心境障碍(英文)ppt课件.ppt

精神病学精神病学Affective(mood)Disorders XIE Guang-rong M.D.Definition Affectivedisordersarecharacterizedbyobviousandpersistentelationordepressionofmood.Themooddisturbanceiscommonlyassociatedwithcognitiveandbehavioralchanges.Inseverecases,psychoticsymptoms,suchashallucinationanddelusion,maybeobserved.Thereisarecurrenttendency.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 hypomania)symptom disorders Mixed type Rapid-cyclingbipolar disorder Dysthymia Cyclothymia disorder ClinicaldescriptionofmooddisordersTheepisodeSeverityMild,moderate,orsevereTypeDepressive,manic,mixedSpecialfeaturesWithmelancholicsymptomsWithneuroticsymptomsWithpsychoticsymptomsWithagitationWithretardationorstuporThecourseUnipolarorbipolarAetiologyPredominantlyreactivePredominantlyendogenousEtiologyGeneticCausesFamilyStudies: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.Molecular GeneticsLinkageStudiesChromosomalLocationReference18pBerrettinietal19Stineetal199521qStraubetal1994Detera-Wadleighetal1996Xq26Pekkarinenetal199511p15Egelandetal1987Kelsoeetal1991Gurlingetal19955qCoonetal19934pBlackwoodetal199618qFreimeretal1996Stineetal1995Other(including10p,12q)Craddocketal1994Ewaldetal1995Ginnsetal1996NIMHGeneticsInitiative1997Summaryn The lifetime 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 parents is more than 50%.Overall risk figures appear to be rising in recent years.Biological theoriesNeurotransmitters.We now know that all clinically effectiveantidepressantsincreaseneurotransmitterconcentrationsatpostsynapticreceptorsitesbyinhibitingtheirreuptake(intothepresynapticneuron)fromthesynapticcleft,Thisactionhasledtothehypothesisthatdepressioniscausedby a neurotransmitter deficiency and thatantidepressants exert their clinical effect bytreatingthisimbalance.Theserotonin-norepinephrine-gluco-corticoidlinkhypothesisofaffectivedisorders.Neuroendocrine factors.Thetwoendocrinesystemsmostextensivelystudiedinpsychiatryarethehypothalamic-pituitary-adrenal(HPA)axisandthehypothalamic-pituitary-thyroid(HPT)axis.Abouthalfofpatientswithmajordepressionexhibitcortisolhypersecretionthatreturnstonormaloncethedepressioniscured.Life events Recent evidence confirms that crucial life events,particularly 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,psychosocial,or characterological in nature.DepressiveepisodeDefinitionThedisorderischaracterizedbydepressedmoodthatisoutofkeepingwiththecircumstances.Itmayvaryfromlowmoodtomelancholia,orevenstupor.Inseverecases,psychoticsymptoms,suchasdelusionsandhallucinations,maybepresent.EpidemiologySymptomsanddisordersofthedepressionspectrumarerathercommon.Lifetimeprevalenceratesfordepressivesymptomsare13%20%andformajordepressivedisorder3.7%6.7%.Majordepressivedisorderisabouttwotothreetimesascommoninadolescentandadultfemalesasinadolescentandadultmales.Inprepubertalchildren,boysandgirlsareaffectedequally.Ratesinwomenandmenarehighestinthe25-to44-year-oldagegroup.Signs&SymptomsMajor depressive episode Thecardinalfeatureofamajordepressiveepisodeisadepressedmoodorthelossofinterestorpleasurethatpredominatesforatleast2weeksandcausessignificantdistressorimpairmentintheindividualssocial,occupational,orotherimportantareasoffunctioning.1.Depressed mood.Depressedmoodisthemostcharacteristicsymptom,occurringinover90%ofpatients.Thepatientusuallydescribeshimselforherselfasfeelingsad,low,empty,hopeless,gloomy,ordowninthedumps.Thequalityofmoodislikelytobeportrayedasdifferencefromanormalsenseofsadnessorgrief.Thephysicianoftenobserveschangesinthepatientsposture,speech,faces,dress,andgroomingconsistentwiththepatientsself-report.Manydepressedpatientsstatethattheyareunabletocry,whereasothersreportfrequentweepingspellsthatoccurwithoutsignificantprecipitants.2.AnhedoniaAninabilitytoenjoyusualactivitiesisalmostuniversalamongdepressedpatients.Thepatientorhisorherfamilymayreportmarkedlydiminishedinterestinall,oralmostall,activitiespreviouslyenjoyedsuchassex,hobbies,anddailyroutines.3.Indecisiveness or decreased concentrationAbout one half of depressed patientscomplainoforexhibitaslowingofthought,Theymayfeelthattheyarenotabletothinkaswellasbefore,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 ideationManydepressedindividualsexperiencerecurrentthoughtsofdeath,rangingfromtransientfeelingsthatotherswouldbebetteroffwithoutthem,totheactualplanningandimplementingofsuicide.Upto15%ofpatientswithseveremajordepressivedisorderarelikelytodiebysuicide.6.Change in appetite About70%ofpatientsobservedareductioninappetitewithaccompanyingweightloss;7.Change in sleepAbout80%ofdepressedpatientscommonbeinginsomnia.Insomniaisusuallyclassifiedasinitialmiddle,orlate.Themostcommonformofsleepdisturbanceinmajordepressivedisorderislateinsomnia,withworseningofdepressivemoodinthethemorning.8.Change in body activityAbout one half 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,unusualfatigueortiredness.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;(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 subjective 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,providedthatthecriteriaofschizophreniaarenotmet.Ifthecriteriaofschizophreniaarefulfilled,adiagnosisofdepressiveepisodecanonlybemadeifthedepressivesymptomslastformorethan2weeksfollowingtheresolutionofschizophrenicsymptoms.5.Note The criteria only refer to single depressive episode.DifferentialDiagnosisAdiagnosisofdepressionismadeiftheindividualissignificantlyimpairedbythedepressivesymptomsoutlinedabove,andiftheexclusioncriteriaaremet:(1)theillnessisnotduetotheeffectsofasubstanceorageneralmedicalcondition,(2)thesymptomsarenotbetteraccountedforbybereavement.1.Medical Conditions Many medications and medical disorders 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(eg,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 Brucellosis EncephalitisHIV_ Neoplasms Bronchogenic carcinoma CNS tumorsMetabolic and endocrine disorders Addisons disease Anemia Apathetic hyperthyroidismCushings diseaseDiabetesCollagen-vascular conditionsGiantcellarteritisRheumatoidarthritisSystemiclupuserythematosusCardiovascular conditionsChronicheatfailureHypoxiaMitralvalveprolapseMiscellaneousChronicpyeionephritisPancreatitisTreatmentsPharmacologicTreatmentsBe aware of the cycling course of thedisease,itnecessitatesdifferenttreatmentapproaches:acute treatment for floridsymptoms;continuationtherapytoprevent early relapse;and maintenancetherapytomakerelapselesslikelyor,ifitoccurs,Lesssevere.Antidepressantsareusuallyinitiatedatalowdosageandincreasedovera7-to10-dayperiodtoachievetheinitialtargetdosage.Once a therapeutic effect is achieved,theantidepressantmedicationshouldbecontinued through the period of highvulnerabilityforrelapse.More than 60%of depressed patients willeventuallyrelapse,especiallyifunprotectedby medication,it has been proposed thatsomedepressedpatientsbeplacedonlong-termtreatment.Maintenancetherapyforextendedperiodsoftimeshouldbeconsideredif:(1)thepatientisolderthan40yearsandhadtwoormorepriorepisodesofillness.(2)thefirstepisodeoccurredatage50yearsorolder,(3)thepatienthasahistoryofthreeormoredepressiveepisodes(4)thepatienthasbeendepressedordysthymicfor2ormoreyearsbeforetreatment.Electroconvulsive therapy ECT has shown efficacy in all types of major depressive disorder Cognitive-behavioral therapyMarital therapy and family therapy Interpersonal psychotherapyTreatment of bipolar disorderCourseandprognosisofmooddisorders.ManicepisodeDefinitionThe disorder is characterized by elated andexpansivemoodthatisoutofkeepingwiththeindividualscircumstances.Themooddisturbancemayvaryfromcarefreejovialitytouncontrollableexcitement.Sometimes,irritabilityisthepredominantpresentation.Inmildcases,impairmentofsocialfunctionmaybe absent or minimal.Psychotic symptoms,suchasdelusionsandhallucinations,maybeobservedinseverecases.Signs&symptomsThecentralfeaturesofthesyndromeofmaniaareelevationofmood,increasedactivity,andself-importantideas.Whenthemoodiselevated,thepatientseemscheerfulandoptimistic.However,otherpatientsareirritableratherthaneuphoric,andthisirritabilitycaneasilyturntoanger.Manic patients are overactive.Sometimes their persistent overactivityoveractivity leads to physical exhaustion.Their speech isoftenrapidandcopiousasthoughtscrowdintotheirmindsinquicksuccession.Whenthedisorderismoresevere,thereisflightofideaswithsuchrapidchangesthatitisdifficulttofollowthetrainofthought.Sleepisoftenreduced.Thepatientwakesearlyfeelinglivelyandenergetic;oftenhegetsupandbusieshimselfnoisily,tothesurpriseofotherpeople.Appetiteisincreasedandfoodmaybeeatengreedilywithlittleattentiontouninhibited.Sexual desires are increased and behavior may be uninhabited Expansive ideasarecommon.Thepatientbelievesthathisideasareoriginal,hisopinionsimportant,andhisworkofoutstandingquality.Manypatientsbecomeextravagant,spendingmorethantheycanaffordonexpensive.Sometimestheseexpansivethemesareaccompaniedby grandiose delusions.Delusionsofreferencealsooccur.Schneiderianfirst-ranksymptomshavebeenreportedinabout10-20percentofmanicpatients.Hallucinations alsooccur.Theyareusuallyconsistentwiththemood,takingtheformofvoicesspeakingtothepatientabouthisspecialpowers.Insightisinvariablyimpaired.Thepatientmayseenoreasonwhyhisgrandioseplansshouldberestrainedorhisextravagantexpenditurecurtailed.Heseldomthinkshimselfill,orinneedoftreatment In mild mild cases there is increased physical activity and speech;mood is labile being mainly euphoric 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,anddepression;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 expansive 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)orflightofideas;(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 function,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 one 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 onlyapplicabletosingleepisodeofmania.DifferentialDiagnosis1.MedicaldisordersNumerousmedicaldisordersandmedicationscaninduceormimictheclinicalpictureofbipolardisorder,exacerbateitscourseandseverity,orcomplicateitstreatment.OrganiccausesofmaniaandhypomaniaMedications Neurologic disordersAnticonvulsantsHuntingsdiseaseBarbituratesMultiplesclerosisBenzodiazepinesPoststrokeMetabolic disturbances NeoplasmAddisons disease Other condition2.PsychiatricDisordersThepsychoticfeaturesassociatedwithSchizophreniaorschizoaffectivedisorderareoftenindistinguishablefromthosewithacutemania.Patientswithcertainpersonalitydisorderscanexhibitimpulsi