A 45 year old female civil servant presented to primary care for a routine evaluation of her lipid profile. When questioned, she described a history of lethargy and low mood. The patients GP noted features of agitation and sweating and organised a range investigations including thyroid function tests. Past medical history included systemic lupus erythematosus, a diagnosis that the patient had experienced difficulty accepting, requiring an extended period of counselling.
Thyrotoxicosis was confirmed; fT4 32.1 pmol/l, TSH<0.01 mU/l likely secondary to Graves disease with elevated thyroid microsomal and TSHR antibodies. The patient was adamant that she had neither discussed nor consented to an assessment of thyroid function. As a result, she persistently expressed denial regarding the diagnosis, initially declining all intervention and subsequently demonstrating non-compliance with thionamide medication.
After six months, the patient agreed to be reviewed by a liaison psychiatrist to explore her anxieties accepting the diagnosis. In conjunction with frequent specialist thyroid nurse contact, reassurance, reminders and encouragement she adhered to a six month course of carbimazole and thyroxine. On becoming euthyroid, the patient was able to achieve a coherent perspective of the disease. She has remained in remission seven months after discontinuation of medical therapy.
Patients may experience prolonged difficulties accepting a diagnosis due to psychosocial circumstances, religious beliefs, level of education, cognitive impairment and psychiatric disorders. This is observed more commonly with diagnoses of malignancy and conditions requiring long term management such as diabetes mellitus.
As thyrotoxicosis may be associated with anxiety, depression, cognitive impairment and paranoid ideation, this may exacerbate pre-existing difficulties in rationalising illness. Such patients should be counselled carefully regarding planned investigations with maintenance of thorough documentation.