Diseases, Disorders information

Unsatisfactory for Evaluation

The “unsatisfactory for evaluation” designation indicates that the specimen is unreliable for the detection of cervical abnormalities and a repeat specimen should be obtained. If abnormal cells are detected in a specimen, the specimen is never categorized as unsatisfactory.

General Categorization

This category allows a clinician to evaluate a Pap test quickly. Three choices are provided: “within normal limits,” “benign cellular changes,” and “epithelial cell abnormality.” A descriptive diagnosis is used to further categorize changes that are other than normal. If infectious or reactive changes (benign cellular changes) are identified along with an epithelial cell abnormality, the specimen is categorized according to the most clinically significant lesion.

Descriptive Diagnoses

Benign Cellular Changes
Diseases information
In this category, the Bethesda System provides for those samples that show changes consistent with infection or repair. Several infections may be identified cytologically with high specificity: trichomoniasis, yeast, and changes consistent with bacterial vaginosis. Changes associated with chlamydial infections should not be reported due to the low specificity of these changes. The term “reactive changes” is used to report cellular findings that are consistent with a reactive or reparative process, such as inflammation resulting from radiation or an intrauterine device.

The Bethesda System
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In December 1988, the National Cancer Institute held a workshop in Bethesda, Maryland, to address the standardization of cervical and vaginal cytology reports to facilitate peer review and quality assurance. From this workshop, the Bethesda System for cytologic reporting was developed.

The Bethesda System report includes three general categories:

1. Adequacy of the specimen

2. General categorization

3. Descriptive diagnoses

Adequacy of the Specimen

Satisfactory for Evaluation

A statement that the specimen is “satisfactory” indicates that it includes all of the following: appropriate labeling and identification, relevant clinical information, adequate numbers of interpretable squamous epithelial cells, and an adequate endocervical or transformation zone component. Well-preserved and well-visualized squamous cells should be spread over more than 10% of the slide surface.

Satisfactory for Evaluation but Limited by
Cancer treatment
The clarification “satisfactory for evaluation but limited by” indicates that any of the following apply: lack of pertinent clinical information accompanying the slide or inability to interpret more than 50% of the epithelial cells due to obscuring blood, inflammation, poor fixation, air drying, or contaminant. There should be at least two clusters of well-preserved endocervical or squamous metaplas-tic cells, with each cluster composed of at least five cells. The report indicates that the specimen can be interpreted; however, the interpretation is compromised. Determination of specimen adequacy is ultimately the responsibility of the clinician who correlates the findings of the cytology report with the clinical status of the patient. The absence of an endocervical or transformation zone component does not necessarily require a repeat Pap test. Data from the literature are thus far inconclusive with regard to the endocervical component as a measure of adequacy. Short-term longitudinal studies have demonstrated no increase in the frequency of subsequent squamous lesions among women whose initial specimens lacked endocervical cells.

Eating disorders. Anorexia versus bulimia. Anorexics are those really really thin women. They are about 5’8″ and they weigh about 80 pounds. Bulimics are normal weight and sometimes overweight. The anorexics starve themselves, the bulimics binge and purge. They eat all these Twinkies; they eat all these donuts and then the throw it all back up. The anorexics have to weigh like less than 85% of their normal body weight, and they have to have missed three consecutive periods, if they are post-menarche. Bulimics just basically do the eating and then the purging. Now there’s all kinds of funny variations. There’s anorexics who will purge, there’s bulimics who will starve themselves. Sometimes they won’t do the bingeing and purging, sometimes they will use laxatives or diuretics. There’s a thing called Russell’s sign, which is scraping the back of their palm in bulimics. What’s that from? Making yourself throw up. They remove tooth enamel, they become hypokalemic, bulimics do.
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Two zebras: this is important, under eating disorder differential. There’s two zebras, particularly I think for neurologists. One is Klüver-Bucy. When somebody loses their temporal lobes because they had such bad seizures, the neurosurgeon had to take them both out. Or they have something like Herpes encephalitis and they lose a temporal lobe. They get this syndrome where they are hyper-oral, hyper-sexual, constantly masturbating or constantly mounting things. It’s really a tragic disorder. Loss of rage, sometimes loss of memory, very docile. And also Kleine-Levin syndrome. Classically adolescent males with hyper-somnolence and bingeing. The way I tell people to remember it is to think about adolescent males and what they do normally; sleep a lot and eat a lot. Right? Just multiply that tenfold and that’s Kleine-Levin. And there are mental status changes that you will see with that. Patients may also be confused or psychotic.
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Adjustment disorders. An adjustment disorder is having so bad a to a situation that you are suicidal. Post-traumatic stress disorder is the opposite. Post-traumatic stress disorder is you see something that’s not normal. Unfortunately, in some neighborhoods to see a lot of violence and stuff like that. But in post-traumatic stress you see something that would rattle anybody. You are raped, or you are assaulted, or you see combat, or an accident. That would disturb anybody. Adjustment disorder, you have something that everybody has had. You know, loss of a job, something like that. A breakup of a marriage or a relationship or an engagement. Something that’s pretty much part of the normal human experience but it goes beyond normal sadness. Your adjustment to that is terrible. You are suicidal or you are just intensely anxious, more so that your average person would be.

Gender identity disorder. How does that differ from transvestic fetishism? The male or female is uncomfortable with their assigned biological gender. What does that mean, assigned biological gender? Just means what you were born as. “I was born as a man and I feel like I’m trapped in a man’s body. I’m really a woman.” Or vice-versa. Often in childhood. This starts early. The kid may start dressing in the opposite gender clothing and they just kind of always felt like they should have been a little boy, or they should have been a little girl. And eventually they save up their money and commonly have sex reassignment surgery, a sex change operation. Sexually these people may be attracted to men, women, both, neither. It’s very independent of homosexuality or heterosexuality. It’s not who I’m attracted to, it’s who I am. Now classic Boards question is “How do you differ this from transvestic fetishism?” The person with gender identity disorder, that guy, he’s dressing like a woman because he want to be a woman and he feels inside that he is a woman. The transvestic fetishes patient, he’s dressing that way because he feels sexy, he feels aroused when he does that.

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.

Sexual and gender identity disorders. Sexual dysfunctions: problems with desire, orgasm, function and pain. Always consider medical causes. Don’t say, “Gosh, you have this repressed hostility and that’s why you are impotent.” Well, maybe you have diabetes. Thioridazine, Mellaril. Remember there’s three Board important things about thioridazine or Mellaril. Trazodone. What can trazodone do, or Desyrel? Priapism. Painful erection that you can get with trazodone, which is an antidepressant. In reality, you don’t really see a lot of priapism with that. You’ll see women come in and say, “You know what? I can’t have an orgasm anymore since starting Prozac and this is ruining my relationship.” Or you’ll see women come in and say, “You know, I’m not interested in sex anymore, and this is really okay because I don’t like men. Men are a pain in the butt, I’m not in a relationship and actually it makes my life easier.” Similarly you will see men who will say, “Since I started Prozac it takes two hours for an orgasm, and this is terrible. It’s ruining my relationship. I don’t even want to have sex anymore.” Or you’ll have men come in and say, “You know, sex used to be five minutes and now it’s 35 minutes. Sometimes you will see SSRIs used for premature ejaculation specifically.
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Paraphilias. paraphilias are what used to be called the perversions. Commonly associated with males. Include exhibitionism. Guys like to expose themselves and they get sexually aroused by doing that. Fetishism. This is sort of like where a person is into boots, or leather, or rubber, or something like that. Now people will ask, and patients will ask, “Gosh my husband really likes to see me wear boots. Is that pathology?” and the answer is, not necessarily. It’s pathology when the wife comes in and says that the “Husband likes the boot more than he likes me.” Or, “We can’t just have sex. We can’t just make love. It’s 2 o’clock in the morning and I’ve got to put on those damn boots, otherwise he can’t …” It’s a problem when either the spouse or the partner or the law says it’s a problem. Frotteurism (?): rubbing against a non-consenting partner, like on a subway or an elevator. Obviously that’s always going to be a problem because you’ve got a non-consenting partner. Pedophilia: obviously always a problem, sex with children. That’s always considered pathology. Sexual masochism, “I like to be tied up.” Sexual sadism, “I like to tie my partner up” that’s pathology if it interferes with your relationship or the law. But you know, a lot of people will come in and say, “Yeah, I like to tie my wife up, I like it, she likes it.” Not necessarily pathology. Voyeurism: people will come in and say, “Hey, I like to watch Baywatch. Is that pathology?” No. It’s pathology if you have binoculars and you are looking into your neighbors windows and you are now on probation because of your behavior.
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Transvestic fetishism, what used to be called cross-dressing or transvestism. Paraphilia, not otherwise specified, like bestiality, sex with animals, necrophilia, sex with corpses, and telephone scatologia, making dirty phone calls. Transvestic fetishism is a person, usually a male, classically heterosexual. He likes women and likes to wear women’s clothing.
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Generalized anxiety disorder. Chronic excessive worry about real life events. Okay, it’s not like a phobia where somebody is worried about … they see a praying mantis and they kind of freak out. This is like, “I’m worried about my job, my finances, my health, my parents health, my husband’s health.” It’s what we all do but they do it so much and so often that they really need a psychiatrist because it’s really getting out of hand. Health care mall

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.