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1、神经症性障碍,Neurotic Disorder,Department of Psychiatry, Shanghai Mental Health Center Shanghai Jiao Tong University School of Medicine,Definition,Neurotic disorder is a term generally used to describe a nonpsychotic mental illness which triggers feelings of distress and anxiety and impairs functioning.,2
2、016/10/25 Renji Hospital,3,Xu,Yeqing,Shanghai Mental Health Center,with psychological causationgeneticpredisposition and personality traitchronic and recurrent coursebe in touch with realityunusual fear and anxiety to escape certain situationsmixtures of symptoms, especially anxiety and depressive o
3、nes are commonunderstand the nature of their problems but cant resolve with the exception of social phobia their frequency is higher in women than in men,Common features,2016/10/25 Renji Hospital,4,Xu,Yeqing,Shanghai Mental Health Center,Reclassification in DSM-5,The conditions formerly referred to
4、as neurotic are now described with many other terms, such as:Anxiety disorder （Phobia）Obsessive-Compulsive and related DisorderSomatic symptom and related disordersDissociative Disorders,2016/10/25 Renji Hospital,5,Xu,Yeqing,Shanghai Mental Health Center,ICD-10,Neurotic, Stress-Related and Somatofor
5、m Disorders (F40-F48) F40 Phobic anxiety disorders F41 Other anxiety disorders F42 Obsessive-compulsive disorder F43 Reaction to severe stress, and adjustment disorders F44 Dissociative conversion disorders F45 Somatoform disorders F48 Other neurotic disorders,2016/10/25 Renji Hospital,6,Xu,Yeqing,S
6、hanghai Mental Health Center,Etiology and pathogenesis,Environmental Stress, PsychosocialfactorsTemperamental Genetic multiple genes confer vulnerability to neurotic disorder. however, the exact genes, gene products, or functions related to the genetic regions implicated remain unknownPhysiological
7、neuro-anatomyneurological biochemistry,2016/10/25 Renji Hospital,7,Xu,Yeqing,Shanghai Mental Health Center,Phobic Anxiety disorders,Phobic Anxiety disorders,The ICD-10 ClassificationF40.0Agoraphobia F40.1Social phobias F40.2Specific (isolated) phobias F40.8Other phobic anxiety disorders F40.9Phobic
8、anxiety disorder, unspecified,2016/10/25 Renji Hospital,9,Xu,Yeqing,Shanghai Mental Health Center,Agoraphobia,Clinical manifestationsmarked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations individuals typically experience thoughts that somethin
9、g terrible might happenfear or anxiety is evoked nearly every time the individual comes into contact with the feared situationactively avoids the situation or, if he or she either is unable or decides not to avoid it, the situation evokes intense fear or anxietythe fear, anxiety, or avoidance must b
10、e out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context,2016/10/25 Renji Hospital,10,Xu,Yeqing,Shanghai Mental Health Center,ICD-10 Diagnostic Criterion:All of the following criteria should be fulfilled for a definite diagnosis:the psychological
11、or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms, such as delusions or obsessional thoughts;the anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public places, travelling away from home, and trav
12、elling alone; andavoidance of the phobic situation must be, or have been, a prominent feature.,Agoraphobia,2016/10/25 Renji Hospital,11,Xu,Yeqing,Shanghai Mental Health Center,Social Phobia,Clinical manifestationsoften start in adolescenceare centred around a fear of scrutiny by other people in comp
13、aratively small groups (as opposed to crowds), usually leading to avoidance of social situations Unlike most other phobias, social phobias are equally common in men and women. They may be discrete (i.e. restricted to eating in public, to public speaking, or to encounters with the opposite sex) or di
14、ffuse, involving almost all social situations outside the family circle. A fear of vomiting in public may be important.,2016/10/25 Renji Hospital,12,Xu,Yeqing,Shanghai Mental Health Center,Social Phobia,Clinical manifestationsDirect eye-to-eye confrontation may be particularly stressful in some cult
15、ures. Social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the individual sometimes being convinced that one of these secondary manifestations of anxiety is the primary problem;s
16、ymptoms may progress to panic attacks. Avoidance is often marked, and in extreme cases may result in almost complete social isolation.,2016/10/25 Renji Hospital,13,Xu,Yeqing,Shanghai Mental Health Center,ICD-10 Diagnostic Criterion:All of the following criteria should be fulfilled for a definite dia
17、gnosis:the psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts;the anxiety must be restricted to or predominate in particular social situations; andthe phobic situation is avoided
18、whenever possible.,Social Phobia,2016/10/25 Renji Hospital,14,Xu,Yeqing,Shanghai Mental Health Center,Specific (isolated) phobias,Clinical manifestationsThese are phobias restricted to highly specific situations such as proximity to particular animals, heights, thunder, darkness, flying, closed spac
19、es, urinating or defecating in public toilets, eating certain foods, dentistry, the sight of blood or injury, and the fear of exposure to specific diseases. Although the triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobias. Specific phobias usually ar
20、ise in childhood or early adult life and can persist for decades if they remain untreated.,2016/10/25 Renji Hospital,15,Xu,Yeqing,Shanghai Mental Health Center,Specific (isolated) phobias,Clinical manifestationsThe seriousness of the resulting handicap depends on how easy it is for the sufferer to a
21、void the phobic situation. Fear of the phobic situation tends not to fluctuate, in contrast to agoraphobia. Radiation sickness and venereal infections and, more recently, AIDS are common subjects of disease phobias.,2016/10/25 Renji Hospital,16,Xu,Yeqing,Shanghai Mental Health Center,ICD-10 Diagnost
22、ic Criterion:All of the following criteria should be fulfilled for a definite diagnosis:the psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts;the anxiety must be restricted to or
23、 predominate in particular social situations; andthe phobic situation is avoided whenever possible.,Specific (isolated) phobias,2016/10/25 Renji Hospital,17,Xu,Yeqing,Shanghai Mental Health Center,Anxiety disorders differ from developmentally normative fear or anxiety by being excessive or persistin
24、g beyond developmentally appropriate periods.share features of excessive fear and anxiety and related behavioral disturbances.Anxiety Disorder: Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. OCD: They are, however, recognized as
25、 the individuals own thoughts, even though they are involuntary and often repugnant.,Differential diagnosis,2016/10/25 Renji Hospital,18,Xu,Yeqing,Shanghai Mental Health Center,Hypochondriasis: The somatic symptoms of anxiety are sometimes interpreted as signs of serious physical illness, but in the
26、se disorders the patients are usually reassured by physiological explanations, and convictions about the presence of physical illness do not develop.Temporal LobeEpilepsy,TLE: derealisationLoss of awarenessEEGNeurological signs,Differential diagnosis,2016/10/25 Renji Hospital,19,Xu,Yeqing,Shanghai M
27、ental Health Center,Clinical Management,Cognitive-Behavioural therapy (CBT)psychopharmacotherapyTricyclic antidepressantsMOAIs (tranylcypromifle)SSRIs (clomipramine, citalopram, fluoxetine, fluvoxamine, paroxetitle, sertraline)SNRI (venlafaxine); well tolerated, no abuse potentialBenzodiazepines: al
28、prazolam, clonazepam) - for several weeks (potential for abuse, development of tolerance and addiction beta-blocking drugs - for the short treatment of performance anxiety, especially somatic symptoms like tremor,2016/10/25 Renji Hospital,20,Xu,Yeqing,Shanghai Mental Health Center,Anxiety disorders,
29、Generalized anxiety disorder,Clinical manifestationsThe essential feature is anxiety, which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is free-floating). As in other anxiety disorders the dominant sympto
30、ms are highly variable, but complaints of continuous feelings of nervousness, trembling, muscular tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort are common.,2016/10/25 Renji Hospital,22,Xu,Yeqing,Shanghai Mental Health Center,Generalized anxiety disorder,Clini
31、cal manifestationsFears that the sufferer or a relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings. This disorder is more common in women, and often related to chronic environmental stress. Its course is variable but tend
32、s to be fluctuating and chronic.,2016/10/25 Renji Hospital,23,Xu,Yeqing,Shanghai Mental Health Center,ICD-10 Diagnostic Criterion:The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time, and usually for several months. These symptoms should usually involve e
33、lements of:apprehension (worries about future misfortunes, feeling on edge, difficulty in concentrating, etc.);motor tension (restless fidgeting, tension headaches, trembling, inability to relax); andautonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric discomfort,
34、 dizziness, dry mouth, etc.).,Generalized anxiety disorder,2016/10/25 Renji Hospital,24,Xu,Yeqing,Shanghai Mental Health Center,Panic disorder,Clinical manifestationsThe essential features are recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of
35、circumstances, and which are therefore unpredictable. As in other anxiety disorders, the dominant symptoms vary from person to person, but sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization) are common. There is also
36、, almost invariably, a secondary fear of dying, losing control, or going mad. Individual attacks usually last for minutes only, though sometimes longer; their frequency and the course of the disorder are both rather variable.,2016/10/25 Renji Hospital,25,Xu,Yeqing,Shanghai Mental Health Center,Panic
37、 disorder,Clinical manifestationsAn individual in a panic attack often experiences a crescendo of fear and autonomic symptoms which results in an exit, usually hurried, from wherever he or she may be. If this occurs in a specific situation, such as on a bus or in a crowd, the patient may subsequentl
38、y avoid that situation. Similarly, frequent and unpredictable panic attacks produce fear of being alone or going into public places. A panic attack is often followed by a persistent fear of having another attack.,2016/10/25 Renji Hospital,26,Xu,Yeqing,Shanghai Mental Health Center,ICD-10 Diagnostic
39、Criterion:In this classification, a panic attack that occurs in an established phobic situation is regarded as an expression of the severity of the phobia, which should be given diagnostic precedence. Panic disorder should be the main diagnosis only in the absence of any of the phobias in F40.-.For
40、a definite diagnosis, several severe attacks of autonomic anxiety should have occurred within a period of about 1 month:in circumstances where there is no objective danger;without being confined to known or predictable situations; andwith comparative freedom from anxiety symptoms between attacks (al
41、though anticipatory anxiety is common).,Panic disorder,2016/10/25 Renji Hospital,27,Xu,Yeqing,Shanghai Mental Health Center,Anxiety disorder due to another medical condition The diagnosis of anxiety disorder associated with another medical condition should be assigned if the individuals anxiety and
42、worry are judged, based on history, laboratory findings, or physical examination, to be a physiological effect of another specific medical condition (e.g., pheochromocytoma, hyperthyroidism). Substance/medication-induced anxiety disorder A substance/medication-induced anxiety disorder is distinguish
43、ed from generalized anxiety disorder by the fact that a substance or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically related to the anxiety. For example, severe anxiety that occurs only in the context of heavy coffee consumption would be diagnosed as caffeine-in
44、duced anxiety disorder.,Differential diagnosis,2016/10/25 Renji Hospital,28,Xu,Yeqing,Shanghai Mental Health Center,Depressive, bipolar, and psychotic disorders Generalized anxiety/worry is a common associated feature of depressive, bipolar, and psychotic disorders and should not be diagnosed separa
45、tely if the excessive worry has occurred only during the course of these conditions.,Differential diagnosis,2016/10/25 Renji Hospital,29,Xu,Yeqing,Shanghai Mental Health Center,Clinical Management,Psychotherapy: e.g., CBTPsychopharmacotherapyBenzodiazepines: alprazolam, clonazepam) - for several wee
46、ks (potential for abuse, development of tolerance and addiction SSRIs (clomipramine, citalopram, fluoxetine, fluvoxamine, paroxetitle, sertraline)SNRI (venlafaxine); well tolerated, no abuse potentialTricyclic antidepressantsMOAIs (tranylcypromifle)beta-blocking drugs - for the short treatment of pe
47、rformance anxiety, especially somatic symptoms like tremor,2016/10/25 Renji Hospital,30,Xu,Yeqing,Shanghai Mental Health Center,Obsessive-Compulsive disorder,Predominantly obsessional thoughts or ruminationsThese may take the form of ideas, mental images, or impulses to act. They are very variable i
48、n content but nearly always distressing to the individual. A woman may be tormented, for example, by a fear that she might eventually be unable to resist an impulse to kill the child she loves, or by the obscene or blasphemous and ego-alien quality of a recurrent mental image. Sometimes the ideas ar
49、e merely futile, involving an endless and quasi-philosophical consideration of imponderable alternatives. This indecisive consideration of alternatives is an important element in many other obsessional ruminations and is often associated with an inability to make trivial but necessary decisions in d
50、ay-to-day living.,Obsessive-Compulsive disorder,2016/10/25 Renji Hospital,32,Xu,Yeqing,Shanghai Mental Health Center,Obsessive-Compulsive disorder,Predominantly compulsive acts obsessional ritualsThe majority of compulsive acts are concerned with cleaning (particularly hand-washing), repeated checki
