Heinrich and Grahm
4 stated that myxedema madness can be the presenting symptom of underlying hypothyroidism in approximately 15% of cases. Because myxedema is rare, however, it is often overlooked as the cause of psychosis.
5,6 As seen in our case and in previously reported cases,
7 hypothyroid-related psychosis typically resolves after the administration of levothyroxine sodium, the standard therapy for new-onset hypothyroidism.
In the present case, the patient's hypothyroidism was believed to be caused by a rare somatovisceral reflex dysfunction. Such dysfunctions of the thyroid have been described in the osteopathic literature for over a century. In the early 1900s, Burns
8 observed a relationship between somatic dysfunction of C4 through C7 and the thyroid in animal studies. During the next few decades, Webster
9(pp102-104, 136-142) and Unverferth
10 described the thyroid as a "somatovisceral responder" and as a vis-cerosomatic source of somatic dysfunctions. In the 1980s, Camilleri and colleagues
11 demonstrated gastric effects of somatovisceral reflexes in humans, and in the 1990s, Sato
12 demonstrated the existence of somatovis-ceral reflexes in experimental animals. Around the same time as Sato's work, Chang and colleagues
13 reported a small study demonstrating the existence of a somatovisceral pathway for the esophagus in humans. In the first edition of
Foundations for Osteopathic Medicine,14 Willard and colleagues described a feed-forward loop, or the process by which pathologic processes of the thyroid worsen somatic dysfunction and, in turn, somatic dysfunction worsens thyroid function.
Sympathetic innervation of the thyroid comes from the sympathetic fibers at spinal levels T1 through T4, which innervate both the blood vessels that supply the thyroid and the cells of the thyroid that produce its secretions.
8(pp4-6,187,192),8(pp491,493) The superior, middle, and inferior cervical paraspinal ganglia are found in the fascia of the cervical spine at spinal levels C2, C6, and C7, respectively.
8(p491) The fascia surrounding the thyroid cartilage and thyroid gland is continuous, extending from the occiput into the thorax.
17 Sympathetic innervation is believed to be associated with altering secretions of the thyroid.
8(pp4,187) Parasympathetic innervation of the thyroid comes from the superior and inferior laryngeal nerves and a branch from the main vagus nerve.
8(pp5-6,192),16(pp491,493) Despite some transient effects that have been demonstrated by sectioning parasympa-thetic innervation of the thyroid in rats,
18 the influence of parasympathetic innervation on the thyroid remains unknown.
8(p187) It can be discerned that the neurologic and anatomic features of the cervical region influence thyroid function and that somatovisceral reflex dysfunction can result in hypothyroidism.
The most common sites of somatic dysfunction associated with thyroid problems include the upper cervical spine (C1-C2), the cervicothoracic junction (C7-T1), and the upper thoracic spine (T1-T4).
19 Resolution of the present patient's hypothyroidism occurred after surgical refusion of the patient's cervical spine at the C5-C7 vertebrae. For many cases of somatic dysfunctions related to thyroid viscerosomatic dysfunctions, however, osteopathic manipulative treatment of C4 through C6 is indicated.
8(p317)