心境障碍(英文).ppt

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