Thyro-stress.

Our understanding of the biopsychosocial model of health, and its influence on chronic endocrine conditions, has improved over the past few decades. We can distinguish, for example, between diabetes distress and major depressive disorders in diabetes. Similar to diabetes distress, we suggest the existence of "thyrostress" in chronic thyroid disorders. Thyro-stress is defined as an emotional state, characterized by extreme apprehension, discomfort or dejection, caused by the challenges and demand of living with thyroid disorders such as hypothyroidism. This communication describes the etiology, clinical features, differential diagnosis, and management of thyro-stress.

HYPOTHYROIDISM

Hypothyroidism is a common, and seemingly “benign” condition, with multiple and diverse symptomatology. There is evidence to show that hypothyroidism is associated with a significant impact on psychological, including sexual health. We also know that many of our hypothyroid patients are unhappy.[1] Many of the symptoms of hypothyroidism are cognitive in nature, and overlap those of major depressive disorder. The physical complaints, too, may impair emotional health and quality of life. In general, however, not much attention has been paid to the psychosocial aspects of hypothyroidism.

DISTRESS IN DIABETES

This is in stark contrast to the attention that psychosocial health receives in the management of diabetes mellitus, which is also a chronic endocrine condition.[2] It is noteworthy that the same specialty of doctors looks after people with hypothyroidism and with diabetes. Yet, while patient-centered care is the core mantra of diabetology, the concept of patient-centered thyroidology has not been highlighted till recently.[3]

Our understanding of the psychosocial aspects of diabetology has evolved markedly over the past few decades. Especially important is our ability to differentiate between major depressive disorders and a condition termed as diabetes distress.[4] The American Diabetes Association (ADA) clearly mentions the need to assess and address diabetes distress as a part of routine diabetes care. The ADA supports this recommendation by pointing out the benefits that accrue from such interventions.[5]

Simply put, diabetes distress is defined as a state of extreme apprehension, discomfort, or dejection, in dealing with the challenges and demands of living with diabetes. The symptoms are similar to those of depression, but do not meet the severity required for a diagnosis of major depressive disorder. The phenomenon of diabetes distress has been studied in depth, and validated tools are available for its screening and diagnosis. The therapy of diabetes distress is still a fluid area, through it is accepted that treatment should be nonpharmacological, rather than drug based, in nature.

DISTRESS IN HYPOTHYROIDISM

Individuals living with hypothyroidism also suffer from symptoms similar to those of diabetes distress. They may be concerned about the impact of hypothyroidism on their physical or mental health. The impact of the condition on social health can be a serious matter; a “hypothyroid” label may impair marriage prospects in a society which follows arranged marriage. Potential impact on transgenerational health, i.e., potential of transmission to the next generation, and on fertility, is also a cause of stress. Apart from the possible influence on physical, mental, and social health, hypothyroidism may cause deterioration in financial health: the cost of investigations and therapy may not be affordable for all, especially in pay-from-pocket markets. All these concerns may contribute to impaired quality of life in patients with hypothyroidism.[6]

We propose the word “thyro-stress” [Box 1] as a label to explain these emotions, which may range from concern to fear, from apprehension to dejection, or from lack of confidence to discomfort. While many of these symptoms may be explained by uncontrolled hypothyroidism per se, they may also be a manifestation of hitherto unrecognized stress. There may be a tendency on part of the treating physician to attribute all such concerns to high thyroid-stimulating hormone levels, while actually the etiology is much more complex. The biopsychosocial triad,[7] therefore, should be utilized to study hypothyroidism, just as it is for other chronic illnesses such as diabetes.

Box 1

Thyro-Stress

DIAGNOSIS

For “thyro-stress” to be accepted as a disease entity, it has to have objective diagnostic criteria, a proposed etiopathogenesis, a list of clinical features, and a rubric for management. Thyro-stress can be diagnosed using psychometric instruments, which have been developed for the use in oncology.[8] The etiopathogenesis similar to that postulated for diabetes distress. Thyro-stress does not seen to be a separate comorbid condition but is a part of living with hypothyroidism.

The clinical features are alluded to in the definition: thyro-stress is an emotional state, rather than a physical one. Similar psychosocial distress has been described in patients with thyroid cancer.[9]

The main differential diagnosis of thyro-stress is uncontrolled hypothyroidism per se. Other differentials include psychiatric conditions such as anxiety neurosis and major depressive disorder, with a theoretical differential of tissue hypothyroidism.[2]

MANAGEMENT

The management of thyro-stress is nonpharmacological, and based on the triptych of education, counseling, and support. We suggest a tri-pronged “thyroid therapy by the ear,” similar to what has been proposed in “diabetes therapy by the ear.”[10] Active listening, empathic explanation, and helping filter misinformation about thyroid health (gained from various sources, including hearsay) form the three pillars of therapy by the ear.

Inclusion of these simple communication-based interventions in routine thyroidology practice will help improve patient satisfaction, patient-physician bonding, and adherence to therapy, while relieving thyro-stress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.