文摘
介绍。dsm - 5列出了两个障碍:躯体障碍症状和疾病焦虑症,取代在dsm - iv疑病症。患者疾病都非常担心的可能性未确诊的疾病或投入过多的时间和精力去健康问题和不易保证。失调引起相当大的痛苦和生活的破坏,即使在中等水平。然而,疑病症(dsm - iv)表明睾丸固定术和睾丸切除术。这是这份报告的理由是第一个可用的最好的文学。这是一个原始病例报告感兴趣的一个特定的临床专业心理健康,但会在医学界广泛的临床影响。案例展示。30岁的黑人男性呈现给一个初级保健诊所与多个网络搜索主题的睾丸疼痛及其鉴别诊断。他有一个双边疑似扭转的睾丸固定术。他被称为精神卫生单位,进一步确定适合手术。结论。如果怀疑疑病症是在医疗或外科住院病人,应该执行心理医学咨询,说明诊断,避免不必要的程序,优化病人的护理。
1。介绍
睾丸固定术(或睾丸固定术)隐睾手术移动一个(患隐睾病的人)睾丸在阴囊和永久修复它。睾丸固定术通常还描述了用于解决睾丸扭转的手术(1]。睾丸切除术的手术切除是一个或两个睾丸,睾丸,在人类男性。它也被称为一个睾丸切除术,尤其是在英国出版物(2]。
疑病症的其他躯体疾病是最困难、最复杂的精神疾病治疗一般医疗设置。的基础上,许多在这个领域的新发展,诊断标准被修订促进临床护理和研究[3]。正如所有精神障碍、躯体形式障碍创意的需求,丰富的生物心理社会治疗计划的团队,包括初级护理医师,subspecialists,心理健康专家3]。但是,这往往是理所当然的。
疑病症正在直接或间接在许多专业评估,包括心脏病、皮肤病、耳鼻喉科学,胃肠病学、传染性疾病、妇产科、眼科、手术、肿瘤(4]。在这种背景下,他或她的身体症状的病人的报告可能不是特定的,和物理考试可能不支持一个明确的医疗诊断,经常导致诊断难题(4,5]。“医生购物”的历史是常见的。因为多个评估和样本不能结实,挫折就会随之降低,病人觉得医生不在乎,有时导致心情抑郁等问题(5]。
的一些“测试”患者是可预测的。病人常常请求一个特定的血液检测,放射性研究,或侵入性程序或组合(6]。病人可能质疑主治医生的专业技能和请求推荐不同的专家和一个正在进行的检查。任何可能的收益率必须平衡的一项调查潜在的医疗风险和心理风险加强周期性忧郁症的模式(6]。医生应该尽可能的让病人参与决策过程。
新批准的精神疾病诊断与统计手册(第五版)包含许多修正,但很少有涉及躯体形式障碍的那样全面。在更新后的版本,疑病症和几个相关的条件已经被两个新的所取代,经验派生概念:躯体症状障碍和疾病焦虑障碍(7,8]。他们从dsm - iv的躯体形式障碍明显不同。因此满足的标准障碍,躯体症状患者必须有一个或多个慢性躯体症状的过分关心,关注,或害怕。这些恐惧和行为造成严重的困扰和障碍,虽然病人可能经常使用医疗服务,他们很少放心,经常感到他们的医疗已经不足7,9]。疑病症是一种高度禁用状态。疑病症患者被发现查看他们的健康不如并表现出比年龄更严重的精神病症状,sex-matched对照组(9]。
相对很少有人知道的流行病学疑病症,尤其是在一般人群。为数不多的以人群为基础的研究使用采访一直显示没有或只有很少的疑病症的情况下10]。只研究基于不那么严格的入选标准或研究使用自我报告的问卷调查反映了更高的病例数。这些患病率从4%变化到10%以人群为基础的样本(11]。
疑病症一直在调查更多的病人。一般医疗实践,疑病症不同的患病率在0.8%和9%之间(12),平均患病率为4.2%七初级保健样本报道(13]。这些研究表明,忧郁症的问题经常出现在医疗设置(12]。然而,临床样本可能受到选择性偏差或低的怀疑指数(12,13]。
因此这份报告旨在呈现出不同寻常的表示在手术环境和可避免的但是奇怪的手术在一个年轻的男性与明显的躯体症状和疾病焦虑症和医疗实践的含义,在不同专业之间需要更好的合作在医学上,以优化病人护理。
2。案例展示
34岁的尼日利亚男子提出心理健康/精神病学临床外科门诊部门的推荐后的持久睾丸疼痛的心因性自然,坚持双边睾丸切除术。历史表明六年的双边睾丸疼痛持续时间,最初仅影响左睾丸,会阴和骨盆疼痛辐射,据说与发麻的感觉和影响了他的睡眠和性生活。虽然是一个积极的多异性恋伴侣的历史,屏障避孕避孕套的形式练习。没有发烧和其他宪法的历史特性,未降到阴囊的睾丸,儿童流行性腮腺炎,类固醇修剪肚子综合症,会阴外伤,阴囊疼痛或瘙痒,exanthematous阴囊和色素的变化,改变睾丸一致性,阴茎放电,排尿疼痛和自慰。
然而,睾丸疼痛是与无法执行性行为以及自慰。
由于症状的持久性,他继续总医院Ahoada,河流州,尼日利亚,在一连串的未知测试进行(包括图纸血液和几个x射线和超声波扫描),结果没有发现任何异常,药物,和他记不起他们的名字;然而,痛苦依然存在。随后,他开始一个三级中心(BMH, PH值),在进一步测试和药物在门诊管理;然而,持续的疼痛。然后他开始海军医院,Borokiri,哈科特港,尼日利亚,在腹部x射线以及腹部和睾丸超声波扫描,以及彻底的身体检查外生殖器;他被告知什么是错误的与他和药物管理,但症状是持久的。类似的发现被报道时,他去了一个三级卫生设施,UPTH。他还去了非正统的,tradomedical从业者在追求一个永久的解决方案;几个未知混合物是由他咒语,但这一切都无济于事。他在2010年来到这个设施(迁往巴耶尔萨州后,尼日利亚); the battery of tests aforementioned earlier were made, including semen analysis (obtained via masturbation, a fact, he had earlier denied but is present in his medical record), and he began complaining a feeling that the right testis was ascending up into his stomach; a surgery (nature of surgery unknown to him) was performed in March, 2014; on recovery and discharge, pain persisted, with no worsening or relief; he claims that dribbling of urine began after the surgery.
有关联的无用的感觉疼痛症状后,失去“男子气概/性能力,”自杀意念,和自杀企图的6年时间,这增加了在强度、频率、持续时间和逐步恶化后访问医生/几家医院没有提供救济。毫无价值与低能量的感觉,在快乐的活动失去兴趣,停止自雇工作,收入会减少,减少的意志力,失去自尊,和极端无助的感觉;然而,病人声称他对生活充满了情趣。自杀意念的5年时间;尝试失败后获得治疗咨询的医生后,他开始考虑采取毒药结束自己的生命;然而,他没有告诉任何人关于他的思想;没有相关的错觉,幻觉,或其他干扰感知。自杀企图开始4年前;他吞下“有毒”植物,电池酸和杀虫剂残杀威”。没有历史的试图通过暴力手段结束自己的生命,自残,或摄入的安眠药。 Suicidal attempts were not revealed to anyone; however, the last “attempt’’ to end his life occurred 3 weeks prior to psychiatric consultation, with his mother privately reporting that he came to her privately, weeping bitterly and showed her some ropes he had in his possession for the purpose of killing himself, but he never carried through with the plan; he summarily denied this but later admitted it as a fact. Feeling of loss of “manliness’’ was of 5-year duration and began after he noticed that he could not have sex anymore due to the intense pain. This was associated with an increased desire to have his testicles removed, in order to be relieved of the pain. Although he considers himself as male, he insists he feels unmanly and incomplete; there was, however, a strong insistence that he is not a female on further probing during history taking.
但是,没有增加的历史活动,搅拌,坐立不安,漫无目的的游荡,增加性欲,非理性的说话,食欲不振、睡眠障碍和听到声音,不合群,缺乏自我保健,暴力行为,收集的碎片,或任何异常行为。过去的精神病史显示,有一个积极的精神药物使用的历史,具体地说,大麻通过吸烟,他使用的干叶子裹着一条纸;他开始使用它16/17岁(17年前);他被介绍给朋友和希望实验和反抗;他使用药物独立和与朋友;习惯是靠他的津贴和偷他的父母;药物使用持续了几年,停止在他二十出头。25岁左右,2006年(9年前),他变得孤僻、无缘无故离开家,并开始独自生活;然后他消失了3 - 4个月(他后来承认他前往尼日尔失败为了移民欧洲)和主动回家,只有开始生活在未完成的建筑和非理性,与历史引发了暴力袭击后店主被指责为“精神的情况。”随后,2008年,他考入神经医院,Rumuigbo,和诊断”物质使用障碍”了;我们做了一些调查和药物管理;一个月之后他就被释放了,两个星期。 Follow-up was regular for two months; however, he defaulted because he claimed he was not “mental’’ and because of the side effects of drugs. There is no history or evidence of a relapse following discharge. In the past medical history, there was no history of hypertension, epilepsy, asthma, diabetes mellitus, sickle cell disease, neurocutaneous disorders, and erectile dysfunction. Family history showed that he is the only male as well as the first of four children in a monogamous setting. However, his mother had 2 children in a later marriage after the divorce of his parents, making a total of 6 children, 3 full sisters and 2 half-sisters. His mother is a middle aged matron with tertiary level of education. His father is deceased, had tertiary level of education, and was a senior civil servant with the Ministry of Agriculture. He was not close to his father and appeared to have had a troubled relationship with him following the divorce of his parents; his father died three years earlier, at age 61, from an unknown medical condition. The personal history revealed that the patient completed his basic education. However, he did not pass the UME with good scores and failed to obtain a university admission, and he was said to be an average student. He enrolled in a part time program, in the National Open University, 2 years earlier, but did not complete the course because of his present illness. Subsequently, he said he has received training as an electrician and construction worker. He claims to be a single father of an 18-year-old boy (with elaborate information about the nonexistent child); however, his mother denies this and he later admitted he told us this so that we would remove his testes since he has a child. Social history showed that, in the past, he occasionally drank alcoholic beverages but has seldom done so for the past seven years. He smoked tobacco in cigarette form occasionally. Patient seldom interacts with people except his family members whom he lives with; he initially said he lives alone but his mother said he lives with her and he admitted this. Psychosexual history as elicited showed that adrenarche was attained at age 14 while onset of nocturnal emissions began at age 17. First sexual activity was with a female partner, experience was pleasurable and exciting, and subsequent experiences have been pleasurable and in almost all cases barrier contraception in the form of male condoms was used. The patient insisted that his sexual orientation and love interest has been strictly heterosexual. He has seldom had any early morning erections over the last 6 years and cannot recall having experienced any nocturnal emissions within the same period. He denies any masturbation as well as orgasm/ejaculation; however, semen for analysis was obtained via masturbation without the use of pornography. In the forensic assessment history, patient has not been convicted for any crime, sentenced to jail, or jumped bail; however, he has been arrested thrice and detained for minor offences such as moving at night during a curfew. Premorbidly, leisure activities included watching football matches; he formed deep ties in relationships, had few friends, and was introverted/quiet. His prevailing mood was happy.
2.1。精神状态检查
外观和行为表现出一个穿着得体的和梳得整齐的年轻人(注意细节,如修剪指甲和完美风格的头发)出现适合的年龄,保持良好的目光接触,并与抑郁的姿态撑着一把雨伞。讲话的语气很低,温和的语气,被动的情况下,相干和相关。心情悲伤,影响抑郁。知觉异常包括体细胞幻觉。没有疾病的思维过程和正式的思想障碍检测。认知下,病人完全面向时间,地方,人,和环境。注意,浓度,以及计算机能力,理解和抽象是在正常范围内。此外,立即召回,长时间运行和短时间记忆是在正常范围内。判断好和洞察力是部分(他不相信任何好处的药物将会和他的案子是绝望)。
2.2。诊断
主要诊断是疑病症和共病二级精神病症状严重的抑郁症的诊断。
2.3。计划
病人使用生物-心理-社会模型管理。药物治疗是通过使用三环抗抑郁药(阿米替林)和抗精神病药物(奥氮平)。心理疗法进行认知行为疗法。最后一封信被送到SOPD要求诊断和双边睾丸切除术不相称。
2.4。进步
初始改进(就是减少疼痛强度)是前3周;然而,疼痛一直持续。有他的最后一次访问期间坚持双边睾丸切除术。
3所示。讨论
病人检查的结果同意疑病症是评估直接或间接地在众多医疗设置和排斥的诊断(4]。以前在我们的病人在许多情况下,描述(3,4,14)诊断延误的原因是不寻常的临床表现。临床表现是经常混淆,尤其是在发达国家4]。这是病人的报告的结果可能不是具体体检不会导致一个明确的医疗诊断,导致诊断难题(4,5]。(我)虽然有令人信服的药理数据支持假说,疑病症是一种强迫性障碍,消除的疾病数据也同样引人注目的假说(15]。值得注意的是强迫症困扰,模仿疑病症患者,复发性和持久性和症状是侵入性的,但这些担忧超越担忧疾病(例如,担心门没有锁),并且往往伴随着主题相关的补偿行为(例如,检查锁),这个病人的情况并没有被报告(16]。(2)偶尔病人精神物质(烟草)。这是因为许多疑病症患者滥用药物的应对焦虑,因害怕有未确诊的疾病可以在情感上压倒性的(17]。疑病症患者可能成为吸引短期放松来自滥用药物,这可能会导致上瘾,最终会恶化的知觉不存在疾病(17]。(3)这份报告的结果同意情绪障碍是与疑病症相关的大多数疾病在这个病人的忧郁症的症状(5]。疑病症患者通常请求很多调查和程序,由这个病人表现出(6]。此外,安慰病人通常仍然是失败的(7]。情况并非不同在我们的病人坚持他的医疗已经不足(7,9]。因此,他们经常要求被称为(6]。这将导致“医生购物”或称为“旋转门综合症”(5]。他在几家医院接受治疗,综合医院Ahoada,布雷斯韦特纪念专家医院,和哈科特港大学教学医院,之前被称为联邦医疗中心,Yenagoa。(iv)这个同意的事实通常有不止一个医生,在极端情况下,甚至有可能多个住院和手术(3,18]。(v)病人没有其他躯体症状疾病和症状的无二次利用他所提到的,从而区分从躯体变形障碍,装病,人为的障碍16]。医疗实践的含义是不同专业之间需要更好的合作在医学上不寻常的演讲后,呈现与诊断难题,以优化病人护理,为了避免不必要的手术病人。
4所示。结论
这种情况下证实了非典型报告和诊断难题与疑病症有关。
缩写
| FWACP: | 西非医学院的研究员 |
| 黑带大师: | 医学学士,学士手术 |
| 硕士: | 科学硕士学位 |
| IFPE: | 国际精神病学联合会 |
| WACP: | 西非医学院 |
| BMSH: | 布雷斯韦特纪念医院专家 |
| UPTH: | 哈科特港大学教学医院 |
| 梅花: | 大学入学考试 |
| 强迫症: | 强迫症 |
| AFMHA: | 非洲的基础心理健康宣传 |
| SOPD: | 外科门诊。 |
附加分
作者信息:(1)答:美国Nwaopara博士是一位西非医学院的专家会诊-联络精神病学的兴趣和公共卫生方面的心理健康。他目前顾问法医精神病学家和精神卫生部门主管联邦医疗中心,巴耶尔萨州,尼日利亚,multispecialty治疗中心,是非洲的主席受托人心理健康宣传(AFMHA)的基础。(2)博士Erefagha莱昂纳多p Allagoa面交,MSc,目前住院医师,进行精神病学专家培训,在multispecialty治疗中心。
同意
从患者获得书面知情同意是出版的病例报告和任何附带的图片。
相互竞争的利益
作者宣称没有利益冲突。
作者的贡献
Erefagha莱昂纳多p Allagoa做演讲。a . Nwaopara和Erefagha莱昂纳多p Allagoa写道。病人comanaged心理健康和手术部门。所有作者处理的文献搜索和阅读和批准了期末论文。
确认
作者要感谢所有住院医生的心理健康,联邦医疗中心,Yenagoa。