Chapter 11 Stress-related Disorders
-
Upload
marvin-holcomb -
Category
Documents
-
view
31 -
download
3
description
Transcript of Chapter 11 Stress-related Disorders
Chapter 11
Stress-related Disorders
Zhai Jin-guo
Jining Medical University
Beautiful Wenchuan
Air disaster
Hostage events
Conflict
9.11
Busy, busy,
too busy !
现象:生活节凑加快 竞争机制加强 精神压力加大 人际关系复杂
生机?危机?
活力?压力?
Outline
1 . Master :( 1 ) The concept of stressor, psychological
stress, stress-related disorders ;
( 2 ) Classification of stress-related disorders a
nd the clinical features
2. Familiar with :( 1 ) the process and mesomerism fact
ors of stress
( 2 ) treatment rule of stress-related disorders
3 . Understand : the cause of stress-related disorders
Stress Reaction and Influential Factors
stressH. Selye (1907-1982)
stressor
Selye’s stress theory
Stressor
较强烈的刺激,足以引起机体内稳态变化的刺激。 Stress : General Adaptation Syndrome, GAS (一般适应综合
征 ) Phase 1 : alarm phase (警觉期) Phase 2 : resistance phase (抵抗期) Phase 3 : exhaustion phase (衰竭期)
一般适应症候群(General adaptation syndrome,GAS. Selye,1936)
第一阶段:警觉阶段(动员期)
第二阶段:搏斗阶段(适应或抵抗期) 全力投入对事件的应对,消除压力,适应压力,压抑或退却。
第三阶段:衰竭阶段(衰竭期)
消耗大量生理和心理资源,最后“筋疲力尽”
stressstress coping
stress coping
coping
normal stressor appears alarm phase
resistance phase exhaustion phase
Stress
Personality theory and psychological stress
本我 id 自我 ego 超我 superego
意识 consciousness 前意识 preconsciousn
ess 潜意识 subconsciousn
ess
Lazarus’s psychological stress theory
Psychological stress 个体在觉察(认知评价)到威胁或挑战,必须做出适应或应对时的心身紧张状态。
Richard S. Lazarus
拉泽鲁斯 , US
以认知因素为核心
的一种多因素作用过程
Stressor
Biological, psychological, social attr
ibutive( 属性 ) classification
Phenomenological classification
Individual influence
Objective attributive classification
Stressor
Biological, psychological, social attrib
utive classification
生物性应激源:理化 \躯体因素等 心理性应激源:心理冲突、挫折 社会性应激源:灾害 文化性应激源:道德、风俗习惯
Stressor
Phenomenological classification
工作问题 恋爱、婚姻和家庭问题 人际关系问题 经济问题 个人健康问题 喜庆事件
Stressor
Individual influence
Positive life events :积极作用
Negative life events :消极作用
Objective attributive classification
客观事件
主观事件
Social psychological stressors
Marriage and family problem
Occupation ( school ,work ) problem
Social environmental factor
Individual situation
Stress reaction
Physical stress reaction
Psychological stress reaction
Physical stress reaction
Cannon
Psychological stress reaction
Cousciousness :觉醒程度增高 Attention :分散 Thinking :单一、刻板、杂乱 Affect :易激惹、哭泣、焦虑、恐惧 Behavior :坐立不安、震颤、小动作多 Others: 头昏无力,睡眠障碍、全身慢性疼痛 烟、酒、镇静剂用量增加
输入 中介 反应 结果
应激源 中介因素 应激反应
生活应激源
实验室应激源
环境变化
心理社会中介(认知性评价)
生物学中介(躯体因素)
应激反应系统 心身障碍
心理障碍
Stress Model
适应不良
适 应
Influence Factor of stress
Cognitive appraisal (认知评价 ):关键性因素 Psychological defense mechanism( 心理防御机制 ) Coping( 应对 ) Social support( 社会支持 ) Individual experience ( 个人经历 ) Individual characteristics ( 个性特征 ) Function state ( 当时的机能状态 )
Cognitive appraisal
认知评价是指个体从自己的角度对遇到的生活事件的性质、程度和可能的危害情况作出估计
Primary appraisal : Is Stressor Negative?
Secondary appraisal : Can I Control the Situation?
问题
初评
次评 问题关注应付
情绪反应(不适应)
适应
情绪关注应付
有利害关系
无利害关系
可改变
有效
无效
有效
无效 认知评价在应激过程中的作用
To pour out one's heart
To get along with others with pleasure
Finding pleasure in helping others
To forgive
Self-confident
Influence Factor of stress
Psychological defense mechanism
是人应对各种紧张性刺激维护心理健康的潜意识的手段,以来摆脱困境。
否认、升华、转移、幽默、合理化等 Coping 是个体对生活事件以及因生活事件而出现的自身
不平衡状态所采取的认知和行为措施。 Coping style : positive, negative
Coping strategies
Influence Factor of stress
Social support :“可利用的外部资源”
是指个体与社会各方面包括亲属、朋友、同事、伙伴等社会人以及家庭、单位、党团、工会等社团组织所产生的精神上和物质上的联系程度。
Individual experience
Personality characteristics
Function state
Stress and Health
Positive influence
Negative influence
How to form psychological stress ?
Psychological conflict
approach-approach conflict (双趋冲突 ) conflict between double evasions (双避冲突 ) conflict between taxis & evasion (趋避冲突 ) conflict of varieties (多重趋避冲突)
How to form psychological stress ?● Approach-approach conflict (双趋冲突 )
Conflict between double evasions (双避冲突 ) ● Conflict between taxis & evasion (趋避冲突 )
● Conflict of varieties (多重趋避冲突)
Stress-related Disorders
Stress-related Disorders
Definition
一组主要由心理、社会(环境)因素引起异常心理反应所导致的精神障碍,也称反应性精神障碍。不包括癔症、神经症、心理因素所致生理障碍,及各种非心因性精神病性障碍。
决定本组精神障碍的发生、发展、病程,及临床表现的因素有:
(1) 生活事件和生活处境,如剧烈的超强精神创伤或生活事件,或持续困难处境,均可成为直接病因;
(2) 社会文化背景;
(3) 人格特点、教育程度、智力水平 , 生活态度和信念等 .
Stress-related disorders The factors determining the occurrence, developm
ent, duration and clinical manifestations of this disorder are:
①life events and life situations, such as severe superstrong mental trauma or life events or continuous difficult situation all may be direct causes;
②social cultural background; ③personality trait, level of intelligence, attitude of li
fe and creed; ④excluding hysteria, neurosis, physiological disord
ers associated with psychological factors and psychotic disorders.
Classification
- acute stress disorder
- posttraumatic stress disorder, PTSD
- adjustment disorder
Stress-related Disorders—overview
Common clinical features 精神刺激是发病的直接原因 症状表现与精神刺激的内容有关 病程、预后与精神因素的消除有关
Epidemiology prevalence : 0.68 ‰ ( 1993) sex: M=F Age : adolescent
Cause
Stressors : Personality charac
teristics :
Acute stress disorders
A transient psychotic disorder is directly caused by very severe or continued psychological traumatic events, which usually onsets within an hour. The main picture is delusions, severe affective disturbances, and psychomotor excitement, with experience of severe phobia, or psychomotor inhibition, even stupor. There must be a close connection between the stressor and the content of symptoms. The symptoms usually are transient, with favorable prognosis, complete remission, if the stressor is eliminated.
Acute stress disorder
定义:“急性应激反应”、“急性心因性反应”。 是由于突然而来且异乎寻常的强烈应激性生活事件所引
起的 一过性精神障碍。 临床表现 初期“茫然” :定向力障碍、注意狭窄 精神运动性抑制 精神运动性兴奋
Diagnosis A. Symptom criteria: There are evidences of exceptionally
severe mental stimulus before onset of the disorder, and at least one of the following items:
(1) delusions, severe affective disturbances, and psychomotor excitement, with experience of severe phobia;
(2) psychomotor inhibition, even stupor, and sometimes with slightly conscious disorders.
B. Severity criteria: Serious impairment of social functioning. C. Course criteria: The onset caused by traumatic events
usually occurs within several minutes to several hours and the symptoms last from several hours to one week. Then, the symptoms can usually remit within 1 month.
D. Exclusion: Hysteria, organic mental disorders, mental disorders due to non-addictive substances, and depression are excluded.
Acute stress psychosis(acute reactive psychosis)
A subtype of transient psychotic disorder is directly caused by severe or continued psychological traumatic events. The main picture is delusions, severe mood disorders. There must be a close connection between the stressor and the content of symptoms. The symptoms usually are transient, with favorable prognosis, complete remission.
A. Symptom criteria: (1) Evidence of severe mental stimulus before onset of the
disorder is present; (2) The symptoms are characterized by delusions and seve
re affective disorders. The content of symptoms has a close relation to the stressor and less associated with personal trait.
B. Severity criteria: Serious impairment of social function and insight of illness.
C. Course criteria: The symptoms can remit rapidly by eliminating cause or changing circumstance (e.g. releasing from arrest), in few cases the duration of illness is over 1 month.
D. Exclusion: Hysteria, mental disorders due to nonpsychological factors are excluded.
Treatment
及时、就近、简洁、紧扣重点
积极与患者讨论应激性事件。
心理治疗 摆脱创伤环境、避免进一步的刺激 建立良好的医患关系 帮助患者建立自我的、有力的心理应激应对方式
药物治疗 主要是对症治疗的,但在急性期也是采取的措施之一。适当的药物可以使患者症状较快地获得缓解,便于心理治疗的开展和奏效。
Posttraumatic stress disorder, PTSD
posttraumatic stress disorder, PTSD
定义:“延迟性心因反应”,是由于受到异乎寻常的威胁性、灾难性心理创伤,导致延迟和长期持续的精神障碍。
流行病学居民终生患病率为: 1-14%
高危人群 ( 战后复员军人,天灾人祸中的幸存者 ) : 3-58%
女性多于男性
Epidemiology 1987年美国:越南战争退伍老兵中,终生患病率男性为 31%,女性为 27%,时点患病率 15.2% 和 8.5%
Madakasia 等:不同灾害后的 PTSD 的患病率≥ 30%
Kessler : PTSD 的终生患病率男性为 5%,女性为 10.4%,总体为 7.8%
张本等:唐山大地震后 23%出现 PTSD
刘光雄等:车祸后有 40.7%的人符合急性应激障碍的诊断, 38.3%符合 PTSD的诊断
Clinical manifestation
(1) 反复发生闯入性的创伤性体验重现(病理性重现) ;
(2) 持续的警觉性增高;
(3) 持续的回避;
(4) 对创伤性经历的选择性遗忘;
(5) 对未来失去信心。
Diagnosis Symptom criteria: (1) The patients have the experience of unusually traumatic
events or situation (e.g., natural and man-made calamities);
(2) There is reappearance of traumatic experience (flash-backs) , with at least 1 of the following:
①involuntary recall of the experience of being attacked; ②repeated manifestation of nightmare with traumatic
content; ③repeated manifestation of illusions, hallucinations; ④repeatedly feel affiliation when the scene retakes place in
memories (e.g., revisiting a place). It may cause individual unusual affiliation and cause marked physiological reaction (e .g., palpitation, sweat, looking pale).
(3) Sustained hyperviligance, with at least 1 of the following: ①difficulty of falling sleep, or unreality of sleep; ②irritability; ③difficulty of concentration; ④excessively feeling alarmed; (4) Avoidance of situation similar to stimulus or related, wit
h at least 2 of the following: ①trying not to think people and events related to traumatic
experience; ②avoiding activities or places that may cause agony recall; ③unwilling to contact, becoming cold on relatives; ④narrowing of range of interests, but interested in some ac
tivities unrelated to traumatic experience; ⑤unable to recall traumatic experience (selective amnesia); ⑥loss of longing for future.
【严重标准】社会功能受损。 【病程标准】精神障碍延迟发生(即在遭受创伤后数日至数月后,罕见延迟半年以上才发生),符合症状标准至少已 3 个月。
【排除标准】排除情感性精神障碍、其他应激障碍、神经症、躯体形式障碍等。
Risk Factors of PTSD Demographic
correlatesSexAgeEducation IncomeMarital status
Trauma related Type of traumaSeverity of trauma
Biological correlatesGeneticsPersonalityPsychophysiology
PTSD 典型病例
某男, 41 岁,机械厂工人,退伍军人。 1979 年参加自卫反击战,当时作为先遣部队深入敌占区。途中,有战友踩地雷被炸死,其中有两位是他的好朋友。亲眼目睹战友被炸得血肉横飞,其中一战友的一条血淋淋的大腿就落在他的眼前,惨不忍睹,他自己也负轻伤。其后,敌军反击,经过浴血奋战,我方部 队死亡过半。后退守到一掩蔽区,眼望四周,到处都是阵亡战士的尸体,血肉模糊,
PTSD 典型病例
有掉眼睛的、有胃肠外流的、有断胳膊少腿的。更令人害怕的是,我方战 士已弹尽粮绝,饥饿和死亡随时威胁着他们。如此竖持近 4天。后被我方大部 队救回而幸免于难。战争结束后,病人退役到长沙某厂当工人,同事发现这位英雄常常沉默少语,不太喜欢与人交往。家人反映,病人似乎性格都有改变,对亲友冷淡,无故发脾气。
PTSD 典型病例
病人自诉睡眠差,恶梦频频,有时常在噩梦中惊醒,脑于里经常控制不住的浮现战友被炸死时的那一幕幕惨景。病人不愿看有关战争的电影或电视,甚至听到放鞭炮声都紧张不安。曾多次就诊精神科,服用过阿米替林、地西泮、阿普唑仑等多种药物,症状反复不定,现仍未结婚,受单位照顾从事工厂绿化工作。
诊断:创伤后应激障碍
PTSD 的治疗 心理治疗
支持性心理治疗
认知治疗
药物治疗
心理治疗合并药物治疗
PTSD treatment Antidepressants
SSRIs SNRIsTCASMAOIsOthers
Others BZDs NBZDs Anti-convulsive drugsΒ-receptor antagnistsAtypical antipsychotics
adjustment disorder
定义 临床表现
适应障碍典型病例
某女, 18 岁,大学一年级学生。因缓起不愿与人交往、烦躁、情堵低落 2 月余求诊。 患者自幼在生活上受到父母的宠爱,想吃什么父母就买什么,但在学习和行为上严格要求。到了中学,父母更是不让她做任何家务事,衣来伸手,饭来张口,整天看书学习。 1996 年考入某大学, 9月由父母陪同入学,安顿后,父母欲回家,病人不让,经父母再三安慰劝说后方同意 父母回家。开始病人表现尚正常,只是生活自理能力差。临近考试,病人忙于学习,经常吃不到饭,
适应障碍典型病例
衣服也不洗,有时不梳头就去上课,考试成绩也不理想,受到父母的严厉批评。病人渐出现情绪低落,不愿与同学交往,常独自一人在宿舍里唉声叹气、哭泣,觉得自己没有能力,甚至对父母说不想读书,想退学。并出现失眠,表现为入睡困难,常辗转床笫久久不能入睡,次日感头昏脑胀,心烦,上课注意力不能集中。食欲差,食量明显减少,病人自诉没有胃口,不想吃。既往史无特殊。足月顺产,幼时生长发育正常。
适应障碍典型病例7 岁读书,学习成绩好。 18 岁考入大学,与同学来往少。平素性格内向、胆小、顺从。家族史无特殊。躯体及神经系统检查:未发现阳性体征。精神状况检查;意识清晰,接触合作,衣着整洁,年貌相符,定向准确,未引出幻觉、妄想。思维联想连贯性与逻辑方面无 异常,情绪稍低。自诉在家什么都好,自从上大学后,什么都要自己做,还要读书,感到力不从心,极不适应学校生活,经常想回家,不想继续读大学,爸爸、妈妈又不同意。自知力存在。 诊断:适应障碍
应激相关障碍的治疗
心理治疗 药物治疗
如何应对精神应激?(应对方式)
压抑
否认
倾诉
发泄
升华
投射
文饰
物质滥用
自我惩罚
消遣娱乐
与您共勉( 以下内容取自张亚林老师的课件,特致谢 )
值得庆幸,得意之余还有挫折,
要不然从 18岁到 80岁岂不是一段漫长的平庸无奇?
——要学会珍惜挫折。
与您共勉
值得庆幸,欢笑之余还有泪水,
要不然满腹的委屈和忧郁岂不是无处排解?
所以,要有泪就流。
说“男子有泪不轻弹”的人不懂得心理学。
男人哭吧!哭吧!哭吧!不是罪!
与您共勉
值得庆幸,理解之余还有误解,
要不然一切都被人洞悉得一清二楚,自己岂不是成了一个透明的躯壳?
——要善待误解。
与您共勉
值得庆幸,热闹之余还有孤独,
要不然,满脑纷繁的思绪岂不是无暇梳理?
——要学会享受孤独。
与您共勉 朋友,凡事别太在意,吃亏是福! 什么金钱,什么功名利禄,乃身外之物,人不能把这些带入坟墓,相反,这些却可能把人送往坟墓!
请记住:保持一颗平常心,平平淡淡才是真!
健康才是人生第一财富!
思考题
什么是应激和应激相关障碍? 应激相关障碍包括哪几种主要表现形式? 急性应激障碍和 PTSD 各有哪些特点? 应激相关障碍的的诊治原则是什么?
进一步阅读的书目
沈渔邨.精神病学(第四版).北京:人民卫生出版社, 20
02
赵靖平 . 精神药物治疗学 . 北京:人民军医出版社, 2005
中华医学会精神科分会 . 中国精神障碍分类与诊断标准 ( 第三版 ). 济南:山东科学技术出版社, 2001
Oxford Text Book of Psychiatry, 2006
Synopsis of Psychiatry, 2007
健康的心灵!
精彩的人生!