Homosexuality has been a controversy among psychiatrists for decades, even Freud addressed it. He wrote a letter to a homosexual patient’s mother and talked about it, “You know, it’s not that bad” and stuff like that. Currently it is not considered as pathology, per se, by the American Psychiatric Association. The APA came out and said this is not pathology. There was a time in history when there used to be what was called ego-syntonic versus ego-dystonic homosexuality where gay men who were happy with themselves were ego-syntonic, gay men who were not happy with themselves were ego-dystonic. People who have done research in this area have come to the conclusion that most gay men have what is called a “coming out” process. That is a period where they are unhappy with their sexual orientation before they accept their sexual orientation. So they got rid of that ego-syntonic, ego-dystonic stuff.

Agoraphobia is not a specific phobia. A specific phobia is a thing that isn’t a social situation. It has nothing to do with people. If it’s people it’s a social phobia. Specific phobia is airplanes, blood, bats, trains, tunnels, thunder, dark, water. It’s things like that. Spiders, snakes, insects. Agoraphobia is … now if agoraphobia wasn’t associated with panic disorder they might have thrown it in there but agoraphobia, literally speaking, is fear of open places. But in reality it plays out as fear of going outside your home and mixing in the world. Sometimes you can see it without panic attacks, but really classically, and I think for the Boards, it’s very associated with panic disorder. The agoraphobia usually goes hand-in-hand with panic, because it’s secondary to the panic, classically at least.

Free floating anxiety: I’m nervous and I don’t know why. I’m feeling anxious and I don’t know what I’m anxious about. “What are you worried about?” “I don’t know.” One of the things to screen for is first of all, if it’s panic or not panic. That’s definitely an important thing. If there’s no panic attacks – in other words they are not having the tachycardia and palpitations – just “I’m feeling nervous and I don’t know why.” You definitely want to do a medical workup and make sure they don’t have thyroid or something weird like carcinoid or pheochromocytoma. A lot of people come in with this free floating anxiety and what you do is send them to the psychiatrist and the psychiatrist puts them on Prozac, starts them in therapy, has trouble coming up with a diagnosis, and then maybe it gets better and maybe it doesn’t. That was back in the old days with the Freudian cartoons where the guy comes in and sits on the couch once a week and talks about his childhood. That was supposedly what that was supposed to treat, that sort of free floating anxiety. But it doesn’t really have a neat name anymore.

The etiology of OCD. There’s a few things going on. One, there may be some evolutionary components. You know, chimpanzees groom each other. It might be grooming rituals gone nuts.
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It’s one of the few things in psychiatry that is very similar in kids as it is in adults. You see a lot of kids with OCD and they think it may be related to strep infections now. Occasionally, one of the things about OCD by definition, is there has to be some un-comfort with it. People have to say, “I know this is stupid.” That’s what differentiates this from psychosis. The schizophrenic, why does he check all the food in the refrigerator before he eats it? Because he thinks the CIA is coming in and tampering with it. The OCD person says, “No, no. I know this is stupid but I feel like I have to check it because otherwise it’s going to be contaminated somehow by germs and if I don’t check it something bad is going to happen.”

Treatment of OCD. It changes all the time, but clomipramine was thought to be a bit more efficacious than the others, Anafranil. That’s the TCA that looks like a TCA but acts like an SSRI. Clomipramine or Anafranil. The trouble with that is no one wants to start a tricyclic antidepressant. It’s like Elavil. Elavil has a lot of side effects. Clomipramine is similar to Elavil online. So we like to use the SSRIs. Currently approved, I think, fluoxetine, sertraline, and paroxetine – Cheap Zoloft, Canadian Pharmacy Paxil, Prozac Online and Luvox. There’s five American SSRIs now and rour of them are approved for OCD. Luvox may be a little better than the others. The other thing is behavior therapy. What you do, just in a nutshell, if the person has a problem with washing their hands all the time you say to them, “Look, I want you to not wash your hands. Here’s your homework. You don’t wash your hands, and you’ve got to touch everything in the house. Go in the mud, not wash your hands, touch the toilet seats.” And if the person is very motivated – they’ve got to be very motivated – they’ll do it and they will have sky-high anxiety for about three or four days and then it will go down to nothing. That’s very good and they won’t relapse all that often. If they just go on Prozac they’ll feel better but you stop the Prozac and it all gets worse again. There is a schism. There’s people who say that the original studies that validated the efficacy of clomipramine were not that good and that in reality cognitive therapy is better.

Post-traumatic stress disorder. Response to a trauma, like assault, rape, or combat. Characterized by flashbacks, nightmares, avoidance. Easy to startle, insomnia, diminished interest in activities. Used to be in the old DSM, the psychiatry …acute stress disorder is just like PTSD but it resolves in four weeks.

Dysthymic disorder is basically a low-level depression. This is like people who are chronically depressed. Major depressive illness is, people are going along fine and then boom! They are down there and then you put them on Prozac and they come back up to their baseline. People with dysthymia, they are like down here. They are not way down at the bottom but they are not normal. They just can’t get excited about life.
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Bipolar disorder, formerly manic depression. Mania means episodes of irritable moods, severe enough to cause problems with function. Classically people feel great but judgment is impaired. The symptoms include for bipolar disorder: they are grandiose, diminished need for sleep, pressured speech. What’s pressured speech? It’s like they have this pressure to keep talking. Flight of ideas. It’s just one idea after another, and “I’m going to write a book, I’m going to paint my house …” and just a whole bunch of ideas at once. Very distractible. Increased goal-directed activity but often sloppy and not really productive, and bad judgment. They get involved in driving too fast, spending, sex, involved in crimes sometimes. I had a patient who committed a string of bank robberies and did a lot of time for that, and alleged to me that he was bipolar. That he was having manic episodes when it was happening. I don’t know. Some patients will get psychotic. People will come in and say, “I’m a special messenger from God. I am king of the United States” when they are manic.

In bipolar type II disorder, the person is hypomanic. Hypomanic is they have problems with depression and they don’t have problems with mania, they have problems with hypomania which is sort of a low level mania. When people are manic they are bad. They are out of control, they are dangerous, and they are just not sleeping, they’ve got to be in the hospital basically. Hypomanic people sometimes can do well. They are just really really up and really really enthusiastic. Sometimes it can help their career.

Another important point is what happens to REM sleep during a major depressive episode. REM increases; REM density increases. You are in REM quicker and you are in REM longer when you are depressed. Most antidepressants will decrease REM sleep. An old trick back before there were good antidepressants, a thing you could do for refractory patients was keep them up all night. You would just sleep deprive them and the depression would get better. Because depressed people are spending too much time in REM. But it really didn’t work. They would relapse fairly quickly after being kept awake.

When people get depressed, or manic, they can get psychotic. A thirty-five-year-old housewife comes in says the devil is punishing me. She’s not interested in doing anything anymore. She is sleeping two hours a night. She says she can’t get to sleep. She has a lot of psychomotor retardation, what’s going on? She doesn’t have schizophrenia. She has major depressive illness. When people get too high or too low they can get psychotic. But not everybody who is delusional or hallucinating is schizophrenic.

Okay, we have a few more to go. This is a sort of characteristic … you see this little bulls-eye when you do your funduscopic? This is pretty characteristic. This is the lenticonus because what’s happening is you are looking in and the conical-shaped lens is like this, so you are going in and making your cuts in and I’ve never seen it described anywhere, but I’ve seen it a zillion times. And this is what it looks like. It almost looks circumferential. Bulls-eye in nature.

Tuberous sclerosis; you’ve heard about tuberous sclerosis. The renal abnormalities, renal angiomyolipoma, cystic kidneys and renal cell carcinoma. An important clinical link and association. Other features, underline adenoma sebaceae, underline CNS tubers, retinal phacoma and of course some of the skin, the shagreen patches, the White Mountain ash spots. We’ll talk about Drash syndrome, which is diffuse mesangial sclerosis, nephrotic syndrome in end-stage renal disease. The association here is Wilms tumor and male pseudohermaphroditism. So let’s first … looks like I have Drash syndrome up here first. Here’s mesangial sclerosis, diffuse mesangial sclerosis and ambiguous genitalia. If you get a patient, a case, with nephrotic syndrome and ambiguous genitalia like this, what study do you want to do? A renal ultrasound because you want to look for Wilms tumor. And that’s the link and association, a very important link and association here. This is named after Alan Drash, the first person. It’s also called Denny’s Drash syndrome, nephrotic syndrome in childhood, diffuse mesangial sclerosis, Wilms tumor, male pseudohermaphroditism. So these are males that have ambiguous genitalia. The females do not.

Finally, what is this? Recognizable? Anaphylactoid purpura, right. Remember, it is usually classically over the lower limbs and buttocks. It is alliterative, palpable purpura. Write down, as a link and association, palpable purpura. Because you can feel it. Little lumps. Palpable purpura on the lower extremities, crampy abdominal pain, arthralgia, peak at 4-5 years of age. It’s mediated by IgA immune complexes. Histology in the kidney, mesangial proliferation and/or epithelial crescents. The worse the biopsy the worse the prognosis. If you have nephrotic syndrome and nephritis, that is the worst outcome. We biopsy them and if we see crescents, that’s the issue.