Addressing Thyroid Imbalance for Anxiety Relief and Depression Relief | Counseling Tools

Hey there, everybody, and welcome to this counseling CEU presentation on stress, thyroid hormones and mood. I'm your host, Dr. Donnelly Snipes. In the next hour, we're going to identify the connection between thyroid hormones and mental and cognitive health. We'll also explore the relationship between thyroid hormones and gonadal hormones and how they impact mental and cognitive health. Then we'll identify interventions to assist prevention people with thyroid and mood disorders. So let's start out with a primer on thyroid hormones. T4 or thyroxine is the main thyroid hormone, and you may be sort of familiar with that if you have clients that are on levothyroxine, which is a medicine that people who have hypothyroid often get. So T4, however, is inactive until it gets converted to T3. So the stress response kicks off. T4 is released, is broken down into T3. T3 causes the metabolism to be increased, blood sugar to be freed up into the bloodstream to be used, and energy consumption to be increased. So you can see right from here that the HPA axis and the HPT axis dovetail with one another, and a change in one is going to result in a change in the other. You can also see here that altered thyroid hormones are going to alter blood glucose levels, which can be important for people who are diabetic or pre diabetic. Now, T3 tests are most useful for diagnosing hyperthyroidism, but not as useful for detecting or diagnosing hypo or low thyroidism. Thyroid stimulating hormone or TSH tests detect whether the thyroid is being triggered to release T4. So when the HPA axis kicks off, TSH triggers the thyroid to release T4 into the system. So your TSH tests figure out is that part of the process working or not? Normal or low TSH and a low T4 indicate hypothyroidism. So if somebody's TSH test comes back low, it means that either the body is not releasing enough TSH to, to prompt the release of enough T4, or there's enough TSH, a normal level of TSH being released, but not enough T4 is coming out. We don't know why. So the thyroid, when it secretes that primary T4, there's a breakdown at that part of the system. Now, just like with neurotransmitters, there can be a lot of different places where this system breaks down. So this is just one of them. Elevated T3 or a low TSH and a high free floating T4 indicate hyperthyroidism. All right, so elevated T3. Remember, that's what T4 gets broken down into. And if there's a high level of T3, it had to come from somewhere. So that probably means that we had some hyperactivity early in the system. A high free floating T4 can also indicate that too much is being released, especially if there's a low tsh. So if the thyroid didn't need much encouragement at all to secrete a whole bunch of T4, that could indicate hyperthyroidism. Now, T3 testing is rarely helpful in the hypothyroid patient since it is the last test to become abnormal. So I thought that was interesting. Patients can be severely hypothyroid with a high TSH and a low T4, but have a normal T3. So what does that mean? There's lots of T's here and you can read all this and go, okay, but what does it really mean? Well, let's go through it a little bit at a time. So in order to get enough T4 out to keep the system going, the body is having to release a whole lot more tsh. So TSH is just pouring in. We have that tsunami of tsh, but unfortunately we're still not getting a whole lot of T4 out. Now there's a normal T3 because that tsunami of TSH is pushing out enough T4 to keep T3 somewhat in the normal ranges. But eventually that system is going to start becoming imbalanced. Acute stress has been shown to cause activation of the HPT or, or hypothalamic pituitary thyroid axis, whereas prolonged stress is associated with decreased activity. This is the same thing we see in the hpa, hypothalamic pituitary adrenal axis and the hpg hypothalamic pituitary gonadal axis. And it's the same basic principle that we've talked about with those other axes. When the system is functioning normally, there's a stressor. It responds to the stressor and then it balances out and recoups. But if the stressor, whatever that stressor, is ongoing, whether it's environmental or physical or emotional, whatever that stressor is, if that HPA axis stays active, if the body remains under stress, then eventually the body is going to turn down the sensitivity of that system so it can figure out how to conserve energy. It says, I can't keep responding to all the stuff I normally respond to. I just don't have it in me, so I'm going to turn down the sensitivity. So then if I can restore myself a little bit. And if there is something that I need to respond to and if there's something big enough that's actually going to trigger me, then I will have the necessary resources to do that. Significantly lower thyroid stimulating hormone and T3 levels have been found in populations reporting stress related mental health problems. So in people with stress related mental health problems, what we're seeing is the HPA axis is, is, has gone into that flat area where there is just not responding very much. It's not secreting very much TSH unless there's a huge reason to do so. And unless they go into the Flat and the Furious, unless there is a dysregulation and it is triggered to respond, the amount of TSH that's being released in response to normal stressors is low. As a result, there's less free floating T4 that can get broken down or converted into T3. So this all makes sense when we start thinking about how the changes in the HPA axis and the concurrent changes in the HPT and HPG axes as a result of ongoing stress. So yeah, it makes sense that we're going to see lower levels of these hormones. Hyper and hypothyroidism have been shown to be associated with oxidative stress and inflammation. Now this is another thing I thought was interesting because I can see hyper, but my thought was hypo. How does that happen? Well, hyperthyroidism, the system is running more intensely. And think about that HPA axis again and the HPT axis, the whole stress response system. Initially the body is going to be secreting a whole lot more energy, it's going to be secreting a whole lot more thyroid hormone to try to respond to this threat. So when people who've experienced trauma or who are under a lot of stress initially, we often see higher levels of thyroid hormones and cortisol and all those other things because the body is responding to this acute stressor. But after a point when the body decides hey, not going to continue throwing good energy after bad, got to turn down the sensitivity. Then we start seeing hypothyroidism, hypocortisolism, hypo, fill in the blank. Now what does that have to do with oxidative stress? When the body operates, it produces what's called free radicals. That's sort of the garbage, if you will, of the byproducts. Garbage. Byproducts of the living process. So this garbage builds up in the system. Think about a factory. Garbage builds up. And at the end of the day when the person or when the factory shuts down, the cleaning crew comes through, gets rid of all that garbage so the workers aren't tripping over it the next day. Well, when there's stress ongoing, then the factory never shuts down. That HPA axis keeps the factory running, at least at minimal levels or all the time. So the cleaning crew never comes through. And that oxidative stress is, or that those free radicals are produced faster than the body can clear it out. And that causes oxidative stress. That means those free radicals are hanging around and impairing the factory's ability to function. And that's what we call oxidative stress. Okay, so that explains oxidative stress with hyperthyroidism. But what about hypothyroid hypothyroidism? Well, one of the interesting things when we see hypocortisolism is that during periods of prolonged or extreme stress, eventually cortisol, our stress hormone, when the system is functioning normally, cortisol has anti inflammatory effects. It is a steroid that works to reduce inflammation, but as the system gets bombarded with it continuously, eventually it actually loses its anti inflammatory effects. It doesn't affect those receptors the same way anymore. And so we start seeing more pro inflammatory hormones starting to circulate throughout the system. Because. Because even though the person is stressed, the system can't hold down the inflammation anymore. The inflammatory workers have kind of taken over. When we have inflammation, it produces more free radicals, which produces more oxidative stress. So these all sort of make sense that when the person, when the thyroid is out of whack, it contributes to stress on the body. Now this could be because, because the HPA axis is out of whack, it could be because of something completely organic to the thyroid. But either way, when the thyroid is out of sync with the rest of the body, it causes stress and that will activate the HPA axis as well. Now, low T3 syndrome is a condition characterized by a reduced conversion of T4 to T3. So the right amount of TSH is coming out, the right amount of T4 is coming out, but T4 is just not being broken down to T3. Now let's think about why might that be. So the thyroid is functioning just fine, but somewhere along the way it's not getting broken down. T4 is converted to T3 in the gut, the liver and the kidneys. Oh, well, for a lot of people, low T3 syndrome may start or may have some connections to disruption in the gut microbiome if the gut is not healthy. If the gut microbiome doesn't have the right workers to break down T4 into T3, then it ain't going to happen. If the liver is unhealthy because of too much drinking, too much inflammation, fatty liver disease, whatever, it may not be able to convert T4 into T3. And the same thing with the kidneys. If they are not functioning well for some reason, we need to look. And a lot of times when people get their blood work done every year, every couple of years, depending on how old you are, you know, the doctor does do tests to evaluate your liver and kidney functioning. There is no test for your gut microbiome. So a lot of times it's a rule out sort of situation. And the physician will look and say, okay, liver is working fine, so that's probably not it. Kidney's working fine, that's probably not it. There may be something going on in the gut and so then a nutritionist may be included in the process. Low T3 syndrome occurs in a variety of non thyroidal illnesses, including autoimmune disorders, and is defined as non thyroidal illness syndrome. So this is something that occurs, it's something that's very real. The person is experiencing low levels of T3 even though the thyroid is functioning normally. So a lot of your normal thyroid tests aren't going to pick up on what's going on here. And it's important to continue to explore if the person has autoimmune disorders, if they have those autoimmune markers. It's especially important to also be evaluated for low T3. Estrogen and progesterone also directly impact T4 and T3 levels. And I'm not going to go into huge detail on that. We talked about gonadal hormones in, in last week's class, but the take home, if your patients are aging and genetically female, then we need to be aware that the body alters the ratios of estrogen and progesterone as the person ages. And as estrogen goes down, we, we're going to often see thyroid production go down. Iodine, vitamin D, iron and B12 deficiencies can also impact thyroid functioning, leading to symptoms of hypothyroidism. So it's important to recognize that nutritional deficiencies, medications that somebody takes, like birth control pills that alter estrogen and progesterone levels, or even aging. And the natural changes in hormone levels that occur with aging can also affect thyroid levels. 30 to 50% of patients experience inadequate response to antidepressants. That's why we're talking about this today. Persistent symptoms may include irritability, anxiety, mood swings, sleeplessness, and restlessness. All of these are also symptoms of hyperthyroidism. And sometimes it's referred to the, quote, manic veneer of hyperthyroidism. Somebody may be diagnosed with generalized anxiety or hypomania if they have hyperthyroidism. So it's something that we do need to pay attention to. If we've got somebody with mood symptoms, we need to rule out organic dysfunction. It's just there's no other way around it. Hypothyroidism is associated with depression, fatigue, problems in attention and concentration, memory perception, language, and even executive functioning like problem solving, weight gain, reduced libido, and reproductive challenges. So hypothyroidism mimics, in many ways, major depressive disorder or persistent depressive disorder. We don't want to miss this because no amount of SSRI is going to upregulate a thyroid that is misbehaving. For some reason, Hypothyroid and hyperthyroid women have a greater prevalence of menstrual disturbances. It's important to recognize that thyroid hormones impact gonadal hormones and vice versa. But people who have hyperthyroid, for example, well, and hypothyroid may experience more difficulty with erratic periods or difficulty with libido or getting pregnant. Many people with autoimmune hypothyroid also have pcos, which is polycystic ovarian syndrome. And PCOS, or polycystic ovarian syndrome, has actually been connected with, and I talked about this in, in the presentation on the hypothalamic pituitary gonadal axis, your sex hormones. But PCOS has actually been connected to chronic stress. So we do see changes in the reproductive system as a result of chronic stress. If we have a person presenting with polycystic ovarian syndrome, it's important to figure out if they've been assessed for hypothyroid. They probably have if they've gotten the PCOS diagnosis. And we need to screen for depression. A lot of times, people's first point of contact is with a therapist. When they're having these symptoms, they present with depression. And we need to be alert to the fact that, that there's often some organic dysfunction going on as well, and a physical can help rule those things out. Now, remember, PCOS symptoms include severely thinning hair, facial hair in people who are genetically female or biologically female, and low mood, oily skin. Those are the big things. Facial hair, thinning hair, oily skin, low mood. They can have pain in their joints, but if you see and weight gain. If you see those symptoms, it's imperative to refer them to their doctor if they haven't already gotten a PCOS diagnosis. Thankfully, most physicians would pick up on this if the person is getting their routine physicals. But unfortunately, a lot of people still don't get their routine physicals, so it's maybe flying under the radar. Total T4 and T3 levels are positively correlated with estrogen, progesterone and testosterone. As we age, estrogen and testosterone decrease, and it's important to recognize that. So as normal, normal aging progresses, thyroid hormones will also similarly probably decrease. And if the person has a significant drop in sex hormones, then they may have a significant and precipitous drop in thyroid hormones. Women who have radical hysterectomies and have their ovaries removed may develop very quickly hypothyroid. So it's important to monitor that in people who have significant changes in their sex hormones. Environmental toxins, smoking, obesity, stress, aging, and alcohol use all impact the levels of gonadal hormones, which also impact the hypothalamic pituitary thyroid axis. Those toxins act to cause stress on the body. That stress activates the HPA axis, which will also activate the HPT axis. High gonadal and thyroid hormones may contribute to symptoms of anxiety and irritability. Symptoms of thyroid dysfunction experienced in the elderly due to changes in gonadal hormone levels are often misinterpreted as just signs of the aging process. And some of the symptoms we may see include fatigue and neurological disorders. Instead of seeing them as very treatable alterations as a result of gonadal or thyroid level, gonadal or thyroid hormone level alterations, or both, it's often just dismissed as, oh, they're just aging. There's nothing that can be done. Oh, that's so not right. And it's important that we encourage patients to advocate for themselves and advocate for their highest quality of life. Hyperthyroidism in individuals older than 60 years ranges from 1% to 15%. You know, that's kind of interesting because as I just said, as we get older, our sex hormones that often are positively correlated with our thyroid hormones, our sex hormones drop. So you'd expect to see a drop in thyroid hormones, but that doesn't always happen. Up to 15% of people who are older experience hyperthyroidism. Hyperthyroidism, particularly very elevated free floating T4, was associated with an increased risk of dementia, increased frailty, and decreased functional capacity in older patients. That's important to recognize that people who are older who tend to start having a lot of anxiety, a lot of stress, their thyroid may have become overactive. And because that is related to dementia and cortisol levels and they really haven't ferreted out all of the causation there. But it's important to address, especially since subclinical hypothyroidism, low thyroid was associated with a reduced risk of dementia. Hmm. So sit with that for a second. One of the preventable factors of dementia may be thyroid dysfunction. Chronic stress is associated with both hyper and hypothyroid thyroidism related to increased estrogen, oxidative stress and inflammation. Depression is associated with increased inflammation. When we have stress that goes on for too long and we start having increased inflammation because that cortisol loses its ability to suppress inflammation, we also start seeing the system turn down its sensitivity, which means there's less thyroid stimulating hormone, which means there's less T3, which means there's often lower metabolism, people feeling slower and more depressed and increased inflammation. Just to kind of touch on some of the neurotransmitters while we're at it. Serotonin is positively correlated to T3. As serotonin goes up, T3 goes up. Well, that makes sense. Low serotonin tends to correlate with low T3 tends to correlate with hypothyroidism. High serotonin, serotonin that's higher than its supposed to be is often correlated with high T3 and anxiety and irritability. Remember, with our neurotransmitters we go by the Goldilocks principle. Too little is going to cause symptoms, too much is going to cause symptoms. We want it to be just right, right in the middle. Norepinephrine, which is responsible for energy and focus is also positively correlated to T3. Acetylcholine, glutamate are also both stimulatory neurotransmitters that are positively correlated to thyroid levels. GABA is your body's natural volume, if you will. It's your main relaxation neurotransmitter. It inhibits thyroid stimulating hormone. So when the threat has passed, when it's time for the HPA axis and the HPT axis to wind down because the threat has passed, GABA helps inhibit the release of TSH and promote the relaxation response. Unfortunately, they found that long term cortisol released inhibits the conversion of T4 to T3. So just like cortisol loses its anti inflammatory ability when it's released habitually, T4 loses its ability when there's too much stress for too long. T4 loses its ability to break down into T3. The body's saying, no, you know, we just, we can't stimulate the system right now. So T4, you've just got to be in a holding pattern. Endocannabinoids and cannabinoids, these are your cannabis receptors. Now, remember, we have natural chemicals in our brain that are called endocannabinoids. Your endocannabinoids and cannabinoids also impact thyroid. They inhibit TRH release or thyroid levels through the effects in the hypothalamus and the pituitary gland. So what they're doing is they're relaxing the system. Basically, they're saying, no, we're not going to release T4, convert it to T3, and, you know, get the system all worked up. We're just. We're just not going to do it. So endocannabinoids can inhibit, just like GABA can inhibit thyroid hormone levels. Thyroid hormone status also modulates the endocannabinoid system. So if you have high levels of thyroid hormones, then your endocannabinoid system is going to behave differently than if you have low levels of thyroid hormones. Hypothyroid. So people who don't have enough thyroid, and let's just say we're talking about somebody who has experienced chronic stress and is feeling depressed. Hypothyroid reduces the effectiveness of cannabinoid receptor agonists. So hypothyroid reduces the effectiveness of cannabinoids to do their job. Dopamine is positively correlated with T3 levels. Okay, that makes sense, too. Dopamine is our perseverance neurochemical. It's our I want to do that again neurochemical. So it makes sense that that would be associated with thyroid hormones. Thyroid hormones give us the energy. Dopamine directs us to what to do. People with Parkinson's or restless leg syndrome often have low dopamine levels. People with schizophrenia often have high dopamine levels. So we want to recognize that people with Parkinson's and restless leg syndrome may also have hypothyroid, and people with schizophrenia may have hyperthyroid. It is important, and it is noted in the literature multiple times, that thyroid levels should regularly be evaluated in people on antipsychotic medications. For that reason, antipsychotic medications lower dopamine levels. And by lowering dopamine levels, we're also potentially inadvertently impacting thyroid hormone levels. If you've worked with people who have been on antipsychotics, you know that when they take that antipsychotic medication, it makes them very, very sick, sleepy. That is that inhibition of that of those thyroid hormones to produce energy and to release glucose into the system and everything. So it's going to slow the system. Thyro Stress is a term that is defined as an emotional state characterized by extreme apprehension, discomfort, or dejection caused by the challenges and demand of living with thyroid disorders such as hypothyroidism. And it's important to consider what these challenges might be. Physically, when somebody's thyroid is not in sync, if they have hypothyroid, they're going to be tired, they're not going to have much energy. It's going to be hard to get through the day. If they have thyroid, they may be agitated and restless and have difficulty sitting still. And it's hard for people who don't have thyroid issues to really understand what's going on. So they may not understand this person's behavior. The person with hyperthyroid, like I said, may look hypomanic. They also may look like they've got symptoms of ADD or ADHD because they are more revved, if you will, than the average person. Affectively, what's going on? Again, people with hyperthyroid tend to be more irritable, sometimes more impulsive, hypomanic, like. Sometimes they may be very gregarious, but their affect tends to be more intense and anxious, irritable or elated. Affectively, people with hypothyroid tend to be more depressed, and explaining that is difficult. But just living with that level of depression and lethargy can be really difficult. Cognitively, both hypo and hyperthyroid people have difficulty with problem solving and memory. Environmentally, there may not be a whole lot of environmental challenges, except for accommodating somebody's physical needs when they are experiencing dysregulated thyroid. So maybe having a place where they don't have to sit down all the time if they're really agitated, or likewise having an environment that doesn't require as much movement if they're feeling super exhausted until their thyroid levels get balanced out, until they work with their physician. And relationally, because people's thyroids, thyroid hormones do fluctuate with time, do fluctuate based on stress levels, do fluctuate based on a variety of things, they may not always present exactly the same. And that can cause challenges in relationships, too. And there may be guilt if the person doesn't feel like they can do what they're supposed to in relationships, especially with hypothyroid, because they're so slowed down and so lethargic, or in hyperthyroid if they have difficulty sitting still. Sitting through a kid's hour and a half, third grade play can be really challenging to sit still for that long. So it's important to help people figure out how to discuss their symptoms with the people that are important to them and develop strategies in order to best manage their symptoms when they are going through a period where those symptoms are uncontrolled. So let's talk about some interventions. Physically gonadal and thyroid hormone testing annually for adults. And if there are symptoms in younger people, then obviously that can be someplace to check. Teenagers and even younger, when children are going through puberty and adolescence, their hormones are all over the place, which will also affect their thyroid levels. Now, this may not mean that they develop hyper or hypothyroid, but we have to recognize that as one system goes a little bit wonky, which for adolescents and puberty is a lot of times their hypothalamic pituitary gonadalaxis, it's going to also impact their hypothalamic pituitary adrenal axis, their stress response system, and their hypothalamic pituitary thyroid axis, or what I refer to as the energy response system. So gonadaline thyroid hormone testing for adults is just good practice nutrient monitoring, whether this is working with a dietitian or just keeping an app on their phone where they monitor to make sure that they're getting, you know, in general, the nutrients that they need. But iodine, selenium, iron, zinc, copper, vitamin D, B12 and calcium all impact not only neurotransmitter levels, but also thyroid hormone levels. Meditation and relaxation can be helpful interventions for those people who are experiencing thyroid dysregulation as a result of chronic stress or chronic pain. Pain, meditation and relaxation can help them basically manually override their stress response system and promote some relaxation. As I mentioned earlier, it's important to also monitor anybody who is on lithium, which is a mood stabilizer, antipsychotics, or your older or what's called tricyclic antidepressants. All three of these are known to significantly impact thyroid levels. Now, you can also make the argument that anyone who's on a psychotropic medication may need to be aware of their thyroid levels, because, as I mentioned, for example, serotonin is positively correlated with T3. So as serotonin goes up, T3 goes up. As serotonin goes down, T3 goes down. So one would follow that if they start taking SSRIs that it will impact their thyroid. Now, most of the time, what we see when people start taking SSRIs is as their serotonin goes up, their thyroid goes up, so their energy goes up and they start feeling better. They don't develop hyperthyroid. They just actually start feeling like they've got some energy. It's important to also encourage sobriety because alcohol in particular is really hard on the body. It causes a lot of stress and inflammation within the body. Causes the hypothalamic pituitary, thyroid and hypothalamic pituitary adrenal axes to really kind of go into overdrive. Especially during the last half. They drink, they feel that depressant effect. They may feel relaxed for a little bit. And then as the alcohol leaves their body, it triggers the stress response. So that triggering of the stress response, that habitual triggering of the stress response can lead to dysregulation of the HPT axis. Adequate quality sleep and circadian rhythm regulation is also important. Thyroid function is known to be influenced by the sleep wake status and people's circadian rhythms. So if somebody doesn't have stable circadian rhythms, their body may not know when to secrete cortisol. It may not know when it's supposed to get up in the morning. Our cortisol response, the body, the HPA axis, actually kind of kicks off in the morning and dumps some cortisol and some thyroid stimulating hormone and some T4 to create T3 to give us energy to get out of bed in the morning. But if our circadian rhythms are off, then our body may not be secreting that cortisol at the right time. For people with sleep apnea, sleep studies may also be necessary to determine, you know, what's going on or for. Also for people with circadian rhythm disorders, it's important to work with a sleep specialist because insomnia and sleep deprivation both cause systemic stress. Systemic stress, we know if it's ongoing, is going to contribute to dysfunction in the HP axes. Affectively and cognitively, effective treatment of thyroid abnormalities may help reverse some cognitive issues. Okay, I'm just going to let that sit with you for a minute. For people who are having difficulty with memory, with thinking clearly, with problem solving, effective treatment of thyroid or abnormalities may help. Now, I just want you to reflect for a second. When in the immediate postpartum period, a lot of people refer to having something that we kind of colloquially call mommy, mommy mind, we don't think very clearly and, you know, our circadian Rhythms are all out of whack and we have a harder time sometimes solving problems and remembering things. Well, we're sleep deprived and that sleep deprivation and that stress and those hormone changes in the postpartum period often contribute to changes in thyroid levels. Now whether the changes are large enough to throw someone out of the quote, normal range varies from person to person. But any change of what you're used to, if you're used to being dead center in the middle of the normal range and all of a sudden you're at the bottom of the normal range, you're going to feel effects of it. For people who have ongoing, not just situational thyroid issues like the postpartum period, but, but for people who have ongoing thyroid abnormalities, addressing those may help reverse some of their cognitive dysfunction. Now don't get me wrong, it's not a cure for Alzheimer's or anything like that, but for people with normal age related dementia, it can improve their cognitive trajectory, distress tolerance and coping skills. These are essential tools that we can help provide people to reduce HPA axis hyperactivation. If the HPA axis is hyperactivated, the HPT hypothalamic pituitary thyroid axis is also going to be hyperactivated. So if we can turn down the HPA axis so it's not hypervigilant, then we are also reducing some of the demand on the HPT axis. The goal is to help the body get back to the point where it can regulate itself and it's not in a constant on position. It turns on for stressors and then turns off to relax. Addressing trauma and chronic stress to reduce cortisol and help regulate the HPA axis are also going to be important. If somebody is dealing with long standing PTSD or cptsd, it's going to be important to address those issues because those things are contributing to hypervigilance and anxiety and triggering of that HPA axis on a, on a consistent basis. Those people consistently feel unsafe and disempowered. Until they can feel safe and empowered, their HPA axis is going to be hyperactivated. Thyroid hormones can be altered by physical or emotional stress. Thyroid hormones via the hypothalamic pituitary thyroid axis are intertwined with the HPA axis. Dysfunction in one is going to produce dysfunction in the other. Again, you can have a thyroid gland that becomes dysfunctional in itself and that will trigger other areas. We don't have to wait for the HPA axis to become dysfunctional to have thyroid problems. Thyroid problems can happen and trigger dysfunction in all the other systems. So remember, it's like a matrix. Many cognitive, affective and behavioral symptoms commonly seen in behavioral health settings may have some underpinnings in thyroid dysfunction. There are a lot of people with thyroid issues. It doesn't matter your age. We see hypo and hyperthyroid in children all the way up. Through elderly mental health clinicians, we can educate patients about the far reaching impact of thyroid hormones and why it's important to be aware of their thyroid status and help them address cognitive and emotional stress, trauma, sleep and circadian rhythms in order to help them address their symptoms and create the most conducive environment for their HP axes to all balance out. It.