BP, BPD, Thyroid- Trying to Sort It Out
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Q:  BP, BPD, Thyroid - Trying to Sort It Out

Dear Dr. Phelps,

My daughter since age 12 has beeen diagnosed with Hypothyriodism. Over the years her Endocrinologist progressed her Levoxyl to 100mmg. She felt pretty good at this dosage. She is now 20 and over this past year her local Dr. lowered her dosage to 75mmg. After about a month of being on the lowered dose she started having mood swings, poor concentration, muscel cramps, irritability, depression, ect... During this time she enlisted in the Service, when she got to Boot Camp the Service Dr. confinscated her Levoxyl, do to a mixup with the Dr's she never got her perscription. After nearly 4 weeks without her meds she got very depressed and went to talk to the Service Pschologist. She was administered a test and it was determined that she has Boderline Personnality Disorder. She was dismissed and when she got home we got her back on the Levoxyl, and had her TSH level checked, it was very high. 9 days after being home we got her into see the local Psychologist, again she was given a test, this time it was determined that she has a mild form of Bipolar II Disorder. She was perscribed Paxil 12mg. After 2 months of being back on her thyrioid med. and 6 weeks on the Paxil we did another TSH test and it showed that she was now Hyperthyroid. She has since stoped taking the Paxil and we are trying to get her TSH on an even keel. Did the Paxil interact with her Levoxyl? I am wondering why the Service Psych. and the local Psych. hvae two different diagnosis? How accurate are these tests since there has never been a history of Borderline Personnallity Disorder or Bipolar II. It sounds like she was given the same test both times, with the local test being a little more indepth. Can Hypo and Hyperthyroidism cause these same symptoms and is there any material out there that can  confirm this? Also has there been much studies done on a defective thyroid and it's effect on the emotional and mental psyche? Sorry for any inconvenience of my long history explination.


Dear Jeanne -- 
As you obviously understand, this is a very complicated set of interactions of time and several medications (not to mention diagnoses).  Let's see if we can tease out something without guessing too much. 

First of all, the diagnosis if "borderline personality disorder" is worth questioning under almost any circumstances, in my view, as long as the questioning is done in a way that doesn't make your daughter's situation worse, which is not a trivial concern.  Here's an essay about the relationship, diagnostically, of "borderline" and bipolar.  As you'll see, my emphasis there is that the label should not interfere with the focus on treatment options. 

Second:  what happened to her thyroid status during this mess, and why was she "hyperthyroid" on a dose that seemed to have been managing things well before it was stopped?  Well, first we could wonder if there was a TSH done fairly near the time it was (so oddly) stopped.  Perhaps she was "hyperthyroid" even before she got to boot camp, i.e. by the test anyway, though not by symptoms (which can certainly happen), and it just wasn't detected then because the 100 mcg dose had been working fine for a long time prior to that.  

But, that's probably not the answer.  I'll bet it's way more complicated than that, but here the guessing starts.  I think there's some sort of relationship of the two disorders, thyroid and bipolar disorder, and that the symptoms which emerged (called by the military  "borderline personality disorder") while she was off thyroid were directly related to being off thyroid (no way to prove that, no point, in my view, in chasing after the military to blame them, because this relationship is too speculative).  However, I would also speculate that once they emerged, they represented the emergence of something closer to bipolar II (as "hypothyroidism" should not lead to such diagnostic speculations if that's really what was going on; those two are not thought to be related in terms of how they show up).  That emergence could, causatively, have had something to do with the thyroid shift, is my guess, and let me emphasize that this is a guess based on how often I hear about thyroid disturbances somehow appearing near the onset of bipolar symptoms.  

Third: why "hyperthyroid" on the previously effective dose of thyroid?  Again, guessing:  I think that the relationship of bipolar and thyroid is "two-way", i.e. that bipolar disorder can affect thyroid production too.  Fairly often I see a TSH down around 0.2 in someone where it had been closer to 1.0, during a mildly hypomanic-symptom phase.  The relationship is remarkably fuzzy though:  it's not directly related enough to say the "hyperthyroidism" (note this is by lab test, a too-low TSH, not by symptoms of hyperthyroidism) caused the bipolar symptoms, but rather just that I occasionally seem to see these things showing up at the same time in someone who does not have formally recognized underlying thyroid problems. 

Fourth: did the Paxil interact with levoxyl?  Not likely; there is no such recognized interaction I'm aware of.  Rather, I would guess that Paxil interacted with an underlying mood condition that was emerging then (as above, perhaps in some relation  to the thyroid condition; and I would guess there's a family history of mood problems?), namely this bipolar -like thing, and that in that fashion the Paxil might have contributed to the "hyperthyroid" thing via it's well-known capacity to adversely affect bipolar disorder (as all antidepressants may).  Now this one is really  speculating, trying to draw some connection between Paxil and what happened.  It's certainly possible that Paxil was an "innocent bystander". 

Lastly, about diagnosing bipolar disorder:  there is no test.  Any testing the psychologists may have done, e.g. the MMPI or some such, has not been connected to the diagnostic process (psychologists and psychiatrists, with the latter responsible for the official naming system, the DSM, sort of live in two different worlds, by a rather odd political history).  There is no blood test for bipolar, for example.  There is only the "Mood Disorders Questionnaire", which is supposed to be a "quick and dirty" test that can be used instead of a long diagnostic interview.  In my view the only "test" for bipolar is to make sure the patient understands in some detail the nature of bipolar II, as described on my website for example, and then see if she comes back in from reading it and goes "that's me!"  In that case, it's almost certain the MDQ would be strongly positive as well (the best way to try that test, which you can complete about her as well, is to take the link in this paragraph and read up about BPII, then use the links you'll find there to take the MDQ; it comes at the end of the section about Diagnosis.  This allows you to read about how to score it and how to interpret that score). 

Thanks for your interesting questions.  I hope things get smoother from here. 

Dr. Phelps

Published July, 2003


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