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1、欢迎各位专家同行欢迎各位专家同行 亲临指导亲临指导双相障碍诊断与治疗研究双相障碍诊断与治疗研究 最新进展最新进展汕 头 大 学 精 神 卫 生 中 心 林勇强 编译 马光瑜 校2 0 0 1 年 5 月背背 景景 1 1 近几年精神病学科迅猛发展，以近几年精神病学科迅猛发展，以SSRISSRI类类 药物药物 和新型抗精神病药物的应用为代表，而和新型抗精神病药物的应用为代表，而 双相障碍成为一个双相障碍成为一个“ “被广泛忽视的问题被广泛忽视的问题” ”。 2 2双相障碍是一个独立的疾病吗？双相障碍是一个独立的疾病吗？ 3 3双相障碍是否比我们预料的更为常见？双相障碍是否比我们预料的更为常见？
2、4 4临床上是否存在大量的误诊和诊断不全临床上是否存在大量的误诊和诊断不全 ？ 5 5现有治疗有何不足？现有治疗有何不足？ 6 6双相障碍的预后如何？双相障碍的预后如何？ 7 7双相障碍治疗未来发展的趋势如何？双相障碍治疗未来发展的趋势如何？双向障碍： 确诊，扩大治疗选择和改善病人预后 Bipolar Disorder: Refining Diagnosis,Expanding Therapeutic Options and Improving Patient Outcomes Vivek Kusumakar, MD FRCPC MRCPsych Associate Head (Academi
3、c 264(19):25118 SchizophreniaAffectiveBipolarMajor disorders (total)disorderdepressionOverlap of symptomatology（症状交叉状况）: Psychotic symptoms（精神症状）双相障碍Bipolar disorder分裂情感障碍Schizoaffective disorder单相抑郁Unipolar depression妄想障碍Delusional disorder精神分裂症Schizophrenia双相障碍谱系 The bipolar spectrum重型抑郁（不伴躁狂）Majo
4、r depression (without mania)轻躁狂， 抑郁和轻躁狂或躁狂亚症状Hypomania and subsyndromal symptoms of depression and hypo/mania单纯，混合或精神病 性躁狂 Pure, mixed or psychotic maniaSpectrum of disorders双相障碍流行病学 Epidemiology of Bipolar Disorder Prevalence: 1% for Bipolar IPrevalence: 1% for Bipolar I（双相I型）（患病率）患病率）3% 3% for Bip
5、olar I and IIfor Bipolar I and II（双相双相I I 和和II II型）型）4% for Bipolar Spectrum Disorder4% for Bipolar Spectrum Disorder（双相谱系）双相谱系） Gender preference: None (M=F)Gender preference: None (M=F)（性别倾向：无）性别倾向：无） Cause: Genetic plus developmental, social, cultural, Cause: Genetic plus developmental, social, c
6、ultural, environmeenvironme- - - -ntnt events events（病因：遗传学进展，社会、文化和环境变化）病因：遗传学进展，社会、文化和环境变化） Peak age onset: 15-19 years (commonly, depression begins Peak age onset: 15-19 years (commonly, depression begins earlier, and earlier, and hypomaniahypomania and mania manifest later) and mania manifest la
7、ter)（好发年龄：好发年龄： 15-1915-19岁。抑郁症起病较早，躁狂症起病明显较晚）岁。抑郁症起病较早，躁狂症起病明显较晚） Goodwin & Jamison, 1990双相谱系障碍患病率 Prevalence Rates of Bipolar Spectrum Disorders (range from 2.6-7.8)WeissmanWeissman & Myers & Myers19781978LTLT 3.0 3.0 Oliver & SimmonsOliver & Simmons19851985LTLT 3.3 3.3 FaraveliFaraveli & & Incerp
8、iIncerpi198519851 yr1 yr 3.4 3.4 HeunHeun & Maier & Maier19931993LTLT 6.5 6.5 LevavLevav et al. et al.199319936 6 mthmth 2.62.6 AngstAngst19951995LTLT 5.5 5.5 AngstAngst19981998LTLT 7.8 7.8 SzSzddczkyczky et al. et al.19981998LTLT 5.1 5.1 WittchenWittchen et al. et al.19981998LTLT 3.4 * 3.4 *%*age 1
9、4-24 Angst, 1999 Bipolar Disorder: The Early Evolution 双相障碍：早期演变 First impairment associated with affective symptoms (15.5 years) 首次发生与情感症状有关 的损害（155岁）First fulfillment of diagnostic criteria (RDC) (18.7 years) 首次达到诊断标准 （187岁）First treatment (22.0 years) 首次接受治疗（ 220岁）First hospitalisation (25.8 year
10、s) 首次住院（258岁）3025201510 Age in years年龄Egeland et al. J Affect Disord, 1987Bipolar Disorder: Onset（起病 ）Often preceded by a “prodrome” of（前驱症状）: anxiety, OCD, dysthymia and behavioral storms 焦虑，强迫，心境恶劣和行为冲动 Chaotic mood dysregulation before discrete episodes （散发发作前混乱的心境失常）: risk of effects on personal
11、ity 作用于个体的危险性 First “episode”（首次发作）: usually a depression in adolescence 通常于青春期发 作 Many episodes of depression before the first episode of hypomania or mania（首次轻躁狂或躁狂发作前曾多 次抑郁发作） Bipolar Disorder: Course 病程Increased frequency of episodes: without treatment or with antidepressant treatment 无治疗或抗抑郁治疗增
12、加发作 15-20% lifetime risk of suicide 15-20%伴有终生自杀危险性 Deterioration in executive functioning 技巧性功能的衰退 40% risk of alcohol and substance abuse 40%伴有酒精和物质滥用危险性 Increased lifetime risk of cardiovascular disease (20%?) 增加终身患心血管疾病危险性 （20%？）Kraepelin 1921, Parikh et al 1997, Miklowitz et al 1988.Psychosocia
13、l Stress and Episodes 心理社会应激与发作Psychosocial stress: Likely greater influence in early part of illness 心理社会应激：较多影响疾病早期 Autonomous cycling: Later pattern 自主循环：晚期 Adverse life events: More commonly associated with rapid cycling illness 有害生活事件：常与快速循环疾病有关 Relapse: Associated with negative HEE in families
14、 复发：与 家庭中高情感表达有关 Less than 40% respond to monotherapy, less than 30% respond to lithium monotherapy 至少40%对单一治疗有效，至少 30%对单纯锂盐治疗有效Diagnosing Bipolar Disorder 双相障碍的诊断Is Bipolar Disorder Still Underdiagnosed? 双相障碍是否仍未得到诊断1981 (Edinburgh) 136 patients with a diagnosis of mania a total of 129 non-affective diagnoses had been given in the past在129例既往未曾诊断情感障碍病例中36例诊断为躁狂1999 (Harvard) 248 consecutive admissions for bipolar disorder40% were previously misdiagnosed as unipolar depression48例连续确诊为双相障碍者40%既往曾误诊为单相抑郁1Horgan: Psychol Med, 1981 2Ghaemi et al: J Affect Dis,1999
