Download Hyperaldosteronism and bipolar mixed episode: A case

IJABS 2015: 2:1
© 2015 Behavioral Research Center
of SBMU Arbabi
Hashempour,
Brief Article
Hyperaldosteronism and bipolar mixed episode: A case report
Hashempour Sarah1, Arbabi Mohammad*2
1
. Psychiatrist, University of Welfare and Rehabilitation Sciences, Tehran, Iran.
. Associate Professor, Department of Psychiatry, Tehran University, Tehran, Iran.(Corresponding Author: Mohammad
Arbabi, [email protected], Roozbeh Hospital, South Kargar Street, Tehran-Iran)
2
(Received: 8 Mar 2015; Revised: 12 May 2015; 10 Jan 2015)
Abstract
Introduction: Aldosterone is a steroid hormone produced by the outer section of the adrenal cortex.
Both glucocorticoids and mineralocorticoids receptors are present in brain structures (e.g.
hippocampus and amygdala) that are involved in behavior such as fear and anxiety.
Methods: We report a 54 year old male who was referred from the endocrine ward presented with a
dysphoric mood, irritability, insomnia, decreased in appetite, talkativeness, anhedonia,
hopelessness, worthlessness, recurrent thought of death, somatic symptoms, which include
palpitation and sweating.
Mental status examination revealed bipolar 1 disorder, single episode mixed, severe, without
psychotic feature based on diagnostic statistical manual of mental disorder (DSM4TR)
The aldosterone was high and renin was low. Other clinical examination was normal.
Conclusion: The age of onset, no history of mood episodes, atypical feature of this episode and
associated hyperaldosteronism suggest the causal role of aldosterone in this episode.
The patient was treated with Depakin 500m/d, Quetiapine 50mg/d and Haloperidol 5mg/d.
His mental and somatic symptoms improved in 4 weeks.
This case can show the relationship between hyperaldosteronism and mood episodes.
For future studies, it is decent to do more investigation to find the role of aldosterone in mood
regulation.
Declaration of Interest: None.
Keywords: Hyperaldosteronism, Bipolar mood disorder, mixed episode
Introduction
Aldosterone is a steroid hormone produced
by the outer section of the adrenal glands,
which had an important role in reabsorption of
sodium ions and chloride ions, secretion of
potassium and hydrogen ions, thus preserving
the extracellular fluid (1). As a result of
overproduction of aldosterone secretion unrelated
to renin, the primary hyperaldosteronism is
diagnosed (2-4). Sodium and potassium are two
important ions in action potential of neurons in
the central nervous system (4).
Mineralocorticoid receptors (such as glucocorticoid
receptors) are scattered in brain structures,
which are involved in anxiety and fear and
selection of targeted behaviors (as hippocampus
and amygdala structures) (5, 8). Aldsterone is
secreted due to response of hypotalamopituitary- adrenal (HPA) axis. In the past, this
combination effect of behavior was not
attractable but recent studies have shown more
attention to this hormone and its correlation
with patients' behavior (3,9). Recent studies
have shown a higher prevalence of anxiety and
International Journal of Applied Behavioral Sciences (IJABS) volume 2 number 1 Spring 2015. Journals. smbu.ac.ir/ijabs
41
Hyperaldosteronism and bipolar mixed episode: A case report...
depression in primary hyperaldosteronism patients
(6, 9).
In a study by Sonino et al. in 2006, clinical
manifestation have been evaluated in 10
psychiatric patients with primary hyperaldosteronism. The result of this study is indicated
that generalized anxiety disorder, obsessive
compulsive disorder, physical and irritable
mood was seen in 6 patients with primary
hyperaldosteronism (7).
Another study by Kunzel, Sonino, Apostolopoulouk and Hendler were shown that higher
levels of aldosterone in patients with depression,
anxiety and mania (6-9).
Another study conducted by Hallberg has
demonstrated that the lower levels of aldosterone
had a positive relationship with suicide in
depressed patients (12).
In 1995, a study was conducted by Walton et
al. on two groups of students presented that
students who learned and used the anxiety
reduction method, the result had lower level
serum aldosterone and also lower appearance
of mood and anxiety disorders than others (14).
Therefore, the aim of this case report is to
introduce a case with hyperaldosteronism and
mixed mood disorder episode. The present case
indicates that the mood symptoms coincided
with the increased aldosterone appears to be
related to his symptoms.
Case report
A 54 year old male was admitted to the
endocrine ward and referred to our hospital for
psychiatric consult due to symptoms of
malaise, dysphoric mood, irritability, insomnia,
loss of appetite, increasing the amount of
speech, lack of enjoyment of life, hopelessness,
thoughts of worthlessness, and thoughts of
death. These symptoms were started from 4
months ago, after change in his career. Other
symptoms such as sweating and palpitations
were seen as well. According to DSM4TR
criteria, he was admitted in the psychiatric
ward with diagnosis of bipolar disorder single
mixed episode, severe, without psychotic
feature.
There was no history of mood episodes in this
patient. He had a history of cigarette smoking
42
and opioid consumption but has been in
abstinence from four years ago.
In family history, there was a depressive mood
episodes and suicide behavior was seen in his
sons. Laboratory studies on this patient
demonstrated high aldosterone and low renin
levels, which represented the primary Hyperaldosteronism. Sodium and potassium serum
levels were normal.
This patient had been treated in hospital for two
weeks by Depakin 500 mg, haloperidol 5 mg
and 50 mg daily of Quetiapine for control of
symptoms, then he was discharged.
Conclusion
Since sodium ions have an important role in
action potentials of neurons, so, increased
levels of aldosterone can be made by increasing
the sodium ion level, which can cause nerve
cell excitability (4). The mineralocorticoid
receptor changes in the brain such as the
hippocampus and amygdala, which could be a
result of changes in aldosterone level, and
could account for changes in mood and anxiety
levels (5-15).
In this case, according to symptoms in upper
age with no previous history of mood disorder,
atypical and mixed manifestations with
increased aldosterone level can be discussed.
Studies by Hlavacova and Gripo in 2008 and
2006 presented that the result of stress can be
created by increasing the aldosterone
exacerbation cycle (10, 15).
In a study by Handler et al. and sonio et al. in
2006 and 1975 demonstrated that an increase in
aldosterone can change the mood in depression
and anxiety in manic patients. In these studies,
obsessive and panic irritable mood had been
noted, but the present patient presented mixed
episodes, and irritability (7, 11).
In a study in 2014 by Apostopoulou indicated
that women are more affected of aldosterone
level than men, but mixed episode are usually
more common in women than man (9).
Therefore, this presentation in this patients can
be seen as a result of patient's endocrine
etiology.
In a study by kunzel in 2012, more improve in
physical symptoms than anxiety and depression
symptoms were noted (6), so in our patients,
International Journal of Applied Behavioral Sciences (IJABS) volume 2 number 1 Spring 2015. Journals. smbu.ac.ir/ijabs
Hashempour, Arbabi
the physical symptoms such as sweating,
palpitations and headache were more improved.
The presence of a positive family history may
point to the role of independent genetic factors
in endocrine disease incidence. It seems that
aldosterone level can be evaluated in patients
with a family history of mood disorder. Thus,
more studies are needed around this issue.
Also, more study on aldosterone levels during
treatment is more needed. Knowing the
physiopathology of aldosterone level and its
relation with mood disorders can help to find
more completed treatment approaches such as
using aldosterone antagonists and so on.
Acknowledgment
We would like to thank to our colleagues and
the organizations for all provided insight and
expertise that greatly assisted this research and
patients who helped us kindly in the project.
We also tried to consider all ethical issues in
this study.
11. Hendler N. Lithium-responsive hyperaldosteronism
in manic patients. Journal of Nervous and Mental
Disease. 1975; 161(1):49-54.
12. Hallberg L. Decreased aldosterone in the plasma of
suicide attempters with major depressive disorder.
Psychiatry Research. 2011; 187(1-2): 135-9.
13. Murck H, Held K, Zigenbein M, Kunzel H, Kokh K,
Steiger A. The rennin–angiotensin–aldosterone
system in patients with depression compared to
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Stress reduction and preventing hypertension:
preliminary support for a psychoneuroendocrine
mechanism. The Journal of Alternative and
Complementary Medicine. 1995; 1(3):263–283.
15. Grippo AJ. Sadness and broken hearts: neurohumoral
mechanisms and co-morbidity of ischemic heart
disease and psychological depression. Journal of
Physiology and Pharmacology. 2006; 57:5–29.
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International Journal of Applied Behavioral Sciences (IJABS) volume 2 number 1 Spring 2015. Journals. smbu.ac.ir/ijabs
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