실기 3일 - CPX 1독 3일차 - 정신/신경 2)

 

참고문헌: Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. 5th Edition. 2013.

하아...

 

Edvard Munch - Separation

(출처: 위키미디어)

 

막상 정신/신경 1)을 정리하고 나니 이후에 주제별 정리를 새로이 할 때에 뭘 하지 싶은 생각은 들지만 그래도 이 쪽은 감별이 목적이니 쭉 다루는 것이 나쁘진 않겠군요. 일단 지난 편에 덜 다룬 PTSD, ASD, 그리고 Adjustment disorder를 후딱 다루고, 수면 장애, 기억력 저하에서 외워야되는 포인트들을 다뤄보겠습니다.

 

이제 PTSD(외상후 스트레스 장애)를 보면,

 

<Posttraumatic Stress Disorder> - DSM-5

Note: The following criteria apply to adults, adolescents, and children older than 6 years.
For children 6 years and younger, see corresponding criteria below. (는 생략하자...)
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains: police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

 

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

 

이번엔 ASD(Acute stress disorder; 급성 스트레스 장애)를 보면,

 

<Acutes stress disorder> - DSM-5

 

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

 

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

 

Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

 

 

이제 PTSD, ASD를 쭈욱 한 번 읽고 감을 잡았을 테니 정리하겠습니다.

 

1) PTSD > 1month, ASD < 1month면서

2) 재경험, 회피, 과각성의 3대 양상을 보인다. + negative mood

 

외우는 것도 좋지만, 감을 잡는 것이 훨씬 중요합니다.

 

 

이번엔 Adjustment disorder(적응장애)를 보면,

 

<Adjustment disorder> - DSM-5

 

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
2. Significant impairment in social, occupational, or other important areas of functioning.
C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.
E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

 

대강 정리하자면, stressor가 생긴 3개월 이내에 불안 증상이 생기고, 정도가 꽤 과한 기능 장애가 오며, stressor가 사라지면 6개월 이상 추가적으로 지속되지 않는 질환이 적응장애입니다.. PTSD, ASD랑 다른 점이 있다면 외상과는 관련이 꼭 관련이 있진 않다는 점도 알아두세요.

 

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이제 수면장애를 살펴볼 때가 왔습니다. DSM-5에는 수면-각성 장애(Sleep-Wake disorder)가 다음과 같이 정리되어 있습니다. 즉, 일차성.

 

Insomnia disorder

 

Hypersomnolence disorder

 

Narcolepsy

 

Breathing-related disorders

- Obstructive sleep apnea/hypopnea (대강 앞에 거만 생각해서 OSA라고 줄여 쓰기도 함)

- Central sleep apnea

- Sleep-related hypoventilation

 

Circadian-rhythm sleep-wake disorders

- Delayed sleep phase type

- Advanced sleep phase type

- Irregular sleep-wake type

- Non-24-hour sleep-wake type

- Shift work type

 

NREM sleep arousal disorders

 

Nightmare disorders

 

REM sleep behavior disorders

 

Restless leg syndrome(RLS)

 

Subtance/medication-induced sleep disorder - 이건 이차성이 되겠지요

 

DSM-5 기준을 모두 실으면 아주 분량이 많아지므로, 포인트만 짚어볼게요.

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그렇다고 하더라도 Insomnia 자체의 정의는 알아야 하므로 Insomnia disorder의 기준은 실어보겠습니다. 더불어 Hypersomnolence disorder의 기준도 실어보자. 물론 시험에 나올지는 모르겠으나! (필기엔 나올 수 있지..)

 

<Insomnia disorder> - DSM-5   A. A predominant complaint of dissatisfaction witli sleep quantity or quality, associated with one (or more) of the following symptoms: 1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.) 2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.) 3. Early-morning awakening with inability to return to sleep. B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. C. The sleep difficulty occurs at least 3 nights per week. D. The sleep difficulty is present for at least 3 months. E. The sleep difficulty occurs despite adequate opportunity for sleep. F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia). G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

 

포인트를 짚어보자면,

 

1) 수면의 개시/유지 등에 문제가 있거나 너무 새벽에 깼는데 다시 잠들 수 없는 것이

2) 일주일의 약 50% 이상이며 3개월 이상 지속되었으며

3) 잠을 잘 수 있는 기회는 충분했어야 함

 

으로 정리할 수 있겠습니다. 그러니까 수면의 개시와 유지, 그리고 잠을 잘 수 있는 기회가 충분한지에 대해 물어보아야 합니다.

 

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반대로 많이 잔다는 것의 진단 포인트는 무엇인지 보겠습니다. (이건 나한테 도움이 될 수 있는 정보네요.)

 

<Hypersomnolence disorder> - DSM-5   A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms: 1. Recurrent periods of sleep or lapses into sleep within the same day. 2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing). 3. Difficulty being fully awake after abrupt awakening. B. The hypersomnolence occurs at least three times per week, for at least 3 months. C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning. D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia). E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).  F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.

 

포인트를 짚어보자면,

 

1) Main sleep이 최소 7시간이면서

2) 같은 날 내에 반복적으로 수면기와 수면개시기가 나타나거나 (--> cf. Narcolepsy하고 헷갈리면 안 됨. Cataplexy와는 전혀 다르다.)

3) 깨어난 상태에서도 각성상태가 완전히 이루어지지 못하는 것, 혹은 잠을 9시간 이상 잠에도 여전히 개운하지 않은 것이

4) 일주일의 약 50% 이상이며 3개월 이상 지속되었던 것

 

으로 정리할 수 있겠습니다. 그러니까 Main sleep, 즉 실질적인 수면시간을 반드시 물어봐야 하고, 잠을 자도 개운하지 않은지, 낮잠은 자는지, 각성 상태 유지가 잘 안 되는지(주간 피곤함?) 등을 물어봐야 할 것입니다. 하지만 Chief complaint에서 일단 다른 질환들과 감별이 되고, MDD 등과 차라리 감별을 해야 한다는 점을 생각하면 관련된 것들을 물어보는 것도 생각해야겠네요.

 

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다음으로 narcolepsy에 대해서 보자. 기면병으로 알려져있는데, 진단의 포인트가 비교적 명확합니다.

 

<Narcolepsy> - DSM-5   A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months. B. The presence of at least one of the following: 1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month: a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking. b. In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers. 2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values (less than or equal to one-third of values obtained in healthy subjects tested using the same assay, or less than or equal to 110 pg/mL). Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection. 3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.

 

포인트는!

 

1) Cataplexy(허탈발작): 웃거나 농담 등을 할 때 갑자기 양측 muscle tone이 사라지는 episode가 있음

2) Hypocretin deficiency --> CSF tapping을 하면 되겠다고 생각하겠지만.. 그거보다는

3) Polysomnographical findings! 이거처럼 비침습적인 검사가 있는데 뭐하러 hypocretin을 먼저 보겠나! (물론 1, 3이 없는 상황에서 진단이 필요하면 하겠지만..) 보일 수 있는 소견은

- REM sleep latency <= 15min

- Mean sleep latency <= 8min

- SOREMP라고 부르는 sleep-onset REM period >=2

4) 그리고 DSM-IV-TR까지 매우 중요한 임상양상으로 등장했던 hypnagogic hallucination(입면 환각), sleep paralysis(수면 마비)도 알아두자. 흔히 Tetrad of narcolepsy라고 하는 것은 excessive daytime sleepiness(심한 주간 졸음증)까지 포함하여 4가지 증상을 말한다.

 

그러니, narcolepsy를 의심하기 위해서는 주간 졸음증이 심한 환자에서 웃거나 하는 상황에서 갑자기 팔다리 힘이 쫙 빠지는 때는 없었는지(cataplexy)를 물어보고, 계속 자고 싶은 욕구가 드는지에 대해 물어본 것을 종합해서 PSG를 하자고 하면 되는 것입니다. 그리고 hypnagogic hallucination이나 sleep paralysis까지 물어보면 금상첨화!가 되지 않을까....

 

치료는 약물/생활습관 교정..

 

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Breathing-related sleep disorder의 경우는 결국 중추성이든 구인두 부분의 구조적인 문제든 숨을 안 쉬는 시점이 있어야 하는 것이다. 그러니 문진만으로 의심 가능하고 PSG를 하자고 하면 된다. 치료는 약물/행동, 그리고 정말정말 중요한 CPAP!!!!! 이외에 수술도 가능하다.

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Circadiam rhythm sleep-wake disorder는 결국 하루 생활 패턴을 물어봐야 알 수 있는 것입니다.

 

실제 수면시간이 지연되면서 잠들기는 힘들고(제 시간에) 아침에 일어나긴 어렵고 아침에는 엄청 졸린 delayed type이든,

나이든 분들 처럼 일찍 자고 일찍 일어나서 낮에는 또 졸린 advanced type이든,

직업 스케줄 특성 상 밤시간에 근무해야 하는 사람들이 겪는 shift work type이든

 

결국 문진을 통해서 알아야 하는 것입니다. 그리고 교육에서 수면일기를 쓰라고 해서 더 정확하게 패턴을 파악하는 것이 중요할 것이고(교육 부분에서), 치료는 결국 패턴을 평균적인 수면패턴에 수렴하도록 도와주는 것이 됩니다. 이에 빛 조절을 해주는 것이 도움이 될 수 있다는 점도 알아주면 더 좋겠습니다.

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Nightmare disorder의 경우는 뭐.. night terror와는 조금 다르다고 배웠지만 어찌 되었든 왜 잠을 깨는지를 물어봄으로써 알 수 있게 됩니다. 악몽 때문에 잠을 설치지는 않으시나요? 등등을 물어보면 되겠지요. 아마도 실질적인 치료를 제시할 수 있는 다른 질환들이 학생 수준의 시험에 많이 출제되지 않을까 하는 기대를 합니다ㅠㅠㅠ

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Restless leg syndrome은 진단기준을 조금 보면,

 

A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following: 1. The urge to move the legs begins or worsens during periods of rest or inactivity. 2. The urge to move the legs is partially or totally relieved by movement. 3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night. B. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3 months. C. The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. D. The symptoms in Criterion A are not attributable to another mental disorder or medical condition (e.g., arthritis, leg edema, peripheral ischemia, leg cramps) and are not better explained by a behavioral condition (e.g., positional discomfort, habitual foot tapping). E. The symptoms are not attributable to the physiological effects of a drug of abuse or medication (e.g., akathisia).

 

포인트는,

 

1) 가만히 있으면 벌레 기는 것 마냥 불편하거나, 저리거나, 심하면 아프기도 하면서

2) 움직이면 이런 불편함이 사라지며

3) 저녁에 심하다(저녁에만 이런 증상이 있기도 함)

 

역시 문진만으로 해결할 수 있으며(다리 불편감은 없는지) 진단은 PSG! 치료는 신경증상에 의한 것이라면 기저 질환을 치료하고(Fe deficiency, AKI/CKD, peripheral neuropathy 등), 아니면 lifestyle modification을 하거나(족욕, 마사지, 스트레칭, 규칙적 수면 습관 등), 약물치료도 해볼 수 있다(dopamine agonist, gabapentin 등)

 

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드디어 기억력 저하에 도달했습니다! 외워야 하는 것은 MMSE입니다. 감별포인트는 치매인지 가성치매(우울증)인지, 혈관성인지 기질성(?)인지, hydrocephalus는 아닌지(mnemonic은 3W로 wet, wacky, wobbly인데 urinary incontinence, dementia, gait disturbance에 해당함) 등입니다. 문진으로 어느 정도 감별이 가능하겠네요.

 

K-MMSE를 보면

 

지남력(10)

시간(5): 연/월/일/요일/계절

장소(5): 주소? --> 도(시)/군(구)/면(동) 여기는 어떤 곳? 뭐하는 곳?

 

기억등록(3): 비행기, 연필, 소나무

 

주의 집중 및 계산(5): Serial 7 (학력에 따라 '삼천리 강산' 거꾸로 말하는 것으로 대체 가능)

 

기억회상(3): 등록한 것 다시 말하기

 

언어(8)

- 물건 identification: 연필, 시계

- '오른손으로 종이를 집어서 반으로 접고, 무릎 위에(혹은 책상 위에) 놓기(혹은 저에게 주세요)': 반드시 3가지 명령이 있어야 하고, 이의 실행을 봐야 정확히 검사된다고 배웠던 것 같다...

- Interlocking pentagon

- '간장 공장 공장장' 따라하기

 

이해 및 판단(2)

- 옷은 왜 세탁해서 입나?

- 길에서 남의 주민등록증을 주웠을 때 어떻게 하면 쉽게 주인에게 되돌려 줄 수 있습니까?

 

총 30점

 

5-5-3-5-3-8-2 무슨 전화번호 같군.. 개수 맞게 물어보면 많이는 점수 안 깎일 것입니다. 아 그리고 비행기/연필/소나무 같은 항목 마음대로 물어보면 안 됩니다. 저게 범주 하나도 안 겹치게 고안한 것이라서 순서까지는 잘 모르겟지만 아무 물건 3개나 쓴다면 즉시 감점될 가능성이 있습니다.

 

참고서적: Real CPX 5판, 메딕메디슨 학술국. 10minutes CPX, 퍼시픽 학술국.