Sheehan's syndrome presenting as psychosis: a rare clinical presentation
A 31 year old Muslim female patient, housewife by occupation, reported to our department of psychiatry accompanying her family members with recent onset of aggressive behavior with friends and family. On detail enquiry, her family members revealed that they have noticed a change in her behavior for the last four months which apparently started about 16 -18 days after her first delivery. The complaints included use of abusive language, fearfulness, talking to self, absconding tendencies, dressing unusual clothes, and history of persecutory ideas, saying that her friends and family members are spying against her and they are planning to hurt her. She also complained of hearing voices conspiring against her. Recently her sleep pattern has also become quite irregular, sleeping for only few hours a day, and not doing house hold work. She neglected her personal hygiene as well as her child's care. Patient had a full term hospital delivery with history of postpartum haemorrhage during the delivery. There was failure of lactation after her delivery and since then she had amenorrhea. There was no past history of any psychiatric or neurological illness in her or any of her family members. She was neither a smoker nor a drinker and had never abused illicit drugs. There was not any past forensic record related to her. Her family members had attended various faith healers, and surprisingly not consulted any doctor for her abnormal behaviour. On general physical examination, she looked pale and anaemic; breast atrophy was present; as were features of hypothyroidism. She was afebrile, and vital signs were normal. She was oriented to time, place, and person. Neurological examination revealed bilateral up going plantars. Her gait was normal. Mental status examination revealed her appearance as unkempt, apathetic and uncooperative. Her speech was largely irrelevant and incoherent. Thought had persecutory delusions. Her memory was intact. However, her performance in attention and concentration tasks and verbal fluency tests were unsatisfactory. She had no insight and had no understanding of why she was brought to hospital and her social judgment was poor.\nLaboratory investigation including renal function, liver function as well as workup for inflammatory and infectious conditions did not reveal any abnormalities. Her Hormonal profile revealed low levels of serum T3, T4, Cortisol, FSH & LH as given in .\nUltra sonogram (USG) of abdomen and pelvis showed small atrophic uterus with shrunken ovaries and computed tomographic scan of brain showed partially empty sella. Thus the diagnosis of Sheehan's syndrome was confirmed. Patient was put on olanzapine 10 milligram for 1 week but did not show any significant improvement and then was later shifted to prednisolone 5 mg/day and thyroxine sodium 100 ug/day. Over a period of few weeks, there was improvement of all her physical and psychiatric symptoms. Patient was given counselling about continuation of treatment for her life time and importance of maintaining a regular follow-up.