Hypopituitarism (Sheehan's syndrome presenting with organic psychosis.

The patient was a woman aged 55. For two years before her admission to a psychiatric hospital she started to develop delusions and auditory hallucinations-for example, she would not go out of the house because she was followed by a car; she said, 'There is a man watching my house', 'Meetings are held in a hall behind my house to decide to have me sent away'; she heard the occupants of an aeroplane telling her that she 'will be put away'. She would sit in a chair for hours crying. She remained like this for nearly two years. At first she refused to see a doctor and rejected all efforts to help, even a domiciliary visit was not acceptable. Eventually she was persuaded to see a psychiatrist who recommended her admission and prescribed thioridazine 50 mg t.d.s. On admission she was apathetic, retarded, hallucinated, disorientated; her memory was impaired and she gave an especially muddled and inaccurate account of recent events. She could repeat four digits forward and three backwards. A diagnosis of a paranoid state with an organic dementia was made. A week after her admission she had a grand mal fit which was thought to be possibly due to the phenothiazine. Her blood pressure on admission was 150/80 mm Hg. A week later it dropped to 110/70 mm Hg, and she became more lethargic. On the same day her condition deteriorated rapidly, she became very lethargic, her blood pressure dropped further to 95/65 mm Hg and she became semi-conscious. This was when the author first saw her. She was semi-conscious, pale, had a dry skin, and no axillary or pubic hair (Figs. 1 and 2). A history was obtained from her daughter. The patient had not been well since her last childbirth 21 years before. She had triplets, it was a difficult delivery, and she had a severe haemorrhage. Afterwards she developed 192 amenorrhea, became pale, tired quickly, increasingly felt cold, and also lost her axillary and pubic hair. The diagnosis of hypopituitarism (Sheehan's syndrome) was made. She was treated with intravenous hydrocortisone to which there was a dramatic response in her physical condition. Next day she became alert and a good history was obtained from her. Her electroencephalogram (EEG) showed no normal alpha rhythm, but the EEG was dominated by a 6 Hz rhythm interspersed by short episodes of 2 to 3 Hz waves. This is common in fairly severe generalized abnormalities, including hypopituitarism. Treatment was continued with oral cortisone (37 5 mg daily) and initially a small dose of thyroxine (0 05 mg daily), which was later increased (015 mg daily). Within