精神科综合征

精神科综合征,1、幻觉症 2、幻觉妄想综合征 3、精神自动症综合征 Kandinsky- Clerambault综合征,4、疑病综合征 5、遗忘综合征 柯萨可夫综合征或遗忘虚构综合征6、紧张综合征,7、人格解体-现实解体综合征 8、神经衰弱综合征,9、赔偿综合征特点 多数病人具有极强的赔偿意识，并表现在其言行举止上；临床表现虽有表演性、夸张性，但不因环境、对象改变而消失，不完全受其主观意志控制；症状常迁延不愈，心理、药物治疗效差；病人为其症状存在而感到苦恼，有的可发现躯体征，如代偿性肢体增粗、萎缩,10、脑震荡后综合征11、幸存者综合征12、Cotard综合征(Cotards syndrome),13、Othello综合征(Othellos syndrome) 病理嫉妒综合征，奥赛罗综合征,14、Capgras综合征 双重错觉综合征，双重人身症，替身综合征 15、Fregoli综合征 替身错觉症，人身变换症，Fregoli妄想,One man show,16、De Clerambault syndrome 色情综合征 爱情狂17、Briquets syndrome 躯体化障碍,DefinitionAs defined in DSM-IV, somatization disorder is a polysymptomatic somatoform disorder characterized by multiple recurring pains and gastrointestinal, sexual and pseudoneurological symptoms occurring for a period of years with onset before age 30 years. The physical complaints are not intentionally produced and are not fully explained by a general medical condition or the direct effects of a substance.,General Description“A history of many physical complaints”Symptoms required: 4 pain, 2 nonpain gastrointestinal, 1 nonpain sexual or reproductive, and 1 Pseudoneurological (conversion or dissociative) No exclusive list of symptomsOnset before age 30 years” “occur for a period of several years”,Epidemiologyfemale/male ratio of approximately 10 : 1 The lifetime prevalence 0.2 and 2%,Course, Natural History and Prognosis Somatization disorder is rare in children younger than 9 years of age. Characteristic symptoms of somatization disorder usually begin during adolescence, and the criteria are met by the midtwenties.Somatization disorder is a chronic illness characterized by fluctuations in the frequency and diversity of symptoms. Full remissions occur rarely, if ever Longitudinal follow-up studies have confirmed that 80 to 90% of patients initially diagnosed with somatization disorder will maintain a consistent clinical picture and be rediagnosed similarly after 6 to 8 years,TreatmentTreatment is difficult and patients often consume large amount of resourcesThe foundations of treatment for this disorder are: 1) establishment of a strong physicianpatient relationship or bond;2) education of the patient regarding the nature of the psychiatric condition; and 3) provision of support and reassurance.,18、Munchausens syndrome做作性障碍（Factitious Disorder） 住医院癖 住院流浪者症Munchausens syndrome by Proxy,The term “factitious” means “willfully produced”. Factitious disorders are disorders in which the individual produces the signs or symptoms of illness.The illness may be manifested either by physical or psychological symptoms. The patients primary goal is to receive medical,surgical,or psychiatric care; secondary motivations involve obtaining drugs or financial assistance.,Asher, who in 1951 coined the term Munchausens syndrome to denote a disorder observed in certain patients who traveled widely in England,Factitious Disorder with Predominantly Physical Signs and SymptomsThe three main methods patients use to create illness are: 1) giving a false history, 2) faking clinical and laboratory findings, and 3) inducing illness (e.g., by surreptitious medication use, inducing infection, or preventing wound healing). There are reports of factitious illnesses in all of the medical specialties. Particularly common presentations include fever, self-induced infection, gastrointestinal symptoms, impaired wound healing, cancer, renal disease (especially hematuria and nephrolithiasis), endocrine diseases, anemia, bleeding disorders and epilepsy (Wise and Ford, 1999),Factitious Disorder with Predominantly Psychological Signs and SymptomsThere are reports of factitious psychosis, posttraumatic stress disorder and bereavement. In addition, there are reports of psychological distress due to false claims of being a victim of stalking, rape, or sexual harassment, and these cases are often diagnosed with a factitious psychological disorder such as post traumatic stress disorder.,Factitious Disorder with Combined Psychological and Physical Signs and Symptoms,Clinical VignetteA 46-year-old man presented complaining of symptoms of post traumatic stress disorder (PTSD). He reported intense fl ashbacks, numbing and avoidance, and irritability resulting from his experience as a combat veteran. He began intensive treatment for PTSD including support groups, individual therapy and medication management. He was an extremely active participant in the support groups and would recount detailed horrors of his time in combat. A staff member verifying the patients history learned the patient had served in the military but was not a combat veteran. The patient was confronted in a supportive manner, and he admitted that he had fabricated his history. It was recommended that the patient continue in psychiatric treatment, and he agreed to do so.,DSM-TR CriteriaFactitious DisorderA. Intentional production or feigning of physical or psychological signs or symptoms.B. The motivation for the behavior is to assume the sick role.C. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent.,Epidemiology Such attempts have generated estimates that 0.5 to 3% of medical and psychiatric inpatients suffer from factitious disorder. Of 1288 patients referred for psychiatric consultation at a Toronto general hospital, 10 (0.8%) were diagnosed with factitious disorder. A prospective examination of all 1538 patients hospitalized in a Berlin neurology department over 5 years found five (0.3%) cases of factitious disorder. An examination of 506 patients with fever of unknown origin (FUO) revealed that 2.2% of the fevers were of factitious origin, and a review of 199 Belgian patients with FUO found seven of 199 (3.5%) to be factitious. A similar study of patients with FUO at the National Institutes of Health (NIH) revealed that 9.3% of the fevers were factitious.,Gault and colleagues (1988) examined 3300 renal stones brought in by patients and found that 2.6% of these stones were mineral and felt to be submitted by factitious or malingering patients. A study of psychiatric inpatients showed a prevalence of 0.5% of admissions determined to be a result of a factitious psychological condition.,Factitious Disorder by ProxyIn factitious disorder by proxy, one person creates or feigns illness in another person, usually a child, though occasionally the victim is an elder or developmentally delayed adult.,DSM-TR CriteriaFactitious Disorder by ProxyA. Intentional production of or feigning of physical or psychological signs or symptoms in another person who is under the individuals care.B. The motivation for the perpetrators behavior is to assume the sick role by proxy.C. External incentives for the behavior (such as economic gain) are absent.D. The behavior is no better accounted for by another mental disorder.,19、恶性综合征 药源性/神经阻断剂恶性症状群（DMS/NMS）Adilyanjee等（1988）制定的标准必备条件 意识障碍 至少2名医师独立观察，持续2天 以上 肌强直 发热 39，持续24H，并除外躯体合并症所致 自主神经症状 2个 P90，R25，血压波动收缩压30mmHg，舒张压15 mmHg ，过度出汗、大小便失禁 辅助条件 CPK及白细胞升高,Lazarus等 5项条件（1989）发病前7天内服过抗精神病药发热38肌强直具备下述3个 意识状态改变，心动过速，高血压或低血压，呼吸困难或缺氧、CPK升高，白细胞升高、代谢性酸中毒不是由于躯体或神经精神疾病引起 治疗？,20、致死性紧张症起病年龄较轻，起病急，进展快临床特点：剧烈的精神运动性兴奋，并反复出现紧张性木僵或亚木僵，激动伴高热、意识混浊和植物神经功能紊乱症状，如皮肤潮红、出汗、肢端紫绀等 部分患者症状可波动迁延，多数如果没有积极治疗，很快衰竭死亡（1-2W） 注意： NMS与致死性紧张症鉴别,21、Gjessings syndrome,Gjessing在1947年描述的一个罕见的精神分裂症样障碍 与症状同时出现的氮平衡改变 紧张性兴奋和木僵周期性发作，伴有自主神经系统紊乱，如脉搏、血压和体温的变化。 化学物质（氮）的堆积和排泄造成周期性的临床变化 甲状腺激素可防止氮在体内的保留和积累，有利于该病的缓解。可能是快速循环双相障碍的一种变异,22、5-HT综合征,23、代谢综合征,第二代（也称非典型）抗精神病药(SGAs)的引入曾极大的改善了抗精神病治疗的有效性和耐受性 但越来越多的研究证实SGAs与患者的体重增加、糖尿病、高甘油三酯血症等有关，并可导致心血管疾病（CVD）、脑血管疾病，继而影响抗精神病治疗的依从性和精神疾病患者的结局。,使用SGAs治疗患者发生糖尿病、酮症酸中毒、高血糖症、血脂代谢失调等的报道增多，引起了有关人员对SGAs与代谢影响的关注有关SGAs与代谢综合征之间关联性的相关研究已成为相关领域专业人员关注的热点,代谢综合征（MS） 美国国家胆固醇教育计划(NCEP)成人治疗指南 的定义 ( 3项 )腹型肥胖(腰围男性 102cm ,女性 88 cm) 血压升高( 130/ 85 mmHg) 和(或) 进行高血压治疗TG 1. 7 mmol/ L 、低HDL-C(男性 1. 03 mmol/ L ,女性 1. 29 mmol/ L) 空腹血糖升高( 6. 1 mmol/ L) 或接受口服降糖药治疗以控制糖尿病。 Adult Treatment Panel III. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection , Evaluation , and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report . Circulation , 2002； 106 : 3143-3421 .,2003年11月，ADA、APA、AACE、NAASO(共识会)联合声明：第二代抗精神病药与体重增加、糖尿病、血脂障碍相关联选择抗精神病药时首先要考虑其是否会引起MS American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care，2004；27:596601.,FDA的最新注释体重增加与高血糖症的关系已经在抗精神病药治疗的患者身上得到证实要求所有第二代抗精神病药的说明书必须警示其有发生高血糖症、糖尿病的风险,精神疾病与MS的有关现状,事实精神分裂症较多的与躯体疾病共病，并有较高的死亡率 抗精神病药的副作用、高肥胖率等可恶化其躯体疾病精神疾病（包括精神分裂症、双相障碍、抑郁症等）的死亡率高于普通人群,CVD 重性精神疾病患者的头号杀手1.荟萃分析（包括18项研究），精神分裂症的标准死亡率为1.51，死亡粗率为189人/万人年，10年存活率为81%。精神分裂症患者80%属自然死亡 ，CVD是精神分裂症的头号死因（男性34%，女性31%） Br J Psychiatry，1997; 171: 502-8 2.瑞典的一项研究发现，CVD是精神分裂症患者最重要的死因，死亡率高于普通人群 Schizophr Res，2000; 45(1-2): 21-8. 3. 对400例心境障碍患者长达33-38年的随访研究发现，心境障碍患者死亡率高于普通人群，其中CVD也是死亡率增加的重要原因 J Affect Disord，2002; 68(2-3): 167-81,CVD 重性精神疾病患者的头号杀手4.美国CDC公布的精神疾病患者的死亡率 (1997-2000、8个州) 精神疾病患者比一般人群有较高的死亡风险 死亡时年龄比全国的同龄人群更低 重性精神障碍是其最重要的风险因素 心脏病是精神病患者的头号死因 Colton CW,Manderscheid RW.Congruencies in increased mortality rates,years of potential life lost,and causes of death among public mental health clients in eight states.Prev Chronic Dis serial online 2006;3:A42.,重性精神疾病患者因CVD而死亡率增加，已经明确的风险因素有体重增加、胰岛素抵抗、血糖、血脂水平升高，而体重增加、肥胖是胰岛素抵抗、高血糖、血脂障碍的重要风险因素。体重增加、肥胖会带来糖脂代谢异常，从而导致高血压。体重增加、肥胖、高血糖、吸烟、血脂障碍是CVD公认的可以控制的风险因素。,SGAs代谢方面的副作用可对患者产生副面影响，既影响抗精神病治疗的疗效，也影响患者的躯体健康。 体重增加及其相关疾病所招致的危险性，已成为精神分裂症的首位死因，并超过药物所挽救的生命（包括自杀率降低） Psychiatry Res，2001;101:277-88. J Clin Psychiatry，2004;65(suppl 18):13-16. 如果这方面的副作用严重，岂不弄巧成拙抵消了药物的临床贡献，从而失去其存在的价值？,？,SGAs致体重增加的可能性大小Newcomer（2005年）,氯氮平、奥氮平体重增加最明显，利培酮、喹硫平、佐替平、氨磺必利中等程度增加体重，齐拉西酮、阿立哌唑体重增加最不明显。Maria等人（2006年）：氯氮平奥氮平维思通=喹硫平齐拉西酮=阿立哌唑。 Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs，2005；19 Suppl 1:1-93. Maria D, Llorente,Victoria U. Diabetes,Psychiatric Disorders,and the Metabolic Effects of Antipsychotic Medications. CLINICAL DIABETES，2006；24（1）：18-24.,一个多学科共识 American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care，2004；27:596601.,2003年11月，美国糖尿病协会（ADA）、美国精神病学协会（APA）、美国临床内分泌医师协会（AACE）、北美肥胖研究协会（NAASO）召开了关于抗精神病药物和肥胖及糖尿病的共识会议，并发表联合声明Diabetes Care，2004APA处境被动尴尬,一致认为SGAs疗效，但也有令人讨厌的不良反应，其中最主要的是它们会增加患者出现肥胖、糖尿病和血脂异常的风险。共识指出：氯氮平、奥氮平使患者体重增加的幅度最大，出现糖尿病、血脂异常的可能性最大喹硫平、利培酮对患者体重和代谢影响居中已有证据（有限数据）表明使用齐拉西酮、阿立哌唑的患者出现明显的体重增加、糖尿病和血脂异常的可能性最小，甚至没有。,共识指出选择抗精神病药时首先要考虑其是否会引起MS一致通过了针对初始治疗者的几项基础评估的建议：临床医师应该了解患者的家族史（诸如肥胖、糖尿病、血脂障碍、高血压、心血管病等），女性还应了解有无妊娠期糖尿病史；评估基础身高、体重、腰围，测算BMI，检查基础血压、血糖、血脂水平。,（2007年）分析CATIE研究和其它大量的随机临床实验发现：使用氯氮平、奥氮平能明显增加体重，相关的代谢紊乱风险也增加与其它非典型抗精神病药比较，使用维思通、奎的平可中等程度的增加体重，而有关代谢风险的结论尚有差异阿立哌唑、齐拉西酮对体重影响最小，且没有代谢功能紊乱的副作用。 Newcomer JW Metabolic considerations in the use of antipsychotic medications: a review of recent evidence. J Clin Psychiatry，2007;68 Suppl 1:20-7,越来越多的证据表明SGAs的使用与患者的体重增加、糖尿病、高甘油三酯血症等有关，虽然不同的SGAs对MS的影响不尽相同。MS及MS所致的CVD影响精神疾病患者的治疗依从性，并恶化其结局。临床医师处方SGAs前，应仔细筛查患者心血管、代谢性疾病的风险因素，包括询问个人史、家族史中的糖尿病风险因素，检查血压、血糖、血脂等。,治疗用药时要着重考虑四个风险因素：体重增加、肥胖、高血糖、血脂障碍。药物选择上，应注意个体化原则，权衡体重增加、疗效、其它因素，对BMI较高者或既往有肥胖史者则尽量避免可明显增加体重的药物，避免用药后弊大于利、事与愿违的尴尬。制定出恰如其分的策略监测SGAs的风险与收益比，以改善精神病患者及其躯体疾病的长期结局。,24、网络成瘾综合征,“专家和网友，到底谁才是精神病？”正方反方网络的危害毋庸置疑,2009年中国青少年网瘾调查报告（2010.01）,中国青少年网络协会 中国传媒大学调查统计研究所30个省城市青少年网民（6-29岁）中网瘾青少年14.1%，约2404.2万；加上农村，推测共3330万。是否将网瘾纳入广义精神疾病？网瘾和非网瘾青少年，反对赞同各一半。,大量研究显示成瘾者存在如下特点多见于青少年；男性多于女性；社会地位和文化程度均较低，多为单身、失业或半失业者(如家庭妇女、退休人员、残疾人、学生)；网络依赖多发生在初次上网的一