Fiona Judd，Grant Blashki，Leon Piterman，Hui Yang

1 病史

陳女士，51歲，已婚，有一個(gè)23歲的女兒。陳女士很少來(lái)你的診所看病，而且一向身體很健康，沒(méi)有什么大病。她一直在丈夫的雜貨店幫忙，做一些臨時(shí)性的工作。最近她有兩次感覺(jué)不舒服，呼吸困難，渾身燥熱，有被困住的感覺(jué)，有幾次不得不跑出雜貨店，去外面呼吸新鮮空氣。她擔(dān)心自己是不是得了什么嚴(yán)重的病，所以來(lái)診所找你看病。

2 其他病史

你和她交談，詢(xún)問(wèn)她一些問(wèn)題。陳女士告訴你說(shuō)，最近一年多來(lái)感覺(jué)自己不是原來(lái)的樣子，找不到原來(lái)的那種感覺(jué)。她的睡眠變得不好，經(jīng)常半夜醒來(lái)，渾身燥熱出汗。她的心境變得有些煩躁，她發(fā)現(xiàn)自己與來(lái)雜貨店買(mǎi)東西的一些顧客發(fā)脾氣。她還擔(dān)心自己的記憶出現(xiàn)問(wèn)題，因?yàn)樗l(fā)現(xiàn)很難記住丈夫要她做的事情。她對(duì)很多事情失去興趣，而且想過(guò)不去雜貨店幫助她丈夫打理生意。她女兒6年前離開(kāi)她去澳大利亞學(xué)習(xí)，她現(xiàn)在沒(méi)有女兒陪伴和支持。

3 體檢

陳女士梳洗整潔，穿著得體。她渴望和你談話。她有一些焦慮，不過(guò)看起來(lái)她并不抑郁。她否認(rèn)自己感到抑郁，不過(guò)說(shuō)自己時(shí)常感到焦慮，特別是在“有一股股熱浪沖向她的時(shí)候”，會(huì)感到非常煩躁。她沒(méi)有奇怪的思維內(nèi)容，也沒(méi)有不尋常的想法，沒(méi)有周期性反復(fù)的焦慮，不過(guò)她很在意自己的健康和生活。她說(shuō)她害怕自己變老，而且懷疑自己身上有些地方正在變得不正常。她的談話中沒(méi)有抑郁的主題，也沒(méi)有自殘或自殺想法。

軀體檢查結(jié)果沒(méi)有異常發(fā)現(xiàn)。血壓120/75 mm Hg(1 mm Hg=0.133 kPa)，脈搏規(guī)律，70次/min。

4 提問(wèn)

4.1 應(yīng)該考慮什么診斷？

4.2 需要進(jìn)一步采集哪些病史、做哪些進(jìn)一步的體檢和檢查？

5 解答

5.1 應(yīng)該考慮的診斷 陳女士說(shuō)自己大約12個(gè)月來(lái)有一些新出現(xiàn)的癥狀，其中包括各種焦慮的感覺(jué)、驚恐癥狀以及睡眠紊亂，可能還有一些抑郁癥狀。當(dāng)中年人出現(xiàn)新發(fā)的焦慮或抑郁癥狀時(shí)，應(yīng)該考慮到引起這些癥狀的軀體原因的可能性。在中年女性中，更年期癥狀可能酷似焦慮和抑郁，或者更年期加重焦慮和抑郁癥狀，醫(yī)生應(yīng)該考慮到這一點(diǎn)[1]。此外，陳女士正在經(jīng)歷比較大的生活變化，她女兒不僅僅是離開(kāi)了家，而且是移居到很遠(yuǎn)的澳大利亞。

5.2 進(jìn)一步采集的病史以及進(jìn)一步的體檢和檢查 首先，你需要采集更詳細(xì)的病史，以便確定她的癥狀在多大程度上是由于更年期引起的以及她是否真的有焦慮癥或抑郁障礙。由于焦慮、抑郁和更年期之間有些癥狀是相似的，比如疲勞感、集中力和記憶力問(wèn)題、睡眠紊亂、性功能障礙、心悸等，因此會(huì)給診斷帶來(lái)困難。

做出抑郁障礙的診斷，需要你確定病人存在典型的抑郁特征。比如持續(xù)的心境低落、缺乏興趣、缺乏快樂(lè)、經(jīng)?？奁?。還要確定病人存在抑郁的認(rèn)知，比如負(fù)罪的想法、自身沒(méi)有價(jià)值的想法、自殘或自殺的想法。而且要確定病人是否存在日常功能受損的情況。做出焦慮障礙的診斷，需要你確定病人存在焦慮的心理學(xué)癥狀，比如感到激動(dòng)或緊張、表現(xiàn)出內(nèi)在性的擔(dān)憂、回避引起焦慮的場(chǎng)景以及焦慮所具有的認(rèn)知特點(diǎn)。要記住的一個(gè)要點(diǎn)是抑郁和焦慮往往同時(shí)存在。

為了澄清是否病人的更年期造成了她的臨床表現(xiàn)或者她的臨床表現(xiàn)與更年期有關(guān)，你需要認(rèn)真和詳細(xì)地采集病史，包括她的月經(jīng)的頻率和規(guī)律性以及更年期的癥狀，比如感到陣陣發(fā)熱、夜間出汗、焦躁易怒、心境改變、性欲降低、陰道干燥等。

為了排除軀體原因造成病人的癥狀，你需要安排病人做全面的體檢和實(shí)驗(yàn)室檢查，包括全血檢查、尿素和電解質(zhì)檢查、肝功能檢查、甲狀腺功能檢查、維生素B12和葉酸檢查、紅細(xì)胞沉降率檢查等。因?yàn)楦昶诳赡茉斐杉に氐淖兓?，你還可以安排病人做卵泡刺激素和雌二醇水平的檢查。

6 隨診發(fā)現(xiàn)的情況

通過(guò)進(jìn)一步采集病史，你了解到18個(gè)月前陳女士的月經(jīng)還是有規(guī)律的。不過(guò)18個(gè)月以來(lái)，她的月經(jīng)變得越來(lái)越不規(guī)律，在過(guò)去的12個(gè)月中，她只來(lái)了4次月經(jīng)，而且她說(shuō)最近一次月經(jīng)是3個(gè)月前來(lái)的。她以前和現(xiàn)在都沒(méi)有服用過(guò)激素。她告訴你說(shuō)，她的性欲一直不強(qiáng)，而且一直受到陰道干燥的困擾。

你進(jìn)一步和她談?wù)摗瓣囮嚢l(fā)熱”(潮熱)的感覺(jué)，她說(shuō)每天會(huì)出現(xiàn)4～5次這種感覺(jué)，而且經(jīng)常渾身出汗。夜間的發(fā)熱和出汗會(huì)讓她從睡夢(mèng)中醒來(lái)。這些感受往往不伴隨焦慮的癥狀，只有兩次感到要跑出房間去外面呼吸新鮮空氣。

她的化驗(yàn)結(jié)果顯示卵泡刺激素水平升高，雌二醇水平下降，這與更年期的發(fā)展過(guò)程相一致。她的其他檢查結(jié)果都正常。

7 進(jìn)一步的提問(wèn)

你怎樣管理陳女士的這些癥狀？

8 解答

陳女士的焦慮和抑郁癥狀是輕微的，而且這些輕微的焦慮和抑郁癥狀很像是更年期癥狀群的一部分，而不是焦慮或抑郁障礙的表現(xiàn)。因此，最適宜的策略是先針對(duì)更年期癥狀采取管理措施，然后再評(píng)估是否需要針對(duì)焦慮和抑郁癥狀進(jìn)行治療[1-2]。

激素替代療法(hormone replacement therapy,HRT)對(duì)更年期癥狀(包括血管緊張癥狀)往往是有效的，并且可以改善輕度的心境癥狀。如果病人對(duì)激素替代療法有禁忌證，或者對(duì)此出現(xiàn)嚴(yán)重的不良反應(yīng)，則可以采用其他的藥物來(lái)緩解血管緊張癥狀，如選擇性5-羥色胺再攝取抑制劑(SSRIs)。如果效果不好，則可以采用可樂(lè)寧或加巴噴丁。

重要的是要記住，激素替代療法并非是抗抑郁藥物治療。因此如果病人的焦慮和抑郁癥狀是潛在的心境障礙導(dǎo)致的，那么病人的焦慮和抑郁要采用另外的特定治療措施。這是個(gè)通用的治療原則，適用于其他年齡的病人。不過(guò)你一定要記住，中年是婦女一生中心理-社會(huì)變化最大的時(shí)期，因此給她們提供心理和社會(huì)的干預(yù)服務(wù)會(huì)有特別的效果和幫助。比如陳女士的案例，她非常思念女兒，因此采用人際治療這種心理學(xué)治療方法對(duì)于她應(yīng)對(duì)“失去”女兒是很有效的，你可以通過(guò)人際治療，幫助她從照顧小女孩的母親階段轉(zhuǎn)換到一個(gè)新的人生階段[3]。

1 Hickey M,Bryant C,Judd F.Evaluation and management of depressive and anxiety symptoms in midlife[J].Climacteric,2012,15(1):3-9.

2 Jean Hailes Foundation menopause management algorithm[EB/OL].www.jeanhailes.org.au.

3 Blashki G,Judd F,Piterman L.General Practice Psychiatry[M].Mc Graw Hill Medical,2007.

·WorldGeneralPractice/FamilyMedicine·

【IntroductionoftheColumn】 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 University of Melbourne.The Column′s purpose is to respond to the increasing need for the development 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 amongst community health professionals in managing mental illnesses and psychological problems in general practice.A patient-centred 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 the new wave of general practice and mental health service development both in practice and research.A number of Australian experts from the disciplines of general practice,mental health and psychiatry will contribute to the Column.Professor Blashki,Professor Judd and Professor Piterman are authors of the text 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 reach new heights under this international cooperation.

1 History

Mrs Chin is a 51 year old married woman with a daughter now aged 23 years.She has only attended your practice occasionally,and has no major health problems.She has been working part-time in her husband′s grocery business.Recently,on two occasions she has been overcome with feelings of being unable to get her breath,feeling hot and feeling trapped and has run out of the shop to escape into the fresh air.She is worried there is something seriously wrong with her,and comes to you for help.

2 Additional history

On questioning,Mrs Chin tells you she has not felt herself for the last 12 months or so.She has been sleeping poorly,waking in the night feeing hot and sweaty.Her mood has been a little irritable,and she has found herself becoming irritated with some of the people coming into her husband′s shop.Her memory has been worrying her,as she has been finding it hard to remember things her husband asks her to do.She has been less interested in things and has thought about giving up her job helping her husband.Her daughter moved to Australia 6 years ago for further study and Mrs Chin is missing her company and support.

3 Examination

Mrs Chin is well groomed,and eager to talk to you.She is a little anxious,but does not seem depressed.She denies feeling depressed,but does admit that she feels anxious at times,especially when she has the ′waves of hotness′ come over her.Thought content reveals no odd or unusual thoughts,no recurring anxieties,but a focus on her own health and wellbeing.She mentions her fear that she is getting old and that maybe something is going wrong with her body.There are otherwise no depressive themes and no thoughts of self harm or suicide.Physical examination is unremarkable.Her blood pressure is 120/75 mm Hg(1 mm Hg=0.133 kPa),her pulse 70 and regular.

4 Questions

4.1 What diagnoses should be considered?

4.2 What further history,examination and investigations are required?

5 Answers

5.1 What diagnoses should be considered Mrs Chin is describing new onset symptoms of approximately 12 months duration.These include feelings of anxiety,including panic symptoms,as well as sleep disturbance and possibly some depressive symptoms.New onset anxiety and depressive symptoms in mid-age persons should always raise the possibility of a physical cause for these symptoms.In women of mid age,menopausal symptoms mimicking or exacerbating anxiety and depression should also be considered[1].In addition,Mrs Chin has been dealing with a major life change,or loss,as not only has her daughter left home,but she is away in Australia.

5.2 What further history,examination and investigations are required First,you need to take a more detailed history to determine to what degree her symptoms could be attributable to menopause,or whether she does have a syndromal anxiety or depressive disorder.This is made difficult by the similarity between some symptoms of anxiety and depression such as fatigue,concentration and memory problems,sleep disturbance,sexual dysfunction,and palpitations and common symptoms of menopause.

Diagnosis of a depressive disorder requires the identification of characteristic symptoms,such as persistent low mood,loss of interest and pleasure,tearfulness,as well as depressive cognitions,such as thoughts about guilt or worthlessness,or self-harm and suicide,together with impairment in day-to-day functioning.In order to identify an anxiety disorder you need to identify physiological symptoms of anxiety,such as feeling keyed up or nervous,the presence of intrusive worries,and avoidance of situations because of the anxiety they provoke as well as the characteristic anxiety cognitions.It is important to remember that depression and anxiety commonly co-exist.

In order to determine whether her menopausal status is causing or contributing to the presentation a careful history to determine frequency and regularity of menses as well as common menopausal symptoms such as hot flushes,night sweats,irritability,mood changes,fatigue,low libido and vaginal dryness is needed.

In order to exclude physical causes for her symptoms a thorough physical examination is required as well as a number of laboratory tests including FBE,U&E,LFT,thyroid function tests,vitamin b12 and folate,and ESR.Given the possibility of menopausal changes you may also order FSH and oestradiol levels.

6 Follow-up consultation

Further history confirms that Mrs Chin has had regular periods until about 18 months ago.Since that time they have been less regular,she has had only 4 periods in the last 12 months,and she indicates her last period was actually 3 months ago.She is not taking,and has not in the past taken,any hormonal therapies.She acknowledges that she has had poor libido,and has been troubled by vaginal dryness.

When you talk further to her about her ′waves of hotness′ she describes that she has 4-5 of these per day,often with sweating,and has similar episodes which wake her at night.These are not usually accompanied by feelings of anxiety,and she has only experience two episodes when she felt the need to escape into fresh air.

Her test results show a raised FSH level and low oestradiol level,consistent with progression to menopause.Her other investigations are normal.

7 Further question

How will you manage the symptoms?

8 Answer

As the anxiety and depressive symptoms are mild and are likely to be part of her constellation of menopausal symptoms rather than due to a syndromal anxiety or depressive disorder,it is appropriate treat the menopausal symptoms and then review her to determine whether the anxiety and depressive symptoms require additional treatment[1-2].

Hormone replacement therapy is frequently effective for menopausal symptoms including vasomotor symptoms,and may improve mild mood symptoms.If there are contra-indications to the use of HRT,or if HRT produces problematic side-effects,vasomotor symptoms may be helped by a range of other medications including selective serotonin reuptake inhibitors (SSRIs),or if these are not effective clonidine or gabapentin.

Importantly,HRT is not an anti-depressant,and so if anxiety and depressive symptoms are due to an underlying mood disorder they may not resolve without specific treatment.The approach to management should then follow the broad principles applied at other life stages.However,it is important to note that mid-life is a time of major psychosocial change ina woman′s life and so psychological and social interventions may be particularly helpful.For example,Mrs Chin is missing her daughter and a psychological therapy such as interpersonal therapy may be useful to help her deal with the ′loss′ of her daughter and her role transition from a mother caring for a dependant child to a new phase of her life[3].

1 Hickey M,Bryant C,Judd F.Evaluation and management of depressive and anxiety symptoms in midlife[J].Climacteric,2012,15(1):3-9.

2 Jean Hailes Foundation menopause management algorithm[EB/OL].www.jeanhailes.org.au.

3 Blashki G,Judd F,Piterman L.General Practice Psychiatry[M].Mc Graw Hill Medical,2007.