Diagnostic Uncertainty in a Complex Young Man: Autism Versus Psychosis.
Diagnostic Uncertainty in a Complex Young Man: Autism Versus Psychosis.
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一个复杂的年轻人的诊断不确定性：自闭症与精神病。
DOI：
10.1097/dbp.0000000000000635
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发表时间：
2019
期刊：
影响因子：
--
通讯作者：
Gonzalez-Heydrich,Joseph
中科院分区：
文献类型：
--
作者：
Fogler,Jason;Kuhn,Jocelyn;Prock,Lisa;Radesky,Jenny;Gonzalez-Heydrich,Joseph
案例：詹姆斯是一名 7.5 岁的男孩，出生于越南，母亲患有精神疾病。人们对他的早期历史知之甚少。他在孤儿院度过了生命的前六个月，随后接受寄养和中断的收养。他 1.5 岁时移居美国，4 岁时加入目前的收养家庭。此后不久，詹姆斯的精神科护士诊断他患有注意力缺陷多动障碍（ADHD）和自闭症谱系障碍（ASD）。从小就注意到语用语言和句法缺陷。詹姆斯现在在上厕所时表现出焦虑、顽固的信念和倒退。他开始“在房间里自言自语”并使用新词。基于学校的评估得出了基于社交脱节和侵犯他人个人空间的多动症和自闭症教育诊断。詹姆斯的父母觉得“发生了其他事情”，并向多学科团队（由一名儿科心理学家和一名发育儿科医生组成）寻求第二意见。考虑到詹姆斯的病史、之前的评估及其评估组合（儿童行为评估系统、执行功能行为评定量表、自闭症诊断观察表和罗夏墨迹测试），研究小组将他目前的症状描述为一种新出现的精神障碍。在接下来的 9 个月的学期中，进行了多次咨询。首先，精神病科的临床医生证实了功能衰退、认知紊乱和幻觉的症状，这些症状归因于创伤后应激而不是精神障碍。其次，当詹姆斯开始使用非典型抗精神病药物并且症状得到良好控制时，学校团队认为多动症（而不是精神病）最能解释他的表现，这增加了诊断的不确定性。关于在制定患者诊断时应在多大程度上考虑父母病史和罗夏墨迹测试数据，医疗团队和咨询学校心理学家之间存在重大争议。两年半后，詹姆斯戒掉了利培酮，以应对新的抽动副作用。随后，他表现出严重的偏执，对同事的想象中的轻视和侮辱表现出反应性攻击，他可以“发誓他听到了”。另一位学校签约的心理学家根据几年来的临床观察进行了重新评估，证实了精神分裂症的诊断。第一位学校心理学家认为早发性精神病太罕见，而且太侮辱人了，不适用于“注意力不集中的孩子”，因此他仍然坚持认为多动症和自闭症谱系障碍是最合适的诊断，而詹姆斯“服用了大量的抗精神病药”将受到不公正的对待。他现在回到原来的儿科发育行为咨询团队。为了弥合这一僵局，你会采取什么措施？
CASE: James is a 7½-year-old boy born in Vietnam to a mother with mental illness. Little is known about his early history; he spent the first 6 months of his life in an orphanage, followed by foster care and a disrupted adoption. He moved to the US at age 1½ and joined his current adoptive family at age 4 years. Shortly thereafter, James’ psychiatric nurse practitioner diagnosed him with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Pragmatic language and syntax deficits were also noted from an early age. James is now exhibiting anxiety, perseverative beliefs, and regression in his toileting. He began “talking to himself in his room” and using neologisms. A school-based evaluation resulted in educational diagnoses of ADHD and ASD based on social disconnectedness and invading others’ personal space. James’ parents felt “something else was going on” and sought a second opinion with a multidisciplinary team (consisting of a pediatric psychologist and a developmental pediatrician). Considering James’ history, previous assessments, and their assessment battery (Behavior Assessment System for Children, Behavior Rating Inventory of Executive Function, and Autism Diagnostic Observation Schedule, and Rorschach Inkblot Test), the team characterized his current symptoms as an emerging psychotic disorder. Several consultations occurred over the next 9 months of the school term. First, clinicians in the psychiatry department confirmed symptoms of functional decline, cognitive disorganization, and hallucinations, which were attributed to post-traumatic stress rather than a psychotic disorder. Second, adding to the diagnostic uncertainty, when James started an atypical antipsychotic medication and was under good symptom control, the school team believed that ADHD—not psychosis—best accounted for his presentation. There was significant contention between the medical team and consulting school psychologist regarding the extent to which data from the parental history and Rorschach should be considered in formulating the patient’s diagnosis. Two-and-a-half years later, James was weaned off risperidone to manage a new side effect of tics. He subsequently manifested significant paranoia with reactive aggression toward peers for imagined slights and insults that he could “swear he heard.” A different school-contracted psychologist’s re-evaluation corroborated the diagnosis of schizophrenia based on the several years of unfolding clinical observations. Acting from the supposition that early-onset psychosis was too rare and too stigmatizing a condition to apply to a “kid who’s just having trouble paying attention,” the first school psychologist remained adamant that ADHD and ASD were the most appropriate diagnoses, and James would be ill-served “pumped full of neuroleptics.” He returns now to the original Developmental Behavioral Pediatric consulting team. What would you do to try to bridge this impasse?
影响因子：
158.5
作者：
TAYLOR, HR;WEST, SK;EMMETT, EA
通讯作者：
EMMETT, EA
晶状体混浊的临床分级。
DOI：
--
发表时间：
1989
期刊：
Australian and New Zealand journal of ophthalmology
影响因子：
--
作者：
Taylor,HR;West,SK
通讯作者：
West,SK
白内障的检测和分级：流行病学的角度。
影响因子：
5.1
作者：
West,SK;Taylor,HR
通讯作者：
Taylor,HR