广泛性焦虑障碍的病历分享-课件

单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,Click to add Title,Click to edit Master text styles,Second level,Third level,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,单击此处编辑母版标题样式,Edit Master text styles,Second level,Third level,Fourth level,Fifth level,6,7,8,9,*,*,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,Click to add Title,Click to edit Master text styles,Second level,Third level,广泛性焦虑,障碍病例分享,1,目录,一、病例信息,二、诊断,三、治疗,四、讨论,2,一、病例信息,3,一般资料,性别,女性,年龄,48,岁,教育程度,小学文化,婚姻状况,已婚,职业,无业,4,主诉,眠差、担心焦虑半年余，加重,1,周。,5,病史（1）,诱因,：患者于半年前因买房子后担心自己钱被别人骗去后出现夜眠差，很晚才能入睡。,发病经过,：自诉半年前开始出现入睡困难，有时早醒，每日最多睡眠,2-3,小时，担心焦虑，乏力，头晕，胸闷，有时在房间内来回走动，心烦气躁，爱发火，病情时好时坏。近,1,周以来夫妻关系紧张后上述症状加重，并有轻生想法，但未付出行动，故在女儿陪同下来诊。,6,病史（2）,个人史：性格内向，好强；夫妻关系一般，育有二女一子。在家做家务，无业。,既往史：自诉颈椎不好，具体也没有详细检查；无肝炎、结核，糖尿病及高血压病史。,家族史：否认二系三代精神失常史。,7,检查,躯体检查：生命体征正常，心肺腹未见异常，神经系统检查（,-,）。,辅助检查：,实验室检查：血常规、尿常规、生化全套、心电图、胸片、,B,超、脑电图、头颅,CT,均正常；,HAMA,：,22,分（严重,29,分，明显,21,分，肯定,14,分，,7,可能有）。,HAMD,：,21,分（,24,项评分。严重,35,分，轻,-,中度,20,分）。,BPRS,：,23,分。,8,精神检查,意识清晰，接触好，年貌相称，定向准确，面部表情焦虑，能够诉说自己的病情，与工作人员眼神交流差，注意力欠集中，未引出持久的情感低落及兴趣减退体验，思维连贯，未明显的幻觉、妄想。主动求医，自知力存在。智能检查粗检未见异常。,9,广泛性焦虑,ICD-10,诊断标准,GAD,必须是至少几周内的大部分时间有焦虑症状，通常已持续,6,个月以上，社会功能受损，其焦虑症状包括：,1.,忧虑：如担心未来，感到“紧张不安”，注意力集中困难，经常过分担心，且有紧张不安，易激惹等，往往有持续的无明确对象或无固定的恐惧。,2.,运动性不安：运动紧张，舌唇震颤，肢体发抖不能放松。,10,广泛性焦虑,ICD-10,诊断标准,自主神经功能失调症状：如头晕出汗，心率加快，口干，胃不适，尿频尿急症状者即可诊断该病。,诊断过程中，注意广泛性焦虑障碍合并抑郁及其他共病问题，除外躯体疾病伴发的焦虑情绪，除外神经衰弱。,11,二、诊断,12,广泛性焦虑障碍,13,三、治疗,14,治疗考虑,(1),改善睡眠质量，增加有效睡眠时间。抗焦虑及抑郁症状。,(2),恢复社会功能，提高患者的生活质量；,(3),建议行心理治疗，改善家庭关系；,(4),避免药物干预带来的负面效应。,(5),戒除烟酒，我科门诊随访。,15,干预方式,药物治疗：抗焦虑,+,丁螺环酮,+,苯二氮卓类药物。,非药物治疗：心理行为治疗,+,认知治疗,+,生物反馈疗法。,16,治疗经过,帕罗,西汀,丁螺,环酮,心理,治疗,HAMA,HAMD,氯硝,西泮,第一周,20mg/d,5mg tid,睡眠卫生教育,22,21,1mg,晚,第三周,20mg/d,10mg,tid,认知,治疗,15,12,0,5mg,晚,第五周,20mg/d,10mg tid,心理,教育,4,5,停用,药物按需服用,17,讨论,1.,患者出现眠差，每天休息时间,3,小时左右，入睡困难及易早醒，故给半衰期长的药物氯硝西泮,1mg,晚口服，以促进睡眠。,2.,患者出现广泛性焦虑并可能伴有轻度抑郁，故选用帕罗西汀口服。每日,20mg,，每周以,10mg,递增，抗焦虑最大剂量不应超过,50mg,，减量速度应更加缓慢。,3.,给予丁螺环酮口服，主要对广泛性焦虑有效，对惊恐障碍及恐怖障碍无效，较少产生药物依赖和戒断症状。,18,