And It's About Time There Was Some Support For Cushing's!
A Literature Review
3 Sep 1999
by Troya Renee Yoder, used with permission
as originally posted on Suite 101.com, Pituitary
Disorders
Psychiatric symptoms such as depression, apathy, irritability, and hostility have long been associated with pituitary disorders. In 1913, Harvey Cushing published a paper in the American Journal of Insanity (what a title!) entitled “Psychic disturbances associated with disorders of the ductless glands.” Cushing recognized that a significant proportion of his endocrine patients displayed psychiatric symptoms, and that even after successful treatment of the endocrine disorder (i.e.-hormone levels restored to normal), often residual psychological symptoms remained. He questioned whether the pituitary disease caused the stress and depressive symptoms he observed in his patients, or whether stress caused the pituitary disease (Cushing, 1913).
Since Cushing, there have been numerous studies documenting the relationship between depression and pituitary tumors. Here is a brief summary of a few of the most interesting:
Hyperprolactinaemic patients are more depressed, more anxious, and less self-controlled than the general population. These psychological symptoms generally improve with administration of dopamine agonists such as bromocriptine (Buckman and Kellner, 1985).
Hyperprolactinaemic patients with no visible pituitary adenoma on their CT scans demonstrated higher levels of anxiety and hostility than those with definite pituitary adenomas, despite comparable prolactin levels (Saffron, 1997).
A study comparing nursing mothers with hyperprolactinaemic women due to a pituitary tumor found that the adenoma group demonstrated depressed mood, decreased libido, and increased irritability compared to the nursing group. These symptoms improved in some cases with the surgical removal of the tumor (Rothchild, 1985).
Numerous studies have found a significant correlation between idiopathic hyperprolactinemia (no visible adenoma) and paternal deprivation during childhood (i.e.-through absence, alcoholism, or violence). In addition, the onset of hyperprolactinemia was often preceded by pregnancy or a loss event (Sobrinho et al., 1984). This data led to the hypothesis that some women may be predisposed early in childhood to develop hyperprolactinemia later in life.
Numerous studies have estimated that up to 85% of Cushing’s patients demonstrate psychiatric symptoms. The most common are increased irritability, depression, fatigue, decreased libido, memory impairments, difficulty concentrating, insomnia, and social withdrawal (Starkman et al., 1981).
Cushing’s patients demonstrate major depression more than any other endocrine or non-endocrine medical condition. There is no difference between pituitary-dependent (Cushing’s disease) and pituitary gland-independent (Cushing’s syndrome) with regard to depression (Sonino et al., 1993a).
Cushing’s patients reported significantly more losses and uncontrolled, undesirable life events than healthy controls in the year prior to the onset of disease (Sonino et al., 1993b).
In one study: prior to treatment, 67% of Cushing’s syndrome patients demonstrated significant psychopathology. Within 3 months of correcting hypercortisolism, only 54% of these patients showed psychopathology. At 6 months this number decreased to 36% and at 12 months, 24% still showed psychopathology, despite correction of cortisol levels (Dorn et al., 1997).
Anti-depressant therapy is generally ineffective in acutely hypercortisolemic Cushing’s patients. However, once cortisol levels are normalized, antidepressant drugs may be very effective at reducing depressive symptoms (Sonino and Fava, 1998).
Acromegalics often demonstrate a loss of initiative and spontaneity, mood swings, diminished libido, self-esteem issues, body image distortion, and social withdrawal (Richert et al., 1983; Ezzat, S., 1992).
Prediagnosis – “Despite my personal strength of character I began to notice several changes in personality within the year prior to my diagnosis with acromegaly. I experienced increased levels of irritability and agitation, increased periods of emotional lability, feelings of extreme anxiety and stress and the beginnings of periods of anger. At times I became enraged following the slightest provocation. I recall attempting to understand what in my life was precipitating these intense emotions, which hitherto had been relatively absent.” --Keli Furman, in “Psychological Features of Acromegaly”, Psychother Psychosom (1998); 67: 150.
Severe psychological distress may arise after surgery to remove a pituitary tumor. Often patients expect to recover quickly once the offending tumor is removed. However, recovery generally takes years, leaving patients with symptoms similar to posttraumatic stress disorder (PTSD). These symptoms may include diminished recall, feelings of detachment, difficulties falling or staying asleep, irritability, diminished concentration, depression, and social withdrawal (Furman and Ezzat, 1998).
Buckman, M.T., and Kellner, T. (1985). Reduction of distress in hyperprolactinemia with bromocriptine. Am J Psychiatry, 142: 242-244.
Cushing, H. (1913). Psychiatric disturbances associated with the ductless glands. Am J Insanity, 69: 965-990.
Dorn, L.D., Burgess, E.S., Friedman, T.C., Dubbert, B., Gold, P.W. and Chrousos, G.P. (1997). The longitudinal course of psychopathology in Cushing’s syndrome after correction of hypercortisolism. J Clin Endocrinol Metab, 82: 912-919.
Ezzat, S. (1992). Living with acromegaly. Endocrinol Metab Clin North Am, 21(3): 753-760.
Furman, K. and Ezzat, S. (1998). Psychological features of acromegaly. Psychother Psychosom, 67: 147-153.
Richert, S., Eversmann, T., Fahlbush, R., et al. (1983). Psychopathology, mental functioning and personality in patients with acromegaly. Acta Endocrinol (Copenh) Suppl., 253: 33.
Rothchild, E. (1985). Psychologic aspects of galactorrhea. J Psychosom Obstet Gynecol, 4: 185- 196.
Saffron, R., Fisher, A.D., Owen, D., Creed, F.H. and Davis, J.R.E. (1997). Psychological distress in patients with hyperprolactinemia. Clin Endocrin, 47: 343-348.
Sobrinho, L.G., Nunes, M.C.P., Calhaz-Jorge, C., Afonso, A.M., Pereira, M.C., and Santos, M.A. (1984). Hyperprolactinemia in women with paternal deprivation during childhood. Obstet & Gynecol, 64: 465-468.
Sonino, N., and Fava, G. (1998). Psychosomatic aspects of Cushing’s disease. Psychother Psychosom, 67: 140-146.
Sonino, N., Fava, G.A., Belluardo, P., Girelli, M.E., and Boscaro, M. (1993a). Course of depression in Cushing’s syndrome: Response to treatment and comparison with Graves’ disease. Horm Res, 39: 202-206.
Sonino, N., Fava, G.A., and Boscaro, M. (1993b). A role for the life events in the pathogenesis of Cushing’s disease. Clin Endocrinol, 38: 261-264.
Starkman, M.N., Schteingart, D.E., and Schork, M.A. (1981). Depressed mood and other psychiatric manifestations of Cushing’s syndrome: Relationship to hormone levels. Psychosom Med, 43(1): 3-17.
