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Psychiatric symptoms and diagnosis . 主講者 : 傅綢妹副教授. 疾病分類的目的. 有共同的診斷分類,臨床上才能溝通病人的症狀、預後、治療。 在研究工作上才能找到各種群組病人相互比較分析。. Diagnosis and Classification. DSM-IV: Diagnostic and statistical manual of mental disorder, 4th edition. (1994) DSM-IV TR ( Text Revision 2000)

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Psychiatric symptoms and diagnosis

Psychiatric symptoms and diagnosis

主講者: 傅綢妹副教授


Psychiatric symptoms and diagnosis

疾病分類的目的

  • 有共同的診斷分類,臨床上才能溝通病人的症狀、預後、治療。

  • 在研究工作上才能找到各種群組病人相互比較分析。


Diagnosis and classification

Diagnosis and Classification

DSM-IV: Diagnostic and statistical manual of mental disorder, 4th edition. (1994)

DSM-IV TR (Text Revision2000)

ICD-10: International classification of diseases 10th version. (1992)


Psychiatric symptoms and diagnosis

Classification of Mental Illness精神疾病分類


Organic mental disorders organic brain syndrome

Organic mental disorders( Organic brain syndrome )器質性腦症候

  由腦組織功能受損所引起或與之有關的一種疾患。

可能表現為定向力障礙、記憶力喪失及學習、理解、計

算與實行判斷諸能力的缺損。可到達精神病之地步,亦

可不達於此地步,可為輕微、中度或嚴重。單純的醉酒

可做為非精神病性器質性腦症候群之一例,而老年期癡

呆則已達精神病的地步。


Functional disorder

Functional disorder 功能性障礙

沒有器官組織構造上的變化或很明顯的原

因所導致的障礙.如multiple personality

disorder


Psychosis

Psychosis 精神病

  一種嚴重的器質性或功能性的精神疾患,病人的思

考、感情反應、記憶、溝通、了解現實及產生適當行為

的能力已受到足夠的損害,以致無法面對生活的正常要

求,其特徵常為退化的行為、不相稱的情緒、薄弱的衝

動抑制力及種種異常的精神內涵如妄想和幻覺。此名詞

適用的範圍很廣,可以有不同程度的嚴重性及發病期。


Dsm iv multiaxial evaluation

DSM IV Multiaxial Evaluation

Axis I: Clinical Disorders and Other Conditions

That May be a Focus of Clinical Attention

Axis II: Personality Disorders and Mental

Retardation

Axis III: ICD-9-CM General Medial Conditions

Axis IV: Psychosocial and Environmental

Problems

Axis V: Global Assessment of Functioning (GAF)

Scale


Dsm iv multiaxial evaluation1

DSM IV Multiaxial Evaluation

Axis I: Clinical Disorders and Other Conditions

That May be a Focus of Clinical Attention

Axis II: Personality Disorders and Mental Retardation

Axis I and Axis II make up the entire classification of

mental disorders

Axis III: ICD-9-CM General Medial Conditions

Axis III list any general medical condition in addition

to the (related or unrelated) mental disorder

Axis IV: Psychosocial and Environmental Problems

Axis IV is used to code the problems thatsignificantly

contribute to the current disorder

Axis V: Global Assessment of Functioning (GAF) Scale

Axis V is to judge patients’ overall levels of functioning

during a paticular time (social, occupational and

psychological functioning)


Dsm iv axis ii personality disorders and mental retardation

DSM-IV Axis II: Personality Disorders and Mental Retardation

Paranoid personality disorder

Schizoid personality disorder

Schizotypal personality disorder

Antisocial personality disorder

Borderline personality disorder

Histrionic personality disorder

Narcissistic personality disorder

Avoidant personality disorder

Dependent personality disorder

Obsessive-compulsive personality disorder

Personality disorder not other wise specified

Mental retardation


Dsm iv axis iv psychosocial and environmental problems

DSM-IV Axis IV: Psychosocial and Environmental Problems

Problems with primary support group

Problems related to the social environment

Educational problems

Occupational problems

Housing problems

Economic problems

Problems with access to health care services

Problems related to interaction with the legal system/crime

Other psychosocial and environmental problems


Dsm iv global assessment of functioning gaf scale

DSM-IV global Assessment of Functioning (GAF) Scale


The mental state examination

The Mental State Examination

1. General appearance( 一般外觀)

a. Dress and self-care

b. Facial expressions

c. Manner

d. Posture

2. Behavior-level of activity or queer(行為)

3. Speech-loud, hoarse, mutism, fast, slow or

pressured(語言表達)

4. Mood (心情)

a. Subjective report

b. Depression or elation

c. Tense, irritability or fear

d. Incongruity or blunting of affect

5. Thought(思想)

a. Content-delusions, obsessions, autistic

thinking or worries


Psychiatric symptoms and diagnosis

b. Form-pressure or poverty of thought; thought

blocking; loosening of associations or flight of

ideas or perseveration

6. Perception-hallucinations; illusions(知覺)

7. Cognition(認知;JOMAC)

a. Orientation

b. Attention and concentration

c. Memory-subjective report and:

i. Immediate memory

ii. Recent memory

iii. Remote memory

d. Judgment-ability to understand relationship

between fact and to draw conclusions

8. Insight(病識感)-realizing that there is physical or mental problems


Psychiatric symptoms and diagnosis

Disturbances in content of thought

Delusion(妄想): false belief, based on incorrect

inference about external reality, that is not

consistent with patient's intelligence and

cultural background and cannot be corrected

by reasoning

與一個人的知識水準和文化背景不合的錯誤信念。這些信念源自潛意識的需要,雖然不合邏輯且有明顯反證,卻仍然存在。


Psychiatric symptoms and diagnosis

a. Nihilistic delusion(虛無妄想): false feeling that

self, others, or the world is nonexistent or ending

b. Delusion of poverty(貧因妄想): false belief that

one is bereft, or will be, of all material possessions

c. Somatic delusion(身體妄想): false belief involving

functioning of one's body(e.g., belief that one's brain

is rotting or melting)

d. Delusion of persecution(被害妄想): false belief that

one is being harassed, cheated, or persecuted

認為自己被選為迫害對象的意念

e. Delusion of grandeur(誇大妄想): exaggerated conception

of one's importance, power, or identity

對個人的重要性或身份過分誇大的信念。


Psychiatric symptoms and diagnosis

f. Delusion of reference(關係妄想): false belief that

the behavior of others refers to oneself

認為某些偶發的或不相干的事件或別人的行為與自己

有關的錯誤假設。

g. Delusion of self-accusation(自責妄想): false feeling of

remorse and guilt

h. Delusion of control(被控制妄想): false feeling that

one's will, thoughts, or feelings are being controlled by

external forces

i. Thought withdrawal(思考被抽走): delusion that one's

thoughts are being removed from one's mind by other

people or forces

ii. Thought insertion(思考被插入): delusion that thoughts

are being implanted in one's mind by other people or

forces


Psychiatric symptoms and diagnosis

iii. Thought broadcasting(思考被廣播): delusion that

one's thoughts can be heard by others, as though

they are being broadcast into the

iv. Thought control(思考被控制): delusion that one's

thoughts are being controlled by other persons or

forces

I. Delusion of infidelity (delusional jealousy)(不貞思考)

false belief derived from pathological jealousy that

one's lover is unfaithful

j. Erotomania(色情狂):delusional belief, more common

in women than in men, that someone is deeply in love

with them(also known as Clerambault-Kandinsky

complex).


Psychiatric symptoms and diagnosis

PERCEPTION: process of transferring physical

stimulation into psychological information;

mental process by which sensory stimuli are

brought to awareness 

A. Hallucinations(幻覺): false sensory perceptions

not associated with real external stimuli; there

may or may not be a delusional interpretation

of the hallucinatory experience; hallucinations

indicate a psychotic disturbance only when

associated with impairment in reality testing

沒有真正的外界刺激而產生的感覺,可因情緒或其

他因素如藥物、酒精和心理壓迫而發生,可以各種

感覺形式出現。


Psychiatric symptoms and diagnosis

1. Hypnagogic hallucination(入眠期幻覺): false sensory perception occurring while falling asleep

指在入眠期產生之各種幻覺,通常並非病態的。

2. Hypnopompic hallucination(初醒期幻覺): false

sensory perception occurring while awakening

from sleep

3. Auditory hallucination(聽幻覺): false perception of

sound, usually voices, but also various noises,

such as music or rustling leaves

4. Visual hallucination(視幻覺): false perception involving sight, consisting of both formed images

(e.g., people) and unformed images (e.g., flashes

of light)


Psychiatric symptoms and diagnosis

5. Olfactory hallucination(嗅幻覺): false perception

in smell

6. Gustatory hallucination(味幻覺): false perception

of taste

7. Tactile (haptic) hallucination(觸幻覺): false

perception of touch or surface sensation, as from

an amputated limb (phantom limb) or crawling

sensation on or under the skin (formication)

8. Somatic hallucination(身體幻覺): false sensation

of things occurring in or to the body, most often

visceral in origin (also known as cenesthetic

hallucination)

B. Illusions(錯覺): misperceptions or misinterpretations

of real external sensory stimuli

有真正的外界刺激,但產生的是錯誤的感覺。


Psychiatric symptoms and diagnosis

ICD-10

There are clinical description and diagnostic guidelines for psychiatric disorders. A supplement for providing diagnostic criteria for research is also available.

It uses a three-axis system:

Axis I – Clinical Diagnosis

Axis II – Disablements

Axis III – Contextual Factors


Dsm iv

根據美國精神疾病診斷手冊第四版【DSM-IV】

  • 一、精神分裂症的診斷標準如下:

  • A症狀:下列中含有兩項﹝或兩項以上﹞症狀,每一項症狀出現至少一個月:

  • 1.妄想:是一種錯誤且偏離事實的想法,雖然經過不斷的解釋或事實證明,仍無法改變其想法(如,認為有人要害他的被害妄想、認為旁人的一言一行都與他有關的關係妄想等)。

  • 2.幻覺:是一種知覺障礙,有視、聽、觸幻覺等,精神分 裂症以「聽幻覺」最常見;在別人聽不到或旁邊沒有人講話時,但病人可清楚且確定的聽到有人對他說話的聲音。


Dsm iv1

【DSM-IV】

  • 注意:若妄想內容古怪,或幻覺包含一種人聲繼續不斷評論病人的行為或思想,或幻覺為兩種或兩種以上的聲音彼此交談,則症狀僅需一項即可。

  • 3.語無倫次或常表現脫軌語言。

  • 4.混亂﹝disorganized﹞或僵直﹝catatonic﹞的行為。

  • 5.負性病徵,如情感淡漠、貧語症﹝alogia﹞或無動機﹝avolition﹞。


Dsm iv2

【DSM-IV】

  • B社會職業功能障礙:自從疾病開始發生後,主要職業功能領域諸如工作、人際關係、或自我照顧等,有一種或一種以上領域的功能明顯低於病發前的水準﹝或若發病是在兒童期或青少年期,也指不能達到其人際關係、學業、或職業成就的預期水準﹞。

  • C總時期:連續有病徵的時期至少延續六個月,此六個月時期內必須至少一個月時期﹝若成功的治療可更短﹞,其症狀符合準則A即活躍期症狀,此六個月並可包含前驅症狀或殘餘症狀的時期。在這些前驅期以及殘留期內,此障礙的病徵可能


Dsm iv3

【DSM-IV】

  • 只表現負性症狀、或兩種或兩種以上符合準則A,但以較弱化的型式﹝attenuated form﹞表現的症狀﹝如古怪的信念、不尋常的知覺經驗﹞﹝孔繁鐘和孔繁錦,民86﹞。

  • D已排除被診斷為重鬱症及躁鬱症疾患的可能。

  • E 已排除被診斷為器質性腦疾患的可能。

  • 精神分裂症的症狀若持續六個月,診斷即可成立。文獻指出四分之三的病人在17-25歲時發(Stuart & Sundeen, 1995﹞。若持續6個月至2年即屬亞急性,若超過2年即屬一種慢性疾病。


Psychiatric symptoms and diagnosis

精神分裂病的五項特徵

對壓力適應力薄弱;小量及中量的壓力即導致病態反應。

調適能力差;無法執行日常生活活動包括處理錢財、做三餐、個人衛生等。

依賴;無助需要家人、朋友及社會資源的支持

人際關係困難;個體感到孤獨、被隔離、顯得畏縮,有困難發展及維持人際關係。

在競爭的場合中工作有困難;個體有困難找到工作及維持一個固定工作﹝Gary & Kavanagh, 1991﹞


Psychiatric symptoms and diagnosis

憂鬱症的三層面

  • 情緒低落:常想哭泣,什麼都不感興趣,甚至鬱卒到想自殺或出現自傷、他傷之行為。

  • 認知障礙:自責很強,罪惡感重,悲觀,覺得人生無意義,注意力和記憶力大大減低,遇事無法做出決定。

  • 身體症狀:嚴重失眠,很疲倦,體力很差,胃口下降,體重減輕,性慾減退


Dsm iv 1

DSM-IV重鬱症之診斷準則-1

  • A.至少兩週期間內,同時出現下列症狀五項(或五項以上),且呈現由原先功能的改變:(1)憂鬱心情、(2)失去興趣或喜樂此兩項症狀至少有其中之一。

    • 憂鬱心情,幾乎整天都有,幾乎每日都有,可由主觀報告(如感覺悲傷或空虛)或由他人觀察(如看來含淚欲哭)而顯示。注意:在兒童及青少年可為易怒的心情。


Dsm iv 2

DSM-IV重鬱症之診斷準則-2

  • 在所有或幾乎所有的活動,興趣和喜樂都顯著減少,幾乎整天都有,幾乎每日都有(可由主觀報告或由他人觀察而顯示)。

  • 非處於節食而明顯體重下降,或體重增加(如:一個月體重變化量超過5%);或幾乎每天都食慾減少或增加。注意:在兒童,無法增加預期應增的體重即應考慮。

  • 幾乎每日失眠或嗜睡。

  • 幾乎每日精神運動性激動或遲滯(可由他人觀察得到,而非僅主觀感受不安定感或被拖滯感)。


Dsm iv 3

DSM-IV重鬱症之診斷準則-3

  • 幾乎每日疲累或失去活力。

  • 幾乎每日有無價值感,或過分、不合宜的罪惡感(可達妄想程度)(並非只是對生病的自責或罪惡感)。

  • 幾乎每日思考能力或專注能力減退、或無決斷力(由主觀陳述或經由他人觀察而顯示)。

  • 反覆想到死亡(不只是害怕自己即將死去)、重複出現無特別計畫的自殺意念、有過自殺嘗試、或已有實行自殺的特別計畫。


Dsm iv 4

DSM-IV重鬱症之診斷準則-4

  • B.此症狀不符合混合發作的準則

  • C.此症狀造成臨床上重大痛苦,或損害社會、職業、或其他重要領域的功能

  • D.此障礙非由物質使用或身體疾病的直接生理效應所造成

  • E.此症狀無法以傷慟反應做更佳解釋


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