Psychiatrie
Inhoud
1. Schizofrenie-spectrum en andere psychotische stoornissen .......................................................... 9
1.1 Symptomen ............................................................................................................................. 9
1.1.1 Wanen: + symptoom ....................................................................................................... 9
1.1.2 Hallucinaties: + symptoom .............................................................................................. 9
1.1.3 Gedesorganiseerd denken (formele stoornissen): + symptoom ................................... 10
1.1.4 Ernstige gedesorganiseerde of abnormale psychomotoriek ........................................ 11
1.1.5 Negatieve symptomen .................................................................................................. 11
1.1.6 Opmerkingen ................................................................................................................. 12
1.2 Classificatie ............................................................................................................................ 12
1.2.1 Schizofrenie ................................................................................................................... 12
1.2.2 Schizofreniforme stoornis ............................................................................................. 13
1.2.3 Kortdurende psychotische stoornis............................................................................... 13
1.2.4 Waanstoornis ................................................................................................................ 13
1.2.5 Schizo-affectieve stoornis.............................................................................................. 13
1.2.6 Psychotische stoornis door een middel......................................................................... 13
1.2.7 Psychotische stoornis door een somatische aandoening ............................................. 14
1.2.8 Katatonie ....................................................................................................................... 14
1.3 Terminologie: schizofrenie .................................................................................................... 14
1.4 Ziektebeloop v Schizofrenie .................................................................................................. 14
1.5 Etiologie v Schizofrenie ......................................................................................................... 15
1.5.1 Genetica......................................................................................................................... 16
1.5.2 Environmental hypothese (cannabis en migratie!) ....................................................... 16
1.5.3 Ontwikkelingshypothese ............................................................................................... 17
1.5.4 Toxiciteit (oa drugs) ....................................................................................................... 17
1.6 Behandeling v Schizofrenie ................................................................................................... 17
1.6.1 Historische evolutie ....................................................................................................... 17
1.6.2 Medicamenteuze behandeling ...................................................................................... 17
1.6.3 Psycho-Educatie ............................................................................................................ 19
1.6.4 Cognitieve gedragstherapie (CBT) ................................................................................. 19
1.6.5 Familiezorg .................................................................................................................... 20
1.6.6 Rehabilitatie .................................................................................................................. 20
2. Depressieve stoornissen................................................................................................................ 20
1
,2.1 Introductie ............................................................................................................................. 20
2.2 Indeling depressieve stoornissen .......................................................................................... 21
2.3 Klinische beelden v depressieve stoornissen ........................................................................ 21
2.3.1 Majeur depressieve stoornis ......................................................................................... 22
2.3.2 Persisterende depressieve stoornis (Dysthyme stoornis) ............................................. 22
2.3.3 Premenstruele dysfore stoornis .................................................................................... 22
2.3.4 Depressieve stemmingsstoornis door somatische aandoening .................................... 22
2.3.5 Depressieve stoornis dr middel/GM ............................................................................. 23
2.4 Diagnostiek depressieve stoornis .......................................................................................... 23
2.5 Epidemiologie depressieve stoornis...................................................................................... 23
2.6 Etiopathogenese depressieve stoornissen ............................................................................ 23
2.6.1 Neurobiologische factoren ............................................................................................ 23
2.6.2 Psychologische factoren ................................................................................................ 24
2.6.3 Sociale factoren ............................................................................................................. 24
2.6.4 Model vd etiopathogenese v depressieve stoornissen ................................................. 24
2.7 Behandeling van depressieve stoornissen ............................................................................ 25
2.7.1 Psycho-educatie bij depressieve stoornissen ................................................................ 25
2.7.2 Neurobiologische behandeling depressieve stoornissen .............................................. 25
2.7.3 Medicamenteuze behandeling depressieve stoornissen (zie ook tutorial) .................. 26
A. Tricyclische antidepressiva ................................................................................................ 26
B. SSRI: Selectieve Serotonine Reuptake Inhibitoren ............................................................ 27
C. Nieuwe generatie SNRI: Serotonerge en Noradrenerge Reuptake Inhibitoren ................ 28
D. NDRI: Noradrenaline Dopamine Reuptake Inhibitoren..................................................... 28
2.7.4 Neurobiologische niet-farmacologische behandeling v depressieve stoornissen ........ 28
2.7.5 Psychologische behandeling van depressieve stoornissen ........................................... 28
2.8 Beloop depressieve stoornissen ............................................................................................ 28
2.9 Depressie in de huisartsgeneeskunde ................................................................................... 31
2.9.1 Epidemiologie depressie ............................................................................................... 31
2.9.2 Hoe de diagnose depressie stellen? .............................................................................. 31
A. Eraan denken: vage klacht depressie ........................................................................... 31
B. 2 gerichte kernvragen........................................................................................................ 31
C. Andere mogelijke verklaringen ......................................................................................... 31
2.9.3 Hoe de ernst inschatten? .............................................................................................. 32
2.9.4 Indicaties voor medicamenteuze aanpak? .................................................................... 33
2.9.5 Medicamenteuze aanpak in de eerste lijn? .................................................................. 33
A. Bijwerkingen ...................................................................................................................... 33
2
, B. Keuze tss SSRI en TCA ........................................................................................................ 34
C. Uitleg aan ptn .................................................................................................................... 34
D. Follow-up ........................................................................................................................... 34
2.9.6 Wanneer de patiënt verwijzen? .................................................................................... 34
3. Bipolaire stoornissen ..................................................................................................................... 35
3.1 Inleiding ................................................................................................................................. 35
3.1.1 Manische episode .......................................................................................................... 35
3.1.2 Manische vs hypomane episode ................................................................................... 36
3.2 Klinische beelden bipolaire stoornis ..................................................................................... 36
3.3 Epidemiologie van bipolaire stoornis .................................................................................... 36
3.4 Diagnostiek van bipolaire stoornis ........................................................................................ 37
3.5 Differentiaal diagnostiek ....................................................................................................... 38
3.6 Etiopathogenese.................................................................................................................... 38
3.6.1 Neurologische factoren ................................................................................................. 38
3.6.2 Psychologische en sociale factoren ............................................................................... 38
3.7 Behandeling bipolaire stoornis.............................................................................................. 38
3.7.1 Medicamenteuze behandeling ...................................................................................... 38
A. Middelen bij verschillende episodes vd bipolaire stoornis ............................................... 38
B. Aanvang en duurtijd medicamenteuze behandeling ........................................................ 39
C. Lithium behandeling .......................................................................................................... 39
D. Valporaat (depakine) behandeling .................................................................................... 40
E. Probleem van non-compliance.......................................................................................... 40
3.7.2 Psychoeducatie .............................................................................................................. 40
4. Angststoornissen ........................................................................................................................... 41
4.1 Inleiding ................................................................................................................................. 41
4.2 Syndromen ............................................................................................................................ 41
4.2.1 Paniekstoornissen ......................................................................................................... 41
A. PaniekAANVAL ................................................................................................................... 42
B. PaniekSTOORNIS................................................................................................................ 42
4.2.2 Agorafobie ..................................................................................................................... 42
4.2.3 Sociale angststoornis ..................................................................................................... 43
4.2.4 Specifieke fobie ............................................................................................................. 44
4.2.5 Gegeneraliseerde angststoornis (GAD) ......................................................................... 45
4.2.6 Separatie angststoornis ................................................................................................. 45
4.2.7 Selectief mutisme .......................................................................................................... 45
4.3 Diagnostiek ............................................................................................................................ 46
3
, 4.4 Differentiaal diagnose ........................................................................................................... 46
4.5 Epidemiologie angst stoornissen........................................................................................... 46
4.6 Etiopathogenese van angststoornissen................................................................................. 46
4.6.1 Neurobiologische factoren ............................................................................................ 46
4.6.2 Psychologische factoren ................................................................................................ 47
4.7 Behandeling angststoornis .................................................................................................... 47
4.7.1 Psycho-educatie ............................................................................................................ 47
4.7.2 Farmacologische behandeling ....................................................................................... 47
4.7.3 Psychotherapeutische behandeling .............................................................................. 48
4.8 Beloop angst stoornis ............................................................................................................ 48
5. Obsessieve-compulsieve en verwante stoornissen (dwangstoornissen)...................................... 48
5.1 Indeling .................................................................................................................................. 48
5.2 Obsessieve-Compulsieve Stoornis (OCD) .............................................................................. 48
5.2.1 Inleiding OCD ................................................................................................................. 48
5.2.2 Syndroom OCD .............................................................................................................. 48
5.2.3 Diagnose en DD OCD ..................................................................................................... 49
5.2.4 Epidemiologie en beloop OCD....................................................................................... 49
5.2.5 Etipathogenese OCD...................................................................................................... 50
A. Neurobiologische factoren ................................................................................................ 50
B. Psychologische factoren .................................................................................................... 50
5.2.6 Behandeling OCD ........................................................................................................... 50
A. Neurobiologische behandeling OCD.................................................................................. 50
B. Psychologische behandeling.............................................................................................. 50
5.2.7 Beloop OCD ................................................................................................................... 50
5.3 Morfodysfore stoornis (Body Dysmorphic Disorder) ............................................................ 50
5.4 Verzamelstoornis (Hoarding Disorder).................................................................................. 51
5.5 Trichotillomania (haaruittrekstoornis) .................................................................................. 51
5.6 Excoriatiestoornis (huidpulkstoornis, Skin Picking Disorder) ................................................ 51
6. Trauma en stressorgerelateerde stoornissen ............................................................................... 51
6.1 Inleiding ................................................................................................................................. 51
6.2 Klinische beelden................................................................................................................... 52
6.2.1 Reactieve hechtingsstoornis.......................................................................................... 52
6.2.2 Ontremd-sociaalcontact stoornis .................................................................................. 52
6.2.3 Post-traumatische-stressstoornis (PTSS)....................................................................... 52
A. DSM5 criteria ..................................................................................................................... 52
B. Bemerkingen ..................................................................................................................... 53
4
Inhoud
1. Schizofrenie-spectrum en andere psychotische stoornissen .......................................................... 9
1.1 Symptomen ............................................................................................................................. 9
1.1.1 Wanen: + symptoom ....................................................................................................... 9
1.1.2 Hallucinaties: + symptoom .............................................................................................. 9
1.1.3 Gedesorganiseerd denken (formele stoornissen): + symptoom ................................... 10
1.1.4 Ernstige gedesorganiseerde of abnormale psychomotoriek ........................................ 11
1.1.5 Negatieve symptomen .................................................................................................. 11
1.1.6 Opmerkingen ................................................................................................................. 12
1.2 Classificatie ............................................................................................................................ 12
1.2.1 Schizofrenie ................................................................................................................... 12
1.2.2 Schizofreniforme stoornis ............................................................................................. 13
1.2.3 Kortdurende psychotische stoornis............................................................................... 13
1.2.4 Waanstoornis ................................................................................................................ 13
1.2.5 Schizo-affectieve stoornis.............................................................................................. 13
1.2.6 Psychotische stoornis door een middel......................................................................... 13
1.2.7 Psychotische stoornis door een somatische aandoening ............................................. 14
1.2.8 Katatonie ....................................................................................................................... 14
1.3 Terminologie: schizofrenie .................................................................................................... 14
1.4 Ziektebeloop v Schizofrenie .................................................................................................. 14
1.5 Etiologie v Schizofrenie ......................................................................................................... 15
1.5.1 Genetica......................................................................................................................... 16
1.5.2 Environmental hypothese (cannabis en migratie!) ....................................................... 16
1.5.3 Ontwikkelingshypothese ............................................................................................... 17
1.5.4 Toxiciteit (oa drugs) ....................................................................................................... 17
1.6 Behandeling v Schizofrenie ................................................................................................... 17
1.6.1 Historische evolutie ....................................................................................................... 17
1.6.2 Medicamenteuze behandeling ...................................................................................... 17
1.6.3 Psycho-Educatie ............................................................................................................ 19
1.6.4 Cognitieve gedragstherapie (CBT) ................................................................................. 19
1.6.5 Familiezorg .................................................................................................................... 20
1.6.6 Rehabilitatie .................................................................................................................. 20
2. Depressieve stoornissen................................................................................................................ 20
1
,2.1 Introductie ............................................................................................................................. 20
2.2 Indeling depressieve stoornissen .......................................................................................... 21
2.3 Klinische beelden v depressieve stoornissen ........................................................................ 21
2.3.1 Majeur depressieve stoornis ......................................................................................... 22
2.3.2 Persisterende depressieve stoornis (Dysthyme stoornis) ............................................. 22
2.3.3 Premenstruele dysfore stoornis .................................................................................... 22
2.3.4 Depressieve stemmingsstoornis door somatische aandoening .................................... 22
2.3.5 Depressieve stoornis dr middel/GM ............................................................................. 23
2.4 Diagnostiek depressieve stoornis .......................................................................................... 23
2.5 Epidemiologie depressieve stoornis...................................................................................... 23
2.6 Etiopathogenese depressieve stoornissen ............................................................................ 23
2.6.1 Neurobiologische factoren ............................................................................................ 23
2.6.2 Psychologische factoren ................................................................................................ 24
2.6.3 Sociale factoren ............................................................................................................. 24
2.6.4 Model vd etiopathogenese v depressieve stoornissen ................................................. 24
2.7 Behandeling van depressieve stoornissen ............................................................................ 25
2.7.1 Psycho-educatie bij depressieve stoornissen ................................................................ 25
2.7.2 Neurobiologische behandeling depressieve stoornissen .............................................. 25
2.7.3 Medicamenteuze behandeling depressieve stoornissen (zie ook tutorial) .................. 26
A. Tricyclische antidepressiva ................................................................................................ 26
B. SSRI: Selectieve Serotonine Reuptake Inhibitoren ............................................................ 27
C. Nieuwe generatie SNRI: Serotonerge en Noradrenerge Reuptake Inhibitoren ................ 28
D. NDRI: Noradrenaline Dopamine Reuptake Inhibitoren..................................................... 28
2.7.4 Neurobiologische niet-farmacologische behandeling v depressieve stoornissen ........ 28
2.7.5 Psychologische behandeling van depressieve stoornissen ........................................... 28
2.8 Beloop depressieve stoornissen ............................................................................................ 28
2.9 Depressie in de huisartsgeneeskunde ................................................................................... 31
2.9.1 Epidemiologie depressie ............................................................................................... 31
2.9.2 Hoe de diagnose depressie stellen? .............................................................................. 31
A. Eraan denken: vage klacht depressie ........................................................................... 31
B. 2 gerichte kernvragen........................................................................................................ 31
C. Andere mogelijke verklaringen ......................................................................................... 31
2.9.3 Hoe de ernst inschatten? .............................................................................................. 32
2.9.4 Indicaties voor medicamenteuze aanpak? .................................................................... 33
2.9.5 Medicamenteuze aanpak in de eerste lijn? .................................................................. 33
A. Bijwerkingen ...................................................................................................................... 33
2
, B. Keuze tss SSRI en TCA ........................................................................................................ 34
C. Uitleg aan ptn .................................................................................................................... 34
D. Follow-up ........................................................................................................................... 34
2.9.6 Wanneer de patiënt verwijzen? .................................................................................... 34
3. Bipolaire stoornissen ..................................................................................................................... 35
3.1 Inleiding ................................................................................................................................. 35
3.1.1 Manische episode .......................................................................................................... 35
3.1.2 Manische vs hypomane episode ................................................................................... 36
3.2 Klinische beelden bipolaire stoornis ..................................................................................... 36
3.3 Epidemiologie van bipolaire stoornis .................................................................................... 36
3.4 Diagnostiek van bipolaire stoornis ........................................................................................ 37
3.5 Differentiaal diagnostiek ....................................................................................................... 38
3.6 Etiopathogenese.................................................................................................................... 38
3.6.1 Neurologische factoren ................................................................................................. 38
3.6.2 Psychologische en sociale factoren ............................................................................... 38
3.7 Behandeling bipolaire stoornis.............................................................................................. 38
3.7.1 Medicamenteuze behandeling ...................................................................................... 38
A. Middelen bij verschillende episodes vd bipolaire stoornis ............................................... 38
B. Aanvang en duurtijd medicamenteuze behandeling ........................................................ 39
C. Lithium behandeling .......................................................................................................... 39
D. Valporaat (depakine) behandeling .................................................................................... 40
E. Probleem van non-compliance.......................................................................................... 40
3.7.2 Psychoeducatie .............................................................................................................. 40
4. Angststoornissen ........................................................................................................................... 41
4.1 Inleiding ................................................................................................................................. 41
4.2 Syndromen ............................................................................................................................ 41
4.2.1 Paniekstoornissen ......................................................................................................... 41
A. PaniekAANVAL ................................................................................................................... 42
B. PaniekSTOORNIS................................................................................................................ 42
4.2.2 Agorafobie ..................................................................................................................... 42
4.2.3 Sociale angststoornis ..................................................................................................... 43
4.2.4 Specifieke fobie ............................................................................................................. 44
4.2.5 Gegeneraliseerde angststoornis (GAD) ......................................................................... 45
4.2.6 Separatie angststoornis ................................................................................................. 45
4.2.7 Selectief mutisme .......................................................................................................... 45
4.3 Diagnostiek ............................................................................................................................ 46
3
, 4.4 Differentiaal diagnose ........................................................................................................... 46
4.5 Epidemiologie angst stoornissen........................................................................................... 46
4.6 Etiopathogenese van angststoornissen................................................................................. 46
4.6.1 Neurobiologische factoren ............................................................................................ 46
4.6.2 Psychologische factoren ................................................................................................ 47
4.7 Behandeling angststoornis .................................................................................................... 47
4.7.1 Psycho-educatie ............................................................................................................ 47
4.7.2 Farmacologische behandeling ....................................................................................... 47
4.7.3 Psychotherapeutische behandeling .............................................................................. 48
4.8 Beloop angst stoornis ............................................................................................................ 48
5. Obsessieve-compulsieve en verwante stoornissen (dwangstoornissen)...................................... 48
5.1 Indeling .................................................................................................................................. 48
5.2 Obsessieve-Compulsieve Stoornis (OCD) .............................................................................. 48
5.2.1 Inleiding OCD ................................................................................................................. 48
5.2.2 Syndroom OCD .............................................................................................................. 48
5.2.3 Diagnose en DD OCD ..................................................................................................... 49
5.2.4 Epidemiologie en beloop OCD....................................................................................... 49
5.2.5 Etipathogenese OCD...................................................................................................... 50
A. Neurobiologische factoren ................................................................................................ 50
B. Psychologische factoren .................................................................................................... 50
5.2.6 Behandeling OCD ........................................................................................................... 50
A. Neurobiologische behandeling OCD.................................................................................. 50
B. Psychologische behandeling.............................................................................................. 50
5.2.7 Beloop OCD ................................................................................................................... 50
5.3 Morfodysfore stoornis (Body Dysmorphic Disorder) ............................................................ 50
5.4 Verzamelstoornis (Hoarding Disorder).................................................................................. 51
5.5 Trichotillomania (haaruittrekstoornis) .................................................................................. 51
5.6 Excoriatiestoornis (huidpulkstoornis, Skin Picking Disorder) ................................................ 51
6. Trauma en stressorgerelateerde stoornissen ............................................................................... 51
6.1 Inleiding ................................................................................................................................. 51
6.2 Klinische beelden................................................................................................................... 52
6.2.1 Reactieve hechtingsstoornis.......................................................................................... 52
6.2.2 Ontremd-sociaalcontact stoornis .................................................................................. 52
6.2.3 Post-traumatische-stressstoornis (PTSS)....................................................................... 52
A. DSM5 criteria ..................................................................................................................... 52
B. Bemerkingen ..................................................................................................................... 53
4
