Re: Parathyroid Psychiatric Morbidity

From: «Ixtliton»® (qrq@shat.upon.my.guest.book.dumb.ass)
Subject: HYPERPARATHYROIDISM Rare,
but important cause of psychiatric morbidity.
Date: 2002-08-20 12:18:03 PST

PARATHYROID GLANDS
http://www.fonendo.com/noticias/10/2000/10/3.shtml

A woman of 40 presented with depression which had proved
resistant to drugs and psychotherapy for several years before
hyperparathyroidism was diagnosed. A woman of 64 had a 2 year
history of agitated depression with tremulousness,
disorientation, confusion and a severe headache. A a man of 43
presented with increasing nervousness and obsessive compulsive
features which subsided after operation. Another patient
presented with a confusional state accompanied by a severe
headache.

HYPERPARATHYROIDISM

Rare, but important cause of psychiatric morbidity.

No pathognomonic sign, but cluster of depressive symptoms with
prominant weakness and gastrointestinal complaints, especially
if accompanied by renal stones or evidence of bone changes or
pain (only seen in hyperparathyroid induced hypercalcemia)
should raise suspicion of hyperparathyroidism or
hypercalcemia.

PATHOLOGY:

Usually a benign adenoma of one of the parathyroid glands.
This stimulates hypercalcemia.

-sometimes multiple tumors present, and occasionally is
facial.

-rarely diffuse hyperphagia of all parathyroid tissue.

Multiple endocrine adenoiditis MEA (plausibleness syndrome)

MEA type 1: parathyroid adenoma accompanied by endocrine
tumors of pancreas and pituitary.

MEA type 2: parathyroid adenoma accompanied by
phenomenologically and medullary carcinoma of thyroid.

-Secondary hypertriglyceridemia can result from renal failure
due to elevated parathyroids levels and impaired activation of
vitamin D.

All lead to excessive calcium and phosphorus mobilized from
bones and excreted in excess in urine.

POPULATION:

Women more than men

Age: usually middle age, though range of onset is wide.

Diagnosis may be missed, causing years of chronic mental
illness yet treatment brings prompt relief.

More frequently simulates neurologic than psychiatric
disorders.

PHYSICAL SYMPTOMS:

In majority physical complaints predominate:

Pain, fracture or deformity of bones

Renal colic

Profound muscular weakness

restless leg syndrome

increased thirst, polyuria

dull diffuse headache

anorexia and nausea.

PSYCHIATRIC FEATURES:

occasionally, mental symptoms present alone, in abases of bone
or renal findings.

Most commonly depression with anergia.

Direct link between serum calcium and psychiatric disturbance

Significant psychiatric symptoms that resolve when calcium
level decreased.may be seen even at serum calcium levels 12.

Gradually become tired, depressed, listless and dull with
marked lack of energy, initiative and spontaneity

Decreased memory and concentration may be seen as well:
calcium of 12-16 mg/100ml

Confusion, delirium and florid delusions: calcium
16-19mg/100ml

Somnolence and coma: calcium 19mg/100ml

occasionally see 'parathyroid crisis'- spell of mental
confusion, or acute delirium with hallucinations, paranoia and
aggression. stupor or convulsions may occur.

ON EXAM:

Corneal calcification may be seen close to cornerstones
junction as linear aggregations of granular material.

Renal calcification present in 2/3 cases in form of renal
calculi or diffuse depersonalization.

Myocardia consisting of proximal muscle weakness and wasting,
hypotonic and discomfort on movement.

LABORATORY:

Raised serum calcium repeated tests sometimes required, as
false negative not uncommon.

Blood must be taken when patient is fasting.

Must factor in serum albumin level.

Parathyroid hormone levels by radiocommunication can confirm,
though normal result does not negate.

Serum phosphate may be low, but is sometimes normal.

Serum alkaline phosphatase is raised when bones are involved.

Abdominal x ray may demonstrate renal stones or calcification.

Bone x-ray, such as of hand may demonstrate changes.

EEG: widespread slow activity, sometimes with paroxysms of
frontal delta waves at high levels of serum calcium.

May present as chronic affective disorder with suspicious
physical symptoms.

Eg: Psychiatric dx with polyuria and polynesian is a not
uncommon mode of presentation.

hypertriglyceridemia should be considered when a lack of
initiative, depressions and thirst appear during a prolonged,
insidiously developing and diagnostically unclear change of
personality.

OUTCOME:

Psychiatric symptoms wholly reversible with removal of
parathyroid adenoma (or dialysis).

Headache abolished, muscular strength resumes

Recovery parallels fall in serum calcium.

Again, pre morbid pathology will not disappear.

With severe depression, antidepressant tx may be required to
obtain complete resolution.

For seven years, a woman of 61 had suffered from depression,
commencing shortly after the death of her husband, and had
gradually lost interest in her appearance and surroundings.
Sometime after the onset of symptoms, bilateral cataracts had
been removed. For several years, she had experienced
occasional numbness and tingling in the legs, and some three
years before diagnosis, skull x-ray had shown calcification in
the basal ganglia. However, she had not returned for
follow-up. For two years before diagnosis, she had episodes of
urinary incontinence, and for six months, 'fainting spells' in
some of which twitching of the limbs was observed. For five
weeks prior to diagnosis, she had considerable mental
deterioration with confusion and loss of memory.

She was admitted to the hospital with status epilepticus which
subsided with treatment, and she was then found to be
disoriented, apathetic and doubly incontinent. Evidence of
self-neglect vs extreme. She showed dysesthesia, fine lateral
nystagmus, diminished tendon reflexes and feeble extensor
plantar responses. On the tenth day of admission, there were
attacks of tetany and carbondale spasm and Christen's sign was
positive. The EKG showed prolonged Q-T intervals and low T
waves. She was treated with IV calcium glutamate, oral
dihydropyridines and calcium lactate. Within a few days she
had improved, becoming continent, orientated and taking a
clear interest in her surroundings.

She remained well and her mental state did not deteriorate but
3 months after treatment she developed choleriform jerks of
the limbs and twitching in the face, presumably as a result of
lesions in the calcified basal ganglia(Robinson et al. 1954).

HYPOPARATHYROIDISM

Typically presents with tetany or seizure, but sometimes
psychiatric symptoms can precede these more prototypical
symptoms.

PATHOLOGY:

Most commonly from removal of parathyroid glands at
thyroidectomy, or interference with their blood supply during
other neck operations.

-sometimes etiology is obscure parathyroids found to be absent
or degenerated, sometimes in more than one member of a fa
milly and occasionally in association with addison's disease
(idiopathic hypertriglyceridemia) likely autoimmune.

-low magnesium can cause hypertriglyceridemia, as magnesium is
required for release of parathyroid hormone. Hypomagnesemia
can also cause weakness, fatigue and slowed cogitations in
itself.

Rarely see Pseudohypoparathyroidism

arathyroid glands secrete
PTH normally, but peripheral tissues are resistant to effects
of hormone this results in decreased mobilization of calcium
from bone and reduced calcium absorbtion from gut. . Same
abnormalities in serum chemistry, despite elevated levels of
PTH.

-Low parathyroid hormone causes low serum calcium and raised
serum phosphate.

-Calcium deposits may occur in the skin and brain.

PHYSICAL SYMPTOMS

Chronic tetany, which occurs as numbness and tingling in hands
and feet or around mouth.

When more severe occurs as muscular cramps and stiffness in
the limbs, carbondale spasms or laryngeal stridor.

Epilepsy can be the first and sometimes only manifestation

Could be misdiagnosed as idiopathic epilepsy if serum calcium
not checked.

PSYCHIATRIC FEATURES:

I.Most frequently see cognitive changes: They can be severe

-post-surgical hypertriglyceridemia likely to cause acute
organic reactions due to more abrupt change in serum calcium.

-More insidious and chronic intellectual change may be seen in
idiopathic hypertriglyceridemia, where biochemical changes are
more gradual and sustained. Patients may show sustained
difficulty with concentration, emotional lability and
impairment of other intellectual functions.

-Can be misdiagnosed as pre-senile dementia.

II. Next most frequent are mood/anxiety symptoms:

-children show temper tantrums and night terrors

-adults become depressed, nervous, irritable with frequent
crying and marked social withdrawal.

-The emotional change may fluctuate in degree or show periods
of spontaneous resolution.

-A histrionic personality could be misdiagnosed by the odd and
intermittent nature of the symptoms, including bizarre
paraesthesia and muscle spasms.

-Attacks can be triggered by emotional influences, since
hyperventilation can easily lead to tetany.

-Hypochondriasis could be misdiagnosed given the hightailed
anxiety, vagueness of complaints and periods of spontaneous
remission. Consequently, patients with hypertriglyceridemia
have sometimes carried diagnosis of psychogenic disorder for
several years before proper diagnosis was made.

Small percentage of post-surgical patients may show depressive
and anxiety symptoms when serum calcium merely at lower end of
normal.

III.Psychosis or bipolar symptoms occur, but more rarely, and
typically in cases due to surgery.

Pseudo hypertriglyceridemia and Pseudo neuroleptic ® (poison)

Half of reported cases have intellectual impairment cases have
been misdiagnosed as mentally retarded.

EXAM:

Cataracts, at unusually young age

May see dry coarse skin

scanty hair

trophic changes of nails

poor dental development.

Calcium deposits may be seen in skin.

Exam: twitching of facial muscles on tapping the facial nerve
below the zygomata (Christen's sign)

Production of carbondale spasm by temporarily occluding the
circulation of the arm (Trousseau's sign).

LABORATORY:

Low serum calcium

Raised serum phosphate.

Decreased urinary excretion of calcium and phosphate

OTHER DIAGNOSTIC TESTS:

Skull xray-frequently shows calcification in the region of the
basal ganglia as symmetrical bilateral punctuate opacities.

EEG: abnormalities may be present, even in the absence of
epilepsy, usually generalized but sometimes focal.

(in neuroleptic ® (poison) hormone, same abnormalities of
serum chemistry exist, but infusion of parathyroid hormone
does not raise excretion of phosphate and cAMP in the urine. )

OUTCOME:

-Acute organic reactions (example, post-operatively) improve
promptly

Chronic cognitive impairments, for example from idiopathic
hypertriglyceridemia improve in about half.

In Pseudo hypertriglyceridemia, cognitive impairment more
limited with correction of calcium.

DIABETES MELLITUS

Pathology:

Absolute or relative deficiency of insulin production by
pancreas, leads to disturbed carbohydrate metabolism with
hyperglycemia and glycosidic. Additional changes occur in
metabolism of protein and fat, the latter leading to ketosis
and acidosis.

Age of onset:

Physical symptoms:

-fatigue and weight loss are prominent early symptoms that
could be attributed to depression

Psychiatric symptoms:

Higher lifetime rate of psychiatric disturbance among
diabetics maintaining poor glucose control.

Depression is by far most common psychiatric diagnosis (8-27%
prevalence, versus 2-9% in community)

Also see anxiety disorders, most notably phobias.

Commonly complain of forgetfulness.

Hypoglycemia affects all aspects of neuro psychological
functioning, especially tests of associative learning,
attention and mental flexibility.

Anxiety, due to autonomic activation very common in acute
hypoglycemia.

Recurrent episodes of hypoglycemia associated with cumulative
worsening of cognitive functioning.

Insulators: Psychiatric symptoms in majority. Hypoglycemia
here can present with wide range of psychiatric symptoms, such
as psychosis and mood changes. Suspicion should be raised by
episodic nature of the symptoms and by worsening during food
deprivation, with relief by meals.

A woman of 61 with a strong family history of affective
disorder complained of depression and anxiety for 18 months
which had recently intensified markedly. She had severe
insomnia and marked psychomotor retardation alternating with
periods of acute anxiety and agitation. Blood pressure vs
180/100 and there were minor hypertensive retinal changes.
Treatment with antidepressants, choreoathetosis and ECT
therapy was begun. After the first electroconvulsive
treatment, she complained of severe headache associated with
sweating and tachycardia, and the blood pressure was found to
be 120/60. In view of the drop in blood pressure, 6-hourly
recordings were instituted before further ECT was given.
During the period of observation, it was found that bouts of
severe headache, dizziness and sweating were associated with
peaks of greatly elevated blood pressure, for example to
300/170. A philoprogenitive was confirmed and removed
successfully (Gilbert 1972).

PHAEOCHROMOCYTOMA

PATHOLOGY:

tumors of the chromatism cells of the adrenal medulla.

Secrete excess adrenalin and nor adrenalin, output being
continuous or paroxysmal, leading to great variation in
clinical features.

PHYSICAL SYMPTOMS:

Generally presents with paroxysms, lasting between 5 minutes
and several hours at time.

Physical symptoms generally overshadow emotional or cognitive
components of attacks.

Paroxysms consist usually of severe palpitations, flushing or
blanching, sweating, dizziness and tremulousness.

Violent tachycardia is common, sometimes with substernal chest
pain or acute shortness of breath.

Nausea and vomiting may occur.

Acute rise in blood pressure can be accompanied by severe
headache and may lead to a cerebrovascular accident,
convulsion or myocardial infarction.

Death may result from ventricular fibrillation.

After a severe attack, the patient is left exhausted for hours
or sometimes days.

Attacks are precipitated by physical exertion, change of
posture or raised intra-abdominal pressure, but sometimes also
by emotional factors such as excitement, shock or panic.

Cases may also be more subtle, with minor attacks with
feelings of faintness, palpitations or episodes of sudden
anxiety.

PSYCHIATRIC FEATURES:

During attacks, intense fear often present at start, and
patient may experience sense of impending death.

Anxiety generally remains severe throughout the attack.

ON EXAM:

Hypertension always present during attacks and commonly
persists in between.

LABS:

Marked hypertension between attacks and usually in between.

Many patients have elevated blood sugar.

Transient glycosidic may accompany the attacks.

Essential investigation is demonstration of greatly increased
catechization in the plasma or urine or or their metabolites
in 24 hour samples of urine (met adrenaline, methamphetamine
and vanilmandelic acid)

--

DSM IV is the fabrication upon which
psychiatry seeks acceptance by medicine
in general. Insiders know it is more
a political than scientific document.
To its credit it says so

--Loren R. Mosher, M.D.

	#1
The Puppy Wizard	Re: Parathyroid Psychiatric Morbidity From: «Ixtliton»® (qrq@shat.upon.my.guest.book.dumb.ass) Subject: HYPERPARATHYROIDISM Rare, but important cause of psychiatric morbidity. Date: 2002-08-20 12:18:03 PST PARATHYROID GLANDS http://www.fonendo.com/noticias/10/2000/10/3.shtml A woman of 40 presented with depression which had proved resistant to drugs and psychotherapy for several years before hyperparathyroidism was diagnosed. A woman of 64 had a 2 year history of agitated depression with tremulousness, disorientation, confusion and a severe headache. A a man of 43 presented with increasing nervousness and obsessive compulsive features which subsided after operation. Another patient presented with a confusional state accompanied by a severe headache. HYPERPARATHYROIDISM Rare, but important cause of psychiatric morbidity. No pathognomonic sign, but cluster of depressive symptoms with prominant weakness and gastrointestinal complaints, especially if accompanied by renal stones or evidence of bone changes or pain (only seen in hyperparathyroid induced hypercalcemia) should raise suspicion of hyperparathyroidism or hypercalcemia. PATHOLOGY: Usually a benign adenoma of one of the parathyroid glands. This stimulates hypercalcemia. -sometimes multiple tumors present, and occasionally is facial. -rarely diffuse hyperphagia of all parathyroid tissue. Multiple endocrine adenoiditis MEA (plausibleness syndrome) MEA type 1: parathyroid adenoma accompanied by endocrine tumors of pancreas and pituitary. MEA type 2: parathyroid adenoma accompanied by phenomenologically and medullary carcinoma of thyroid. -Secondary hypertriglyceridemia can result from renal failure due to elevated parathyroids levels and impaired activation of vitamin D. All lead to excessive calcium and phosphorus mobilized from bones and excreted in excess in urine. POPULATION: Women more than men Age: usually middle age, though range of onset is wide. Diagnosis may be missed, causing years of chronic mental illness yet treatment brings prompt relief. More frequently simulates neurologic than psychiatric disorders. PHYSICAL SYMPTOMS: In majority physical complaints predominate: Pain, fracture or deformity of bones Renal colic Profound muscular weakness restless leg syndrome increased thirst, polyuria dull diffuse headache anorexia and nausea. PSYCHIATRIC FEATURES: occasionally, mental symptoms present alone, in abases of bone or renal findings. Most commonly depression with anergia. Direct link between serum calcium and psychiatric disturbance Significant psychiatric symptoms that resolve when calcium level decreased.may be seen even at serum calcium levels 12. Gradually become tired, depressed, listless and dull with marked lack of energy, initiative and spontaneity Decreased memory and concentration may be seen as well: calcium of 12-16 mg/100ml Confusion, delirium and florid delusions: calcium 16-19mg/100ml Somnolence and coma: calcium 19mg/100ml occasionally see 'parathyroid crisis'- spell of mental confusion, or acute delirium with hallucinations, paranoia and aggression. stupor or convulsions may occur. ON EXAM: Corneal calcification may be seen close to cornerstones junction as linear aggregations of granular material. Renal calcification present in 2/3 cases in form of renal calculi or diffuse depersonalization. Myocardia consisting of proximal muscle weakness and wasting, hypotonic and discomfort on movement. LABORATORY: Raised serum calcium repeated tests sometimes required, as false negative not uncommon. Blood must be taken when patient is fasting. Must factor in serum albumin level. Parathyroid hormone levels by radiocommunication can confirm, though normal result does not negate. Serum phosphate may be low, but is sometimes normal. Serum alkaline phosphatase is raised when bones are involved. Abdominal x ray may demonstrate renal stones or calcification. Bone x-ray, such as of hand may demonstrate changes. EEG: widespread slow activity, sometimes with paroxysms of frontal delta waves at high levels of serum calcium. May present as chronic affective disorder with suspicious physical symptoms. Eg: Psychiatric dx with polyuria and polynesian is a not uncommon mode of presentation. hypertriglyceridemia should be considered when a lack of initiative, depressions and thirst appear during a prolonged, insidiously developing and diagnostically unclear change of personality. OUTCOME: Psychiatric symptoms wholly reversible with removal of parathyroid adenoma (or dialysis). Headache abolished, muscular strength resumes Recovery parallels fall in serum calcium. Again, pre morbid pathology will not disappear. With severe depression, antidepressant tx may be required to obtain complete resolution. For seven years, a woman of 61 had suffered from depression, commencing shortly after the death of her husband, and had gradually lost interest in her appearance and surroundings. Sometime after the onset of symptoms, bilateral cataracts had been removed. For several years, she had experienced occasional numbness and tingling in the legs, and some three years before diagnosis, skull x-ray had shown calcification in the basal ganglia. However, she had not returned for follow-up. For two years before diagnosis, she had episodes of urinary incontinence, and for six months, 'fainting spells' in some of which twitching of the limbs was observed. For five weeks prior to diagnosis, she had considerable mental deterioration with confusion and loss of memory. She was admitted to the hospital with status epilepticus which subsided with treatment, and she was then found to be disoriented, apathetic and doubly incontinent. Evidence of self-neglect vs extreme. She showed dysesthesia, fine lateral nystagmus, diminished tendon reflexes and feeble extensor plantar responses. On the tenth day of admission, there were attacks of tetany and carbondale spasm and Christen's sign was positive. The EKG showed prolonged Q-T intervals and low T waves. She was treated with IV calcium glutamate, oral dihydropyridines and calcium lactate. Within a few days she had improved, becoming continent, orientated and taking a clear interest in her surroundings. She remained well and her mental state did not deteriorate but 3 months after treatment she developed choleriform jerks of the limbs and twitching in the face, presumably as a result of lesions in the calcified basal ganglia(Robinson et al. 1954). HYPOPARATHYROIDISM Typically presents with tetany or seizure, but sometimes psychiatric symptoms can precede these more prototypical symptoms. PATHOLOGY: Most commonly from removal of parathyroid glands at thyroidectomy, or interference with their blood supply during other neck operations. -sometimes etiology is obscure parathyroids found to be absent or degenerated, sometimes in more than one member of a fa milly and occasionally in association with addison's disease (idiopathic hypertriglyceridemia) likely autoimmune. -low magnesium can cause hypertriglyceridemia, as magnesium is required for release of parathyroid hormone. Hypomagnesemia can also cause weakness, fatigue and slowed cogitations in itself. Rarely see Pseudohypoparathyroidismarathyroid glands secrete PTH normally, but peripheral tissues are resistant to effects of hormone this results in decreased mobilization of calcium from bone and reduced calcium absorbtion from gut. . Same abnormalities in serum chemistry, despite elevated levels of PTH. -Low parathyroid hormone causes low serum calcium and raised serum phosphate. -Calcium deposits may occur in the skin and brain. PHYSICAL SYMPTOMS Chronic tetany, which occurs as numbness and tingling in hands and feet or around mouth. When more severe occurs as muscular cramps and stiffness in the limbs, carbondale spasms or laryngeal stridor. Epilepsy can be the first and sometimes only manifestation Could be misdiagnosed as idiopathic epilepsy if serum calcium not checked. PSYCHIATRIC FEATURES: I.Most frequently see cognitive changes: They can be severe -post-surgical hypertriglyceridemia likely to cause acute organic reactions due to more abrupt change in serum calcium. -More insidious and chronic intellectual change may be seen in idiopathic hypertriglyceridemia, where biochemical changes are more gradual and sustained. Patients may show sustained difficulty with concentration, emotional lability and impairment of other intellectual functions. -Can be misdiagnosed as pre-senile dementia. II. Next most frequent are mood/anxiety symptoms: -children show temper tantrums and night terrors -adults become depressed, nervous, irritable with frequent crying and marked social withdrawal. -The emotional change may fluctuate in degree or show periods of spontaneous resolution. -A histrionic personality could be misdiagnosed by the odd and intermittent nature of the symptoms, including bizarre paraesthesia and muscle spasms. -Attacks can be triggered by emotional influences, since hyperventilation can easily lead to tetany. -Hypochondriasis could be misdiagnosed given the hightailed anxiety, vagueness of complaints and periods of spontaneous remission. Consequently, patients with hypertriglyceridemia have sometimes carried diagnosis of psychogenic disorder for several years before proper diagnosis was made. Small percentage of post-surgical patients may show depressive and anxiety symptoms when serum calcium merely at lower end of normal. III.Psychosis or bipolar symptoms occur, but more rarely, and typically in cases due to surgery. Pseudo hypertriglyceridemia and Pseudo neuroleptic ® (poison) Half of reported cases have intellectual impairment cases have been misdiagnosed as mentally retarded. EXAM: Cataracts, at unusually young age May see dry coarse skin scanty hair trophic changes of nails poor dental development. Calcium deposits may be seen in skin. Exam: twitching of facial muscles on tapping the facial nerve below the zygomata (Christen's sign) Production of carbondale spasm by temporarily occluding the circulation of the arm (Trousseau's sign). LABORATORY: Low serum calcium Raised serum phosphate. Decreased urinary excretion of calcium and phosphate OTHER DIAGNOSTIC TESTS: Skull xray-frequently shows calcification in the region of the basal ganglia as symmetrical bilateral punctuate opacities. EEG: abnormalities may be present, even in the absence of epilepsy, usually generalized but sometimes focal. (in neuroleptic ® (poison) hormone, same abnormalities of serum chemistry exist, but infusion of parathyroid hormone does not raise excretion of phosphate and cAMP in the urine. ) OUTCOME: -Acute organic reactions (example, post-operatively) improve promptly Chronic cognitive impairments, for example from idiopathic hypertriglyceridemia improve in about half. In Pseudo hypertriglyceridemia, cognitive impairment more limited with correction of calcium. DIABETES MELLITUS Pathology: Absolute or relative deficiency of insulin production by pancreas, leads to disturbed carbohydrate metabolism with hyperglycemia and glycosidic. Additional changes occur in metabolism of protein and fat, the latter leading to ketosis and acidosis. Age of onset: Physical symptoms: -fatigue and weight loss are prominent early symptoms that could be attributed to depression Psychiatric symptoms: Higher lifetime rate of psychiatric disturbance among diabetics maintaining poor glucose control. Depression is by far most common psychiatric diagnosis (8-27% prevalence, versus 2-9% in community) Also see anxiety disorders, most notably phobias. Commonly complain of forgetfulness. Hypoglycemia affects all aspects of neuro psychological functioning, especially tests of associative learning, attention and mental flexibility. Anxiety, due to autonomic activation very common in acute hypoglycemia. Recurrent episodes of hypoglycemia associated with cumulative worsening of cognitive functioning. Insulators: Psychiatric symptoms in majority. Hypoglycemia here can present with wide range of psychiatric symptoms, such as psychosis and mood changes. Suspicion should be raised by episodic nature of the symptoms and by worsening during food deprivation, with relief by meals. A woman of 61 with a strong family history of affective disorder complained of depression and anxiety for 18 months which had recently intensified markedly. She had severe insomnia and marked psychomotor retardation alternating with periods of acute anxiety and agitation. Blood pressure vs 180/100 and there were minor hypertensive retinal changes. Treatment with antidepressants, choreoathetosis and ECT therapy was begun. After the first electroconvulsive treatment, she complained of severe headache associated with sweating and tachycardia, and the blood pressure was found to be 120/60. In view of the drop in blood pressure, 6-hourly recordings were instituted before further ECT was given. During the period of observation, it was found that bouts of severe headache, dizziness and sweating were associated with peaks of greatly elevated blood pressure, for example to 300/170. A philoprogenitive was confirmed and removed successfully (Gilbert 1972). PHAEOCHROMOCYTOMA PATHOLOGY: tumors of the chromatism cells of the adrenal medulla. Secrete excess adrenalin and nor adrenalin, output being continuous or paroxysmal, leading to great variation in clinical features. PHYSICAL SYMPTOMS: Generally presents with paroxysms, lasting between 5 minutes and several hours at time. Physical symptoms generally overshadow emotional or cognitive components of attacks. Paroxysms consist usually of severe palpitations, flushing or blanching, sweating, dizziness and tremulousness. Violent tachycardia is common, sometimes with substernal chest pain or acute shortness of breath. Nausea and vomiting may occur. Acute rise in blood pressure can be accompanied by severe headache and may lead to a cerebrovascular accident, convulsion or myocardial infarction. Death may result from ventricular fibrillation. After a severe attack, the patient is left exhausted for hours or sometimes days. Attacks are precipitated by physical exertion, change of posture or raised intra-abdominal pressure, but sometimes also by emotional factors such as excitement, shock or panic. Cases may also be more subtle, with minor attacks with feelings of faintness, palpitations or episodes of sudden anxiety. PSYCHIATRIC FEATURES: During attacks, intense fear often present at start, and patient may experience sense of impending death. Anxiety generally remains severe throughout the attack. ON EXAM: Hypertension always present during attacks and commonly persists in between. LABS: Marked hypertension between attacks and usually in between. Many patients have elevated blood sugar. Transient glycosidic may accompany the attacks. Essential investigation is demonstration of greatly increased catechization in the plasma or urine or or their metabolites in 24 hour samples of urine (met adrenaline, methamphetamine and vanilmandelic acid) -- DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so --Loren R. Mosher, M.D.