心境障碍(英文).ppt
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心境障碍(英文).ppt
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精神病学,Affective(mood)Disorders,XIEGuang-rongM.D.,Definition,Affectivedisordersarecharacterizedbyobviousandpersistentelationordepressionofmood.Themooddisturbanceiscommonlyassociatedwithcognitiveandbehavioralchanges.Inseverecases,psychoticsymptoms,suchashallucinationanddelusion,maybeobserved.Thereisarecurrenttendency.Incertaincases,anepisodemaybecomechronicandresidualsymptomsareobserved.,TheClassificationofAffectiveDisorders,Manicepisode(mania)Depressionsingleepisode(unipolar)recurrentepisodeWithorAffectivewithoutDisordersBipolar-I(withmania)PsychoticBipolarBipolar-II(withhypomania)symptomdisordersMixedtypeRapid-cyclingbipolardisorderDysthymiaCyclothymiadisorder,Clinicaldescriptionofmooddisorders,TheepisodeSeverityMild,moderate,orsevereTypeDepressive,manic,mixedSpecialfeaturesWithmelancholicsymptomsWithneuroticsymptomsWithpsychoticsymptomsWithagitationWithretardationorstuporThecourseUnipolarorbipolarAetiologyPredominantlyreactivePredominantlyendogenous,Etiology,GeneticCausesFamilyStudies:
InastudyattheNationalInstituteofMentalHealth,25%ofrelativesofbipolarprobandswerefoundtohavebipolardisorderorunipolarillness(depression)themselves,comparedto20%ofrelativesofunipolarprobandsand7%ofrelativesofcontrolsubjects.,Somedatahavesupportedmultifactorialmodels,Thesemodelsimplymultiplefactors:
genetic,environmental,orboth.Analternativeexplanationisheterogeneity.Inotherwords,singlemajorgenesareimportantinatleastsomefamilies,butitisnotthesamegeneineachfamily.,Twinstudies:
Onaverage,MZtwinpairsshowconcordance65%ofthetime,andDZtwinpairsshowconcordance14%ofthetime.,AdoptionStudies:
Inonestudy,theriskforaffectivedisorderinthebiologicalrelativesofbipolarprobandswas31%asopposedto2%intherelativesofcontrolprobands.Theriskinbiologicalrelativesofadoptedbipolarprobandswassimilartotheriskinrelativesofbipolarprobandswhowerenotadoptedaway(26%).Adoptiverelativesdidnotshowincreasedrisk.,Adoptionstudiesthatusedabroaderclassofaffectiveprobandsshowedevidenceforgeneticfactorsbutalsopossibleenvironmentalinfluences.,MolecularGenetics,LinkageStudiesChromosomalLocationReference18pBerrettinietal19Stineetal199521qStraubetal1994Detera-Wadleighetal1996Xq26Pekkarinenetal199511p15Egelandetal1987Kelsoeetal1991Gurlingetal19955qCoonetal19934pBlackwoodetal199618qFreimeretal1996Stineetal1995Other(including10p,12q)Craddocketal1994Ewaldetal1995Ginnsetal1996NIMHGeneticsInitiative1997,Summary,Thelifetimeriskforsevereaffectivedisorderisabout8%.Riskisincreasedtoabout20%infirst-degreerelativesofunipolarpatientsandto25%infirst-degreerelativesofbipolarpatients.Riskappearstobe40%inrelativesofschizoaffectivepatients.Therisktooffspringoftwoaffectivelyillparentsismorethan50%.Overallriskfiguresappeartoberisinginrecentyears.,Biologicaltheories,Neurotransmitters.Wenowknowthatallclinicallyeffectiveantidepressantsincreaseneurotransmitterconcentrationsatpostsynapticreceptorsitesbyinhibitingtheirreuptake(intothepresynapticneuron)fromthesynapticcleft,Thisactionhasledtothehypothesisthatdepressioniscausedbyaneurotransmitterdeficiencyandthatantidepressantsexerttheirclinicaleffectbytreatingthisimbalance.,Theserotonin-norepinephrine-gluco-corticoidlinkhypothesisofaffectivedisorders.,Neuroendocrinefactors.Thetwoendocrinesystemsmostextensivelystudiedinpsychiatryarethehypothalamic-pituitary-adrenal(HPA)axisandthehypothalamic-pituitary-thyroid(HPT)axis.Abouthalfofpatientswithmajordepressionexhibitcortisolhypersecretionthatreturnstonormaloncethedepressioniscured.,Lifeevents,Recentevidenceconfirmsthatcruciallifeevents,particularlythedeathoflossofalovedone,canprecedetheonsetofdepression.However,suchlossesprecedeonlyasmallnumberofcasesofdepression.Fewerthan20%ofindividualsexperiencinglossesbecomeclinicallydepressed.Theseobservationsarguestronglyforapredisposingfactor,possiblygenetic,psychosocial,orcharacterologicalinnature.,Depressiveepisode,DefinitionThedisorderischaracterizedbydepressedmoodthatisoutofkeepingwiththecircumstances.Itmayvaryfromlowmoodtomelancholia,orevenstupor.Inseverecases,psychoticsymptoms,suchasdelusionsandhallucinations,maybepresent.,Epidemiology,Symptomsanddisordersofthedepressionspectrumarerathercommon.Lifetimeprevalenceratesfordepressivesymptomsare13%20%andformajordepressivedisorder3.7%6.7%.Majordepressivedisorderisabouttwotothreetimesascommoninadolescentandadultfemalesasinadolescentandadultmales.Inprepubertalchildren,boysandgirlsareaffectedequally.Ratesinwomenandmenarehighestinthe25-to44-year-oldagegroup.,Signs&Symptoms,MajordepressiveepisodeThecardinalfeatureofamajordepressiveepisodeisadepressedmoodorthelossofinterestorpleasurethatpredominatesforatleast2weeksandcausessignificantdistressorimpairmentintheindividualssocial,occupational,orotherimportantareasoffunctioning.,1.Depressedmood.,Depressedmoodisthemostcharacteristicsymptom,occurringinover90%ofpatients.Thepatientusuallydescribeshimselforherselfasfeelingsad,low,empty,hopeless,gloomy,ordowninthedumps.Thequalityofmoodislikelytobeportrayedasdifferencefromanormalsenseofsadnessorgrief.,Thephysicianoftenobserveschangesinthepatientsposture,speech,faces,dress,andgroomingconsistentwiththepatientsself-report.Manydepressedpatientsstatethattheyareunabletocry,whereasothersreportfrequentweepingspellsthatoccurwithoutsignificantprecipitants.,2.Anhedonia,Aninabilitytoenjoyusualactivitiesisalmostuniversalamongdepressedpatients.Thepatientorhisorherfamilymayreportmarkedlydiminishedinterestinall,oralmostall,activitiespreviouslyenjoyedsuchassex,hobbies,anddailyroutines.,3.Indecisivenessordecreasedconcentration,Aboutonehalfofdepressedpatientscomplainoforexhibitaslowingofthought,Theymayfeelthattheyarenotabletothinkaswellasbefore,thattheycannotconcentrate,orthattheyareeasilydistracted.Frequentlytheywilldoubttheirabilitytomakegoodjudgmentsandfindthemselvesunabletomakeevensmalldecisions.,4.Feelingsofworthlessnessandexcessiveorinappropriateguilt,5.Suicidalideation,Manydepressedindividualsexperiencerecurrentthoughtsofdeath,rangingfromtransientfeelingsthatotherswouldbebetteroffwithoutthem,totheactualplanningandimplementingofsuicide.Upto15%ofpatientswithseveremajordepressivedisorderarelikelytodiebysuicide.,6.Changeinappetite,About70%ofpatientsobservedareductioninappetitewithaccompanyingweightloss;,7.Changeinsleep,About80%ofdepressedpatientscommonbeinginsomnia.Insomniaisusuallyclassifiedasinitialmiddle,orlate.Themostcommonformofsleepdisturbanceinmajordepressivedisorderislateinsomnia,withworseningofdepressivemoodinthethemorning.,8.Changeinbodyactivity,Aboutonehalfofdepressedpatientsdevelopaslowing,orretardation,oftheirnormallevelofactivity.Theymayexhibitaslownessinthinking,speaking,orbodymovementoradecreaseinvolumeorcontentofspeech.Insomepatients,anxietyisobvious.,9.Lossofenergy,Almostalldepressedpatientsreportasignificantlossofenergy,unusualfatigueortiredness.,Diagnosis,1.Symptomcriteria,Thedepressedmoodmustbeaccompaniedbyatleast4ofthefollowing:
(1)lossofinterestorenjoyment;
(2)lackofenergyorfatigability;(3)Psychomotorretardationoragitation;(4)Reducedself-esteem,worthlessness,self-blame,orpreoccupationwithguilt;,(5)Feelthinkingretardation,orthinkingefficiencyreduced;(6)Repeatedideasorattemptsofself-harmorsuicide;(7)Disturbedsleep,e.g.,insomnia,earlymorningwakening,orhypersomnia;(8)Poorappetiteorobviousweightloss;(9)Decreased,2.Severitycriteria,Impairmentofsocialfunction,individualsubjectivedistress,orundesirableoutcomesononeself,3.Coursecriteria,Symptomandseveritycriteriaaremetforatleast2weeks.,4.Exclusion,
(1)Excludingorganicmentaldisorders,ordepressionattributabletopsychoactiveandnon-addictivesubstances;
(2)Schizophrenicsymptomsmaybepresent,providedthatthecriteriaofschizophreniaarenotmet.Ifthecriteriaofschizophreniaarefulfilled,adiagnosisofdepressiveepisodecanonlybemadeifthedepressivesymptomslastformorethan2weeksfollowingtheresolutionofschizophrenicsymptoms.,5.Note,Thecriteriaonlyrefertosingledepressiveepisode.,DifferentialDiagnosis,Adiagnosisofdepressionismadeiftheindividualissignificantlyimpairedbythedepressivesymptomsoutlinedabove,andiftheexclusioncriteriaaremet:
(1)theillnessisnotduetotheeffectsofasubstanceorageneralmedicalcondition,
(2)thesymptomsarenotbetteraccountedforbybereavement.,1.MedicalConditions,Manymedicationsandmedicaldisorderscommonlyproducesymptomsofdepression.,2.OtherpsychiatricDisorders,Depressioncanbeafeatureofalmostallotherpsychiatricdisorders,eg.Schizophrenia,Schizoaffectivedisorder.,Organiccausesofdepression,MedicationsAnalgesics(eg,indomethacin,opiates)Antibiotics(eg,ampicillin)Antihypertensiveagents(eg,propranolol,reserpine,-methyldopa,clonidine)Antineoplasticagents(eg,cycloserine,vincristine,vinblastine)CimetidineL-DopaSubstancesofabuseAlcoholCocaineOpiates,NeurologicdiseaseChronicsubduralhematomaDementiasHuntingtonsdiseaseMigraineheadachesMultiplesclerosisInfectiousdiseaseBrucellosisEncephalitisHIV_NeoplasmsBronchogeniccarcinomaCNStumorsMetabolicande
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