Bipolar Disorder 雙極性障礙
CASE 案例
10
At the time of his referral to a psychiatrist working in the outpatient program of
當他被轉介給門診計劃中的精神科醫生時
a private psychiatric hospital, Buddy King was a 28-year-old married African
私人精神病醫院，布迪·金是一名 28 歲已婚的非洲裔
American man who worked as a manager in a family food business (he had
美國人，曾在家庭食品事業擔任經理（他有）
obtained a degree in business administration at the age of 24) and had a wife and
在 24 歲時取得了工商管理學位）並且有了一位妻子和
two daughters (ages 18 months and 4 years). Buddy was referred by his family doc-
兩個女兒（分別年齡 18 個月和 4 年）。Buddy 由他的家庭醫生推薦-
tor after his wife had called the doctor to express concern over her observations
在妻子撥打醫生電話表達對她觀察到的擔憂之後，他等了幾小時
that her husband was becoming increasingly depressed. Over the prior 2 to 3
其丈夫的抑鬱情況逐漸加重。過去兩到三年間
months, Buddy's symptoms of depression had indeed escalated. These symptoms
在幾個月內，布迪的抑鬱症狀確實加重了。這些症狀
included sustained depressed mood and lack of energy, difficulties concentrating,
包含持續的抑鬱情緒和缺乏能量，注意力集中困難，
decreased interest and withdrawal from the activities he usually enjoyed, pessimistic
減少興趣和從他通常喜愛的活動中退出，消極的
views and rumination about the future, and sleep disturbance (i.e., awakening in
未來的觀點和沉思，以及睡眠障礙（即頻繁醒來）
the morning several hours before he intended). More recently, Buddy had experi-
清晨在他打算之前幾個小時。最近，Buddy 有過這種經驗。
enced a decrease in his interest in sexual relations with his wife, and occasionally
增強了對與妻子的性關係失去興趣的傾向，並時常
he had thoughts about committing suicide.
他有過自殺的念頭。
Despite these escalations in his symptoms of depression, Buddy was hesitant to
不論這些憂鬱症症狀的升級，布迪仍然猶豫不決
see a psychiatrist due to his fear of being revealed as "mentally ill" or "weak."
因害怕被揭露為"精神失常"或"軟弱"，所以去看精神科醫生。
However, these symptoms were beginning to interfere with his work, social life,
然而，這些症狀開始干擾他的工作和社交生活
and marriage. Buddy had previously been very energetic and devoted to his work.
並且婚姻。巴迪以前非常有活力，對工作非常投入。
He now found it difficult to get up in the morning to go to the office. Furthermore,
他現在發現早上起床去辦公室變得困難。此外，
he had been an avid athlete, but recently he had discontinued nearly all of his ath-
他曾是一名熱情的運動員，但最近他已經停止了幾乎所有的運動
letic activities. Based on these factors, Buddy reluctantly agreed to set up an initial
活動。根據這些因素，Buddy 不情願地同意設立一個初步的
appointment with the psychiatrist.
與精神科醫生的約見
Clinical History 病史
Buddy's decision to agree to make this appointment was also influenced by his
巴迪同意安排這次約會的決定也受到他的影響
experiences in college. When Buddy was in his senior year at a prestigious univer-
大學的經驗。當 Buddy 在一所著名的大學的最後一年時，
sity in the Midwest, he had experienced symptoms of depression. During this time,
在中西部的一個城市，他經歷了抑鬱症的症狀。在這段時間裡，
138
Bipolar Disorder 139 雙極性障礙 139
Buddy was under a great deal of stress arising from his family (his parents were
布迪承受著巨大的壓力，這源自於他的家庭（他的父母）
upset that he was taking too long in college), and his strong concerns about what
對他在大學花費了太多時間感到不滿意），以及他對大學時間過長的強烈關切
he would do for a career after graduation. However, unlike Buddy's more recent
畢業後會做什麼作為職業。然而，與 Buddy 最近的選擇不同的是
experiences (i.e., his symptoms predating his referral to the psychiatrist), these
經驗（即，他的症狀先於他被轉介給精神科醫生），這些
symptoms of depression were followed a few days later by more dramatic symp-
憂鬱症的症狀在幾天後被追蹤，隨後出現了更為戲劇性的症狀
toms. Specifically, Buddy had experienced a full manic episode, characterized by
湯姆斯。特別是，布迪經歷了一次完整的躁狂發作，特徵為
symptoms of abnormally and persistently elevated mood, grandiose and persecutory
異常且持續情緒過高的症狀，自大和被迫害的妄想
delusions, hyperactivity, and a substantially decreased need for sleep (described in
妄想，過度活躍，以及大幅減少的睡眠需求（在以下部分描述）
more detail later). During this episode, Buddy's school performance diminished
後續會提供更多細節）。在這段期間，布迪的學業表現下滑了
greatly, and he often skipped classes altogether. Although he had previously been
非常頻繁，他經常完全不上課。雖然他之前一直
a sensible drinker (he only drank socially at college parties), Buddy engaged in sev-
理性飲酒者（他只在大學派對上社交性飲酒），Buddy 參與了多場活動
eral alcohol and marijuana binges.
長期酒精和大麻過量使用
This manic episode was accompanied by other bizarre and risky activity. Dur-
這段躁狂期伴隨著其他古怪和冒險的活動。
ing the manic episode, Buddy experienced a marked increase in sexual desire.
在躁狂症發作期間，布迪（Buddy）的性慾顯著增加。
However, at the time, Buddy was not in a relationship to satisfy his sexual long-
然而，當時，Buddy 並沒有關係可以滿足他的性需求
ings. The most significant negative consequence of Buddy's manic episode was his
Buddy 的躁狂症最嚴重的負面後果是他
arrest by campus police after he was found naked with a 15-year-old girl in a
校園警員在發現他與 15 歲女孩在一处赤身裸體後將他逮捕
vacant office building on campus. Although Buddy was arrested and charged
校園內的空置辦公大樓。雖然巴迪被捕並被起訴
with trespassing, these charges were later dropped. The police also threatened to
侵權行為，這些指控後來被撤銷。警方也威脅要
charge him with sexual misconduct with an underage female, but these charges
對他提出性侵未滿歲女性的指控，但這些指控
never materialized. 從未實現
The morning after his arrest, Buddy was taken to a hospital where he was
被逮捕的第二天早晨，布迪被帶到一家醫院，在那裡他被
involuntarily hospitalized with the diagnosis of an acute manic episode. This hospi-
被迫住院，診斷為急性狂躁症發作。此住院情況-
talization lasted 6 weeks. During the first 2 weeks of hospitalization, Buddy was
轉換過程持續了 6 週。在住院的前 2 週，Buddy 被
very resistant to treatment and refused most medications. However, he gradually
非常抗拒治療，拒絕大多數藥物。然而，他逐漸
accepted the notion of medications but refused lithium treatment (lithium carbonate
接受了藥物治療的概念，但拒絕了锂治療（碳酸锂）
is the most widely used drug for the treatment of mania). He was treated with a
是治療狂躁症最常使用的藥物）。他接受了一種治療
combination of Depakote (an antiseizure drug), divalproex (occasionally used in
結合使用 Depakote（一種抗癲癇藥物）和 divalproex（偶爾用於）
the treatment of mania because it seems to "depress" the central nervous system,
躁狂症的治療，因為它似乎「抑制」了中樞神經系統，
and Haldol (haloperidol, an antipsychotic drug used in the treatment of psychotic
並且 Haldol（Haloperidol，一種用於治療精神分裂症的抗精神病藥物）
symptoms such as delusions and hallucinations), which resulted in a gradual reduc-
症狀如妄想和幻聽），導致了逐漸減少-
tion in his manic symptoms. At the time of his discharge from the hospital, Buddy
在他的躁狂症狀期間。在他從醫院出院時，巴迪
insisted on the discontinuation of Haldol, although he reluctantly agreed to con-
堅持要求停止使用 Haldol，雖然他不情願地同意進行-
tinue taking Depakote. 繼續服用 Depakote。
For a time after his discharge, things were rough for Buddy. Although his legal
出獄後的一段時間裡，布迪的日子過得很艱難。雖然他的法律
charges were eventually dropped, college authorities refused to allow Buddy to con-
最終撤銷了指控，大學管理方拒絕讓 Buddy 進行-
tinue in school. Thus, Buddy was forced to transfer and complete his degree at
繼續在學校學習。因此，Buddy 被迫轉學並在另一處完成他的學位。
another university. He was somewhat shunned by his friends (who did not under-
另一所大學。他在朋友中有些被排擠（因為他們不理解-）
stand why Buddy had suddenly acted in a manner so out of character), and his fam-
不解為何 Buddy 會突然表現得如此不合常態），並對他的家人-
ily was very disturbed by the onset of these serious manic symptoms. Although they
她對這些嚴重的躁狂症狀突然出現非常困擾。雖然他們
continually pressured him to comply with his treatment, the family was dismayed
不斷對他施加壓力，要求他遵守治療，家人感到驚慌失措
that Buddy had become increasingly noncompliant with medical recommendations
巴迪對醫療建議的遵從程度逐漸增加
to continue taking Depakote and submit to regular laboratory tests that were
繼續服用 Depakote 並接受定期的實驗室檢測
required for his medication regimen (i.e., blood tests that evaluate whether the
所需用於其藥物療程的（即評估血液是否符合）檢驗項目
drug is present at a therapeutic level in the person's system and that rule out the
藥物在該人的體內達到治療水平，並且排除了
presence of negative side effects). This resulted in numerous family conflicts and
存在副作用的現象導致了眾多家庭衝突和問題。
heated discussions between Buddy and his parents. Buddy rejected his parents'
布迪和他的父母之間激烈的辯論。布迪拒絕了他父母的意見。
140 Case 10 140 案例 10
arguments for medication compliance by pointing out that his manic symptoms
藥物遵從性的論點，指出他的躁狂症狀
were no longer present, and so he no longer needed to take the drug.
當不再有這些存在，所以他不再需要服用藥物。
However, unlike many people who have experienced a manic episode, Buddy,
然而，與許多經歷過躁狂發作的人不同，布迪，
（Translation directly to Traditional Chinese without additional text）
in fact, had had no additional manic episodes since college, even though he had
實際上，從大學畢業以來，他甚至沒有再經歷過任何額外的躁狂症發作，儘管他有
totally stopped taking medications. Buddy completed college at another school
完全停止服用藥物。Buddy 在另一所大學完成了大學學業。
and, not having found employment elsewhere, decided to work in the family's
因此，未能在其他地方找到工作，決定在家族的
food business (where he continued to work at the time of his referral). During
食品業務（當時他被轉介時仍在工作的業務）。在此期間，
the first year after college, Buddy met the woman he eventually married, and he
大學畢業後的第一年，Buddy 遇到了他最終結婚的那位女士，而他
settled into working in the family business. Although Buddy had not experienced
適應在家族企業工作。雖然 Buddy 沒有經驗
any additional manic episodes, he continued to have brief periods of depression
繼續有短期的抑鬱時期，他沒有額外的癲狂發作
from time to time, none of them long or severe enough to cause Buddy to obtain
不時發生，每次都不夠長或嚴重到足以讓 Buddy 獲得
treatment, although his wife had often urged him to do so. Had it not been for his
治療，雖然他的妻子經常勸他這樣做。如果不是因為他
wife's urgings, Buddy might have never agreed to the initial appointment with the
妻子的催促，Buddy 可能永遠不會同意初診與的安排
psychiatrist. 精神科醫生
Buddy was born and raised in a very pressured and high-achieving family. His
夥伴出生並成長在一個極度有壓力和追求高成就的家庭中。他的
father was a successful food manufacturer who gradually incorporated all of his
父親是一位成功的食品製造商，逐步將他的所有業務整合在一起
children in the family business. Buddy was the youngest of five children; he often
家庭事業中的子女。布迪是五個孩子中最小的；他經常
struggled with competition with his older brothers. He stated that he often felt
與年長的兄弟們競爭，他經常感到很吃力。他提到自己經常有這種感受。
that he had to "go the extra mile" in order to measure up to his older brothers in
他必須"多走一里路"，才能與年長的兄弟們相匹敵
his parents' 他父母的
eyes. Buddy's father was a somewhat harsh, yet supportive man who
眼睛。布迪的父親是一個有些嚴苛，但又支持的人，
demanded performance and conscientiousness from all of his children. Differences
要求所有孩子表現出高效率和責任感。差異
of opinion were not well-tolerated in the family, and each child was pressured to
意見在家中並不受歡迎，每個孩子都受到強烈的壓力要
agree with parental views. Although the family was very wealthy, much of the par-
同意家長的觀點。雖然家庭非常富裕，但許多人認為這種觀點並不符合實際情況。
ents' support (both emotional and financial) was tied to such compliant attitudes.
各個支持者（包括情感和財務上的）都與這樣的順從態度有關聯。
For example, those children who rebelled (e.g., had differing views on how aspects
例如，那些反抗（例如，對事物的觀點不同）的兒童
of the family business should be run were often ostracized and would later rejoin
家庭事業應該由誰來運作的問題往往被孤立，後來再重新加入
after agreeing to give up their "rebellious"
在同意放棄他們的"叛逆"之後
attitudes. Buddy described himself as
態度。Buddy 說自己是
being hyper-conscientious and driven during his childhood years, a characteristic
在童年時期，他表現出過度的警覺和動力，這是一項特徵
that he attributed to his family environment. He also recalled being perfectionistic
他歸因於他的家庭環境。他也回憶起自己曾是個完美主義者。
in high school and college athletics (he played on the basketball team) and to some
在高中和大學的運動（他曾在籃球隊出賽）以及某些
degree in his school work. Buddy claimed that these family dynamics had resulted
學業中獲得學位。Buddy 主張這些家庭動態導致了
in several recent conflicts regarding decisions within the family food business, which
在最近幾起家庭食品企業內部決策的爭議中，
he cited as possible contributing factors to his current depression.
他提到了幾個可能的 contributing factors 致使他目前的抑鬱狀態。
Buddy's family had various members with mood disorders. His mother had
巴迪的家庭有各種情緒障礙的成員。他的母親有
recurring bouts of depression that had been treated with antidepressant medica-
反覆出現的抑鬱症，曾用抗抑鬱藥物治療
tions. Buddy's maternal grandmother, paternal uncle, and oldest brother had also
親屬。布迪的母親的祖母、父親的叔叔以及最年長的哥哥也都去世了。
received outpatient treatment for depression. Buddy's maternal uncle had alcohol-
收治門診治療抑鬱症。布弟的姨丈有酒精-
ism and possible bipolar disorder, although the presence of this latter diagnosis
同性戀和可能的雙極障礙，雖然後者診斷的存在
was uncertain because he was estranged from the family and lived in another part
無法確定，因為他與家庭疏遠，住在另一個地方
of the country. 國家的
DSM-5 Diagnosis DSM-5 診斷
Based on the information presented, Buddy was assigned the following DSM-5
根據所提供的資訊，Buddy 被分配了以下的 DSM-5
(Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis:
(精神障礙診斷與統計手冊，第 5 版）診斷：
296.52 Bipolar I disorder, current or most recent episode depressed, moderate
296.52 双極型 I 型障礙，現時或最近一階段為抑鬱，中度
Bipolar Disorder 141 雙極性障礙 141
Bipolar disorder is the formal diagnostic term for a condition that has been
雙極性障礙是正式診斷用語，用以描述一種症狀
more commonly referred to by laypersons as "manic depression." Although Buddy
常被非專業人士稱為"狂躁症". 尽管 Buddy
did not show any signs of mania at the time of his referral to the psychiatrist, the
當時轉介給精神科醫生時，他並未顯示出狂熱的徵兆
diagnosis of bipolar disorder is still appropriate because he had a history of a full
雙極性障礙的診斷仍然適當，因為他有完整的病史
manic episode. In DSM-S (American Psychiatric Association, 2013), a manic ei-
躁狂症發作。在 DSM-S（美國精神醫學會，2013 年），躁狂症發作-
sode is defined as a distinct period of abnormally and persistently elevated, expan-
sode 被定義為一段時間內異常且持續高漲、擴展的獨特時期
sive, or irritable mood and abnormally and persistently increased
疾患，或是易怒情緒和異常且持續增加
goal-directed 目標導向
activity or energy that is accompanied by at least three of the following symptoms:
活動或能量，伴隨以下至少三項症狀：
(a) inflated self-esteem or grandiosity, (b) decreased need for sleep (e.g., feeling
(a) 膨脹的自我尊嚴或自大，(b) 眠需要減少（例如，感覺
rested after only 3 hours of sleep), (c) more talkative than usual or pressure to
休息了僅 3 小時後就睡覺了), (c) 比平常更健談或感到有壓力
keep talking, (d) flight of ideas (e.g., jumping from one topic to another in mid-
繼續談話，（d）思想飄移（例如，在中間從一個主題跳到另一個主題）
conversation) or subjective experience that thoughts are racing, (e) distractibility
對話) 或主觀經驗中，想法在飛快地閃過，(e) 注意力分散
(i.e., attention too easily drawn to unimportant or irrelevant external stimuli),
（即，注意力過於容易被不重要或無關的外部刺激所吸引），
(t) increase in goal-directed activity (e.g., writing a torrent of letters to public figures
目標導向活動的增加（例如，向公眾人物寫大量的信件）
or friends, taking on new business ventures) or psychomotor agitation (e.g., con-
或朋友，接手新的商業項目）或心理運動性興奮（例如，進行-）
stant pacing, carrying on several conversations at the same time), and (g) excessive
站著踱步，同時進行多個對話），以及（g）過度
involvement in pleasurable activities that have a high potential for painful conse-
參與可能導致痛苦後果的愉悅活動
quences (e.g., buying sprees, foolish business investments, or, as in Buddy's case,
序列（例如，大肆消費、愚蠢的商業投資，或者，如 Buddy 的例子，）
sexual indiscretions). To qualify as a manic episode, the disturbance must last at
性行為失當）。要被認為是狂躁症發作，這種干擾必須持續至少一週。
least 1 week or can be of any duration if hospitalization is necessary (as was the
至少 1 週，或如果需要住院則可以為任何持續時間（如前所述）
case with Buddy). 與 Buddy 的案例。
When establishing a diagnosis, the clinician must make the distinction between
在確立診斷時，臨床醫生必須區分以下內容：
manic and hypomanic episodes. In DSM-5, both manic and hypomanic episodes
躁狂和輕躁狂發作。在 DSM-5 中，既包括躁狂發作也包括輕躁狂發作。
have the same characteristic symptoms listed in the preceding paragraph. However,
具有前一段中列出的相同特徵症狀。然而，
the two types of episodes are distinguished primarily by the extent to which they
兩種集數主要區分在於它們的範圍，尤其是它們的程度
are accompanied by lifestyle impairment. In contrast to a manic episode, a hypo-
伴隨生活機能障礙。與躁狂發作相反，抑鬱發作會導致生活機能障礙。
manic episode is not severe enough to cause marked impairment in social or occu-
躁狂症的發作並不足以導致顯著的社交或職業功能障礙
pational (or academic) functioning and does not require hospitalization. Moreover,
國家（或學術）功能正常，且不需要住院。此外，
the duration criterion for a hypomanic episode is briefer (4 days or more) than for a
躁狂症發作的持續時間標準比以下的躁狂症發作短（至少 4 天）
manic episode (at least 1 week). The presence of at least one lifetime manic episode
躁狂症發作（至少一週）。至少有一次生命中的躁狂症發作
is required for the DSM-5 diagnosis of bipolar I disorder. Hypomanic episodes are
躁狂 I 型障礙的 DSM-5 診斷所需。過度興奮期是
common in bipolar I disorder but are not required for this diagnosis.
在雙極 I 型障礙中常見，但不是此診斷的必要條件。
If a person presents to a clinic with current or past manic symptoms, a number
若有人向診所現有或過去出現狂躁症狀，則會涉及數量
of potential DSM-5 diagnoses may be applicable. As noted above, if the person has
可能適用於 DSM-5 診斷的潛在對象可能適用。如上所述，如果該人有
experienced symptoms that meet criteria for a full manic episode, the diagnosis of
經驗到符合全範疇躁狂發作的症狀，診斷為
bipolar I disorder is appropriate (as was the case for Buddy). Although the term
雙極 I 型障礙對於布迪來說是適當的（就像實際情況那樣）。雖然這個術語
bipolar may imply otherwise (i.e., two poles of mood from extremely high to
雙極可能暗示其他情況（即，情緒的兩個極端，從極高到）
extremely down), the diagnosis of bipolar I disorder is still appropriate if the person
極度低落）的情況下，如果該人符合躁鬱 I 型障礙的診斷標準，則仍然適用躁鬱 I 型障礙的診斷
has experienced a manic episode but not a major depressive episode. However, pre-
經歷過躁狂症發作，但未經歷過重大抑鬱症發作。然而，預-
sentations involving full manic episodes only are infrequent, and most patients with
涉及完整躁狂症发作的案例很少見，大多數患有
bipolar I disorder experience alterations in mood cycling between manic episodes
雙極 I 型障礙體驗情緒在狂躁發作之間的波動
and major depressive episodes (often separated by periods of normal mood).
重度抑鬱發作（通常由正常情緒的時期分隔開）。
The diagnosis of bipolar Il disorder is used in reference to clinical presentations
雙極型第 II 期障礙的診斷用於參考臨床表現
of one or more major depressive episodes and at least one hypomanic episode (and
一或多個主要抑鬱癥發作和至少一個輕躁狂發作（和）
no history of full manic episodes). The defining feature of the diagnosis cyclothymic
無全範疇躁狂發作的病史）。診斷的特徵為循環性躁鬱症
disorder is the chronic (at least 2 years) presence of numerous periods of hypomanic
混亂是至少兩年的長期存在，期間有多個躁狂症發作的時期
symptoms and numerous periods of depressive symptoms that are not severe
症狀和多個時期的非嚴重抑鬱症狀
142 Case 10 142 案例 10
enough to meet criteria for a hypomanic episode and a major depressive episode,
足以符合躁狂症发作和重度抑鬱症发作的標準
respectively. If the person has at any time met criteria for major depressive, manic,
分別而言。如果此人曾符合主要抑鬱症或躁狂症的標準，
or hypomanic episodes, the diagnosis of cyclothymic disorder is not assigned.
或過度興奮的症狀期，並非會被診斷為迴圈性障礙。
As you may have noted from Buddy's diagnosis, his bipolar disorder was
如您可能已從 Buddy 的診斷中注意到，他的雙極性障礙是
assigned with two specifiers (i.e., "current or most recent episode depressed,"
被賦予兩個限定詞（即，「當前或最近一集抑鬱」）
"moderate"). In addition to the use of specifiers to convey the severity of the disor-
"中等")。除了使用限定詞來傳達疾病的嚴重程度之外，
der (e.g., "mild," "moderate," "severe," "with psychotic features"), there are speci-
特定的（例如，“輕微的”，“中等的”，“嚴重的”，“具有精神分裂症特徵的”），存在特定的分類。
fiers included with the diagnosis of bipolar disorder to describe the nature and
躁郁症診斷所附帶的症狀用以描述其性質和
course of the disturbance. Specifically, because most persons with this disorder
干擾的過程。特別是，因為大多數患有這種障礙的人
cycle between periods of depression and mania, a specifier is used to indicate the
在抑鬱和狂躁的周期之間交替，使用特定的標記來表示
person's current or most recent mood state (e.g., "current or most recent episode
人物當前或最近的情緒狀態（例如，“當前或最近的時期”）
manic"). When applicable, additional specifiers can be assigned to better convey
"躁狂症")。當適用時，可以分配額外的限定詞以更好地傳達
the nature of the disturbance. An example of one such specifier is "with rapid
干擾的本質。這樣的特徵之一的例子是“快速”
cycling," which is used to characterize presentations where 4 mood episodes
"騎自行車",用來描述包含 4 個情緒發作的展示
(meeting the criteria for manic, hypomanic, or major depressive episode) have
（符合躁狂、轻躁狂或主要抑鬱症的標準）
been experienced in the previous 12 months. The mood episodes can occur in any
過去十二個月內有經驗過。情緒波動可以發生在任何
combination and in any order.
組合，並以任意順序。
CASE FORMULATION USING THE INTEGRATIVE MODEL
整合模型下的案例形成
Like each of the anxiety and mood disorders discussed in this book, the integra-
本書中討論的每種焦慮和情緒障礙一樣，整合
tive theory of bipolar disorders is based on a diathesis-stress model (Barlow &
雙極性障礙的理論基礎是傾向壓力模型（Barlow &
Durand, 2015). The "diathesis" component of the integrative model refers to the
杜蘭, 2015 年）。整合模型中的"病理傾向"部分指的是
biological vulnerability to develop a bipolar disorder. Although no specific genetic
生物學上的易感性發展為雙極障礙。雖然沒有特定的遺傳
or biological markers have been confirmed as risk factors for bipolar disorders, at
或生物標記已被確認為雙極障礙的風險因素，在
present this vulnerability seems to be best described as an overactive neurological
現今這個脆弱性似乎最適合被描述為過度活躍的神經系統
response to stressful life events (the "stress" component of the diathesis-stress
對壓力生活事件的反應（「壓力」成分的病態-壓力理論）
model). Although some research suggests that the bipolar, mood, and anxiety
模式)。雖然有些研究指出，雙極、情緒和焦慮
disorders share a common, genetically determined biological vulnerability (e.g.,
障礙共享一個共同的、由遺傳決定的生物學易感性（例如，
Kendler, Neale, Kessler, Heath, & Eaves, 1992b), there is some evidence that the
肯德勒,奈勒,克 esz 勒,希思,及伊夫斯,1992b)，有一些證據顯示，
genetic basis for bipolar disorder is distinct from the inheritability of mood disor-
雙極性障礙的遺傳基礎與情緒障礙的遺傳性是不同的
ders (Nurnberger, 2012).
Evidence of the presence of this genetic vulnerability in Buddy was his extensive
寶貝身上顯示這項遺傳易感性的證據，就是他廣泛的
family history of depression (and possibly bipolar disorder). This is consistent with
遺傳憂鬱症（以及可能的雙極障礙）的家族史。這與...一致。
research findings showing that the rate of mood disorders in the families of persons
研究發現，顯示了個體的家庭中情緒障礙的發生率
with bipolar disorder is considerably higher than the rate among other families (Lau
躁鬱障礙的發生率在其他家庭中要高出許多（Lau）
& Eley, 2010). However, one interesting result emerging from these studies is that
"Eley, 2010)。然而，這些研究中出現的一個有趣結果是，"
the most frequent mood disorder in the relatives of persons with bipolar disorder is
親友中有雙極性障礙的人的最常見情緒障礙是
not bipolar disorder but rather major depression. For persons with major depres-
不是雙極性障礙，而是重度抑鬱症。對於有重度抑鬱症的人來說，
sion, there seems to be a negligible chance that their relatives will have a greater
在這種情況下，似乎他們的親屬有更大機會的機會微乎其微
incidence of bipolar disorder than will people with no emotional disorder. Thus,
雙極性障礙的發生率將高於無情緒障礙的人。因此，
among the mood disorders, there may not be a specific or separate genetic contribu-
在情緒障礙中，可能並沒有特定或單獨的遺傳貢獻
tion to bipolar disorder. Instead, bipolar disorder may represent a more severe man-
轉換為雙極性障礙。相反，雙極性障礙可能代表更嚴重的男性-
ifestation of this underlying genetic vulnerability. This manifestation would be
此基礎遺傳脆弱性的表現形式。此表現形式會是
determined by other psychosocial or biological factors that occur in addition to
由其他心理社會或生物因素決定，這些因素除了一般因素之外還會出現
genetic vulnerability. This connection is not yet certain, and researchers have long
遺傳性脆弱性。這條聯繫尚未確定，研究人員長期以來一直在研究這個問題。
disagreed as to whether bipolar disorder and major depression are two distinct
在雙極性障礙與主要抑鬱症是否為兩種不同的疾病上存在分歧
Bipolar Disorder 143 雙極性障礙 143
disorders or one disorder that varies in its severity (Angst & Sellaro, 2000; Blehar,
障礙或一種在嚴重程度上有所變化的障礙（Angst & Sellaro, 2000; Blehar,
Weissman, Gershon, & Hirschfeld, 1988; Nurnberger, 2012).
威斯曼, 吉爾森, 及 赫希爾德, 1988 年; 尼倫伯格, 2012 年。
Findings from twin studies have also supported the role of genetics in the ori-
雙生子研究的發現也支持了基因在起源中的作用
gins of bipolar disorder. For example, in a study by Bertelsen, Harvald, and Hauge
雙極性障礙的藥物。例如，在貝爾森、哈爾瓦德和豪格的研究中
(1977), if one twin had bipolar disorder, there was an 80% chance that a monozy-
(1977 年)，如果其中一個雙胞胎有躁鬱障礙，那麼另一個雙胞胎有此障礙的機率為 80%
gotic (identical) twin had some form of mood or bipolar disorder (e.g., major
哥特（同卵）雙胞胎有某種情緒或雙極障礙（例如，主要）
depression, bipolar disorder). This was substantially higher than the rate of mood
憂鬱症，雙相情感障礙）。這遠高於情緒障礙的發生率。
disorders (16%) in dizygotic (fraternal) twins, if one twin had bipolar disorder. As
同卵雙胞胎（兄弟姊妹）中，如果其中一人的躁鬱症，另一人患精神障礙的機率為 16%。
monozygotic twins have exactly the same genes and dizygotic twins share only
同卵雙胞胎擁有完全相同的基因，而異卵雙胞胎只共享一部分基因
about 50% of each other's genes (the same amount shared among first-order rela-
約 50%的基因（與彼此的第一級親屬共享相同數量的基因）
tives), the higher rate of mood disorders in monozygotic twin pairs suggests that
單卵雙胞胎組合中情緒障礙的高發率暗示了
genetic factors contribute to the development of bipolar disorder. However, subse-
遺傳因素對雙極障礙的發展有貢獻。然而，子題目-
quent studies have observed somewhat weaker concordance rates in twin pairs
許多研究已經注意到雙胞胎配對中的相容率略為較弱
compared to those obtained by Bertelsen et al. (1977) (e.g., McGuffin & Katz,
與 Bertelsen 等人 (1977) 所得到的結果相比（例如，McGuffin & Katz，）
1989; McGuffin et al., 2003), although in general the genetic contributions for
1989；麥高根等人，2003 年），雖然總體而言，遺傳貢獻對於
bipolar disorder appears to be stronger than for depressive disorders.
雙極性障礙的強度似乎比抑鬱障礙更高。
Numerous studies have attempted to identify neurobiological factors contribut-
多項研究試圖識別貢獻於神經生物學因素
ing to the development and maintenance of bipolar disorder. Despite this issue's
根據雙極性障礙的發展和維護。儘管這個問題的
considerable research attention, no neurobiological component has been linked
在大量的研究關注中，並沒有任何神經生物學成分被聯繫起來
with certainty to this disorder. Researchers generally concur that the balance
對於這種紊亂，有著確定的認識。研究人員普遍認為，這種平衡
among a variety of neurotransmitters is more important than the absolute level of
在各種神經傳遞素中，相對水平比絕對水平更重要
any one neurotransmitter in bipolar disorder. For instance, there is increasing inter-
雙極性障礙中任何一種神經傳遞素。例如，有越來越多的交際。
est in the role of dopamine in the context of this balance among neurotransmitters,
在這些神經傳遞素之間的平衡中，多巴胺在此角色中的作用
based on evidence that drugs that increase the activity of dopamine (dopamine
根據增加多巴胺活動的藥物的證據（多巴胺
"agonists" such as L-dopa) produce mild manic-like states (i.e., hypomania) in
"拮抗劑"如 L-多巴)在患者中產生輕微的躁狂狀態（即輕躁狂）
patients with bipolar disorder (Anand et al., 2000; Dunlop & Nemeroff, 2007).
雙極性障礙的患者（Anand 等人，2000 年；Dunlop 及 Nemeroff，2007 年）。
Additionally, research has shown that patients with bipolar disorder and their
此外，研究顯示，雙相障礙患者及其
children (who are at greater risk for bipolar disorder) show increased sensitivity to
兒童（他們有較高的雙極障礙風險）對
（輸入的文字過短，無法完成完整的句子翻譯。根據上下文，可能需要翻譯的完整句子是：children who are at greater risk for bipolar disorder show increased sensitivity to...）
light, that is, when exposed to light at night, they show greater suppression of the
光,也就是在夜晚受到光照射時,他們顯示出對的更大抑制
hormone melatonin (Nurnberger et al., 1988). Melatonin is a hormone activated by
荷爾蒙褪黑激素（Nurnberger et al., 1988）。褪黑激素是由
darkness to control the body's biological clock and to induce sleep. There is also
黑暗用來控制身體的生物鐘並誘導睡眠。此外，
evidence that extended bouts of insomnia trigger manic episodes (Malkoff-
失眠長期持續的證據引發狂躁症發作（Malkoff-）
Schwartz et al., 2000; Wehr, Goodwin, Wirz-Justice, Breitmeier, & Craig, 1982).
施瓦茨等人，2000 年；華爾，古德溫，維爾-司法，布里特邁爾，克雷格，1982 年。
These findings suggest that onsets of bipolar disorder are related to disruptions in
這些發現表明，雙極障礙的發作與神經系統的中斷有關
circadian rhythms (resulting from low levels of the neurotransmitter serotonin; cf.
日間週節律（由神經傳遞物質血清素的低水平引起；參照）
Goodwin & Jamison, 2007).
古德溫與賈米森，2007 年。
Other evidence of the role of neurotransmitters in bipolar disorder comes from
雙極性障礙中神經傳質物作用的其他證據來自
a host of studies and clinical observations attesting to the effectiveness of the drug
一連串的研究和臨床觀察，證明了該藥物的有效性
lithium in the treatment of this condition. A detailed description of lithium is pro-
此情況的治療中使用 lithium。對 lithium 的詳細描述是進行中的。
vided in the next section. The fact that many patients with bipolar disorder respond
在下一個部分中提供。事實上，許多雙極性障礙的患者會有反應
favorably to lithium has been viewed by some researchers as indicating that the
一些研究人員將對鈉的有利觀點視為暗示，表明了
drug is regulating the levels of neurotransmitters contributing to bipolar disorder.
藥物正在調節對雙相障礙有貢獻的神經傳導物質的水平。
However, it is not clear how lithium works. It is possible that lithium reduces the
然而，锂如何起作用尚不明确。有可能锂减少了
availability of the neurotransmitters dopamine and norepinephrine. Yet, it has also
神經傳質物多巴胺和去甲腎上腺素的可用性。然而，它也
been hypothesized that lithium affects the endocrine system, particularly neuro-
已被假設锂影響內分泌系統，特別是神經系統
chemicals that affect the production and levels of sodium and potassium, which
影響生產和鈉和鈾水平的化學品，
are electrolytes found in our body fluids (Goodwin & Jamison, 2007). Much more
體內液體中發現了電解質（Goodwin & Jamison, 2007）。更多
144 Case 10 144 案例 10
research is needed to identify lithium's mechanisms of action. These findings could
需要進行研究以識別 lithium 的作用機制。這些發現可能
potentially lead to more effective drug treatments for bipolar disorder, in addition
可能導致對雙相障礙更有效的藥物治療，此外
to a greater understanding of the neurobiological factors contributing to this
對促成這一點的神經生物學因素有更深入的理解
disturbance. 干擾
As noted in the beginning of this section, stressful life events appear to play a
如本節開頭所指出，壓力大的生活事件似乎扮演著重要的角色
significant role in the onset of mood disorders and manic episodes. A large body of
情緒障礙及躁狂症發作的起始階段扮演著重要角色。大量的
Translation: 情绪障碍及躁狂症发作的起始阶段扮演著重要角色。大量的
research indicates that stressful life events (family difficulties, job loss, etc.)
研究顯示，壓力大的生活事件（如家庭困難、失業等）
are strongly related to the onset of mood disorders, particularly major depression.
情緒障礙，特別是主要抑鬱症，與其發作有著密切的關係。
A few studies have also produced data that support the connection between stress
幾項研究也產生了支持壓力與聯繫之間關係的數據
and the onset of manic episodes (Goodwin & Jamison, 2007; Hammen & Gitlin,
躁狂症發作的開始（Goodwin & Jamison, 2007; Hammen & Gitlin,
1997). These findings are consistent with Buddy's experiences, as he connected the
1997 年）。這些發現與 Buddy 的經驗一致，因為他將這些聯繫了起來。
emergence of his first manic episode (and subsequent periods of depression) to
首次躁狂症發作（以及其後的抑鬱期）到
stress in his life (e.g., senior year of college, familial conflict on how the family busi-
生活中的壓力（例如，大學的最後一年，家庭衝突，關於家庭企業的處理方式）
ness should be run). The limited data that do exist on the role of stress in bipolar
應當運行 ness。現有的有限數據顯示了壓力在雙極疾病中的角色。
disorder suggest that while stressful life events may trigger initial manic episodes,
混亂表明，雖然壓力大的生活事件可能會引發最初的躁狂發作，
once the disorder develops, these episodes take on a life of their own and occur
一旦疾病發展，這些症狀就會自行其是，並發生
with no obvious connection to life stress (Post, 1992). According to current
與生活壓力無明顯關聯（Post, 1992）。根據當前
diathesis-stress models, stress contributes to the development of bipolar disorder
分佈重力模型，壓力對雙極性障礙的發展有貢獻
because stressful life events activate our stress hormones, which, in turn, have
因為壓力生活事件會激活我們的壓力荷爾蒙，而這些荷爾蒙又會產生影響
wide-ranging effects on our neurotransmitter systems (e.g., serotonin, norepineph-
廣泛影響我們的神經傳遞素系統（例如，血清素，去甲腎上腺素）
rine, dopamine). If these stress hormones remain activated, structural and chemical
腎上腺素，多巴胺）。如果這些應激荷爾蒙持續活躍，會導致結構和化學
changes in the brain may occur (e.g., atrophy of neurons in the areas of the brain
大腦中可能會發生變化（例如，腦部特定區域的神經元萎縮）
that contribute to the regulation of emotions and neurotransmitter activity). For
調節情緒和神經傳質活動的）貢獻。
instance, the extended effects of stress may be associated with disruptions in a per-
例如，壓力的延長效果可能與個體的中斷有關
son's circadian rhythms, causing them to be susceptible to the recurrent cycling that
兒子的生理時鐘，導致他們對反覆循環變得敏感
is a defining feature of many mood disorders. As noted earlier, another psychoso-
情緒障礙的許多特徵是其定義性特點。如早前所述，另一個心理素質
cial precipitant of mania appears to be loss of sleep (as might occur in the postpar-
躁狂的醫學誘發因素似乎是睡眠的缺失（這可能會在產後發生）
tum period following childbirth), supporting the notion that the emergence of
產後恢復期），支持了這個觀點，即產後的出現
bipolar disorder may be related to a disruption of circadian rhythms (Goodwin &
雙極性障礙可能與 circadian 節律的打亂有關（Goodwin &
Jamison, 2007). 賈米森，2007 年。
Many of the psychosocial features that contribute to the onset and maintenance
許多對發病和維持有貢獻的心理社會特徵
of major depression (e.g., social support; negative perceptions of one's self, world,
主要抑鬱（例如，社會支持；對自己、世界的負面看法，）
and future; sense of helplessness or hopelessness) may also play a significant role in
未來；無助感或絕望感）也可能在其中扮演重要角色
bipolar disorder. Because many of these features are discussed in detail in Case 9,
雙極性障礙。由於這些特點在案例 9 中有詳細討論，
the remainder of this section will focus on factors that are more specific to bipolar
本節的餘下部分將集中探討更針對雙極性的情緒障礙的特定因素
disorder. One important factor that may contribute to the maintenance of bipolar
混亂。一個可能對雙極障礙維持有貢獻的因素是
disorder and predict a poor treatment response is denial or minimization of the
混亂和預測治療反應不良是對問題的否認或輕描淡寫
problem. Unlike most of the other disorders discussed in this book, the manic or
問題。與本書中討論的其他大多數障礙不同，狂躁或
hypomanic aspect of bipolar disorder is often associated with low subjective dis-
雙極性障礙的輕躁狂特徵往往與低主觀不適感相聯繫
tress. Patients may find the "high" of a manic episode to be so pleasurable that
樹木。患者可能會發現躁狂發作的“高點”如此愉悅，以至于
they consider their symptoms and behavior perfectly reasonable and fail to see the
他們認為自己的症狀和行為完全合理，並未能意識到問題所在
need for treatment. Moreover, this factor is often associated with poor compliance
治療的需要。此外，這個因素經常與遵醫行為不良有關聯。
with drug treatment. Specifically, some individuals stop taking their prescribed
使用藥物治療。具體來說，一些人停止服用他們被開的藥物。
medications during periods of distress and depression in an attempt to bring on
在壓力和抑鬱期間，試圖通過服用藥物來引發
the manic state once again.
狂躁狀態再次出現。
This feature was clearly evident in Buddy. During the initial portion of his hos-
這個特點在 Buddy 身上顯而易見。在剛開始的住院期間，
pital admission, Buddy did not comply with treatment (he refused all medications).
入院治療, Buddy 不遵守治療方案 (他拒絕所有藥物治療)。
Bipolar Disorder 145 雙極性障礙 145
Although he eventually conceded to medications, he quickly stopped taking them
雖然他最終承認需要藥物治療，但他很快就停止了服用
following his discharge (against medical advice) because he downplayed the likeli-
在他不顧醫學建議被解除拘留後，因為他低估了可能性-
hood of his need to continue them to prevent future manic and depressive
他需要繼續進行以防止未來的躁狂和抑鬱的罩蓋
episodes. 集數
Treatment Goals and Planning
治療目標和規劃
The key intervention that the psychiatrist planned to use in the treatment of
精神科醫生計劃在治療中使用的關鍵干預措施
Buddy's mood disorder was medication. Because Buddy's principal complaint was
巴迪的情緒障礙是通過藥物治療的。因為巴迪的主要抱怨是
depression and because he had experienced only a single manic episode several
憂鬱症，並且他只經歷過一次躁狂發作
years ago, the psychiatrist opted to initiate treatment with the tricyclic antidepres-
多年前，心理醫生選擇開始使用三環抗抑鬱藥進行治療
sants (a group of medications that block the reuptake of neurotransmitters such as
聖坦斯（一組藥物，用於阻斷神經傳遞物質如）
serotonin and norepinephrine). Another reason for this strategy was Buddy's refusal
血清素和去甲腎上腺素）。此策略的另一個原因是 Buddy 的拒絕。
to consider taking lithium carbonate, a medication that is commonly used in the
考慮服用碳酸鋰，一種常被用於治療的藥物
treatment of patients with bipolar disorder. Lithium is a common salt that is widely
躁鬱障患者之治療。鎳酸是一種常見的鹽，廣泛使用。
available in the natural environment. For example, it is found in our drinking water
在自然環境中可獲得。例如，它出現在我們的飲用水中
in amounts that are too small to have any effect. As noted earlier, in therapeutic
在規模太小無法產生任何影響的情況下。如早前所述，在治療上
doses, lithium is often effective in treating and preventing manic episodes. However,
劑量方面，锂通常在治療和預防躁狂發作時有效。然而，
the side effects of therapeutic doses of lithium are potentially more serious than
療效劑量的鈣鎂的副作用可能比
those of other antidepressants. The dosage of lithium has to be carefully regulated
其他抗抑鬱藥物的。锂的劑量必須小心調節
to prevent toxicity (poisoning) or thyroid problems (lowered thyroid function in
防止毒性（中毒）或甲状腺問題（甲状腺功能降低）
particular) that can increase patients' lack of energy associated with their depres-
特別是）可以增加患者與其抑鬱症相關的疲勞感
sion. Substantial weight gain is another common side effect of this drug. In addition
副作用。這種藥物的另一個常見副作用是體重顯著增加。此外
to the potential for side effects, Buddy's resistance to lithium was based on his diffi-
對副作用的潛力，Buddy 對鈉石灰的抵抗基於他的困難性
culty in accepting the diagnosis of bipolar disorder. Although Buddy was resistant
接受雙極障礙診斷的困難。雖然 Buddy 抗拒
to any form of medication treatment, he was especially reluctant to taking lithium
對於任何形式的藥物治療，他特別不願意接受鎵酸鈉治療
because he believed that people who needed lithium must have severe mental illness
因為他相信需要使用鎳酸鈉的人必定有嚴重的精神疾病
(based on his limited knowledge from hearing or reading about the uses of lithium
（基於他從聽取或閱讀 lithium 使用方法所獲得的有限知識）
on television shows or news articles). This issue is discussed in more detail in the
在電視節目或新聞文章中）。這個問題在更詳細的討論中被探討，具體在
next section. 下一節。
In addition to pharmacotherapy with antidepressant drugs, Buddy's treatment
除了使用抗抑郁藥物進行藥物治療外，Buddy 的治療
plan included supportive and cognitive-behavioral therapy. The psychosocial aspect
計劃包括了支持性和認知行為療法。心理社會方面
of treatment would address such issues as Buddy's acceptance of the problem and
治療方案將會處理如 Buddy 接受問題這樣的議題和
of his need to comply with treatment, his withdrawal from social and occupational
他需要遵守治療，並從社會和職業中退出來
activities, identification of sources of family stress, and learning ways to cope effec-
活動，識別家庭壓力的來源，並學習有效應對策略
tively with these stressors.
與這些壓力因素相對應。
Course of Treatment and Treatment Outcome
治療方案和治療結果
This section presents a brief summary of Buddy's treatment, which occurred over the
本節提供了一個簡短的總結，描述了布迪的治療過程，該過程發生在
span of 8 years. Because of Buddy's refusal to take lithium, the psychiatrist proceeded
範圍為 8 年的期間。由於 Buddy 拒絕接受锂鹽，心理醫生接著進行了行動。
cautiously with the initiation of tricyclic antidepressant medication. The reason for
謹慎地開始三環抗抑鬱藥物治療。原因為
his caution was that these medications, while potentially effective in reducing Buddy's
他警告說，這些藥物雖然可能有效用於降低布迪的
depression, might possibly induce another manic episode in Buddy if too much of the
憂鬱症，如果過度影響 Buddy，可能會引發另一個躁狂症發作
drug was prescribed. In fact, research has shown that tricyclic antidepressants may
藥已被開立。實際上，研究顯示三環抗抑鬱藥可能
induce manic episodes in persons with depression who do not have a preexisting
引發抑鬱症患者中的躁狂發作，這些患者並無既存的
146 Case 10 146 案例 10
bipolar disorder (Goodwin & Jamison, 2007; Prien et al., 1984). Thus, Buddy had to
雙極性障礙（Goodwin & Jamison, 2007; Prien et al., 1984）。因此，Buddy 必須
be closely monitored while he was on the drug, and he had to comply fully with the
在服藥期間，他必須密切監控，並完全遵守規定
prescribed medication regimen.
開立的藥物治療方案
Buddy, in fact, complied very well with the moderate dose of antidepressant
夥計，實際上，他對中等劑量的抗抑鬱藥物的遵從性非常好
medication he was prescribed. Within a few weeks, his symptoms of depression
他被開出的藥物。幾個星期內，他憂鬱症的症狀開始減輕。
decreased substantially. After his favorable response, he was maintained on a
大幅減少。在得到他的積極回應後，他被維持在了一個
slightly lower dosage of the drug for several months. After 7 months had passed
藥物的微量減量幾個月。在經過 7 個月後
without a recurrence of his depression (and without any signs of mania), Buddy
沒有重現他的抑鬱症（並且沒有任何躁狂的跡象），布迪
was slowly weaned off the medication. During the first few months, when Buddy
逐漸停用藥物。在最初的幾個月裡，當巴迪
was taking a maintenance dosage of antidepressant medication, he also saw the
他正在服用抗抑郁藥物的維護劑量，同時也看到了
psychiatrist regularly for supportive psychotherapy (the same psychiatrist who
定期看精神科醫生進行支持性心理治療（同一精神科醫生）
monitore Bed re last ote to of done, The sedy was curred tic decreasing
監測床的最後一筆記錄是減少的，該數字已經被更正
After he had fully discontinued the medication without signs of the depression
在他完全停止藥物治療，並且沒有出現抑鬱症狀之後
returning, Buddy and his psychiatrist mutually agreed to terminate their sessions
回歸後，Buddy 和他的心理醫生雙方同意終止他們的會談
of supportive psychotherapy.
支持性心理治療
Over the next 18 months, Buddy experienced very few symptoms of depression.
在接下來的十八個月裡，Buddy 很少出現抑鬱的症狀。
Although occasional conflicts within the family continued over how certain aspects
雖然家庭內部在某些方面如何處理的問題上仍時有衝突，但這種情況持續存在
of the family business should be managed, Buddy found that his sense of devotion
家庭事業的管理，巴迪發現了他的奉獻感
and enthusiasm for his work had returned. In fact, he was given a promotion to be
其對工作的熱情已經回歸。實際上，他被提升了一級，成為
the head of a division within the family business. Although Buddy initially was very
家庭事業中部門的負責人。雖然 Buddy 最初非常
gratified by his change in job status, he soon experienced a great deal of stress aris-
他對職位變動感到欣慰，很快就經歷了很大的壓力
ing from the marked increase in responsibilities that his promotion entailed. In
由於升級所帶來的職責顯著增加。在
addition, because Buddy was in a position of greater responsibility that required
此外，因為 Buddy 所處的責任更大，需要
him to make more decisions about the business, he found himself in increasing con-
他發現自己需要越來越頻繁地為公司做出決定，這讓他陷入了不斷增加的困境
flict with one of his older brothers, who often questioned his decisions (partly
與他年長的兄弟之一發生衝突，這位兄弟經常質疑他的決定（部分原因）
because his brother had not adjusted well to the fact that Buddy was now at a
因為他的兄弟還沒有適應巴迪現在的情況
level of management that was equal to his).
管理層級與他相等的層級
As these stressors continued, Buddy began to notice that he had difficulty fall-
隨著這些壓力持續存在，Buddy 開始注意到自己有難以入睡的問題
ing and staying asleep. Shortly thereafter, he became extremely hyperactive and
醒來並保持睡眠。不久之後，他變得極度多動和興奮。
started having grandiose and suspicious thoughts (grandiose and persecutory delu-
開始產生宏偉且懷疑的想法（宏偉和迫害性妄想）
sions), coinciding with changes in his mood that varied between feeling expansive
轉換，與他情緒的變化相吻合，這些變化在從感到開朗到感到收斂之間波動
and "on a high" to feeling irritable. He began to work at a feverish pace, often
並且感到焦躁。他開始以熱切的速度工作，經常
staying at the office 15 to 18 hours a day. He started to develop plans to expand
每天在辦公室停留 15 到 18 個小時。他開始制定擴展計劃
his division of the business to various parts of the country. Increasingly, Buddy
他將業務分派到全國各地的不同部分。越來越多，Buddy
was convinced that only he could lead the family business in the direction where
確信只有他能將家族企業引導到正確的方向上
it needed to go. Buddy felt that he was "at the top of his game" (grandiose
它需要離開。Buddy 覺得自己「處於最佳狀態」（過於自大的）
delusions). 幻覺)
However, these plans were considered unrealistic and impractical by his family
然而，這些計劃被他的家人認為是不切實際和不實際的
and coworkers. Buddy became irritated and uncharacteristically enraged with his
與同事。Buddy 變得煩躁，並以不典型的憤怒對待他。
coworkers and subordinates, who he believed were plotting against him and talking
同事和下屬，他認為他們正在對他進行陰謀和議論
about him behind his back (persecutory delusions). Buddy experienced a gradual
關於他背後（迫害妄想）。Buddy 經歷了一個漸進的過程
increase in the speed of his thoughts. Others noticed that he had become quite dis-
思考速度的增加。其他人注意到他变得相当不
tractible and that his speech had become very loud and rapid (pressured speech).
可操控的，而且他的言語變得非常大聲和快速（受壓迫的言語）。
Often, in the middle of a conversation about the business, Buddy would utter things
經常地，在談論業務的中途，Buddy 會說出一些事情
that were either nonsensical or totally off the topic (e.g., off-color jokes). When his
這些話或是無意義的，或是完全離題（例如，不適當的玩笑）。當他的
coworkers tried to give Buddy corrective feedback on his inappropriate behavior, he
同事們嘗試給 Buddy 關於他不適當行為的糾正反饋，他
Bipolar Disorder 147 雙極性障礙 147
became very irritated with them and felt that any problem was with them, not him.
對他們變得非常煩躁，覺得所有問題都是出在他們身上，而不是他身上。
Consequently, the coworkers began to mistrust Buddy's leadership and approached
因此，同事開始懷疑 Buddy 的領導能力，並開始接近
other members of the family to discuss the importance of controlling some of his
家庭其他成員一起討論控制某些事項的重要性
actions. Buddy's family, his wife in particular, continually urged Buddy to contact
行動。Buddy 的家人，尤其是他的妻子，不斷催促 Buddy 聯繫
his psychiatrist. Buddy refused and denied the significance of his symptoms. Learn-
他的心理醫生。Buddy 拒絕了，並否認了他症狀的意義。學習-
ing that some of his coworkers had consulted with his family about his conduct in
發現有些同事曾向他的家人詢問過他行為的問題
the office had the effect of fanning the flames of his suspicion that people were plot-
辦公室的效果是煽動了他的懷疑，認為人們在策劃-
ting against him. Buddy's delusions intensified to the point where the family found
對抗他。布迪的幻覺變得越來越嚴重，家人發現
his behaviors impossible to tolerate. Because Buddy had vehemently refused to seek
他的行為無法忍受。因為 Buddy 堅決拒絕尋求
treatment (even in the face of his wife's threat of marital separation), his wife finally
治療（即使面對妻子離婚的威脅），他的妻子最後
telephoned the psychiatrist behind Buddy's back. The psychiatrist, alarmed at the
背後電話聯繫了布迪的心理醫生。心理醫生在得知此事後感到驚慌。
news that Buddy had been in a full manic episode for nearly 2 weeks, ordered him
布迪已經經歷了近 2 週的完整躁狂症發作，並下令他進行治療
to be involuntarily admitted to the hospital.
被迫入院
The first few days of Buddy's hospitalization were somewhat reminiscent of his
Buddy 住院的前幾天，有些像他的
hospital stay during college. However, although Buddy was reluctant to take lith-
大學期間的住院治療。然而，雖然 Buddy 不情願接受立石-
ium, he finally accepted this intervention. He quickly responded to the drug and
他最終接受了這個干預。他迅速對藥物做出了反應。
was released from the hospital 8 days later. A central aspect of Buddy's hospital
出院是在醫院 8 天後。布迪在醫院的治療過程中的核心部分
discharge plan was to have him continue on a maintenance dosage of lithium and
治療計劃是讓他繼續使用維持劑量的鎵
visit the psychiatrist regularly for individual psychotherapy and drug monitoring.
定期訪問心理醫生進行個別心理治療和藥物監測。
Although Buddy initially complied with this plan, he soon began to attend these ses-
雖然 Buddy 最初遵循這個計劃，但他很快開始參加這些 ses-
sions quite erratically. The psychiatrist believed that Buddy's resistance to treatment
治療的抵抗行為表現得非常不規律。心理醫生認為，布迪對治療的抵抗
was due in large part to his feeling ashamed, weak, and stigmatized by his bipolar
主要部分是因為他感到羞愧、軟弱，並且因為他的雙極性而被污名化
disorder. For the most part, Buddy had accepted his history of depression (because
混亂。大多數時候，Buddy 已經接受了他有抑鬱症的過去（因為）
"it is not too unusual for a person to feel down from time to time") but found it
"對於一個人偶爾感到心情低落並不算太不尋常" 但發現了它
very hard to acknowledge his past symptoms of mania, which he regarded as very
承認他過去的躁狂症狀非常困難，他認為這些症狀非常
weird and indicative of significant mental illness. During times when he was not
怪異且顯示出重大精神疾病。在他不在的時候
experiencing symptoms of depression or mania, Buddy felt that there was no need
體驗到抑鬱或狂躁的症狀，Buddy 覺得沒有必要
to continue using lithium (which served as an unwelcome reminder that he had
繼續使用鈉離子（這是一個不愉快的提醒，他已經）
acted so strangely in the past). The psychiatrist worked hard to assist Buddy to
過去行為如此古怪）。心理醫生努力協助布迪（Buddy）
accept his diagnosis (e.g., by challenging his beliefs that the presence of the diagno-
接受他的診斷（例如，通過挑戰他認為診斷存在的信念）
sis was suggestive of a mental defect or indicated that he was fundamentally differ-
該詞暗示了精神缺陷，或是表明他根本上存在差異
ent from everyone else and to accept the need for continued use of lithium to
隔離其他人並接受繼續使用鈉的需要
prevent the occurrence of future manic episodes. Buddy finally voiced his agreement
防止未來躁狂症發作。Buddy 終於表達了他的同意
with his psychiatrist's statements, although he did so mainly to placate him. A few
利用心理醫生的陳述，雖然主要是為了安慰他。幾句
months after his hospital discharge, Buddy stopped coming to his outpatient ses-
出院後幾個月，布迪停止來他的門診會診
sions and he stopped taking lithium.
他停止了藥物治療，並停止了服用鎵離子。
Three months later, Buddy experienced a hypomanic episode. Unlike past inci-
三個月後，Buddy 遭遇了一次輕躁狂症發作。與過去的事件不同，
dents when he had experienced manic symptoms, Buddy quickly agreed to his
當他經歷過躁狂症狀時出現的缺口，Buddy 頗快地同意了他的建議
family's pleas to reinitiate treatment. His psychiatrist promptly put him back on
家庭的請求，重新啟動治療。他的精神科醫生馬上讓他重新開始治療。
lithium, which again produced a rapid therapeutic response. The fact that he had
鎳，這再次產生了快速的治療反應。他之所以會
yet another manic-like episode finally convinced Buddy of the need for compliance
又一場狂熱似的發作，終於讓布迪意識到遵守規定的必要性
with treatment. This realization proved to be one of the most important aspects of
經過治療。這個認識證明了治療方面最重要的方面之一。
Buddy's treatment. From then on, Buddy gradually accepted his problem and
巴迪的治療。從那以後，巴迪逐漸接受了他所面對的問題，
learned to manage his medications adequately and responsibly. Buddy worked
學會了妥善且負責任地管理他的藥物。Buddy 工作了
with his therapist to learn to identify the first signs of mood disorder symptoms so
與他的治療師一起學習辨識情緒障礙症狀的最初徵兆
that drug and psychosocial interventions could be deployed promptly to prevent an
那種藥物和心理社會干預可以迅速部署以防止出現
escalation into a full manic or depressive episode. Following several treatment
升級為全面的狂躁或抑鬱發作。經過幾次治療
148 Case 10 148 案例 10
sessions that his wife attended, Buddy enlisted his wife and the rest of his family to
他妻子參加的會議，巴迪請他的妻子和他全家的其他成員參與
help in this endeavor (i.e., monitor early signs of symptom recurrence).
在這個努力中提供幫助（即，監控症狀復發的早期徵兆）。
Over the next 4 years, Buddy attended all scheduled follow-up sessions, which
在接下來的 4 年中，Buddy 參加了所有預定的追蹤會，這
focused on monitoring and adjusting his dosages of lithium. Once his symptoms
專注於監控並調整他的鎳酸鈉劑量。一旦他的症狀
and medication were stabilized, these sessions were scheduled less frequently. Dur-
當藥物治療穩定後，這些會談的頻率就被安排得較不頻繁。
ing this period, Buddy occasionally called his psychiatrist when he was worried
在這段時間裡，當 Buddy 感到擔心時，他偶爾會打給他的精神科醫生
about the potential recurrence of symptoms or when he had questions about adjust-
關於可能再次出現症狀，或當他對調整有疑問時
ing his medication to protect against the return of symptoms. Clearly, Buddy's atti-
服用藥物以防止症狀復發。顯然，巴迪的態度
tude and behavior now differed
態度和行為現在已經不同
I markedly from his initial presentation, when he
我從他最初的陳述中顯著地不同，當他
resisted treatment, medications, and his diagnosis. This change in attitude was also
抗拒治療，藥物，以及他的診斷。這種態度的改變也是
evident when Buddy developed complications from extended lithium treatment. For
顯而易見，當 Buddy 從長期使用鎵酸鹽治療出現併發症時。
example, at one point in treatment, Buddy developed some rashes from the lithium
例如，在治療的某一階段，Buddy 產生了一些由 lithium 引起的疹子
therapy. This side effect was managed through a consultation with a dermatologist.
治療。這個副作用是通過與皮膚科醫生的會診來管理的。
At no time did Buddy use this complication to question the wisdom of continuing
巴迪從未在任何時候利用這個複雜性來質疑繼續進行的智慧
on lithium. 鋰
Buddy became self-sufficient in maintaining adequate pharmacological protec-
布迪成為能夠自行維持足夠藥物保護的人
tidius ain medicatin laces if yani apo de restre sins on he lean red to-
細微的醫學鞋帶，如果雅尼從減少的睡眠中恢復，他會變得紅潤
rence). During the last 3 years that the psychiatrist worked with him, Buddy
在過去 3 年中，精神科醫生與他合作的期間，布迪
attended sessions on a biyearly basis for medication maintenance checks, renewal
每兩年參加一次藥物維護檢查和續期的會議
of prescriptions, and laboratory blood tests. Although Buddy had initially been
藥方，以及實驗室血液測試。雖然 Buddy 最初曾是
very resistant to lithium treatment, the psychiatrist believed that Buddy ultimately
非常抵抗锂治療，心理醫生認為布迪最終
exhibited one of the most profound beneficial responses to this medication that he
展示了對這種藥物最深遠且最有益的反應之一，這是他
had seen in patients with bipolar disorder (making Buddy a somewhat atypical case
在雙極性障礙的患者中所見到的（使 Buddy 成為了一個相對不常見的案例）
of bipolar disorder in terms of his treatment response; see the discussion section).
躁郁症在治療反應方面的討論；請見討論部分。
Over the 6 years since Buddy had been stabilized on lithium (the time this case
自巴迪開始穩定使用碳酸鈉的 6 年以來（這就是這個案例的時間）
was written), he has shown no further signs of manic or depressed symptoms.
他所寫的），他並沒有顯示出進一步的狂躁或抑鬱症狀。
Buddy went on to form his own food company, which he now directs. He has pro-
巴迪接著成立了自己的食品公司，現在由他領導。他已經開始進行這項工作。
ductively developed new business ventures that continue to prosper. Despite these
有誘惑力地發展出新的事業，這些事業持續繁榮。不論這些
new occupational responsibilities, Buddy has become more involved in leisure activ-
新職業責任下，Buddy 在休閒活動中扮演的角色更加重要
ities. Often, he is able to interrupt his once-driven work habits to spend more time
特性。經常，他能夠中斷他以前強烈的工作習慣，花更多時間
with his wife and children.
與他的妻子和子女在一起
DISCUSSION 討論
A population-based survey of more than 9,000 people from ages 18 and older esti-
一項針對 9,000 多名 18 歲及以上人士的基於人口的調查估計-
mated that 3.9% had experienced a bipolar disorder (either bipolar I or bipolar II)
已婚的 3.9%曾經歷過雙極障礙（包括一型或二型雙極障礙）
at some time during their lives and that 2.6% had experienced a bipolar disorder
在他們一生中的某個時候，並且 2.6%的人曾經歷過雙極障礙
within the prior year (Kessler, Berglund, et al., 2005; Kessler, Chiu, Demler, &
在前一年（Kessler, Berglund 等人，2005 年；Kessler, Chiu, Demler 等人，）
Walters, 2005). Unlike major depression, which is much more prevalent in females,
沃爾特斯，2005 年）。與廣泛存在的女性中較為普遍的重度抑鬱症不同，
bipolar I disorder is about equally common in men and women (Kessler et al.,
雙極 I 型障礙在男性和女性中的發生率大致相同（Kessler 等人，）
1994; Merikangas & Pato, 2009), although bipolar II disorder appears to be more
1994 年; Merikangas & Pato, 2009 年), 尽管双相 II 型障礙似乎更為
common in women. There are no known differences among racial groups in the
在女性中很常見。各種族群之間並無已知的差異。
prevalence of either bipolar I or bipolar II disorder.
雙極 I 型或雙極 II 型障礙的盛行率。
Research has found that the median age of onset for bipolar disorder is about
研究發現，雙極性障礙的中位發病年齡約為
25 years of age, although onset can occur in childhood (Kessler, Berglund, et al.,
二十五歲，雖然發病可能在童年出現（Kessler, Berglund 等人，
2005; Merikangas & Pato, 2009). In fact, a considerable number of cases of
2005; Merikangas & Pato, 2009)。事實上，有大量的案例
Bipolar Disorder 149 雙極性障礙 149
bipolar disorder begin in adolescence (as many as one-third; Goodwin & Jamison,
雙極性障礙在青春期開始（高達三分之一的病例；Goodwin & Jamison，）
2007; Merikangas et al., 2007). However, there is often a 5- to 10-year interval
2007 年；Merikangas 等人，2007 年）。然而，通常會有 5 到 10 年的間隔
between the age of onset of symptoms and the age at first treatment or first hospi-
癥狀出現與首次治療或首次入院的年齡之間
talization. Bipolar disorder may begin more abruptly than major depression (Angst
雙極性障礙可能比主要抑鬱症開始得更突然（Angst
& Sellaro, 2000; Winokur, Coryell, Endicott, & Akiskal, 1993). However, the typ-
& Sellaro, 2000; Winokur, Coryell, Endicott, & Akiskal, 1993)。然而，類型-
ical pattern of onset in males and females appears to differ. The first episode in
男性和女性的發病模式似乎有所不同。首次發作在
males is more likely to be a manic episode, whereas in females the first episode is
男性較有可能是狂躁症發作，而女性的首次發作
more likely to be depression. Frequently, a person experiences several episodes of
更有可能是抑鬱症。經常，一個人經歷多個發作期的
depression before a manic episode occurs (Goodwin & Jamison, 2007). Up to a
躁狂發作前的抑鬱（Goodwin & Jamison, 2007）。直到一
quarter of persons with bipolar Il disorder will eventually progress to bipolar I dis-
四分之一的雙極型障礙患者最終將進展為雙極 I 型障礙
order (e.g., Birmaher et al., 2009).
命令（例如，Birmaher 等人，2009 年）。
Once the disorder appears, the course is chronic. Untreated persons with bipolar
一旦出現紊亂，病情會成為慢性。未治療的雙極性病患者
disorder may have more than 10 total episodes of mania and depression during their
混亂期間，可能有超過十次的躁狂和抑鬱的總發作
lifetime, with the duration of episodes and inter-episode symptom-free periods often
一生中，病發期間和發作間的無症狀時期的持續時間通常
stabilizing after the fourth or fifth episode (Goodwin & Jamison, 2007). For women
在第四或第五次發作後穩定（Goodwin & Jamison, 2007）。對於女性
with bipolar I disorder, a higher risk for subsequent episodes is present in the imme-
雙極型 I 型障礙患者，後續發作的風險較高，在即將發生的情況下存在
diate postpartum (after childbirth) period. Often 5 or more years may pass between
產後恢復期（產後）。通常可能有 5 年或更多年間的間隔。
the first and second episode, but the time periods between subsequent episodes usu-
首集和第二集，但後續集之間的時間段通常-
ally narrow. However, it should be emphasized that the variable and episodic nature
盟友關係往往較為狹窄。然而，應強調的是，變異性和短暫性本質
of bipolar disorder is a hallmark and a unique feature of this condition, as was evi-
雙極性障礙的特徵和獨特之處是這種情況的標誌，這一點是顯而易見的
dent in Buddy, whose initial manic episode emerged abruptly in his senior year of
Buddy 的初始躁狂症突然在他高年级那年出现，造成了一個缺口
college and was not followed by subsequent episodes until several years later.
大學，直到幾年後才出現了後續的集數。
Bipolar disorder usually produces substantial disruptions in the afflicted per-
雙極性障礙通常會在受影響的人中產生重大的打擾
son's life. For instance, marital discord is a common associated feature. Divorce
子的生命。例如，婚姻糾紛是常見的相關特徵之一。離婚
rates are much higher in persons with bipolar disorder, approaching two to three
躁郁症患者中的比率要高得多，接近二到三倍
times the rate in persons without emotional disorders. Compared to persons with-
無情緒障礙人士的倍數。與有情緒障礙的人相比-
out emotional disorders, the occupational status of persons with bipolar disorder is
排除情緒障礙後，雙極障礙患者的工作狀態
twice as likely to deteriorate (Coryell et al., 1993). Persons with bipolar disorder
雙相障礙患者比常人有兩倍的可能性病情惡化（Coryell 等，1993 年）。雙相障礙患者
often meet criteria for other disorders; for example, the substance use disorders
經常符合其他疾病的標準；例如，物質使用障礙
and the anxiety disorders are quite prevalent in these individuals (Goodwin & Jami-
這些個體中的焦慮障礙相當普遍（Goodwin & Jami-）
son, 2007; Kessler, Chiu, et al., 2005).
子, 2007; Kessler, Chiu, 等, 2005)。
Suicide is an unfortunately common associated feature of bipolar disorder.
自殺是雙相障礙不幸常見的相關特徵。
Among patients with emotional disorders, patients with bipolar disorder have
在情緒障礙的患者中，雙相障礙的患者有
among the highest risks for suicide (Fawcett et al., 1987; Goodwin & Jamison,
在自殺風險中，屬於最高風險之一（Fawcett 等，1987 年；Goodwin 及 Jamison，）
2007). Estimates of suicide in bipolar disorder range from 8% to as high as 60%,
躁郁症的自殺估計比率從 8%到高達 60%不等（2007 年）。
with an average rate of about 19% (e.g., Angst & Sellaro, 2000; Goodwin & Jami-
平均比率約為 19%（例如，Angst & Sellaro, 2000；Goodwin & Jami-）
son, 2007). Suicide occurs more often in males than in females and is most likely to
子，2007 年）。自殺在男性中比女性更常發生，最有可能發生。
occur during a depressive episode. Persons with bipolar disorder who also have
在抑鬱發作期間發生。雙相障礙患者如果也具有
coexisting substance abuse or anxiety disorders are at substantially greater risk of
共存的物質濫用或焦慮障礙的患者有著顯著更高的風險
suicide and poor long-term treatment outcome (e.g., Keller, Lavori, Coryell,
自殺及長期治療效果不良（例如，Keller, Lavori, Coryell）
Endicott, & Mueller, 1993).
恩迪科特, & 蘇勒, 1993 年).
The medication lithium is currently the treatment of choice for bipolar disorder.
锂藥目前是治療雙相障礙的首选治療方法。
Results indicate that 50% of patients with bipolar disorder respond well to lithium
研究結果顯示，50%的雙極性障礙患者對鎵離子有良好的反應
initially (Goodwin & Jamison, 2007). Thus, while lithium is effective, many
最初（Goodwin & Jamison, 2007）。因此，雖然鎳酸鹽有效，但許多人
patients do not show meaningful improvement. However, for the patients who
患者並未顯示有意義的改善。然而，對於那些
show a favorable acute response, some studies suggest that lithium is usually effec-
顯示出對急性情況的有利反應，一些研究建議，鎳通常是有效的
tive in preventing future manic and depressive episodes. For example, a review of
預防未來躁狂和抑鬱發作的關鍵。例如，對
150 Case 10 150 案例 10
10 well-done treatment outcome studies indicated that patients taking lithium had a
十項完成良好的治療結果研究顯示，服用鎵酸鹽的患者有
significantly lower probability of having future episodes than patients taking a pla-
未來發病的機率比服用藥物的患者顯著低
cebo. Overall, 34% of the patients taking lithium had additional manic or depres-
碳酸锂治療的患者中，總共有 34%的患者出現了額外的躁狂或抑鬱症狀。
sive episodes during the follow-up period, compared to 81% of the patients taking
追蹤期間的某些事件，與接受治療的 81%的患者相比
placebo (Goodwin & Jamison, 2007). Lithium maintenance treatment has also been
安慰剂（Goodwin & Jamison, 2007）。锂维持治療也已經被
found to lower the frequency of suicide attempts and completions (Müller-
發現可以降低自殺嘗試和完成的頻率（Müller-）
Oerlinghausen, Muser-Causemann, & Volk, 1992). In fact, whereas untreated
奧爾林豪森, 肌肉-原因馬, 及沃爾克, 1992 年）。實際上，與未治療
bipolar disorder may be associated with a mortality rate that is two to three times
雙極性障礙可能與死亡率增加一至二倍有關
higher than that of the general population, some studies have found that the mor-
一些研究發現，某些研究發現，高於普通人群的比例，關於摩-
tality rate of patients in long-term lithium treatment does not differ from that of
長期使用锂治療的病人的存活率並無不同於
persons without emotional disorders (e.g., Coppen et al., 1991).
無情緒障礙的人（例如，Coppen 等人，1991 年）。
However, a handful of studies examining longer follow-up periods (e.g., 5 or
然而，有幾項研究檢視了較長的追蹤期間（例如，5 年或
more years) have found less encouraging results of the long-term maintenance
更長時間）發現了較不鼓舞人心的長期維持結果
effects of lithium (e.g., Gitlin, Swendsen, Heller, & Hammen, 1995; Keller et al.,
锂的影響（例如，Gitlin、Swendsen、Heller 和 Hammen，1995 年；Keller 等人，
1993). As noted earlier in this case, one problem associated with lithium treatment
1993 年）。如本案例早前所述，锂治疗相關的一個問題是
(or with any drug treatment, for that matter) is noncompliance. Noncompliance
（無論是哪種藥物治療）都是不遵從。不遵從
with drug treatment is a major cause of relapse in patients with bipolar disorder
在使用藥物治療的情況下，是雙極性障礙患者復發的主要原因
(Colom, Vieta, Tacchi, Sanchez-Moreno, & Scott, 2005). Patients with bipolar dis-
(科洛姆, 维埃塔, 塔奇, 圣安地列斯-莫雷诺, 史考特, 2005) 患有雙極性障礙的病患
order may be noncompliant with drug therapy for a number of reasons, including
命令可能因多種原因不符合藥物治療，包括
denial or failure to believe that they have an emotional disorder (a factor relevant in
拒絕或不相信自己有情緒障礙（這是一個與之相關的因素）
Buddy's treatment), reluctance to give up the pleasurable experience of mania, and
巴迪的治療),對躁狂狀態帶來的愉悅體驗的不願放棄,和
drug side effects. Indeed, as was true for Buddy, up to 75% of patients treated with
藥物副作用。確實，就像對 Buddy 來說，接受治療的病患中高達 75%的人都會出現副作用。
lithium experience some side effects (Goodwin & Jamison, 2007).
lithium 遇到一些副作用（Goodwin & Jamison, 2007）。
In addition to lithium, several other medications have proven to be of some
除了鈉，還有其他幾種藥物已被證明具有某種程度的效果
benefit. For instance, patients who are nonresponsive or intolerant to lithium may
利益。例如，對锂無反應或無法忍受的患者可能
benefit from certain antiseizure medications, such as valproate and carbamazepine
從某些抗癲癇藥物中獲益，例如 валпроат和卡巴馬唑
(Thase & Kupfer, 1996). Recall that Buddy was initially treated with an antiseizure
(Thase & Kupfer, 1996). 請記住，Buddy 最初是接受抗癲癇治療的。
medication, due in part to his refusal to take lithium. Indeed, valproate has over-
藥物治療，部分原因是其拒絕服用鎵。確實， валпроат的治療效果超過了鎵。
taken lithium as the most commonly prescribed mood stabilizer (Goodwin et al.,
使用锂作為最常開立的情緒穩定劑（Goodwin 等人，
2003; Keck & McElroy, 2002). However, lithium should still be considered the
2003 年；Keck 與 McElroy, 2002 年）。然而，鎳仍應被視為
drug of choice for bipolar disorder because evidence indicates that valproate is con-
躁鬱障的首選藥物，因為證據顯示瓦普妥具有穩定情緒的作用
siderably less effective than lithium in preventing suicide (e.g., Goodwin et al.,
比锂離子在防止自殺方面的效果低得多（例如，Goodwin 等人，）
2003; Thase & Denko, 2008; Tondo, Jamison, & Baldessarini, 1997). Electrocon-
2003 年; Thase & Denko, 2008 年; Tondo, Jamison, & Baldessarini, 1997 年。電極-
vulsive therapy (ECT), while typically associated with severe major depression, has
電擊療法（ECT），通常與嚴重的重度抑鬱症聯繫在一起，但也有其他用途
also been found to be effective in treating manic episodes (Mukherjee, Sackeim, &
也已被發現對治療狂躁症發作有效（穆克吉，薩克伊姆，&）
Schnuur, 1994). Additionally, many research psychiatrists believe that ECT should
施努爾，1994 年）。此外，許多研究精神科醫生認為，ECT 應該
be considered as a primary treatment for the depressed phase of bipolar disorder
被認為是雙相障礙抑鬱期的主要治療方法
whenever a rapid response is necessary (e.g., due to marked suicidal ideation and
當需要快速反應時（例如，由於顯著的自殺意圖和）
intent) or when drug treatments are contraindicated (e.g., in pregnancy, in patients
目的) 或當藥物治療不適用時（例如，在懷孕期間，或在患者
who have not responded to lithium or antiseizure medication; American Psychiatric
未對鈉離子通道阻斷劑或抗癲癇藥物有反應的人；美國精神醫學學會
Association, 1994, 2010).
協會，1994 年，2010 年。
Psychological 心理學
treatments for bipolar disorder have not been widely studied
雙極性障礙的治療方法尚未廣泛研究
However, the importance of these interventions is increasingly recognized. Specifi-
然而，這些干預措施的重要性日益受到認可。專門
cally, researchers have recognized the potential benefits of these treatments to foster
學術界已認可這些治療方法的潛在好處，以促進
compliance with medications (Colom et al., 2005), to address the psychosocial con-
遵守藥物治療（Colom 等人，2005 年），以應對心理社會問題
sequences and stress triggers of the disorder (e.g., occupational, marital), and to
障礙的序列和壓力誘發因素（例如，職業，婚姻），以及
treat coexisting disorders (e.g., substance use, anxiety disorders) that are associated
處理共存的疾病（例如，物質使用，焦慮障礙）這些疾病是相關的
Bipolar Disorder 151 雙極性障礙 151
with an unfavorable long-term course and treatment response (Miklowitz, 2014).
具有不利的長期發展趨勢和治療反應（Miklowitz, 2014）。
Although lithium was the primary factor in Buddy's favorable treatment response,
雖然鈉離子是布迪獲得有利治療反應的主要因素，
the psychological component of his therapy was very important in addressing
他治療的心理成分在處理問題上非常關鍵
acceptance of his problem, dealing with the social (and marital) consequences of
接受他的問題，處理社會（和婚姻）後果
his symptoms, and enlisting persons in his social environment (wife, parents, sib-
他所呈現的症狀，並徵求他社會環境中的人（妻子、父母、兄弟姐妹）的協助
lings) to assist him in detecting the early signs of possible relapse.
為了協助他識別可能復發的早期徵兆。
Although a few reports have appeared in the literature on the effects of psycho-
雖然在文獻中出現了幾篇報告，討論心理治療的效果，
logical treatments alone in the treatment of bipolar disorder, most research has exam-
在雙極性障礙的治療中，僅使用邏輯治療，大多數研究已經進行了評估
ined the effectiveness of these treatments combined with drug treatment. For example,
已評估這些治療方法與藥物治療結合的有效性。例如，
a pilot study has examined the impact of the addition of family therapy and psychoe-
一項試點研究已經探討了家庭治療和心理治療加碼後的影響
ducation to standard drug treatment on the long-term outcome for bipolar disorder
教育至標準藥物治療對雙極性障礙長期結果的影響
(Miller, Keitner, Epstein, Bishop, & Ryan, 1991). Compared to patients who received
(Miller, Keitner, Epstein, Bishop, & Ryan, 1991). 与接受治療的患者相比，
drug treatment alone, patients who received family therapy and psychoeducation plus
單獨藥物治療，接受家庭治療和心理教育的患者，以及
drugs had lower rates of family separations, greater improvements in the level of fam-
藥物治療的患者家庭分離率較低，家庭成員的整體情況有更大的改善
ily functioning, and lower rates of rehospitalization over the 2 years following treat-
正常運作，並且在治療後的 2 年內，再入院率較低
ment. Moreover, the patients receiving psychological treatment also had higher rates
心理治療的患者也具有較高的比率。
of full recovery (56%) than patients receiving medications only (20%). These initial
完整恢復（56%）的比例比僅接受藥物治療的患者（20%）高。這些初步
findings suggest that the addition of psychological elements to the treatment of bipolar
研究結果顯示，將心理學元素加入雙極疾患的治療中，有其重要性
disorder holds promise for improving the short- and long-term effectiveness of our
混亂為提高我們短期和長期效果帶來了希望
current interventions. Indeed, other adjunctive psychosocial interventions, such as
當前的干預措施。確實，其他輔助的心理社會干預措施，例如
family-based treatments, treatments aimed at fostering lifestyle regularity (e.g., main-
家庭為基礎的治療方法，旨在促進生活方式的規律性（例如，主要的）
taining regular sleep and other daily schedules), and cognitive therapy have also been
訓練規律的睡眠和其他日常安排），以及認知治療也已經被
（注意：由於上下文不夠明確，這句話可能需要更多的上下文來確保正確的翻譯。提供的翻譯基於給出的句子結構和單詞。）
shown to augment the long-term benefits of pharmacotherapy of bipolar disorder
顯示了用於增強雙極性障礙藥物治療長期好處的方法
(e.g., Frank et al., 1997, 1999; Lam, Hayward, Watkins, Wright, & Sham, 2005;
(例如，Frank 等人，1997 年，1999 年；Lam，Hayward，Watkins，Wright 和 Sham，2005 年；)
Miklowitz, George, Richards, Simoneau, & Suddath, 2003; Simoneau, Miklowitz,
米克洛維茨，喬治，西蒙諾夫，蘇達思，2003 年；西蒙諾夫，米克洛維茨，
Richards, Saleem, & George, 1999).
理查茲, 薩利姆, 及喬治, 1999 年。
THINKING CRITICALLY 批判性思考
1. Noncompliance with the prescribed medication regimen (e.g., lithium) is a
1. 遵守規定的藥物療程（例如，鎳酸鈉）的不遵從是一種
frequent complicating factor in the treatment of bipolar disorder. What are
治療雙極性障礙時的經常性複雜因素。這是什麼
the main reasons that patients with this disorder are inclined to avoid their
此種疾病的患者傾向於迴避的主要原因
medications, even when they have seen benefits from them?
藥物，即使他們從中獲得好處時？
What factors do you think account for the finding that bipolar disorder is
你認為導致雙極性障礙研究結果的因素除了什麼？
associated with one of the highest suicide rates, a rate higher than that found
與其中一個最高自殺率相關，該率高於所發現的那種
even in major depressive disorder? Why are males more likely to commit a
重大抑鬱障礙中？為什麼男性更有可能進行自我傷害行為？
successful suicidal act than females?
成功自殺行為的比例比女性高嗎？
3.
Although drugs have traditionally been the most common treatment for bipolar
雖然藥物一直是治療雙極性疾病的最常見方法
disorder, there are possible advantages of using a psychological treatment as an
混亂中，心理治療的使用可能存在一些優點
additional intervention for this condition. What are these possible advantages?
此情況的額外干預。這些可能的優點是什麼？
Do you believe that psychological treatments could be used effectively as the
你是否相信心理治療可以有效用作治療手段？
sole treatment for bipolar disorder? Why or why not?
單一治療法對於雙極性障礙嗎？為何或為何不？
4. Occasionally, bipolar disorder is misdiagnosed as schizophrenia. What features
4. 偶爾，雙極性障礙會被誤診為精神分裂症。哪些特徵
of bipolar disorder could possibly be mistaken for schizophrenia?
雙極性障礙的症狀有可能被誤認為是精神分裂症嗎？