Woodbury (1918) described the manifestations of Graves' disease as fatigue, irritability, intolerance to heat, fine tremor, restlessness, insomnia, excitability, labile emotional disposition, nervousness, weight loss, palpitations, doubts, and fears. Similarly, Sachar (1975) included nervousness (manifested as apprehension, restlessness, and inability to concentrate), marked emotional lability, and hyperkinesis as the most common presenting symptoms. That fatigue, irritability, emotional instability, and excitability are all common features of the hyperthyroid state, as are episodes of severe and often disabling anxiety, is therefore, accepted. On the other hand, no clear picture exists concerning any fixed constellation of psychotic symptoms or progression of psychiatric disease. The psychiatric presentations vary from a delirious state to periods of hyperexcitability simulating mania that alternate with periods of exhaustion and depression. Greer & Parsons (1968) reported that some patients do. however, develop a clear schizophrenia-like picture, closely associated with the course of hyperthyroidism, with prominent paranoid symptoms and no pre-morbid history of psychosis.

A doctor is trained, perhaps over-trained, to try to limit his diagnosis to a single disease process or entity. This may lead on occasion to a somewhat blinkered approach to the management of patients. The following case illustrates multiple and concomitant pathology in a single individual.