PC1177: Worsening Anxiety with a New Origin: New-onset Graves Disease in an Adolescent

Introduction: The global incidence of anxiety symptoms in adolescents has increased during the COVID-19 pandemic and pediatric providers are critical to addressing this mental health crisis (N. Meyers et al, 2021). Further, comprehensive differential diagnoses in patients with mental health disorders that are presenting with new findings are critical to mitigating anchoring bias during diagnosis.

Case Description: An 18-year-old female with a medical history significant for anxiety, panic disorder, cannabis use disorder, migraines, and asthma presented to the adolescent clinic with heart palpitations, shortness of breath, headache, and worsening anxiety symptoms. These symptoms began one month prior to presentation and had become more severe. Notable physical exam findings were tachycardia at rest (134 bpm), tachypnea (20 bpm), and dyspnea. She was referred to the Emergency Department for further work-up and management where lab studies revealed a suppressed TSH ( < 0.01 mIU/L), elevated Total T4 (15.0 ug/dL), and free T4 (4.08 ug/dL), with serum presence of thyroid-receptor antibodies. Thyroid ultrasound showed an enlarged, mildly heterogeneous thyroid gland with diffusely increased vascularity. Altogether, the patient was diagnosed with new-onset Graves Disease and initiated treatment with methimazole and atenolol.

Discussion: In adolescents, hyperthyroidism is known to potentiate conditions such as ADHD, bipolar disorder, depression, anxiety, and suicidality in both stable and unstable thyroid disease (Zader et al, 2019). However, in contrast, a much smaller proportion of adolescents with anxiety and depression have been found to suffer a comorbid thyroid disorder (Fukao et al, 2020; Luft et al, 2019). For this reason, providers treating patients already diagnosed with mental health diagnoses may be less likely to discover a new diagnosis of thyroid disease, especially given that in greater than 40% of cases, the diagnosis of a mental health disorder precedes that of the diagnosis of hyperthyroidism (Zader et al). Of the heuristic cognitive biases in medical decision-making, anchoring bias is among the most common (Saposnik et al, 2016). Anchoring bias refers to “physician’s practices of prioritizing information and data that support their initial impressions, even when first impressions are wrong” (Doherty et al, 2020). The impact of anchoring bias in children and adolescents with psychiatric disorders may contribute to rates of thyroid disease being retroactively identified to be as high as 6% in children and adolescents hospitalized for psychiatric disorders (Luft et al, 2019).

Conclusion: This case highlights the importance of mitigating anchoring bias when managing patients with pre-existing mood and anxiety disorders. Providers should be mindful of anchoring biases (Croskerry, 2003; Rehana et al, 2020) when treating patients with mental health disorders so as not to delay the diagnosis of other organic medical causes for worsening anxiety or depression.