 6 Common Thyroid Problems & Diseases. Healthline. https://www.healthline.com/health/common-thyroid-disorders
3. Memon, N. (med. reviewed 2022). Thyroid Storm vs Thyrotoxicosis: Differences. MedicineNet. https://www.medicinenet.com/thyroid_storm_vs_thyrotoxicosis_differences/article.htm
4. Marian, G., Nica, A.E., Ionescu, B.E., & Ghinea, D. (2009). Hyperthyroidism–cause of depression and psychosis: a case report. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3019023/#:~:text=Hyperthyroidism%20is%20frequently%20associated%20with,are%20symptoms%20that%20accompany%20hyperthyroidism.
5. Chakrabarti, S. (2011). Thyroid Functions and Bipolar Affective Disorder. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144691/#:~:text=Hypothyroidism%20either%20overt%20or%20more,refractory%20forms%20of%20the%20disorder.
6. Kupka, R.W, Nolen, W.A., Post, R.M., McElroy, S.L., … Altshuler, L.L. (2002). High rate of autoimmune thyroiditis in bipolar disorder: lack of association with lithium exposure. PubMed. https://pubmed.ncbi.nlm.nih.gov/11958781/
7. Hashimoto’s Disease. (No date). University of Michigan Health. https://www.uofmhealth.org/conditions-treatments/endocrinology-diabetes-and-metabolism/hashimotos-disease#:~:text=This%2C%20and%20the%20fact%20that,thyroid%20gland%20overactivity%20(hyperthyroidism).
8. Shahbaz, A., Aziz, K., Umair, M., & Sachmechi, I. (2018). Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto’s Thyroiditis: A Case Report and Review of Literature. PubMed. https://pubmed.ncbi.nlm.nih.gov/30123726/#:~:text=Hashitoxicosis%20is%20the%20initial%20hyperthyroid,for%20one%20to%20two%20months.
9. Buttaccio, J.L. (Updated 2023). The Symptoms, Causes, Diagnosis, and Treatment of Hashitoxicosis. VeryWellHealth. https://www.verywellhealth.com/hashitoxicosis-overview-4582192#:~:text=Hashitoxicosis%20(Htx)%20is%20the%20initial,enough%20of%20it%20(hypothyroidism).
10. Vita, R., Cernaro, V., & Benvenga, S. (2019). Stress-induced hashitoxicosis: case report and relative HLA serotype and genotype. SciELO Brazil. https://www.scielo.br/j/ramb/a/nvzKLXcHqQDtwbVh6bPVgqy/
11. Simpson, E.P. (2010). Neurologic Complications of Systemic Disease. In Rolak, L.A., Neurology Secrets (Fifth Edition). Mosby. https://www.sciencedirect.com/topics/nursing-and-health-professions/thyrotoxicosis#:~:text=Thyrotoxicosis%20may%20manifest%20with%20reversible,symptoms%20suggesting%20depression%20or%20dementia.
12. Morris, Z.S., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241518/
13. del Campo, A., Bustos, C., Mascayano, C., Acuna-Castillo, C., Troncoso, R., Rojo, L.E. (2018). Metabolic Syndrome and Antipsychotics: The Role of Mitochondrial Fission/Fusion Imbalance. Frontiers. https://www.frontiersin.org/articles/10.3389/fendo.2018.00144/full#:~:text=Metabolic%20Syndrome%20and%20Antipsychotics%3A%20The%20Role%20of%20Mitochondrial%20Fission%2FFusion%20Imbalance,-Andrea%20del%20Campo&text=Second%2Dgeneration%20antipsychotics%20(SGAs),hyperphagia%2C%20and%20accelerated%20weight%20gain.
14. Lambert, C.G., Mazurie, A.J., Lauve, N.R., Hurwitz, N.G., … Young, S.S. (2016). Hypothyroidism risk compared among nine common bipolar disorder therapies in a large US cohort. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089566/
15. Promberger, R., Hermann, M., & Ott, J. (2012). Hashimoto’s Thyroiditis in Patients With Normal Thyroid-stimulating Hormone Levels. Medscape. https://www.medscape.com/viewarticle/760417?form=fpf
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