脑小血管病诊疗进展

脑小血管病是一组影像学表现各有特点、互不相同的脑血管病,是最常见的脑血管病类型。多隐匿起病,缓慢进展,早期无特异性临床表现,其病因、病理机制、临床表现与传统脑血管病存在差异,人们对它认识尚不充分。但其发病率高,后期加重脑卒中致残,加重认知障碍及情感障碍,甚至参与神经变性疾病进程中,现在越来越受到关注。本文就脑小血管病的危险因素、发病机制、病理改变、临床和影像表现、检测指标以及治疗等方面作一综述。     

Neuropsychiatric aspects of Parkinson's disease

Parkinson's disease (PD), a disorder characterized by movement abnormalities, is frequently complicated by psychiatric syndromes. Psychiatric assessment of the PD patient requires familiarity with the motor and cognitive aspects of PD, the various effects of antiparkinsonian medications, and how these relate to mental status changes and psychiatric phenomena. This review describes the various motor and nonmotor features of PD and focuses on the differential diagnosis of affective disorders in PD and their treatment.     

Evidence for activation of microglia in patients with psychiatric illnesses.

Activation of microglia/macrophages is a key event in response to pathological changes in the CNS. HLA-DR is a valuable immunohistochemical marker that specifically reacts with activated microglia cells. In order to elucidate a potential role of microgliosis in severe psychiatric illnesses, post-mortem frontal cortex and hippocampus of patients with schizophrenia (n = 14) and affective disorder (n = 6) and control specimens (n = 13) were studied. Additionally Alzheimer's disease cases (n = 8) were included as a human model system with typical neurodegenerative alterations and microglia activation. All patient groups revealed subjects with abundant microglia immunostaining (schizophrenia, three patients; affective disorder, one patient; Alzheimer's disease, four patients) in both gray and white matter. This finding provides evidence for distinct neuropathological changes in brains of patients with schizophrenia and affective disorder. The activation of microglia cells, which represent a major part of the brain immune response, may help to unravel the pathophysiological processes in severe psychiatric illnesses.     

Wilson's disease presenting as isolated obsessive-compulsive disorder

Wilson's disease (WD) is a genetic neurodegenerative disorder; it exhibits wide heterogeneity in symptoms and usually presents with liver disease and/ or neuropsychiatric manifestations. The common neurological manifestations observed are dysarthria, gait disturbance, dystonia, rigidity, tremor, dysphagia and chorea. The frequent psychiatric manifestations reported are personality and mood changes, depression, phobias, cognitive impairment, psychosis, anxiety, compulsive and impulsive behavior. Isolated obsessive-compulsive disorder (OCD) is a rare presentation of WD. Reported herein is a case of a 17-year-old boy with isolated OCD. He presented to the psychiatrist with symptoms of contamination obsessions and washing compulsions, along with compulsion of repeated feet tapping and was treated with adequate doses of fluoxetine for 6 months but did not improve. Later on, he was diagnosed as a case of WD and showed improvement with chelating and behavior therapy. This implies the importance of the occurrence of isolated psychological symptoms in WD.     

Is donepezil useful for improving cognitive dysfunction in bipolar disorder?

BACKGROUND: Cognitive dysfunctions are being recognized as a major roadblock to functional recovery in patients with bipolar disorders. Little is known about the treatment of these cognitive dysfunctions. Donepezil, approved to treat memory dysfunction in Alzheimer's disease, is evaluated for cognitive dysfunctions common in bipolar disorder. Of concern is some evidence that donepezil may trigger affective instability. METHODS: All bipolar disordered patients in a private practice setting treated with donepezil for memory problems were analyzed. Patients were assessed for memory improvement and change in psychiatric status with the Clinical Global Impression of Improvement Scale. RESULTS: Thirty-nine of 58 patients (67%) reported improvement with a mean score of 1.82 (standard deviation+/-0.82). Nine treatments were stopped because of side effects and 4 showed no response. No bipolar I patient received benefits. Thirty-six of 43 (84%) of bipolar II patients showed improvement. Fifty percent of bipolar NOS showed improvement. Four bipolar I patients (57%), 1 bipolar II patient (2%) and 2 bipolar NOS patients (25%) stopped donepezil due to worsening affective symptoms. LIMITATIONS: This is a naturalistic case series with a single evaluator. Other medications used in treatment were changed as clinically indicated. CONCLUSIONS: This case series suggests utility for donepezil in the treatment of cognitive problems associated with bipolar II disorder and bipolar disorder NOS. Bipolar I patients showed no improvement and a concerning trend to destabilize with donepezil treatment.     

Neurasthenia in the 1980s: chronic mononucleosis, chronic fatigue syndrome, and anxiety and depressive disorders

In the 1980s, patients suffering from unexplained fatigue and what seemed like a prolonged attack of acute mononucleosis were given the diagnosis of chronic mononucleosis or chronic infection with the Epstein-Barr virus. Although the diagnosis has great appeal, the Epstein-Barr virus does not cause the syndrome (CFS) of chronic fatigue, which has been renamed and redefined chronic fatigue syndrome to remove the inference that the virus is its cause. From a historical perspective, both syndromes represent the 1980s equivalent of neurasthenia, a disease of fatigue that influenced the development of psychiatric nosology. Because patients with depression and anxiety also have chronic fatigue and because most patients with CFS have an affective disorder, the assessment of organic causes of this syndrome requires careful psychiatric diagnosis and treatment. Defining chronic fatigue syndrome as a medical disorder may deprive patients of competent treatment of their affective disorder.     

Increased risk of developing dementia in patients with major affective disorders compared to patients with other medical illnesses

BACKGROUND: The association between affective disorder and subsequent dementia is unclear. Our aim was to investigate whether patients with unipolar or bipolar affective disorder have an increased risk of developing dementia compared to patients with other chronic illnesses. METHOD: By linkage of the psychiatric and somatic nation-wide registers of all hospitalised patients in Denmark, 2007 patients with mania, 11741 patients with depression, 81380 patients with osteoarthritis and 69149 patients with diabetes were identified according to diagnosis at first-ever discharge from a psychiatric or somatic hospital between 1 January 1977 and 31 December 1993. The risk of receiving a diagnosis of dementia on subsequent re-admission was estimated with the use of survival analyses. RESULTS: Patients with unipolar or bipolar affective disorder had a greater risk of receiving a diagnosis of dementia than patients with osteoarthritis or diabetes. Differences in age and gender and the effect of alcohol- or drug-abuse did not explain these associations. CONCLUSION: Patients with unipolar or bipolar affective disorder seem to have an increased risk of developing dementia compared to patients with other illnesses. LIMITATION: The study includes only patients who have been hospitalised at least once. CLINICAL RELEVANCE: Patients with unipolar or bipolar affective disorder may be at increased risk of developing dementia.     

Impaired cognition and decision-making in bipolar depression but no 'affective bias' evident

BACKGROUND: Depression is usually the predominant affective state in bipolar disorder. There are few studies, with discrepant views, examining the extent of cognitive impairment in patients with bipolar depression. To our knowledge, there are no previous studies examining decision-making ability or whether there is an affective attentional bias in bipolar depression. METHOD: We ascertained 24 depressed bipolar I patients from acute psychiatric hospital wards and out-patient clinics and 26 age- and IQ-matched healthy controls. Using computerized tests we evaluated their performance on 'neutral' (non-emotional) cognitive tasks (i.e. memory, attention and executive function) and on novel tasks of emotional cognition (i.e. the decision-making task and the affective go/no-go task). RESULTS: Accuracy measures were significantly impaired on tests of visual and spatial recognition and attentional set-shifting in bipolar depression compared with age- and IQ-matched controls. The quality of decision-making was also significantly impaired in the patients. A mood-congruent attentional bias for 'sad' targets was not evident on the affective go/no-go task. CONCLUSIONS: We found widespread evidence of significant cognitive impairment and impaired quality of decision-making in symptomatically severe depressed bipolar patients. This cognitive impairment may contribute to difficulties with daily living, decision-making and the ability to engage and comply with psychological and drug treatments.     

Depressed mood and other psychiatric manifestations of Cushing's syndrome: relationship to hormone levels

Thirty-five consecutive patients with Cushing's syndrome were studied prospectively prior to treatment. A consistent constellation of psychiatric disturbances was found, including impairments in affect (depressed mood and crying), cognitive functions (decreased concentration and memory), and vegetative functions (decreased libido and insomnia). A statistically significant relationship was found between the overall psychiatric disability rating and cortisol and ACTH level. The relationship of depressed mood and hormone levels was examined. Low ACTH levels were significantly associated with milder rather than pronounced depressed mood. The implications of the similarities in psychiatric manifestations between Cushing's syndrome and the primary affective disorders are discussed.     

Psychiatric manifestations in systemic lupus erythematosus

Psychiatric abnormalities are common in systemic lupus erythematosus (SLE) with a prevalence of 17% to 75%, reflecting different methods of patient selection and assessment, the different professional orientation of clinicians, and lack of an accepted consensus for diagnosing active neuropsychiatric lupus (NPSLE). The psychiatric syndromes included in the ACR Neuropsychiatric Lupus Nomenclature Committee criteria are cognitive dysfunction, acute confusional state (delirium), anxiety disorder, mood disorder, and psychosis. In SLE patients, identification of psychiatric phenomena and the generation of a differential diagnosis are crucial. Possible mechanisms include vascular injury and pathogenic antibodies. Treatment strategies are based on small case studies. The purpose of this review is to discuss clinical manifestations, pathogenesis and the present therapeutic options in psychiatric lupus.     

Movement and mood disorder in two brothers with Gaucher disease

Gaucher disease (GD) is a lysosomal storage disorder with a wide spectrum of phenotypic presentations. We report the case histories of two adult brothers with GD who developed both parkinsonism and psychiatric symptoms. Direct sequencing and real-time polymerase chain reaction were used to establish that the patients were homozygous for mutation L444P. While parkinsonism has been described previously in GD, these patients had atypical features, including a complicated mood disorder. The comorbidity of GD and a mood disorder is a new finding, as psychiatric manifestations of GD have been described rarely. The etiology of the mental illness could be related to the processes contributing to the development of parkinsonism.     

Pharmacological interventions for bipolar youth: developmental considerations

Despite the high prevalence rate, there have been relatively few controlled studies to systematically examine pharmacological treatments for children and adolescents with bipolar disorder. We review the differences in clinical characteristics between youth and adults with bipolar disorder and the extant literature of pharmacological treatments for children and adolescents with bipolar disorder, as well as discuss the effectiveness of pharmacological interventions for treating children and adolescents who are at familial risk for developing bipolar disorder. Although the number of controlled studies of youth with manic and mixed episodes is rapidly growing, there are few studies examining treatments for depression and the prevention of recurrent affective episodes in this population. Although children and adolescents with bipolar disorder commonly present with co-occurring psychiatric disorders, such as attention-deficit/hyperactivity disorder, there are limited data to guide the treatment of these patients. Recently, studies have begun to characterize prodromal manifestations of bipolar disorder and identify early intervention strategies for treating children and adolescents with an elevated risk for developing bipolar disorder.     

Head injury as a risk factor for bipolar affective disorder

BACKGROUND: Case reports have associated head injury with psychoses including affective disorders, but little is known regarding head injury as a risk factor for the onset of bipolar affective disorder. METHODS: The Danish Psychiatric Case Register and the Danish National Patients Register were linked together with the Danish Population Register, thus identifying 10,242 patients with bipolar affective disorder, and 102,420 matched controls. History regarding head injury was recorded from the National Patients Register data. Data were analysed using conditional logistic regression. RESULTS: Bipolar affective disorder was associated with an increased risk of a history of head injury (IRR=1.55; 95% CI 1.36-1.77). The increased risk was confined to head injury occurring less than 5 years before the first psychiatric admission. The finding could not be ascribed to increased accident proneness (as evaluated through the occurrence of other fractures not involving the skull). LIMITATIONS: In studies based on clinical diagnoses only and limited to patients who were hospitalised for psychiatric disorder, exposure was limited to injuries leading to admission to hospital. CONCLUSIONS: Head injury may be a contributing factor to the onset of bipolar affective illness. However, this factor is probably only relevant to a relatively small minority of cases.     

Effects of the active constituents of Crocus Sativus L., crocins,in an animal model of obsessive–compulsive disorder

Crocins are among the active components of the plant Crocus Sativus L. C. Sativus L. and its constituents were effective in different models of psychiatric disorders including anxiety and depression. Obsessive–compulsive disorder (OCD) is a common psychiatric disorder defined by the presence of obsessive thoughts and repetitive compulsive actions. The non selective serotonin (5-HT) receptor agonist mCPP is known to induce OCD-like behavior (excessive self-grooming) in rodents and exacerbate symptoms in patients with OCD. The present study investigated whether or not crocins were able to counteract excessive self-grooming induced by mCPP (0.6 mg/kg, i.p.) in rats. Crocins (30 and 50 mg/kg, i.p.) attenuated mCPP-induced excessive self-grooming. The present results also indicate that these effects of crocins on an animal model of OCD cannot be attributed to changes in locomotor activity. Our findings suggest that the active constituents of C. Sativus L. crocins might play a role in compulsive behavior and support a functional interaction between crocins and the serotonergic system.     

Affective symptoms at index hospitalization in childhood and depressive symptoms in adulthood: a "catch-up" study

PURPOSE: To analyze whether affective symptoms during psychiatric treatment in childhood or adolescence could predict the later development of depressive symptoms. METHOD: We used a "catch-up" design. A cohort of former child and adolescent psychiatric patients was assessed in adulthood with standardized instruments according to the criteria of ICD-10 (SCAN) and dimensional values for depression (both self-reported and observer-rated). Initial affective symptoms had been extracted from clinical records according to a standardized system (AMDP). RESULTS: We assessed 164 former patients. Twelve percent of these fulfilled diagnostic criteria of an affective disorder (F3) according to ICD-10. In univariate analyses of variance the depression scores were significantly related to affective symptoms during childhood treatment, even if the presence of an affective disorder at catch-up was considered as an independent covariate variable. Nevertheless, the latter variable explained a large part of the variance of depression scores, while initial affective symptoms explained no more than 6%. CONCLUSION: Affective symptoms in childhood and adolescence may predict the later development of subthreshold depressive symptomatology.     

Neuropsychiatry of Huntington's disease and other basal ganglia disorders

Degenerative diseases of the basal ganglia, such as Huntington's disease (HD), Parkinson's disease, and Wilson's disease, are characterized by motor, cognitive, and psychiatric manifestations. HD, in particular, can be considered a paradigmatic neuropsychiatric disorder that has all three components of the "Triadic Syndromes": dyskinesia, dementia, and depression. The authors examine the phenomenology, prevalence, and management of psychiatric disturbances occurring in diseases of the basal ganglia. They address psychiatric conditions such as depression, mania, psychosis, obsessive-compulsive disorders, aggression, irritability, apathy, sexual disorders, and delirium, discussing subtleties of diagnosis, and making reference to more unusual disorders of the basal ganglia, such as postencephalitic parkinsonism and Fahr's disease.     

The relationship of family history of alcoholism to primary affective disorder.

One hundred sixty-eight patients with primary affective disorder were studied regarding history of alcohol-related problems. Alcohol-related problems were identified in 19 patients. We found that the morbid risk for alcoholism was significantly increased among relatives of male patients with drinking problems as compared to relatives of male patients without drinking problems. Our data suggest that psychiatric illness in relatives of probands with severe bipolar illness tends to be affective disorder tends to include alcoholism plus affective disorder.     

The Kleine-Levin syndrome: A review

Because of its rarity, the Kleine-Levin syndrome may go unrecognized or be misdiagnosed. Primarily affecting male adolescents, it is characterized by periodic hypersomnia, excessive eating, and psychiatric symptoms ranging from lethargy to hallucinations. This article reviews the manifestations, diagnosis, and treatment of the disorder, with particular attention to psychiatric symptoms as described in 33 well-documented cases. Psychiatrically, it may be the mirror image to anorexia nervosa.     

Research review on anger in psychotherapy.

This article selectively reviews clinically relevant research on the theory and treatment of anger. Anger is first defined, within the context of emotion theory, as the cognitive, behavioral, physiological, experiential, and social manifestations of a central nervous system process. The theories and techniques used to treat anger from several theoretical perspectives are then evaluated, making conceptual links to a basic affective model. We then review research on the treatment of anger in clinical populations (aggressive adults and children, clients with post-traumatic stress disorder, and clients with cardiovascular disease). We conclude with a discussion of anger suppression and inhibition.