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An update from the WPA Section on Anxiety and Obsessive-Compulsive Disorders 世界心理学会焦虑症和强迫症分会提供的最新信息
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21255
Naomi A. Fineberg, Dan J. Stein, Katharina Domschke, Eric Hollander, Susanne Walitza, Michael Van Ameringen, Bernardo Dell'Osso, Joseph Zohar
<p>The WPA Section on Anxiety and Obsessive-Compulsive Disorders focuses its activities on a broad range of common and burdensome psychiatric conditions encompassing anxiety and fear-related disorders, obsessive-compulsive and related disorders, and behavioural addiction disorders, including problematic Internet use. This is an exciting area of developing clinical practice, as anxiety and obsessive-compulsive symptoms are increasingly played out in the digital environment.</p><p>The Section provides a forum for clinician scientists and academics to exchange experiences and research advances. It organizes activities at WPA meetings, produces scientific publications and develops guidance on relevant topics, in collaboration with key stakeholder groups such as the World Health Organization (WHO), the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) (www.icocs.org), the Anxiety Disorders and Obsessive-Compulsive Research Networks of the European College of Neuropsychopharmacology (ECNP) (www.ecnp.eu), and the European Network for Problematic Usage of the Internet (www.internetandme.eu). Here we review some of the Section's recent initiatives and its ambitions for the next five years.</p><p>The ICD-11 has refined and expanded the classification of anxiety disorders, and created two new groupings, one for Obsessive-Compulsive and Related Disorders and another for Disorders due to Addictive Behaviours, including several new diagnoses.</p><p>The ICD-11 grouping of Anxiety or Fear-Related Disorders differentiates fear-related disorders (i.e., phobias related to discrete aversive situations) from anxiety disorders related to a sustained expectation that diffuse aversive events will occur. Separation anxiety disorder and selective mutism have been moved into this grouping.</p><p>Obsessive-compulsive and related disorders often present late for treatment, resulting in poor clinical outcomes. To improve recognition and diagnosis, some members of our Section worked with the WHO to reclassify disparate diagnoses into a single Obsessive-Compulsive and Related Disorders grouping. A seminal field study demonstrated that health care practitioners make more accurate diagnoses of these disorders using the ICD-11 vs. ICD-10<span><sup>1</sup></span>. Moreover, this new classification has advanced research heuristics establishing compulsivity as a transdiagnostic neuropsychological domain.</p><p>Another new ICD-11 grouping was created for Disorders due to Addictive Behaviours. This includes two new disorders – gaming disorder and gambling disorder (on- or off-line) – and a residual category for possible diagnosis of other forms of problematic behaviour with addictive, impulsive and/or compulsive features, including buying or shopping, pornography use, social media use, cyberchondria, digital hoarding, and online streaming.</p><p>Evidence of overlap between compulsive and addictive mechanisms and disorders has led to the establishment of the
世界精神病学协会焦虑症和强迫症分会的活动重点是广泛的常见和负担沉重的精神疾病,包括焦虑和恐惧相关疾病、强迫症和相关疾病,以及行为成瘾疾病,包括有问题的互联网使用。该分会为临床科学家和学者提供了一个交流经验和研究进展的论坛。它与世界卫生组织 (WHO)、国际强迫症学院 (ICOCS) (www.icocs.org)、欧洲神经精神药理学学院 (ECNP) 焦虑症和强迫症研究网络 (www.ecnp.eu) 以及欧洲互联网问题使用网络 (www.internetandme.eu) 等主要利益相关团体合作,在世界心理学会会议上组织活动,出版科学刊物,并就相关主题制定指南。在此,我们回顾了该科最近的一些举措及其未来五年的雄心壮志。ICD-11细化并扩展了焦虑症的分类,并创建了两个新的分类,一个是强迫症及相关障碍,另一个是成瘾行为导致的障碍,其中包括几个新的诊断、ICD-11 将恐惧相关障碍(即与离散的厌恶情境有关的恐惧症)与持续预期会发生弥漫性厌恶事件的焦虑障碍区分开来。分离焦虑症和选择性缄默症也被归入了这一组。强迫症及相关障碍往往很晚才接受治疗,导致临床疗效不佳。为了改进识别和诊断,我们科的一些成员与世界卫生组织合作,将不同的诊断重新归类为单一的强迫症及相关障碍组。一项开创性的实地研究表明,医护人员使用 ICD-11 与 ICD-101 对这些疾病做出的诊断更为准确。此外,这一新的分类方法还推动了研究启发式方法的发展,将强迫症确定为一种跨诊断的神经心理学领域。这包括两个新的疾病--游戏障碍和赌博障碍(在线或离线)--以及一个残余类别,用于诊断其他形式的具有成瘾、冲动和/或强迫特征的问题行为,包括购买或购物、使用色情制品、使用社交媒体、网络成瘾症、数字囤积和在线流媒体。该网络出版了有关诊断、基本机制和评估的重要共识文件2,最终举办了科学与艺术节、一系列教育网络研讨会、在WPA《全球心理健康实践丛书》中出版了一本教科书3,并出版了一本广受欢迎的电子书《学会应对有问题的互联网使用》,该书被翻译成五种语言,免费下载数百次(www.icocs.org)。COVID-19大流行病及其后果使人们更加关注焦虑症和强迫症以及有问题的互联网使用。对于患有上述疾病的人来说,大流行期间固有的感染危险直接影响了临床治疗,因为这增加了他们对社会的回避,阻碍了他们参与重要的治疗活动。僵化的思维和对健康的执着关注导致了公共卫生方面的挑战,如对疫苗的犹豫不决以及难以摆脱 COVID-19 封闭状态。这些挑战和风险包括如何平衡在线和离线时间、滥用和错误信息的传播以及社会分裂等问题。有问题的互联网使用是一个总的类别,代表了各种形式的适应不良的互联网使用,涉及失控或危险的使用模式,对个人和社会的健康和福祉具有深远的有害影响2, 4。认知控制能力尚未发育成熟的青少年和有某些心理健康问题的青少年受这种情况的影响尤为严重,可将其视为自我管理紊乱的标志。重要的是,在 COVID-19 大流行期间,全球有问题的互联网使用率有所增加,在一项荟萃分析中达到了 7.9%,在一些中低收入国家超过了 30%5。
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引用次数: 0
Implementation of the ICD-11 CDDR in China 在中国实施 ICD-11 CDDR
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21251
Jiang Long, Na Zhong, Jingjing Huang, Geoffrey M. Reed, Zhen Wang, Yifeng Xu, Min Zhao
<p>Since 2007, China has been actively collaborating with the World Health Organization (WHO) and international colleagues in the revision, field testing, training, and implementation of the ICD-11 chapter on mental, behavioural and neurodevelopmental disorders, and the related Clinical Descriptions and Diagnostic Requirements (CDDR)<span><sup>1</sup></span>. In 2018, the National Health Commission clearly highlighted the importance of the ICD-11 and requested all health care providers in China to use the ICD-11 in their clinical practice<span><sup>2</sup></span>. The ICD-11 CDDR are particularly instrumental to achieving this goal in mental health systems in China, as a vast country with over 30 provincial-level administrative regions and a population of more than 1.4 billion.</p><p>The Shanghai Mental Health Center (SMHC), as a WHO Collaborating Centre for Research and Training in Mental Health and a National Center for Mental Disorders, has led the field testing and implementation of the ICD-11 CDDR in China<span><sup>3</sup></span>. Together with other WHO Collaborating Centers in China, National Centers for Mental Disorders, and prestigious institutions across the country, the SMHC has built a core team for ICD-11 CDDR implementation with over 60 national mental health leaders, including heads of leading mental health institutions and presidents of scientific and professional mental health associations. The implementation of the CDDR in China involves an interrelated and growing set of activities including translation, field testing, research, advocacy and training.</p><p>Translation is the cornerstone of implementing the ICD-11 CDDR in China. The translation process started in 2016, and was a collective effort by experts from Shanghai, Beijing and Changsha, coordinated by the SMHC. It was an iterative process involving eight rounds of review and revision over eight years, with 24 translators and 12 reviewers contributing to the work. The final Chinese version of the ICD-11 CDDR is now available for all mental health professionals in China.</p><p>In conjunction with the translation process, China conducted field testing of the ICD-11 CDDR from 2016 to 2021, following the protocols provided by the WHO. The SMHC was designated as an International Field Study Centre by the WHO, and the president of the SMHC, Min Zhao, was selected as chair of the ICD-11 International Advisory Group on Training and Implementation.</p><p>The Chinese field-testing work involved 2,224 patients, 59 clinical raters, 59 referring clinicians, and 23 research assistants from 10 field testing sites nationwide. The field testing was conducted through a rigorous, multidisciplinary and participatory approach, and the results were submitted to the WHO in 2021 to support the ICD-11 CDDR validation and finalization.</p><p>In June 2018, after most of the content in the CDDR had been finalized, the SMHC coordinated efforts with various government and professional agencies t
此外,由于中国目前缺乏有关博弈障碍的知识和专业技能,国医健委牵头开展了相关研究,开发了中文筛查工具,提供了公共卫生建议7,参与了世界卫生组织关于开发新的博弈障碍国际筛查和诊断工具的合作项目8,并与世界卫生组织和其他重要合作伙伴合作,组织了网络研讨会,以提高评估和治疗博弈障碍的能力。在超过15年的工作中,有几个因素促成了中国成功实施《中国儿童发展报告》。首先,中国政府在制定和推广国家卫生保健国际标准方面发挥着至关重要的作用。政府对 ICD-11 的大力支持为 CDDR 的实施和推广提供了良好的氛围。其次,为在中国实施 CDDR 而确定并授权一个地方倡导者对于提供领导、整体协调、资源动员、培训、质量保证、变革管理和可持续性至关重要。受世卫组织委托,国家卫生健康委员会领导了实施工作,并在应对实施新分类系统的巨大挑战中发挥了重要作用。第三,公众宣传活动和利益攸关方参与举措提高了人们对实施 ICD-11 CDDR 好处的认识。未来,我们将继续推动ICD-11 CDDR在中国的应用和推广,最终实现在中国推广精神卫生保健的目标9。首先,我们将继续在全国范围内开展有关 ICD-11 CDDR 的培训,培训对象包括精神科医生、心理医生、全科医生、护士、社工、卫生管理人员和政策制定者等精神卫生专业人员。其次,将建立一个采用 ICD-11 CDDR 的互动网络,以推动研究、培训和临床举措,从而提高该国精神卫生保健的质量。第三,将开展进一步的活动,如开发新的辅助诊断工具、筛查工具和基于 ICD-11 的教学课程,以促进 ICD-11 和 CDDR 的本地化调整和应用。最后,中国将继续加强与国际精神医学专家和组织的国际合作,促进全球精神卫生事业的发展。
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引用次数: 0
Prevention, treatment and care of substance use disorders among adolescents. Statement by the UNODC-WHO Informal Scientific Network, 2024 青少年药物使用失调的预防、治疗和护理。联合国毒品和犯罪问题办公室-世界卫生组织非正式科学网络的声明,2024 年
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21260
Nora D. Volkow, Michael P. Schaub, Anja Busse, Vladimir Poznyak, Dzmitry Krupchanka, Giovanna Campello
<p>Since 2014, the United Nations Office on Drugs and Crime (UNODC) - World Health Organization (WHO) Informal Scientific Network (ISN) has brought the voice of science to international drug policy discussions at the Commission on Narcotic Drugs, the drug-control policy-making body of the United Nations (UN). The public health dimensions of substance use, including prevention and treatment of substance use disorders, have become prominent in policy debates within the UN system.</p><p>Adolescence, which is the focus of this ISN statement, has been defined as individuals aged between 10 and 19 years<span><sup>1</sup></span>. While no global data on substance use within this full age range could be located, global data among more limited subsets are available. Alcohol is the most commonly used substance among all people 15+ years of age<span><sup>2</sup></span>: 155 million, i.e. more than a quarter (26.5%) of all those aged 15-19, are current drinkers. In addition, the 15-19 age group exhibits higher rates of heavy episodic drinking when compared to the total population of drinkers<span><sup>3</sup></span>. Cannabis is the internationally controlled substance most widely used by adolescents, and its use among 15-16-year-olds varies by region, from less than 3% annual prevalence in Asia to over 17% in Oceania. In most geographical areas, the proportion of adolescents using cannabis is higher than in the general population aged 15-64<span><sup>3</sup></span>.</p><p>Consistent with Sustainable Development Goals<span><sup>4</sup></span> and other international commitments<span><sup>5</sup></span>, UN Member States called for comprehensive, evidence-based prevention of substance use, including early prevention<span><sup>6</sup></span> and available, accessible, diverse, evidence-based treatment and care for children and young people with substance use disorders<span><sup>7</sup></span>. There is a joint responsibility for policy makers, scientists, service providers, and communities to implement effective demand-reduction strategies and to adequately address prevention, treatment and recovery support, as well as measures to reduce the negative health and social consequences of substance use disorders among adolescents.</p><div>The UNODC-WHO ISN makes the following recommendations: <ul><li>Expand the availability and use of evidence-based prevention, treatment and care strategies and interventions for adolescents, and ensure sustainable funding for their implementation.</li><li>Facilitate the availability of evidence-based prevention programs in the public domain with reimbursement schemes, thus allowing for preventive interventions to be inclusive and to address the needs of socio-economically disadvantaged groups, ensuring that minoritized populations, Indigenous groups; and lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ+) people are included.</li><li>Promote population-based and environmental prevention measures, such as enfor
确保人道主义应急准备和响应计划考虑到如何应对药物使用和亚药物使用障碍,包括青少年中的药物使用和亚药物使用障碍,以加强支持系统在这些紧急情况下的应变能力,包括在冲突、战争环境、自然灾害、被迫迁徙和其他流离失所的情况下。应用在线和远程学习元素,加强预防和治疗队伍、投资于青少年药物滥用病症的循证预防和治疗,并投资于相关研究,以加强对青少年药物滥用病症的了解(包括生物心理社会风险和保护因素),从而为不同情况下的青少年制定有效的预防和治疗策略提供依据。科学家、政策制定者、从业人员和社区必须共同努力,实施最有效的预防和治疗战略、政策和干预措施,例如联合国毒品和犯罪问题办公室-世界卫生组织《国际药物滥用预防标准》和联合国毒品和犯罪问题办公室-世界卫生组织《国际药物滥用病症治疗标准》中概述的那些战略、政策和干预措施。国际青少年网络建议决策者将针对青少年药物使用和药物使用失调的循证和道德政策付诸实践,并提供必要的资源,使每个青少年都能达到最高的健康水平。
{"title":"Prevention, treatment and care of substance use disorders among adolescents. Statement by the UNODC-WHO Informal Scientific Network, 2024","authors":"Nora D. Volkow, Michael P. Schaub, Anja Busse, Vladimir Poznyak, Dzmitry Krupchanka, Giovanna Campello","doi":"10.1002/wps.21260","DOIUrl":"https://doi.org/10.1002/wps.21260","url":null,"abstract":"&lt;p&gt;Since 2014, the United Nations Office on Drugs and Crime (UNODC) - World Health Organization (WHO) Informal Scientific Network (ISN) has brought the voice of science to international drug policy discussions at the Commission on Narcotic Drugs, the drug-control policy-making body of the United Nations (UN). The public health dimensions of substance use, including prevention and treatment of substance use disorders, have become prominent in policy debates within the UN system.&lt;/p&gt;\u0000&lt;p&gt;Adolescence, which is the focus of this ISN statement, has been defined as individuals aged between 10 and 19 years&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt;. While no global data on substance use within this full age range could be located, global data among more limited subsets are available. Alcohol is the most commonly used substance among all people 15+ years of age&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt;: 155 million, i.e. more than a quarter (26.5%) of all those aged 15-19, are current drinkers. In addition, the 15-19 age group exhibits higher rates of heavy episodic drinking when compared to the total population of drinkers&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt;. Cannabis is the internationally controlled substance most widely used by adolescents, and its use among 15-16-year-olds varies by region, from less than 3% annual prevalence in Asia to over 17% in Oceania. In most geographical areas, the proportion of adolescents using cannabis is higher than in the general population aged 15-64&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt;.&lt;/p&gt;\u0000&lt;p&gt;Consistent with Sustainable Development Goals&lt;span&gt;&lt;sup&gt;4&lt;/sup&gt;&lt;/span&gt; and other international commitments&lt;span&gt;&lt;sup&gt;5&lt;/sup&gt;&lt;/span&gt;, UN Member States called for comprehensive, evidence-based prevention of substance use, including early prevention&lt;span&gt;&lt;sup&gt;6&lt;/sup&gt;&lt;/span&gt; and available, accessible, diverse, evidence-based treatment and care for children and young people with substance use disorders&lt;span&gt;&lt;sup&gt;7&lt;/sup&gt;&lt;/span&gt;. There is a joint responsibility for policy makers, scientists, service providers, and communities to implement effective demand-reduction strategies and to adequately address prevention, treatment and recovery support, as well as measures to reduce the negative health and social consequences of substance use disorders among adolescents.&lt;/p&gt;\u0000&lt;div&gt;The UNODC-WHO ISN makes the following recommendations: &lt;ul&gt;\u0000&lt;li&gt;Expand the availability and use of evidence-based prevention, treatment and care strategies and interventions for adolescents, and ensure sustainable funding for their implementation.&lt;/li&gt;\u0000&lt;li&gt;Facilitate the availability of evidence-based prevention programs in the public domain with reimbursement schemes, thus allowing for preventive interventions to be inclusive and to address the needs of socio-economically disadvantaged groups, ensuring that minoritized populations, Indigenous groups; and lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ+) people are included.&lt;/li&gt;\u0000&lt;li&gt;Promote population-based and environmental prevention measures, such as enfor","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":"15 1","pages":""},"PeriodicalIF":73.3,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142248420","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Emotion regulation and mental health: current evidence and beyond 情绪调节与心理健康:现有证据及其他
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21244
Matthias Berking
<p>The concept of emotion regulation (ER) is receiving considerable attention in research on psychiatric disorders and their treatment. The popularity of the concept is largely rooted in its premise that deficits in adaptive responses toward undesired affective states contribute to the development and maintenance of most forms of psychopathology.</p><p>This appears obvious when considering psychiatric disorders that are primarily defined by an excess of undesired affective states (e.g., anxiety and mood disorders). For these conditions, it follows almost by definition that the perpetuation or escalation of undesired affective states results from the individual's inability to regulate them.</p><p>However, given that many behavioral and cognitive symptoms of other psychiatric disorders can also be conceptualized as dysfunctional ER strategies, the scope of this paradigm extends much further. Consider, for example, when avoidance is used to reduce anxiety, when alcohol is consumed to numb loneliness, when binge eating serves to distract from emotional anguish, or when appraising a situation as uncontrollable and hopeless is used to reduce the pressure to solve one's problems or to shield oneself from further disappointment. In all these scenarios, behavioral or cognitive strategies yield short-lived relief from undesired affective states. Since the immediate ameliorating effects of these maladaptive strategies reinforce their usage, individuals tend to progressively increase their adoption until criteria for an anxiety, alcohol use, eating or mood disorder, etc. are met.</p><p>Importantly, this trajectory is preventable if the individual realizes the negative mid- and long-term consequences of maladaptive strategies, and pivots to more adaptive ways of coping with undesired affective states. However, any such shift will fail to the extent that the individual lacks effective ER skills. Since all psychiatric disorders are arguably maintained by behaviors and cognitions that initially reduce negative affect, and since a distressed individual is more likely to utilize those strategies in the absence of more adaptive alternatives, it can be hypothesized that all psychiatric disorders are, to a significant degree, perpetuated by insufficient ER skills.</p><p>Drawing on this framework, it can be deduced that patients with psychiatric disorders should benefit from treatments that systematically enhance effective ER skills. Evidence-based ER frameworks, such as the Adaptive Coping with Emotions Model<span><sup>1</sup></span>, posit that such treatments should foster the ability to modify the intensity and duration of undesired affective states, as well as the ability to accept and tolerate such states when modification is not possible.</p><p>Additionally, these treatments should foster so-called preparatory ER skills that facilitate the successful utilization of modification- and acceptance-focused ER skills. Examples of such preparatory skills include
情绪调节(ER)的概念在精神疾病及其治疗的研究中备受关注。这一概念的流行在很大程度上源于它的前提,即对不良情绪状态的适应性反应的缺陷是大多数精神病理学发展和维持的原因。对于这些病症,从定义上就可以看出,不良情绪状态的持续或升级是由于个体无法调节这些情绪状态。然而,鉴于其他精神疾病的许多行为和认知症状也可以被概念化为功能失调的应急反应策略,因此这一范式的范围可以延伸得更远。举例来说,当回避被用来减轻焦虑时,当饮酒被用来麻痹孤独感时,当暴饮暴食被用来转移情绪上的痛苦时,或者当把某种情况评价为无法控制和毫无希望时,被用来减轻解决问题的压力或避免进一步的失望。在所有这些情况下,行为或认知策略都能在短期内缓解不想要的情绪状态。重要的是,如果个体意识到适应不良策略所带来的中长期负面影响,并转而采用适应性更强的方式来应对不良情绪状态,那么这一轨迹是可以避免的。然而,如果个体缺乏有效的应急技能,任何这种转变都会失败。由于所有的精神障碍都可以说是通过最初减少负面情绪的行为和认知来维持的,而且在没有更多适应性替代方法的情况下,痛苦的个体更有可能使用这些策略,因此可以假设,所有的精神障碍在很大程度上都是由于缺乏有效的应急反应技能而长期存在的。以证据为基础的ER框架,如 "适应性情绪应对模式"(Adaptive Coping with Emotions Model1),认为此类治疗应培养患者改变不良情绪状态的强度和持续时间的能力,以及在无法改变不良情绪状态时接受和容忍这种状态的能力。这些准备技能的例子包括意识到自己的感受、充分识别和标记自己的感受、建立一个解释自己目前的感受是如何维持的心理模型,最好是以验证和消除自己的经历的方式,同时也提出具体的工具来促进成功的改变/接受。因此,以ER为重点的治疗还应加强患者的自我支持技能,使其能够坚持不懈地采取适应性策略,尽管这些策略最初可能会加重患者的负面情绪。此外,大量的纵向研究和实验研究表明,这种关联是由急诊室技能缺陷影响心理健康造成的,而不是(完全)相反3。关于特定应急反应技能的重要性,大量证据支持重新评估、接纳和自我同情的有效性4、5。更多的研究表明,明确侧重于提高应急反应技能的治疗方法(如辩证行为疗法)可有效治疗多种精神障碍。文献中更具体的证据表明,专门针对提高ER技能的干预措施(如情感调节训练、情绪调节疗法)可有效治疗多种失调症2、6。最后,在这些研究中观察到的明显中介效应表明,ER技能的提高是症状严重程度减轻的主要驱动力7、8。虽然这些发现令人鼓舞,但精神病理学背景下的ER研究仍然充满了挑战。首先,关键术语的概念定义不够清晰,从情感一词开始,尽管已经有人提出了更具体的定义(如:"情绪"、"情感 "和 "情绪"),但该词仍被广泛用于各种情感状态。
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引用次数: 0
Improving education in psychiatry in an evolving scenario: the activities of the WPA Section on Education in Psychiatry 在不断变化的形势下改进精神病学教育:世界精神病学协会精神病学教育分会的活动
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21258
Gaia Sampogna, Hasanen Al-Taiar, Franziska Baessler, Bulent Coskun, Hussien Elkholy, Mariana Pinto da Costa, Rodrigo Ramalho, Andrea Fiorillo
<p>Education of mental health professionals should reflect the changes occurring at scientific, clinical and sociocultural levels, and thus it should be continuously updated. However, in many parts of the world, psychiatric education is still based on a knowledge formed in the last century, and the most recent knowledge on the structure and functioning of the brain, human behaviors and social relationships is missing.</p><p>Moreover, the mission of psychiatrists has evolved over time, from the diagnosis and management of full-blown mental disorders to the identification of a series of mental health problems which are associated with high levels of personal and societal burden. The involvement of experts by experience in policy, clinical and research activities is now acknowledged as a priority<span><sup>1, 2</sup></span>, and the need for a clinical characterization of individual patients beyond diagnosis in order to personalize treatment is widely recognized<span><sup>3, 4</sup></span>. These changes should be taken into account by current educational curricula, but this is not always the case.</p><p>The WPA Section on Education in Psychiatry is committed to improve training and education worldwide, with a special attention to low- and middle-income countries (LMICs), since the future of psychiatry as a discipline strongly depends on the education of the new generations of professionals.</p><p>The Section is updating the type of educational materials available for mental health professionals, and is keen to disseminate them worldwide<span><sup>5</sup></span>. In the last triennium, it has contributed to several educational activities, including the development of informational packages for the general public to decrease misconceptions on people with mental disorders, the update of training curricula for undergraduate medical students, and the organization of educational workshops and meetings for psychiatrists and other mental health professionals.</p><p>In the triennium 2020-2023, following the COVID-19 pandemic – which has represented an unprecedent traumatic event with a detrimental impact on education, training and practice worldwide – the Section has been particularly active in developing and producing new tools to improve education in mental health worldwide<span><sup>6-8</sup></span>.</p><p>The Chair of the Section, in collaboration with the WPA Past-President, has promoted a survey targeting the WPA Zonal Representatives, to identify the educational needs and interests of professionals associated with the WPA<span><sup>9</sup></span>. The main finding has been that these professionals are mostly concerned with public mental health activities and with primary prevention of mental disorders. The main unmet need is the development, implementation and dissemination of educational activities in languages other than English, in order to broaden their accessibility.</p><p>Moreover, the Section has collected experiences on education and tr
研讨会的互动结构使与会者能够交流教育和专业经验,提出问题并获得专家的建议。在主旨发言人中,A. Javed教授和N.A. Javed教授和N. Sartorius教授分享了他们的经验,介绍了如何找到创新的解决方案来改进精神病学的培训和教育,并特别强调了领导力和沟通技巧。该研讨会的成功证实,在线互动教育活动是降低组织和后勤成本的有用工具。该科一直在不断加强与致力于改善精神病学教育和培训的国际组织的合作,如欧洲精神病学协会(EPA)教育委员会和欧洲专科医生联盟(UEMS)。此外,分会主席还积极参加了在布鲁塞尔欧洲议会举行的会议,与来自欧洲医学专家联盟(UEMS)和世界卫生组织(WHO)的代表合作,分享有关精神健康教育机会的想法。我们期待着有更多机会与所有同仁和其他对提升全球精神病学教育感兴趣的利益相关者进行交流。
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引用次数: 0
The WHO Flexible Interview for ICD-11 (FLII-11) 世卫组织 ICD-11 灵活访谈(FLII-11)
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21227
Geoffrey M. Reed, Karen T. Maré, Michael B. First, T.S. Jaisoorya, Girish N. Rao, John-Joe Dawson-Squibb, Christine Lochner, Mark van Ommeren, Dan J. Stein
<p>The movement to a descriptive, symptom-based diagnostic system that started with the DSM-III was in part a response to widespread concerns and criticisms regarding the reliability of psychiatric diagnoses. This fueled an emphasis on increasingly precise operationalization of diagnostic constructs and criteria, based on the assumption that this would produce successive improvements in reliability.</p><p>Clinician-administered structured diagnostic interviews were subsequently developed. For example, the Research Diagnostic Criteria were used to develop a Schedule for Affective Disorders and Schizophrenia<span><sup>1</sup></span>, while the DSM-III criteria were incorporated into the Structured Clinical Interview for DSM (SCID)<span><sup>2</sup></span>. In addition, the Diagnostic Interview Schedule<span><sup>3</sup></span> was developed for use by non-clinician interviewers in epidemiological surveys of mental disorders. These instruments have been widely used in research on mental disorders.</p><p>Structured diagnostic interviews have subsequently been developed or adapted for successive revisions of the DSM and the ICD. The SCID, a semi-structured interview – meaning that the interviewer probes unclear responses and makes certain clinical judgments – has been updated with each edition of the DSM<span><sup>4</sup></span>. The briefer and fully structured Mini International Neuropsychiatric Interview (MINI)<span><sup>5</sup></span> has also been widely employed. The Composite International Diagnostic Interview (CIDI)<span><sup>6</sup></span> incorporated both DSM and ICD diagnostic requirements and was used in the National Comorbidity Survey and the World Mental Health Surveys. Similarly, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), based on the Present State Examination, assessed for both DSM and ICD requirements<span><sup>7</sup></span>. Structured diagnostic interviews for children have also been developed, as have a range of more focused interviews that cover specific conditions or diagnostic groupings.</p><p>Based on an extensive program of field testing, the reliability of the diagnostic guidance provided in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)<span><sup>8</sup></span> was found to be higher than that of other mental disorder classification systems, ranging from moderate to almost perfect according to the specific category. This finding was perhaps counterintuitive, insofar as the CDDR avoid highly prescriptive symptom counts and duration requirements, unless these are specifically supported scientifically, in order to facilitate clinical use.</p><p>These results, therefore, challenge the assumed relationship between operational precision and diagnostic reliability. They also suggest that the diagnoses based on the CDDR would be sufficiently reliable for certain types of research projects (e.g., studies focusing on diagnostic gr
从 DSM-III 开始的以症状为基础的描述性诊断系统的发展,在一定程度上是为了回应人们对精神病诊断可靠性的广泛关注和批评。这促使人们开始强调诊断结构和标准的日益精确的可操作性,并假定这将使诊断的可靠性不断提高。例如,"研究诊断标准 "被用于制定 "情感障碍和精神分裂症时间表 "1 ,而 "DSM-III 标准 "则被纳入了 "DSM 结构化临床访谈(SCID)"2。 此外,还制定了 "诊断访谈时间表 "3,供非临床医师访谈者在精神障碍流行病学调查中使用。这些工具已被广泛应用于精神障碍的研究中。结构化诊断访谈随后被开发或改编用于 DSM 和 ICD 的历次修订。SCID 是一种半结构化访谈--即访谈者对不明确的回答进行试探并做出某些临床判断--已随着 DSM4 的每一版进行了更新。更简短、完全结构化的迷你国际神经精神病学访谈(MINI)5 也被广泛采用。国际综合诊断访谈(CIDI)6 纳入了 DSM 和 ICD 的诊断要求,并被用于全国发病率调查和世界精神健康调查。同样,基于现状检查的神经精神病学临床评估表(SCAN)也同时评估了 DSM 和 ICD 的要求7。根据一项广泛的现场测试计划,《ICD-11 精神、行为和神经发育障碍临床描述和诊断要求》(CDDR)8 提供的诊断指导的可靠性高于其他精神障碍分类系统,根据具体类别从中等到几乎完美不等。这一结果可能与直觉相反,因为 CDDR 避免了高度规范化的症状计数和持续时间要求,除非这些要求得到科学的具体支持,以方便临床使用。这些结果还表明,基于 CDDR 的诊断对于某些类型的研究项目(例如,以医疗机构中的诊断群体为重点的研究)来说是足够可靠的。然而,在其他类型的研究中,标准化的诊断评估是可取的,以控制与不同技能水平、面谈风格和临床判断相关的临床医生层面的变异性。例如,在根据特定诊断要求选择参与者的药理学试验中,可靠、可重复地记录特定症状模式的能力往往非常重要。流行病学调查或其他基于人群的调查中,涉及非专业(即未接受过临床培训)访谈者时,也需要预设问题和严格的决策规则,因为这些调查不能依靠访谈者的临床知识来判断是否存在特定特征。因此,诊断访谈几乎从一开始就是 CDDR 相关工作计划的一部分。因此,诊断性访谈几乎从一开始就是 CDDR 相关工作计划的一部分。相关工作采用了严格的开发流程,并邀请了分类学和诊断性访谈领域的国际专家参与。自 2014 年以来,ICD-11 结构化临床访谈(SCII-11)的工作一直在进行。这是一个半结构化的诊断访谈--旨在由训练有素的临床医师进行--提供了一套标准化的问题,每个问题评估一个特定的诊断要求,以形成鉴别诊断。尽管 SCII-11 是为研究应用而开发的,但它也可用于培训目的和临床环境。由于 CDDR 对诊断要求的设定更加面向临床,因此在开发 SCII-11 时有必要增加可操作性。具体来说,SCII-11 用更精确的诊断阈值取代了 CDDR 中不那么规范的术语(例如,至少有三个而不是 "几个 "症状;至少有三个月而不是 "持续")。此外,还针对 CDDR 中可能以各种不同方式表现出来的内容(如精神分裂症中的 "持续妄想")开发了特定的问题。
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引用次数: 0
How the ICD-11 and the CDDR address the public health dimensions of substance use ICD-11 和 CDDR 如何解决药物使用的公共卫生问题
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21252
María Elena Medina-Mora, Rebeca Robles
<p>The use of psychoactive substances is highly prevalent and contributes substantially to risk behaviours, morbidity and mortality. The United Nations Office on Drugs and Crime World Drug Report<span><sup>1</sup></span> estimated that, in 2021, one in every 17 people aged 15-64 in the world had used an illicit drug in the year before. Users increased from 240 million in 2011 to 296 million in 2021, substantially more than accounted for by population growth.</p><p>Cannabis continued to be the most used illicit drug (219 million users, 4.3% of the global adult population); 36 million people had used amphetamines, 22 million cocaine, and 20 million methylenedioxymethamphetamine (MDMA or “ecstasy”) or related drugs in the previous year. An estimated 60 million people engaged in non-medical opioid use, 31.5 million of whom used opiates (i.e., non-synthetic opioids; mainly heroin).</p><p>Globally, there is very limited implementation of efficient and effective prevention strategies for substance use<span><sup>2</sup></span>, and there is a substantial treatment gap for disorders due to this use<span><sup>3</sup></span>. Global evidence has called attention to the need for a new and comprehensive conceptualization of substance use disorders that incorporates the full range of relevant conditions, from risky consumption to mental disorders linked to harmful drug use<span><sup>4</sup></span>.</p><p>In response to these challenges, the World Health Organization (WHO) adopted a public health approach to the development of the classification of disorders due to substance use in the ICD-11. By public health approach, we refer to a broader perspective that integrates health and social aspects, aiming to benefit affected individuals and their community, and focusing on population well-being<span><sup>5</sup></span>.</p><p>From a public health perspective, it is essential to identify persons who exhibit a hazardous use of substances that increases the risk of harmful psychological or medical consequences, but whose symptoms do not meet the diagnostic requirements for substance use disorders. These individuals can benefit from education, prevention, and community interventions. People with diagnosable disorders need harm reduction and treatment services of differing intensities and settings, depending on the nature of their condition and the substance involved. Those who suffer physical or psychological harm due to others’ substance use should also be identified and may require services<span><sup>6</sup></span>.</p><p>In line with this perspective, the range of psychoactive substances classified in the ICD-11 section on disorders due to substance use has been expanded, reflecting changes in the substances associated with public health impact in different parts of the world. An extended set of substance classes will help track patterns more accurately, in order to formulate appropriate clinical and social policy responses nationally and globally. For example
精神活性物质的使用非常普遍,是导致危险行为、发病率和死亡率的重要因素。据联合国毒品和犯罪问题办公室《世界毒品报告》1 估计,到 2021 年,全世界每 17 个 15-64 岁的人中就有一人在前一年使用过非法药物。大麻仍然是使用最多的非法药物(2.19 亿使用者,占全球成年人口的 4.3%);上一年有 3,600 万人使用过苯丙胺,2,200 万人使用过可卡因,2,000 万人使用过亚甲二氧基甲基苯丙胺(MDMA 或 "摇头丸")或相关药物。据估计,有 6,000 万人使用过非医用类阿片,其中 3,150 万人使用过阿片剂(即非合成类阿片;主要是海洛因)。在全球范围内,针对药物使用的高效和有效预防战略的实施非常有限2 ,而针对药物使用导致的失调症的治疗存在巨大差距3。全球证据表明,有必要对药物使用失调症进行新的、全面的概念化,将从危险消费到与有害药物使用相关的精神障碍等所有相关情况纳入其中4。为应对这些挑战,世界卫生组织(WHO)采用了公共卫生方法来制定 ICD-11 中药物使用失调症的分类。我们所说的公共卫生方法,指的是一种将健康和社会方面结合起来的更广阔的视角,旨在使受影响的个人及其社区受益,并关注人口福祉5。从公共卫生的角度来看,有必要识别那些表现出有害使用药物,从而增加了有害心理或医疗后果风险,但其症状并不符合药物使用失调诊断要求的人。这些人可以从教育、预防和社区干预中受益。有可诊断病症的人需要不同强度和环境的减低危害和治疗服务,这取决于他们的病症性质和所涉及的物质。那些因他人使用药物而遭受身体或心理伤害的人也应被识别出来,并可能需要服务6。根据这一观点,ICD-11 中关于药物使用引起的失调部分所分类的精神活性物质的范围已经扩大,反映了世界不同地区与公共健康影响相关的物质的变化。扩展后的物质类别将有助于更准确地跟踪模式,以便在国家和全球范围内制定适当的临床和社会政策应对措施。例如,新增了一组合成大麻素引起的失调类别。合成大麻素被喷洒在天然草药混合物上,以模仿大麻的兴奋效果,并可产生呼吸抑制作用7。高收入国家报告了合成大麻素的使用情况,但中低收入国家的资料很少1。正如《ICD-11 精神、行为和神经发育障碍的临床描述和诊断要求》(CDDR)8 中所述,每一类精神活性物质都有四种主要病症,这些病症按等级划分,相互排斥:a) 危险物质使用,其概念是一种在频率或数量上足以增加对使用者或他人的身体或精神 健康造成有害后果的风险的物质使用模式;由于它涉及尚未发生的伤害的递增风险,因 此不被视为精神障碍(相反,它出现在 ICD-11 关于 "影响健康状况或与医疗服务接触的因 素 "的章节中,便于医疗专业人员及早关注并提供建议);b) 有害药物使用发作,指已经对个人的身体或精神健康造成伤害,或导致伤害他人健康的行为,但不存在已知的药物使用模式;c) 有害的物质使用模式,这是一种亚依赖诊断,其特点是持续和重复的物质使用模式,通过个人行为直接对个人或他人造成伤害;以及 d) 物质依赖,即由于重复或持续使用某种物质而导致的物质使用调节障碍,通常伴有使用该物质的强烈内驱力。在 ICD-11 中,药物依赖诊断比 ICD-10 有所简化。它基于三个关键特征中至少两个特征的存在:a) 对药物使用的控制能力受损;b) 药物使用越来越优先于其他活动;c) 耐受或戒断的生理特征。
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引用次数: 0
Scientific validation of the ICD-11 CDDR ICD-11 CDDR 的科学验证
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21226
Mario Maj
<p>The process of scientific validation of the ICD-11 Clinical Descriptions and Diagnostic Requirements (CDDR) for Mental Disorders has spanned more than 10 years, being remarkably comprehensive and inclusive as well as truly international, with the involvement of many hundreds of clinicians and researchers from all regions of the world.</p><p>The field trials of the ICD-11 CDDR – contrary to those of the ICD-10 Clinical Descriptions and Diagnostic Guidelines (CDDG) and the DSM-5 diagnostic criteria – have been genuinely “developmental” (as opposed to “summative” or “evaluative”) in their nature<span><sup>1</sup></span>. That is, they have been conducted <i>before</i> the finalization of the relevant sets of criteria or guidelines – thus allowing the identification of conceptual or terminological problems in the proposed texts, the correction of those texts, and the further testing of the revised versions – rather than being conducted or concluded <i>after</i> the finalization of the relevant sets of criteria or guidelines, thus just providing information to clinicians about what they could expect from those products. As we will see, several amendments to the CDDR were actually implemented as a consequence of this design.</p><p>The CDDR field trials can be subdivided into two main groups: a) Internet-based trials, implemented through the Global Clinical Practice Network (involving, at the time when the trials were conducted, more than 15,000 mental health and primary health care professionals from more than 150 countries), which used a case vignette methodology to assess the effects of specific differences between the CDDR and the ICD-10 CDDG on the participants’ clinical decision making; b) clinic-based (or ecological) trials, assessing the reliability and clinical utility of the CDDR in real clinical contexts. The clinic-based trials differed from the DSM-5 field trials in that they used a joint-rater design (with two clinicians jointly interviewing each patient) rather than a test-retest design (with two clinicians separately interviewing each patient at different time points), thus controlling for information variance and more specifically testing the reliability of the proposed guidelines (rather than testing more generally the reliability of the relevant psychiatric diagnoses)<span><sup>2</sup></span>.</p><p>Among the Internet-based CDDR field trials, of special interest have been those focusing on disorders specifically associated with stress<span><sup>3</sup></span>, and on feeding and eating disorders<span><sup>4</sup></span>. A case-control field trial on the former grouping of disorders<span><sup>3</sup></span>, conducted with 1,738 mental health professionals from 76 countries, found that several changes introduced in the ICD-11 – including the addition of complex post-traumatic stress disorder (complex PTSD) and prolonged grief disorder – resulted in significantly improved diagnostic decisions. However, the trial also identified s
从《疾病分类与诊断登记表》初稿的编制到最终定稿,中间间隔了较长的一段时间,这也使得我们能够对《疾病分类与诊断登记表》中新引入的一些类别进行广泛而详细的验证。根据2024年2月8日在PubMed上进行的搜索,自2013年以来发表的关于长期悲伤障碍的具有原始数据的论文共有57篇。总体而言,这些论文证明了这一新类别的建构有效性、与其他疾病(如抑郁症和创伤后应激障碍)的区别、与明显功能障碍的关联(超越了伴随疾病的影响),以及与DSM-5持续性复杂丧亲障碍相比,在纵向研究中与长期悲伤模式的一致性更高。同日进行的PubMed搜索发现了自2013年以来发表的199篇关于复杂创伤后应激障碍的原始数据。总体而言,这些论文证明了这一新类别的有效性,并证明了它与创伤后应激障碍的不同之处,包括在广泛的文化背景下、在儿童和青少年以及成年人中、在多个遭受创伤的人群中7。ICD-11 CDDR 与经过国际测试的 DSM-5 诊断标准之间的另一个显著差异是关于儿童和青少年严重易激惹的分类。一项对来自 48 个国家8 的 196 名临床医生进行的研究发现,与 DSM-5 解决方案(引入了破坏性情绪调节障碍这一新类别)和 ICD-10 分类标准(将对立违抗障碍列为几种行为障碍之一,而不关注易激惹性)相比,CDDR 中提出的表述(将慢性易激惹-愤怒作为诊断对立违抗障碍的特指符)能更准确地识别严重易激惹性,并更好地与边界表现进行区分。通过在印度、英国和美国进行的一项国际研究(INCLUDE),ICD-11 CDDR 验证过程的另一个创新方面是通过经验让专家系统地参与进来9。这项研究收集了用户对抑郁发作、广泛性焦虑障碍、精神分裂症、双相 I 型障碍和人格障碍这五种诊断的意见。总的来说,CDDR 在许多情况下都被认为是有用的,与生活经验息息相关。当然,CDDR 科学验证中目前缺少的一个关键因素是其在普通临床实践中的表现。目前正在努力将 CDDR 翻译成尽可能多的语言,广泛传播 CDDR,并加快各国政府对 CDDR 的认可和实施。
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引用次数: 0
Ethics from the lens of the social dimension of psychiatry 从精神病学的社会维度透视伦理学
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21238
Sam Tyano
<p>From a historical perspective, Engel<span><sup>1</sup></span> conceptualized psychopathology as resulting from an interaction of three orders of factors: biological, psychological and social. The first half of the 20th century has been mostly devoted to conceptualizing the psychological component of mental disorders, the second half to the understanding of the biological component. We are now, in the 21st century, busy at better understanding the role of social processes that impact treatment approaches to psychopathology as well as the psychiatrist-patient relationship.</p><p>Even more than other medical disciplines, psychiatry is influenced by external events that plague society, such as epidemics, natural disasters and wars. These events often require the involvement of ethics committees that will determine the duties and rights of the physician in potentially conflictual ethical contexts, such as triage situations (i.e., choosing whom to treat first). The COVID-19 pandemic has shown how deeply interwoven the epidemiology of mental disorders and the access to mental health services are with both social factors and somatic health. Grief, isolation, loss of income and fear exacerbate existing mental health problems or create new ones. The pandemic has demonstrated that the biological and social dimensions of medicine and public health are inextricably linked<span><sup>2</sup></span>.</p><p>Profound changes in social values and norms, such as the legitimization of medical procedures for transgender individuals, or the availability of euthanasia in some countries, require a redefinition of the psychiatrist's role within the medical staff, and the development of ethical guidelines that take into account a variety of emotional, religious and ideological aspects pertaining to both the patient and the physician.</p><p>This changing scenario is extensively reflected in Galderisi et al's paper<span><sup>3</sup></span>. I will focus here on three of the issues discussed by the authors. The first is stigma related to mental disorders in society in general, and particularly in the medical world. Studies documenting the importance of social/environmental components in the development of psychopathology<span><sup>4</sup></span>, as well as those showing the close relationship between physical illness and emotional states, have contributed to reduce that stigma. The inclusion of psychiatric wards within general hospitals has been both a consequence and a further determinant of this evolution. Likewise, the importance of the psychiatrist's presence in transdisciplinary medical teams, as well as in hospital ethics committees, has become more obvious than in the past. It is also increasingly clear that codes of ethics of physical medicine and psychiatry overlap to a large extent, especially with regard to the therapist-patient relationship.</p><p>The second topic I wish to emphasize is the changing relationship between psychiatrists and representatives of
从历史的角度来看,恩格尔1 将精神病理学概念化为生物、心理和社会三种因素相互作用的结果。20 世纪上半叶主要致力于精神障碍的心理因素的概念化,下半叶则致力于对生物因素的理解。进入 21 世纪,我们正忙于更好地理解社会进程的作用,这些进程影响着精神病理学的治疗方法以及精神科医生与患者之间的关系。这些事件往往需要伦理委员会的参与,委员会将决定医生在分流(即选择先治疗谁)等可能发生冲突的伦理环境中的职责和权利。COVID-19 大流行表明,精神障碍的流行病学和心理健康服务的获取与社会因素和躯体健 康是多么紧密地交织在一起。悲伤、孤独、失去收入和恐惧会加剧现有的心理健康问题或产生新的问题。大流行病表明,医学和公共卫生的生物和社会层面有着千丝万缕的联系2。社会价值观和规范的深刻变化,如变性人医疗程序的合法化,或某些国家安乐死的可用性,都要求重新定义精神科医生在医务人员中的角色,并制定考虑到病人和医生情感、宗教和意识形态等多方面因素的伦理准则3。在此,我将重点讨论作者所讨论的三个问题。首先是整个社会,尤其是医学界对精神障碍的成见。有研究表明,社会/环境因素在精神病理学的发展过程中具有重要作用4 ,还有研究表明,身体疾病与情绪状态之间存在密切关系,这些都有助于减少这种成见。将精神科病房纳入综合医院既是这一演变的结果,也是其进一步的决定因素。同样,与过去相比,精神科医生在跨学科医疗团队以及医院伦理委员会中的重要性也变得更加明显。我想强调的第二个话题是精神科医生与患者和家属代表之间不断变化的关系。最近,我们目睹了前住院病人、他们的家人和人权组织举行的反对精神病学的示威活动。我们在社会层面的参与使得我们从家长式的立场转变为更加倾听、平等的立场。我们开始邀请这些示威者 "过马路",来参加我们的会议,与我们分享他们的观点,并在相互尊重的背景下,与我们讨论有关生活质量、患者权利、治疗效果与副作用以及胁迫情况等问题的困境。如今,在许多国家,精神病患者的代表被邀请参加讨论这些问题和分配研究资源的委员会。在一些国家,曾经的患者和/或其亲属也会参与医学生和住院医生的教学工作。这种合作提高了我们思维和工作方式的透明度,有助于减少精神病学所带来的耻辱感。这种态度的转变清楚地反映在了WPA的职业道德规范中2。其中一个仍然存在冲突并助长对精神科职业偏见的问题是强制措施的使用,这似乎剥夺了病人的自主权,而自主权是任何医疗职业道德规范的四项基本原则之一,其他三项原则分别是受益原则、非渎职原则和公正原则4。 自主权一词反映了病人拒绝接受治疗的权利。对于精神病患者而言,"自主 "的定义非常复杂,因为患者的 "自由 "意志受到其精神病症状和缺乏洞察力的影响。治疗(包括强制治疗)的目的是恢复病人独立工作所需的判断能力。
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引用次数: 0
Associations between physical diseases and subsequent mental disorders: a longitudinal study in a population-based cohort 身体疾病与后续精神障碍之间的关系:一项基于人群的队列纵向研究
IF 73.3 1区 医学 Q1 Medicine Pub Date : 2024-09-16 DOI: 10.1002/wps.21242
Natalie C. Momen, Søren Dinesen Østergaard, Uffe Heide-Jorgensen, Henrik Toft Sørensen, John J. McGrath, Oleguer Plana-Ripoll
People with physical diseases are reported to be at elevated risk of subsequent mental disorders. However, previous studies have considered only a few pairs of conditions, or have reported only relative risks. This study aimed to systematically explore the associations between physical diseases and subsequent mental disorders. It examined a population-based cohort of 7,673,978 people living in Denmark between 2000 and 2021, and followed them for a total of 119.3 million person-years. The study assessed nine broad categories of physical diseases (cardiovascular, endocrine, respiratory, gastrointestinal, urogenital, musculoskeletal, hematological and neurological diseases, and cancers), encompassing 31 specific diseases, and the subsequent risk of mental disorder diagnoses, encompassing the ten ICD-10 groupings (organic, including symptomatic, mental disorders; mental disorders due to psychoactive substance use; schizophrenia and related disorders; mood disorders; neurotic, stress-related and somatoform disorders; eating disorders; personality disorders; intellectual disabilities; pervasive developmental disorders; and behavioral and emotional disorders with onset usually occurring in childhood and adolescence). Using Poisson regression, the overall and time-dependent incidence rate ratios (IRRs) for pairs of physical diseases and mental disorders were calculated, adjusting for age, sex and calendar time. Absolute risks were estimated with the Aalen-Johansen estimator. In total, 646,171 people (8.4%) were identified as having any mental disorder during follow-up. All physical diseases except cancers were associated with an elevated risk of any mental disorder. For the nine broad pairs of physical diseases and mental disorders, the median point estimate of IRR was 1.51 (range: 0.99-1.84; interquartile range: 1.29-1.59). The IRRs ranged from 0.99 (95% CI: 0.98-1.01) after cancers to 1.84 (95% CI: 1.83-1.85) after musculoskeletal diseases. Risks varied over time after the diagnosis of physical diseases. The cumulative mental disorder incidence within 15 years after diagnosis of a physical disease varied from 3.73% (95% CI: 3.67-3.80) for cancers to 10.19% (95% CI: 10.13-10.25) for respiratory diseases. These data document that most physical diseases are associated with an elevated risk of subsequent mental disorders. Clinicians treating physical diseases should constantly be alert to the possible development of secondary mental disorders.
据报道,患有躯体疾病的人罹患继发性精神障碍的风险较高。然而,以往的研究只考虑了几对疾病,或者只报告了相对风险。本研究旨在系统地探讨身体疾病与继发精神障碍之间的关联。研究调查了2000年至2021年期间居住在丹麦的7,673,978人,并对他们进行了总计1.193亿人年的跟踪调查。研究评估了九大类身体疾病(心血管疾病、内分泌疾病、呼吸系统疾病、胃肠道疾病、泌尿生殖系统疾病、肌肉骨骼疾病、血液和神经系统疾病以及癌症),包括 31 种具体疾病,以及随后诊断出精神障碍的风险,包括 10 个 ICD-10 分组(器质性精神障碍,包括症状性精神障碍;使用精神活性物质导致的精神障碍;精神分裂症及相关障碍;情绪障碍;神经症、压力相关障碍和躯体形式障碍;饮食障碍;人格障碍;智力障碍;广泛性发育障碍;以及通常在儿童和青少年时期发病的行为和情感障碍)。在对年龄、性别和日历时间进行调整后,采用泊松回归法计算了躯体疾病和精神障碍的总体发病率比和与时间相关的发病率比。绝对风险采用 Aalen-Johansen 估算法进行估算。在随访期间,共有 646 171 人(8.4%)被确认患有精神障碍。除癌症外,所有身体疾病都与任何精神障碍的风险升高有关。在九种躯体疾病和精神障碍的广泛配对中,IRR 的点估计中位数为 1.51(范围:0.99-1.84;四分位间范围:1.29-1.59)。癌症的 IRR 为 0.99(95% CI:0.98-1.01),肌肉骨骼疾病的 IRR 为 1.84(95% CI:1.83-1.85)。在确诊躯体疾病后,风险会随着时间的推移而变化。在确诊躯体疾病后的 15 年内,精神障碍的累积发病率从癌症的 3.73%(95% CI:3.67-3.80)到呼吸系统疾病的 10.19%(95% CI:10.13-10.25)不等。这些数据表明,大多数躯体疾病都与随后出现精神障碍的风险升高有关。治疗躯体疾病的临床医生应时刻警惕继发性精神障碍的可能发展。
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