PD的精神症状.pptx

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2018/7/1,#,Parkinsons disease psychosis,1,Psychosis in,PD,In a recent meta-analysis,of,prospective studies,visual hallucinations,were reported in,16-37%,of patients,auditory in,less than 2-22%and,delusions in,about,1-14%.,The number of variables that differed among studies make any estimate,very approximate,.,Visual hallucinations,tend to be complex and,formed,may be clearly seen or,not,tend,to,be stereotyped,tend,to occur when the patient is in a low sensory,environment,and are thus more state-dependent than related to,drug dose.,Auditory,hallucinations,are often indistinct,with party sounds,heard coming,from another room,people talking indistinctly,outside,music,of various,types.Sometimes,the visual hallucinations,talk to the,patient and may carry on,conversations.,Delusions,tend to be paranoid.The most common delusions,are of,stealing,thinking their house is not really theirs,spousal,infidelitv,and being,abandoned.,Friedman,J H.Parkinsons disease psychosis 2010:a review articleZ.2010:16,553560,2,Differential,S,chizophrenia:Psychotic,symptoms present in schizophrenia such as,thought broadcasting,delusions of grandeur,voices talking about,the patient,mind reading,being controlled by foreign forces,religiosity,are,almost never seen,other than in patients who have,comorbid psychiatric problem.,The number of cases of schizophrenia who develop IPD is difficult to determine due to the fact that all neuroleptics other than clozapine and quetiapine cause parkinsonism in some patients,so that the diagnosis of IPD on clinical grounds is often impossible in a patient on an anti-psychotic drug.,SPECT scanning with cocaine analogs can reliably distinguish the drug induced from the cases of IPD exacerbated by the drugs,.,Bonnets syndrome,a disorder in which elderly people with visual impairment,have benign,visual hallucinations as release phenomena can be,impossible,to distinguish from PDP.,Vivid,dreams,REM intrusions,hypnogogic,and hypnopompic hallucinations can also be described in,ways that,are difficult or impossible to distinguish from PDP hallucinations,.,Friedman,J H.Parkinsons disease psychosis 2010:a review articleZ.2010:16,553560,3,Risk factors of psychosis,in PD,Disease duration,Medication for PD,Dementia,Sleep disturbances,Abnormalities,of,visual perception,and,processing,Older,age,pathological changes in the medial temporal,lobe.,1,dopaminergic agonists,cognitive impairment,older,age/longer duration of PD,disease severity,altered dream phenomena,daytime somnolence,and possibly depression and dysautonomia,.,2,药物暴露、认知功能下降、年龄增加、病程长、视觉障碍，伴随焦虑、抑郁和睡眠障碍者易出现精神病性症状,。,3,目前认为老龄、,PD,病程、病情的严重程度、认知功能障碍、睡眠障碍是,PD,患者出现精神症状的危险因素,。,4,1,Friedman,J H.Parkinsons disease psychosis 2010:a review articleZ.,2010:16,553560,2,Fnelon G,Alves G.Epidemiology of psychosis in Parkinsons diseaseJ.Journal of the Neurological Sciences,2010,289(1-2):,1217,3,中华医学会神经病学分会神经心理学与行为神经病学组，中华医学会神经病学分会帕金森病及运动障碍学组,.,帕金森病抑郁、焦虑及精神病性障碍的诊断标准及治疗指南,Z.2013:46,5660,4,孟莉，刘娜，李艳敏，等,.,帕金森病的非运动症状,精神症状的研究进展,J.,临床神经病学杂志,2012(02):156158,4,帕金森中的精神性障碍,帕金森病,患者的精神病性症状主要表现为幻觉,、错觉,、妄想和存在的错误,观念。,帕金森病,幻觉可涉及任何,感觉形式,，但以,视幻觉最为常见,，帕金森病,视幻觉常为生动的,人或者,动物，很少为无生命的物体,。,听,幻觉,类型可以为低语,、音乐,或威胁的声音，一般,与视幻觉伴发,，,很少单独出现,，,据此可以,与听幻觉型精神分裂症相鉴别,。,帕金森病,幻觉可间歇出现，每次发生持续数秒至数分钟，,常反复,发生。,夜间或患者独处在安静的环境中易发生,幻觉,。,存在,的错误观念是一种体验，即感觉某人或某物在,周围,，但实际上该人或该物此刻并不在周围，其感知模式,(,如,听觉,、视觉,),并不明确,。,中华医学会神经病学分会神经心理学与行为神经病学组，中华医学会神经病学分会帕金森病及运动障碍学组,.,帕金森病抑郁、焦虑及精神病性障碍的诊断标准及治疗指南,Z.2013:46,5660,5,帕金森病精神病性障碍诊断,标准,符合,以下,1,一,5,条者即可考虑帕金森病精神病,性障碍。,1.,符合,英国帕金森病协会脑库诊断标准或中国,帕金森病,诊断标准确诊的原发性帕金森病。,2,.,出现至少,1,个以下症状,:,幻觉、错觉、妄想以及存在,的错误,观念。,3,.,精神病性症状在帕金森病发生之后出现，至少为,帕金森病,诊断,1,年后出现，多数为帕金森病诊断,10,年以后出现。,4,.,持续时间,:,幻觉、错觉和妄想以及存在的错误观念,反复,发生，或持续,1,个月。,5,.,需排除其他疾病导致的精神病性症状，如路易体,痴呆,、精神分裂症、精神分裂样疾病、伴有精神病性症状的,情感障碍,及药物导致的精神病性障碍,或谵妄,状态。,6,.,伴发情况,:,应注明有或无自知力，有或无痴呆，是否,在抗,帕金森病治疗。,中华医学会神经病学分会神经心理学与行为神经病学组，中华医学会神经病学分会帕金森病及运动障碍学组,.,帕金森病抑郁、焦虑及精神病性障碍的诊断标准及治疗指南,Z.2013:46,5660,6,治疗帕金森的药物出现精神症状的危险性,PD,精神病性症状的出现可能与年龄大，病程长，合并,全身疾病,，多巴,丝肼,(,美多芭,),、,苯海索的剂量高有关,。吡贝,地,尔（泰舒达）的,症状出现可能性稍,高。,1,多巴,丝肼精神病,性症状出现率为,:2.,63%,吡贝,地尔为,:20.69%,，苯海索为,:20.00,%,，卡,左双,多巴（息宁）,:9,.09%,。,吡,贝,地尔的精神病性症状出现率明显高于除了苯海索外的其他抗帕金森药物，有,显著性差异,(P0.05,),2,在多巴胺能药物中，多巴胺比左旋多巴更容易引起这些精神症状，不同的多巴胺能药物诱发精神症状的风险各不相同，培高利特具有较高的风险，,普拉克索（森福罗）相比,罗匹尼罗致幻觉的风险也较高。在其他抗,PD,药物中，,司来吉兰（米多吡）、,金刚烷胺、抗胆碱能药物、儿茶酚胺,-O-,转甲基酶抑制,剂（琼丹）均,可加重精神症状,.,甚至可加快其进展。,3,1,黄中坚,.,帕金森病精神病性症状的原因分析,J.,中外医疗,2009,28(3):,90,2,钟静玫，武绍远，马莎，等,.,抗帕金森药物精神病性症状出现率的观察,Z.,北京,:,2008161162,3,孟莉，刘娜，李艳敏，等,.,帕金森病的非运动症状,精神症状的研究进展,J.,临床神经病学杂志,2012(02):156158,7,帕金森病精神病性,障碍的治疗,1.,氯,氮平可以改善帕金森病患者视幻觉,、谵妄,等,精神病,性症状，且不加重帕金森病运动症状，推荐用于治疗,帕金森病,患者伴发的精神病性症状,(B,级推荐,),，但需监测,血常规,，关注有无粒细胞减少,。,2.,哇,硫平可改善帕金森病精神病性症状，不加重锥体外,系症状,，也可以考虑应用于帕金森病患者的精神病性症状,治疗,(,C,级推荐,),。,3.,不,推荐奥氮平用于帕金森病精神病性症状的治疗,(B,级推荐,),。,（本文,所用证据水平和推荐级别的判定参照美国,神经病学,会质量标准分委会制定的,标准,）,8,谢谢！,9,