- Slides: 63
Mood, Affect, Emotion • Mood - Subjective - Sustained - Pervasive • Affect - brief, expressed, psychophysiological state • Emotion - emotional state + expression + experience
기분장애의 분류(DSM-IV) • Depressive disorders - Major depressive disorders - Dysthymic disorders - Depressive disorders NOS • Bipolar disorders • Mood disorders due to a general medical condition • Substance-induced mood disorders • Mood disorders NOS
우울증의 분류 원 인 임상양상 Endogeneous Biological Melancholic Typical Agitated Psychotic Exogeneous Reactive Characterological Atypical Retarted Neurotic cf) Unipolar depression v. s. Bipolar depression
HPA axis 불균형 • Dexa suppression test(DST): + cf) false +인 경우 : Cushing synd’, 간/신장 질환, 당뇨병, 발열, 임신 급성 정신과적 입원 steroid/estrogen/phenytoin/p-b 복용 중 Schizophrenia, Anorexia nervosa/Bulimia nervosa, Dementia of Alzheimer’s type, Borderline PD, Alcoholism, OCD, OCPD, SAD, Mania
임상 양상 • Mood • Physical(motor): (neuro)vegetative symptoms • Cognitive
Mood change • • Depressed mood Irritable mood Persistent feeling of sadness Reduced capacity to experience pleasure; anhedonia
Physical change • 식욕, 체중, 수면의 변화 - 식욕 감소, 증가 - 체중 감소, 증가 - 수면 감소, 증가 : fragmented sleep, terminal insomnia • Psychomotor retardation/agitation - 피로감, 기력 없음
Cognitive change • Cognitive contents의 변화 - Beck의 cognitive triad - Hopelessness, Helplessness, Pessimism - Unreasonable/excessive guilty - Loss of self-esteem/self-confidence • Cognitive function의 변화 - Attention & concentration impairment - Memory impairment - Mental slowing
주요 우울 삽화 A. Five(or more) of the following symptoms have been present during the same 2 -week period and represent a change form previous functioning ; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood , irritable mood. (2) markedly diminished interest or pleasure (3) significant weight loss when not dieting or weight gain or decrease or increase in appetite (4) insomnia or hypersomnia (5) psychomotor agitation or retardation (6) fatigue or loss of energy (7) feelings of worthlessness or excessive or inappropriate guilt (8) diminished ability to think or concentrate, or indecisiveness (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation/attempt/or plan B. C. D. The symptoms are not due to the direct physiological effects of a substance (e. g. , a drug of abuse, a medication)or a general medical condition(e. g. , hypothyroidism). E. The symptoms are not better accounted for by bereavement, i. e. , after the loss of a loved one, the symptoms persist for longer than 2 months or are characterizd by marked functional impairment, morbid preoccupation with worthiessness, suicidal ideation, psychotic symptoms.
주요 우울 삽화의 specifier • • • Specify (for current or most recent episode): Severity / Psychotic / Remission Specifiers Chronic With Catatonic Features With Melancholic Features With Atypical Features With Postpartum onset Specify : Longitudinal Course Specifiers (With and Without Interepisode Recovery) • With Seasonal Pattern
Melancholic feature • Loss of pleasure in all, or almost all, activities • Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens) • Distinct quality of depressed mood • Depression regularly worse in the morning • Early morning awakening • Marked psychomotor retardation or agitation • Significant anorexia or weight loss • Excessive or inappropriate guilt
Atypical feature • Mood reactivity(I. e. , mood brightens in response to actual or potential positive events • Significant weight gain or increase in appetite • Hypersomnia • Leaden paralysis(I. e. , heavy, leaden feelings in arms or legs) • Long standing pattern of interpersonal rejection sensitivity(not limited to episodes of mood disturbance) resulting in significant social or occupational
일반의학적 상태에 의한 기분장애 A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following : (1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities. (2) elevated, expansive, or irritable mood B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
물질에 의한 기분장애 A. B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2) : (1) the symptoms in Criterion A developed during, or within a month or, Substance Intoxication or Withdrawal (2) medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Mood Disorder that is not substance induced might include the following : the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time(e. g. , about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use ; or there is other evidence that suggests the existence of an independent non-substance-induced Mood Disorder(e. g. , a history of recurrent Major Depressive Episodes. D. E. Note : This diagnosis should be made instead of a diagnosis of substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal
물질 유발에 의한 기분장애 Cardiovascular Drugs Hormones Alpha-methyldopa (+/-) Reserpine (++) Propranolol (+/-) Guanethidine Thiazide diuretics Digitalis Oral contraceptives (+/-) ACTH (corticotropin) and glucocorticoids (++) Anabolic sterods (+) Anticancer Agents Cycloserine Ethambutol Disulfiram Sulfonamides Baclofen Metoclopramide Anti-Inflammatory/ Anti-Infective Agents Nonsteroidal anti-inf ammatory agents Amphetamines (withdrawal) (++) L-dopa(+/-) Cimetidine Ranitidine Psychotropics Benzodiazepines Neuroleptics Others Cocaine (Withdrawal) (++)
일반 의학적 상태에 의한 기분장애 • 내분비 장애 - 갑상선 기능 항진증/저하증/thyrotoxicosis - DM - Cushing’s disease • 신경계 - MS - Parkinson’s disease - Huntington’s disease - Stroke - Brain tumor - Head trauma • Cancer • RA • IM
가성 치매와 치매 Pseudodementia Dementia Family aware of dysfunction Onset of symptoms Seek medical help Progression of symptoms History of psychiatric dysfunction Clinical feaures aware can be dated early rapid Common unaware hard to be exact Late Insidious Unusual Attention & concentration Response to questions Momory loss Often well preserved "Don't know" answers typical Memory gaps for specific periods Faulty Frequently Provide near miss answers loss of recent events more severe than remote events Marked variability Consistent poor Performance Clinical Course Performance on tasks of similar difficulty
가성 치매와 치매 Pseudodementia Dementia Complaints & Clinical Behaviors Patient's complaint Attitude Effort describe deficit in dtail complains little, try to Emphasize disabillty, Highight conceal deficit failures Shows delight in accomplishments Concern about deficit Social Skills Nocturnal accentuation of dysfunction Make little effort to perform even simple tasks very concerned Loss prominent and early on uncommon Struggle to Perform tasks. Rely on notes, calendars to keep up appear unconcerned Social Skills retained Common
Bipolar/Unipolar depression Hx of mania/hypomania Postpartum onset Onset of episode Psychomotor activity Sleep FHx of Bipolar FHx of Unipolar TCA Lithium Bipolar Dep Unipolar Dep Yes More common Often abrupt Retardated Hypersomnia Yes Induce hypomania/mania Ac’ antidepressant effect No Less common More insidious Agitated Insomnia +/Yes +/Ineffective
Mortality & Morbidity • 자살 • 물질 남용
약물 치료 synopsis • 작용 기전 - NE, SA, (DA)의 synaptic transmission 증가 • • • 반응률이 70%이상이다. TCA: imipramine / amitriptyline / clomipramine MAOi: moclobemide / clorgyline SSRI: fluoxetine / sertraline / paroxetine Atypical antidepressants - trazodone / nefazodone / venlafaxine / mirtazapine
• Anti-cholinergic - 말초: 구갈, 변비, blurred vision, 소변장애 - 중추: 1) general: convulsion 2) arousal 감소, confusion, delirium 3) 기억력 감소 4) 항 파킨슨 효과 Thalamus Hypothalamus Stiratal local circuit Hippocampus Cortex Cerebellum Amygdala Cranial N. nuclei
• 5 -HT 1 a stimulating - anti-depressive effect, - anti-panic effect, - anti-bulimic effect - anti-OC effect - anti-social phobic effect • 5 -HT 2 stimulating - agitation/anxiety/akathisia - insomnia - panic attack - sexual dysfunction • 5 -HT 3 stimulating - Nausea - Diarrhea - GI distress - Headache
TCA 적응증 • Depression : Endogeneous depression에 효과적 : Unipolar depression, Bipolar depression(manic switch 가능성) : Neurotic depression, 감정부전장애 : Depressive symptoms, anxiety & agitation of schizophrenia, schizoaffective disorder • • • Chronic pain, Psychosomatic disorder Enuresis ADHD OCD: clomipramine Panic disorder, agoraphobia, SAD, social phobia, PTSD : imipramine • Nightmare, narcolepsy, bulimia, withdrawal of cocaine
TCA의 부작용 • • NE reuptake 차단: psychomotor activation SA reuptake 차단: sedation Muscarinic receptor 차단: H 1 수용체 차단: alpha 1 차단: quinidine like effect 조증 유발 진정 및 항콜린 작용: 내성이 생긴다.
MAOi synopsis • Hypertensive crisis with tyramine-containing food - mocleobemide는 가능성이 적다. • Atypical depression에 효과적이다. • Rapid cycler에 효과적 • Bipolar depression시 manic switch 가능성이 가 장 적다.
Venlafaxine synopsis • 작용기전 - Serotonin Noradrenaline Reuptake Inhibitor(SNRI) • Severe depression with melancholic feature에도 효과적 • GI trouble이 많다. • 용량 의존적으로 고혈압의 위험성이 있다.
Mirtazpine synopsis • 작용 기전 - presynaptic alpha 2 blocker --> NE, SA release 촉진 - 5 -HT 2, 5 -HT 3 antagonist --> GI trouble, sexual dysfunction이 없다. - 5 -HT 1 a agonist --> 항 불안, 항 우울 • 부작용 - 이론적 장점과 달리, 구갈, 식욕증가, 어지럼증 등이 있다. - 성기능장애가 없다.
정신치료 synopsis • Mild - moderate major depressive disorder를 대상 • 지지 정신치료 • 역동적 정신치료
기타 정신사회적 치료 • 인지치료 • 대인관계치료 - 대인관계에 초점 - unresolved grief, role disputes, role transitions, social skills defcit • Self-efficacy
기분부전장애 주요 우울장애 2 years Depressed mood 2 additional symptoms More cognitive symptoms Mild onset may be followed after 2 years by major depression 2 weeks Depressed mood 4 additional symptoms More vegetative symptoms Onset may begin with more severe symptoms