心身疾病的诊断与治疗幻灯片.ppt

* * 焦虑是指一种对尚未发生的事情，怀有一种忐忑不安的不愉快的情绪体验。 焦虑的症状有很多，包括精神症状和躯体症状两部分。很多患者直到出现严重躯体症状时才去就诊，因此耽误了治疗时间。早发现、早诊断、早治疗才不会导致严重后果。 一般来说，焦虑常见的精神症状有情绪紧张不安、担心、甚至恐惧等；并伴有植物神经功能紊乱，表现为紧张、多汗、心律增加等，同时伴有失眠。 值得注意的是：焦虑的核心症状是过度担心，这也是区别于其他精神障碍的重要一点。 * CNS serotonergic pathways incorporate serotonergic neurons with cell bodies in the upper pons and the midbrain—specifically, the median and dorsal raphé nuclei, caudal locus ceruleus, area postrema, and interpeduncular area. Serotonergic neurons in the brain also project down the spinal cord and modulate the transmission of sensory pain input. These spinal cord tracts are thought to be the site of action for serotonergic antidepressants that have been used to control pain. The largest grouping of noradrenergic neurons occurs in the locus ceruleus of the pons. Projections of the noradrenergic system reach many areas in the forebrain, the cerebellum, and the spinal cord. Norepinephrine is secreted in response to physical and psychological stressors and modulates various brain functions. Serotonin and norepinephrine influence a wide variety of brain functions, including mood, sleep, cognition, regulation of the sympathetic nervous system, sensory perception, temperature regulation, nociception (eg, migraine headache), appetite, and sexual behavior. Frazer A. Norepinephrine involvement in antidepressant action. J Clin Psychiatry 2000; 61 (Suppl 10): 25-30. Hardman JG, et al. Goodman Gilman’s The Pharmacological Basis of Therapeutics. 9th ed. 1996. Kaplan HI, Sadock BJ. Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry. 8th ed. 1998: chap 3. Nemeroff C. The neurobiology of depression. Sci Am 1998; 278: 42-49. * 焦虑的发生无处不在。焦虑症状也是精神科和非精神科中最常见的病症。 但是值得我们注意的是：即使是在精神科高度发展的美国，据不完全统计，因焦虑症状寻求治疗的美国人中，约有74％就医于非精神科医生。而不幸的是在非精神科就医的病例中，约一半的病人被漏诊。即便是诊断的病人也仅有不到十分之一得到了恰当的治疗。 相当多的焦虑患者得不到正确地诊断和治疗，值得重视！ * 3 * 首先来看已被广泛接受的单胺递质假说，认为：是突触间隙单胺类神经递质减少引起抑郁。 请看图，与正常情况相比，抑郁状态下突触间隙单胺递质的含量明显减少。 * 通常认为导致抑郁发生主要源于三种单胺类神经递质：5-HT、NE、DA。 而三种神经递质功能不足会有不同的症状表现，其中5-