辽宁省居民情感、焦虑和酒精使用障碍共病影响因素分析

目的分析辽宁省居民情感障碍、焦虑障碍及酒精使用障碍的共病率及主要危险因素。方法辽宁省居民精神疾病调查以DSM-III-R为诊断标准,共诊断1 214例精神障碍患者,以单纯情感障碍、单纯焦虑障碍和单纯酒精使用障碍患者为对照,采用Logistic回归模型分析情感与焦虑共病、焦虑与情感共病、酒精与情感或焦虑共病的各主要危险因素的OR值及95%CI。结果情感与焦虑障碍是最常见的共病,离异者情感共病焦虑、焦虑共病情感、酒精共病情感或焦虑的危险度增加3～5倍,女性酒精使用障碍共病情感或焦虑障碍的危险性明显高于男性(OR=5.28,95%CI=1.84～15.15),农村居民焦虑共病情感障碍的危险性明显低于城市居民(OR=0.57,95%CI=0.36～0.92)。结论辽宁省居民精神障碍患者中情感障碍、焦虑障碍和酒精使用障碍共病普遍存在,精神疾病共病的预防、诊断和治疗水平亟待提高。     

Disordered (pathologic or problem) gambling and axis I psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

The authors' objective in this study was to examine the role of disordered gambling as a risk factor for the subsequent occurrence of specific Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I psychiatric disorders after adjusting for medical conditions, health-related quality of life, and stressful life events. Community-dwelling respondents from nationally representative US samples (n = 33,231) were interviewed in 2000-2001 and 2004-2005. Past-year disordered gambling at baseline was associated with the subsequent occurrence of any Axis I psychiatric disorder, any mood disorder, bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, any substance use disorder, alcohol use disorders, and alcohol dependence disorder after adjustment for sociodemographic variables. After simultaneous adjustment for medical conditions, health-related quality of life, and recent stressful life events, disordered gambling remained significantly related to any mood disorder, generalized anxiety disorder, posttraumatic stress disorder, alcohol use disorders, and alcohol dependence. The clinical implications of these findings are that treatment providers need to screen gambling patients for mood, anxiety, and substance use problems and monitor the possible development of later comorbid conditions.     

Intention to change drinking behaviour in general practice patients with problematic drinking and comorbid depression or anxiety

AIMS: This paper examines the interaction of intention to change drinking behaviour with comorbid depression and anxiety in pro-actively recruited individuals with a range of drinking problems. METHODS: Cross-sectional data of 408 general practice (GP) patients aged 18-64 years, who meet the diagnostic criteria of alcohol dependence or abuse according to DSM-IV, criteria of at-risk drinking or binge drinking, were drawn from a brief intervention study. Of the sample, 89 participants were diagnosed with comorbid anxiety and/or depressive disorders. The Transtheoretical Model (TTM) of behaviour change constructs: stages and processes of change, self-efficacy, and decisional balance were assessed in relation to presence and absence of the respective psychiatric disorders. RESULTS: Analysis including all categories of problematic drinking revealed comorbid anxiety and/or depression to be significantly related to later stages of change. Within subgroups, this was only true for alcohol abuse, not for dependence, at-risk or binge drinking. In addition, comorbidity was related to higher use of processes of change and more pros and cons of drinking, when compared to non-comorbid participants. Comorbid individuals showed higher temptation to drink and lower self-efficacy to abstain from drinking. Separate analyses of readiness to change drinking between the categories anxiety/no comorbidity and depression/no comorbidity both obtained significance, while for anxiety disorders, this was more profound. A multinomial logistic regression analysis revealed that adverse consequences better predicted readiness to change when compared to comorbidity. DISCUSSION: Individuals with problematic drinking and comorbid anxiety or depression may be well accessible for pro-active intervention to reduce drinking. Strategies should focus on the enhancement of coping skills to control temptation and self-efficacy.     

Do comorbid anxiety disorders in alcohol-dependent patients need specific treatment to prevent relapse?

AIMS: It has been repeatedly stated that comorbid anxiety disorders predict poor outcome of alcoholism treatment. This statement is based on the high comorbidity of alcohol use disorders and anxiety disorders, and the negative influence of other comorbid psychiatric disorders on the outcome of treatment of alcohol dependence. This review focuses on outcome results of alcohol-dependent patients with a comorbid anxiety disorder. We try to answer the question whether anxiety disorders should be treated in alcohol-dependent patients to improve outcome results in alcoholism treatment. METHODS: In a search through Pubmed, Psychinfo and Cochrane, we found only 12 articles on this subject. We distinguished three perspectives: (1) studies on the predictive value of comorbid anxiety disorders on the outcome of alcoholism treatment; (2) studies on the improvement of abstinence rates and anxiety symptoms by offering pharmacological treatment for comorbid anxiety disorders; (3) studies on psychotherapeutic treatment. RESULTS: Most studies showed methodological limitations. Only one high quality study showed that comorbid anxiety disorders predict poor outcome of the treatment of alcohol dependence. CONCLUSIONS: We cannot conclude that comorbid anxiety disorders in alcohol-dependent patients need a specific treatment to prevent relapse. However, medication and perhaps cognitive behavioural therapy can be useful in alcohol-dependent patients with a comorbid anxiety disorder to reduce anxiety symptoms. Methodological implications for further research are discussed.     

The course of anxiety, depression and drinking behaviours after completed detoxification in alcoholics with and without comorbid anxiety and depressive disorders

We studied the associations between comorbid anxiety and depressive disorders in treated alcoholics, the course of current anxiety and depression during the early and late post-detoxification periods, and drinking behaviours after discharge. Lifetime psychiatric comorbidity was assessed in 100 alcoholics using the Composite International Diagnostic Interview (CIDI). Three subgroups defined as group DA (comorbid depressive and anxiety disorders, n = 15), group A (anxiety disorder only, n = 23), and group NO (no comorbid disorder, n = 62) were studied. Beginning 21 +/- 13 days after cessation of drinking, state anxiety (STAI-X1), trait anxiety (STAI-X2) and depression (BDI) were assessed once per week (t1 to t4) and once more 6 months after discharge (t5, n = 68). The severity of psychopathology decreased during the first 4 weeks after detoxification in all subgroups. However, trait anxiety remained at higher levels in both the comorbid subgroups from t1 to t4. In the follow-up sample, 60.5% of the non-comorbid subjects remained abstinent, but only 26.7% of all comorbid patients and only 12.5% of those with comorbid depressive disorder plus severe current trait anxiety or depression at t1. Independent of their comorbidity status, relapsers at t5 had already reported more trait anxiety than abstainers at t1. We conclude that severe trait anxiety persisting after 3 weeks of abstinence, comorbid depressive and/or anxiety disorders, and combinations of these with moderate or severe current anxiety and depressive states represent the greatest risks of relapse and therefore may indicate a treatment need.     

Comorbidity between social phobia and premature ejaculation: study on 242 males affected by sexual disorders

Several studies have reported high comorbidity between psychiatric and sexual disorders, particularly between anxiety and mood disorders and sexual dysfunction. The goal of the present study is to examine the comorbidity between premature ejaculation and Axis I psychiatric disorders. Of 242 males referred to an outpatient clinic of sexology between November 2000 and July 2003, 52 were diagnosed with premature ejaculation (PE). These patients were also administered the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1995) for the evaluation of Axis I psychiatric disorders and a modified SCID based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) criteria for the evaluation of sexual disorders. We also determined the age of onset of the disorders. We found that 21.5% of the overall clinical population was affected by PE, and 64.4% of PE patients were affected by at least one Axis I psychiatric disorder. PE was highly associated (p=0.015) with social phobia (SP), with an odds ratio of 2.55. The debut of SP preceded the onset of PE. Social phobia may represent risk factor for the development of PE, and adrenergic hyperactivity may represent a pathophysiology common to both disorders.     

Eating disorders in a national sample of hospitalized female and male veterans: detection rates and psychiatric comorbidity

OBJECTIVE: Using a national sample of hospitalized female and male veterans, this study examined the point prevalence of detected cases of eating disorders and explored psychiatric comorbidity in cases with an eating disorder. METHODS: Prevalence rates were determined by reviewing the discharge diagnoses of 24,041 women and 466,590 men hospitalized in Veteran Affairs medical centers during fiscal year 1996. Comorbidity was examined by individually matching eating disorder cases (N = 161) with patients without an eating disorder, using sex, race, and age as matching variables. RESULTS: On the basis of routine clinical diagnosis, 0.30% of the female veterans and 0.02% of the male veterans were diagnosed with a current ICD-9-CM eating disorder. Women with eating disorders had significantly elevated rates of comorbid substance, mood, anxiety (particularly posttraumatic stress disorder [PTSD]), adjustment, and personality (particularly borderline personality disorder [BPD]) disorders. Men with eating disorders were found to have high rates of comorbid organic mental, schizophrenic/psychotic, substance, and mood disorder. CONCLUSIONS: Our study illustrates the value of administrative data sets for the investigation of uncommon diseases.     

Comorbid phobic disorders do not influence outcome of alcohol dependence treatment. Results of a naturalistic follow-up study

AIMS: Despite claims that comorbid anxiety disorders tend to lead to a poor outcome in the treatment of alcohol dependence, the few studies on this topic show conflicting results. OBJECTIVE: To test whether the outcome of treatment-seeking alcohol-dependent patients with a comorbid phobic disorder is worse than that of similar patients without a comorbid phobic disorder. METHODS: The probabilities of starting to drink again and of relapsing into regular heavy drinking in (i) a group of 81 alcohol-dependent patients with comorbid social phobia or agoraphobia were compared with those in (ii) a group of 88 alcohol-dependent patients without anxiety disorders in a naturalistic follow-up using Cox regression analysis. RESULTS: Adjusted for initial group differences, the hazard ratio for the association of phobic disorders with resumption of drinking was 1.05 (95% CI, 0.85-1.30, P = 0.66) and the adjusted hazard ratio for the association of phobic disorders with a relapse into regular heavy drinking was 1.02 (95% CI, 0.78-1.33, P = 0.89). CONCLUSION: The findings of this study do not confirm the idea that alcohol-dependent patients who have undergone alcohol-dependence treatment are at greater risk of a relapse if they have a comorbid anxiety disorder. No differences were found in abstinence duration or time to relapse into regular heavy drinking between patients with and without comorbid phobic disorders.     

儿童心理障碍共病的临床研究与实践

共病在精神/心理障碍中很常见,共病的研究包括流行病学特点、疾病之间的横向关系、纵向发展关系、共同的病因、病理机制、产生的影响和治疗。共病中的每一种疾病都改变了患者的整体临床表现和治疗反应,而且共病对个体功能的损害更大。本文介绍了几种常见儿童期精神障碍共病的流行病学特点,如焦虑障碍与抑郁障碍的共病,注意缺陷多障碍的共病,孤独症的共病、Tourette 综合征的共病等。共病之间结构性和发展性的相关研究,可从早发性儿童精神障碍中寻找,预测以后共患的障碍的信息和发展路径。在临床实践中,准确地诊断共病以及共病之间的关系,影响着是否能准确地制订治疗方案、采取预防性干预措施以及预测未来发展。最后,作者就根据共病的诊断制定全程治疗方案提出了几点建议。     

Study of dopamine receptors genes polymorphisms in bipolar patients with comorbid alcohol abuse

Alcoholism is present in approximately 40-60% of bipolar patients. This comorbidity between bipolar disorder and alcoholism is high and may result from existence of common genetic factors for the two disorders. In both disorders, dysregulation of the dopaminergic neurotransmission had been implicated. Association analyses revealed several candidate genes acting in the dopaminergic pathway and polymorphisms in those genes that might be associated with both disorders. AIM: The aim of this study was to analyse possible relationship between polymorphisms in the dopaminergic pathway genes (one SNP for each dopamine receptor gene 1-4) and alcohol abuse comorbidity in bipolar patients. METHODS: We analysed 317 patients with bipolar disorder. In this group, 42 patients were diagnosed with alcohol abuse. The diagnosis was made for each patient by at least two psychiatrists, using structured clinical interviews for DSM-IV Axis I disorders (SCID). The control group consisted of 350 subjects. We performed RFLP analysis of polymorphisms in four genes: DRD1, DRD2, DRD3, and DRD4. RESULTS: We have not found association of any of the analysed polymorphisms in the dopamine genes in the group of bipolar patients with comorbid alcohol abuse as compared to the control group. In the male group of bipolar patients with comorbid alcohol abuse, we also have not observed any significant differences between the patients and the control subjects. CONCLUSION: Our findings suggest that the analysed polymorphisms of the dopamine genes polymorphisms may not be involved in the shared genetic vulnerability to both, bipolar disorder, and alcohol abuse.     

Symptom heterogeneity in comorbid alcohol disorder

The heterogeneity of signs and symptoms of alcohol disorder was examined in a community sample of 1,955 persons with either alcohol disorder alone or alcohol disorder plus one of four categories of major mental disorder (antisocial personality disorder, schizophrenia, affective disorder, anxiety disorder). When all diagnostic categories were combined, persons with comorbid mental and alcohol disorders showed evidence of more severe alcohol-related symptoms than did persons with alcohol disorder alone. Distinct symptom patterns distinguished the four diagnostic groups, reflecting heterogeneity in the manifestation of comorbid alcohol disorder. Most notably, comorbid antisocial personality disorder and schizophrenia were associated with higher levels of alcohol consumption and more severe social consequences of alcohol use. These findings substantiate the need for development of specialized dual diagnosis programs and suggest that additional specialization may be required to address diagnostic group differences in the characteristics of comorbid alcohol disorder.     

Psychiatric comorbidity of eating disorders in men: a national study of hospitalized veterans

OBJECTIVE: This study examined eating disorders and their psychiatric comorbidity in a national sample of hospitalized male veterans. METHOD: Review of discharge summaries for 466,590 male patients from Veterans Affairs medical centers for fiscal year 1996 resulted in the identification of 98 men with a current ICD-9-CM diagnosis of an eating disorder. For the comorbidity analyses, eating disorder cases were matched with controls drawn randomly from the pool of male patients without an eating disorder, using age and race as matching variables. RESULTS: There was a high rate of comorbid substance use and mood disorder for men with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Men with AN were also at high risk for comorbid schizophrenia/psychotic disorder, men with BN were at risk for comorbid personality disorder, and men with EDNOS were at special risk for comorbid organic mental disorder and schizophrenia/psychotic disorder. DISCUSSION: For each eating disorder, there was a distinct pattern of psychiatric comorbidity that deserves further study.     

Relationships between features associated with vomiting in purging-type eating disorders

OBJECTIVE: Vomiting is a pernicious symptom of eating disorders. We explored the relation between the symptom of vomiting and features of eating disorder course and severity, personality traits, and Axis I and II comorbidity in individuals with purging-type eating disorders. METHOD: The sample included participants from the multisite, international Price Foundation Genetic Studies, who had an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified) and had data available for the frequency of purging behaviors (n = 1,048). Axis I disorders, personality disorders, trait anxiety, perfectionism, and temperament and character dimensions were included as possible correlates. RESULTS: The presence of vomiting was associated with less regular laxative use, lower self-directedness, organization, personal standards, and higher novelty seeking. CONCLUSION: Vomiting remains a prevalent and potentially destructive symptom of eating disorders, with significant dental and medical morbidity. Our findings suggest that certain clinical and personality variables distinguish individuals with purging-type eating disorders who vomit from those who do not, although there were no marked differences in Axis I or II comorbidity. Specifically targeting treatment to decrease duration of exposure to this dangerous symptom continues to be an important clinical objective.     

The Association of Sexual Dysfunction and Substance Use Among a Community Epidemiological Sample

This study examines the prevalence of DSM-III sexual dysfunctions and their association with comorbid drug and alcohol use in a community epidemiologic sample. The data for these analyses are based on the Epidemiological Catchment Area Project, a multistage probability study of the incidence and prevalence of psychiatric disorders in the general population conducted in 1981-83. Only the sample of 3,004 adult community residents in the St. Louis area was queried on DSM-III sexual dysfunctions of inhibited orgasm, functional dyspareunia (painful sex), inhibited sexual excitement (i.e., lack of erection/arousal), and inhibited sexual desire. There was a prevalence rate of 11% for inhibited orgasm, 13% for painful sex, 5% for inhibited sexual excitement, 7% for inhibited sexual desire, and 26% for any of these sexual dysfunctions (14% for men and 33% for women). The prevalence of qualifying lifetime substance use among the population was 37%, with males meeting more drug and alcohol use criteria than females. After controlling for demographics, health status variables, and psychiatric comorbidity (depression disorder, generalized anxiety disorder, antisocial personality disorder, and residual disorders), inhibited orgasm was associated with marijuana and alcohol use. Painful sex was associated with illicit drug use and marijuana use. Inhibited sexual excitement was more likely among illicit drug users. Inhibited sexual desire was not associated with drug or alcohol use.     

Childhood sexual,physical, and psychological abuse and their relationship to comorbid psychopathology in bulimia nervosa

We examined the relationship between childhood sexual, physical, psychological, and “multiple” abuse (i.e., abuse in more than one form) and comorbid Axis I and personality psychopathology among women with a lifetime history of bulimia nervosa (BN group; n = 80) and a control group of noneating-disordered women (n = 40). Subjects were recruited primarily by newspaper advertisement. They participated in structured clinical interviews for diagnosis of Axis I and personality pathology, and they completed child abuse questionnaires in the interview setting. At odds with prediction, child abuse in various forms was not associated with the presence of lifetime comorbid Axis I disorders in general (i.e., 1 or more) or disorder classes in particular (mood, alcohol/substance use, anxiety) among BN subjects, although sexual, psychological, and multiple abuse were associated with the diagnosis of a higher total number of Axis I conditions. A history of psychological and multiple abuse (but not physical or sexual abuse alone) among BN subjects was strongly associated with the presence of personality disorder diagnoses, especially those in the “anxious-fearful” cluster (Cluster C). Finally, we found that when a personality disorder was present in addition to the Axis I conditions in question, significant relationships emerged between abuse and Axis I pathology, particularly for psychological and multiple abuse. In general, control group findings were in accord with BN group findings, indicating that our findings were not specific to eating-disordered women. Our results suggest that childhood abuse, particularly psychological abuse and abuse in multiple forms, increase the likelihood of lifetime comorbid Axis I disorders and personality pathology among bulimic patients. Eating-disordered women with a history of child abuse may thus represent a subgroup of patients requiring especially intensive intervention. © 1994 by John Wiley & Sons, Inc.     

Recurrent detoxification may elevate alcohol craving as measured by the Obsessive Compulsive Drinking scale.

Research has demonstrated a relationship between the number of previous alcohol detoxifications and increased severity of the alcohol withdrawal syndrome (AWS) that is hypothesized to be similar to an electrophysiologic "kindling process." Application of a "kindling" model to AWS suggests that neuroadaptation of the central nervous system to repeated detoxifications may also cause neurobehavioral alterations that may affect "craving." This study examined craving as assessed by the Obsessive Compulsive Drinking Scale (OCDS) in 67 adult outpatients meeting DSM-IV criteria (American Psychiatric Association, 1994) for alcohol dependence and AWS having either < 2 and > or = 2 previous detoxifications. Results of ANCOVA revealed that patients with > or = 2 previous detoxifications had higher scores on a scale that measures obsessive thoughts about alcohol, drinking urges and behaviors, and a composite of these scores after controlling for alcohol dependence severity, depressive symptoms and number of drinks 2 weeks prior to the study. Findings emphasize the need to address craving and other psychological variables with respect to treatment of AWS.     

Age-related differences in the course of alcohol withdrawal in hospitalized patients.

The aim of this study was to compare the course of alcohol withdrawal (AW) syndromes in different age groups of hospitalized patients. Medical records of 892 patients treated for AW in Nowowiejski Hospital in Warsaw, Poland from 1973 to 1987 were reviewed using a structured questionnaire; a further 321 patients were observed on a prospective basis in the years 1990-1999. We compared severity of the symptoms and the course of AW episodes in five age groups: <30, 30-39, 40-49, 50-59 and > or =60 years old. Although the age groups did not differ in respect of gender, there were significant differences in other demographic variables, such as marital status, education, employment and number of households. We found a greater prevalence of somatic diseases and hypokalaemia in the older age groups. Older patients were hospitalized longer than the younger patients. The amount of alcohol consumed was significantly smaller in the older patients. No significant differences were found between age groups in the duration and severity of AW symptoms. All age groups required comparable doses of medication. The relationship between the duration of AW and the amount of alcohol consumed during the last drinking bout was significant in patients aged >50 years. There was also a significant positive correlation between the occurrence of withdrawal seizures or the severity of AW symptoms and the number of previous AW episodes in patients aged > or =40 years. Although the results did not confirm some previously reported differences in the course of AW between older and younger patients, they point to some new important differences in the conditions and course of AW in the elderly.     

Double diagnosis or comorbidity? Definition and clinical observation

There is a high prevalence of a comorbid substance use disorder in subjects with psychotic or mood disorders. Psychiatric patients are reported to abuse alcohol or drugs. This comorbidity raises the question whether one disorder is a consequence of the other. The self-medication hypothesis of substance abuse suggests that drug abuse is driven by an attempt to alleviate specific psychological distress but this unidirectional causality is not supported. The main aims of this review are to describe the difference between dual diagnosis and comorbidity in psychiatric patients and the possible patterns of different clinical conditions.     

Axis I comorbidity onset and parasuicide in women with eating disorders

OBJECTIVE: We examined differences in the onset pattern of comorbid disorders in eating-disordered women with and without a history of parasuicide to elucidate potential etiologic differences between the two groups. METHODS: Fifty-four women with a current or past eating disorder partcipated. Of these women, 27 had a history of suicide attempts and self-injury and 27 had no history of suicide attempts or self-injury. The age and pattern of onset for the eating disorder relative to comorbid major depression, anxiety disorder, and substance use disorder were compared between the groups. RESULTS: The onset of major depression and anxiety disorders occurred at a younger age in the parasuicidal group. In addition, the onset of major depression in the parasuicidal group occurred significantly more often before the onset of the eating disorder. DISCUSSION: The eating disorder may be secondary to a mood disturbance in women with parasuicidal histories.