大學(xué)生精神疾患的辨識(shí)華梵大學(xué)

1、1,從混亂到平靜(上)：大學(xué)生精神疾患的辨識(shí),華梵大學(xué) 衛(wèi)保組輔仁大學(xué) 醫(yī)學(xué)系國(guó)泰醫(yī)院 精神科邱偉哲,2,簡(jiǎn)歷,學(xué)歷國(guó)立陽(yáng)明醫(yī)學(xué)院醫(yī)學(xué)系畢業(yè)國(guó)立臺(tái)灣大學(xué)管理學(xué)院EMBA畢業(yè)現(xiàn)職國(guó)泰醫(yī)院 身心科 主治醫(yī)師輔仁大學(xué)醫(yī)學(xué)系 講師華梵大學(xué)通識(shí)中心 講師 心理醫(yī)師臺(tái)灣精神醫(yī)學(xué)會(huì)?？漆t(yī)師教育部部定講師,3,課程大綱,Mental Illness 是什麼?壓力與Mental Illness Mental Illness 分

2、類自殺的一些概念Mental Illness的治療概論案例,4,何謂精神疾病?,,5,Mental Illness 分類,Organic or Substance relatedPsychosis(精神病)Schizophrenia, bipolar disorder, major depressive disorder, delusional disorderNeurosis(精神官能癥)Anxiety disorder

3、, panic disorder, OCD, PTSD,Adjustment disorder Psychosis 與 Neurosis主要分別在現(xiàn)實(shí)感,6,Psychosis 與 Neurosis主要分別在?,何謂現(xiàn)實(shí)感?,7,Stress,壓力的特性失掉控制力不可預(yù)期性失去發(fā)洩管道,壓力源包括下列五者：(一)環(huán)境壓力源(二)災(zāi)變事件(三)生活改變(四)日常瑣事(五)心理因素,8,壓力源(短期，長(zhǎng)期)?耗竭?

4、體質(zhì)或基因的脆弱性?精神疾病,壓力不解除會(huì)如何?,9,,(Holmes, T.H.& Rahe, R.H.,1967),社會(huì)再適應(yīng)評(píng)分量表 社會(huì)再適應(yīng)評(píng)分量表,10,精神分裂癥診斷,依據(jù)DSM-Ⅳ-TR的診斷標(biāo)準(zhǔn)，至少須符合下述2項(xiàng)標(biāo)準(zhǔn)： 1. 妄想 2. 幻覺(jué) 3. 言語(yǔ)混亂 4. 混亂或僵直之行為 5. 其他負(fù)性癥狀，例如無(wú)適當(dāng)情

5、感表達(dá)。明顯社交職業(yè)功能退化而且這些癥狀持續(xù)6個(gè)月以上者。依據(jù)癥狀群可分為5種次型，分別為妄想型、混亂型、僵直型、未分類型及殘餘型等。,11,憂鬱癥的診斷,下列兩項(xiàng)至少有一項(xiàng)憂鬱心情失去興趣或喜樂(lè)下列七項(xiàng)與上述兩項(xiàng)最少五項(xiàng)體重下降或增加，食慾減少或增加失眠或嗜睡激動(dòng)或遲滯疲累或失去活力無(wú)價(jià)值感或罪惡感注意力減退自殺意念,DSM-IV,1994,12,憂鬱癥的共病,人格疾患物質(zhì)濫用飲食疾患焦慮疾患,,DSM

6、-IV,1994,13,14,Dx for Manic Episodes (DSM-VI),A. Duration more than 1 week （期間大於一星期）B. Three (or more) of the following symptoms :下列癥狀大於 3 項(xiàng)或以上:(1) inflated self-esteem or grandiosity 　自信心增高(2) decreased need for sle

7、ep　 睡眠需求減少 (3) more talkative than usual or pressure to keep talking　多話(4) flight of ideas or subjective racing thoughts　跳躍性思考(5) distractibility 易分心(6) increase in goal-directed activity or psychomotor agitation增加目

8、的性行為或激躁不安 (7) excessive involvement in pleasurable activities that have a high potential for painful consequences 增加享樂(lè)性行為,15,憂鬱癥的就醫(yī)行為,,16,7成民眾未尋求就醫(yī),,其中超過(guò)四成不覺(jué)得癥狀嚴(yán)重，但家人有憂鬱癥傾向，九成以上民眾會(huì)鼓勵(lì)就醫(yī),17,,Disease Course of Major Depr

9、essive Disorder (MDD),Adapted from Kupfer DJ. J Clin Psychiatry. 1991;52(suppl 5):28-34.,,,,,,,Symptoms,Syndrome,Treatment phases,Progressionto disorder,Acute,Continuation,Maintenance,Recurrence,,,+,Response,,,“Normalcy

10、”,+,Recovery,,Remission,+,Relapse,,,18,自殺的一些概念,每天全世界有1000人死於自殺自殺佔(zhàn)全美十大死因第8位自殺佔(zhàn)全美青少年死因第3位每1個(gè)自殺死亡的案例的背後有20個(gè)自殺獲救的個(gè)案有100個(gè)自殺想法的個(gè)案,自殺的發(fā)生率,大部分（97%）自殺者生前罹患精神疾病重鬱癥（89%）物質(zhì)濫用（酒癮）（45%）情緒不穩(wěn)之性格障礙為名前三名之精神疾病憂鬱癥合併物質(zhì)濫用是最常見(jiàn)的共病

11、狀態(tài),(鄭泰安，1995),精神疾病與自殺,超過(guò)90%的自殺者生前罹患憂鬱癥。因憂鬱癥自殺身亡的平均年齡：47.1歲（男：49.1歲；女：44.1歲）憂鬱癥發(fā)作具自殺身亡時(shí)間：5.3個(gè)月罹患酒癮自殺者，多合併憂鬱癥（65~78%）酒癮合併憂鬱癥自殺者，男多於女。,（鄭泰安，1995）,憂鬱癥與自殺,,Mood disorder,15%suicide,,Suicide attempt,10% suicide within

12、10 years,,Suicide,19-24% had previous suicide history,45-70% with mood disorder,,,,,Suicide, suicide attempt and mood disorder,失落的生活事件一等親有自殺行為重鬱癥情緒不穩(wěn)人格障礙,,（鄭泰安，2000）,自殺的危險(xiǎn)因子,失落與非失落之生活事件預(yù)測(cè)力不同。失去生活重要的價(jià)值（loss of a cheri

13、shed idea），失去親密的親友是自殺者最常經(jīng)歷的失落生活事件。生活壓力事件與精神疾病的因果關(guān)係？,（鄭泰安，2000),生活壓力事件與自殺,親屬有自殺行為是一項(xiàng)獨(dú)立的自殺危險(xiǎn)因子。自殺者家族中自殺與憂鬱癥病史比例高。,(鄭泰安，2000),家族史與自殺,43%至70%的自殺者生前半年都曾到過(guò)醫(yī)療院所求診，且集中在最後一個(gè)月。生前求醫(yī)的自殺者就醫(yī)的科別多為非精神科醫(yī)師，僅13%求助精神科。8%的自殺者曾求助過(guò)非醫(yī)療機(jī)構(gòu)（教會(huì)

14、，生命線）。至少21%的自殺者有過(guò)不止一次的自殺行為。,（鄭泰安，1995）,自殺者生前的求助行為,27,Adjustment Disorder,Maladaptive reaction within three months of onset of stressor/sDistress in excess of normal reactionNot manifestation of personality disorderSy

15、mptoms resolve within 6 months of termination of stressorAcute versus Chronic,28,DSM-IV Diagnostic Criteria for Panic Attack,A discrete period of intense fear or discomfort, in which four (or more) of the following symp

16、toms developed abruptly and reached a peak within 10 minutes:Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking,C

17、hest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or g

18、oing crazy Fear of dying Paresthesias (numbness or tingling sensations) Chills or hot flashes,29,Panic Disorder,Recurrent, unexpected panic attacksPersistent concernPreoccupation with having another attackWorry abo

19、ut consequences of attackSignificant behaviour change in response to attacks,General diagnostic criteria for a Personality Disorder (DSM IV),inner experience and behavior that deviates markedly from the expectations of

20、the individual's culture. manifested in two (or more) of the following areas: (1) cognition (i.e., ways of perceiving and interpreting self, other people, and events) (2) affectivity (i.e., the range, intensity, l

21、ability, and appropriateness of emotional response) (3) interpersonal functioning (4) impulse control,General diagnostic criteria for a Personality Disorder (DSM IV),inflexible pervasive. significant distress or impa

22、irment in social, occupational, or other important areas of functioning. stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.,Personality disorder(in the therapy),Agg

23、ravating & demandingRejected by therapists who expect them to have “poor prognosis”Seductive, dependent, sexual interest, the urge to rescueBlurring the professional boundariesTests the limits of physician’s theo

24、retical knowledge, practical skills, maturity of character,DSM-IV Qualitative Clusters and Subtypes of Personality Disorders,34,案例,,35,怕光的女孩,大一無(wú)病史其中考前，突然躲在寢室，緊閉雙眼，不敢開(kāi)燈自述遇到光，會(huì)死掉,36,橫衝直撞的男孩,期中考前，在學(xué)校語(yǔ)無(wú)倫次，未進(jìn)食，橫衝直撞高中開(kāi)始就醫(yī)

25、來(lái)華梵時(shí)，已列為追蹤的學(xué)生,37,日夜顛倒的研究生,表情平淡，不洗澡表示自己情緒低落日夜顛倒白天在實(shí)驗(yàn)室睡覺(jué)，無(wú)法完成老師的作業(yè),38,躲在家中的自強(qiáng),大四曾至衛(wèi)保組就醫(yī)，不規(guī)則醫(yī)院就醫(yī)數(shù)週未來(lái)學(xué)校上課（家教、自修）情緒易怒，想自殺,39,自殺的小傑,男同志，裝扮帶點(diǎn)女性化有憂鬱史，未就醫(yī)因同伴欲分手，企圖跳樓,40,酒醉失常的同學(xué),酒醉後攻擊師長(zhǎng),41,當(dāng)同學(xué)出了問(wèn)題，我們?cè)撛觞N辦？,,42,華梵的特色,獨(dú)立的地理位置

26、最高學(xué)府就醫(yī)的獨(dú)特性慈悲為懷,43,一日為師，終生為父,44,學(xué)校的資源,老師教官諮輔組衛(wèi)保組醫(yī)師同學(xué),45,如何判斷學(xué)生的問(wèn)題？,嚴(yán)重性學(xué)生生病了嗎？輔導(dǎo)與治療要如何輔導(dǎo)？何時(shí)要治療？,46,我們忽略了什麼？,,47,家屬,有哪些家屬？最主要的家屬(key person)是誰(shuí)？家屬是否了解病情？家屬的態(tài)度是否可以與學(xué)校溝通？,48,何時(shí)要就醫(yī)?,不就醫(yī)可以嗎?為何要就醫(yī)?何時(shí)要就醫(yī)?,49,Men

27、tal Illness 的治療,心理治療藥物治療電氣痙治療,門(mén)診治療住院治療全日住院日間住院長(zhǎng)期復(fù)建住院強(qiáng)制治療,50,強(qiáng)制就醫(yī),何時(shí)應(yīng)強(qiáng)制就醫(yī)？如何強(qiáng)制就醫(yī)？強(qiáng)制就醫(yī)還有什麼事情要注意？,51,精神衛(wèi)生法,第5條本法所稱病人，係指精神疾病患者。本法所稱嚴(yán)重病人，係指病人呈現(xiàn)出與現(xiàn)實(shí)脫節(jié)之怪異思想及奇特行為，致不能處理自己事務(wù)，或有明顯傷害他人或自己之虞，或有傷害行為，經(jīng)?？漆t(yī)師診斷認(rèn)定者。,52,強(qiáng)制治療,精神

28、衛(wèi)生法第二節(jié) 強(qiáng)制鑑定及住院治療第21條嚴(yán)重病人如有明顯傷害他人或自己之虞，或有傷害行為時(shí)，經(jīng)?？漆t(yī)師診斷有全日住院治療之必要者，保護(hù)人應(yīng)協(xié)助病人，前往精神醫(yī)療機(jī)構(gòu)辦理住院。前項(xiàng)嚴(yán)重病人不接受全日住院治療時(shí)，應(yīng)由二位以上?？漆t(yī)師鑑定，經(jīng)書(shū)面證明有全日住院治療之必要者，應(yīng)強(qiáng)制其住院；其強(qiáng)制住院，應(yīng)在中央衛(wèi)生主管機(jī)關(guān)指定之精神醫(yī)療機(jī)構(gòu)為之。前項(xiàng)鑑定，以全日住院方式為之者，其住院鑑定期間，以七日為限。,53,處置與後續(xù)發(fā)展,