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SUBTLE PSYCHIATRIC PRESENTATIONS OF ENDOCRINE

DISEASES

Burton Hutto, MD

Psychiatry and endocrinologyintersect in the pathogenesis and clinical pre- sentation of many illnesses. The close relationship of these disciplines led Sig- mund Freud'" to write in 1923:

From a clinical standpoint the neuroses must necessarily be put alongside the intoxications and such disorders as Graves' disease. These are condi- tions arising from an excess or a relative lack of certain highly active substances, whether produced inside the body or introduced into it from outside -in short, they are disturbances of the chemistry of the body, toxic conditions. If someone succeeded in isolating and demonstrating the hypothetical substance or substances concerned in neuroses, he would have no need to worry about opposition from the medical profession. For the present, however, no such avenue of approach to the problem is open.

Such avenues have opened, and now the biologic basis of mental illnesses and endocrine disorders are studied in great depth and detail. The interactions of the central nervous system and endocrine systems have also been investigated in depth. This article does not review these intricate interactions, nor does it focus on the important neuroendocrine hypotheses on the etiology of some mental illnesses. This article describes the common psychiatric manifestations of primary endocrinopathies in the attempt to help the clinician recognize endo- crine disorders disguised as psychiatric illness.

As all physicians make the effort to become more efficient, psychiatrists have been led to shorten evaluations and to utilize laboratory investigation more sparingly. The traditional underemphasis on physical examination by psychiatrists compounds the problems posed by brief evaluations with minimal

From the Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 21 NUMBER 4 * DECEMBER 1998 905

906 HUTTO

laboratory screening. In addition, only patients admitted to a psychiatric hospital are likely to receive the most thorough evaluation, and presently only the few patients who meet very strict criteria are hospitalized. This scenario is a trap that could easily catch most psychiatrists in a missed medical diagnosis. Endocrine disorders are especially easy to miss due to their common presentation with psychiatric symptoms and their elusive and painstaking diagnosis even when they are suspected.

In a study of 658 consecutive psychiatric outpatients, 46% were suffering from medical illnesses previously unknown to either them or their physician.16 The medical illness produced the presenting psychiatric complaint in over 9% of these patients. Twenty-one of the patients had endocrine disorders. In a study of 100 inpatients, 46% were found to have medical illnesses that caused or exacerbated their psychiatric condition, and an additional 34% had a previously undiagnosed and untreated medical i1lne~s.I~

Another contributing factor to the underdiagnosis of all medical illnesses in some psychiatric patients is the patients' atypical descriptions of and reactions to their physical symptoms. Many severe medical illnesses cause extreme mental disorganization suggestive of psychosis or dementia. These patients are fre- quently unable to express clearly the nature of the subtle physical symptoms that could lead an astute physician to the correct diagnosis of their underlying medical illness. Even when they can adequately describe physical symptomatol- ogy, these complaints can be dismissed as delusional or inconsequential because the patient does not express the expected reaction or level of concern about their symptoms.

In a similar way, it is important to recognize that psychiatric patients are not immune to comorbid medical illnesses and that their descriptions of their physical complaints may seem distorted or unconvincing. The potential for this distortion should lower the psychiatrists' threshold for seeking consultation if needed to evaluate the physical complaints of their patients.

This article summarizes the psychiatric symptoms of major endocrine disor- ders. The symptoms that might present to the clinical psychiatrist first are emphasized. Many endocrine disorders have severe neuropsychiatric symptoms as components of severe and advanced cases, but this article stresses the more subtle psychiatric presentations of common endocrine disorders.

THYROID DISORDERS

Hypothyroidism

Recognition by physicians long ago of psychiatric symptoms in hypothy- roidism led to the term myxedema madness. Psychiatric symptoms, such as depres- sion, anxiety, and cognitive impairment, may commonly precede the onset of other recognizable signs or symptoms of The typical distinc- tive symptoms and signs of hypothyroidism, such as cold intolerance, husky voice, constipation, menorrhagia, and muscle cramps, could be easily overlooked by most psychiatrists. Many of the symptoms, such as fatigue, decreased mem- ory, and weight gain, might suggest primary psychiatric illness. Given the common practice in psychiatry of omitting a physical examination during rou- tine evaluation of outpatients, distinctive signs, such as dry, coarse skin, mild edema, bradycardia, and goiter, might never come to the psychiatrist's attention.

Despite this prospect of regularly missing the diagnosis of hypothyroidism, it is unclear how often such misdiagnoses occur. For many psychiatrists this

SUBTLE PSYCHIATRIC PRESENTATIONS OF ENDOCRINE DISEASES 907

most well-known endocrinopathy is routinely considered a diagnostic possibility, especially in young women with depressive or anxiety symptoms. Utilization of laboratory testing in initial evaluations differs, but some clinicians routinely screen for thyroid illness. In cases of treatment-refractory depression, a thyroid- stimulating hormone level (TSH) is strongly indicated.

A rapid onset of severe hypothyroidism is sometimes accompanied by delirium with psychotic features. Elderly patients can develop cognitive impair- ments suggestive of progressive dementia. When a delirium or dementia is the presenting clinical picture, the patient is more likely to receive a thorough physical examination and laboratory evaluation, including a TSH and sometimes thyroid function tests, to rule out thyroid illness. Thus, frank hypothyroidism within these populations may only rarely escape detection.

The psychiatrist might overlook iatrogenic hypothyroid states that contrib- ute to suboptimal recovery for their patient. The effects of lithium on thyroid hormone biosynthesis and release are generally well appreciated by psychia- trists. To monitor for these effects, patients on lithium should have TSH levels assayed twice yearly. When thyroid supplements used as augmentation for treatment of mood disorders are withdrawn rapidly, a hypothyroid state can be induced. A study of patients whose thyroid replacement after thyroidectomy was withdrawn found that patients with a history of mood disorders were more likely than those without such a history to experience mood changes off their thyroid repla~ement.~

More controversial, less well understood, and far more easily missed is the diagnosis of subclinical hypothyroidism. Hypothyroidism is graded based on laboratory data. Elevated TSH and decreased thyroid hormone levels are known as grade I hypothyroidism. Grade I1 hypothyroidism is diagnosed by elevated TSH only. Grade I11 hypothyroidism presents with normal or high normal TSH, but an exaggerated response of TSH to thyroid stimulating hormone (thyrotro- pin-releasing hormone stimulation test). Grade I hypothyroidism typically pre- sents with the distinguishing signs and symptoms discussed previously. Grade I1 and I11 hypothyroidism, which may occur in 5% to 10% of the general population,51 may present with few if any nonpsychiatric signs or symptoms?

The relationship of grade I1 or I11 (subclinical) hypothyroidism to depression has been investigated. Some data suggest that subclinical hypothyroidism is additive with other risk factors for patients predisposed to depression. One study of 148 general medical patients found a history of treatment for depression in 50% of those with TSH values greater than 3 IU compared with only 18% of those with values less than 3 IU.I3 Another study by the same group examined 31 patients at risk for thyroid illness before their thyroid function was assessed and found a 56% lifetime prevalence of depression in those who had subclinical hypothyroidism compared with an 18% prevalence in the euthyroid patient^.'^

One recent study further substantiated the relationship of subclinical hypo- thyroidism to cognitive impairment. Dementia assessments and TSH levels on 194 older subjects found an odds ratio of 3.8 for association of elevated TSH with definite or probable dementia."

Others suggest that subclinical hypothyroidism does not significantly affect mood or functioning. A recent study comparing patients with subclinical hypo- thyroidism with euthyroid patients with goiter found no difference in mood disorder using the Hamilton rating scales for depression and anxiety and the brief psychiatric rating scale. They did find memory impairment. The authors suggest that the perception of illness, common to both groups in their study, may be a confounding factor in comparing subclinical hypothyroid patients with patients who have no thyroid pathology.2 This cross-sectional study, however,

did not look for a history of depression in the way that the previously cited studies did. One randomized, double-blind, placebo-controlled study of 37 pa- tients with subclinical hypothyroidism compared treated patients with untreated patients using several measures including health-related quality of life scales and cognitive testing.lg Despite finding a significant improvement in a composite psychometric memory score with treatment, the authors concluded that it may not be harmful to monitor middle aged and older patients with subclinical hypothyroidism without treatment.

Hyperthyroidism

Depression46, and a n x i e v may frequently herald the onset of hyperthy- roidism. Common symptoms of hyperthyroidism, such as anxiety, fatigue, in- somnia, mood lability, decreased concentration, and decreased memory, could mislead a clinician toward a diagnosis of anxiety or mood disorder, or even stimulant intoxication. Close questioning on evaluation, however, can often detect the hyperthyroidism. Heat intolerance, increased appetite accompanied by weight loss, diaphoresis, and warm skin all strongly suggest hyperthyroid- ism. One might even note the characteristic proptosis or a tremor as further evidence of the illness.

Attempts to rely on the presence or absence of psychological stressors that might account for the onset of a mood disorder or depression can mislead the clinician who hopes to rule out primary medical illness as the etiology of new psychiatric symptoms. The presence of stressors can be incidental in the presentation of any illness. Hyperthyroidism was once considered a prototype of psychosomatic illness. That view has been mostly unsupported by research, but one recent study compared self-reports of 208 Graves’ disease patients (the most common cause of hyperthyroidism) with 372 selected and matched con- t rol~.’~ It found significantly more negative life events and higher negative life event scores in the Graves’ disease patients during the 12 months preceding the diagnosis. This finding does not necessarily support the hypothesis that hyperthyroidism is a classical psychosomatic illness, but it illustrates that relying on the patient’s report of recent stressors as a means of distinguishing between psychiatric illness and hyperthyroidism is not necessarily helpful or valid.

In the elderly, the typical presentation includes severe psychomotor retarda- tion, known as apathetic hyperthyroidi~m.~~ Elderly patients may also demonstrate more prominent cognitive impairments in hyperthyroidism. The higher suspi- cion of medical illness presenting with psychiatric symptoms in older patients likely prevents misdiagnosis from occurring often as it may in younger patients.

In patients known to have bipolar disorder, a new onset of concomitant hyperthyroidism can be especially subtle to detect. Hyperthyroid states can precipitate manic episodes in predisposed patients, and the mania might be addressed without new work-up. The increasing use of mood stabilizers other than lithium heightens this problem. The use of lithium mandates close monitor- ing of thyroid status and lithium treatment can help partially treat the hyperthy- roid state by its effects on thyroid hormone production and release.

In a similar way hyperthyroidism can exacerbate chronic psychotic disor- ders, and clinicians might often initiate standard treatment for the exacerbation of psychosis in well-established patients before thoroughly re-evaluating their thyroid status. Psychotic patients may poorly communicate common hallmark signs and symptoms of hyperthyroidism, thereby further obscuring the diagno- sis.

SUBTLE PSYCHIATRIC PRESENTATIONS OF ENDOCRINE DISEASES 909

The standard method for confirming (or discovering) the diagnosis of hyper- thyroidism is through laboratory testing of thyroid functions. In psychiatric populations, transient elevations of thyroid hormone levels have been reported, especially at the height of illness or at the time of h~spitalization.”,~~ This possibility of false-positive results from laboratory testing makes diagnosis of hyperthyroidism especially difficult in psychiatric populations. It is recom- mended that the finding of elevations on thyroid function tests in psychiatric patients with no clear nonpsychiatric signs or symptoms of hyperthyroidism be followed with repeat testing in 2 weeks.

Frequently, psychiatric patients are screened for hypothyroidism or hyper- thyroidism with a serum TSH assay only. The finding of a low value is sugges- tive of hyperthyroidism, but the diagnosis requires the finding of elevations in thyroid hormone levels? Standard thyroid function tests typically assay total T4; T3 resin uptake; and free T4 index, a derived value. Some patients, however, have hyperthyroidism based on elevated levels of free T3, known as T3 thyrotoxi- cosis, typically associated with a thyroid nodule. These patients’ hyperthyroid state might be missed by following a decreased TSH with thyroid function tests only. Free T3 levels should also be assessed in such patients.

ADRENAL DISORDERS

Hypercortisolemia or Cushing’s Syndrome

Cushing’s disease, a pituitary tumor secreting adrenocorticotropic hormone (ACTH), is the most common cause of noniatrogenic Cushing’s syndrome of elevated corticosteroids. This syndrome routinely presents with psychiatric symptoms6 and depression is prominent in the course of the syndrome, oc- curring in about half or more of 53 Anxiety, confusion, or mania can occur in Cushing’s syndrome. Psychosis in Cushing’s syndrome may be more associated with adrenal carcinoma than Cushing’s disease.22

Discriminating between depression and Cushing’s syndrome can be com- plex. In one study, 7 (17%) of 44 patients had psychiatric hospitalizations before their Cushing’s syndrome was diagnosed, and one had received electroconvul- sive therapy.I2 When asked what symptoms disrupt their lives, Cushing’s syn- drome patients report fatigue, weight gain, mood lability, impaired concentra- tion, depressed mood, decreased libido, and sleep disturbance.I2 The depression typically found in Cushing’s syndrome is best classified as atypical instead of melancholic,6 a finding that emphasizes mood reactivity and weight gain in contrast to anhedonia and weight loss. Depression in Cushing’s syndrome is more common in women and in patients with a recent history of adverse life events. A woman presenting with symptoms of major depression with atypical features in the context of recent stressors does not often lead most psychiatrists to consider Cushing’s syndrome.

The signs and symptoms that might allow one to suspect Cushing’s syn- drome could be easily overlooked. Obesity, hypertension, acne, hirsutism, and hyperglycemia are each prevalent problems. The clinician must maintain some suspicion of Cushing’s syndrome. Although there is no one hallmark finding on routine psychiatric evaluative procedures, some signs and symptoms should trigger further investigation. Central obesity, ecchymoses, plethora, proximal muscle weakness, osteopenia, hypertension, and white blood count greater than ll,000/mm3 have been shown to be good discriminant indices for the presence of Cushing’s syndrome.44

The laboratory work-up of suspected Cushing's syndrome often requires consultation with an endocrinologist. The best test for differentiating depression and Cushing's syndrome in questionable cases is the corticotropin-releasing hormone stimulation test, and even this test sometimes gives ambiguous results.35, 39

The psychiatric effects of exogenous corticosteroids, such as prednisone, are well re~ognized.~~ The differential diagnosis of lupus cerebritis versus steroid- induced psychosis can be troublesome, but issues related to exogenous steroids are not discussed further because they are beyond the scope of this article of endogenous endocrinopathies.

One noteworthy diagnosis related to exogenous steroids is the primarily psychiatric illness of factitious Cushing's syndrome. Cizza et a14 report on six such patients who presented to the National Institutes of Health Clinical Center for evaluation of hypercortisolemia. All six (five women and one man) had had multiple surgeries unrelated to Cushing's syndrome and a history of depression or anxiety. They report that the diagnosis was difficult, and that high-pressure liquid chromatography analysis of urine steroids was the most definitive test. Obviously, these patients would rarely present willingly to a psychiatrist, but awareness of this diagnosis could help a consulting psychiatrist.

Adrenal Insufficiency

Adrenal insufficiency, or Addison's disease, most often follows autoimmune destruction of the adrenal glands. Symptoms typically manifest after more than 90% of the adrenal function is lost. The initial symptoms of adrenal insufficiency often are prototypical symptoms of depression: weakness and fatigue, weight loss, and anorexia. Anxiety, depression, paranoia, progressive dementia, or delir- ium may develop.2O Because of the anorexia and weight loss, adrenal insuffi- ciency is sometimes mistaken for anorexia nerv0sa.4~

Important physical symptoms also typically herald the onset of adrenal insufficiency. Hypotension, nausea, and vomiting should raise suspicions. Hy- perpigmentation is pathognomonic, but does not occur in cases of secondary adrenal insufficiency caused by decreased ACTH because it is the melanin- stimulating properties of elevated ACTH that cause hyperpigmentation in adre- nal failure.

Pheochromocytoma

Pheochromocytomas are rare catecholamine-releasing tumors typically found in the adrenal medulla. The clinical picture includes paroxysmal attacks of anxiety, and these attacks could be confused with panic attacks. The somatic symptoms, however, overshadow the emotional or cognitive components of the attacks, and patients with pheochromocytoma do not develop the phobic avoidances so often seen with panic disorder.4O One study of 17 patients with pheochromocytoma found that none met diagnostic criteria for panic disorder, but two met criteria for generalized anxiety disorder." Symptoms of headache, palpitations, and diaphoresis are prominent; they may be associated with eleva- tions of blood pressure. Although blood pressure elevations may be truly inter- mittent in these patients, many with pheochromocytoma have elevated baseline blood pressures.

SUBTLE PSYCHIATRIC PRESENTATIONS OF ENDOCRINE DISEASES 911

PARATHYROID DISORDERS

Hyperparathyroidism

Hyperparathyroidism, most commonly caused by a benign adenoma, stimu- lates hypercalcemia. Hypercalcemia in turn produces a variety of problems including psychiatric symptoms. At very high calcium levels, confusion or delirium predominate, but at more moderately elevated calcium levels, depres- sion, decreased concentration and memory, and fatigue are common initial complaints for patients with hyperparathyroidism. Even mild degrees of hyper- calcemia with calcium levels less than 12 mg/dL may produce significant psychi- atric symptoms that resolve when the calcium level is de~reased .~~ The other physical symptoms of hypercalcemia can also be mistaken as psychiatric com- plaints. The typical gastrointestinal symptoms include anorexia. Typical neuro- muscular symptoms include weakness or restless legs syndrome.

There is no one pathognomonic sign or symptom, but the cluster of de- pressive symptoms with prominent or excessive weakness and gastrointestinal complaints, especially if accompanied by renal problems (typically stones) or evidence of bone changes or pain (a symptom of hyperparathyroidism but not hypercalcemia from other causes), should raise the suspicion of hypercalcemia or hyperparathyroidism. In the laboratory investigation of hypercalcemia, false negatives are not uncommon, and serial determinations or correlation of calcium levels with parathyroid hormone levels are often required to detect true hyper- parathyroidism, especially if it is mild.

Hypoparathyroidism

Hypoparathyroidism can have several etiologies, but the resulting hypocal- cemia can have severe effects on the central nervous system. Typically, cases present with tetany or seizures, but in some cases psychiatric symptoms can precede these more prototypical symptoms.** Hypocalcemia can lead to severe cognitive impairment, but more subtle psychiatric symptoms, such as depres- sion, irritability, and anxiety, may be characteristic of the illness.25 Mild or partial hypoparathyroidism that does not progress to tetany or seizures can go undetected unless calcium levels are screened.

Pseudohypoparathyroidism refers to a resistance to adequate parathyroid hormone levels. The symptoms include those of congenital hypoparathyroidism, such as mental retardation. This rare diagnosis does not present initially to a clinical psychiatrist.

Decreased magnesium levels can be one of the causes of hypoparathy- roidism because magnesium is required for the release of parathyroid hormone. Hypomagnesemia can have additional neuropsychiatric symptoms, such as weakness, fatigue, and slowed cognition.

ENDOCRINE PANCREAS

Diabetes Mellitis

Diabetes mellitis is a disorder of insulin production (type I) or insulin receptors (type 11). This most prevalent endocrine disorder might be mistaken for a psychiatric condition very early in its presentation. Fatigue and weight

912 m o

loss are prominent early symptoms that could be attributed to a depressive illness. The metabolic toll taken by this illness becomes increasingly difficult to overlook. This condition of hyperglycemia is also often easily detected by the most cursory laboratory investigation.

The long-term effects of this illness include those on the central nervous system, most of which are mediated by microvascular changes. It is important for the clinical psychiatrist to be aware of the acute and chronic effects of hyperglycemia and hypoglycemia. Although prolonged hyperglycemia is associ- ated with fatigue, in experimental conditions where glucose levels can be "locked at a certain level: diabetic patients held to hyperglycemic levels show little decrement of function as measured by neuropsychological testing. At hypoglycemic levels, however, all aspects of tested neuropsychological function- ing, and especially tests of associative learning, attention, and mental flexibility, are significantly impaired. Anxiety due to autonomic activation is very common in acute hypoglycemia. Recurrent episodes of hypoglycemia are associated with cumulative worsening of cognitive

Thus, although the clinical psychiatrist may not frequently make the initial diagnosis of diabetes mellitus, this prevalent illness can lead to anxiety, confu- sional states, or cognitive impairment that could be misinterpreted.

lnsulinoma and Other Causes of Hypoglycemia

The physiologic state of hypoglycemia is often divided into food-stimulated and food-deprived hypoglycemias in the effort to diagnose the underlying illness. Food-stimulated hypoglycemia is controversial, and may occur only when the diet is primarily comprised of simple carbohydrates. Food-deprived hypoglycemia has a variety of possible etiologies: ethanol-induced hypoglycemia in malnourished or fasting patients, insulinoma, factitious hypoglycemia, and others.

The clinical picture of hypoglycemia as described previously in the section on diabetes mellitis typically includes cognitive changes and anxiety. The fre- quent hypoglycemia seen in insulinoma can present a wide variety of psychiatric symptoms, such as psychosis and mood changes.g Psychiatric symptoms may occur in up to 80% of patients with insulinomas. Clinical suspicion should be raised by the episodic nature of the symptoms and by worsening during food deprivation, with relief by meals.

Insulinoma is thus easier to detect than factitious hypoglycemia, where the patient gratifies unconscious needs by a strategy designed to outwit the physi- cian. The measurement of C-peptide is often required to diagnose factitious hyp0glycemia.4~

DISORDERS OF REPRODUCTIVE ENDOCRINOLOGY

Most disorders of male reproductive endocrine function are congenital, and those presenting in adulthood do not usually exhibit psychiatric symptomatol- ogy that directly leads to psychiatric evaluation. The disorders of female repro- ductive endocrine function also are often congenital or not typically manifested with prominent psychiatric symptoms. There are conditions in the female repro- ductive cycle, however, that must be considered.

Once menses have begun, the loss of menses (secondary amenorrhea) is one of the diagnostic criteria for anorexia nervosa. The combination of weight loss

SUBTLE PSYCHIATRIC PRESENTATIONS OF ENDOCRINE DISEASES 913

and secondary amenorrhea may deserve careful evaluation in some cases to rule out other etiologies for these protean symptoms.

Pregnancy is by no means a disorder or illness, but this condition can present with fatigue or mild personality changes. Pregnancy in the context of psychiatric illness has serious significance, including the potential teratogenic effects of psychiatric medications. It is imperative that the psychiatrist know if the patient is pregnant. This is a simple diagnosis to make, but can be missed if not considered.

Likewise, menopause is not an illness, but this expected transition can present with psychiatric complaints. The interrelationships between the typical hormonal changes in menopause, the common psychological conflicts during this period, and mood changes during this period are incompletely understood and controversial?, 34, 37, 38 Perhaps the more common problem in this arena is the underdiagnosis of major depression, where depressive symptoms are misattrib- uted to menopause.18

ANTERIOR PITUITARY

Tumors of the pituitary can cause overproduction of the hormone found in the cell-type of the tumor. ACTH-producing pituitary tumors are known as Cushing’s disease, as described previously. Tumors that secrete growth hormone produce the condition known as acromegaly, and prolactinomas in the pituitary cause the amenorrhea-galactorrhea syndrome in women. Other pituitary prob- lems can lead to hypopituitarism, the underproduction of all pituitary hormones.

Acromegaly presenting before adulthood leads to gigantism, but onset in adulthood can lead to lethargy, decreased initiative and spontaneity, and de- creased libido. One recent study of patients with established acromegaly found no increase in psychiatric morbidity in general, nor an increased incidence of depression, in comparison with general population and patient samples.’

Prolactinomas can present with hostility, anxiety, and decreased self- esteem.21, 23 Men with prolactinomas report decreased libido, and obviously lack the amenorrhea and galactorrhea that bring women to medical attention more quickly. In the more advance stage when men are more likely to be diagnosed, they may present with significant apathy.

In hypopituitarism, where all pituitary hormones are diminished, patients can present with a wide range of psychiatric symptomatology ranging from mild personality changes to delirium. Psychiatric comorbidity, especially depres- sion and dysthymia, is high in established cases of hypopituitari~m.~~

POSTERIOR PITUITARY

The posterior pituitary produces oxytocin and arginine vasopressin, the antidiuretic hormone (ADH). Pathologic states related to oxytocin are poorly

27 Diabetes insipidus is the disturbance of water homeostasis re- lated to decreased levels of ADH or end-organ resistance to ADH in the kidneys. Increased levels of ADH, known as the syndrome of inappropriate ADH lead to hyponatremia. This syndrome can occur in psychiatric populations for various reasons including as a side effect of some psychiatric medicines.4I Hyponatremia can also occur with self-induced water intoxication, and hyponatremia from any cause can lead to progressive cognitive impairment or delirium.

CONCLUSION

As reviewed previously, many endocrinopathies can present initially with psychiatric symptoms. Given that the endocrine system regulates many aspects of metabolism, including brain metabolism, the overlap of symptomatology between psychiatry and endocrinology should not be surprising. That diagnoses are sometimes missed is regrettable, but cognizance of this overlap enhances the likelihood of a psychiatrist correctly diagnosing endocrine disorders.

As can be seen in this article, there are few clear discriminating features between the psychiatric symptoms of endocrine disorders and those of primary psychiatric illnesses. The likelihood of the psychiatrist correctly diagnosing en- docrine disorders is enhanced by an appreciation of their pathophysiology and knowledge of their characteristic features. Many endocrine disorders can be diagnosed if a few extra questions are asked or if observation or physical examination targets the expected findings of these disorders. Judicious use of the laboratory and careful interpretation of results also detects many of the endocrine disorders.

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