Diseases, Disorders information

Obsessive-compulsive disorder (OCD. OCD is sort of the hand-washing, the checking, the counting. How many of you have some OCD traits? You don’t have to raise your hand because I know the answer. Probably all of us do. Probably 80-90% of college and professional athletes have some OCD stuff going on. The basketball player who has to bounce the ball three times before he makes a free-throw.

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.

It’s not schizoaffective. In a nutshell, what is schizoaffective? We’ll go through the five schizos before we are done. Unfortunately, psychiatrists thought it was a good idea to name five similar disorders starting with schiz and there’s no real easy way to sort that out. So we’ve got to go through them one by one. Basically, here’s schizoaffective. Let’s say you are a schizophrenic and you are like a street person and you hear voices, and you believe that the moon is made out of cheese or whatever, and you get depressed. You are not a schizophrenic with major depressive illness. Psychiatrists won’t allow you to be that. You have to have a new special name and that new special name is schizoaffective disorder. It’s like congestive heart failure can coexist with a broken arm. Well, in psychiatry-land if you are a schizophrenic you can’t have major depressive episodes. You magically become schizoaffective. That’s all that is. Major depressive illnesses differ in that when you treat the person, the schizophrenic goes back to being a street person, but the major depressive disorder goes back to being a housewife. She’s perfectly fine between episodes. The schizophrenic is not fine between episodes.

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.

Symptoms of major depressive disorder include problems of sleep, interest, guilt, energy, concentration, appetite, psychomotor symptoms, and suicidal thoughts. Five symptoms of the criteria are needed to make a diagnosis. Commonly in depressive illness you see a lot of anxiety and a loss of libido(erectile dysfunction).

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.

Histamine antagonists

Histamine2 (H2) receptor antagonists are moderately effective for treating GERD. These drugs are safe, with rare side effects. However, cimetidine may cause mental status changes, antiandrogenic activity (gynecomastia), and inhibition of the cytochrome P-450 system, which may alter levels of drugs metabolized by this pathway (eg, theophylline, warfarin, phenytoin).

The indicated oral doses for the treatment of reflux esophagitis are cimetidine (Tagamet), 800 mg twice daily; ranitidine (Zantac), 150 mg two to four times daily; famotidine (Pepcid), 20 mg to 40 mg twice daily; and nizatidine (Axid), 150 mg twice daily. The efficacy of all the H2 receptor antagonists is equivalent.

Proton pump inhibitors

The proton pump inhibitors (PPIs), omeprazole (Prilosec) and lansoprazole (Prevacid), are the most effective acid-suppressing medications available. These drugs inhibit the proton pump.

The usual dosage for treatment of reflux esophagitis is 20 to 40 mg of omeprazole (Prilosec) daily or 30 mg of lansoprazole (Prevacid) daily. At these doses, reflux symptoms are abolished in most patients. PPIs are safe and well tolerated. Side effects of headache, abdominal pain and diarrhea are rare.

Patients with classic symptoms who are less than 40 years old and who have had symptoms for less than 10 years do not require diagnostic studies. Indications for upper gastrointestinal endoscopy include onset of new symptoms in older patients with long-standing GERD, the presence of alarm symptoms, atypical or equivocal symptoms, and failure of full-dose H2 receptor antagonist therapy.

Alarm symptoms in patients with suspected GERD: Hematemesis Melena Dysphagia Unexplained weight loss Frequent vomiting.
PROTONIX helps to control NIGHTTIME heartburn and other symptoms associated with erosive Gastroesophageal Reflux Disease (GERD).

GERD Diagnosis
Esophageal endoscopy is the most popular test for initial evaluation of GERD symptoms. Barium swallow modified by a barium-coated test meal is the most sensitive test for evaluation of dysphagia. The observation of reflux of free barium into the esophagus establishes the diagnosis of GERD.

Ambulatory esophageal pH monitoring is the best test to establish the presence of abnormal acid esophageal reflux, although it provides no information about the esophageal structure or mucosa.

Treatment

Lifestyle modifications recommended for all patients with GERD:
Stop smoking cigarettes. Lose excess weight. Eat small meals Reduce consumption of caffeine, chocolate, fatty foods, alcohol, onions, peppermint, and spearmint. Elevate head of bed 6 to 9 in. Avoid tight-fitting garments

Antacids. Antacids work by neutralizing gastric acid and are indicated for treatment of occasional heartburn. Antacids have a very short duration of action, necessitating frequent dosing.

Gastroesophageal Reflux Disease
About 18% of the adult population in the United States have heartburn at least once a week. Gastroesophageal reflux describes the movement of gastric acid into the esophagus. The major antireflux barrier is the lower esophageal sphincter (LES), located at the esophagogastric junction. Patients with disordered esophageal motility from connective-tissue diseases or primary motility disorders and those with hyposalivation from chronic xerostomia, cigarette smoking, or anticholinergic medications are predisposed to increased severity of GERD.

Clinical evaluation

Heartburn, defined as a retrosternal burning sensation radiating to the pharynx, and acid regurgitation are classic symptoms of GERD. They usually occur postprandially, especially after large meals.

Symptoms may be exacerbated by recumbency, straining, and bending over and are usually improved by antacids. These symptoms are specific enough that their presence establishes the diagnosis of GERD without confirmatory tests.

Complications

Esophagitis with ulceration may result in gastrointestinal hemorrhage, which is reported in about 2% of patients with reflux esophagitis.

Esophageal strictures form in about 10% of patients with GERD. These patients are managed with periodic dilations and acid suppression with proton pump inhibitors.

Barrett’s esophagus. Metaplastic changes in the esophageal mucosa that result from GERD are referred to as Barrett’s esophagus. The presence of columnar-appearing epithelium more than 3 cm above the proximal gastric folds is a criterion for diagnosis. The reported incidence of adenocarcinoma in Barrett’s esophagus, which is considered a premalignant condition, is 1 in 52 patient-years.

Extraesophageal manifestations of GERD may include noncardiac chest pain, chronic hoarseness and cough, and asthma