the clinical society of london  first linked myxedema with psychosis in the latter half of 19 century . the study noted 109 patients of myxedema and reported that  delusions and hallucinations occur in nearly half of the cases mainly with advanced disease . the relationship between myxedema ( severe hypothyroidism ) and psychosis was strengthened by works of  asher  who coined the term  myxedema madness ,  in the latter half of 20 century . since then , numerous case reports have been published strengthening the existence of this entity . hypothyroidism is a common disorder . patients having advanced form of this disease ( myxedema ) and presenting with a myriad of psychiatric symptoms are difficult to link and diagnose , unless seen with a high degree of suspicion . the common symptoms are fatigue , cold intolerance , menstrual abnormalities , decreased appetite and constipation . commonly recognized signs include hoarse voice , bradycardia , non - pitting edema , facial puffiness , slow speech , delayed relaxation phase of deep tendon reflex and fatigue . the psychiatric symptoms range from inattentiveness , lethargy , affective abnormalities , delusions , hallucinations and delirium . at times , the behavior abnormalities are so striking that a patient is first diagnosed with primary psychiatric disturbance rather than hypothyroidism . the neurobehavioral effects of thyroxin on the brain may be related to its action on neurotransmitters . it has been shown that in rats with iatrogenically induced hypothyroidism increase in cerebral dopamine level and tyrosine hydroxylase activity is there . the clinical society of london  first linked myxedema with psychosis in the latter half of 19 century . the study noted 109 patients of myxedema and reported that  delusions and hallucinations occur in nearly half of the cases mainly with advanced disease . the relationship between myxedema ( severe hypothyroidism ) and psychosis was strengthened by works of  asher  who coined the term  myxedema madness ,  in the latter half of 20 century . since then , numerous case reports have been published strengthening the existence of this entity . patients having advanced form of this disease ( myxedema ) and presenting with a myriad of psychiatric symptoms are difficult to link and diagnose , unless seen with a high degree of suspicion . the common symptoms are fatigue , cold intolerance , menstrual abnormalities , decreased appetite and constipation . commonly recognized signs include hoarse voice , bradycardia , non - pitting edema , facial puffiness , slow speech , delayed relaxation phase of deep tendon reflex and fatigue . the psychiatric symptoms range from inattentiveness , lethargy , affective abnormalities , delusions , hallucinations and delirium . at times , the behavior abnormalities are so striking that a patient is first diagnosed with primary psychiatric disturbance rather than hypothyroidism . the neurobehavioral effects of thyroxin on the brain may be related to its action on neurotransmitters . it has been shown that in rats with iatrogenically induced hypothyroidism increase in cerebral dopamine level and tyrosine hydroxylase activity is there . the psychiatric symptoms range from inattentiveness , lethargy , affective abnormalities , delusions , hallucinations and delirium . at times , the behavior abnormalities are so striking that a patient is first diagnosed with primary psychiatric disturbance rather than hypothyroidism . the neurobehavioral effects of thyroxin on the brain may be related to its action on neurotransmitters . it has been shown that in rats with iatrogenically induced hypothyroidism increase in cerebral dopamine level and tyrosine hydroxylase activity is there . x , a 30-year - old female without a known significant past medical history was brought with a 1 year continuous disturbance in the form of having suspiciousness , fearfulness and quarrel with neighbors with gradual and progressive work impairment . she along with her children would be harmed and daughters sold off in flesh trade by the neighbors .  for self - defense , she used to sleep with a knife under her pillow . at home , mostly she was noted to be withdrawn and fearful . whenever husband went out to work then she d run to her sister 's house and had to be fetched back home for which she was reluctant always in coming . on active enquiry ; she reported a voice commanding her to run away from the house if she wished to be safe , also of having other auditory hallucinations of people ( neighbors ) talking amongst themselves about ways of harming her and her family . patient was admitted to our psychiatry ward for evaluation and work - up . after admission mrs . , she was conscious and oriented to time , place and person with poor eye contact , low tone rough voice with a paucity of speech , psychomotor activity was decreased and affect was apathetic . she was guarded about her hallucinations but came out easily with her delusions with a bprs score of 41 . depressive features or death thyroid profile was altered with thyroid stimulating hormone - 63.71 miu / l , free tri iodo thyronine ( ft3 ) - 2.1 pg / ml , free tetra iodo thyronine(ft4 ) - 0.6 ng / ml and normal ulltrasound - thyroid . patient was started on thyroxin 100 g after consultation from the endocrine department of our hospital and a low dose risperidone 2 mg , which was then withdrawn over a week with the recovery of her behavioral abnormalities and then she was continued with thyroxin alone . she was discharged after about 2 weeks of hospitalization with the absence of any hallucinations and delusions with a bprs score of 8 . after 1 month , on second follow - up , relatives reported a 90% overall improvement and absence of delusions and hallucination . the myxedema patient presenting with frank psychotic features of delusions and hallucination without having affective symptoms was benefitted from an early intervention and apt correction of hypothyroidism . so every patient presenting with psychotic features having signs or symptoms suggestive of hypothyroidism should have a complete thyroid work - up to minimize the unnecessary long - term administration of antipsychotics .
myxedema madness is a very rare but established entity . 
 a psychotic patient having hypothyroid features should always be evaluated regarding same . a 30-year - old female without known significant past medical history had , for the past one and half year , continuous persecutory and referential delusions ; second and third person auditory hallucinations , facial puffiness and brief psychiatric rating scale ( bprs ) score of 41 on admission . 
 her thyroid profile was : thyroid stimulating hormone - 63.71 
 miu / l , free tri iodo threonine ( ft3 ) - 2.1 pg / ml , free tetra iodo thyronine ( ft4 ) - 0.6 ng / ml with normal ultrasound - thyroid . 
 patient was started on thyroxin 100 g with a low dose risperidone 2 mg . 
 risperidone was withdrawn over a week and the patient was discharged on thyroxin alone with bprs score of 8 and absence of delusions and hallucinations .