心境障碍PPT医学课件.ppt

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,*,心境,(,情感,),障碍,Mood(Affective)disorders,Historic overview,Hippocrates:,Kahlbaum(1882):,“,Cyclothymia”,“Dysthymia”,Kraepelin(1886):,“manic-depressive disorder”,Definition,Mood disorders are a group of mental disorders characterized by obvious and persistent elation or depression of mood.,The mood disturbance is commonly associated with cognitive and behavioral changes.,In severe cases,psychotic symptoms,such as hallucination and delusion,may be observed.,There is a tendency for the disorders to recur,but most recurrent episodes will eventually remit.In certain cases,an episode may become chronic and residual symptoms are observed.,定 义,以显著而持久的情绪障碍为主要症状的精神障碍，以心境高扬或低落为基本临床相，伴有相应的思维和行为改变。有反复发作的倾向，间歇期大都精神活动正常。少数病例可有残留症状或转为慢性。,classification,Mood,Disorders,With or,Without,psychiatric,symptoms,Manic episode(mania),Depression,(unipolar),Single episode,Recurrent episode,Bipolar,disorders,Bipolar-(with mania),Bipolar-(with hypomania),Mixed type,Rapid-cycling bipolar disorder,Cyclothymia disorder,Dysthymia,为一大类疾病,情,感,性,障,碍,躁狂,发作,(,症,),抑郁症,单次发作,反复发作,激越性,迟钝性,精神病性,双相,障碍,双相,I,型,双相,II,型,混合相,快速循环型,环性,心境障碍,心境恶劣障碍,(,抑郁性神经症,),Manic episode,（,unipolar,）,The disorder is characterized by elated and expansive mood that is out of keeping with the individuals circumstances.,The mood disturbance may vary from carefree joviality to uncontrollable excitement.Sometimes,irritability is the predominant presentation.,In mild cases,impairment of social function may be absent or minimal.Psychotic symptoms,such as delusions and hallucinations,may be observed in severe cases.,2.Major Depressive episode,（,unipolar,）,characterized by depressed mood that is out of keeping with the circumstances.It may vary from low mood to melancholia,or even stupor.,In severe cases,psychotic symptoms,such as delusions and hallucinations,may be present.,Anxiety and motor agitation may be more prominent than depression in some cases.,3.Biopolar disorders,Bipolar I disorder:,consisting of episodes of mania cycling with depressive episodes.,Experiences a major depressive episode and has had one or more manic episodic.,3.Biopolar disorders,Bipolar II disorder:,consisting of episodes of hypomania cycling with depressive episodes,Experiences a major depressive episode and has had one or more hypomanic episodic,3.Biopolar disorders,Rapid cycling Bipolar disorder,Patients with Rapid cycling Bipolar disorder experience four or more affective episodes per year.,4.Cyclothymic disorder,consisting of cycling episodes of hypomania and less severe episodes of depression.,5.Dysthymia,Consists of a depressed mood,and at less two other depressive symptoms.,Not of sufficient severity to meet the criteria for major depression.,Not any manic or hypomanic episodic.,6.Other Mood Disorders,Mood disorder due to a general medical condition,Analgesics(eg,indomethacin,opiates),Antibiotics(eg,ampicillin),Antihypertensive agents(eg,propranolol,reserpine,-methyldopa,clonidine,),Antineoplasticagents(eg,cycloserine,vincristine,vinblastine,),Cimetidine,L-,Dopa,Substance-induced mood disorder,Alcohol,Cocaine,Opiates,Epidemiology,人类前十位功能障碍性,(disability),疾病:(,C J L Murray,等,1995,),*,单相重性抑郁,10.7%,缺铁性贫血,4.7%,跌伤,4.6%,*,酒精滥用,3.3%,慢阻肺,3.1%,*,双相情感障碍,3.0%,先天性疾病,2.9%,骨关节炎,2.8%,*,精神分裂症,2.6%,*,强迫症,2.2Prevalence,（患病率）,America,男性终身患病率,4.8,女性终身患病率,9%,平均,7%,双相障碍,1.6%,恶劣心境,3.3%,抑郁症,1320%,Prevalence,（患病率）,影响因素,女性高于男性约为,23:1,双相低于单相,国内报道低于国外,发病年龄：,20,25,岁,病因和发病机制,(,一,),遗传研究,临床表现,家系调查寄养子研究双生子研究遗传模式分析连锁分析候选基因基因组扫描,遗传研究,家系调查：（,1924-1954,）躁郁症亲属患病率,父母：,.,.,，平均 ,.,兄弟、姐妹：,.,23,，平均,.,遗传研究,Gorshon,（,1982,）：,单相双相患者一级亲属患病率为,15,20,双相家属抑郁症患病率,.,抑郁症家属抑郁症患病率,.,为对照组倍多,心境障碍的单卵双生与双卵双生的同病率,单卵,双生,双卵,双生,references,同病的,双生子对数,/,总双生子对数,同病,率,(%),同病的,双生子对数,/,总双生子对数,同病,率,(%),Luxenberger(1930),3/4,75.0,0/13,0.0,Rosanoff,et al(1935),16/23,69.6,11/67,16.4,Slater(1953),4/7,57.1,4/17,23.5,Kallman(1954),25/27,92.6,15/55,23.6,Harvald,and Hauge(1965),10/15,66.7,2/40,5.0,Allen et al(1974),5/15,33.3,0/34,0.0,Bertelsen(1979),32/55,58.3,0/52,17.3,总平均,95/146,65.0,39/278,14.0,数据未经年龄校正，诊断包括了双相和单相障碍,遗传研究,双生子研究总结,(McGuffin),：,双相障碍主要由遗传决定,单相障碍可能主要源于遗传和环境的共同作用,遗传研究,寄养子研究：,双相障碍生物学亲属中情感障碍患病率为,31%,对照组患病率为,2%,被收养和未被收养的双相障碍先证者的亲属患病率类似,(26),遗传研究,寄养子研究总结：,遗传因素而不是寄养关系，影响的家庭患病率,分子遗传学研究,双相障碍与,18,号染色体联锁,21,号染色体联锁,与,X,染色体长臂末端连锁,与,5-HT,受体基因多态性可能关联,研究结果不一致,疾病的遗传异质性,遗传研究,家系研究小结：,在情感障碍家系中，发生疾病的机率远 较一般人口高；血缘关系越近，发病机率越高,双生子和寄养子研究显示,遗传因素与发病有密切关系,双相遗传倾向似较单相型明显,.,遗传传递方式不明,分子遗传研究结果不一致，难以定论,(,二,),生化机理,去甲肾上腺素（,Norepinephrine,NE),抑郁症尿,MHPG,（,3-,甲氧,-4-苯酚糖，,NE,的中枢代谢产物）减少,抗抑郁剂使,NE,受体敏感性降低,电休克使,NE,受体敏感性降低,抗抑郁剂使受体介导作用延迟,NE,受体敏感性增高,抑郁,5-,羟色胺（,Serotonin,5-HT),抑郁症血浆色氨酸水平降低,抑郁症,CSF,中,5-HIAA,降低,三环类、,SSRI,类抑制,5-HT,重摄取发挥抗抑郁作用,胆碱能、多巴胺能和,GABA,能系统,1.,胆碱能假说：抑郁症存在过度的胆碱能活动,2.,多巴胺能活动抑制,脑脊液,HVA,浓度降低,L-,多巴及,DA,受体激动剂有一定抗抑郁作用,3.GABA,系统作用：,抗抑郁药影响,GABA,受体,抗癫痫药卡巴西平等影响,GABA,含量的调控，对抑郁起作用,抑郁症发病的主要生化机理总结,中枢和,/,或功能不足,突触前受体（,2,肾上腺素受体）数目增多或受体敏感性增加（释放减少或功能下降）,（三）神经内分泌研究,1.,内分泌疾病如甲状腺功能低下，柯兴氏综合征等有明显抑郁症状,2.,：下丘脑垂体肾上腺轴（,HPA,）功能障碍,半数患者皮质醇分泌增加,对地塞米松（,dexamethasone,）不产生抑制反应,(DST,阳性,),3.,：下丘脑垂体甲状腺轴（,HPT,）功能障碍,15%,的患者甲状腺自身抗体增高,抗抑郁药,+T,3,对部分难治性患者有效,(,四,),器质性因素,MRI,：,额叶和颞叶皮质散在高密度影像增多,fMRI,：,左额叶和左颞叶局部血流低灌注,PET,：,左扣带回前部和额叶背外侧有血流量减少,(,五,),心理社会因素,负性的认知方式（,Negative cognitive style,）,Becks cognitive theory(Aaron Beck,1967),One of the most influential theories of depression,Negative cognitions are central to depression,Early experience,Depression,Formation of dysfunctional beliefs,Critical incidents,Beliefs activated,Negative automatic thoughts,symptoms of depression,Behavioral,Motivational,Affective,cognitive,Somatic,Negative cognitive triad,(,抑郁症的认知三联征,),：,Negative thought about the self(,负性的自我反省,):,“I am ugly”“I am worthless”“I am failure”,Negative thought about ones experience and the surrounding world(,对经历事件的负性解释,):,“No one love me”People treat me badly”,Negative thought about the future(,对未来的负面看法,)”,“It is hopeless because things will always be this way”,负性自动思维（,Negative automatic thoughts,）,特点,它是自动的，不经逻辑推理突现于脑内。,它的内容消极，常和不良情绪相联系。,它随时间、地点而有变化,能为意识所察觉，具有认知过程的特征，为临床表现的一部分。,它存在于意识边缘，稍纵即逝。,它存在时间短暂，但力量很大，并且不能由自己意愿选择或排除。,它蕴涵认知曲解，而患者却信以为真，不认识它正是情绪痛苦的原因。,一位抑郁女病人的认知模式,早年经验,容貌不如姐姐好,功能失调性假设,我不如别人,我的生活决定于别人如何看待我,;,我不按别人的要求做,就会被排斥,生活事件,婚姻破裂,负性自动思维,我把事情搞糟了,我真笨,我无能,.,我将永远孤独,症状,情感 行为 认知 生理等方面,人格（,Personality,）,易感模式：,某种人格特征易发生抑郁症,谱系模式：,某种特征是疾病较轻微的表现,Pagkel,发现患者经历不幸事件的次数是正常对照组的3,倍,抑郁过程中的不良生活事件可使症状恶化,预防治疗阶段的恶性生活事件与增加疾病复燃的风险有关,缺乏社会支持直接与轻度抑郁发作有关,应激性生活事件（,Stressful Life events,）,婚姻问题,高婚姻冲突、低婚姻支持与抑郁症的发生有显著正相关,抑郁可能导致婚姻关系的实质性恶化,社会角色和社会支持,女性的性别角色：被动、敏感、依赖性,女性的社会地位：劣势,良好的社会支持有助于减少抑郁的发生，或促进抑郁的恢复,Mood disorder,Definition,obvious and persistent elation or depression of mood.,associated with cognitive and behavioral changes.,Classification,Unipolar,Biopolar,Cyclothymia disorder,Dysthymia,Epidemiology,Age:20-25y,Sex:femalemale,Type:UnipolarBiopolar,Cause,Biological Factor Psychosocial Factor,