全科醫學中的心理健康病案研究 (一)——驚恐發作

Grant Blashki，Fiona Judd(著)，楊 輝 (譯)

全科醫學中的心理健康病案研究 (一)
——驚恐發作

Grant Blashki，Fiona Judd(著)，楊 輝 (譯)

驚恐發作;全科醫學;精神衛生服務

戈蘭特·布拉斯基，醫學學士，醫學博士，澳大利亞皇家全科醫生學會會員，澳大利亞公司管理碩士，澳大利亞Melbourne大學全球健康研究所副教授，澳大利亞全科醫生學會考官。他是一名優秀的全科醫生，同時致力于初級衛生保健和心理健康的研究，在國際雜志上發表80余篇學術文章，是《全科醫學中的精神病學》的首席作者。他是澳大利亞心理健康服務改革項目的評價專家，開展了多個全科醫學中心理健康技能培訓的隨機對照研究。

菲奧娜·賈德，醫學學士，醫學博士，心理醫學學歷，澳大利亞新西蘭精神病醫生學會會員，澳大利亞Melbourne大學精神病學系教授，墨爾本皇家婦女醫院婦女心理健康中心主任。她是臨床精神病學家，在醫學與精神病學的共病研究中卓有建樹，并致力于孕期、絕經期、中年轉換期的心理學問題研究。在國際雜志上發表160余篇文章，是《全科醫學中的精神病學》和《綜合醫院中精神病學研究手冊》的合作作者。

譯者按:心理疾病指的是各種程度和類型的行為和心理異常狀態。焦慮是最常見的心理疾病之一。心理疾病在人群中的流行率很高，如澳大利亞16～85歲成人中有20%在過去的1年中經歷過心理問題。處于事業起步和建立家庭階段的年輕人的心理問題更為普遍，14%的澳大利亞兒童和青少年存在心理疾病。

在全科醫學服務中，心理問題是非常常見的。全科醫生往往是第一個接觸病人心理問題的衛生工作者，2008—2009年，澳大利亞132萬次全科服務中涉及了病人的心理問題，而且數量呈現持續的增長趨勢［1－2］。根據沙良等對上海某醫院門診病人的流行病學調查，中國門診病人中有51.3%有驚恐發作的癥狀，13.4%的門診病人確診為驚恐發作［3］。全科醫生怎樣識別和診斷驚恐發作?怎樣在全科醫學服務場所管理驚恐發作?布拉斯基副教授和賈德教授在這里提供了一個在全科醫學場所管理驚恐發作的案例分析。

1 病史

朱某，女，23歲，在澳大利亞學習的中國學生，主修商業。今天早晨到全科醫學診所看病的原因是在期末考試過程中感到頭暈、渾身發抖、呼吸困難。癥狀持續大約10 min，自己感到很害怕，擔心自己會死掉，只能中途退出考試。在醫生面前，她顯得很痛苦，想知道自己出了什么問題。

2 其他病史

這種情況的發作是第二次了。上一次是2個月前，那時候她正在擁擠的城鐵車廂里，中途不得不下車，30 min后癥狀才緩解。她沒有其他既往病史，只是服用口服避孕藥，也沒有發現任何過敏史。她每天抽10支煙，喝4杯咖啡，為的是能在學習中保持清醒。她不喝酒。

3 身體檢查

醫生在看病時，發現病人面色蒼白，出汗，雙手緊握。生命體征顯示呼吸20次/min，脈搏88次/min，血壓115/80 mm Hg，體溫正常。病人雙手濕冷，發抖。心血管和呼吸系統體檢正常。未發現小腿壓痛，也沒有甲狀腺眼病癥狀。

4 提問

4.1 問題1:可能的心理學診斷是什么?

4.2 問題2:應該考慮哪些軀體疾病?

4.3 問題3:驚恐發作能發展成哪些繼發的心理學問題?

4.4 問題4:可以采用哪些治療方法?

5 問題解答

5.1 問題1的解答:可能的心理學診斷是驚恐發作。驚恐發作是指有明確發作期的強烈恐懼和不適。診斷標準是突然出現4個及以上下列癥狀，并在10 min內癥狀最明顯:

－心慌，心悸，心跳加快;

－出冷汗;

－發抖，痙攣;

－感覺呼吸短促或窒息;

－感到憋悶，透不過氣;

－胸痛或不適;

－惡心或腹部疼痛;

－感到頭暈，走路搖晃，頭重腳輕，或者暈倒;

－現實感喪失 (感覺不是生活在現實中)或人格解體(感到自己被拆散);

－害怕失去控制，或害怕變得瘋狂;

－害怕死亡;

－感覺異常 (麻木感，針刺樣的感覺);

－發冷，或皮膚有灼熱感。

5.2 問題2的解答:對驚恐發作的診斷往往通過病史就能得到陽性診斷，而且往往不需要采用排除診斷法。然而，全科醫生應該對一些重要的軀體健康問題進行鑒別診斷，比如甲狀腺機能亢進、二尖瓣脫垂、陣發性心動過速、低血糖、扁桃體炎發作，還有很少見的嗜鉻細胞瘤。過度的咖啡因攝入，或者過于刺激的飲食也可以造成驚恐發作。可以做一些相關的檢查，如全血、尿素、電解質、肌氨酸酐、肝功能、空腹血糖、甲狀腺功能等檢查。根據臨床表現可以慎重考慮其他檢查，如心電圖 (特別是胸痛癥狀明顯的病人)、超聲心動圖、腦部CT、腦電圖、動態心電圖、尿兒茶酚胺、毒品檢測等［4－5］。

5.3 問題3的解答:有些驚恐發作的病人能發展成為恐慌癥。恐慌癥是指周期性、不可預料地發生驚恐發作。驚恐發作還可能發展成為期待性焦慮，即病人擔心再次發生驚恐發作。驚恐發作還可能發展成為廣場恐懼癥，一種在某場所或情形下擔心不能逃脫的焦慮狀態，或者擔心在驚恐發作或類似癥狀發生的時候不能得到幫助的一種焦慮狀態。有這種焦慮的人總是避免某些場合，比如自己一個人在室外或自己一個人在家里、人多的場合、乘坐汽車、公共汽車或飛機旅行、站在橋上、乘坐電梯等。此外，很多經歷過驚恐發作的人會過于擔心自己的健康，即過度健康焦慮，把任何軀體的癥狀都當作疾病，不斷地找醫生看病，期望醫生能打消他們的顧慮［4－5］。

5.4 問題4的解答:治療驚恐發作的第一步，是做出診斷，明確排除軀體疾病。而且要明確能加重驚恐發作的因素，如咖啡因攝入過多，如果有這些因素，應該勸告病人停止使用。要消除病人的疑慮，并對病人進行教育，告訴病人驚恐發作的原因，這一點是很必要的。要跟病人解釋，這種心理問題是過度地激活了交感神經系統對有威脅情形做出的反應 (即“戰斗－逃跑”反應)。教會病人放松和減壓的方法，減少工作和家庭生活事件中的壓力，這對病人也很有幫助。有充分證據表明，不少心理學治療方法對驚恐發作和恐慌癥有很好的療效，這些治療主要針對兩個方面，即控制驚恐發作和克服逃避行為。最著名和有效的方法是認知行為治療，包括教會病人緩慢呼吸的技術，防止換氣過度;糾正病人的錯誤想法，如不要把人體正常的“戰斗－逃跑”反應當作嚴重的軀體疾病。對于有廣場恐懼癥的病人，一旦病人的焦慮有所控制，則可以采用逐級暴露法進行治療。抗抑郁藥，如選擇性5－羥色胺再攝取抑制劑 (SSRI類)可以減少或“阻斷”驚恐發作。不過對苯二氮的使用是存在爭議的，這種藥一方面在短期內有治療效果，或者可以作為輔助用藥，但另一方面要慎重使用，因為它有成癮的危險［4－5］。

1 Austin D，Blashki G，Barton D，et al.Managing panic disorder in general practice［J］.AustFam Physician，2005，34(7):563－571.

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

3 Department of Health and Ageing.National Mental Health report 2010:Summary of 15 years of reform in Australia's Mental Health Services under the National Mental Health Strategy 1993—2008 ［Z］.Commonwealth of Australia，Canberra.

4 AIHW.Mental Health Services in Australia 2007—2008［Z］.Australia Institute of Health and Welfare，Canberra，2010.

5 Liang Sha，Jianlin Ji.Panic attack in outpatient department of hospital in Shanghai［Z］.National Anxiety Conference，Dalian China，2009.

譯者注:“戰斗－逃跑”反應(fight or flight reaction)是哈佛大學心理學家Walter Cannon提出的理論。這是一種人體對危險情況所做出的正常反應。指當人面對挑戰或危險時，下丘腦刺激和啟動交感神經系統分泌腎上腺素，使心跳加快、瞳孔放大、身體出于激發狀態，準備跟這個挑戰或危險作戰(fight)或逃跑(flight)。腎上腺素的分泌是不受人的主觀意識控制的，也就是非理性的反應。腎上腺素能夠提高心率、加快呼吸、促進血液從皮膚和內臟流到肌肉。焦慮的很多癥狀是人體正常的“戰斗－逃跑”反應造成的，這些癥狀包括處于警惕狀態、呼吸加快、心動過速、身體發抖、出冷汗等。

(本文編輯:閆行敏)

【Introduction of the Column】 The Journal of Chinese General Practice and Monash University have successfully established Murtagh's General Practice Case Studies.Now 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 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.

Managing mental illnesses is no longer a narrow task of institutionalized psychiatry services.General practice is often the first contact of mental health problem.General practitioners have more opportunity and more potential to help patients suffering from mental illnesses.Ideally，patient－centred and whole－person approach in general practice is the best way to maintain and improve the physical and mental health of residents.In China，mental health services，especially that at community level，could be strengthened.Knowledge and skills of mental health need to be improved dramatically in order to help GPs meet patient's need and improve their biopsychosocial health.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，including Associate Professor Grant Blashki，Professor Fiona Judd，Professor Leon Piterman，Professor Shane Thomas，Professor Colette Browning，and others.We will invite other international experts join us in some specific case analyses.They have highly regarded international reputations in the fields of general practice，psychology，psychiatry and psychometrics.You will find A/Professor Balshki，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.

The cases published in the Column will be translated，developed and commented by Dr Hui Yang of Monash University.

Affiliation:University of Melbourne，Victoria 3010，Australia

【About Authors】

Associate Professor Grant Blashki，MD，MBBS，FRACGP，GAICD Associate Professor in Global Health of University of Melbourne，is a practicing GP，a Fellow and Examiner for the Royal Australian College of General Practitioners.He is lead editor of General Practice Psychiatry，has published 80 peer review papers，is co－evaluator of the Australian Government's multi million dollar mental health reforms，and has undertaken several randomized controlled trials of mental health education for GPs.

Fiona Judd MB BS，MD，DPM，FRANZCP is Professorial Fellow in the University of Melbourne's Department of Psychiatry and Director，Centre for Women's Mental Health at the Royal Women's Hospital in Melbourne.She is a practicing psychiatrist with clinical and research interests in medical and psychiatric co－morbidity，and psychological issues at the time of pregnancy，menopause and mid－life transition.She has published over 160 peer reviewed papers and is co－editor of General Practice Psychiatry，and Handbook of Studies in General Hospital Psychiatry.

Introduction of the case study Mental illness is a term describing a diverse range of behavioural and psychological conditions.One of the most common mental illnesses is anxiety.Mental illnesses have high prevalence，for instance，one in five(20%)Australians aged 16～85 years experienced one of more common mental illnesses in the preceding 12 months.Prevalence rates are highest in the early adult years，the period during which people are usually establishing families and independent working lives.In Australia，14%of children and young people are affected by mental disorders(including anxiety and depression)within any six month period［1－2］.

In General practice，mental health is one of most common conditions，and general practitioners are often a first contact point for mental health concerns.In 2008－2009，13.2 million GP－patient encounters involved management of a mental health issue，and the number continuously increased.In China，based on Sha Liang(2009)，51.3%of outpatient encounters in a hospital of Shanghai had anxiety － like symptoms and 13.4%of patients diagnosed as panic attack［3］.How general practitioners recognize and diagnose panic attack and how to manage the problem in general practice setting?A/Professor Grant Blashki and Professor Fiona Judd will provide a case study here of panic attack management in general practice.

1 History

Mei Zhou，aged 23，is a Chinese student studying in Australia，who presents because of feeling dizzy，shaky and breathless this morning during her university Business Studies examination.The symptoms came on over about 10 minutes and she felt very frightened，like she was going to die，and had to leave the exam.She presents to you in great distress，asking what is wrong with her.

2 Other History

This is the second time she has had such an attack.She had one 2 months ago whilst travelling on a busy train and had to get out at the station，and the symptoms only subsided after 30 minutes.She has no other past medical history，is taking the oral contraceptive pill，and has no known allergies.She smokes 10 cigarettes a day，drinks 4 cups of coffee a day to stay awake for studying，and drinks no alcohol.

3 Examination

The patient was pale and sweaty and clasping her own hands tightly during the consultation.Vital signs showed a respiratory rate of 20 breaths per minute，pulse 88 beats per minute and blood pressure 115/80 mm Hg and she was afebrile.Her hands were clammy and trembling.Cardiovascular and respiratory examinations were normal.She had no calf tenderness，or thyroid eye signs.

4 Question

4.1 Question 1:What is the probability psychological diagnosis?

4.2 Question 2:What physical disorders should be considered?

4.3 Question 3:What secondary psychological problems can arise from panic attacks?

4.4 Question 4:What treatments are available for this disorder?

5 Answer

5.1 Answer 1:The probability psychological diagnosis is that is a panic attack.A panic attack is defined as distinct episode of intense fear or discomfort，with four or more of the following symptoms developing suddenly，without warning，and usually reaching a peak within 10 minutes:

－ palpitations，pounding heart，or accelerated heart rate，

－sweating，

－trembling or shaking，

－sensation of shortness of breath or smothering，

－feeling of choking，

－chest pain or discomfort，

－nausea or abdominal distress，

－ feeling dizzy，unsteady，light headed，or faint，

－derealisation(feelings of unreality)or depersonalisation(being detached from oneself)，

－fear of losing control or going crazy，

－fear of dying，

－parasthesis(numbness or tingling sensations)，－chills or hot flushes.

5.2 Answer 2:The diagnosis of panic attack should be a positive diagnosis made by the characteristic the history，rather than a diagnosis of exclusion.However important physical differential diagnoses(depending on the prominent symptoms experienced)for the GP to consider are hyperthyroidism，mitral valve prolapse，paroxysmal tachycardia，hypoglycaemia，and temporal lobe seizures and although rare phaeochromocytoma.Excessive caffeine intake or stimulant use can also cause panic attacks.Relevant investigations include full blood examination，urea，electrolytes and creatinine，liver function tests，fasting glucose and thyroid function tests.Tests to use with discretion depending on the clinical presentation include:electrocardiogram(especially in those with chest pain as a prominent symptom)，echocardiogram，CT brain，electroencophelogram，holter monitor，urine catecholamines and drug screen［4－5］.

5.3 Answer 3:Some patients who experience panic attacks go on to develop panic disorder，that is the presence of recurrent，unexpected panic attacks.A secondary problem that can arise is marked anticipatory anxiety－the worry about having further panic attacks.This may then lead to Agoraphobia－anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having a panic attack or panic－like symptoms.The anxiety typically leads to a pervasive avoidance of a range of situations that may include being alone outside the home or being home alone，being in a crowd of people，travelling in a car，bus or airplane or being on a bridge or in an elevator.In addition，many people who experience panic attacks become preoccupied with their health－hypochondriacal preoccupation－convinced their somatic symptoms indicate physical ill health and so constantly seek consultation and reassurance from their GP［4－5］.

5.4 Answer 4:The first step in treating panic is to make the diagnosis，clearly excluding physical ill health.It is also important to identify any exacerbating factors such as caffeine use and advise their cessation.Reassurance and education of the patient about the cause of their symptoms is essential.A useful explanation is to frame the disorder as an over active fight or flight reaction of the sympathetic nervous system.Teaching relaxation and stress management strategies and reducing life stresses where possible at work and in the family can also help.There is strong evidence that a range of psychological treatments work well in treating panic attacks and panic disorder.These treatments target two key areas－control of panic attacks and overcoming avoidance behavior.Notably，cognitive behavioral therapy is very effective.This involves control of hyperventilation by teaching patients slow breathing techniques，and challenging faulty thinking such as the misinterpretation of the normal bodily sensations of the fight or flight response as signs of serious physical illness，and once anxiety is controlled，graded exposure to the feared situation in the case of agoraphobia.Antidepressant medication such as the SSRIs can reduce('block')panic episodes.Controversy surrounds the use of benzodiazepines，which can be useful in the short term or as an adjunct to treatment，but need to be used cautiously because of risks of dependence［4－5］.

1 Austin D，Blashki G，Barton D，et al.Managing panic disorder in general practice［J］.AustFam Physician，2005，34(7):563－571.

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

3 Department of Health and Ageing.National Mental Health report 2010:Summary of 15 years of reform in Australia's Mental Health Services under the National Mental Health Strategy 1993—2008 ［Z］.Commonwealth of Australia，Canberra.

4 AIHW.Mental Health Services in Australia 2007—2008［Z］.Australia Institute of Health and Welfare，Canberra，2010.

5 Liang Sha，Jianlin Ji.Panic attack in outpatient department of hospital in Shanghai［Z］.National Anxiety Conference，Dalian China，2009.

Notes Fight or flight reaction:A theory was firstly described by Professor Walter Cannon，physiologist of Harvard University.A normal response of the human body to a threatening situation is called the fight or flight response.The body's sympathetic nervous system prepares the body for battle(fight)or running away(flight)through release of adrenaline，which increasing the heart rate，raises the respiratory rate and diverts blood towards the muscles(away from the skin and gut).Many symptoms of anxiety can be understood by these mechanisms.Characteristic symptoms are feeling alert，rapid breathing，pounding of the heart，shaking and sweating.

Case Studies of Mental Health in General Practice(1)——A Panic Attack

Grant Blashki，Fiona Judd

Panic attack;General practice;Mental health services

【編者按】中國全科醫學雜志與澳大利亞Monash大學共同合作創建了John Murtagh全科病案研究專欄，深受廣大讀者的歡迎。2012年伊始，我刊與澳大利亞的全科醫學專家和心理學專家共同推出“全科醫學中的心理健康病案研究”學術專欄。這個新專欄的誕生，是為了響應人民日益增長的心理健康服務需要，通過對心理問題病案的研究和分析，提高中國全科醫學工作者和研究者對居民心理問題重要性的認識，提高其對心理問題的識別、治療技術和技巧。

解決心理問題和精神疾患，并非只是精神病學專家在精神病院里完成的任務。全科醫生和社區護士是最常接觸心理健康問題的衛生工作者，全科醫學服務也最有機會和可能幫助居民解決常見的心理問題。以病人為中心的全科醫學整體服務，不僅僅關注居民的軀體健康，還要重視居民的心理健康和社會健康。我國的心理健康服務，特別是以社區為基礎的心理健康服務，還是相當薄弱的短板，社區衛生工作者的心理學知識和技能還相當欠缺，本專欄期望通過各位專家的案例分析，介紹社區常見的心理問題和解決方法，從而推動我國社區心理學服務的能力建設，并帶動社區心理學研究的深入。

本專欄由澳大利亞Monash大學和Melbourne大學的幾位專家輪流撰寫，他們包括Grant Blashki副教授、Fiona Judd教授、Leon Piterman教授、Shane Thomas教授和Colette Browning教授等。他們既是經驗豐富的全科醫學專家，也是卓有成就的心理學和精神病學專家。本專欄還將邀請國內外其他專家撰寫案例。各位澳大利亞教授合作撰寫的著作《全科醫學中的精神病學》正在由中國全科醫學雜志與國內外專家合作進行翻譯，期望不久在中國出版。我們共同希望通過本學術專欄和翻譯名著等努力，讓中國的全科醫學在心理健康服務方面邁上新的臺階。

本欄目采用中英文對照發表，所有案例由Monash大學的楊輝教授翻譯，并撰寫譯者按和注釋，在此表示衷心感謝!

R 395

B

1007－9572(2012)01－0002－04

作 (譯)者單位:3010澳大利亞維多利亞州，澳大利亞Melbourne大學 (Grant Blashki，Fiona Judd);澳大利亞Monash大學 (楊輝)

注:文后附英文來稿原文

2011－12－09)