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Hyperthyroidism and anxiety — MRCPsych Paper A MCQ

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ModerateNeuroimaging, neuroendocrinology and psychoneuroimmunologyHyperthyroidism and anxietyMRCPsych Paper A

A 36-year-old woman is referred with a 6-week history of anxiety and insomnia. She has lost 6 kg despite an increased appetite and reports heat intolerance, sweating and palpitations. Examination shows a regular pulse of 112 beats per minute, warm moist skin and a fine postural tremor. Which endocrine explanation best accounts for the whole presentation?

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Correct answer: D — Excess thyroid hormone causing thyrotoxic metabolic and autonomic symptoms

Explanation lettering: B = shown as A · D = shown as B · E = shown as C · A = shown as D · C = shown as E

A is correct. Anxiety and insomnia accompanied by weight loss despite increased appetite, heat intolerance, sweating, tachycardia, warm skin and fine tremor are characteristic of thyrotoxicosis. Excess thyroid hormone produces increased metabolic activity and prominent autonomic or adrenergic-like manifestations, so the psychiatric symptoms should not be assumed to represent a primary anxiety disorder. Parathyroid hormone deficiency causes hypocalcaemia, typically with paraesthesia, cramps, tetany or seizures. Hyperprolactinaemia more often causes menstrual disturbance, galactorrhoea, infertility or sexual dysfunction. Primary adrenal insufficiency can cause weight loss but is associated with fatigue, gastrointestinal symptoms, hypotension, salt craving and sometimes hyperpigmentation rather than heat intolerance and tremor. Melatonin excess does not produce this thyrotoxic syndrome.

Reference: NHS. Overactive thyroid (hyperthyroidism): Overview and Symptoms. Last reviewed 11 April 2023. https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/