双相障碍-分裂情感障碍-分裂症鉴别生物学边界

InformingDSM 5 BiologicalboundariesbetweenbipolarIdisorder schizoaffectivedisorder andschizophrenia VictoriaECosgroveandTrishaSuppesBMCMedicine2013 11 128 Figure1 DSM IV TRfeaturesofbipolarIdisorder schizoaffectivedisorder andschizophrenia Table1 Summaryofkeyevidenceattheforefrontoftheboundariesofschizophrenia schizoaffectivedisorder andbipolarIdisorderdebate Table2 Strengthofevidenceforbiologicalfactorssupportingmerginginsomewayschizophrenia schizoaffectiveandbipolarIdisorder Ahundredyearsago Kraepelindistinguishedtwotypesof insanity inhisinstitutionalizedpatients dementiapraecox laterrelabeledasschizophrenia andmanic depressiveillness laterrelabeledasbipolardisorder Hisdichotomywasbasedondifferencesinclinicalfeatures course andoutcomes Butovertheyears Kraepelinrecognizedandadmittedthatsomepatientshaveoverlappingfeatures andhegraduallyacceptedwhatisnowseenasacontinuumofpsychosisthat bridges schizoaffectivedisorder thepureformsofthosetwodisorders Symptoms Beyondadoubt thesetwobraindiseaseshaveoverlappingclinicalfeatures pharmacotherapies andevenoutcomesinasubgroupofpatients However thesediseaseshavemajordifferences asoutlinedintheaccompanyingtable page68 Brainanomalies Neuroimagingstudiesindicatethatschizophreniaisassociatedwithmore severeandpervasivemorphologicbrainanomalies dysplasiaandhypoplasia thanbipolardisorder althoughsomebipolarpatientshavereducedcerebralandfrontalvolumesandmarkedcognitivedeficits 3Progressiveneurotissuelosshasbeenobservedearlyinschizophreniabutnotinbipolardisorder 3 CoffmanJA BornsteinRA OlsonSC etal CognitiveimpairmentandcerebralstructurebyMRIinbipolardisorder BiolPsychiatry1990 27 11 1188 96 Recentgeneticstudiesindicatethatseveralgenesarefoundexclusivelyinschizophreniaorinbipolardisordercohorts 4butsomearesharedbybothdisordersandmayberelatedtodelusionalsymptoms 5Familialtransmissionappearstodiffer transgenerationalstudiesfindanabundanceofmooddisordersinfamilymembersofbipolarprobandsbutrelativelysparseoccurrenceofpsychosisinfamiliesofprobandswithschizophrenia 4 WeinbergerDR Geneticmechanismsofpsychosis invivoandpostmortemgenomics ClinTher2005 27 suppl 8 15 5 SchulzeTG OhlfaunS CzerskiPM etal ArchGenPsychiatry2005 162 2101 8 CandidateGenesinSchizophrenia BipolarDisorderBoundary E Ivleva G Thaker CA Tamminga ComparingGenesandPhenomenologyintheMajorPsychoses SchizophreniaandBipolar1Disorder SchizophreniaBulletin 34 4 pp 734 742 2008 Treatment Thereisnodoubtthatmonotherapywithantipsychotics oldandnew hassimilarefficacy6inschizophreniaandbipolarmania andeveninbipolardepression withsomeatypicals7 6 TandonR FleischhackerWW Comparativeefficacyofantipsychoticsinthetreatmentofschizophrenia acriticalassessment SchizophrRes2005 79 145 55 7 CalabreseJR KeckPJr McFaddenW etal Arandomizeddouble blind placebo controlledtrialofquetiapineinthetreatmentofbipolarIorIIdepression AmJPsychiatry2005 162 1351 60 However thereisminimal ifany evidencethatmonotherapymoodstabilizers lithiumoranticonvulsants haveanytangibleefficacyinschizophrenia Electroconvulsivetherapyisremarkablyefficiousinallphasesofbipolardisorderbutofdubious ifany lastingbenefitinschizophrenia Course Boththepremorbidhistoryandposttreatmentfunctionaloutcometendtobemorefavorableinpatientswithbipolardisorderthanschizophrenia Mostpatientswithschizophreniaexperiencesignificantclinical social andvocationaldeterioration comparedwitharelativeminorityofbipolarpatients summary schizophreniaandbipolardisorderareclearlydistinctintheirpureforms althoughmanypatientshavevaryingmixturesofboth Schizoaffectivedisorderisoneofthemostextensivelyinvestigated Althoughmanyscholarshavestudiedschizoaffectivedisorder theevidencedefieslumpingitwitheitherendofthecontinuum IagreewithDrs LakeandHurwitzthatmostcasesofschizoaffectivedisorder especiallythe schizomanic type areprobablybipolardisorderwithseverepsychoticfeatures Toassert however thatschizophreniadoesnotexistatallandshouldbereclassifiedasbipolardisorderwithpsychoticfeatureswouldcontradictamassivebodyofclinicalandbiologicalevidence ItwouldcauseKraepelintosquirminhisgrave 抗精神病药物对肝功能的影响 本文通过查阅大量文献以及结合多年临床经验发现 几乎所有抗精神病药物均有导致肝功能损害的文献报道 其中典型抗精神病药物氯丙嗪及非典型抗精神病药物氯氮平对肝脏损害较常见 阿立哌唑对肝功能的影响很小且易恢复 一般不需要根据患者的肝功能损害情况调整剂量 齐拉西酮 氨磺必利对肝功能的影响很小 一般很少引起转氨酶明显升高 在临床治疗中对肝功能损伤的患者一般无需调整剂量 毕玉萍 罗小年 常用抗精神病药物对肝功能影响的临床研究报道实录 J 中南药学 2013 11 2 76 79 Antidepressant InducedLiverInjuryUnderestimated 基于对证据的回顾 造成肝损害风险最高的是MAOI TCA 四环类