躁鬱症並不是「匆促隨意」的診斷


  【24drs.com】美國精神科學界當今面對的主要議題可能不是孩童的躁鬱症過度診斷,而是許多醫師並未真正暸解這類診斷的複雜性。
  
  紐約Stony Brook大學醫學院青少年精神科主任、精神科與小兒科教授Gabrielle A. Carlson醫師表示,目前沒有可用於準確診斷孩童躁鬱症的準則。
  
  Carlson醫師向第9屆躁鬱症國際研討會的與會代表表示,一定程度的謙虛是必須的,釐清症狀也是相當重要,切記:環境問題。
  
  賓州Western精神科研究中心與門診、匹茲堡大學醫學院精神科教授、早發性躁鬱症講座的Boris Birmaher醫師表示認同。
  
  他在發表時表示,躁鬱症的診斷是困難的,因為相當複雜、症狀與注意力不足過動障礙症(ADHD)等其他疾病類似。
  
  在這個領域中,我們也探討躁鬱症的週期性與慢性議題(在我們的經驗中,需要孩子有一定的發作次數),迅速循環的定義,以及狹義和廣義躁鬱症之間的差異。
  
  Birmaher醫師表示,當今的一大問題是:孩童躁鬱症的盛行率為何?美國的盛行率是否高於其他國家?
  
  他討論了線上登載於5月31日臨床精神醫學期刊(Journal of Clinical Psychiatry)的一篇新分析,評估了1985至2007年間的12篇流行病學研究,研究者評估了8個國家、7至21歲孩童躁鬱症盛行率,發現診斷比率範圍從0% (愛爾蘭)到3%,與美國相當。
  
  Birmaher醫師表示,另一篇納入廣義躁症的研究發現,這個比率可高達5%,不過,這都顯示出我們和其他國家並無太大差異。
  
  但是,之前的一篇研究(Arch Gen Psychiatry. 2007;64:1032-1039)顯示,醫師訪視次數造成美國小兒科躁鬱症診斷比率在10年間顯著上升。
  
  Birmaher醫師解釋,這些孩童的訪視比率比成人增加40倍,但是我們需小心探討絕對數字,例如,如果你從診斷1個變成2個,那相當於增加了100%。
  
  一篇2010年的全國趨勢研究(Bipolar Disorders. 2010;12:155-162)顯示,在2000年至2007年間,德國小兒科躁鬱症診斷比率從每10萬人有1.13例增加到1.91例。
  
  Birmaher醫師表示,比例上看來增加了68%,但是每10萬人僅從1人增加到約2人。
  
  美國的第一或第二躁鬱症比率並沒有比較高,不過亞症候群(subsyndromal)診斷的比率高於其他國家。
  
  他表示,小兒躁鬱症確實存在,但是我們需仔細,因為它的診斷可能是困難的。Birmaher醫師指出,試著釐清核心症狀,例如孩童的浮誇愛現時是特別困難的。
  
  他指出,雖然有些孩童被誤診為有躁鬱症,但是,相對的,也有許多孩童有躁鬱症,但是卻被誤診而未適當治療。
  
  這是我們必須知道的,因為躁鬱症嚴重影響了孩童的正常發展,增加自殺、物質濫用、社會心理問題的風險,最重要的是及早確認並適當治療。
  
  Carlson醫師也討論了診斷躁鬱症的困難度。她表示,需耗費3小時做一個評估,不是花個30分鐘就可以讓患者離開那麼簡單;就算一個小孩看起來符合躁鬱症診斷,仍需花點時間確認後才可以說「我確定這是躁鬱症」。
  
  Carlson醫師等人在最近接受刊登的一篇研究中評估了家長和老師協同合作、對911名5至18歲孩童之「Child Mania Rating Scale」量表的影響;總共有7.3%的孩童被發現有躁鬱症,其中,20人有第一型躁鬱症、3人有第二型躁鬱症、43人有非特定型躁鬱症。
  
  雖然認為躁症症狀分數高(>15)的家長比較多,最後確認的是:孩童患有ADHD或對立性反抗疾患(ODD);此外,當家長對症狀評比分數較高、老師評比較低時,診斷一般是焦慮症。
  
  這個意義相當重要。如果你認為一個小孩有快速循環型異常,而事實上他是焦慮症,使用的治療可能大相逕庭。
  
  2010年的一篇研究中(Bipolar Disorders. 2010;12:205-212),Carlson醫師等人在2003年1月至2004年6月間,評估了130名孩童實際躁症發作時是否出現憤怒的情況,多數是因為家長提出的暴怒症狀而住院。
  
  雖然家長通常通報為躁症症狀,研究者發現,躁鬱症一般無法解釋這些發作,因為84.8%的孩童在院內的暴怒發作次數在1次以下 。
  
  不令人意外的是,社區醫師比較可能診斷這些孩童有躁鬱症,但是暴怒是相當不具有特定性的,ODD、自閉症、創傷後壓力異常、精神分裂症等等都會出現。
  
  她指出,雖然所有的結構式評估看起來是有用,特別是那些瞭解躁症和憂鬱症者,不過這項工具無法輕易地解釋給那些不暸解現象學、發展、與孩童青少年評估深度者。
  
  這絕對不是說「如果你的家長有躁鬱症,你恐怕也會有」,絕對不是這種簡單而隨性的診斷。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6554&x_classno=0&x_chkdelpoint=Y
  

Bipolar Disorder Not a 'Quick and Dirty' Diagnosis

By Deborah Brauser
Medscape Medical News

June 22, 2011 (Pittsburgh, Pennsylvania) — A major issue facing the field of psychiatry today may not be that children in the United States are being overdiagnosed with bipolar disorder (BD) but that many clinicians do not truly understand the complexities of this type of diagnosis.

Gabrielle A. Carlson, MD, professor of psychiatry and pediatrics and director of the Child and Adolescent Psychiatry Department at the Stony Brook University School of Medicine in New York, said that no formula currently exists for accurately diagnosing BD in children.

"A certain amount of humility is needed, and it is extremely important to clarify symptoms. Remember: context matters," Dr. Carlson told delegates attending the Ninth International Conference on Bipolar Disorder.

Boris Birmaher, MD, professor of psychiatry and endowed chair in early-onset bipolar disease at the University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic in Pennsylvania, agreed.

During his presentation, he said a diagnosis of BD can be difficult because it is highly comorbid and overlaps with symptoms of other illnesses, including attention-deficit/hyperactivity disorder (ADHD).

"As a field, we're also looking at the issues of periodicity vs chronicity in bipolar disorder (in our practice we require that a child has definite episodes), the definition of rapid cycling, and the differences between narrow vs broad bipolar disorders.

"The big questions today are: What is the prevalence of bipolar in children? Is it more prevalent in the US than in other countries?" said Dr. Birmaher.

United States on Par With Other Countries

He discussed a new analysis published online May 31 in the Journal of Clinical Psychiatry that assessed 12 epidemiologic studies conducted between 1985 and 2007. The investigators evaluated the prevalence of pediatric BD in children from 8 countries between the ages of 7 and 21 years and found diagnosis rates ranged from 0% (in Ireland) to 3%, the same range found in the United States.

"Another study that included a very broad definition of manic symptoms found that that rate could go up to 5%. But still, all of this shows that we are not very different from other countries," said Dr. Birmaher.

However, a previous study(Arch Gen Psychiatry. 2007;64:1032-1039) showed that the number of physician visits ending in a diagnosis of pediatric bipolar in the United States increased significantly during 10 years.

"There was a 40-fold increase in the rate of visits for these children compared to adults, but we need to be careful to look at the absolute numbers. For example, if you go from 1 diagnosis to 2, that's an increase of 100%," Dr. Birmaher explained.

A 2010 national trends study (Bipolar Disorders. 2010;12:155-162) showed rates of BD diagnoses increased from 1.13 to 1.91 per 100,000 inpatients in Germany from 2000 to 2007.

"This was technically an increase of 68%, but really it was only up from 1 to 2 per 100,000 people," said Dr. Birmaher.

"It does not seem that the prevalence of bipolar 1 or 2 is higher in the US, but the diagnosis of subsyndromal forms is higher than in other countries."

Pendulum Can Swing Both Ways

"Pediatric bipolar exists, but we need to be careful because its diagnosis can be difficult," he said. Dr. Birmaher added that it is especially challenging when trying to identify core symptoms, such as grandiosity and elation in young children.

He noted that although some children are being misdiagnosed as having BD, the opposite is also true. There are many children, he said, who have BD but whose conditions are misdiagnosed and treated inappropriately.

"This is something we need to be aware of because bipolar seriously affects the normal development of a child and increases their risk of suicide, substance abuse, and psychosocial problems. Early recognition and appropriate treatment are most important."

Dr. Carlson also discussed the difficulties of diagnosing BD.

"It takes me 3 hours to do an evaluation....This is not something that you just take 30 minutes and get the person in and out. Even when it looks like a kid meets the criteria for [BD], time and effort are necessary before you say, 'I unequivocally know this is bipolar,' "she said.

'Profound' Implications

In a study that has recently been accepted for publication, Dr. Carlson and colleagues assessed the implications of parent and teacher concordance on the Child Mania Rating Scale in 911 children between the ages of 5 and 18 years.

A total of 7.3% of the participating children were found to have a BD. Of these, 20 had BD type 1, 3 had BD type 2, and 43 had BD not otherwise specified.

Although a high parent rating score of manic symptoms (>15) was more associated with a diagnosis of BD than a low score, the child usually ended up having ADHD or oppositional defiant disorder (ODD).

In addition, when the parent rating was high and the teacher rating low, the diagnosis was usually an anxiety disorder, she said.

"The implications are pretty profound. If you think a kid is having a rapidly cycling disorder and in fact they have an anxiety disorder, you're going to use very different treatments."

In a 2010 study (Bipolar Disorders. 2010;12:205-212), Dr. Carlson and colleagues also assessed whether rages are actually manic episodes in 130 children between January 2003 and June 2004. Most were hospitalized for parent-reported rages.

Although the parents often reported manic symptoms, the investigators found that BD usually did not explain the episodes because 84.8% of the children had 1 or fewer rages while in the hospital.

"Not surprisingly, community clinicians were more likely to give a diagnosis of bipolar to these kids. But rages are a fairly nonspecific manifestation of a lot of different conditions, such as ODD, autism, posttraumatic stress disorder, schizophrenia, and more."

She noted that although all of the structured assessments appear useful, "especially in the hands of someone who knows what mania and depression are," the tools are not easily translated "to people who don't understand phenomenology, development, and the breadth of child and adolescent assessment.

"It is not just saying, 'if your parent has bipolar, you must have it too.' It's not a simple, quick, and dirty diagnosis."

9th International Conference on Bipolar Disorder (ICBD): Concurrent Session 3, No. S1. Presented June 11, 2011.

    
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