儿童青少年精神疾病课件

兒童青少年精神疾病

台北榮民總醫院精神部兒童青少年精神科主任陳映雪醫師Disordersusuallyfirstdiagnosedininfancy,childhood,andadolescenceMentalretardationBorderlineintellectualfunctionLearningdisordersReading,math,writingMotorskillsdisorderCommunicationdisordersEliminationdisordersPervasivedevelopmentaldisordersAttentiondeficitanddisruptivebehaviordisordersADHDODDCDTicdisorder/Tourette’sdisorderFeedingandeatingdisordersChildabuseandneglectTemperamentproblemsAnxietydisordersseparationanxietydisorderselectivemutismSpecificphobiaSchoolphobiaSocialphobiaOCDPTSDEatingdisordersSchizophreniaMooddisordersBipolardisorderDysthymiamajordepressionSubstanceabuse北榮陳映雪DisruptivebehaviordisordersAttentiondeficithyperactivedsorder(ADHD)Oppositional-defiantdisorder(ODD)Conductdisorder(CD)ADHDDSM-IV診斷標準A.

核心症狀

1.注意力差學習問題

2.好動

3.衝動

＊持續六個月以上B.

於七歲之前就有的症狀C.

至少在兩種情境呈現症狀D.

造成社會生活功能障礙E.

無法由其它精神疾病來解釋

行為問題、人際衝突、易發生意外、青少年時期車禍多北榮陳映雪ADHDDSM-IV診斷標準具有下列(一)或(二)之一達六個月以上與發展程度比較的不適應症狀(一)Inattention（無法專心）(6項以上)常粗心大意或無法注意細節

（功課或工作上）工作或遊戲注意力無法持久別人跟他講話，經常不注意聽無法遵守指示完成功課或工作安排工作或活動常發生困難常常逃避或拒絕需要持續精神（用功）的工作遺忘帶需要的東西容易被外界轉移注意力日常生活中經常遺忘每天該作的事北榮陳映雪(二)Hyperactivity-impulsivity：(6項以上)

Hyperactivity(過動)手腳亂動,坐著也扭來扭去無法安靜坐著或常離座(教室)常過度的跑來跑去，或爬上爬下無法安靜遊戲不停的動，精力過盛話很多

Impulsivity(衝動)

1.

話未問完，就搶著回答

2.

缺乏耐心等待

3.

常干擾別人ADHDDSM-IV診斷標準北榮陳映雪ImpulsivityBehaviorthatisswayedbyemotionalorinvoluntaryimpulsesBehaviorwithoutadequateforethoughtTendencyotchooseimmediateoverlongtermrewardsEngagementinbehaviorsthatarelikelytobepunished.Persistentreward-seekingbehaviors北榮陳映雪TypeofADHDPredominantlyInattentiveType(ADD)

注意力不集中型PredominantlyHyperactive-ImpulsiveType過動衝動型CombinedType結合型(1+2)Forindividuals(especiallyadolescentsandadults)whocurrentlyhavesymptomsthatnolongermeetfullcriteria,"InPartialRemission"shouldbespecified.(adultADD)北榮陳映雪ADHD共病疾病對立異常症(oppositionaldefiantdisorder)56%反社會規範異常症(conductdisorder)31%學習障礙症(learningdisorder)25%溝通障礙(communicativedisorder)20%遺尿症(enuresis)6%焦慮症(anxietydisorder)20%單純性畏懼症(simplephobia)9%社會畏懼症(socialphobia)3%重鬱症(majordepressivedisorder)6%雙相性情感性疾患(bipolardisorder)6%托倫氏症

(Tourette’sdisorder)3%北榮陳映雪ComorbidityofPsychiatricdisordersinADHD40%/14%11%4%34%北榮陳映雪ADHDvs.ADDGender:ADHD:boys>girlsADD:girls>boysAgeofbeingdetected:ADHD<ADDClinicalmanifestation:ADHD:morebehaviorproblem&ODDorCDSelf-regulationdeficit+selectiveattentionproblemADD:moreacademicproblem&LDselectiveattentionproblemmoresocialwithdrawn北榮陳映雪DiagnosisofADHD(I)Clinicalinterview(onlywaytoestablishDiagnosis)Hxfromparents/caretakersReviewschoolinformationSchoolreports,LD?Ratingscales(teacher)ExploreparentteacherrelationshipDocumentsigns&symptomsAgeofonsetDurationDifferentsettingsPhysicalexam北榮陳映雪DiagnosisofADHD(2)MeetsDSM-IVorICD-10criteriaScreenforcomorbiddisordersPsychologicalassessmentsIQtest,Attentiontest,PersonalitytestFordetectindividualstrengthandweaknessforcounseling.北榮陳映雪北榮陳映雪北榮陳映雪PrevalenceforADHDinChildrenAbout3to10%IncreasingprevalencefromDSM-III(9.6%)toDSM-III-R(10.9%,7.3%)toDSM-IV(17.8%,11.4%)Morefrequentinboys

thaningirls(3-4:1)北榮陳映雪Prevalencein

adolescence&adultsNo.andseverityofsymptomsdeclineswithage.PrevalenceinAdolescents:2-6%NoGenderdifferenceTheNationalComorbidityStudy(USA)suggestaprevalenceof4.7%ormoreinadults北榮陳映雪PrognosisofADHDADHDgrownup1/3:remission1/3:adultADDwithresidualsymptom

(inattentive,impulsive),1/3:associatedwithconductdisorder

(drugabuse,antisocialbehavior,injuriesofallsorts)poorereducationalperformanceandwereunderachiever

北榮陳映雪Age-SpecificPrevalenceofADHDRemission:DSM-III-RADHDBiedermanetal.2001北榮陳映雪北榮陳映雪北榮陳映雪AdultADHD:PsychiatricComorbidityBiederman,AmJPsychiatry,1993;150(12):1792-1798.LearningdisabilitiesAnxiety%comorbidconditionAntisocial北榮陳映雪PredictorsofPersistenceofADHDRiskFactors:1. FamilyHistoryofADHD2. Co-morbidity3. AdversityP<0.001Beidermanetal,1995(N=128)北榮陳映雪EtiologyofADHDI.Genetictwinstudiesshowingameanheritabilityof0.8

polygenicdisorder(catecholaminesystem)DRD4,DAT1,DRD5,DRD1,serotoninreceptor(5HTR)2A,5HTR1B,

synaptosomalassociatedproteinof25kD(SNAP-25)

DelaymaturationofbrainMinimalbraindysfunctions(MBD)FetalexposuretoMaternalabuseofalcohol,smoking,drug,PregnancycomplicationorbirthtraumaToxins(mercury,lead,manganese)北榮陳映雪北榮陳映雪北榮陳映雪ADHD:MolecularGeneticsGenesimplicatedbyseveralstudies:

DRD4,DRD5,5HT1BNosinglegenecausesADHDThegeneslikelycombinewitheachotherandenvironmentalriskfactorstocauseADHDSmalley,AmJHumGenet.2002;71(4):959-963.北榮陳映雪北榮陳映雪EtiologyofADHDII.DelaymaturationofbrainMinimalbraindysfunctions(MBD)FetalexposuretoMaternalabuseofalcohol,smoking,drug,PregnancycomplicationorbirthtraumaToxins(mercury,lead,manganese,PCB)北榮陳映雪北榮陳映雪北榮陳映雪EtiologyofADHDIII.Gene–EnvironmentInteractionChaoticfamilyenvironmentsPoorparentingskills北榮陳映雪北榮陳映雪北榮陳映雪PathophysiologyofADHDDysfunctionofthecatecholaminesystemWenderP(1971):dysfunctioninDAandNELevyF(1991):dopaminedeficittheory.Volkowetal(1998):methylphenidate:blockadeDAtransporter.(PET)

Pathophysiologicalfindings:No.ofDATbindingsitesishigherindrug-naivepatients.DecreaseinDOPAdecarboxylaseactivityintheprefrontalcortex,primarydeficitsinsubcorticaldopaminesystems.ComplexdysregulationofDAneurotransmittersystem北榮陳映雪Bothgeneticandenvironmentalriskfactorshavesmall,addictiveandinteractiveeffectsontheprobabilityachildwilldevelopADHD北榮陳映雪Brainimagingstudies(Mid1990s-)

Anatomicabnormalitiesinspecificbrainregionswheredopaminereceptorsaredense.reducedsizeofrightfrontallobeandcaudatenucleusA10-yearstudyby(NIMH):brainsare3-4%smallerthannormal(pharmacologictreatmentisnotthecause)ThemoresevereADHDsymptoms,thesmallerfrontallobes,temporalgraymatter,caudatenucleus,andcerebellumwere.北榮陳映雪GreyMatterDifferenceMaps(A)andStatisticalMaps(B)inChildrenwithADHDandControlsADHDsubjectsshowa20–30%increaseingrey-matterdensityinbilateraltemporal&inferiorparietalregionsSowelletal.,2003北榮陳映雪WorkingMemoryRelatedChangesInAdultswithADHD–Compensation?HC>ADHDADHD>HCSchweitzeretal,BiologicalPsychiatry,2004ControlgroupdemonstratesWMactivationassociatedwithverbalrehearsalstrategies&inhibitorycontrolADHDgroupdemonstratesWMactivationassociatedwithmotor&visualprocessingsuggestiveofcompensatorybrainregionsandstrategies.北榮陳映雪北榮陳映雪北榮陳映雪北榮陳映雪ChildrenwithADHDDemonstrateDelayedCorticalMaturationinMostAreas

AnexceptionisintheprimarymotorcortexwheretheADHDgroupdemonstratedearliercorticalmaturationShaw,P.etal.2007,PNAS.北榮陳映雪nigrostriataldopaminepathway(fromsubstantia

nigratocaudatenucleus)mesolimbicdopaminepathway(

fromventraltegmentumtofrontalcortex)The

dopaminetransporterdensityismorethananorderof

magnitudehigherinthecaudatenucleusthantheprefrontal

cortex,whichisthereversepatternofrelative

densityoftheD4receptors,sotheregulationoflevelsofsynapticdopaminebythereuptakeprocessshoulddifferdramaticallyinthesetwobrainregions.thesiteofactionofmethylphenidate,whichblocksthere-uptakeprocess.

北榮陳映雪.Psychotropicmedications(>4yearsold)improvethecoresymptomsofADHDin70%oftreatedchildrenPsychotherapyorpsychosocialtreatmentBehavioraltherapyorCognitive-behavioraltherapySocialskill/impulsecontrolskilltrainingProblemsolvingtrainingParentaltraining

PsychoeducationOthermanagement,butnoevidenceofeffectivenessSensoryintergration

perceptualstimulation/trainingdietarymanagementherbalandhomeopathictreatmentsbiofeedbackmeditationTreatmentsforADHD北榮陳映雪psychotropicmedicationsCNSstimulants(Shortacting&longacting)methylphenidate(MPH),Ritalin,Concerta

D-amphetamine

Pemoline(hepatictoxicity)Antidepressants

TCA(severeCVsideeffects)SSRI(fluoxetine,sertrazline……)Atomoxetine

Clonidine(forsevereaggressivecases,oversedation)Antipsychotics(oversedation)北榮陳映雪ADHDPharmacotherapy–Responsiveness010080604020%RespondersMethylphenidateAmphetaminePemolineTricyclicantidepressantsBupropionMAOIClonidine/GuanfacineWilensTE,SpencerTJ.PresentedatMassachusettsGeneralHospital’sChildandAdolescentPsychopharmacologyMeeting,March10-12,2000,Boston,MA.北榮陳映雪vvStoragevesicleDATransporterCytoplasmic

DAMethylphenidateblocksreuptakePresynaptic

NeuroneSynapseWilensT,SpencerTJ.HandbookofSubstanceAbuse:NeurobehavioralPharmacology.1998;501-513.AmphetamineblocksreuptakeAmphetamine

blocksMechanismofActionofStimulants北榮陳映雪EffectofMPHonWMBrainActivation:NarrowstheFocusSchweitzeretal,2004MPHmayenhanceperformancebyimprovingPFC’sabilitytofilteroutdistracters.北榮陳映雪北榮陳映雪PervasiveDevelopmentalDisordersAutisticdisorderAsperger’sdisorder

星星的孩

TheStoryofTempleGrandinRettdiseasePDDNOSCharacteristicsofAutisticdisorderDiagnosticcriteria(DSM-IV)

Impairedsocialinteraction(quality&quantity)Impairedcommunication,usuallysevereActivities,behaviorsandinterestthatare

repetitive,Restrictedandstereotype.Onset:<age3yearsdiagnosis:aroundage2-3yearsdelayedorabnormalfunctiondevelopmentMalepredominant北榮陳映雪Autisticdisorder:

Associatedfeatures<1>75%:retardedlevel,<2>PIQ>VIQ<3>languageexpressionbelowlanguagecomprehension<4>splinterability:hyperlexia,(abletoread)goodatpuzzle,date,…<5>oddresponsetostimulioversensitive,exaggeratedreaction,fascinationtostimuli,hypo-sensitive<6>behavioralsymptoms:hyperactivity,inattention,aggression,tempertantrumstereotypebehaviors,self-injury(headbanging,biting),北榮陳映雪Prevalence:2-5/10,000,(severeautism)MalepredominantCourse:life-longPrognosisdependson“languageskills”(5y/o)&“overallintellectuallevel”1/3:partialindependencehighestfunctioningadult:stillhadsymptomsAutisticdisorder北榮陳映雪

Asperger’sdisorderDSM-IVDiagnosticCriteriaA.

Qualitativeimpairmentinsocialinteraction,B.Restrictedrepetitiveandstereotypedpatternsofbehavior,interests,andactivitiesC.

NodelayinlanguageD.Nodelayincognitivedevelopmentorinthedevelopmentofage-appropriateself-helpskills,adaptivebehavior(otherthaninsocialinteraction),andcuriosityabouttheenvironmentinchildhood.

F.Functionimpairment北榮陳映雪ComparisonofAsperger’sdisorderwithautisticdisorder(I)male>female(both),prevalence:1-5/1000(orhigher)Ageofdiagnosis:later,>5y/oSocialandcommunicationdeficitsarelesssevere.NormalcuriosityaboutenvironmentNodelayincognitivefunction,self-helpskills,Languagedevelopmentnormallackofempathyproblemswithpragmaticresponses&difficultywiththeemotionalcontentofcommunicationproblemofintegratingaffectiveandsocialcognitiveaspectsofasituation.北榮陳映雪ComparisonofAsperger’sdisorderwithautisticdisorder(II)Difficultieswithnewenvironmentsandchangesintheirnormalroutine,butlessseverethanautism.(rigid&stubborn)Special&circumscribedinterestaremoreprominente.g.Train,Taiwanhistory,numerical,……Inautism:Puzzle,datememorized,space,mechanical…VIQisusually>PIQ(usuallyreverseinautism)Clumsinessismorefrequentlyseen,butlesssevere.Outcomeisusuallymorepositiveinasperger’s.Gotocollege,getmarried,heldajob,somesocialrelation…familyhistoryismorefrequentlypositive北榮陳映雪EtiologyofAutisticdisorder

Non-psychogenicGeneralizedbraindysfunctionNeurodevelopmentdisturbance(<30weekspregnancy)seizure:EEGabnormal(25%)PKU,maternalrubella,fragilexsyndrome(10%autism,mostlymales),tuberoussclerosis(1/4affectedareautistic)

hyperserotoninImagingfindings:ReducedsizeofCorpusCallosum,AnteriorCingulate

Gyrus,Cerebellumlowactivityintheparietalareasandthecorpuscallosum.北榮陳映雪北榮陳映雪fMRI

CerebellarBloodFlowandActivationAutismandCerebralHypoperfusionAllenetal.,2003AmJPsychiatry160(2):262-73北榮陳映雪MirrorNeuron鏡像神經元大腦內建機制(anteriorcingulatecortex)模仿動作,看到他人動作，感覺再轉到運動。生物存活要件之一，同理心情緒反應上可能扮演重要角色自閉症可能與此功能受損有關情緒圖譜理論(saliencelandscapetheory)杏仁核(amygdala):長期處理情緒獲得情緒圖譜，記載各種情緒意義。自閉症情緒圖譜嚴重扭曲。北榮陳映雪北榮陳映雪Treatment

(forautism&Asperger’sdisorder)NospecifictreatmentBehavioraltherapySpeech,communication,cognitive&socialskilltrainingEducationalinterventionsIndividualpsychotherapy(forsociallyhandicapped&lowesteem)Parenteducationandtraining北榮陳映雪Treatment

(forautism&Asperger’sdisorder)Medication:canhelpwithsymptoms

SSRI(stereotype,se