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PubMed This is a summary of 26 peer-reviewed journal articles Updated
Neurology

Symptoms and Warning Signs of SREAT

At a Glance

SREAT is a rare autoimmune condition that causes a wide range of cognitive, psychiatric, and neurological symptoms. Often called a "great mimicker," its signs vary widely and it is frequently misdiagnosed as dementia, psychiatric disorders, or stroke.

Because SREAT (Steroid-responsive encephalopathy associated with autoimmune thyroiditis) is so rare and its symptoms are so varied, it is often called a “great mimicker” [1][2]. It rarely looks the same in two different people, which can make the process of getting a diagnosis feel confusing and isolating [1][3].

Common Symptoms

The symptoms of SREAT generally fall into three categories: cognitive, psychiatric, and physical [4][5].

  • Cognitive Decline: This is often described as a “brain fog” that goes far beyond simple forgetfulness. It can include profound confusion, difficulty finding words, and a rapid decline in the ability to perform daily tasks [4][6].
  • Psychiatric Features: For some, the first signs are behavioral. This can include intense anxiety, depression, paranoia, hallucinations, or even catatonia (a state where a person becomes unresponsive or unable to move normally) [5][6][7].
  • Neurological/Motor Issues: Physical signs are common and can include:
    • Seizures: These can be the first major sign of the condition [4][8].
    • Ataxia: Sudden clumsiness or a “drunken” gait [9][10].
    • Tremors and Myoclonus: Involuntary shaking or sudden “electric-shock” muscle jerks [11][12].
    • Stroke-like Episodes: Temporary episodes of weakness or trouble speaking that may look like a stroke but resolve [13].

How Symptoms Progress

The “speed” at which SREAT develops can vary significantly between individuals [13][14].

  1. Rapidly Progressive: Symptoms may explode over just a few days or weeks, leading to an acute crisis that requires hospitalization [13][15].
  2. Smoldering Course: Symptoms may develop slowly over months, making it harder to notice that something is medically wrong until the changes become severe [13][16].
  3. Relapsing-Remitting: Some patients experience “flares” where symptoms get worse and then seem to improve slightly before returning [17][18].

The “Mimic” Effect

Because these symptoms are nonspecific—meaning they appear in many different diseases—SREAT is frequently misdiagnosed as other conditions [1][3].

Often Confused With… Why the Confusion Happens
Primary Psychiatric Disorders Intense mood changes or psychosis can look exactly like bipolar disorder or schizophrenia [19][7].
Dementia/Alzheimer’s The memory loss and confusion in the “smoldering” type can look like standard age-related decline [20][19].
Creutzfeldt-Jakob Disease (CJD) In very rapid cases, the severe cognitive decline and muscle jerks can mimic this rare, fatal condition [21][22].
Vascular Events “Stroke-like” episodes may lead doctors to look for blood clots or heart issues instead of an immune problem [2][23].

Identifying these symptoms is not a diagnosis on its own, but it provides the “clues” your medical team needs to investigate further [24]. If your symptoms fluctuate or improved significantly after a trial of steroids, it reinforces the possibility that an autoimmune process like SREAT is involved [25][26].

Common questions in this guide

What are the early warning signs of SREAT?
The first signs of SREAT vary widely but generally fall into cognitive, psychiatric, or physical categories. Some people experience profound brain fog and confusion, while others may first notice severe anxiety, paranoia, or even seizures.
Why is SREAT so frequently misdiagnosed?
SREAT is considered a "great mimicker" because its symptoms are non-specific and overlap with many other illnesses. Depending on how the symptoms present, it is often mistaken for primary psychiatric disorders, Alzheimer's disease, or vascular issues like a stroke.
How quickly do the symptoms of SREAT develop?
Symptom progression varies significantly from person to person. Symptoms can emerge rapidly over a few days causing an acute crisis, develop slowly over several months, or follow a relapsing-remitting pattern with sudden flares and temporary improvements.
Does SREAT cause physical symptoms like shaking or clumsiness?
Yes, neurological and motor issues are very common in SREAT. Patients may experience sudden clumsiness (ataxia), involuntary muscle jerks (myoclonus), tremors, or even temporary stroke-like episodes that eventually resolve.
How can doctors tell the difference between SREAT and standard dementia?
While SREAT's slower "smoldering" course can mimic age-related memory loss, it often presents with additional clues. Features like sudden muscle jerks, significant symptom fluctuation between good and bad days, or improvement after taking steroids suggest an autoimmune issue rather than typical dementia.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Which of my symptoms are most characteristic of SREAT versus other possible conditions?
  2. 2.How did you rule out other rapidly progressive conditions, such as other forms of autoimmune encephalitis?
  3. 3.Given my symptoms, do we need to perform an EEG or a lumbar puncture to look for objective signs of brain inflammation?
  4. 4.Since my thyroid hormone levels are normal, what specific antibody levels led you to consider SREAT?
  5. 5.If my symptoms progressed slowly, how do we distinguish this from a standard form of dementia?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (26)
  1. 1

    Hashimoto's encephalopathy: Follow-up data from neuropsychology, lumbar puncture, and FDG-PET.

    Lagström RMB, Østerbye NN, Henriksen OM, Høgh P

    Clinical case reports 2019; (7(9)):1750-1753 doi:10.1002/ccr3.2367.

    PMID: 31534741
  2. 2

    New onset steroid-responsive Hashimoto's encephalopathy in the older population: a scoping review.

    Sy AJR, Anlacan VMM, Yu AB, Jamora RDG

    Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 2025; (46(8)):3505-3523 doi:10.1007/s10072-025-08223-6.

    PMID: 40323355
  3. 3

    HASHIMOTO'S ENCEPHALOPATHY AS A RARE MANIFESTATION OF HYPOTHYROIDISM.

    Pak KJ, Rahim U, Romano J, Lee D

    The Journal of the Louisiana State Medical Society : official organ of the Louisiana State Medical Society 2015; (167(3)):154.

    PMID: 27159478
  4. 4

    Clinical presentations and treatment outcomes of Hashimoto encephalopathy at Siriraj Hospital - Thailand's largest national tertiary referral center.

    Dumrikarnlert C, Thakolwiboon S, Senanarong V

    BMC neurology 2023; (23(1)):334 doi:10.1186/s12883-023-03305-4.

    PMID: 37737161
  5. 5

    Hashimoto's encephalopathy with psychiatric presentation.

    Singh A, Verma L

    Industrial psychiatry journal 2022; (31(1)):162-164 doi:10.4103/ipj.ipj_61_20.

    PMID: 35800865
  6. 6

    Hashimoto's encephalopathy presenting as catatonia in a bipolar patient.

    Tsai CH, Yu KT, Chan HY, Chan CH

    Asian journal of psychiatry 2021; (66()):102895 doi:10.1016/j.ajp.2021.102895.

    PMID: 34741883
  7. 7

    Attempted Suicide in a Woman With Steroid-responsive Encephalopathy Associated With Autoimmune Thyroiditis: A Case Report.

    Fatica JP, Hussain N, Khan A, Yadav S

    Journal of psychiatric practice 2020; (26(5)):411-416 doi:10.1097/PRA.0000000000000496.

    PMID: 32936588
  8. 8

    An Intriguing Case of Delirium: Recognizing Steroid-Responsive Encephalopathy Associated With Autoimmune Thyroiditis.

    Surapaneni D, Sam N, Dasi SC, N B

    Cureus 2024; (16(9)):e70447 doi:10.7759/cureus.70447.

    PMID: 39473654
  9. 9

    Hashimoto's Encephalopathy as a Cause of Persistent Myoclonic Jerks: A Report of a Unique Case.

    Salama HA, Rastanawie H, Deif A, et al.

    Cureus 2025; (17(10)):e94980 doi:10.7759/cureus.94980.

    PMID: 41267728
  10. 10

    Orthostatic Myoclonus as a Presentation of Hashimoto Encephalopathy.

    Hwang H, Park J, Eun JI, et al.

    Journal of movement disorders 2023; (16(1)):104-106 doi:10.14802/jmd.22146.

    PMID: 36628427
  11. 11

    Cerebellar syndrome as the presenting feature of Hashimoto encephalopathy.

    Choudhury C, Sahib A

    BMJ case reports 2024; (17(5)) doi:10.1136/bcr-2023-256365.

    PMID: 38806398
  12. 12

    Steroid-Responsive Encephalopathy Associated With Autoimmune Thyroiditis Presenting With Parkinsonism.

    Hicham G, Naji Y, Hrouch W, et al.

    Cureus 2024; (16(3)):e56184 doi:10.7759/cureus.56184.

    PMID: 38618344
  13. 13

    Steroid-responsive encephalopathy with a peculiar CSF biomarker profile in an 89-year-old man.

    Sipilä JOT, Rissanen E, Korpela J, Päivärinta M

    Oxford medical case reports 2018; (2018(10)):omy073 doi:10.1093/omcr/omy073.

    PMID: 30263128
  14. 14

    SREAT presenting as decades of intractable seizures and isolated delusional episodes with clinical, laboratory, and EEG confirmation of treatment response.

    Tjong E, Gardner R, Peng YY

    SAGE open medical case reports 2019; (7()):2050313X19850051 doi:10.1177/2050313X19850051.

    PMID: 31205712
  15. 15

    Hashimoto's Encephalopathy Presenting with Smoldering Limbic Encephalitis.

    Nagano M, Kobayashi K, Yamada-Otani M, et al.

    Internal medicine (Tokyo, Japan) 2019; (58(8)):1167-1172 doi:10.2169/internalmedicine.1289-18.

    PMID: 30982805
  16. 16

    Patients with a relapsing course of steroid-responsive encephalopathy associated with autoimmune thyroiditis exhibit persistent intrathecal CD4+ T-cell activation.

    Pfeuffer S, Ruck T, Rolfes L, et al.

    European journal of neurology 2021; (28(4)):1284-1291 doi:10.1111/ene.14657.

    PMID: 33230897
  17. 17

    Behind the mask of relapsing bimodal encephalitis: herpesvirus 7 and Epstein-Barr virus associated with Hashimoto's encephalopathy: a case report.

    Xing Y, Wang J, Li X, Yin X

    Frontiers in immunology 2026; (17()):1782631 doi:10.3389/fimmu.2026.1782631.

    PMID: 42292462
  18. 18

    Hashimoto's Encephalopathy Presenting with Chorea.

    Sharan A, Sengupta S, Mukhopadhyay S, Ghosh B

    The Journal of the Association of Physicians of India 2015; (63(9)):83-4.

    PMID: 27608878
  19. 19

    Hashimoto's encephalopathy presented with mutism: a case report.

    Das S, Reddy B

    General psychiatry 2021; (34(3)):e100502 doi:10.1136/gpsych-2021-100502.

    PMID: 34131628
  20. 20

    Focal neurological presentation in Hashimoto's encephalopathy mimicking a vascular occlusion of the middle cerebral artery.

    Alazzeh A, Jaroudi S, Gooch M, Peiris AN

    BMJ case reports 2017; (2017()) doi:10.1136/bcr-2017-219933.

    PMID: 28710237
  21. 21

    Steroid-responsive encephalopathy in autoimmune thyroiditis (SREAT) as a differential diagnosis of Creutzfeldt-Jakob disease.

    Osmanlıoğlu Ş, Zerr I

    Neurologia i neurochirurgia polska 2023; (57(2)):198-205 doi:10.5603/PJNNS.a2023.0005.

    PMID: 36727548
  22. 22

    Akathisia superimposed to Hashimoto's encephalopathy in an old lady.

    Isik AT, Kaya D, Altunkalem Seydi K

    Acta bio-medica : Atenei Parmensis 2022; (93(S1)):e2022120 doi:10.23750/abm.v93iS1.11828.

    PMID: 35786633
  23. 23

    Plasmapheresis Responsive Rapid Onset Dementia with Predominantly Frontal Dysfunction in the Context of Hashimoto's Encephalopathy.

    Endres D, Vry MS, Dykierek P, et al.

    Frontiers in psychiatry 2017; (8()):212 doi:10.3389/fpsyt.2017.00212.

    PMID: 29123489
  24. 24

    Hashimoto Encephalopathy With Status Epilepticus.

    Sliwinska A, Fumuso P, Stringer B, et al.

    Cureus 2020; (12(12)):e11857 doi:10.7759/cureus.11857.

    PMID: 33409091
  25. 25

    Steroid-Responsive Encephalopathy Associated with Autoimmune Thyroiditis Presenting with Fever and Confusion.

    Liyanage CK, Munasinghe TMJ, Paramanantham A

    Case reports in neurological medicine 2017; (2017()):3790741 doi:10.1155/2017/3790741.

    PMID: 29234548
  26. 26

    Hashimoto's Encephalopathy: A Rare Clinical Diagnosis in a Male Pediatric Patient.

    Herzig M, Fastag-Guttman E, Wu A

    Cureus 2025; (17(3)):e79888 doi:10.7759/cureus.79888.

    PMID: 40166789

This page explains the symptoms of SREAT for educational purposes only. If you or a loved one are experiencing severe cognitive, psychiatric, or neurological changes, seek immediate medical attention from a qualified healthcare provider.

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