Q. Dear Dr. Heller
Iím a mental illness practitioner with a private company. I have 25 years of experience in the mental illness management field. Presently I am working with a client that presents with interesting symptoms, Her psychiatrists feels she is an enigma, I agree. The family has a history of Schizophrenia and just recently I found out, hypothyroidism. The genetic link for Hypothyroidism is particularly strong. She has classic symptoms of fatigue, weight gain and severe memory problems almost dissociation. Her mother told me her sister was having the same symptoms and her TSH was normal it wasn't until their was some kind of mass that they did a radiology test and found out the problem was the thyroid. My client has been severely disabled for three years. I think there is a link. I recently read in your article referring to hypothyroidism in spite of a normal TSH. If TSH is normal ? But highly suspicious what is the diagnostic rationale or criteria for further testing and what tests or process should be initiated.
Thank you for your clinical expertise
A. It's called "non primary" hypothyroidism. Primary hypothyroidism (by far the most common) occurs when the thyroid gland itself fails and the TSH is elevated.
Non primary hypothyroidism is either "secondary" - where the hypothalamus fails to measure the thyroid blood level properly or doesn't release TRH properly. "Tertiary hypothyroidism" refers to the condition where the pituitary doesn't respond to TRH.
Many times - if financial conditions allow it - endocrinologists can do tests to determine which if either is present. Since the treatment is the same for all three types - thyroid replacement hormone - many times the individual doesn't need the thorough evaluation.
Borderlines have a blunted response to TRH - meaning they don't make enough thyroid hormones when stimulated by the hypothalamus.
The symptoms of low thyroid include: fatigue (which can be severe), numbness and tingling, reduced memory and concentration, constipation, panic attacks, weight gain (even with strict dieting and exercise), dry skin, puffiness around the eyes, hair loss, coarse hair, slow heart rate, high cholesterol, fluid retention, PMS, cold intolerance, orange skin color, large tongue, low body temperature, anemia, depression, progressive changes in personality, seizures, and eventually coma and death.
If a great many of these symptoms are present with normal labs, a trial of medication may be indicated - being careful to keep the TSH normal. When the TSH is too low the level may be too high, triggering panic attacks and bone loss.
Another problem is "thyroid resistance" - where the body doesn't respond to normal doses. High doses are needed, but again the TSH must not go too low.