Psychiatric symptoms and diagnosis

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1 Psychiatric symptoms and diagnosis
主講者: 傅綢妹副教授

2 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。

3 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)

4 Classification of Mental Illness精神疾病分類

5 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。

6 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

7 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
　　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。

8 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

9 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)

10 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

11 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

12 DSM-IV global Assessment of Functioning (GAF) Scale
Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. Code (Note: Use intermediate codes when appropriate, eg, 45, 68, 72) 100 │ 91 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. 90 ─ 61 ─ 60 51 Moderate symptoms (eg, flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (eg, few friends, conflicts with peers or coworkers) 50 ─ 11 10 1 Persistent danger of severely hurting self or others (eg. recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death Inadequate information

13 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

14 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

15 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。

16 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。

17 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

18 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).

19 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。

20 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)

21 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。

22 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

23 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。

24 【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﹞。

25 【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

26 【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。

27 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﹞

28 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

29 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。

30 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）。

31 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。

32 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
E.此症狀無法以傷慟反應做更佳解釋