本文轉貼自http://bluesky3.myweb.hinet.net/new_page_20.htm

DSM-IV 診斷手冊簡介 

ABOUT THE DSM-IV

   (美國精神科醫師協會出版)
     翻譯：老趙

精神疾病診斷與統計手冊，第四版(DSM-IV)定義廣泛的精神疾病標準‧因為保險公司和醫院喜歡正確、有條理的形式，大多數的精神科醫師用它來當作診斷病人的基礎‧然而，他們還是專注於用藥物或其他療法緩解病情而不是一心想把病人歸類在嚴格的定義分類裏‧

 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)[2] defines the criteria for a wide array of mental illnesses. Most psychiatrists use it as a basis for diagnosing patients since insurance companies and hospitals like nice, orderly forms. Yet, they tend to focus more on alleviating symptoms with medication and other therapy than on attempting to fit people into strictly defined categories.

研究人員常用DSM-IV裡定義的標準以便與臨床試驗一致，然而，有些研究人員須要多一點彈性而使用一些修正的DSM-IV標準，例如創造新的診斷分類‧(你可以看到有些人提起雙極性三，四型等等‧與其他的項目不在DSM-IV裡‧)

Researchers frequently use the criteria as defined in the DSM-IV to ensure consistency across clinical trials. However, some researchers wanting more flexibility use a modified form of the DSM-IV criteria, such as creating a new diagnostic category. (You may see some people mention Bipolar III, IV, etc. and other categories not part of the DSM-IV).

DSM-IV的情緒性失調症章節從一些發作症狀開始‧然後用這些症狀定義不同的診斷‧最後，定義一套特別類進一步詳述病人的現況與循環的情形‧在整個DSM-IV裡，作者指定診斷編碼(例如196.40)給每一個可能的診斷‧

The DSM-IV chapter on Mood Disorders begins with a list of episodes. It then defines the various diagnoses in terms of these episodes. Finally, it defines a set of specifiers which further detail a patient's current state and how they cycle. Throughout the DSM-IV, the authors give diagnostic codes (e.g. 296.40) for each possible diagnosis.

這裡提供了一個情緒性失調症章節的內容摘要以便病人本身和家屬能明確瞭解術語和觀念‧

We have provided a summary of the information provided in the Mood Disorders chapter to allow someone diagnosed with a mood disorder or a loved one to better understand the terminology and concepts.

DISORDERS

See the page containing DSM-IV Mood Disorders Criteria.

DSM-IV記載一些情緒性失調症‧例如，有些精神躁鬱的病人可以診斷為雙極性一型或二型‧對於每一種病名，病人必須有一種或多種情緒症狀符合診斷標準‧(輕鬱症例外，DSM-IV裡沒有符合的症狀‧) DSM-IV診斷標準包含足夠的細節以區別不同的病名‧

The DSM-IV specifies a number of mood disorders. For example, someone with the mental illness manic depression (bipolar) can be diagnosed with Bipolar I Disorder or Bipolar II Disorder. For each of these disorders, the person must have experienced one or more mood episodes to qualify for the diagnosis (except Dysthymic Disorder, for which there is no corresponding DSM-IV episode). The DSM-IV criteria include enough detail to contrast one disorder from another

下面這個圖表簡介DSM-IV病名與症狀的關係‧症狀表示在圖上靠外面的那一方框，病名在那個內層長方形框子裡‧例如，一個有狂躁加上重鬱的人的診斷是雙極性二型‧用滑鼠點那個病名就會移到該項目的整個說明‧點引號裡項目可得到進一步說明‧

The following table summarizes the relationship between episodes and DSM-IV disorders. Episodes are indicated on the outer border, while disorders are in the internal rectangle. For example, a person experiencing hypomanic episodes and major depressive episodes would be diagnosed with Bipolar II Disorder. Click on the disorders and episodes to jump to a full description of the item selected. Click on items in quotes for some relevant notes.

　老趙：這個圖的意思是橫向左右代表憂鬱症狀，靠左最輕，往右藍色越深表示憂鬱越重‧
    縱向上下代表躁的症狀，最下面最輕，往上紅色越深表示躁症越重‧
    而圖中方框裡面就是說按躁症與憂鬱症不同程度的混合，定義出幾種不同的病名‧
    例如左下角躁跟鬱都沒有，代表正常euthymia. 右上角躁跟鬱都最重定義為雙極性一型
    Bipolar I‧右下角憂鬱最重而躁症輕微，叫重度憂鬱症Major Depressive‧
    左上方只躁不鬱，叫單極性躁症，在本診斷手冊裡包含在雙極性一型裡，所以只用虛線
    隔開‧單極性躁症的下方hyperthymia是輕躁症‧圖中心的Cyclothmic是輕度躁鬱症‧
    中間最下方的Dysthmia就是輕鬱症，也可叫沮喪症，因為這個字面就是沮喪的意思‧
    

單極性躁症(屬於DSM-IV雙極性一型的一部分)
沒什麼研究證據顯示有只躁不鬱或沒有混合的單純「單極性躁症」的存在‧
幾乎所有的例子(1)發作後只維持一段時間，過後鬱狀就出現；或(2)雖然有鬱的時候病人自己並不知道‧有些資料主張單極性躁症的存在，但非常稀少‧90%經驗到躁症的人都會轉移成其他的情緒病症‧

 Unipolar Mania (part of DSM-IV Bipolar I Disorder)
Research has found scant evidence for the existence of "unipolar mania," in which a patient has only manic episodes and no depression or mixed states. For almost all examples (1) only a short history exists since onset, so over time depression may occur; or (2) patients do not recognize their own depression, though others do. [3] Other sources claim that unipolar mania exists, but is extremely rare. 90% of people who experience one manic episode go on to have further mood episodes.

一般而言，單極性躁症的症狀跟雙極性一型一樣，DSM-IV雙極性一型的標準只要求躁症症狀，所以單極性躁症包括在雙極性一型裡‧

In general, the manic episodes of "unipolar mania" seem to be the same as manic episodes of typical Bipolar I Disorder (mania and depression). The DSM-IV criteria for Bipolar I Disorder requires only manic episodes, so "unipolar mania" is classified as Bipolar I Disorder.

情緒高昂(不屬於DSM-IV)
沒有鬱狀或其他症狀的情緒高昂，也不在任何DSM-IV診斷標準之內(除了可能沒有特別指定的躁鬱症或情緒失調)‧Goodwin 和 Jamison 把它歸類於情緒高昂或慢性躁症，屬於輕度躁鬱症的一種‧有個研究，把10%的輕度躁鬱症歸類在情緒高昂裡‧

Hyperthymia (not part of DSM-IV)
A person may experience hypomanic episodes, with no depressive episodes or symptoms and not fall under any DSM-IV disorder criteria (except, possibly Bipolar Disorder, Not Otherwise Specified (NOS) or Mood Disorder, NOS). Goodwin and Jamison classify this as hyperthymia or "chronic" hypomania, a subset of cyclothymia. [4] In one study, 10% of cyclothymic patients were classified as hyperthymic. [5]

欣快情緒(不屬於DSM-IV)
這是正常狀態的情緒‧euthymia通常指從躁或鬱的症狀中解脫出來，可能由於藥物作用或是本身的病程‧

Euthymia (not part of DSM-IV)
This is the "normal" state for moods. The term euthymia is generally used to describe the mood of a patient who has stopped experiencing manic or depressive symptoms, either due to medication or during the general course of their illness.

 

Major Depressive Disorder

重度憂鬱症

DSM-IV Diagnoses:

Major Depressive Disorder, Single Episode 重度憂鬱症，單發型

Major Depressive Disorder, Recurrent
重度憂鬱症，複發型 

重度憂鬱症是憂鬱症中最嚴重的，沒有躁的症狀
常叫作單極性憂鬱症或單極症，會多次發作‧

A person with Major Depressive Disorder (MDD) suffers from the worst type of depression, without any (hypo)manic episodes. This is often called unipolar depression, or just unipolar, when there are multiple episodes.

此症女性較男性為多‧女性終生盛行率10% to 25%，男性5% to 12%‧
(終生盛行率10%就是說一百個人裡有10個一生中有發過病的‧)

This illness is more common among women (10% to 25% over a lifetime) than among men (5% to 12% over a lifetime).

重度憂鬱症者可能有躁鬱症的家族病史(為常人的1.5到3倍)‧這導致有些研究人員假設重度憂鬱症和躁鬱症是一樣的病，不同形式‧研究並未找到一個簡單的遺傳關連‧

Those with MDD may have a family history of bipolar disorder (1.5 to 3 times as likely as the general population). This has led some researchers to hypothesize that unipolar depression and bipolar disorder are the same illness, in different forms. [6] Research has not yet found a simple genetic link.

 

Dysthymic Disorder 

輕度憂鬱症 (沮喪症)

DSM-IV Diagnosis:

Dysthymic Disorder  輕度憂鬱症

Noteworthy DSM-IV Specifiers:

Early Onset  早發型

Late Onset   晚發型 

輕度憂鬱症的人有輕度的憂鬱症狀，沒有任何躁症的症狀‧以前叫作憂鬱性精神官能症‧輕度憂鬱症可以說是不嚴重的憂鬱症，但是憂鬱症狀持續不斷至少兩年‧終生可能發病的機率是6%‧

People with Dysthymic Disorder suffer from mild depression, without any (hypo)manic episodes.Previously known as depressive neurosis, dysthymia could be considered a minor depression, except the depressive symptoms last for at least two years without a break. Approximately 6% of the population will have Dysthymic Disorder in their lifetimes.

當一個病人有輕度憂鬱症兩年後，他可能同時被診斷出有輕度憂鬱症和重度憂鬱症，如果符合診斷標準‧這有時被稱為「雙重憂鬱症」，因為病人同時受害於最嚴重的和最長久的憂鬱症‧

When someone has had Dysthymic Disorder for two years, he or she may be diagnosed as having Dysthymic Disorder and Major Depressive Disorder, at the same time, if the criteria are met. This is sometimes called double depression, as the patient suffers from the worst severity and longest duration of both.

 

 

Cyclothymic Disorder 

輕度躁鬱症

DSM-IV Diagnosis:

Cyclothymic Disorder

輕度躁鬱症包含交替的躁跟鬱的症狀，跟躁鬱症一樣，輕度躁鬱症包含躁跟鬱的循環，但是未達躁症和重度憂鬱症的程度‧以往叫做循環性人格‧終生發病的機率是 0.4% to 1%.
Cyclothymic Disorder involves alternating hypomania and depressive episodes. Like bipolar, cyclothymia involves cycling between highs and lows, but it never reaches full mania or major depression. It was previously called cycloid personality. Over a lifetime, the chances of having Cyclothymic Disorder are from 0.4% to 1%.

由於症狀輕微，常常沒有被診斷出來‧常常診斷為雙極性二型的病人回想起他們早有可以診斷為輕度躁鬱症的症狀‧ 臨床試驗顯示輕度躁鬱症尤其是早發型的經過時間會轉變成躁鬱症‧15% to 50%會轉變成躁鬱症‧

Since it can be so mild, it frequently goes undiagnosed. Quite often, people diagnosed as Bipolar II recall cyclic symptoms before their diagnosis which could qualify as cyclothymia. Clinical trials show a tendency for those with Cyclothymic Disorder, particularly those with an early onset, to develop bipolar disorder over time.[4] From 15% to 50% will develop bipolar disorder.

 

　

 

Bipolar II Disorder 

雙極性(躁鬱症)二型

DSM-IV Diagnosis:

Bipolar II Disorder

Noteworthy DSM-IV Specifiers:

Hypomanic

Depressed

 

雙極性二型包含重度憂鬱症和輕躁症的症狀‧由於有一大部份的躁鬱症病人並沒有完全的躁症症狀，所以躁鬱症要分為雙極性一型和雙極性二型‧然而，雙極性二型常是雙極性一型的第一步，經過五年，5% and 15%的雙極性二型的病人會轉變成雙極性一型‧雙極性二型的終生致病率大約為0.5%‧

Bipolar II Disorder involves Major Depressive Episodes and Hypomanic Episodes. Since a significant portion of those suffering manic depression did not have full manic episodes, the classification was divided into Bipolar I and Bipolar II. However, Bipolar II is often a first step to Bipolar I. Over 5 years, between 5% and 15% of those will Bipolar II will change diagnosis to Bipolar I. Approximately 0.5% of people will develop Bipolar II in their lifetimes.

 

 

Bipolar I Disorder  雙極性(躁鬱症)一型

DSM-IV Diagnoses:

Single Manic Episode

Most Recent Episode Hypomanic

Most Recent Episode Manic

Most Recent Episode Mixed

Most Recent Episode Depressed

Most Recent Episode Unspecified

雙極性一型是傳統性的躁鬱症，包含完全的躁症和重度憂鬱症的症狀‧
(躁鬱症的診斷並非必要有憂鬱的症狀，單極躁症也歸類於躁鬱症中‧)
雙極性一型的終生致病率大約為 0.4% and 1.6%‧

Bipolar I Disorder is the classic form of manic depression, with full Manic Episodes and Major Depressive Episodes. (A person does not need to experience depression to qualify as Bipolar I : see Unipolar Mania.) The lifetime occurrence of Bipolar I Disorder is estimated between 0.4% and 1.6%.


本文出處：http://www.a-silver-lining.org/BPNDepth/dsmiv.html

------------------

急性色胺酸耗竭(acute tryptophan depletion)在精神科領域之研究文獻回顧
賴建翰		國軍花蓮總醫院精神科
簡錦標		(1)台灣大學醫學院精神部兼任教授 　(2)美國加州大學(UCLA)精神科名譽教授 　(3)馬階醫院精神科資深主治醫師 　(4)國軍花蓮總醫院精神科顧問教授
血清素的產生途徑為飲食用色胺酸( dietary tryptophan)經由腸胃道吸收，然後和大型中性胺基酸(large neutral amino acids(LNAAs): tyrosine, valine, leucine, isoleucine, phenylalanine)競爭進入中樞神經系統的途徑，進入後再經由色胺酸氫化脢(tryptophan hydroxylase)形成5-氫化色胺酸(5-hydroxy-tryptophan)，再經由芳香族胺基酸去碳酵素( AAADC: aromatic amino acid decarboxylase)才產生血清素。而使血清素減低的最重要的關鍵點在於使色胺酸從飲食中減少及多給予大型中性胺基酸來和色胺酸競爭進入中樞神經系統的途徑。基於此一簡易的生化原理，近年來有一些研究學者讓病患或健康的自願者在短期間(幾小時到幾天)喝下無色胺酸之胺基酸混合液(tryptophan free amino acid mixture; including large neutral amino acids( LNAAs: tyrosine, valine, leucine, isoleucine, phenylalanine))來造成短期的血漿色胺酸於4到6小時明顯的短缺及中樞神經色胺酸於8到10小時明顯的短缺(減少80-90%)，進而造成血清素代謝物之5氫引朵乙酸( 5-HIAA: 5-hydroxy indole acetic acid)於12到14小時明顯的短缺(減少24-40%)，這個研究技術就稱為急性色胺酸耗竭( acute tryptophan depletion)。後文中其英文名稱就簡稱為ATD。
方　法
以下資料是由國家衛生研究院醫療網路系統(HINT)內精神醫療資料庫( psychINFO database)及心智健康資料庫(mental health collection)做為資料來源，擷取近八年內之42篇文獻來作為參考文獻。
結　果
認知功能 Bell et al等人於文獻中提及ATD會使一般人產生長期記憶形成過程的缺損及注意力的提升。而Murphy et al等人則發現ATD會使一般人對快樂事物測驗(happy target test)、視覺分辨測驗(visual discrimination test)及反向學習測驗(reverse learning task)的反應時間拉長，這可能和視覺額葉皮層(orbitofrontal cortex)及後側前額葉皮層(dorsolateral prefrontal cortex)的迴路被血清素調節所影響有關。
精神分裂症(schizophrenia) Golightly et al 等人在其研究論文中發現ATD對於精神分裂症的病人會造成執行功能上的缺損。Sharma et al等人則發現ATD對於精神分裂症的病人會造成負向症狀的更行惡化。
重度憂鬱症 Bell et al等人的文獻中發現未治療的憂鬱症患者對ATD並未產生憂鬱復發的情形，而有用SSRI治療且最近才治療改善的患者較易有對ATD產生憂鬱復發的情形。此外季節性憂鬱症患者對ATD的反應和重度憂鬱症患者類似。Linda et al等人在他們在對六大ATD和心情的研究重新分析中發現女性、慢性病患(反復發作及大於兩次發作)、自殺意念及自殺動作、曾服用SSRI者會對ATD造成的心情轉變較敏感，造成憂鬱症的復發的機率為50-60 % 。
雙極性情感疾患 Sobczak et al等人在一篇比較雙極性情感疾患第一型的一等親，雙極性情感疾患第二型的一等親和一般人發現ATD對雙極性情感疾患第二型的一等親會造成其於POMS(profile of mood states)上的心情提升的解釋有些許關聯。他們在這篇文章提到雙極性情感疾患第二型基於以下幾點才對ATD引發的躁症如此敏感: (1)自殺率較高 (2)主要為情感症狀，此外他們也發現雙極性情感疾患第一型的一等親及雙極性情感疾患第二型的一等親在ATD後會在壓力測驗下( SIST)導致較少的血漿可體松濃度，象徵其下視丘-腦下腺-腎上腺軸在ATD的失調情形。Sobczak et al 等人則在另一篇雙極性情感疾患第一型的一等親和一般人經由ATD後發現雖然雙極性情感疾患第一型的一等親本身就具有計劃及記憶的功能缺損，但ATD會使其訊息處理速度變慢。因此他們認為雙極性情感疾患第一型為一類認知功能本身就有缺損的疾患。
恐慌症 Bell et al等人在其文獻中提及ATD和恐慌引發物: 乳酸,二氧化碳, 膽囊收縮素等物質合用時易引發恐慌發作。Miller et al等人則發現在恐慌症病患和一般人在ATD後會導致恐慌症病患對5%二氧化碳產生更大的焦慮反應，而一般人無此焦慮反應，這也間接印證了SSRI在治療恐慌症的理論基礎。但也有人認為ATD並不會對病患造成恐慌的症狀。
暴食症 Kaye et al等人發現暴食症病患在ATD後會導致心情低下、對自己身體印象關注度提升及主觀的失去飲食控制能力，他們以此認為血清素減少會對這類病人造成心情及認知的轉變。
衝動及攻擊行為 Marsh et al等人在其研究文獻發現ATD會造成被實驗者的行為更具攻擊性及衝動性。其轉變在原本色胺酸基礎值較高的人尤其更為明顯。Bond et al等人也是認同以上的發現。
性別差異對ATD影響之研究 Booij et al等人發現女性憂鬱症病患在ATD後其自由及全部色胺酸下降的幅度各為81.5%及79.2%，遠比男性憂鬱症病患下降的幅度為大(64.0%及72.4%)，其中在自由色胺酸間的差異更大。
聽覺誘發電位 Seppo et al等人在其文獻中提到一般人在ATD後會有在磁腦波( magneticoencephalogram)上顯示較微弱的MAEF( middle latency auditory evoked fields)之聽覺電位，此外，男性和女性的影響程度也不相同。這也象徵血清素可能和早期聽覺大腦皮質處理訊息速度有關。
經前症候群 Menkes et al等人則發現經前症候群的病患在ATD後會使得經前症候群更惡化，尤其是在情緒激動方面更為明顯。
睡眠上的影響 Isabelle et al等人發現早晨中期的ATD會導致一般人REM睡眠期較晚發生、睡眠破碎率達58%及REM睡眠密度提升二倍；這和晚間ATD造成REM睡眠期較早發生不大相同。
強迫症 Barr et al等人對於治療改善並繼續服藥或Smeraldi et al.等人對於治療改善卻無繼續服藥的強迫症患者對於ATD的實驗中並未發現強迫症症狀惡化而只發現有心情較為低落的情形。
阿茲海默症 Porter et al等人發現ATD會對阿茲海默症的患者造成認知功能上的更形惡化。
健康自願者的心情改變 Young et al及Smith et al等人報告健康自願者對於ATD會產生心情上的低落；但Knott et al及Pradeep et al等人則報告健康自願者對於ATD並不會產生心情上的低落。
討　論
ATD在現代精神研究領域充滿許多的未來性及豐富性，只要是和血清素有關的疾患或是生理機轉，都可以藉此來間接證明或實驗，在上述的一些疾患已有相當的資料來探討其內在病理機轉。但是由於各研究方法及因子的不同，例如包括的人數、性別組成、ATD施行時間的差異、統計方式及軟體的不同、評量表類別及基本值上的差異、種族、評量工具的類型、年齡、個別身體基本代謝之差異:如色胺酸進入中樞神經系統的機率、腸胃道吸收的比率、大型中性胺基酸阻止色胺酸進入中樞神經系統的能力等等、施行研究的時間長短、服用無色胺酸的胺基酸混合液之劑量及大型中性胺基酸混合液之劑量等，所以也會造成彼此間在實驗上的數值差距及統計效力上的不同，而可能造成血清素下降的程度不同及實驗結論上的差異，甚至有的研究者發現ATD對實驗目標疾患並無影響。此外除了在單純的生物因子之外，其實亦有心理及社會因子對心情、血清素代謝、自我評估、症狀的在意程度及敘述、執行測驗的配合度等情形會產生影響，進而造成實驗結果上的差異。因此在以上所提這些疾患的研究結論中正反兩面的意見都有，但以目前的實驗結果來看的話，大多數的研究基本上還是肯定ATD對以上所提議題有產生影響及實驗意義之情形。但在其他一些疾患，像廣泛性焦慮症、社交恐懼症、厭食症、特異恐懼症、創傷後壓力症候群等疾患則較為缺乏實驗上的證據，需要更多的研究來澄清這些疾患對ATD的反應及這些疾患和血清素的詳細關係。
總而言之，血清素在行為、食慾、情緒、思考及認知等方面有其重要性，而ATD則是在研究和血清素有關之疾患或生理、病理機轉的有效研究工具，在本文中回顧過去八年的文獻也支持血清素及ATD在神經精神研究上將有持續發展之潛力，雖然有許多問題及差異未解，但其重要性值得肯定。
參考文獻
1.     Bell C, Abrams J, Nutt D. Tryptophan depletion and its implications for psychiatry. British Journal of Psychiatry. 2001;178, 399-405. 2.     Linda BM, Van der DW, Benkelfat C et al. Predictors of mood response on acute tryptophan depletion: a reanalysis. Neuropsychopharmacology. 2002; 27 852-861 3.     Sobczak S, Honig NA, Nicolson NA, Riedel WJ. Effects of acute tryptophan depletion on mood and cortisol release in first-degree relatives of type I and type ц bipolar patients and healthy matched controls. Neuropsychopharmacology. 2002;27, 834-842 4.     Sobczak S, Riedel WJ, Booij I, Aan het rot M, Deutz NEP, Honig A. Cognition following acute tryptophan depletion: Difference between first-degree relatives of bipolar disorder patients and matched healthy control volunteers. Psychological Medicine. 2002; 32, 503-515. 5.     Pradeep NJ, Harrison BJ. Absence of mood effects after tryptophan and tyrosine/phenylalanine depletion in female volunteers. Presented in poster sessions, 23rd, CINP, Congress, Montreal, Canada, June 26, 2002