Transcript Causes of mood disorders

Emotion Functions:
Mood
Disorders
四川大学华西医院康复医学科
郭华
Mood (Affective) Disorders
Roller coaster
Quiet river
Group of disorders involving severe and
enduring disturbances in emotion
(mood)
 世界名画家蒙克名作《呐喊》是精神的焦虑以
图式显现的最杰出的代表.
 在他日记里，曾记下那激动人心的一幕：
尼斯，1892年1月22日，
我和两个朋友还在散步
太阳已快下山了
天空突然间变得血一样红
我似乎感受到了一种悲伤忧郁的气息
我止住了脚步，轻轻地倚在篱笆边
极度的疲倦已使我快要窒息了
火焰般的云彩像血，又像一把把利剑笼
罩着蓝黑色的挪威和城镇
我的朋友，他继续独自地走着，而我却
呆呆地站在那儿
焦虑使我不停地发抖
我感到四周似乎被一声巨大而又不断的
尖叫声震得摇摇晃晃
Outline
Concepts
The classification
Causes of mood disorders
Treatment of mood disorders
Suicide
Concepts
 Mood disorders
Group of disorders involving severe and enduring
disturbances in emotion (mood) (prevalence in
population between 8% and 19%)
Concepts
Major depressive episode
 Extremely depressed mood state that lasts at least 2
weeks and includes cognitive symptoms(worthlessness,
indecisiveness) and physical symptoms (altered sleeping
pattern, changes in appetite and weight, loss of energy)
Concepts
 Mania
Episode of joy and euphoria marked by
individual’s extreme pleasure in every activity,
hyperactivity, little sleep
Concepts
 Hypomania
 less severe version of a manic episode that does
not cause marked impairment in social or
occupational functioning
 Dysphoric manic or mixed episode
the individual experiences both elation and
depression or anxiety at the same time
Concepts
 Unipolar mood disorder
Individuals experience either depression or
mania but not both
 Bipolar mood disorder
Individuals alternate between depression and
mania
The classification of Mood Disorders
Manic episode
(mania)
Depression
(unipolar)
Single episode
Recurrent episode
With or
Mood
(Affective) Bipolar
Disorders disorders
Bipolar-Ⅰ (with maina)
Without
Bipolar-Ⅱ (with hypomania)
psychiatric
Mixed type
syrnptoims
Rapid-cycling bipolar disorder
Dysthymia
Cyclothymia disorder
心境障碍与精神病性障碍的交
叉重叠
精神病性障碍
双相障碍
伴精神病性
症状的抑郁
症
抑郁症
难治性抑郁
症
反应迟钝，情绪低落，自杀倾向，悲观厌世,
入睡困难，注意力不集中，食欲性、欲降低。
激素问题、头外伤、脑肿瘤或其他疾病。
合并精神分裂症、药物成瘾、焦虑或帕金森等
1.家系研究：2.双生子研究：3.寄养子研究
Look, Holmes's two period?
Vivien Leigh
(1913－1967)
Causes of mood disorders
Causes of mood disorders
Causes of mood disorders
 biological factors
if one twin presents with a mood disorder, an
identical twin is approximately three times
more likely than a fraternal twin to have a
mood disorder (heritability approx. 40% for
women)
 psychological factors
Causes of mood disorders
 stressful life events, hopelessness, negative
cognitive styles - overgeneralization
 social and cultural factors
marital dissatisfaction
70% of people suffering with major depressive
disorder or dysthymia are women
5-HT
NE
焦虑易激惹
焦虑易激惹
精力兴趣
精力兴趣
强迫
迫
强
性
食欲
攻击
动机
内驱力
Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd ed.
Cambridge, UK: Cambridge University Press; 2000:135-197.
中枢神经系统5-HT和NE的神经通路
5-HT和NE的神经通路调节不
同的功能
递减脊髓传导的调节疼痛的
反应
这些通路的异常可引起抑郁
的情绪和躯体症状
抑郁情绪
Locus
ceruleus
睡眠障碍
自杀观念
Dorsal
raphe nuclei
Caudal
食欲改变/
raphe
兴趣缺失
nuclei
Lateral
tegmental
NA cell system
关节,淋巴结,背
部,腹部的不名区
的疼痛
头痛
消化道不适
5NE
HT
–
疼痛反应的调
节效应
与
精
神
活
动
、
思
维
、
情
感
反
应
有
关
。
基底神经节
中脑皮质
通路
额前皮质
中脑边缘
通路
腹侧被盖区
黑质
参
与
协
调
运
动
功
能
。
Treatment of mood disorders
 Medications
Antidepressants (number of side effects)
Monoamine oxidase (MAO) inhibitors (negative
interactions with tyramine)
Selective serotonergic reuptake inhibitors
(SSRIs) (side effects)
Lithium (weight gain, danger of poisoning)
 Electroconvulsive therapy (ECT) and transcranial
magnetic stimulation (TMS) as an alternative to
ECT
抗抑郁药的发展史
多作用机制抗抑郁药
（多受体作用）
1950s
丙咪嗪
1960s
氯丙咪嗪
去甲替林
阿米替林
去甲咪嗪
选择性的抗抑郁药
（单一受体作用）
1970s
麦普替林
阿莫沙平
苯乙肼
异唑肼
Tranylcypromine
苯环丙胺
对多种单胺类靶目标有
效的新药
1980s
氟西汀
舍曲林
帕罗西汀
氟伏沙明
西酞普兰
布普品
Lieberman JA. J Clin Psychiatry. 2003;5(suppl 7):6-10.
1990s
奈发唑酮
米氮平
文拉法辛
2000+
度洛西汀
Treatment of mood disorders
antimanic drugs
——mood stabilizers)
1ithium carbonate
Ｌi+ →Na+ 、K+、Ca2+ 、Mg２+。
离子通道
Ｌi
转运系统（ Na+ -K+）
氟西汀
fluxetine，prozac
“Are you prozac today？”
舍曲林
sertraline，zoloft
一线药:
疗效确切,价格低廉;
2.三环类抗抑郁药（TCAs)：不良反应和禁忌症较多.
米帕明(imipramine， 丙米嗪 )、氯米帕明(clompramine，
氯丙米嗪 ) 、多塞平(doxepin，多虑平 )、曲米帕明
(trimipramine，三甲丙米嗪)。
第一代单胺摄取抑制药，非选择性，抑制NE和5-HT
的再摄取，从而增加突触间隙这两种递质的浓度。
正常人服用米帕明后出现安静、嗜睡，但抑郁症病
人连续服药后，出现精神振奋现象。疗效明显优于ＭＡ
ＯＩ。起效慢，一般１～２周后始起效，２～３周疗效
最佳。
不良反应较多，M受体阻断，抗胆碱作用，口干、
便秘、排尿困难等。αl、Hl受体阻断：过度镇静。心
脏毒性（体位低血压、心律失常、房室传导沮滞等）。
（3）选择性5-HT再摄取抑制剂
选择性高:抑制突触前膜对5-HT的回收。
药动学特性好:口服生物利用度高/半衰期都较
长（18-26小时）
疗效好:优于ＴＣＡ,适用于各种类型抑郁症。
不良反应较少而轻微，抗胆碱及心脏副作用少，
注意:应避免与MAOIs等合用，否则易致5-HT过
多的综合征。
目前为治疗抑郁症的一线药物：
氟西汀、帕罗西汀、舍曲林、
氟伏沙明和西酞普兰。
Treatment of mood disorders
Psychosocial treatments
Cognitive therapy
Interpersonal therapy
Combined treatments  V-Bipolar
in depression (medication and
psychosocial treatments)
in bipolar disorders (combining
medication and family and/or CBT is
crucial)
Suicide
8th leading cause of death in the USA (30
000 people a year) for people aged 25-34
Among teenagers, suicide is the 3rd leading
cause of death
The suicide rate for young men in the USA
is the highest in the world
Suicide
Males are four to five times more likely to
commit suicide than females
90% of suicides are committed by people
suffering from psychological disorder
60% are associated with mood disorders
25%-50% with alcohol use and abuse
10% borderline personality disorder
Suicide
Suicidal attempt
Suicidal ideation
Types of suicide (‘formalized’ suicide –
altruistic suicide, egoistic suicide, fatalistic
suicide etc.)
Psychological autopsy (postmortem
psychological profile of a suicide victim)
Suicide
Imitation of suicide (teenager or celebrity)
Suicide prevention
cognitive-behavioral problem-solving
approach
strong social support and hopefulness
treatment of psychiatric and personality
disorders
Psychophysiology of
Schizophrenia
四川大学华西医院康复医学科
郭华
Concepts
Epidemiology
Etiology
Symptoms
Diagnosis and differential diagnosis
Concepts
Neuropsychology:
A science that studies the relationship between the brain,
nervous
system
and
behavior.
attempts to explain the way in which the activity of the
brain is expressed in observable behavior
Concepts
Schizophrenia comprises a group of psychotic disorders of
unknown specific etiology often presented with a gradual
onset of abnormalities in perception, thought, motion and
behavior since young adulthood.

A puzzling and profound psychological disorder.
- It affects thought, perception, and mood.
- loss of contact with reality.
Epidemiology
Prevalence ：
Point prevalence in China (1982): 4.75‰（rural
area 3.42‰，urban 6.06 ‰ )。
Total prevalence in China(1982):5.69‰，(6.55 ‰
1999)。
Lifetime prevalence in USA（1988）13‰。
Epidemiology
 Age：the age of onset in 50% of patients is
20~30 year old ， over 80% of patients is
16~35year old.
 Gender：
Schizophrenia occurs equally in men and
women(in abroad)
The prevalence in men is more than women
(1.6:1) in China.
The mean age of onset is about 2 to 5 years
earlier in men than women.
Gender differences in onset of schizophrenia in a sample of 470 patients
Etiology
biological factors
1．genetics
2．The neurodevelopmental hypothesis
3．Changes in brain structure
4．Biochemical abnormalities
personality factors
psycho-social factors
Etiology
Studies Method:
Family studies
Twin studies
Adoption studies
Etiology
The results of family studies:
The risk of Schizophrenia. Schizoaffective disorder,
and schizotypal personality is increased in firstdegree relatives of patients with Schizophrenia.
The risk of both Schizophrenia and mood disorder is
increased in first-degree relatives of patients with
schizoaffective disorder.
The risk of bipolar illness is not increased in firstdegree relatives of patients with schizophrenia.
Etiology
The results of twin studies
concordance rates among MZ pairs is higher than that
among control(35-60 times)
concordance rates are about 50% for MZ and about 10%
for DZ. It might be expected that some environmental
factors relevant to etiology.
The risk of schizophrenia in the offspring of an
unaffected twin is the same as that of an affected twin.
This means that an unaffected twin has the same
genetic susceptibility to developing Schizophrenia, but
Etiology
The results of adoption studies
The rate for Schizophrenia is greater among the
biological relatives of the Schizophrenia
Adoptees than among the relatives of control.
The finding supports the genetic hypothesis.
Biochemical studies
The dopamine hypothesis.
 5-HT hypothesis.
 Amino acids in Schizophrenia
Symptoms
 感觉障碍(disorders of sensation)
 感觉过敏(hyperesthesia)
 感觉减退(hypoesthesia)
 内感性不适(senestopathia)
 知觉障碍（disturbance of perception）
 错觉(illusion)
 幻觉(hallucination)
 感知综合障碍(psychosensory disturbance)
Symptoms
Disorders of sensation and perception
幻听(auditory hallucination)
幻视(visual hallucination)
幻嗅(olfactory hallucination)
幻味(gustatory hallucination)
幻触(tactile hallucination)
内脏幻觉(visceral hallucination)
功能性幻觉（functional hallucination）
反射性幻觉（reflex hallucination）
Symptoms
思维形式障碍 (disorders of the thinking form)
 思维贫乏(poverty of thought)
 思维散漫( looseness of thought)
 思维破裂(splitting of thought) 思维不连贯(incoherence of
thought)
 思 维 中 断 (blocking of thought) 思 维 被 夺 ( thought
deprivation)。
 思维插入(thought insertion)和强制性思维(forced thinking)
 思维化声(thought hearing)
 思 维 扩 散 (diffusion of thought) 和 思 维 被 广 播 (thought
broadcasting)
 象征性思维(symbolic thinking)
 语词新作(neologism)
 逻辑倒错性思维(paralogism thinking)
 强迫观念（obsessive idea） 或称强迫性思维
Symptoms
妄想(delusion) 按其起源与其他心理活动的关系可分为原
发 性 妄 想 (primary delusion) 和 继 发 性 妄 想 (secondary
delusion)
 被害妄想(delusion of persecution)
 关系妄想(delusion of reference)
 物理影响妄想(delusion of physical influence)-被控制感。
 钟情妄想(delusion of love)
 嫉妒妄想(delusion of jealousy)
 被洞悉感(experience of being revealed)
 夸大妄想(grandiose delusion)
 罪恶妄想(delusion of guilt)
 疑病妄想（hypochondriacal delusion）
 虚无妄想(delusion of negation)
Symptoms
Three main kinds of mood are common:
 First, there may be sustained abnormalities of mood such as
anxiety ,depression, irritability, or euphoria.
 Second, there may be blunting of affect. Essentially this is
sustained emotional indifference （ 冷 淡 ） or diminution of
emotional response.
 Third, there is incongruity of affect. Here the expressed mood is not
in keeping with situation or with the patient’s own feeling.
Symptoms
 Some acute patients are normal
 Others may present somewhat abnormalities of
volition
hypobulia
abulia
Parabulia（意向倒错）
ambivalence
paranoid schizophrenia may present hyperbulia
Symptoms
 Excitement（兴奋状态）----hebephrenic excitement,
catatonic excitement
 Stupor（木僵）----. The patient remain motionless for a
long time(catatonic stupor), or maintain their limbs or
trunks in unusual positions(waxy flexibilitas ) for various
lengths of time.
 Negativism（违拗）---- refuse to cooperate (active
negativism, passive negativism)
 Passive obedience（被动服从）
Symptoms
 Stereotyped act-（刻板动作）---the patient repeat
various functions or gestures, or imitate other’
movements(echopraxia 模仿动作)
 Mannerism（作态）
 Bizarre behavior（怪异行为）
 Forced act ， compulsive act
 Violence and suicide behavior
 Some patients may cause self-induced water intoxication
or avoid eating because of certain delusional beliefs.
Symptoms
Symptom
Frequency (%)
Lack of insight
97
Auditory hallucinations
74
Ideas of reference
70
Suspiciousness
66
Flatness of affect
66
Delusional mood
64
Delusions of persecution
64
Thoughts spoken aloud
50
Diagnosis and differential diagnosis
Diagnosis
The most recent definition was offered in 1994 in DSM-IV.
Characteristic symptoms ( Delusions,
hallucinations, disorganized speech, catatonic
behavior, and negative symptoms.)
Occupational dysfunction (work, interperonal
relations, or self –care, academic, failure in goal
achievement)
Continuous signs of disturbance for at least 6
months with a least 1 month of active phase
symptoms.
Evidence for the Dopamine Hypothesis
Disorder
Schizophrenia
Symptom
Disordered
thought
and behavior
Drug
Anti
psychotic
Action
treatment
Decreases
dopamine
Effect
1. Calm
Disordered
thought and
behavior
2. Causes
tremors
Chronic schizophrenia
 Symptoms meeting
schizophrenia;
the
diagnostic
 The course lasts for at least 2 years.
criteria
of
CCMD-3 diagnostic criteria
Symptom criteria
There is separate diagnostic criteria for simple
type of schizophrenia:
1.Repeated auditory hallucinations that are
usually not mood congruent;
2. Loosening of association, derailment,
incoherence in thinking or poverty of thought
3.Thought insertion or withdrawal, thought
block or forced thinking
CCMD-3 diagnostic criteria
4. Delusion of control, influence or passivity, thought
broadcasting;
5. Primary delusions including delusional perception,
delusional mood or other bizarre delusions;
6. Paralogic thinking, symbolic thought or neologism;
7. parathymia (情感倒错） or apathy;
8. Catatonic syndrome, unusual or silly behavior;
9. Avolition.
Differential diagnosis
Some neurosis
1.the feature of insight
2.the feature of symptoms
3.some patients need to be following-up
Differential diagnosis
Mood disorder
Manic or severely depressed patients may exhibit
psychotic symptoms during the peak of their
disease states
Accurate historical and clinical data should help to
differentiate from mania-related psychotic features
in the presence of other symptoms
By the same token to differentiate depression from
schizophrenia.
治疗与康复
1.药物治疗
早期、足量、足疗程、单一用药、个体化用
药。根据病人情况、症状特点选择合适的药物。低量
开始逐渐加量，高剂量密切观察不良反应。
急性治疗期（至少6周）、巩固治疗期（3－6个月）
和维持治疗期（1年以上）。
抗精神病药物各自的靶症状
氯丙嗪
利培酮
奋乃静
奥氮平
氟哌啶醇
喹硫平
舒必利
甲硫达嗪
氯氮平
五氟利多
氟奋乃静癸酸酯
泰尔登
精神分裂症的维持治疗：
维持时间：
维持剂量：
首发2年维持
以往认为维持剂量为巩固
治疗期剂量的1/2-1/3，甚
至1/4-1/5左右。
再发5年维持
三发以上终生维持
现在认为维持量应为巩固
治疗期剂量的2/3-3/4甚至
全量。
2.电休克（ECT）治疗
3.心理与社会康复
临床痊愈患者应鼓励参加社会活动和力所能及的
工作。
慢性分裂症有退缩表现的患者可进行生活功能训
练。