Psychiatric complications - thyroid involvement?

[debbie0413]

My 20 year old daughter was diagnosed and treated by radioiodine ablation for Grave's disease 3 years ago.  Within the last 6 weeks she has been in a psychiatric hospital twice, has shown some thyroid fluctuation in blood tests, and has been diagnosed with major depression, eating disorder, and borderline personalilty disorder.  The first hospitalization was involuntary in Philadelphia (where she attends college) due to her taking a non-toxic dose of Motrin, but she checked herself into a local psychiatric hospital once she got home here in Milwaukee, WI.

My husband and I agree with the depression and eating disorder labels, but we have doubts about the borderline diagnosis.  To make matters more complicated, our daughter reacted a bit when my husband and I expressed some doubts about the borderline finding, and she withdrew her permission for us to be involved with her health information and treatment decisions.  Now the docs want to use electroshock therapy on our daughter!  I have read that this treatment has had a comeback in the last 25 years, but it still carries some risks.  The treatment forces your body into a grand mal seizure and can affect memory, cognitive function, and learning in the short term.

Our daughter has displayed symptoms of both mild hyperthyroid and extreme hypothyroid states over the past several months, sometimes even fluctuating over a few hours or days.  This fluctuation has also shown up on thyroid blood tests both in Philadelphia and Milwaukee, but so far she has not had a full thyroid panel done.  I wish I had numbers to share, but I did not write them down when we had a meeting because I thought I would be allowed to get copies.  When our daughter got a blood test in early April in Philly, her doc commented to her that she was "hyperthyroid again" and lowered her levothyroxine from .150 mg. to .125 mg.  I am wondering if this was what triggered her big emotional reaction that landed her in the first psychiatric hospital.  The current psychiatric hospital has an endocrine doc on staff who has done SOME thyroid blood tests and is trying to stablize our daughter's correct thyroid dosage, but they have commented that it would be best if an endocrine specialist direct the correct tests (which might mean more than just tests for the thyroid).

Here is my question: does it make good medical sense for us to continue to strongly encourage our daughter to seek a second opinion with an endocrine physician who specializes in thyroid disorders (or better yet, a neuroendocrinologist if we can find one in our area), or should we just go along with the electroshock treatments our daughter's docs are recommending?  I am guessing that they are looking at this treatment because the depression symptoms continue to fluctuate in and out, even after about 5 weeks on Celexa.  Of course, these symptoms may be fluctuating precisely BECAUSE there is a thyroid imbalance (perhaps hashitoxicosis?)!  We DO have the names of a couple of endocrine docs in the area who do a lot of work with thyroid issues.  I really appreciate any comments you could give us on this.  

[debbie0413]

Just to clarify, Kalina was on Levothyroxine until June when she was prescribed Armour thyroid.

[debbie0413]

Here is the latest from my daughter's medical doctor in the inpatient eataing disorders program: basically he said that nothing is critical right now with either her thyroid or adrenals. The TSH was low (he didn't tell me the result or the range) on May 30th, and the TSH and free T4 were repeated yesterday (I asked if the free T3 was taken, but he said they didn't need that info.). He said if the TSH would be low again, he would slowly reduce her Armour thyroid dosage.

Kalina is currently on two 60 mg. pills, taken at once in the morning. I asked him if Armour should be taken in 2 or more doses, and he said taking it all at once is fine. Kalina was previously on .150 mg., was reduced to .125 back in April (before her first crisis) due to a low TSH, and was upped to alternating .125 and .137 when in her 2nd psychiatric stay before she saw the D.O. doc who put her on two 60 mg. tablets of Armour. This doc also said that prescribing of Armour was "unusual."

This doc also said he gave Kalina a morning cortisol blood test, and it was in normal range (again, he gave me no value), so he believes her adrenals are OK. He explained to me that the binging and purging Kalina did from March through June has likely disrupted her thyroid function and it may take a few months for it to return to normal. This doc highly recommended that Kalina see an endocrinologist in addition to a primary physician just be monitor her after she is discharged from this program.

I am just wondering people's thoughts on all this. I AM relieved that this doc does not think that she has any critical problems with either her thyroid or adrenals at the moment. One of the reasons I encouraged Kalina to ask about adrenal testing is that she had not been able to sleep well at night for the past several weeks so that this hospital put her on Ceraquill a few days ago. She is better able to sleep, but she still wakes up briefly throughout the night.

[debbie0413]

My daughter entered an eating disorders inpatient program yesterday, and we plan on supporting her in her efforts toward emotional and physical wellness. Our daughter has been asking this psych. hospital for help with her eating disorder in addition to depression treatment since the beginning of her 1st stay. We think it is a bit odd that the hospital only yesterday figured out a way for her to be treated at their affiliate institution only a few short hours after we had presented 2 other area psychiatric hospitals with eating disorder programs (competition). Her doctor only yesterday ordered thyroid tests after we asked in a family meeting on Monday if lab tests/medical records were transferred from her doctor or if any thyroid tests had been taken while our daughter was in this hospital. Forum members can reach your own conclusions on all of this.

I WANT my daughter to get effective treatment for her depression and her eating disorder. However, I feel it is crucial for her to have her physical system (including thyroid, any low nutrients, and possibly low adrenals) attended to WHILE she is receiving her mental health treatments. Otherwise, she may be banging her head up against a wall because she is experiencing physical symptoms that interfere with her treatment. I am also aware that LEARNING about her physical thyroid condition may help her adjust her thinking and expectations, especially with her eating disorder. If she realizes that normal food intake may result in gained weight when in a hypo state and pounds may shed too easily if she returns to a hyper state, she will be better equipped to deal with her food and body issues.

I plan on encouraging my daughter to advocate for her own psychological and physical health. I believe it is very difficult to be young and have all of this happening to her. She needs all of the encouragement she can get from family, friends, and health professionals. If you can spare a thought or prayer directed her way, I'd apprecicate it.

[debbie0413]

Magpieannie, thanks for adding to the explanation.  What I have found with my daughter is that a lot of these nutrients get so depleted from thyroid imbalance that it becomes even harder to metabolize the thyroid meds, even when T3 (Cytomel) is added.  Your daughter's doc may be on the right track, but magpieannie is right, there needs to be FREQUENT lab tests and check on her symptoms to get her system back working again.  

If I were you I would get all of the listed tests from her regular doc.  Oh, be sure to take your daughter to the lab in the morning BEFORE taking either levothyroxine or cytomel so that those meds don't skew the results.  Also keep in mind that it might be tough to get an accurate reading of your daughter's adrenals.  I guess there is some blood test that may give a general idea of what is happening with adrenals, but I understand a 24 hour saliva test is the most accurate, and I don't know how many docs will order that test.  There IS also a 24 hour urine test, but I think it only gives an average of the cortisol for that day rather than highs and lows at various times of the day.  If free T3 is either low or too high, and/or any of the antibody tests come back positive, then I think you are well within your rights to ask for a pediatric endocrinologist.  You will need to keep your daughter's doc on your side, since an "ASAP referral" from a physician could be your ticket to see a specialist in a few days to a week or two rather than the end of the summer!  I would think that an endocrinologiest would want to do an iodine uptake scan (something that was skipped with my daughter) to see what shape your daughter's thyroid is in.  Keep in mind that if either Grave's and/or Hashimoto's conditions are present, you will need the expertise of a good endocrinologiest to complete the diagnosis and figure out long term treatment.

When you talk with her, try to talk REALLY softly, since I found out that low magnesium/adrenal levels causes a hyper startle response.  Try telling your daughter that you have found that a lot of these things are really complex but that you'd like to help her get to the bottom of why she has been feeling so awful for so long.  Also tell her that unfortunately, many mental health and general physicians are not up on all of this endocrine medicine.  Perhaps your daughter would be willing to write up a list of symptoms she has been having, along with notes if symptoms change according to time of the month or time of the day.  She could share that list with the doctor (and know that when a teen says she is really bored a lot of the time, that may mean she is depressed).  We have seen a physical change of exhaustion come over our daughter's face in the early evening, and we are guessing that it is when she is most affected by low magnesium, low cortisol from her adrenals, and low T3.

I hope these additional details will help.  It sounds like your daughter's doctor is trying to give her the right meds, but there may be a lot more going on than he/she realizes.  If your daughter is given the right tests and gets a good diagnosis/treatment plan, then perhaps by the end of the summer she will finally start feeling human again.  We wish you well; hope you will be able to report some positive progress!

[magpieannie]

Jumping in here to say that the total t3 and t4 are not necessary, just make sure the FREE t3 and FREET4 are tested along with the TSH and TPOab and Tgab antibodies test for Hashimotos and the Graves test-TSI (?). Also have them throw in the vitamin D,iron (folate), and b level while they are at it. My dayghter is nine and born without a thyroid gland, and she always remembers to take her pills as she knows how important it is too her good health. Your daughter must understand this and take ownership of her health. Other meds and of -course the "pot" smoking can cause havoc for her system and make it impossible for her to get truly well if it is thyroid disease she is suffering from. Do you have her latest labs with date and reference ranges for us to comment on? If she is on a t3 medication as well as a t4 medication, then the doctor should be monitering these levels often with blood labs and you must always get copies of these labs-it's law if you request. I surly hope that her last labs were not done in the 5th grade with her being 17 now? I hope I read that wrong in your post? Your daughter can be well, however you may need a new doctor who moniters her symptoms and labs better. Thyroid disease can cause lots to go wrong if not treated appropriatly and taken seriously. Be very careful of other medications prescribed to treat symptoms and not the real cause of the illness.

[CCB1991]

oh thank you so much for your response.  Again her family doctor only tested tsh in the fifth grade and it was high so he prescribed synthroid.  Since then, when I became concerned aabout her grades, he said lets try cytomel.  he did not ever do any free t testing.  I am making an appt today and will ask for all the testing.  I want to be sure I ask for all that need to be done:
free t 3
free t4
total t3 and total t4
tsh
adrennal
antibodies

can you think of anything else??
She is on lexapro, although i do not see it doing much for her.  she misses a lot of doses which i know is not good,  It gets much harder when your children are at that age to give them their medicine because they are no longer in my same routine, for ex. get out of bed mid afternoon(ugghhh) when I have been long gone.  I can remind her as I walk out the door, but she forgets anyway.  I can hand it to her only to find it at the bottom of her pocketbook.

A wise lady once reminded me, "No martter how much pain your teenage child brings into the family, remember... they are hurting even more."    Any advice at all is sooo welcomed! Thank you!  We are so desperate.