兒童青少年精神疾病課件

兒童青少年精神疾病

臺北榮民總醫(yī)院精神部兒童青少年精神科主任陳映雪醫(yī)師Disordersusuallyfirstdiagnosedininfancy,childhood,andadolescenceMentalretardationBorderlineintellectualfunctionLearningdisordersReading,math,writingMotorskillsdisorderCommunicationdisordersEliminationdisordersPervasivedevelopmentaldisordersAttentiondeficitanddisruptivebehaviordisordersADHDODDCDTicdisorder/Tourette’sdisorderFeedingandeatingdisordersChildabuseandneglectTemperamentproblemsAnxietydisordersseparationanxietydisorderselectivemutismSpecificphobiaSchoolphobiaSocialphobiaOCDPTSDEatingdisordersSchizophreniaMooddisordersBipolardisorderDysthymiamajordepressionSubstanceabuse北榮陳映雪DisruptivebehaviordisordersAttentiondeficithyperactivedsorder(ADHD)Oppositional-defiantdisorder(ODD)Conductdisorder(CD)ADHDDSM-IV診斷標(biāo)準(zhǔn)A.

核心癥狀

1.注意力差學(xué)習(xí)問題

2.好動

3.衝動

＊持續(xù)六個月以上B.

於七歲之前就有的癥狀C.

至少在兩種情境呈現(xiàn)癥狀D.

造成社會生活功能障礙E.

無法由其它精神疾病來解釋

行為問題、人際衝突、易發(fā)生意外、青少年時期車禍多北榮陳映雪ADHDDSM-IV診斷標(biāo)準(zhǔn)具有下列(一)或(二)之一達(dá)六個月以上與發(fā)展程度比較的不適應(yīng)癥狀(一)Inattention（無法專心）(6項以上)常粗心大意或無法注意細(xì)節(jié)

（功課或工作上）工作或遊戲注意力無法持久別人跟他講話，經(jīng)常不注意聽無法遵守指示完成功課或工作安排工作或活動常發(fā)生困難常常逃避或拒絕需要持續(xù)精神（用功）的工作遺忘帶需要的東西容易被外界轉(zhuǎn)移注意力日常生活中經(jīng)常遺忘每天該作的事北榮陳映雪(二)Hyperactivity-impulsivity：(6項以上)

Hyperactivity(過動)手腳亂動,坐著也扭來扭去無法安靜坐著或常離座(教室)常過度的跑來跑去，或爬上爬下無法安靜遊戲不停的動，精力過盛話很多

Impulsivity(衝動)

1.

話未問完，就搶著回答

2.

缺乏耐心等待

3.

常干擾別人ADHDDSM-IV診斷標(biāo)準(zhǔn)北榮陳映雪ImpulsivityBehaviorthatisswayedbyemotionalorinvoluntaryimpulsesBehaviorwithoutadequateforethoughtTendencyotchooseimmediateoverlongtermrewardsEngagementinbehaviorsthatarelikelytobepunished.Persistentreward-seekingbehaviors北榮陳映雪TypeofADHDPredominantlyInattentiveType(ADD)

注意力不集中型PredominantlyHyperactive-ImpulsiveType過動衝動型CombinedType結(jié)合型(1+2)Forindividuals(especiallyadolescentsandadults)whocurrentlyhavesymptomsthatnolongermeetfullcriteria,"InPartialRemission"shouldbespecified.(adultADD)北榮陳映雪ADHD共病疾病對立異常癥(oppositionaldefiantdisorder)56%反社會規(guī)範(fàn)異常癥(conductdisorder)31%學(xué)習(xí)障礙癥(learningdisorder)25%溝通障礙(communicativedisorder)20%遺尿癥(enuresis)6%焦慮癥(anxietydisorder)20%單純性畏懼癥(simplephobia)9%社會畏懼癥(socialphobia)3%重鬱癥(majordepressivedisorder)6%雙相性情感性疾患(bipolardisorder)6%托倫氏癥

(Tourette’sdisorder)3%北榮陳映雪ComorbidityofPsychiatricdisordersinADHD40%/14%11%4%34%北榮陳映雪ADHDvs.ADDGender:ADHD:boys>girlsADD:girls>boysAgeofbeingdetected:ADHD<ADDClinicalmanifestation:ADHD:morebehaviorproblem&ODDorCDSelf-regulationdeficit+selectiveattentionproblemADD:moreacademicproblem&LDselectiveattentionproblemmoresocialwithdrawn北榮陳映雪DiagnosisofADHD(I)Clinicalinterview(onlywaytoestablishDiagnosis)Hxfromparents/caretakersReviewschoolinformationSchoolreports,LD?Ratingscales(teacher)ExploreparentteacherrelationshipDocumentsigns&symptomsAgeofonsetDurationDifferentsettingsPhysicalexam北榮陳映雪DiagnosisofADHD(2)MeetsDSM-IVorICD-10criteriaScreenforcomorbiddisordersPsychologicalassessmentsIQtest,Attentiontest,PersonalitytestFordetectindividualstrengthandweaknessforcounseling.北榮陳映雪北榮陳映雪北榮陳映雪PrevalenceforADHDinChildrenAbout3to10%IncreasingprevalencefromDSM-III(9.6%)toDSM-III-R(10.9%,7.3%)toDSM-IV(17.8%,11.4%)Morefrequentinboys

thaningirls(3-4:1)北榮陳映雪Prevalencein

adolescence&adultsNo.andseverityofsymptomsdeclineswithage.PrevalenceinAdolescents:2-6%NoGenderdifferenceTheNationalComorbidityStudy(USA)suggestaprevalenceof4.7%ormoreinadults北榮陳映雪PrognosisofADHDADHDgrownup1/3:remission1/3:adultADDwithresidualsymptom

(inattentive,impulsive),1/3:associatedwithconductdisorder

(drugabuse,antisocialbehavior,injuriesofallsorts)poorereducationalperformanceandwereunderachiever

北榮陳映雪Age-SpecificPrevalenceofADHDRemission:DSM-III-RADHDBiedermanetal.2001北榮陳映雪北榮陳映雪北榮陳映雪AdultADHD:PsychiatricComorbidityBiederman,AmJPsychiatry,1993;150(12):1792-1798.LearningdisabilitiesAnxiety%comorbidconditionAntisocial北榮陳映雪PredictorsofPersistenceofADHDRiskFactors:1. FamilyHistoryofADHD2. Co-morbidity3. AdversityP<0.001Beidermanetal,1995(N=128)北榮陳映雪EtiologyofADHDI.Genetictwinstudiesshowingameanheritabilityof0.8

polygenicdisorder(catecholaminesystem)DRD4,DAT1,DRD5,DRD1,serotoninreceptor(5HTR)2A,5HTR1B,

synaptosomalassociatedproteinof25kD(SNAP-25)

DelaymaturationofbrainMinimalbraindysfunctions(MBD)FetalexposuretoMaternalabuseofalcohol,smoking,drug,PregnancycomplicationorbirthtraumaToxins(mercury,lead,manganese)北榮陳映雪北榮陳映雪北榮陳映雪ADHD:MolecularGeneticsGenesimplicatedbyseveralstudies:

DRD4,DRD5,5HT1BNosinglegenecausesADHDThegeneslikelycombinewitheachotherandenvironmentalriskfactorstocauseADHDSmalley,AmJHumGenet.2002;71(4):959-963.北榮陳映雪北榮陳映雪EtiologyofADHDII.DelaymaturationofbrainMinimalbraindysfunctions(MBD)FetalexposuretoMaternalabuseofalcohol,smoking,drug,PregnancycomplicationorbirthtraumaToxins(mercury,lead,manganese,PCB)北榮陳映雪北榮陳映雪北榮陳映雪EtiologyofADHDIII.Gene–EnvironmentInteractionChaoticfamilyenvironmentsPoorparentingskills北榮陳映雪北榮陳映雪北榮陳映雪PathophysiologyofADHDDysfunctionofthecatecholaminesystemWenderP(1971):dysfunctioninDAandNELevyF(1991):dopaminedeficittheory.Volkowetal(1998):methylphenidate:blockadeDAtransporter.(PET)

Pathophysiologicalfindings:No.ofDATbindingsitesishigherindrug-naivepatients.DecreaseinDOPAdecarboxylaseactivityintheprefrontalcortex,primarydeficitsinsubcorticaldopaminesystems.ComplexdysregulationofDAneurotransmittersystem北榮陳映雪Bothgeneticandenvironmentalriskfactorshavesmall,addictiveandinteractiveeffectsontheprobabilityachildwilldevelopADHD北榮陳映雪Brainimagingstudies(Mid1990s-)

Anatomicabnormalitiesinspecificbrainregionswheredopaminereceptorsaredense.reducedsizeofrightfrontallobeandcaudatenucleusA10-yearstudyby(NIMH):brainsare3-4%smallerthannormal(pharmacologictreatmentisnotthecause)ThemoresevereADHDsymptoms,thesmallerfrontallobes,temporalgraymatter,caudatenucleus,andcerebellumwere.北榮陳映雪GreyMatterDifferenceMaps(A)andStatisticalMaps(B)inChildrenwithADHDandControlsADHDsubjectsshowa20–30%increaseingrey-matterdensityinbilateraltemporal&inferiorparietalregionsSowelletal.,2003北榮陳映雪WorkingMemoryRelatedChangesInAdultswithADHD–Compensation?HC>ADHDADHD>HCSchweitzeretal,BiologicalPsychiatry,2004ControlgroupdemonstratesWMactivationassociatedwithverbalrehearsalstrategies&inhibitorycontrolADHDgroupdemonstratesWMactivationassociatedwithmotor&visualprocessingsuggestiveofcompensatorybrainregionsandstrategies.北榮陳映雪北榮陳映雪北榮陳映雪北榮陳映雪ChildrenwithADHDDemonstrateDelayedCorticalMaturationinMostAreas

AnexceptionisintheprimarymotorcortexwheretheADHDgroupdemonstratedearliercorticalmaturationShaw,P.etal.2007,PNAS.北榮陳映雪nigrostriataldopaminepathway(fromsubstantia

nigratocaudatenucleus)mesolimbicdopaminepathway(

fromventraltegmentumtofrontalcortex)The

dopaminetransporterdensityismorethananorderof

magnitudehigherinthecaudatenucleusthantheprefrontal

cortex,whichisthereversepatternofrelative

densityoftheD4receptors,sotheregulationoflevelsofsynapticdopaminebythereuptakeprocessshoulddifferdramaticallyinthesetwobrainregions.thesiteofactionofmethylphenidate,whichblocksthere-uptakeprocess.

北榮陳映雪.Psychotropicmedications(>4yearsold)improvethecoresymptomsofADHDin70%oftreatedchildrenPsychotherapyorpsychosocialtreatmentBehavioraltherapyorCognitive-behavioraltherapySocialskill/impulsecontrolskilltrainingProblemsolvingtrainingParentaltraining

PsychoeducationOthermanagement,butnoevidenceofeffectivenessSensoryintergration

perceptualstimulation/trainingdietarymanagementherbalandhomeopathictreatmentsbiofeedbackmeditationTreatmentsforADHD北榮陳映雪psychotropicmedicationsCNSstimulants(Shortacting&longacting)methylphenidate(MPH),Ritalin,Concerta

D-amphetamine

Pemoline(hepatictoxicity)Antidepressants

TCA(severeCVsideeffects)SSRI(fluoxetine,sertrazline……)Atomoxetine

Clonidine(forsevereaggressivecases,oversedation)Antipsychotics(oversedation)北榮陳映雪ADHDPharmacotherapy–Responsiveness010080604020%RespondersMethylphenidateAmphetaminePemolineTricyclicantidepressantsBupropionMAOIClonidine/GuanfacineWilensTE,SpencerTJ.PresentedatMassachusettsGeneralHospital’sChildandAdolescentPsychopharmacologyMeeting,March10-12,2000,Boston,MA.北榮陳映雪vvStoragevesicleDATransporterCytoplasmic

DAMethylphenidateblocksreuptakePresynaptic

NeuroneSynapseWilensT,SpencerTJ.HandbookofSubstanceAbuse:NeurobehavioralPharmacology.1998;501-513.AmphetamineblocksreuptakeAmphetamine

blocksMechanismofActionofStimulants北榮陳映雪EffectofMPHonWMBrainActivation:NarrowstheFocusSchweitzeretal,2004MPHmayenhanceperformancebyimprovingPFC’sabilitytofilteroutdistracters.北榮陳映雪北榮陳映雪PervasiveDevelopmentalDisordersAutisticdisorderAsperger’sdisorder

星星的孩

TheStoryofTempleGrandinRettdiseasePDDNOSCharacteristicsofAutisticdisorderDiagnosticcriteria(DSM-IV)

Impairedsocialinteraction(quality&quantity)Impairedcommunication,usuallysevereActivities,behaviorsandinterestthatare

repetitive,Restrictedandstereotype.Onset:<age3yearsdiagnosis:aroundage2-3yearsdelayedorabnormalfunctiondevelopmentMalepredominant北榮陳映雪Autisticdisorder:

Associatedfeatures<1>75%:retardedlevel,<2>PIQ>VIQ<3>languageexpressionbelowlanguagecomprehension<4>splinterability:hyperlexia,(abletoread)goodatpuzzle,date,…<5>oddresponsetostimulioversensitive,exaggeratedreaction,fascinationtostimuli,hypo-sensitive<6>behavioralsymptoms:hyperactivity,inattention,aggression,tempertantrumstereotypebehaviors,self-injury(headbanging,biting),北榮陳映雪Prevalence:2-5/10,000,(severeautism)MalepredominantCourse:life-longPrognosisdependson“l(fā)anguageskills”(5y/o)&“overallintellectuallevel”1/3:partialindependencehighestfunctioningadult:stillhadsymptomsAutisticdisorder北榮陳映雪

Asperger’sdisorderDSM-IVDiagnosticCriteriaA.

Qualitativeimpairmentinsocialinteraction,B.Restrictedrepetitiveandstereotypedpatternsofbehavior,interests,andactivitiesC.

NodelayinlanguageD.Nodelayincognitivedevelopmentorinthedevelopmentofage-appropriateself-helpskills,adaptivebehavior(otherthaninsocialinteraction),andcuriosityabouttheenvironmentinchildhood.

F.Functionimpairment北榮陳映雪ComparisonofAsperger’sdisorderwithautisticdisorder(I)male>female(both),prevalence:1-5/1000(orhigher)Ageofdiagnosis:later,>5y/oSocialandcommunicationdeficitsarelesssevere.NormalcuriosityaboutenvironmentNodelayincognitivefunction,self-helpskills,Languagedevelopmentnormallackofempathyproblemswithpragmaticresponses&difficultywiththeemotionalcontentofcommunicationproblemofintegratingaffectiveandsocialcognitiveaspectsofasituation.北榮陳映雪ComparisonofAsperger’sdisorderwithautisticdisorder(II)Difficultieswithnewenvironmentsandchangesintheirnormalroutine,butlessseverethanautism.(rigid&stubborn)Special&circumscribedinterestaremoreprominente.g.Train,Taiwanhistory,numerical,……Inautism:Puzzle,datememorized,space,mechanical…VIQisusually>PIQ(usuallyreverseinautism)Clumsinessismorefrequentlyseen,butlesssevere.Outcomeisusuallymorepositiveinasperger’s.Gotocollege,getmarried,heldajob,somesocialrelation…familyhistoryismorefrequentlypositive北榮陳映雪EtiologyofAutisticdisorder

Non-psychogenicGeneralizedbraindysfunctionNeurodevelopmentdisturbance(<30weekspregnancy)seizure:EEGabnormal(25%)PKU,maternalrubella,fragilexsyndrome(10%autism,mostlymales),tuberoussclerosis(1/4affectedareautistic)

hyperserotoninImagingfindings:ReducedsizeofCorpusCallosum,AnteriorCingulate

Gyrus,Cerebellumlowactivityintheparietalareasandthecorpuscallosum.北榮陳映雪北榮陳映雪fMRI

CerebellarBloodFlowandActivationAutismandCerebralHypoperfusionAllenetal.,2003AmJPsychiatry160(2):262-73北榮陳映雪MirrorNeuron鏡像神經(jīng)元大腦內(nèi)建機(jī)制(anteriorcingulatecortex)模仿動作,看到他人動作，感覺再轉(zhuǎn)到運(yùn)動。生物存活要件之一，同理心情緒反應(yīng)上可能扮演重要角色自閉癥可能與此功能受損有關(guān)情緒圖譜理論(saliencelandscapetheory)杏仁核(amygdala):長期處理情緒獲得情緒圖譜，記載各種情緒意義。自閉癥情緒圖譜嚴(yán)重扭曲。北榮陳映雪北榮陳映雪Treatment

(forautism&Asperger’sdisorder)NospecifictreatmentBehavioraltherapySpeech,communication,cognitive&socialskilltrainingEducationalinterventionsIndividualpsychotherapy(forsociallyhandicapped&lowesteem)Parenteducationandtraining北榮陳映雪Treatment

(forautism&Asperger’sdisorder)Medication:canhelpwithsymptoms

SSRI(stereotype,se