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1、精神病学精神病学Affective(mood)Disorders XIE Guang-rong M.D.Definition Affectivedisordersarecharacterizedbyobviousandpersistentelationordepressionofmood.Themooddisturbanceiscommonlyassociatedwithcognitiveandbehavioralchanges.Inseverecases,psychoticsymptoms,suchashallucinationanddelusion,maybeobserved.Therei
2、sarecurrenttendency.Incertaincases,anepisodemaybecomechronicandresidualsymptomsareobserved.TheClassificationofAffectiveDisorders Manic episode (mania)Depression single episode (unipolar)recurrent episode With or Affective without Disorders Bipolar-I(with mania)Psychotic Bipolar Bipolar-II(with hypom
3、ania)symptom disorders Mixed type Rapid-cyclingbipolar disorder Dysthymia Cyclothymia disorder ClinicaldescriptionofmooddisordersTheepisodeSeverityMild,moderate,orsevereTypeDepressive,manic,mixedSpecialfeaturesWithmelancholicsymptomsWithneuroticsymptomsWithpsychoticsymptomsWithagitationWithretardati
4、onorstuporThecourseUnipolarorbipolarAetiologyPredominantlyreactivePredominantlyendogenousEtiologyGeneticCausesFamilyStudies:InastudyattheNationalInstituteofMentalHealth,25%ofrelativesofbipolarprobandswerefoundtohavebipolardisorderorunipolarillness(depression)themselves,comparedto20%ofrelativesofunip
5、olarprobandsand7%ofrelativesofcontrolsubjects.Somedatahavesupportedmultifactorialmodels,Thesemodelsimplymultiplefactors:genetic,environmental,orboth.Analternativeexplanationisheterogeneity.Inotherwords,singlemajorgenesareimportantinatleastsomefamilies,butitisnotthesamegeneineachfamily.Twinstudies:On
6、average,MZtwinpairsshowconcordance65%ofthetime,andDZtwinpairsshowconcordance14%ofthetime.AdoptionStudies:Inonestudy,theriskforaffectivedisorderinthebiologicalrelativesofbipolarprobandswas31%asopposedto2%intherelativesofcontrolprobands.Theriskinbiologicalrelativesofadoptedbipolarprobandswassimilartot
7、heriskinrelativesofbipolarprobandswhowerenotadoptedaway(26%).Adoptiverelativesdidnotshowincreasedrisk.Adoptionstudiesthatusedabroaderclassofaffectiveprobandsshowedevidenceforgeneticfactorsbutalsopossibleenvironmentalinfluences.Molecular GeneticsLinkageStudiesChromosomalLocationReference18pBerrettini
8、etal19Stineetal199521qStraubetal1994Detera-Wadleighetal1996Xq26Pekkarinenetal199511p15Egelandetal1987Kelsoeetal1991Gurlingetal19955qCoonetal19934pBlackwoodetal199618qFreimeretal1996Stineetal1995Other(including10p,12q)Craddocketal1994Ewaldetal1995Ginnsetal1996NIMHGeneticsInitiative1997Summaryn The li
9、fetime risk for severe affective disorder is about 8%.Risk is increased to about 20%in first-degree relatives of unipolar patients and to 25%in first-degree relatives of bipolar patients.Risk appears to be 40%in relatives of schizoaffective patients.The risk to offspring of two affectively ill paren
10、ts is more than 50%.Overall risk figures appear to be rising in recent years.Biological theoriesNeurotransmitters.We now know that all clinically effectiveantidepressantsincreaseneurotransmitterconcentrationsatpostsynapticreceptorsitesbyinhibitingtheirreuptake(intothepresynapticneuron)fromthesynapti
11、ccleft,Thisactionhasledtothehypothesisthatdepressioniscausedby a neurotransmitter deficiency and thatantidepressants exert their clinical effect bytreatingthisimbalance.Theserotonin-norepinephrine-gluco-corticoidlinkhypothesisofaffectivedisorders.Neuroendocrine factors.Thetwoendocrinesystemsmostexte
12、nsivelystudiedinpsychiatryarethehypothalamic-pituitary-adrenal(HPA)axisandthehypothalamic-pituitary-thyroid(HPT)axis.Abouthalfofpatientswithmajordepressionexhibitcortisolhypersecretionthatreturnstonormaloncethedepressioniscured.Life events Recent evidence confirms that crucial life events,particular
13、ly the death of loss of a loved one,can precede the onset of depression.However,such losses precede only a small number of cases of depression.Fewer than 20%of individuals experiencing losses become clinically depressed.These observations argue strongly for a predisposing factor,possibly genetic,psy
14、chosocial,or characterological in nature.DepressiveepisodeDefinitionThedisorderischaracterizedbydepressedmoodthatisoutofkeepingwiththecircumstances.Itmayvaryfromlowmoodtomelancholia,orevenstupor.Inseverecases,psychoticsymptoms,suchasdelusionsandhallucinations,maybepresent.EpidemiologySymptomsanddiso
15、rdersofthedepressionspectrumarerathercommon.Lifetimeprevalenceratesfordepressivesymptomsare13%20%andformajordepressivedisorder3.7%6.7%.Majordepressivedisorderisabouttwotothreetimesascommoninadolescentandadultfemalesasinadolescentandadultmales.Inprepubertalchildren,boysandgirlsareaffectedequally.Rate
16、sinwomenandmenarehighestinthe25-to44-year-oldagegroup.Signs&SymptomsMajor depressive episode Thecardinalfeatureofamajordepressiveepisodeisadepressedmoodorthelossofinterestorpleasurethatpredominatesforatleast2weeksandcausessignificantdistressorimpairmentintheindividualssocial,occupational,orotherimpo
17、rtantareasoffunctioning.1.Depressed mood.Depressedmoodisthemostcharacteristicsymptom,occurringinover90%ofpatients.Thepatientusuallydescribeshimselforherselfasfeelingsad,low,empty,hopeless,gloomy,ordowninthedumps.Thequalityofmoodislikelytobeportrayedasdifferencefromanormalsenseofsadnessorgrief.Thephy
18、sicianoftenobserveschangesinthepatientsposture,speech,faces,dress,andgroomingconsistentwiththepatientsself-report.Manydepressedpatientsstatethattheyareunabletocry,whereasothersreportfrequentweepingspellsthatoccurwithoutsignificantprecipitants.2.AnhedoniaAninabilitytoenjoyusualactivitiesisalmostunive
19、rsalamongdepressedpatients.Thepatientorhisorherfamilymayreportmarkedlydiminishedinterestinall,oralmostall,activitiespreviouslyenjoyedsuchassex,hobbies,anddailyroutines.3.Indecisiveness or decreased concentrationAbout one half of depressed patientscomplainoforexhibitaslowingofthought,Theymayfeelthatt
20、heyarenotabletothinkaswellasbefore,thattheycannotconcentrate,orthattheyareeasily distracted.Frequentlythey will doubt their ability to make goodjudgments and find themselves unable tomakeevensmalldecisions.4.Feelings of worthlessness and excessive or inappropriate guilt5.Suicidal ideationManydepress
21、edindividualsexperiencerecurrentthoughtsofdeath,rangingfromtransientfeelingsthatotherswouldbebetteroffwithoutthem,totheactualplanningandimplementingofsuicide.Upto15%ofpatientswithseveremajordepressivedisorderarelikelytodiebysuicide.6.Change in appetite About70%ofpatientsobservedareductioninappetitew
22、ithaccompanyingweightloss;7.Change in sleepAbout80%ofdepressedpatientscommonbeinginsomnia.Insomniaisusuallyclassifiedasinitialmiddle,orlate.Themostcommonformofsleepdisturbanceinmajordepressivedisorderislateinsomnia,withworseningofdepressivemoodinthethemorning.8.Change in body activityAbout one half
23、of depressed patientsdevelop a slowing,or retardation,of theirnormallevelofactivity.Theymayexhibitaslowness in thinking,speaking,or bodymovement or a decrease in volume orcontentofspeech.Insomepatients,anxietyisobvious.9.Loss of energyn Almostalldepressedpatientsreportasignificantlossofenergy,unusua
24、lfatigueortiredness.Diagnosis1.Symptomcriteria The depressed mood must be accompanied by at least 4 of the following:(1)loss of interest or enjoyment;(2)lack of energy or fatigability;(3)Psychomotor retardation or agitation;(4)Reduced self-esteem,worthlessness,self-blame,or preoccupation with guilt;
25、(5)Feel thinking retardation,or thinking efficiency reduced;(6)Repeated ideas or attempts of self-harm or suicide;(7)Disturbed sleep,e.g.,insomnia,early morning wakening,or hypersomnia;(8)Poor appetite or obvious weight loss;(9)Decreased2.Severitycriteria Impairment of social function,individual sub
26、jective distress,or undesirable outcomes on oneself 3.Coursecriteria Symptom and severity criteria are met for at least 2 weeks.4.Exclusion(1)Excluding organic mental disorders,ordepression attributableto psychoactiveand non-addictivesubstances;(2)Schizophrenicsymptomsmaybepresent,providedthatthecri
27、teriaofschizophreniaarenotmet.Ifthecriteriaofschizophreniaarefulfilled,adiagnosisofdepressiveepisodecanonlybemadeifthedepressivesymptomslastformorethan2weeksfollowingtheresolutionofschizophrenicsymptoms.5.Note The criteria only refer to single depressive episode.DifferentialDiagnosisAdiagnosisofdepr
28、essionismadeiftheindividualissignificantlyimpairedbythedepressivesymptomsoutlinedabove,andiftheexclusioncriteriaaremet:(1)theillnessisnotduetotheeffectsofasubstanceorageneralmedicalcondition,(2)thesymptomsarenotbetteraccountedforbybereavement.1.Medical Conditions Many medications and medical disorde
29、rs commonly produce symptoms of depression.2.OtherpsychiatricDisordersDepression can be a feature of almost allotherpsychiatricdisorders,eg.Schizophrenia,Schizoaffectivedisorder.OrganiccausesofdepressionMedicationsAnalgesics(eg,indomethacin,opiates)Antibiotics(eg,ampicillin)Antihypertensive agents(e
30、g,propranolol,reserpine,-methyldopa,clonidine)Antineoplasticagents(eg,cycloserine,vincristine,vinblastine)CimetidineL-DopaSubstances of abuse AlcoholCocaineOpiatesNeurologic disease Chronic subdural hematoma Dementias Huntingtons disease Migraine headaches Multiple sclerosisInfectious disease Brucel
31、losis EncephalitisHIV_ Neoplasms Bronchogenic carcinoma CNS tumorsMetabolic and endocrine disorders Addisons disease Anemia Apathetic hyperthyroidismCushings diseaseDiabetesCollagen-vascular conditionsGiantcellarteritisRheumatoidarthritisSystemiclupuserythematosusCardiovascular conditionsChronicheat
32、failureHypoxiaMitralvalveprolapseMiscellaneousChronicpyeionephritisPancreatitisTreatmentsPharmacologicTreatmentsBe aware of the cycling course of thedisease,itnecessitatesdifferenttreatmentapproaches:acute treatment for floridsymptoms;continuationtherapytoprevent early relapse;and maintenancetherapy
33、tomakerelapselesslikelyor,ifitoccurs,Lesssevere.Antidepressantsareusuallyinitiatedatalowdosageandincreasedovera7-to10-dayperiodtoachievetheinitialtargetdosage.Once a therapeutic effect is achieved,theantidepressantmedicationshouldbecontinued through the period of highvulnerabilityforrelapse.More tha
34、n 60%of depressed patients willeventuallyrelapse,especiallyifunprotectedby medication,it has been proposed thatsomedepressedpatientsbeplacedonlong-termtreatment.Maintenancetherapyforextendedperiodsoftimeshouldbeconsideredif:(1)thepatientisolderthan40yearsandhadtwoormorepriorepisodesofillness.(2)thef
35、irstepisodeoccurredatage50yearsorolder,(3)thepatienthasahistoryofthreeormoredepressiveepisodes(4)thepatienthasbeendepressedordysthymicfor2ormoreyearsbeforetreatment.Electroconvulsive therapy ECT has shown efficacy in all types of major depressive disorder Cognitive-behavioral therapyMarital therapy
36、and family therapy Interpersonal psychotherapyTreatment of bipolar disorderCourseandprognosisofmooddisorders.ManicepisodeDefinitionThe disorder is characterized by elated andexpansivemoodthatisoutofkeepingwiththeindividualscircumstances.Themooddisturbancemayvaryfromcarefreejovialitytouncontrollablee
37、xcitement.Sometimes,irritabilityisthepredominantpresentation.Inmildcases,impairmentofsocialfunctionmaybe absent or minimal.Psychotic symptoms,suchasdelusionsandhallucinations,maybeobservedinseverecases.Signs&symptomsThecentralfeaturesofthesyndromeofmaniaareelevationofmood,increasedactivity,andself-i
38、mportantideas.Whenthemoodiselevated,thepatientseemscheerfulandoptimistic.However,otherpatientsareirritableratherthaneuphoric,andthisirritabilitycaneasilyturntoanger.Manic patients are overactive.Sometimes their persistent overactivityoveractivity leads to physical exhaustion.Their speech isoftenrapi
39、dandcopiousasthoughtscrowdintotheirmindsinquicksuccession.Whenthedisorderismoresevere,thereisflightofideaswithsuchrapidchangesthatitisdifficulttofollowthetrainofthought.Sleepisoftenreduced.Thepatientwakesearlyfeelinglivelyandenergetic;oftenhegetsupandbusieshimselfnoisily,tothesurpriseofotherpeople.A
40、ppetiteisincreasedandfoodmaybeeatengreedilywithlittleattentiontouninhibited.Sexual desires are increased and behavior may be uninhabited Expansive ideasarecommon.Thepatientbelievesthathisideasareoriginal,hisopinionsimportant,andhisworkofoutstandingquality.Manypatientsbecomeextravagant,spendingmoreth
41、antheycanaffordonexpensive.Sometimestheseexpansivethemesareaccompaniedby grandiose delusions.Delusionsofreferencealsooccur.Schneiderianfirst-ranksymptomshavebeenreportedinabout10-20percentofmanicpatients.Hallucinations alsooccur.Theyareusuallyconsistentwiththemood,takingtheformofvoicesspeakingtothep
42、atientabouthisspecialpowers.Insightisinvariablyimpaired.Thepatientmayseenoreasonwhyhisgrandioseplansshouldberestrainedorhisextravagantexpenditurecurtailed.Heseldomthinkshimselfill,orinneedoftreatment In mild mild cases there is increased physical activity and speech;mood is labile being mainly eupho
43、ric but giving way to irritability at time;ideas are expansive and the patient often spends more than he can afford;sexual drive increases.Inmoderatecases,thereismarkedoveractivityandpressureofspeechwhichseemsdisorganized;theeuphoricmoodisincreasinglyinterruptedbyperiodsofirritability,hostility,andd
44、epression;grandioseandotherpreoccupationsmaypassintodelusions In severe In severe cases,there is frenzied overactivity,thinking is incoherent,delusions become increasingly bizarre and hallucinations are experienced.Diagnosis 1.Symptom criteria:When the predominant mood disturbance is elated or expan
45、sive mood,at least 3 of the following are required(if irritability is the only mood change,at least 4 of the following symptoms should be satisfied):(1)Impairedconcentrationordistractibility;(2)Over-talkativeness;(3)Racing thoughts(exemplified by increasedflowofspeechorpressureofspeech)orflightofide
46、as;(4)Inflatedself-esteemorgrandiosity;(5)Over-energetic,indefatigable,overactivity,difficulttocalmdownorincessantchangeofplansandactivities;(6)Recklessbehavior(e.g.,over-spending,irresponsiblebehavior);(7)Decreasedneedforsleep;(8)Increasedlibido.2.Severity criteria:Severe impairment of social funct
47、ion,or dangerous or harmful outcome(s)inflicted on others.3.Course criteria:The episode meets both the symptom criteria and the severity criteria for at lest one week;If psychotic symptoms are present and fulfil the symptom criteria of schizophrenia,a diagnosis of manic episode can only be made,if o
48、ne week after the schizophrenic symptoms have resolved and the manic episode diagnostic criteria are still fulfilled 4.Exclusion:Excludingorganicmentaldisorders,andmaniaattributabletotheuseofpsychoactiveornon-addictivesubstance(s).5.Note:These diagnostic criteria are onlyapplicabletosingleepisodeofm
49、ania.DifferentialDiagnosis1.MedicaldisordersNumerousmedicaldisordersandmedicationscaninduceormimictheclinicalpictureofbipolardisorder,exacerbateitscourseandseverity,orcomplicateitstreatment.OrganiccausesofmaniaandhypomaniaMedications Neurologic disordersAnticonvulsantsHuntingsdiseaseBarbituratesMult
50、iplesclerosisBenzodiazepinesPoststrokeMetabolic disturbances NeoplasmAddisons disease Other condition2.PsychiatricDisordersThepsychoticfeaturesassociatedwithSchizophreniaorschizoaffectivedisorderareoftenindistinguishablefromthosewithacutemania.Patientswithcertainpersonalitydisorderscanexhibitimpulsi