非精神科门诊抑郁症的躯体化研究

目的探讨非精神科门诊抑郁症的临床特点、治疗及误诊情况.方法对符合DSM-IV抑郁症诊断标准,且汉密顿抑郁量表(HAMD)评分≥18,抑郁自评量表(SDS)评分≥60(标准分)的72例以躯体不适就诊于非精神科门诊,经多方查治无效而转入我院精神科门诊的患者,进行临床及量表分析.结果 72例中,有77.8%的初诊患者第一主诉是躯体不适和睡眠障碍,而非抑郁症状.经氟西汀治疗6周后,HAMD、SDS及HAMA评分明显下降(P＜0.01).结论非精神科门诊抑郁症患者正确识别可减少误诊发生,抗抑郁剂的应用可有效缓解抑郁症状和躯体不适.     

从一例全身肌肉跳动患者谈全科医生4P问诊模式下的全人照顾

全科医生在临床中经常碰到难以解释的症状（MUS）患者，给医生带来诊疗挑战。本文报道1例因“全身肌肉不自主跳动2个月”于2019-07-13就诊于香港大学深圳医院全科门诊的年轻男性患者，通过其就诊及治疗过程，介绍全科医生如何系统地运用生物-心理-社会模型，从症状的易患因素、诱发因素、维持因素及保护因素4个层面（4P模型），采集病史，寻找线索，收集证据来解释患者的症状及让患者明白自己的问题，进行症状管理，改善患者预后，体现全科医生全人照顾的理念。     

全科医生-心理治疗师联合团队模式探讨：以躯体不适为主诉的心理障碍案例报道

以躯体不适为主诉的心理障碍患者常就诊于综合医院消化、妇科、神经内科等非精神心理专科，正确识别率低，以致病情延误，医疗负担加重。本文报道了１例以头晕、胸闷、气短为主诉的心理障碍患者全科医生与心理治疗师共同照顾过程，探讨了全科医生-心理治疗师联合团队模式在照顾以躯体不适为主诉的心理障碍患者上的优势：尽早正确识别、提高心理治疗实际利用率、更好协助促进干预效果。该模式是综合医院心理卫生服务模式的一次创新探索，为日后构建切实可行的综合医院新型心理卫生服务模式提供启发与思路。     

综合医院门诊抑郁症患者的躯体化研究

目的探讨综合医院门诊抑郁症患者的临床特点、治疗及误诊情况。方法将在各科以躯体不适就诊经多方治疗无效而转诊于我院心理门诊,且汉密顿抑郁量表(HAMD)评分≥18分,抑郁自评量表(SDS)≥60分(标准分),符合CCMD-3抑郁症诊断标准(中国精神障碍分类与诊断标准第3版)的患者60例,进行临床、量表及疗效分析。结果47例(78.3%)初诊患者第一主诉是躯体不适、睡眠障碍而非抑郁症状。经氟西汀治疗6周后,HAMD、SDS、及HAMA(汉密顿焦虑量表)评分较治疗前明显下降(P<0.01)。结论对综合医院门诊抑郁症患者的识别、诊断、适当的抗抑郁治疗,可有效地缓解抑郁症状和躯体不适,减少不必要的检查和治疗,有利于患者的早日康复和提高生活质量。     

从门诊病例探讨风湿免疫病的全科诊疗思路

通过介绍1例风湿免疫病患者的门诊就诊过程,探讨风湿免疫病的全科诊疗思路,并进一步分析全科医生的职责以及全科医疗的优势。     

以乏力为表现的未分化疾病全科诊疗思路

据统计,以乏力为主诉就诊的患者占全科门诊的10%～20%,是全科门诊常见的主诉之一。调查发现综合性医院全科线下门诊的未分化疾病患者中以乏力为主诉就诊的患者占据首位。亦有研究表明,乏力可对患者的生活质量产生较大影响,其严重程度与死亡率相关。乏力作为一种常见的未分化疾病,无明显特异性,既可以是人体的正常生理反应,也可能是各种疾病的表现之一。通常将乏力分为生理性乏力与病理性乏力,病理性乏力的病因繁多,可涉及各系统,处于疾病的未分化阶段,故以乏力为表现的未分化疾病的评估与治疗均有一定难度。乏力作为患者主观感受,难以评估,除详细地询问病史与体格检查,全科医生还需利用相关评估量表客观地评估患者的乏力程度。然而,目前尚无以乏力为表现的未分化疾病评估量表。对于以乏力为表现的未分化疾病患者,全科医生的处理包括对症治疗(包括非药物治疗与药物治疗)与长期随访,以减轻症状、缓解情绪及降低日常功能损害。全科医生如何为乏力患者提供连续性服务、帮助部分乏力患者与症状共存、寻找有效的干预措施及治疗方法,尚待进一步研究。本文论述了以乏力为表现的未分化疾病全科诊疗思路,浅析其不足之处,以期为全科医生识别及连续性管理乏力患...     

综合医院心理门诊抑郁障碍的躯体症状调查

目的探讨综合医院抑郁症患者的躯体症状和发生的频率。方法对福建医学院附属漳州市医院2004年5月～2009年4月临床心理门诊首诊诊断为抑郁症患者的临床资料进行分析。结果736例抑郁症患者中有723例（98.2%）合并有躯体症状,症状复杂、多样累及全身多个系统,常见躯体症状表现为神经系统症状、消化系统症状、心血管系统症状。结论综合医院抑郁症患者绝大多数合并多种躯体症状,应提高综合医院医生对抑郁的识别能力,减少医疗资源的浪费。     

躯体化障碍与护理对策

躯体化障碍又名Briquet综合征,是一种以多种多样、经常变化的躯体症状为主的神经症,躯体症状可涉及多个系统器官,患者常常反复就诊于综合医院.据世界卫生组织的统计数据,综合性医院大约有9%的患者符合其诊断标准,躯体化障碍的患者中大约有99%首先到综合性医院就诊[1].     

抑郁障碍患者躯体化症状与BMI、睡眠和认知功能的相关性

目的:研究抑郁障碍患者躯体化症状与体质量指数(body mass index,BMI)、睡眠及认知功能的关系。方法:选取2019年1~12月于心理门诊就诊的119例抑郁障碍患者。按照病人健康问卷躯体症状群量表(patient health questionnaire-15,PHQ-15)得分分为轻度躯体化组( ...     

Murtagh安全诊断策略在全科教学门诊中的应用：以风湿性多肌痛为例

澳大利亚著名全科医学专家约翰·莫塔（John Murtagh）提出的Murtagh安全诊断策略逐渐被全科医生用于临床诊断和治疗,多用于常见病的初步诊断、危急重症的快速识别、分析和判断是否存在导致某种症状/体征而容易被忽略的疾病,同时了解患者的担忧和期待。全科教学门诊是培养全科医生临床思维、提升全科诊疗能力的重要培训方法。本文以1例风湿性多肌痛（PMR）患者为教学案例,应用Murtagh安全诊断策略剖析诊疗思路,结合文献分析诊疗过程、总结诊治经验,指导全科医生从多维度思考疾病诊断、治疗,培训全科住院医师的全科临床思维、提高PMR诊治水平,达到教学目的。     

以躯体症状就诊于耳鼻喉科门诊的抑郁症患者临床资料分析

目的：探讨以躯体症状就诊于耳鼻喉科门诊的抑郁症患者长期误诊原因,为疾病的鉴别诊断提供依据。方法：对24例抑郁症患者以咽喉部症状为主诉就诊而被误诊的临床资料进行回顾性分析。结果：本组误诊的24例患者均符合《中国精神障碍分类与诊断标准》第3版抑郁症的诊断标准,主要表现为咽异物感、吞咽不畅、咽痛、压迫感、声嘶、咽痛、烧心等躯体化症状。经应用抗抑郁剂联合综合心理干预等治疗,总显效率达83．3％。结论：耳鼻喉科医师对抑郁症的识别能力不足是造成误诊的主要原因。综合医院临床医生应加强精神卫生知识学习,提高对精神疾病的识别能力。     

Unexplained somatic symptoms--diagnostic window for mental disorders

Prevalence of common mental diseases eg, anxiety disorders and depression in primary care, general practice and specialists clinics is high but theirdiagnosis in these settings are poor, main reason being the absence of psychological complaints by patients. Such patients commonly present with physical symptoms suggestive of systemic diseases but examination and investigations often fail to substantiate organic basis of these so-called unexplained somatic symptoms (USSs). Several studies have shown that patients with USSs suffer from anxiety and depression. But these USSs are mostly misinterpreted or ignored by clinicians resulting in poor rates of diagnosis. The study objective was to devise algorithm for better and early diagnosis of. mental diseases in a specialist clinic practice setting. Common USSs were interpreted as regards their symptom-correlates both physical and mental and documented while taking detailed history, physical examination and needed investigations to diagnose systemic diseases. The study was in phases during three years and included 1297 patients in four cohorts which included one group of 154 patients with common USSs, treated with long term antidepressants. Data of all patients were recorded in microsoft excel spread-sheets for analysis. Commonest presenting USSs were so-called "gas", "acidity" and "dysentery" expressed in vernacular terms. On elucidation these were found to mean wide varieties of physical symptoms-complexes that were not typical of specific systemic diseases; 85% in one group and 73% in another with these USSs and their symptom-correlates when positively screened for symptoms of neurotic diseases (ICD-10) after detailed history taking were found to have anxiety and depression. Psychiatric comorbidity with systemic diseases was found in various percentages in three different cohorts when these USSs were properly evaluated. By patients' own assessments, 84.4%, 88% and 90% of those presenting with USSs of so-called "gas", "acidity" and "dysentery" (with their symptom-correlates) and who were put on three different low dose antidepressant treatment groups had satisfactory to good results so long as they were being taken regularly. These common USSs and the underlying physical symptoms-correlates were eponyms of anxiety disorders and non-major depression. General practitioners and specialists eg, gastroenterologists, cardiologists, neurologists, etc, should heed the USSs as the starting point for early diagnosis and treatment of comorbid mental disorders along with the systemic diseases for better treatment compliance and outcome and quality of life. Training of physicians and medical students in the diagnosis and management of patients with USSs should be emphasised in clinical teaching programmes. An algorithm for early diagnosis and management of common mental disorders in general and clinic practice is suggested.     

Treating adults with acute stress disorder and post-traumatic stress disorder in general practice: a clinical update

General practitioners have an important role to play in helping patients after exposure to severe psychological trauma. In the immediate aftermath of trauma, GPs should offer "psychological first aid", which includes monitoring of the patient's mental state, providing general emotional support and information, and encouraging the active use of social support networks, and self-care strategies. Drug treatments should be avoided as a preventive intervention after traumatic exposure; they may be used cautiously in cases of extreme distress that persists. Adults with acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) should be provided with trauma-focused cognitive behaviour therapy (CBT). Eye movement desensitisation and reprocessing (EMDR) in addition to in-vivo exposure (confronting avoided situations, people or places in a graded and systematic manner) may also be provided for PTSD. Drug treatments should not normally replace trauma-focused psychological therapy as a first-line treatment for adults with PTSD. If medication is considered for treating PTSD in adults, selective serotonin reuptake inhibitor antidepressants are the first choice. Other new generation antidepressants and older tricyclic antidepressants should be considered as second-line pharmacological options. Monoamine oxidase inhibitors may be considered by mental health specialists for use in people with treatment-resistant symptoms.     

The management of bipolar disorder in general practice

General practitioners have a key role in managing patients with bipolar disorder, a condition which affects at least one in 200 Australians each year and is the sixth leading cause of disability in the population. Although diagnosis and treatment of the illness is complex, effective treatment can lead to good outcomes for many patients. GPs can contribute significantly to early recognition of bipolar disorder, avoiding the long delays in accurate diagnosis that have been reported. As in other complex recurrent or persistent illnesses, GPs are well placed to coordinate multidisciplinary "shared care" with specialists and other health care professionals. GPs also provide continuing general medical care for patients with bipolar disorder, and are in a unique position to understand patients' life circumstances and to monitor their progress over time. The last decade has seen many advances in medication for bipolar disorder, including the introduction of new therapies and the refinement of treatment protocols using older medications. There has also been increasing recognition of the contribution of psychological therapies to symptom relief, relapse prevention, optimal function, and quality of life.     

北京大学医学部全科住院医师规范化培训的探索与实践

随着国家深化医药卫生体制改革意见的出台,健全基层医疗服务体系是深化医改的重要举措。全科医学的发展是分级诊疗实施的关键,而人才培养是学科发展的核心环节。全科医生是综合程度较高的复合型临床医学人才,承担着基层常见病多发病诊疗、预防保健、慢性病管理等连续性医疗服务,管理人群涉及不同性别年龄及其所处的生理、心理、社会等各层面的健康问题。因此,全科医生的培养内容须涵盖医学相关的诸多领域。目前我国基本确立了以"5+3"为主体、"3+2"为补充的全科医生培养模式。全科住院医师规范化培训是培养高质量全科医生的最佳途径。北京大学医学部全科医学学系自2011年开展全科住院医师规范化培训以来,积极致力于探索符合我国国情、适应行业特点、满足患者需要的全科医生培养道路。经过近8年的实践,在管理体系建设、优化培训策略、基于"岗位胜任力"培养方面,积累了丰富的经验并取得了良好的效果。从建立全科住院医师项目委员会管理队伍建设和严格师资队伍选拔方面完善培训体系;从优化导师管理并通过学员反馈优化医院及社区轮转方案提升培训质量;采取以形成性评价和终结性评价相结合的特色多样化评估手段,阶段性稳步提升学员技能,以"岗位胜任力"为目标培养优秀全科医学人才。探索规范高效、可复制、可推广的全科住院医师规范化培训体系,为实现全科人才培养的可持续发展进行了有益的探索。      

躯体症状障碍患者疾病认知现状及影响因素分析

背景　疾病认知与治疗依从性、疗效及预后的关系已得到充分研究,但主要集中在躯体疾病患者。躯体症状障碍（SSD）是临床上处理较为棘手的一种精神疾病,患者普遍对症状和疾病缺乏较好的认识能力,而对SSD患者疾病认知的研究却鲜见报道。目的　探索SSD患者疾病认知现状及其影响因素。方法　选择2018年4-11月于四川省人民医院心身医学中心住院的SSD患者为研究对象,采用一般情况问卷,自制疾病认知问卷,症状自评量表（SCL-90）,艾森克人格问卷（EPQ）评估其疾病认知、心理健康状态及人格特征,并进行事件相关电位（ERP）检测。采用Pearson相关分析进行疾病认知现状的相关性研究,采用多元线性回归分析探讨疾病认知现状的影响因素。结果　共发放问卷135份,回收有效问卷130份,问卷有效回收率96.3%。84.6%（110/130）的患者对所患疾病相当不了解;52.7%（69/130）的患者对药物依赖或成瘾存在较大程度的担心;49.1%（64/130）的患者对药物副作用存在较大程度的担心;43.6%（57/130）的患者基本不接受自己是精神心理疾病;61.8%（80/130）的患者存在较重的沮丧和无助感;55.4%（72/130）的患者对于“可根据自身情况自行停药减药”的错误行为有较大的认可度。患者对疾病了解度得分与对精神心理疾病接受度得分（r=0.278,P=0.005）、对自行减药停药认可程度得分（r=0.328,P=0.001）呈正相关;患者对药物依赖或成瘾的担心得分与对药物副作用的担心得分呈正相关（r=0.561,P<0.001）;患者对精神心理疾病接受度得分与对自行减药停药认可程度得分呈正相关（r=0.263,P=0.007）,与沮丧和无助感得分呈负相关（r=-0.244,P=0.013）。多元线性回归分析结果显示,患者长期居住在城市、对自行减药停药的认可程度、焦虑及躯体化程度是对疾病了解度的影响因素（P<0.05）。对疾病了解度、对药物副作用的担心程度、N2潜伏期是患者对药物依赖或成瘾的担心程度的影响因素（P<0.05）。对药物依赖或成瘾的担心程度、N2潜伏期是对药物副作用担心程度的影响因素（P<0.05）。患者对疾病了解度、恐怖程度、MMN潜伏期是对精神心理疾病接受程度的影响因素（P<0.05）。性别、对精神心理疾病接受度、内-外性（E）程度、P50抑制率是患病后沮丧无助感的影响因素（P<0.05）。患者对疾病了解度、MMN潜伏期是对自行停药减药认可程度的影响因素（P<0.05）。结论　SSD患者疾病认知程度较差,其人格特征、性别、长期居住地、个体躯体化、焦虑程度,以及部分脑诱发电位成分可部分影响或预测患者的疾病认知水平,对于预测患者疾病认知并进行有针对性的干预具有一定指导意义。     

Clinical psychology in general practice: a cohort study

OBJECTIVE: To evaluate whether a collaborative model of mental healthcare involving general practitioners and clinical psychologists benefits patients with common mental disorders in primary care. DESIGN AND PARTICIPANTS: Cohort study of 276 general practice patients with mental health problems receiving collaborative treatment from clinical psychologists and GPs compared with a normative sample of 198 patients attending the same general practice surgeries. SETTING: Nine general practices in three regional cities (Bathurst, Armidale and Ballarat) and two single-doctor practices in two rural and remote townships (Rylstone and Trundle). Data were collected in Bathurst, Rylstone and Trundle during 2001 and 2002 and in Ballarat and Armidale in 2002. INTERVENTION: Full assessment, case formulation and "focussed psychological interventions" relevant to the patient's condition. MAIN OUTCOME MEASURES: Level of psychological dysfunction assessed before and after the intervention, using the DASS (Depression, Anxiety and Stress Scales), GHQ (General Health Questionnaire) and GWBI (General Well Being Index) scales. RESULTS: After the intervention, average scores in the treatment group decreased significantly (P < 0.001) on all DASS and GHQ measures and increased on the GWBI, indicating a positive change in the patients' mental health. The follow-up scores of the treatment and normative groups did not differ significantly on any of these measures. CONCLUSION: Preliminary findings suggest that collaborative care involving GPs and clinical psychologists provides significant gains in patients' mental health.     

心血管疾病患者心理障碍的识别与治疗

临床上心血管疾病合并心理障碍（双心疾病）非常常见,但国内综合医院医生、基层医院全科医生有时尚不能及时准确识别,已成为突出的问题。本文结合国内外有关心血管疾病合并心理障碍诊治的近期进展,针对其流行病学、诊治现状及临床常见类型进行充分阐述,并重点介绍心血管疾病合并心理障碍的识别、诊断方法与主要治疗措施,以期提升综合医院医生尤其是基层医院全科医生对双心疾病的认识及诊治水平。     

综合性康复治疗对精神分裂症患者疗效的影响

目的 探讨综合性康复治疗对慢性精神分裂症患者疗效的影响.方法 抽取我院普通病房（下称对照组）和康复病房（下称干预组）住院的慢性精神分裂症患者各30例,对照组只对患者进行药物治疗和一般性的心理支持治疗,观察组是患者在药物治疗和一般性的心理支持治疗基础上,再进行综合性康复治疗.采用阳性与阴性症状量表（PANSS量表）,对两组患者分别于入组时、3个月和12个月后进行评定.结果 经12个月综合性康复治疗后,干预组PANSS阴性症状量表分低于对照组,两组阴性症状有差别（P＜0.05）.结论 综合性康复治疗能促进精神分裂症患者阴性症状的改善,提高治疗效果.