全科医学中的心理健康病案研究 (五)——双相障碍

Leon Piterman，Fiona Judd，Grant Blashki(著)，杨 辉 (译)

1 病史

辛迪是病人威廉的女朋友。3个月前威廉曾前来看病，那次是为了治疗抑郁症，这次辛迪做了加急预约，再让你给威廉看病。辛迪非常担心威廉，他几乎不睡觉，而且精神头儿还特别好。他不停地说话，而且越说越多。

威廉宣布他发明了几种新方法，用细丝和计算机无线网络技术，让房间的每个地方都能充满电。他认为这是一个革命性的新发明，能让建筑业节省上亿元。他为了推销自己的创新计划，把自己的积蓄全部投入进去。辛迪告诉你，当威廉遇到别人的质疑时，总是争得面红耳赤，总是咄咄逼人的样子。

2 其他病史

威廉，22岁，电工。3个月前看病的主诉是情绪低落，睡眠障碍，缺乏兴趣和动机，注意力不集中，记忆力减退。当时的诊断是抑郁症，并开始使用抗抑郁药进行治疗。经过6周，他的情绪逐渐好转，1个月前重新开始工作。在此之前他没有抑郁病史，不过他的外祖父有“情绪波动”的病史。

3 身体检查

这次威廉自己是不愿意来找你看病的，而是他女朋友辛迪坚持劝说他来诊所的。3个月前威廉找你看病的时候，给他做了全面的躯体检查。威廉不愿意再重复这些检查，不过他还能让你测量体温和血压，结果都在正常范围内。给他做心理状态检查，他看上去跟上次明显不同。他具有某种攻击性，不愿意回答你的提问，而是喋喋不休地谈他那些对发展建筑行业的想法。他情绪高昂，跟你谈话的时候还经常讲一些笑话。他坚持认为自己没有问题，说自己现在“回到了最好的状态”。

4 提问

4.1 提问1:你的初步诊断是什么?

4.2 提问2:3个月前你能诊断他是双相障碍吗?

4.3 提问3:你的治疗重点是什么?

4.4 提问4:制定什么样的长期管理计划，作为全科医生你应该做什么?

5 解答

5.1 对提问1的解答:初步诊断

5.1.1 初步诊断为双相障碍－躁狂阶段。他看上去焦躁不安，失去理性，而且有夸大妄想。这些情况在开始使用抗抑郁药后突然发生。

双相障碍的特点是，周期性出现高昂情绪和抑郁情绪，表现形式不尽相同。开始的时候首先出现的可能是抑郁 (正如本案例的病人)，或者夹杂少许的躁狂。针对某些双相障碍的病人，如果用抗抑郁药治疗抑郁，则可能是引发躁狂的危险因素。高昂情绪的发生严重程度各不相同，轻度的病情称为“轻度躁狂”，严重的病情 (常伴有妄想)称为“躁狂”。躁狂的共同特征包括情绪高昂和 (或)情绪焦躁、过度兴奋、睡眠的需要减少、非特异性的冒险行为、社会活动增加、花钱数量增多、想法浮夸 (有的时候偏执)以及妄想［1］。

5.1.2 急性精神分裂症样精神病。这个诊断的可能性很小，因为病人以前做出过抑郁症的诊断、病人现在的问题在使用抗抑郁药后马上出现、病人的高昂情绪以及与病人情绪一致的夸大妄想。如果要做出精神分裂症样精神病的诊断，那么病人应该存在各种形式的思维方式混乱、与情绪不一致的妄想以及知觉障碍 (通常表现为幻听)。

5.2 对提问2的解答:3个月前是否能诊断为双相障碍 对双相障碍的诊断一定要谨慎，因为这将明显地影响到治疗方案和预后。而且也不应该误诊，否则会导致错误的治疗。如果病人第一次出现抑郁的症状，并做出了抑郁症的诊断，你应该认真地检查病人以前是否存在高昂情绪的情况，即便是高昂情绪很轻微或只存在几天，也要注意到。如果病人以前的确存在过情绪高昂的情况，那么这就提示病人实际表现出来的是双相障碍的早期症状。其次，双相障碍 (而不是抑郁症)的家族史也提示你有可能是双相障碍的早期发作。如果双相障碍的可能性比较大，那么你就要严密地监测针对抑郁症的治疗过程，因为抗抑郁药可能引发双相障碍的高昂情绪。不过，如果没有明确地诊断为双相障碍，就不应该实行针对双相障碍的治疗措施。

5.3 对提问3的解答:治疗重点 鉴于威廉的高昂情绪、妄想信念、缺乏自知力，你应该判断威廉的情况是危险的。他很有可能做出愚蠢的决定，结果造成资金上、人际关系上和就业上的严重问题。躁狂症的病人往往过度饮酒，这会进一步加重危险行为，做出一些错误的决定。

考虑到威廉存在的这些危险因素以及症状的严重程度，而且威廉认为自己没有什么不好，认为自己不需要治疗，因此威廉需要住院治疗。

首先要做的是停用抗抑郁药，换用另外的药 (如苯二氮或抗精神病药)让威廉平静或镇静下来。在正式地治疗他的双相障碍之前，有一个过渡的治疗过程，用于治疗病理性高昂情绪的情绪稳定剂，是需要一定时间才能发挥效应的。

5.4 对提问4的回答:长期的管理计划 一旦明确诊断双相障碍，威廉就需要药物 (情绪稳定剂)来预防抑郁和 (或)躁狂的进一步发展。病人服药的依从性可能比较差，因为很多轻度躁狂的病人认为他们自己感觉特别好，特别有成效。另外一个重要的方面，是对威廉、他的女朋友辛迪以及他的家人提供相应的教育和支持［2－3］。一般来说，双相障碍的病人需要全科医生管理，并需要精神病学专家的治疗。如果心理健康团队能够合作起来给病人提供综合服务，会达到很好的治疗效果。这些综合服务包括［4］:

5.4.1 心理教育 (1)明确病情反复的危险因素，主要包括是睡眠剥夺 (如白班夜班轮换，国际旅行)、饮酒、使用毒品、服药依从性差等。你应该跟病人及其家庭合作，避免或尽量减少这些危险因素。(2)明确病情反复的早期征兆，鼓励使用“情绪日记”的方法，并制定明确的早期预防计划，监测抑郁或轻度躁狂的进一步发展。

5.4.2 严密监测药物治疗 (1)如果使用锂剂、2－丙基戊酸钠、卡马西平等药，应该对血清中的药物水平进行监测，并保证血清药物水平在正常范围内。(2)对常见的药物副作用进行监测，如锂剂带来的甲状腺功能和肠道功能的新陈代谢副作用，以及奥氮平等药的新陈代谢副作用。

5.4.3 定期对病人的情绪状况和一般情况进行复诊。

5.4.4 对照顾者和家庭提供支持。

译者注:妄想:一种无法说服并且坚信不移的错误信念。病人的社会、文化和宗教背景无法解释这种信念。

情绪稳定剂:一种有效治疗急性躁狂和 (或)双相障碍抑郁症的药物，可预防躁狂和 (或)双相障碍抑郁症的发作。常见的情绪稳定剂包括碳酸锂、丙戊酸钠、卡巴咪嗪、奥氮平。

1 Castle DJ，Berk M，Hocking BM.Bipolar disorder.New understandings，emerging treatments［Z］.2010，193:S1－S30.

2 Gleason A，Castle DJ，Piterman L，et al.A guide for the management of bipolar disorder in general practice 2011，version1 ［Z］.Supported by an educational grant from AstraZeneca.

3 Therapeutic Guidelines Psychotropics［Z］.2008.

4 Blashki G，Piterman L，Judd F.General Practice Psychiatry［M］.North Ryde，NSW，McGraw－Hill Australia，2006.

(本文编辑:闫行敏)

【Introduction of the Column】 The Journal presents the Column of Case Studies of Mental Health in General Practice，with academic support from Australian experts in general practice，psychology and psychiatry from Monash University and the U-niversity of Melbourne.The Column's purpose is to respond to the increasing needs of mental health services in China.Through study and analysis of mental health cases，we hope to improve understanding of mental illnesses in Chinese primary health settings，and to build capacity of community health professional in managing of mental illnesses in general practice.Patient－centred and whole－person approach in general practice is the best way to maintain and improve the physical and mental health of residents.Our hope is that these case studies will lead new wave of general practice and mental health development both in practice and academic research.A number of Australian experts from the disciplines of general practice，mental health and psychiatry will contribute to the Column.You will find Professor Blashki，Professor Judd and Professor Piterman are authors of General Practice Psychiatry.The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinese mental health in primary health care will step up to new stage under this international cooperation.

Introduction of the case study:The case study is subsequent story of case study four(depression)that was published in previous issue.

Affiliation:Monash University， Victoria 3806， Australia(Leon Piterman);Melbourne University(Fiona Judd，Grant Blashki)

1 History

Cindy，the partner of your patient William，who consulted you three months ago for treatment of depression makes an urgent appointment to see you.She is very concerned about William.He seems energised despite very little sleep.He is talking incessantly.

He claims that he discovered new ways of electrically wiring houses using micro filaments and computer wireless techniques which will revolutionise the construction industry and save billions of dollars.He is preparing a marketing strategy and is investing all of his savings.Cindy tells you that he is argumentative and aggressive when challenged.

2 Other History

William，who is a 22－year－old electrician，was seen three months ago complaining of low mood，sleep disturbance，loss of interest and motivation，poor concentration and memory disturbance.A diagnosis of depressive disorder was made and he started treatment with an anti－depressant.His mood gradually improved over a period of 6 weeks and he returned to work a month ago.He had no past history of depression，but had reported his maternal grandfather had a history of'mood swings'.

3 Examination

Although William is reluctant to see you，Cindy manages to convince him to attend the surgery.When you saw him3 months ago you conducted a thorough physical examination.William is reluctant to repeat this，but allows you to check his temperature and BP which are within the normal range.On mental state examination，he looks quite different from your last meeting with him.He is somewhat aggressive，not wanting to answer your questions，talking rapidly about his ideas for changing the construction industry.His mood is elevated，and he makes several jokes whilst talking with you.He insists there is nothing wrong with him，stating he's feeling'back to my best'.

4 Question

4.1 Question 1:What are your probability diagnoses?

4.2 Question 2:Could you have made a diagnosis of bipolar disorder when he presented 3 months ago?

4.3 Question 3:What are the management priorities?

4.4 Question 4:What is his long term management and what is your role as a GPin long term management?

5 Answer

5.1 Answer 1:Probability diagnoses

5.1.1 Bipolar disorder－manic phase He seems irritable，irrational，overactive，and has grandiose delusions.This has come on suddenly following the commencement of an antidepressant.

Bipolar disorder，which is characterised by recurrent episodes of elevated and/or depressed mood，may present in various ways.The first episode of this disorder can be one of depression，as has occurred here，or less frequently of mania.Treating an episode of depression in someone with bipolar disorder，with an antidepressant is a known risk factor for triggering a manic episode.Episodes of elevated mood vary in severity－milder episodes are labelled hypomania and more severe episodes，often accompanied by delusions，are labelled as manic episodes.Common features of a manic episode are elevated and/or irritable mood，overactivity，reduced need for sleep，uncharacteristic risk taking behaviour，increased social activity，increased spending of money and grandiose(or sometimes paranoid)ideas and/or delusions［1］.

5.1.2 Acute schizophreniform psychosis This diagnosis is less likely given his past diagnosis of depression，the apparent precipitation of the episode by antidepressants，the elevated mood and the mood－congruent(grandiose)delusions.By contrast if the diagnosis was a Schizophreniform psychosis he would probably present with disorder of form of thought，mood － incronguent delusions，and probably perceptual disturbance，most usually auditory hallucinations.

5.2 Answer2 The diagnosis of bipolar disorder must be made with caution，as it has significant implications for treatment and prognosis.However，it is also important not to miss the diagnosis，and so provide inappropriate treatment.When a patient presents with depressive symptoms for the first time，and a diagnosis of depressive disorder is made，you should always check carefully for a past history of any episodes of elevated mood－even if only mild and of only several days duration.A positive history should alert you to the possibility that this could be the first presentation of bipolar disorder.Second，a family history of bipolar disorder，rather than of depression，should also raise the possibility that this is a first presentation of bipolar disorder.If the possibility is raised，then treatment of the depressive disorder must be carefully monitored，as antidepressants may lead to an episode of elevated mood if the diagnosis is confirmed.However，note that treatment should not be initiated for bipolar disorder unless this diagnosis has been clearly made.

5.3 Answer3 As a result of his elevated mood，delusional beliefs and lack of insight，William is at risk.He is likely to make foolish decisions，which will result in major financial，relationship，and employment problems.Excessive alcohol use commonly accompanies mania and exacerbates risky behaviour and poor decision making.

Given these risks，the severity of his symptoms，and his belief that there is nothing wrong and he does not need treatment，William will require treatment in hospital.

The first step is to stop his antidepressant medication，and to prescribe medication to calm or sedate William(e.g benzodiazepine or antipsychotic medication).This is an interim procedure whilst the definitive treatment for his bipolar disorder，a mood stabiliser which will act specifically on the pathologically elevated mood has time to act.

5.4 Answer4:Long term management Having an established diagnosis of bipolar disorder，William will need to take medication(mood stabiliser)to prevent further episodes of either depression and/or mania.Compliance with this treatment may be difficult as many people say they feel best and most productive when they are mildly hypomanic.Education and support of William and Cindy and William's family will be important［2－3］.Generally，individuals with bipolar disorder require management by both their GPand a treating psychiatrist and/or mental health care team in a shared care arrangement to optimise treatment outcomes.This includes［4］:

5.4.1 Psychoeducation (1)Identifying risk factors for relapse－ common issues are sleep deprivation(e.g.shift work，international flight)，alcohol and/or recreational drug use，and non －compliance with treatment，and working with the patient and family to avoid/minimise these.(2)Identifying early warning signs for relapse，and encouraging use of a mood diary with a clear plan for early intervention if symptoms of depression or hypomania begin to develop.

5.4.2 Carefully monitor drug treatment (1)Serum drug levels should be monitored and maintained within the therapeutic range if prescribed lithium，Valproate or carbamazepine.(2)Monitor for common side－effects e.g.metabolic complications thyroid and renal function on lithium，or metabolic syndrome with Olanzapine and related drugs.

5.4.3 Regular review to monitor mood and general wellbeing.

5.4.4 Support for the carer or family.

Notes:Delusions:are fixed false beliefs，which cannot be reasoned away，and which are not explained by the person's social，cultural or religious background.

Mood stabiliser:a drug which is effective for the acute treatment of mania and/or bipolar depression，and which prevents episodes of mania and/or bipolar depression.The commonly used mood stabilisers are lithium carbonate，sodium Valproate， carbamazepine and olanzapine.

1 Castle DJ，Berk M，Hocking BM.Bipolar disorder.New understandings，emerging treatments［Z］.2010，193:S1－S30.

2 Gleason A，Castle DJ，Piterman L，et al.A guide for the management of bipolar disorder in general practice 2011，version1［Z］.Supported by an educational grant from AstraZeneca.

3 Therapeutic Guidelines Psychotropics［Z］.2008.

4 Blashki G，Piterman L，Judd F.General Practice Psychiatry［M］.North Ryde，NSW，McGraw－Hill Australia，2006.