Leon Piterman，F(xiàn)iona Judd，Grant Blashki(著)，楊 輝 (譯)

1 病史

辛迪是病人威廉的女朋友。3個月前威廉曾前來看病，那次是為了治療抑郁癥，這次辛迪做了加急預(yù)約，再讓你給威廉看病。辛迪非常擔(dān)心威廉，他幾乎不睡覺，而且精神頭兒還特別好。他不停地說話，而且越說越多。

威廉宣布他發(fā)明了幾種新方法，用細(xì)絲和計算機(jī)無線網(wǎng)絡(luò)技術(shù)，讓房間的每個地方都能充滿電。他認(rèn)為這是一個革命性的新發(fā)明，能讓建筑業(yè)節(jié)省上億元。他為了推銷自己的創(chuàng)新計劃，把自己的積蓄全部投入進(jìn)去。辛迪告訴你，當(dāng)威廉遇到別人的質(zhì)疑時，總是爭得面紅耳赤，總是咄咄逼人的樣子。

2 其他病史

威廉，22歲，電工。3個月前看病的主訴是情緒低落，睡眠障礙，缺乏興趣和動機(jī)，注意力不集中，記憶力減退。當(dāng)時的診斷是抑郁癥，并開始使用抗抑郁藥進(jìn)行治療。經(jīng)過6周，他的情緒逐漸好轉(zhuǎn)，1個月前重新開始工作。在此之前他沒有抑郁病史，不過他的外祖父有“情緒波動”的病史。

3 身體檢查

這次威廉自己是不愿意來找你看病的，而是他女朋友辛迪堅持勸說他來診所的。3個月前威廉找你看病的時候，給他做了全面的軀體檢查。威廉不愿意再重復(fù)這些檢查，不過他還能讓你測量體溫和血壓，結(jié)果都在正常范圍內(nèi)。給他做心理狀態(tài)檢查，他看上去跟上次明顯不同。他具有某種攻擊性，不愿意回答你的提問，而是喋喋不休地談他那些對發(fā)展建筑行業(yè)的想法。他情緒高昂，跟你談話的時候還經(jīng)常講一些笑話。他堅持認(rèn)為自己沒有問題，說自己現(xiàn)在“回到了最好的狀態(tài)”。

4 提問

4.1 提問1:你的初步診斷是什么?

4.2 提問2:3個月前你能診斷他是雙相障礙嗎?

4.3 提問3:你的治療重點是什么?

4.4 提問4:制定什么樣的長期管理計劃，作為全科醫(yī)生你應(yīng)該做什么?

5 解答

5.1 對提問1的解答:初步診斷

5.1.1 初步診斷為雙相障礙－躁狂階段。他看上去焦躁不安，失去理性，而且有夸大妄想。這些情況在開始使用抗抑郁藥后突然發(fā)生。

雙相障礙的特點是，周期性出現(xiàn)高昂情緒和抑郁情緒，表現(xiàn)形式不盡相同。開始的時候首先出現(xiàn)的可能是抑郁 (正如本案例的病人)，或者夾雜少許的躁狂。針對某些雙相障礙的病人，如果用抗抑郁藥治療抑郁，則可能是引發(fā)躁狂的危險因素。高昂情緒的發(fā)生嚴(yán)重程度各不相同，輕度的病情稱為“輕度躁狂”，嚴(yán)重的病情 (常伴有妄想)稱為“躁狂”。躁狂的共同特征包括情緒高昂和 (或)情緒焦躁、過度興奮、睡眠的需要減少、非特異性的冒險行為、社會活動增加、花錢數(shù)量增多、想法浮夸 (有的時候偏執(zhí))以及妄想［1］。

5.1.2 急性精神分裂癥樣精神病。這個診斷的可能性很小，因為病人以前做出過抑郁癥的診斷、病人現(xiàn)在的問題在使用抗抑郁藥后馬上出現(xiàn)、病人的高昂情緒以及與病人情緒一致的夸大妄想。如果要做出精神分裂癥樣精神病的診斷，那么病人應(yīng)該存在各種形式的思維方式混亂、與情緒不一致的妄想以及知覺障礙 (通常表現(xiàn)為幻聽)。

5.2 對提問2的解答:3個月前是否能診斷為雙相障礙 對雙相障礙的診斷一定要謹(jǐn)慎，因為這將明顯地影響到治療方案和預(yù)后。而且也不應(yīng)該誤診，否則會導(dǎo)致錯誤的治療。如果病人第一次出現(xiàn)抑郁的癥狀，并做出了抑郁癥的診斷，你應(yīng)該認(rèn)真地檢查病人以前是否存在高昂情緒的情況，即便是高昂情緒很輕微或只存在幾天，也要注意到。如果病人以前的確存在過情緒高昂的情況，那么這就提示病人實際表現(xiàn)出來的是雙相障礙的早期癥狀。其次，雙相障礙 (而不是抑郁癥)的家族史也提示你有可能是雙相障礙的早期發(fā)作。如果雙相障礙的可能性比較大，那么你就要嚴(yán)密地監(jiān)測針對抑郁癥的治療過程，因為抗抑郁藥可能引發(fā)雙相障礙的高昂情緒。不過，如果沒有明確地診斷為雙相障礙，就不應(yīng)該實行針對雙相障礙的治療措施。

5.3 對提問3的解答:治療重點 鑒于威廉的高昂情緒、妄想信念、缺乏自知力，你應(yīng)該判斷威廉的情況是危險的。他很有可能做出愚蠢的決定，結(jié)果造成資金上、人際關(guān)系上和就業(yè)上的嚴(yán)重問題。躁狂癥的病人往往過度飲酒，這會進(jìn)一步加重危險行為，做出一些錯誤的決定。

考慮到威廉存在的這些危險因素以及癥狀的嚴(yán)重程度，而且威廉認(rèn)為自己沒有什么不好，認(rèn)為自己不需要治療，因此威廉需要住院治療。

首先要做的是停用抗抑郁藥，換用另外的藥 (如苯二氮或抗精神病藥)讓威廉平靜或鎮(zhèn)靜下來。在正式地治療他的雙相障礙之前，有一個過渡的治療過程，用于治療病理性高昂情緒的情緒穩(wěn)定劑，是需要一定時間才能發(fā)揮效應(yīng)的。

5.4 對提問4的回答:長期的管理計劃 一旦明確診斷雙相障礙，威廉就需要藥物 (情緒穩(wěn)定劑)來預(yù)防抑郁和 (或)躁狂的進(jìn)一步發(fā)展。病人服藥的依從性可能比較差，因為很多輕度躁狂的病人認(rèn)為他們自己感覺特別好，特別有成效。另外一個重要的方面，是對威廉、他的女朋友辛迪以及他的家人提供相應(yīng)的教育和支持［2－3］。一般來說，雙相障礙的病人需要全科醫(yī)生管理，并需要精神病學(xué)專家的治療。如果心理健康團(tuán)隊能夠合作起來給病人提供綜合服務(wù)，會達(dá)到很好的治療效果。這些綜合服務(wù)包括［4］:

5.4.1 心理教育 (1)明確病情反復(fù)的危險因素，主要包括是睡眠剝奪 (如白班夜班輪換，國際旅行)、飲酒、使用毒品、服藥依從性差等。你應(yīng)該跟病人及其家庭合作，避免或盡量減少這些危險因素。(2)明確病情反復(fù)的早期征兆，鼓勵使用“情緒日記”的方法，并制定明確的早期預(yù)防計劃，監(jiān)測抑郁或輕度躁狂的進(jìn)一步發(fā)展。

5.4.2 嚴(yán)密監(jiān)測藥物治療 (1)如果使用鋰劑、2－丙基戊酸鈉、卡馬西平等藥，應(yīng)該對血清中的藥物水平進(jìn)行監(jiān)測，并保證血清藥物水平在正常范圍內(nèi)。(2)對常見的藥物副作用進(jìn)行監(jiān)測，如鋰劑帶來的甲狀腺功能和腸道功能的新陳代謝副作用，以及奧氮平等藥的新陳代謝副作用。

5.4.3 定期對病人的情緒狀況和一般情況進(jìn)行復(fù)診。

5.4.4 對照顧者和家庭提供支持。

譯者注:妄想:一種無法說服并且堅信不移的錯誤信念。病人的社會、文化和宗教背景無法解釋這種信念。

情緒穩(wěn)定劑:一種有效治療急性躁狂和 (或)雙相障礙抑郁癥的藥物，可預(yù)防躁狂和 (或)雙相障礙抑郁癥的發(fā)作。常見的情緒穩(wěn)定劑包括碳酸鋰、丙戊酸鈉、卡巴咪嗪、奧氮平。

1 Castle DJ，Berk M，Hocking BM.Bipolar disorder.New understandings，emerging treatments［Z］.2010，193:S1－S30.

2 Gleason A，Castle DJ，Piterman L，et al.A guide for the management of bipolar disorder in general practice 2011，version1 ［Z］.Supported by an educational grant from AstraZeneca.

3 Therapeutic Guidelines Psychotropics［Z］.2008.

4 Blashki G，Piterman L，Judd F.General Practice Psychiatry［M］.North Ryde，NSW，McGraw－Hill Australia，2006.

(本文編輯:閆行敏)

【Introduction of the Column】 The Journal presents the Column of Case Studies of Mental Health in General Practice，with academic support from Australian experts in general practice，psychology and psychiatry from Monash University and the U-niversity of Melbourne.The Column's purpose is to respond to the increasing needs of mental health services in China.Through study and analysis of mental health cases，we hope to improve understanding of mental illnesses in Chinese primary health settings，and to build capacity of community health professional in managing of mental illnesses in general practice.Patient－centred and whole－person approach in general practice is the best way to maintain and improve the physical and mental health of residents.Our hope is that these case studies will lead new wave of general practice and mental health development both in practice and academic research.A number of Australian experts from the disciplines of general practice，mental health and psychiatry will contribute to the Column.You will find Professor Blashki，Professor Judd and Professor Piterman are authors of General Practice Psychiatry.The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinese mental health in primary health care will step up to new stage under this international cooperation.

Introduction of the case study:The case study is subsequent story of case study four(depression)that was published in previous issue.

Affiliation:Monash University， Victoria 3806， Australia(Leon Piterman);Melbourne University(Fiona Judd，Grant Blashki)

1 History

Cindy，the partner of your patient William，who consulted you three months ago for treatment of depression makes an urgent appointment to see you.She is very concerned about William.He seems energised despite very little sleep.He is talking incessantly.

He claims that he discovered new ways of electrically wiring houses using micro filaments and computer wireless techniques which will revolutionise the construction industry and save billions of dollars.He is preparing a marketing strategy and is investing all of his savings.Cindy tells you that he is argumentative and aggressive when challenged.

2 Other History

William，who is a 22－year－old electrician，was seen three months ago complaining of low mood，sleep disturbance，loss of interest and motivation，poor concentration and memory disturbance.A diagnosis of depressive disorder was made and he started treatment with an anti－depressant.His mood gradually improved over a period of 6 weeks and he returned to work a month ago.He had no past history of depression，but had reported his maternal grandfather had a history of'mood swings'.

3 Examination

Although William is reluctant to see you，Cindy manages to convince him to attend the surgery.When you saw him3 months ago you conducted a thorough physical examination.William is reluctant to repeat this，but allows you to check his temperature and BP which are within the normal range.On mental state examination，he looks quite different from your last meeting with him.He is somewhat aggressive，not wanting to answer your questions，talking rapidly about his ideas for changing the construction industry.His mood is elevated，and he makes several jokes whilst talking with you.He insists there is nothing wrong with him，stating he's feeling'back to my best'.

4 Question

4.1 Question 1:What are your probability diagnoses?

4.2 Question 2:Could you have made a diagnosis of bipolar disorder when he presented 3 months ago?

4.3 Question 3:What are the management priorities?

4.4 Question 4:What is his long term management and what is your role as a GPin long term management?

5 Answer

5.1 Answer 1:Probability diagnoses

5.1.1 Bipolar disorder－manic phase He seems irritable，irrational，overactive，and has grandiose delusions.This has come on suddenly following the commencement of an antidepressant.

Bipolar disorder，which is characterised by recurrent episodes of elevated and/or depressed mood，may present in various ways.The first episode of this disorder can be one of depression，as has occurred here，or less frequently of mania.Treating an episode of depression in someone with bipolar disorder，with an antidepressant is a known risk factor for triggering a manic episode.Episodes of elevated mood vary in severity－milder episodes are labelled hypomania and more severe episodes，often accompanied by delusions，are labelled as manic episodes.Common features of a manic episode are elevated and/or irritable mood，overactivity，reduced need for sleep，uncharacteristic risk taking behaviour，increased social activity，increased spending of money and grandiose(or sometimes paranoid)ideas and/or delusions［1］.

5.1.2 Acute schizophreniform psychosis This diagnosis is less likely given his past diagnosis of depression，the apparent precipitation of the episode by antidepressants，the elevated mood and the mood－congruent(grandiose)delusions.By contrast if the diagnosis was a Schizophreniform psychosis he would probably present with disorder of form of thought，mood － incronguent delusions，and probably perceptual disturbance，most usually auditory hallucinations.

5.2 Answer2 The diagnosis of bipolar disorder must be made with caution，as it has significant implications for treatment and prognosis.However，it is also important not to miss the diagnosis，and so provide inappropriate treatment.When a patient presents with depressive symptoms for the first time，and a diagnosis of depressive disorder is made，you should always check carefully for a past history of any episodes of elevated mood－even if only mild and of only several days duration.A positive history should alert you to the possibility that this could be the first presentation of bipolar disorder.Second，a family history of bipolar disorder，rather than of depression，should also raise the possibility that this is a first presentation of bipolar disorder.If the possibility is raised，then treatment of the depressive disorder must be carefully monitored，as antidepressants may lead to an episode of elevated mood if the diagnosis is confirmed.However，note that treatment should not be initiated for bipolar disorder unless this diagnosis has been clearly made.

5.3 Answer3 As a result of his elevated mood，delusional beliefs and lack of insight，William is at risk.He is likely to make foolish decisions，which will result in major financial，relationship，and employment problems.Excessive alcohol use commonly accompanies mania and exacerbates risky behaviour and poor decision making.

Given these risks，the severity of his symptoms，and his belief that there is nothing wrong and he does not need treatment，William will require treatment in hospital.

The first step is to stop his antidepressant medication，and to prescribe medication to calm or sedate William(e.g benzodiazepine or antipsychotic medication).This is an interim procedure whilst the definitive treatment for his bipolar disorder，a mood stabiliser which will act specifically on the pathologically elevated mood has time to act.

5.4 Answer4:Long term management Having an established diagnosis of bipolar disorder，William will need to take medication(mood stabiliser)to prevent further episodes of either depression and/or mania.Compliance with this treatment may be difficult as many people say they feel best and most productive when they are mildly hypomanic.Education and support of William and Cindy and William's family will be important［2－3］.Generally，individuals with bipolar disorder require management by both their GPand a treating psychiatrist and/or mental health care team in a shared care arrangement to optimise treatment outcomes.This includes［4］:

5.4.1 Psychoeducation (1)Identifying risk factors for relapse－ common issues are sleep deprivation(e.g.shift work，international flight)，alcohol and/or recreational drug use，and non －compliance with treatment，and working with the patient and family to avoid/minimise these.(2)Identifying early warning signs for relapse，and encouraging use of a mood diary with a clear plan for early intervention if symptoms of depression or hypomania begin to develop.

5.4.2 Carefully monitor drug treatment (1)Serum drug levels should be monitored and maintained within the therapeutic range if prescribed lithium，Valproate or carbamazepine.(2)Monitor for common side－effects e.g.metabolic complications thyroid and renal function on lithium，or metabolic syndrome with Olanzapine and related drugs.

5.4.3 Regular review to monitor mood and general wellbeing.

5.4.4 Support for the carer or family.

Notes:Delusions:are fixed false beliefs，which cannot be reasoned away，and which are not explained by the person's social，cultural or religious background.

Mood stabiliser:a drug which is effective for the acute treatment of mania and/or bipolar depression，and which prevents episodes of mania and/or bipolar depression.The commonly used mood stabilisers are lithium carbonate，sodium Valproate， carbamazepine and olanzapine.

1 Castle DJ，Berk M，Hocking BM.Bipolar disorder.New understandings，emerging treatments［Z］.2010，193:S1－S30.

2 Gleason A，Castle DJ，Piterman L，et al.A guide for the management of bipolar disorder in general practice 2011，version1［Z］.Supported by an educational grant from AstraZeneca.

3 Therapeutic Guidelines Psychotropics［Z］.2008.

4 Blashki G，Piterman L，Judd F.General Practice Psychiatry［M］.North Ryde，NSW，McGraw－Hill Australia，2006.