PSYCHIATRIC SKIN DISORDERS — Delusional Parasitosis and Friends.

“Neurodermatitis” is a medical euphemism for psychiatric skin disorders — skin disorders caused by mental illness. This group of disorders includes delusional parasitosis, Morgellons disease, neurotic excoriations, trichotillomania, and dermatitis artefacta. These conditions are different, yet similar in many respects. All of them are diagnoses of exclusion — diagnoses that are only made after intrinsic skin disorders have been ruled out by the physician. Most of these disorders can be spotted for what they are (by physicians) based on the unique pattern and distribution of the lesions. The skin lesions generally only occur in places that the patient can readily reach and the lesions tend to look highly unusual to the trained eye. The history of the patient is also an important piece of diagnostic evidence in most cases — e.g. a patient with other psychiatric diseases who has been to half-a-dozen dermatologists and no one can figure out what the heck is wrong with them. A skin biopsy can also be useful in equivocal cases. All of these disorders are potentially debilitating, and they all tend to be expensive and sometimes impossible to treat.

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An artist’s illustration of the “gross” (as opposed to “microscopic”) appearance of scabies, definitely not a psychiatric disease. Sometimes when you feel like you have bugs crawling under your skin you really do! As with all conditions, remember that just because someone has a mental illness doesn’t mean that they don’t also get physically ill from time to time like everyone else.

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An electronmicrograph of the scabies mite. Scabies is usually treated with a drug called permethrin. Outbreaks are common in nursing homes and also sometimes occur in hospitals and daycare centers.

Dermatitis artefacta is a form of factitious disorder, an intentionally caused medical problem that is self-inflicted to fulfill a subconscious need to assume the “sick role.” Patients with this disorder don’t feel normal unless everyone thinks that they are sick. When you are sick people tend to be nice to you and to give you lots of attention, and this is what persons afflicted with factitious disorders crave. Sometimes people with factitious disorder intentionally cause medical problems in their children. Instead of craving the “sick role” for themselves, these individuals crave the role of “caregiver for the sick.” This is called Munchausens Disorder by Proxy and it is a form of child abuse, probably the worst form of child abuse given the amount of psychological damage that is done to the child victim, which is immense.

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Self-inflicted skin lesions in a patient with dermatitis artefacta.

Delusional Parasitosis, as the name implies, is a delusional disorder. A delusion is a fixed belief that a person continues to believe even in the face of overwhelming evidence to the contrary. In the case of delusional parasitosis, patients are convinced that they have bugs crawling under their skin when they don’t. Obviously someone with scabies does not have delusional parasitosis — they really do have bugs crawling under their skin! A similar condition to delusional parasitosis is substance-induced formication. That’s “formication,” not “fornication” — the term is derived from the chemical “formic acid” that causes ant bites to sting. People intoxicated with stimulants, such as cocaine and methamphetamine, and persons under-the-influence of hallucinogens, such as LSD and PCP, sometimes feel like they have bugs crawling all over them. This is different than delusional parasitosis because the sensation resolves once the drug is out of their system.

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Crack cocaine. A common cause of substance-induced formication.

Morgellons Disease is now considered by most physicians to be a subtype of delusional parasitosis. Instead of delusions of insects crawling under the skin, people with Morgellons suffer from a belief that painful or itchy fibers are erupting from their bodies. Some people with this condition believe that they are contagious, whereas others suspect that they have been inoculated with nanofibers (or microfibers) by the government or by space aliens. The following ABC Nightline clip (courtesy of YouTube) is an interview of the original Morgellons patient, who also is the person who coined the term “Morgellons” in the contemporary context.

I was highly reluctant to put the link to this YouTube video here for reasons that will be obvious after you watch it. I felt significantly less equivocal about it after I learned that the “founder” of this disease is running a website that sells purported “natural cures” for Morgellons, and a lot of other conditions that are of questionable medical veracity. Still, I wish that the kids weren’t in the video… With that said, the video is highly educational on several levels, and even more so in 20/20 hindsight, both for healthcare providers and for laypeople, which is why I have reluctantly decided to share the link.

This video was produced before a pivotal 2008 CDC study failed to reveal a medical (other than psychiatric) etiology of the Morgellons syndrome. The results were published in 2012 — see Reference #4 below. The CDC researchers scoured the medical records of 2.8 million Kaiser Permanente patients, Kaiser being an HMO that is known for good record keeping and that commands a large percentage of the healthcare market in Northern California, an area with a high concentration of possible Morgellons sufferers. The researchers identified 115 patients who met the criteria for possible Morgellons. Of these patients, 41 chose to participate in the study, which was designed to help determine if Morgellons was a new disease or not.

In summary, after an exhaustive study the CDC did not find evidence of a new disease entity. The fiber samples taken from patients with purported Morgellons disease were found to be mostly cotton fibers of the type found in clothing, etc. Most of the patients in the study also had comorbid psychiatric conditions and/or substance abuse problems. This study is a really good example of how the CDC investigates a potential new disease and it is an excellent read if you are into reading that kind of thing (and probably remarkably boring to you if you aren’t into reading medical studies!). Please note that this study absolutely does not say that folks with “Morgellons” symptoms do not have a disease. It just suggests (indirectly) that the condition that they suffer from is a subtype of delusional parasitosis, which is a highly disabling disorder that is potentially treatable with psychotherapy and with medications, particular with a drug called pimozide that is both an antipsychotic drug and a potent antipruritic (anti-itch) medication.

Finally, Neurogenic Excoriation Disorder is a form of Obsessive-Compulsive Disorder (OCD). It usually starts with a person who suffers from both acne and from OCD. People afflicted with OCD have obsessions — disturbing and recurring thoughts — that can be temporarily alleviated by performing a compulsive act, such as excessive hand washing or, in the case of neurogenic excoriation disorder, skin picking. The bad news is that OCD can be highly disabling. The good news is that it is highly treatable with a combination of counseling and psychiatric medication. The medication of choice is generally a member of the SSRI class of antidepressants, which are among the most commonly prescribed medications in the United States and which have an excellent safety profile. Trichotillomania is a related condition in which sufferers feel compelled to pull their hair out (and they do — see image below).

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An image of a person suffering from neurogenic excoriation disorder.

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Trichotillomania.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

***Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!***

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

REFERENCES

1. Morgellons disease: Managing a mysterious skin condition. http://www.mayoclinic.org/morgellons-disease/art-20044996?pg=1.

2. Gupta, AK. Psychocutaneous Disorders. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Lippincott Williams & Wilkins, Philadelphia, PA. 2009.

3. CDC. Study of an Unexplained Dermopathy. http://www.cdc.gov/unexplaineddermopathy/

4. Michele Pearson, et al. Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0029908.  Published: January 25, 2012. DOI: 10.1371/journal.pone.0029908

5. Scabies Image: Walker, Norman Purvis () An introduction to dermatology (3rd ed.), William Wood and company Retrieved on 26 September 2010.

6. Scabies Mite (Electronmicrograph): Author: Kalumet. Date: 06.11.2004. http://commons.wikimedia.org/wiki/File:Sarcoptes_scabei_2.jpg.

7. Neurodermatitis, Wikipedia Image: “Factitious dermatitis” by Neeraj Varyani, Sunny Garg, Garima Gupta, Shivendra Singh, and Kamlakar Tripathi. – This image in Case Reports in Psychiatry Volume 2012 (2012), Article ID 674136, 3 pages doi:10.1155/2012/674136 Case Report Trichotillomania and Dermatitis Artefacta: A Rare Coexistence. Licensed under CC BY-SA 1.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Factitious_dermatitis.jpg#/media/File:Factitious_dermatitis.jpg.

8. Excoriation Disorder: http://en.wikipedia.org/wiki/Excoriation_disorder#/media/File:Derma_me.JPG

9. Crack Cocaine: Uploaded: March 6, 2005 by David.Monniaux. http://en.wikipedia.org/wiki/Crack_cocaine#/media/File:Crack_street_dosage.jpg.

10. Alien Fibers: Morgellons Disease – ABC’s Nightline. Uploaded August 25, 2011. https://www.youtube.com/watch?v=xsiJpuARHcE.

11. John Y.M. Koo. Dermatitis Artefacta. http://emedicine.medscape.com/article/1121933-overview.

12. Trichotillomania Image: http://commons.wikimedia.org/wiki/File:Trichotillomania_1.jpg.

 

What Happened to Anderson Silva’s Leg? Tib-Fib Fractures Explained.

For those of you who don’t know, I’m a huge UFC fan, a practitioner of Brazilian jiu jitsu, and a former (amateur) practitioner of muay Thai. So it should come as no surprise that I’m devoting today’s posting to Anderson Silva’s horrific injury that was suffered during the former champion’s (for six years!) rematch against the man who took his title, Chris Weidman. Everyone who was watching the fight was shocked when Silva broke his leg in half against Weidman’s knee while throwing a leg kick. And let’s start there. A lot of folk’s think that it was an accident that Weidman’s knee happened to contact the former champ’s leg; in other words, that Weidman “got lucky.” He didn’t. The knee block that Weidman skillfully threw is called a “kow bang” and it is one of the most difficult techniques to execute in all of muay Thai, so difficult that I couldn’t even find an uncopyrighted image to show you, having to settle for the similar, but less difficult to execute, elbow block instead.

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An elbow check. The usual way to block a high Thai kick is to catch it with both of your forearms (one is no good because it will likely break). The elbow block is substantially stronger than the forearm block, potentially damaging your opponent’s shin at the same time that it protects your noggin. The problem is that this block is much more difficult to execute than a traditional, forearm block and that missing the block means catching the full impact of the kick with your head!

The kow bang is intended to cause microfractures and pain in your opponent’s tibia (shin bone) so that they won’t be able to continue landing Thai kicks on your legs — the technique just happened to work a little better than expected in this particular fight. The kow bang requires absolutely perfect timing to execute in the ring and the problems with missing an attempted kow bang are two-fold. The first problem is that it is easy to raise your knee too high, resulting in your opponent’s kick slamming full force into your opposite leg, the one that 100% of your bodyweight is resting on. This usually results in a spill hard onto the floor, which in mixed martial arts is rapidly followed by your opponent pounding your face in. The second issue with the kow bang is the opposite problem. If you don’t raise your knee high enough to block the kick then the kick slams right across your thigh, exactly where your don’t want to be taking Thai kicks if you’re planning to make it out of the first round walking instead of limping.

Okay, so that’s what happened in the fight. Now let’s talk about what happened to Silva’s leg from a medical perspective. Let’s first step back for a second and review the basics. The lower extremity (the calf is technically “the leg”) is composed of three major bones and a bunch of smaller ones in the foot (the patella, or knee cap, is really part of a ligament). The femur is the thigh bone and it articulates (meets) the tibia at the knee joint. The tibia is the major weight bearing bone of the leg/calf and it is the bone that you feel when you rub your fingers down your shin. This is also the bone that Thai boxers and UFC fighters use to land most of their kicks, and it is a very strong bone once it has been conditioned by years of training. The fibula is the smaller bone that runs parallel to the tibia and that at its distal (farthest from your body) termination forms that lateral (away from the midline of your body) portion of your ankle joint. The tibia forms the medial (closest to midline) portion of the ankle joint and the parts of these bones at the ankle are referred to as malleoli. Good ahead, reach down to your ankle and feel them!

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A tibia-fibula (“tib-fib”) fracture, similar to the one that Silva suffered last Saturday.

Silva fractured (fracture = break = fracture) his tibia and his fibula above the ankle joint. Fortunately his fracture was simple, which means that the broken pieces of bone didn’t pierce the skin, a really big deal because compound (open) fractures are much more likely to develop terrible infections, especially if you suffer the fracture in a blood splattered MMA ring. What Silva’s doctor did (see below for the link to his press release) was an open reduction, internal fixation to repair the fractured tibia. He then left the fibula to essentially heal on its own, which is okay because the fibula isn’t a weight bearing bone and it’s biggest contribution to the function of the leg is in stabilizing the ankle joint. In fact, orthopedic (bone) surgeons often harvest the shaft of the fibula when they need to replace a more critical piece of bone somewhere else in the body — the forearm, for instance — and the body usually does pretty well as long as the most distal part, the lateral malleolus of the ankle, is left in place.

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A compound (open) tib-fib fracture. Not good.

Open reduction, internal fixation (ORIF) is a surgical procedure during which a broken bone is loosely approximated (put back into place) in the operating room and then a rod is hammered (literally) into the hollow internal cavity of the bone to hold the healing parts of the bone in place. Recall that the insides of bone are filled with a soft marrow. This marrow is fairly easy to suction out, leaving a nice round cavity to shove a sterile metal rod to support the healing bone! The bone fragments and the rod are held together by surgical screws, which are power-drilled into place in the operating room (using a sterile drill), and after 6-9 months the bone usually heals nicely. The rod is left in place, in case you were wondering.

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Status-post open reduction, internal fixation!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 16-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

RESOURCES

Muay Thai Image. Courtesy of Wikipedia. http://en.wikipedia.org

Tib-Fib Fracture Films. Courtesy of Wikipedia. http://en.wikipedia.org

Compound Tib-Fib, Courtesy of Wikipedia. http://en.wikipedia.org/wiki/File:Offene_Luxation.jpg

ORIF Films. Courtesy of The University of California at San Francisco School of Medicine. http://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fsfghed.ucsf.edu%2FEducation%2FClinicImages%2Flower_extremity_films.htm&h=0&w=0&sz=1&tbnid=I-9_eWuyLrMYlM&tbnh=259&tbnw=194&zoom=1&docid=DXUd9umkQuW6wM&hl=en&ei=yozCUqbXJcrXyAHfzoG4DA&ved=0CAIQsCUoAA

The UFC Orthopedic Surgeon’s Press Release. http://www.lasvegassun.com/news/2013/dec/30/anderson-silvas-doctor-details-surgery-and-recover/

The Best of Medicine on the Big Screen!

This is a list of some of the best portrayals of medical conditions on the Big Screen topped off with a sprinkling of excellent portrayals of medical conditions in otherwise non-medical themed movies. I thought that we’d have a little bit of fun today — enjoy!

The Madness of King George: King George III has recently lost the American Revolution and he now suffers from a strange form of delusional psychosis that seems to be precipitated by eating pears and that turns his urine blue! The unfortunate king, who despite the average American’s opinion of him actually was one of the more enlightened monarchs of the era, probably suffered from a rare genetic disorder called acute intermittent porphyria (AIP). AIP is caused by a genetic defect in the body’s ability to metabolize worn out hemoglobin, the iron-containing protein that enables your blood to efficiently carry oxygen to the rest of your body. People with AIP suffer from severe abdominal pain and from psychiatric symptoms. It’s a great movie that most people have never heard of — check it out!

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King George III is really a tragic figure. Unlike most other monarchs throughout history he wasn’t a womanizer and apparently had few, if any, major vices. He considered himself a man of the people and spent his free time farming in a large garden that he planted with his own two hands.

A Beautiful Mind: John Nash is one of the greatest mathematicians who ever lived, but he also suffered from a raging case of paranoid schizophrenia, a mental disorder characterized by delusions, hallucinations, and bizarre behavioral patterns. Fascinatingly, Dr. Nash actually learned to live with his disease and he functioned for years as a Princeton professor without taking any medications (this is extremely rare for a person with schizophrenia and generally a bad idea; Dr. Nash was fortunate to have exceptionally strong social support and a genius’ way of being able to work around problems, including his personal ones).

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Left: Hollywood John Nash. Right: The real McCoy. Crowe’s depiction of Dr. Nash later in the movie is really, really impressive by the way.

One Flew Over the Cuckoo’s Nest and The Changeling: Two very creepy and very realistic movies about what it was like to be a patient in a mental hospital in the not so distant past, when the rights of the mentally ill were essentially nonexistent. The Changeling is particularly disturbing because it is a true story about the political commitment of an inconvenient person (a mother whose child had been kidnapped) by the Los Angeles Police Department during the 1920s. The Changeling also describes one of the first known cases of a documented serial killer of children — it’s a great flick but not one to watch with the kiddos. For a more modern and less disturbing look at the mental health professions check out Good Will Hunting, a movie about a psychotherapist saving a talented young man from self-destruction and the movie that made Ben Affleck and Matt Damon into stars.

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Even though your girlfriend probably still hates her for breaking up Brad Pitt and Jennifer Aniston, Mrs. Jolie does a great job in this creepy film! It takes a while to really get going, but it’s worth the wait.

Rainman: Dustin Hoffman and Tom Cruise knock the ball out of the stadium with Hoffman’s portrayal of a man with severe autism and Cruise’s depiction of how hard it is to care for a loved one with this condition.

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Definitely Rainman.

King of California: Michael Douglas gives a spot-on performance as a man with bipolar mania and the grief that he causes his estranged daughter. Accurate, funny, and an all around great film that was ignored by the critics.

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Goodfellas and A Clockwork Orange: If you want to see a classic sociopath in action check out “Tommy” (Joe Pesci’s character) in Goodfellas. The dirt bag main character in A Clockwork Orange also hits the nail on the head and the movies description of classic conditioning techniques (one of the foundations of modern psychotherapy) is also spot-on. Trivia: What does Joe Pesci’s last name mean in Italian? Answer: Fish.

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What you call me, prick? Fish…I got yo’ fish!!!

The Abyss: If you SCUBA then you should definitely check this movie out, which is about a crashed U.S. nuclear missile submarine and a crazy Navy SEAL who tries to blow it up by detonating one of the nuclear warheads and nearly causes war with the Soviet Union in the process. Of course, everyone else (not wanting to be blown up in a nuclear explosion — go figure) is trying like mad to stop him. The SEAL is suffering from high pressure neurologic syndrome, a risk of diving to great depths that you’re unlikely to encounter unless you’re a professional diver for an oil company or the military. With that said, nitrogen narcosis is a common side-effect of SCUBA that is a risk to all divers and that shares many of the same symptoms, including altered mental status (you feel like you’re drunk) that progresses to severe somnolence and death (you fall asleep underwater).

Star Wars: What’s Star Wars doing on this list, you ask! Well, Darth Vader’s breathing machine is the answer because it’s nothing but a souped-up version of a mechanical ventilator, aka: “life support.” Check out my article on “What the Heck is Life Support” if I’ve got you interested.

Master and Commander: The ship’s doctor performs some really cool 18th-19th century medical procedures in this Napoleonic Wars naval flick that stars Russell Crowe in one of his better performances! From amputating an arm without anesthetic (it didn’t exist yet!) to draining a cranial hematoma (blood clot under the skull) with a burr hole, this film is as accurate as they come!

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Platoon and First Blood: Sergeant Barns in Platoon is a masterful depiction of untreated PTSD and Rambo: First Blood does an excellent job as well. Platoon is actually based on director Oliver Stone’s personal experiences as a grunt in Vietnam and it should be on everybody’s “to watch” list.

Superman (1978): Yeah, I’m talking about the one with Christopher Reeves and the reason that I mention this film (the only reason) is because Superman’s stepfather dies of a classic STEMI (major) heart attack at the beginning of the film, suddenly feeling short of breath and clutching his left arm in agony as he falls to the ground dead from sudden cardiac death. The classic symptoms are only present in a small minority of heart attacks, by the way — but the depiction is spot-on in this classic film.

The Dark Knight: This Batman film is remarkable for the way that Keith Ledger accurately represented tardive dyskinesia, involuntary facial tics caused by long-term use of antipsychotic drugs, in his portrayal of The Joker. Watch how The Joker’s tongue darts in and out of this mouth at random intervals throughout the film.

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My Nonfiction Books — Click on the Cover if You’re Interested!

Intrusive MemoryMedical School 101

 

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 16-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not necessarily reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

References/Images:

King George III: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.frontporchrepublic.com%2F2010%2F12%2Fmonarchy-and-the-american-constitution%2Fking-george-iii%2F&h=0&w=0&sz=1&tbnid=02xoYSWStykotM&tbnh=204&tbnw=246&prev=%2Fsearch%3Fq%3Dthe%2Bmadness%2Bof%2Bking%2Bgeorge%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=the%20madness%20of%20king%20george&docid=u_NtVJX8aukosM&hl=en&ei=lcTtUfbBNYrA9QSwkoHIDw&ved=0CAUQsCU

A Beautiful Mind: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&biw=1600&bih=752&tbs=sur:fc&tbm=isch&sa=1&q=A+Beutiful+mind&oq=A+Beutiful+mind&gs_l=img.3..0i10l10.2331.4975.0.5118.15.15.0.0.0.0.80.737.15.15.0….0…1c.1.21.img.7x973vvwotk&bav=on.2,or.r_qf.&fp=8bcd504da0d79f95&facrc=_&imgdii=_&imgrc=ptXC8XWenZONKM%3A%3B-IivOoQQR3aV1M%3Bhttp%253A%252F%252Ffarm5.staticflickr.com%252F4108%252F4845691040_be098082cc_z.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fjdxyw%252F4845691040%252F%3B320%3B475

John Nash: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&biw=1600&bih=752&tbs=sur:fc&tbm=isch&sa=1&q=A+Beutiful+mind&oq=A+Beutiful+mind&gs_l=img.3..0i10l10.2331.4975.0.5118.15.15.0.0.0.0.80.737.15.15.0….0…1c.1.21.img.7x973vvwotk&bav=on.2,or.r_qf.&fp=8bcd504da0d79f95&facrc=_&imgdii=aipfZxc4JZ0G6M%3A%3B0hh11B5Z5zdfoM%3BaipfZxc4JZ0G6M%3A&imgrc=aipfZxc4JZ0G6M%3A%3Bk_ZUFElW6stlfM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F9%252F91%252FJohn_f_nash_20061102_3.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253AJohn_f_nash_20061102_3.jpg%3B727%3B1000

The Changeling: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.amazon.com%2FChangeling-Angelina-Jolie%2Fdp%2FB001NFNFNU&h=0&w=0&sz=1&tbnid=ow3ht4iMPMz3-M&tbnh=268&tbnw=188&prev=%2Fsearch%3Fq%3DThe%2BChangeling%2Bmovie%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=The%20Changeling%20movie&docid=6g3vF-TQqV1JlM&hl=en&ei=88_tUd0Qhbb1BJPdgLgE&ved=0CAIQsCU

Rainman: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fthereviewbroads.com%2F2013%2F06%2Fpopular-casino-scenes-in-movies.html%2F&h=0&w=0&sz=1&tbnid=fH5gsHTDlvL__M&tbnh=165&tbnw=306&prev=%2Fsearch%3Fq%3DRainman%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Rainman&docid=2-azxDyULZZ4IM&hl=en&ei=j9DtUb7pJIHo8gSUoYGQAg&ved=0CAMQsCU

King of California: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&biw=1600&bih=752&tbs=sur:fc&tbm=isch&sa=1&q=King+of+California&oq=King+of+California&gs_l=img.3..0l2j0i5l2j0i24l6.2777.7384.0.7579.18.16.0.2.2.0.91.953.16.16.0….0…1c.1.21.img.nyRFJraU7wI&bav=on.2,or.r_qf.&fp=8bcd504da0d79f95&facrc=_&imgdii=_&imgrc=rthdAv21zvzBkM%3A%3Bocczy-FYKaVb8M%3Bhttp%253A%252F%252Ffarm3.staticflickr.com%252F2290%252F2496544558_9756f39810_z.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fphim%252F2496544558%252F%3B433%3B640

Goodfellas: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.gonemovies.com%2FWWW%2FWanadooFilms%2FMisdaad%2FGoodTommyMoeder.asp&h=0&w=0&sz=1&tbnid=sMtBJo4KBst4LM&tbnh=166&tbnw=303&prev=%2Fsearch%3Fq%3DGoodfellas%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Goodfellas&docid=EqubuvpxNrxE3M&hl=en&ei=RNHtUcH5H4vY9ASw8oDgCw&ved=0CAUQsCU

Master and Commander: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fnmedlock.wordpress.com%2F2011%2F04%2F26%2Fmaster-and-commander-vs-behind-enemy-lines%2F&h=0&w=0&sz=1&tbnid=tBZMrRTNt55a6M&tbnh=194&tbnw=259&prev=%2Fsearch%3Fq%3DMaster%2Band%2BCommander%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Master%20and%20Commander&docid=msPatd04cvPuvM&hl=en&ei=6NHtUbOWGpKy9gTWkICADA&ved=0CAMQsCU

The Dark Knight: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=Joker+The+Dark+Knight+&oq=Joker+The+Dark+Knight+&gs_l=img.3..0l10.3867.4732.8.5406.6.6.0.0.0.0.59.274.6.6.0….0…1c.1.21.img.ti3ZH_2cu0k&bav=on.2,or.r_qf.&fp=d10fcddc5d58554c&biw=1600&bih=752&facrc=_&imgdii=_&imgrc=KCVuURdycTQhMM%3A%3B_JkBrgApy2c3eM%3Bhttp%253A%252F%252Ffarm3.staticflickr.com%252F2252%252F2432121324_1b9c3d99d6_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fmorningmagician%252F2432121324%252F%3B1086%3B789

Mental Illness 101: Part 3/3

Posttraumatic stress disorder (PTSD) is caused by exposure to traumatic situations in which your life was threatened. PTSD was first noticed in combat veterans and it has had many names throughout history–“shellshock” in WWI vets and “Vietnam Vet Syndrome” in veterans of that awful war. In order for a stress reaction to meet the diagnosis of PTSD the symptoms–hypervigilance (being on edge all of the time), avoidance of things that remind you of the traumatic event (like the war veteran who avoids places with helicopters), and reexperiencing (nightmares, intrusive memories, or both)–have to be present for more than 3 months. A civilian form of PTSD is common in victims of near death expericences, of sexual assault, and of severe child abuse The disease is usually highly treatable in most cases with a combination of counseling and medications. A famous person with PTSD was Audie Murphey–the most decorated American soldier of WWII.

Attention deficit/hyperactivity disorder (ADHD) is pretty self-explanatory–a severe deficit of attention span and hyperactivity, usually in a child. People with severe ADHD greatly benefit from stimulant medications (e.g. Adderal, which is amphetamine); however, this disorder is probably grossly over-diagnosed. If your kid can’t function because of their poor attention span and hyperactivity then it is reasonable to have them evaluated by a psychiatrist for ADHD. With that said, the overuse of powerful stimulants, which stunt growth and are addictive, is a major concern and this is not a diagnosis that should be given out lightly (as it often is).

Tourette’s Syndrome is a highly debilitating tic disorder in which sufferers have some sort of tic that they cannot suppress–at least not for long. The classic form of Tourette’s disorder is a patient who regularly yells profanities and is unable to stop–something that can make leading a normal life next to impossible. The treatment is with powerful antipsychotic medications and supportive counseling.

Factitious Disorder is a psychiatric disorder in which patients create medical problems in themselves so that they can fill an emotional void in their life by getting attention from healthcare providers. The classic example is a nurse who secretly injects herself with large doses of insulin and then presents to the emergency room with a dangerously low blood sugar (that “can’t be explained”). Factitious Disorder-by-Proxy (Munchausen’s Disorder-by-Proxy) is similar, but instead of making themselves ill the perpetrator makes their children ill. This disorder is one of the worst forms of child abuse and it has a very high mortality for the child. My brothers and I are survivors of Munchausen’s Disorder-by-Proxy.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

Mental Illness 101, Part 2

Depending on the way that you crunch the numbers, either depression or anxiety disorders are the most common psychiatric illnesses. Depression comes in many forms, the worst of which is major depressive disorder—essentially really bad depression. Physicians have a neat little mnemonic to help us to diagnose depression, SIG E CAPS (5/8 = positive for depression)—Sleep changes; loss of Interest; Guilt; decreased Energy; decreased Concentration; Appetite changes; Psychomotor changes (either being more irritable or less responsive to the world than the usual you); and Suicidal ideations. Depression is a really big deal, both because suffering from depression ruins your quality of life and because about 1:20 people with severe depression end up committing suicide—that’s not as bad as the 1:10 people with bipolar disorder who end up committing suicide, but still a terribly high figure. Really, really severe depression can cause psychosis and this is especially common in postpartum depression—depression that strikes some women after childbirth. A common form of depression this time of year is Seasonal Affective Disorder (SAD), which occurs in susceptible people when they aren’t exposed to enough sunlight—this disease responds really well to some time out in the sun or a special UV lamp called a light box. The biochemistry behind SAD is quite interesting—the same gene that codes for melanin (the substance that makes your skin tan) also codes for a naturally occurring opiate, which is why being in the sun makes you feel good! Evolutionarily this probably occurred to ensure that we all got enough vitamin D, which our body makes when the skin is exposed to UV light from the sun. All forms of depression are highly treatable, so see your doctor immediately if you think that this might be you!

Anxiety Disorders include obsessive-compulsive disorder (OCD), social phobia, generalized anxiety disorder (GAD), and performance anxiety. OCD is characterized by obsessions (intrusive thoughts) that are temporarily relieved by the performance of compulsive rituals. The classic case of OCD is someone, like billionaire Howard Hughes in the excellent movie, The Aviator, who feels unclean or infected and constantly washes their hands because of it, drying their hands out and rubbing them so raw that they bleed. Social phobia is the fear of being around other people and in severe cases it can present with agoraphobia, a person who is afraid to leave their home, a debilitating condition that fortunately is highly treatable with medications. GAD is essentially excessive worrying to the point where it begins to compromise the patient’s quality of life—sometimes people with GAD can’t sleep because they are so worried about different things that are going on in their life. Finally, performance anxiety is typified by someone who is terrified of public speaking or by the musician who gets a nervous hand tremor each time he sets in front of his audience. Fortunately, all four of these disorders are highly treatable with medications and therapy in most instances—by the way, a general caveat of mental illness is that most of these diseases respond best when the patient is treated by both a psychologist (talk therapy) and a psychiatrist (primarily treats via psychiatric medications). PTSD is another anxiety disorder but it is very different from the four that we have discussed so far—we’ll pick up with PTSD tomorrow during Mental Illness 101, Part 3 (of an expected four part series).

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!