Somatic Symptoms & Depression in General Practice 情緒障碍躯体化 David Wong 王大卫 MB.,BS, PDip.Com.Psy Med HONG KONG 9 th Beijing/ Hong Kong Medical Exchange 第九届京港医学交流会议 Psychological medicine in Community 社区心理医学 November 2007 Presidential, Plaza Hotel, Beijing, China S.1

What is this & what do you see ? 猜猜这是什么 ? S.2

Review of patients’ record in General Practice 病人纪录在全科医学中的覆检 Somatic symptoms & depression  Associated with medical causes and now found increasingly so with psychiatric disorders as well. 一向被认以为是躯体的疾病, 现在我们知道精神障碍也可以 引起同样症状.  Some medically unexplainable symptoms may be listed under well defined psychiatric disorders, the rest is grouped loosely as medically `unexplained` symptoms (MUS). 部份躯体症状不能以身体疾病解释, 原来是精神障碍症侯一 类. 目前还有一些躯体症状未能 ( 起码暂时 ) 有合理的解释, 有 些学者就冠上一个名词 ” 医学未能解释的症状 ” (MUS).  Management of MUS, also not explainable by the present system of psychiatry, remains a challenge. 对临床和做研究的医学界 MUS 都是一个挑战. Somatic symptoms 躯体症狀 S.3

Somatic symptoms( 躯体症狀 ) in DSM IV & HAM-D Somatic symptoms & depression S.4 Symptoms 症狀 DSM I VHAM-DOthers Sleep 睡眠 Insomnia/hypersomnia 失睡, 昏睡 Early, middle late insomnia 早, 中, 晚段失睡 General 一般 Fatigue or loss of energy, 疲倦 / 沒有精力 Fatigue and loss of energy, heaviness, aches 疲倦, 乏力, 沉重, 疼痛 GI 腸臟 -Appetite 胃口 Weight 体重 Decrease/increase 增加 / 减少胃口 significant weight gain/loss 体重显著上 升或减少 Marked reduction 沒有胃口 Weight loss 体重 下降 Head, Neck, 头, 颈 Aches (ANS) 疼 痛 Aches, dizziness 疼痛, 暈眩 Mouth Throat 口腔喉咙 Globus hysteutus 封喉, Spitting, pain 唾, 疼痛 Abdomen 腹部 Stomach cramps 胃抽筋, belching, diarrhoea 呕吐 (ANS) Abdominal 腹疼痛 and pelvic pain 盆腔疼痛, belching, vomiting 呕吐 diarrhoea, 腹泻

Somatic symptoms( 躯体症狀 ) in DSM IV & HAM-D Somatic symptoms & depression S.5 Symptoms 症狀 DSM IVHAM-DOthers Heart and Chest 心肺 Palpitation, 心悸 hyperventilation 过度换气 (ANS) pain, palpitation 心悸,dyspnoea 呼吸困难, suffocation 窒息, hyperventilation 过度换气 Genital 泌尿 Urinary frequency 频尿 (ANS) Gynecology 婦科 Menstrual disturbance 月经紊乱 Sex 性慾 Loss of libido 失去性慾 Limbs 四肢 Paranesthesia 麻脾, tremor 震颤 (ANS) Mild to severe pain 轻至严重痛楚 Skin 皮膚 Sweating 出汗, Flushing 潮红 (ANS) Coldness, rash 疹, Urticaria 荨麻疹 Ear 耳 Tinnitus 耳鸣, vertigo 眩晕 Proportion of somatic symptoms 軀體症狀攤佔比例 3/98/21

Significance of somatic symptoms 躯体症狀的重要性 Somatic symptoms & depression  Prevalent in depression 忧郁病中很普遍  Number of published articles found in PubMed: 文献里越来越多关于情绪障碍躯体化的文章 : Up to 2000: 1498 (2000 年以前 :1498) Up to 2007 Jan:2718 (2007 年一月以前 :2718)  Diagnosis Implications 对診斷影响 higher no. of somatic symptoms predict depression. 越多症状, 患忧郁的机会起大。 Medically unexplained symptoms associate more frequently with depression. 越多医学未能解释的症状, 患忧郁症的机会越大。 S.6

Significance of somatic symptoms 躯体症狀的重要性 Somatic symptoms & depression  Treatment implications-higher no of SS delays: 对治療的影响 : response, 越多症状, 越可能延誤, 对藥物物的反應 remission, 復原的時間 increases recurrence 增加復發的可能機會 S.7

Somatic symptoms & depression  70-75% (Gps` 家庭科医生 ) 60-65% (psychiatrist 精神專 科医生 ) (Partners in Research,SA,04 南非 Mitchell 们做的研究 )  45% to 95% (Gps`) 69% (psychiatrist) present only with somatic symptoms 純粹躯体症状 (Simon GE et al, N.Eng.J Med 1999;341: )  >65% depressed patients report somatic symptoms 忧郁病人有躯体症状 (Bair MJ et al, Arch Intern Med. 2003;163: Bair MJ et al, Psychosom Med. 2004; 66: ) Percentage of depressed patients presenting with predominantly physical symptoms 抑鬱病人有躯体问题的比率 S.8

Somatic symptoms & depression Analysis of total 437 patients 437 病者的分析 S.9 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Analysis of 429 patients presenting with somatic symptoms 429 位带躯体症状病者的分析 S.10 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Unexplained Somatic Symptoms & Mood Disorders 医学上末能解释的症状与情绪障碍  ~ 32% to 62% of such patients are depressive ~ 32% to 62% 病者有忧郁症  ~ 24% to 50% have anxiety disorders ~ 24% to 50% 病者有焦虑症 (Kroenke K et al Arch Fam Med 1994; )  More frequent association with anxiety disorders and depression MUS 跟焦虑和忧郁有密切出现的关系 (Katon W et al. Ann Intern Med 2001; ) Somatic symptoms & depression S.11

Somatic symptoms & depression Analysis of 91 patients with medically unexplained symptoms (MUS) 91 位带有医学上末能解释症状的患者分析 Mood dominant somatic symptoms (m++ss+) 大部分情绪障碍症状 小部分躯体症状 Somatic symptoms dominant, some mood symptoms (m+ss++) 大部分躯体症状 小部分情绪障碍症状 Somatic symptoms only (ss+++) 纯躯体症状 A B C (7.7%) (33%) (59%) S.12 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Analysis of 99 patients (91 patients with MUS & 8 patients with mood symptoms) 99 位病者（ 91 位未能解释 + 8 位情绪障碍）的分析 A (Total=15, 共 15 人 ) B (Total=30, 共 30 人 ) C (Total=54 共 54 人 ) m+++m++ss+m+ss++ss+++ Depressed Group(Total 53)- 忧郁组（共 53 人） -Depression, 忧郁 -Depression comorbid with anxiety, 忧郁 + 焦虑 -Low mood with MUS 情绪低落 + 未 能 解释症状 Anxiety 焦虑 (Total 13 共 13 人 ) 1039 Bipolar I & II 双相性情绪 (Total 25 共 25 人 ) 2310 Psychosis 重性精神病 (Total 4 共 4 人 ) 2110 ADHD 专功力不足，过度活跃症 (Total 3 共 3 人 ) 2100 Others 其他 (Total 1 共 1 人 ) 1000 S.13 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Diagnosis of “depressed group” of patients (53 patients) 53 位忧郁病者的分析 S.14 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Prevalence of somatic symptoms in 53 “depressed group of patients” (depression, depression comorbid with anxiety, low mood with MUS) S.15 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Conclusion I 小结 (I) 12.1% of 437 patients suffer from depression. 437 到诊病人中 12% 患有忧郁症 21% of 429 patients with somatic symptoms present with medically unexplained symptoms. 429 带有躯体各式各样的症状的病人中有 21% 人属于医学解释不了的例子 58.2% of patients presenting with medically unexplained symptoms suffer from depression. 当中有分 58.2% 患有忧郁症 All depressed patients have somatic symptoms. 所有忧郁的患者都有躯体的问题 S.16 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Treatment for the “depressed group” of patients (53 patients) 53 位抑郁病者的治疗  All patients were receiving antidepressant drugs when surveyed (with or without atypical antipsychotics) 所有患者在统计时正服用 SSRls  4 patients discontinued subsequently. 4 位停止疗程  49 patients remained on antidepressant treatment 49 人正继续服用 SSRls  Number of somatic symptoms per patient : between 1 to 9. 每一位患者平均拥用一至九种躯体症体 S.17 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Outcome of treatment in “depressed group”patients (53 patients) 治疗结果 S.18 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Outcome of treatment in “depressed group” patients (53 patients) 痊愈结果 Number of patients S.19 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Antidepressants are useful in the treatment of somatic symptoms associated with depression. 抗忧郁药可有效治疗忧郁引起的躯体症状 Antidepressants are useful in the treatment of somatic symptoms in the patients with medically unexplained symptoms(MUS). 对 MUS, 目前未能解释的躯体症状, 抗忧郁药可能有效 A systemic review of 96 randomized trials found antidepressants to be moderately effective. Odd Ratio comparing with placebo 3.4 (O’Malley, PG et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999;48: ). 奥马 (O‘Malley) 重复检视了 96 个随机对照试验发现抗忧郁药用于治疗 MUS 有中度效用。 Somatic symptoms & depression Conclusion II 结果二 S.20 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Review of records of patients for January 07 Somatic symptoms & depression Analysis of somatic symptoms in 53 patients with depression 53 位忧郁人位的躯体症状分析 A (Total=2, 共 2 人 ) B (Total=16, 共 16 人 ) C (Total=35, 共 35 人 ) Prevalence 現患率 m+++ & m++ss+ m+ss++ss+++ Sleep 睡眠 % pain 痛楚 % GI upset 肠胃 % Tiredness 疲累 % Dizziness 晕眩 % Blood Pressure 血压 ( 不稳定 ) 02819% Others 其它 Malaise 不适, hotness & chills 寒颤, numbness 麻木, palpitation 心悸, urgency, shortness of breath S.21 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Analysis of 41 depressed patients with pain 痛楚类别分折 (4l 人 ) A (Total=2, 共 2 人 ) B (Total=13, 共 13 人 ) C (Total=26, 共 26 人 ) Prevalence 現患率 m+++ & m++ss+ m+ss++ss+++ General 广泛 % Head 头部 19844% Chest 胸口 % Neck & Shoulder 颈及肩膊 04624% Limbs 四肢 02517% Back 背部 % Others 其它 pain of tongue,soles, joints, heaviness of lower limb 舌头, 脚板, 关节, 下身沉重 S.22 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Somatic symptoms & depression Analysis of 35 patients with GI upset 肠胃常见的问题 (35 人 ) A (Total=1, 共 1 人 ) B (Total=10, 共 10 人 ) C (Total=24, 共 24 人 ) Prevalence 現患率 m+++ & m++ss+ m+ss++ss+++ Pain 痛, 食欲不振 % IBS 肠胃焦虑 % OGD 胃镜 ( 阴性结果 ) 03831% Colonoscopy 大肠内窥 ( 阴性 结果 ) 00514% Gastrectomy 胃部切除 ( 莫须 有 ) % Tenesmus 裏急後重 % Abdominal mass 疑似肿瘤 % Others 其它 Swallowing difficulty, constipation 吞咽困难、大便秘结 S.23 Review of records of patients for January 07 复查 2007 年一月份病人的记录

Questions to be answered 有待回答的问题 1.Why & How are antidepressants effective in the treatment of somatic symptoms? 为何抗忧郁药物对躯体病微有疗效 2.Are all patients with medically unexplained symptoms psychiatric? 一部分患者的躯体症状， 我们目前不能解释，他 们是否都有精神上的问题呢？ Somatic symptoms & depression S.24

Questions to be answered 有待回答的问题 3.How does the mind generate symptoms of the body? 精神（尤其是情绪障碍）如何导致身体不适呢？ 4.Is the pathophysiology producing the psychiatric & medical somatic symptoms the same biological mechanism? 同是躯体不适，情绪障碍和肉体病症引起的不适 是不是一样？它们是否共用同一机制呢 ? Somatic symptoms & depression S.25

Are doctors feeling different parts of the same depressed elephant? 不同科目的医生可能正在摸着同一只大象不同的部位 ? Somatic symptoms & depression The body and the mind 精神与身体 S.26

Psychiatrists, researchers & GPs seeing different parts of a depressed elephant Non-psychiatric doctors in general practice & other specialities e.g. Dr. David Wong 家庭及其它非精神 科医生，例如王大 卫 A depressed elephant The Body 身体 : S.27 一只忧郁的大象

Psychiatrists 精神科医生 Psychiatrists: e.g. Prof. S W TANG 精神科医生 : e.g. 邓兆华教授 A depressed elephant S.28 一只忧郁的大象

Researchers 研究者 Researchers & Psychopharmacologists: e.g. Prof. Brian Leonard e.g. 自烂尼教授 A depressed elephant S.29 一只忧郁的大象

A depressed elephant Mind & Body is One 精神与身体是共为一体 S.30 一只忧郁的大象

Acknowledgment 鸣谢 I would like to thank Professor SW Tang & Professor Brian Leonard for their encouragement and inspiration to make this project possible. 香港大学的邓兆华教授及爱尔兰大学的自烂尼教 授启发了我对精神学的热情及兴趣。在此容许我 表达对他们永远的尊敬及谢意 S.31