Kuwonetsa vuto lakutchova njuga ndi matenda osokoneza bongo (2016)

olemba Rash CJ, Weinstock J, Van Patten R

Carla J Rash,1 Jeremiah Weinstock,2 Ryan Van Patten2

1Center ya calhoun Cardiology - Behaisheral Health, UConn Health, Farmington, CT, USA; 2Dipatimenti ya Psychology, Saint Louis University, St Louis, MO, USA

Mfundo:

Pa mtundu wachisanu wa Kusanthula ndi Buku Lophatikiza la Mavuto a Mitsempha (DSM-5), vuto la kutchova njuga lidapangidwanso kuchokera ku gawo la "Impulse Control Disorder" kupita pagawo "Logwirizana Ndi Zosokoneza". Ndi izi, vuto la kutchova njuga lakhala chizolowezi choyambirira chosagwirizana, kutanthauza zambiri zomwe zimagawidwa pakati pa vuto la kutchova njuga ndi zovuta zogwiritsa ntchito mankhwala osokoneza bongo. Ndemanga iyi imawunikiranso kufanana, komanso kusiyana pakati pa njuga ndi mavuto okhudzana ndi zinthu. Njira zakuzindikira, comorbidity, genetic and zokhudza thupi, komanso njira zamankhwala zimakambidwa.

Keywords: njuga zamatenda, njuga yamavuto, chizolowezi chamakhalidwe, transdiagnostic factor, kusokoneza bongo
 

Introduction

Matenda a kutchova njuga (GD) ndi njira yosalekeza yolipira juga yomwe imayambitsa kusokonezeka kwakukulu kapena mavuto.1 Kuti akwaniritse zofunikira, aliyense payekha ayenera kuwonetsa zina zinayi kapena kupitilira kwa zizindikiro zisanu ndi zinayi mkati mwa mwezi wa 12. GD imatha kukhala ngati episodic kapena yosasunthika ndipo idavoteledwa ngati yofatsa, yolimbitsa thupi, kapena yoipa malinga ndi kuchuluka kwa zizindikiro zomwe zatsimikiziridwa. Pa mtundu wachisanu wa Kusanthula ndi Buku Lophatikiza la Mavuto a Mitsempha (DSM-5),1 njuga zamatenda zinasinthidwa kukhala GD ndikugawanidwanso kuchokera ku vuto la kuwongolera kukhala chisokonezo chokhudzana ndi vuto laukadaulo, ndikuwonetsa malingaliro olimba a GD ngati chizolowezi. Maulalo pakati pa GD ndi mowa ndi zovuta zogwiritsa ntchito mankhwala osokoneza bongo (AUD / DUD) ndizambiri ndipo zimaphatikizira njira zodziwitsira matenda, kuchuluka kwa ma comorbidity, kugawana kwa chibadwa, zotsatira zofanana za neurobiological, ndi njira zodziwika bwino zamankhwala. Pazowunikira, AUD imakhudzana ndi kumwa mowa mwauchidakwa kapena kudalira ndipo DUD imakutanthauza kugwiritsa ntchito mankhwala osokoneza bongo kapena osokoneza bongo (nontobacco, sanali mowa) kapena vuto lakudalira pokhapokha patchulidwa. Poganizira za kubwezerezedwanso kwa GD ngati chizolowezi choyipa chosagwiritsa ntchito mankhwala, pepalali lipereka chiwonetsero cha kulumikizana komwe kungakhalepo pakati pa GD ndi AUD / DUD kuchokera ku etiology kupita ku njira zamankhwala ndikutsindika madera omwe akukhudzidwa ndi DSM-5 gulu.

Njira zoyenera

Kukula kopanda tanthauzo kukudutsa DSM-5 GD ndi AUD / DUD, adapatsidwa choyambirira DSM-III kutchova njuga amayesedwa kutengera njira zomwe zidadalira panthawiyo.2 Komabe, pali kusiyana kwakukulu pamitundu iwiri iyi, ndipo DSM-5 Gulu Logwiritsa Ntchito Zinthu DSM-IV Njira za GD zomwe zasinthidwa m'malo kusintha masanjidwe a SUD a GD.3 In Gulu 1, timayika mndandanda wa GD ndi AUD, kuwonetsa kudutsa kapena zinthu zofananira. Zinthu zomwe zili ndizolimba kwambiri ndizopilira, kusiya, kusiya kuwongolera, ndi zotsatira zoyipa. Pokhudzana ndi zomangidwa zomalizazi, GD ili ndi chinthu chimodzi chokhudzana ndi kusokoneza kwa magawo azachuma, maphunziro, kapena ntchito; kwa AUD, zinthu zinayi zimalongosola zovuta zoyipa zamagulu osiyanasiyana (mwachitsanzo, zamaganizidwe, thanzi). Njira za AUD / DUD zomwe zikuphatikizidwa, kuphatikizapo zotsatira zoyipa izi, zikuwunikidwanso kuti ziwonetsedwenso ndikuthandizanso kusintha m'Dongosolo la DSM,3 potero kuthandizira kusinthasintha kwakukuru pakati pa zovuta zamavuto. Komanso, zinthu zoyipa za GD zitha kukulitsidwa kuti ziphatikize magawo ena monga thanzi la mtima, omwe nthawi zambiri amakhudzidwa ndi omwe ali ndi vutoli.4,5 Makamaka, mitengo yonse ya comorbidity6 ndi chiopsezo cha kudzipha komanso kuyesa7,8 awonetsedwa kuti akwezedwa mwa anthu omwe ali ndi GD.

 
Kufanizira kwa tebulo 1 kwa DSM-5 vuto la kutchova njuga ndi machitidwe osokoneza bongo
Zotsatira: DSM-5, Dawunilodi ndi Maupangiri a Statistical a Matenda a Mental, kope lachisanu.

Mbali yachiwiri yothandizirana yodziwitsa za kukonzekera ndiyo kukonza pamachitidwe olowerera. Mu GD, kupanga kumeneku kumatchulidwa kuti kumatanganidwa kwambiri ndi kutchova njuga, ndipo kumakhudzanso kudalirana ndi zomwe zachitika kale kutchova juga, kukonzekera zomwe zingachitike mtsogolo kutchova juga, komanso njira zabwino zopezera ndalama njuga. Kwa AUD, chinthu chofananira ndi kugwiritsa ntchito nthawi yayitali kupeza, kugwiritsa ntchito, kapena kuchira kuchokera ku kumwa mowa kumafanana ndi zina mwa mapulani zomwe zikuwoneka mu chinthu cha GD. Komabe, chinthu cha AUD sichikukhudzana kwathunthu ndi chidziwitso cha chidwi chomwe chikuwonetsedwa mu GD. Chilichonse cholakalaka kuchokera muyezo wa mowa, chatsopano ku DSM-5, ikhoza kujambula gawo lazomangamanga izi. Chopanga chomwe sichinawonjezedwe pazomwe zimayambitsa GD, zomwe sizikufotokozera mwachindunji zokhumba zake. Ngakhale umboni ukusonyeza kuti kulakalaka ndizofala pakati pa anthu omwe ali ndi GD9,10 ndikuti ali okhudzana ndi chikhalidwe cha njuga,11,12 Funso loti kulakalaka ndizofunikira pakudziwitsa za GD, monga mu SUD, silimayankhidwa. Zinthu zomwe zatsalira, zinayi kuchokera ku GD ndi imodzi kuchokera ku AUD, zilibe umboni wofananira mu vuto lililonse zomwe zimayikidwa ndikuwunikira zapadera zazovuta zilizonse (mwachitsanzo, kuthamangitsa kutayika). Mafunso akukhalabe okhudza momwe mawonekedwe a GD angatsatire kwambiri njira za SUD zomwe zili zopindulitsa ndi njira yodziwira GD komanso kuzindikira komwe kumayambira.

Kukula

AUD yowonetsa ziwonetsero zambiri zokhudzana ndi zovuta zina zambiri zamisala. Mwachitsanzo, masiku amoyo komanso kuchuluka kwa chaka cham'mbuyomu kwa AUD kunali 30.3% ndi 8.5%, motsatana, mu National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).13 Mitengo iyi ndiwokwera kwambiri kuposa kuchuluka kwa kufalikira kwa DUD yopanda mtundu uliwonse wa boti (nthawi yonse ya moyo: 10.3%, chaka chapitacho: 2.0%) ndi zovuta zazikulu zowononga moyo (moyo: 13.2%, chaka chapitacho: 5.3%).13 Zotsatira zochokera pamitundu yoyimira mayiko zikuyerekeza kuchuluka kwapakati pa GD ndi ~ 1% –2% mndandanda wamoyo wopezekera ndi theka la njira zamsonkhano wapitawu.14-17 Unyamata, kugonana kwa amuna, chikhalidwe chotsika, komanso osakhala ndi ukwati (ie, sanakwatirane, kusudzulidwa, kupatukana, akazi amasiye) ndizofala zomwe anthu amagawana ndi GD ndi AUD / DUD.13,15-17

Kuzindikira kuzungulira

Mu DSM-5, njira yodziwitsa za GD idatsitsidwa kuchokera pamiyeso isanu mwa magawo khumi mpaka panjira yomwe yazinthu zinayi mwa zisanu ndi zinayi.1 Kusintha kochitidwa ndi DSM-5 Gulu la SUD Work to GD analengedwa kuti achepetse kuchuluka kwa ziwonetserozi kwinaku akupititsa patsogolo kulondola kwazidziwitso.18 Komabe, kuchuluka kwakuchepa kwa kuchuluka kwa GD kungakhale motere DSM-5 njira zimakhazikitsidwa. Mwachitsanzo, mu zitsanzo za anthu okhala kunyumba zosungidwa ku US (N = 2,417), kuchuluka kwa GD kukwera kuchokera ku 0.1% mpaka 0.2% pogwiritsa ntchito DSM-5 zofunikira.19 Zosintha kuchokera kuzipatala zomwe zimathandizira omwe ali pachiwopsezo chazovuta kwambiri zimakhudzidwanso. Kuwonongeka kwa GD kudakwera kuchokera ku 81.2% pansi DSM-IV mpaka 90.3% yogwiritsa ntchito DSM-5 njira pakati pa West Virginian otchova njuga (N = 2,750) kuyitanitsa boma thandizo njuga.8

Ngakhale njira yotsikira, kusiyana kwakukulu kumakhalabe pakati pa SUD ndi GD pankhani yofufuza komanso kuzindikira mitundu yocheperako yamatendawa.8,20 pakuti DSM-5 Njira za SUD, zomwe zimaphatikiza DSM-IV kugwiritsa ntchito mankhwala osokoneza bongo ndi zinthu zodalira m'njira imodzi yodziwitsa, Zizindikiro ziwiri kapena zingapo zokha zomwe zimafunikira kuti muzindikire. Kukula kumawonetsedwa ndi mawonekedwe ofatsa (2-3), modekha (ma 4-5), komanso zowopsa (zisonyezo zisanu ndi chimodzi kapena zingapo), zomwe sizikugwirizana ndi zotsimikiza za GD: zovuta (4-5), zolimbitsa thupi (6-- Zizindikiro za 7), komanso zowopsa (Zizindikiro za 8-9).

Ngati njira za GD zikadakhala kuti zizingowonetsedwa molingana ndi njira za SUD zokhala ndi malire ake, kuchuluka kwa GD kukwera kwambiri, chifukwa 2% yowonjezera ya anthu imavomereza zovuta zazisangalalo za moyo wawo wonse.14,15 Kuwona kusintha koteroko, ngakhale kungakhudzidwe ndi kuchuluka kwa matendawa, kungakhale koyenera ngati anthu omwe ali ndi vuto la GD akukumana ndi zowonongeka zambiri kapena zowonongeka pofanana ndi AUD / SUD yocheperako komanso ngati angapindule ndi kuzindikira komanso chithandizo. Kafukufuku wambiri amaletsa zotsatira zoyipa zomwe zimakhudzana ndi njuga zamtundu uliwonse, kuphatikizapo chiwopsezo chokhala momasuka,6,21 mavuto azachuma komanso ngongole zokhudzana ndi njuga,8 malingaliro ofuna kudzipha komanso zoyesayesa.7 Poganizira izi, komanso kuchuluka kwamphamvu pakati pa AUD / DUD ndi GD (omwe afotokozeredwa mu gawo lotsatirali), kusasinthika pakati pamagawo othandizirawa kungathandizire azachipatala pogwiritsa ntchito njira zingapo komanso zovuta pazovuta.

Kusokonezeka

GD ndi matenda amisala

Comorbidity ndi zovuta zina zamagetsi, kuphatikiza pazokonda zina, ndizofala mu AUD / DUD ndi GD. Ochuluka monga 96% ya anthu omwe ali ndi moyo GD amakumananso ndi zofunikira zina zazing'ono zamisala.6,15 Ziwerengero zamasiku onse zokhala ndi matenda amisala ambiri zimakwezedwa pakati pa omwe ali ndi GD,16 ndi machitidwe (49% -56%)15,16 ndi nkhawa (41% –60%)15,16 zovuta ndi AUD (73%)16 ndi DUD (38%)16 kukhala wopambana.15 Matenda aumunthu nawonso afala kwambiri pakati pa omwe ali ndi GD16 komanso kuchuluka kwa zovuta zingapo za comorbid kumakulanso. Makamaka, paphunziro lamtundu,15 anthu omwe ali ndi GD anali 30 nthawi zowonjezereka kukhala ndi zovuta zingapo (zitatu kapena zingapo) zamaganizidwe ena amisala poyerekeza ndi omwe alibe GD. Komanso, kafukufuku wobwezeretsanso akuwonetsa kuti zochuluka za comorbidity iyi (74%) zimatsogolera ndipo zitha kukhala pachiwopsezo chotukula GD m'malo motumiza GD monga chiopsezo cha kukulitsa zovuta zina zamisala. Komabe, maphunziro akutsogolo omwe amayembekezeredwa,22,23 zomwe ndizothandiza pakukhazikitsa dongosolo lazosokonezeka kwakanthawi kwakanthawi, zikuwonetsa kuti GD yam'mbuyomu imalumikizidwa ndi kukhazikitsidwa kwazinthu zatsopano zamaganizidwe amisala kuphatikizapo malingaliro, nkhawa, ndi AUD. Chiwopsezo chotenga zovuta zatsopano chikuwoneka kuti chikugwirizana ndi kuopsa kwa machitidwe a juga.23 ndi otchova juga omwe ali pachiwopsezo chachikulu cha kuyambika kwa vuto la comorbid yatsopano poyerekeza ndi vuto kapena otchova juga. Pazonse, mabukuwa amathandizira ubale wogwirizana ndi ma comorbidity kotero kuti matenda amisala amatha kugwiritsa ntchito ngati chiwopsezo cha chitukuko, amatha kugwira ntchito ngati yokonza GD, ndipo imatha kuchitika chifukwa cha GD.15,22,24

GD ndi AUD / DUD

Kuyanjana kwa GD ndi zovuta zina zowonjezera kumakhazikitsidwa bwino. Ziwerengero za meta-analytic zosonyeza kuchuluka kwa anthu zimawonetsa kuchuluka kwa nthawi ya moyo wa AUD ndi DUD comorbidity pakati pa vuto la moyo ndi kutchova kwatsamba, 28% ya otchova masewerawa akunena AUD ndi 17% akunena lipoti losavomerezeka la DUD.25 Mitengo ya kuchuluka kumeneyi imamvetsetsa bwino poyerekeza kusiyana kwa mitundu ya zomwe SUD / DUD imazindikira pakati pa omwe ali ndi opanda GD. Mwachitsanzo, mu Welte et al17 kuphunzira, 25% ya iwo omwe ali ndi GD adakumana ndi njira zodalira pakadali pano, pomwe 1.4% yokha ya omwe alibe GD ndi omwe amadalira mowa. Kutsatira zokambirana za ma comorbidity ambiri omwe adanenedwa kale, kupezeka kwa zovuta zowonjezera ziwiri, monga AUD ndi GD, zimagwirizanitsidwa ndi chiwopsezo chowonjezeka cha matenda owonjezera amisala poyerekeza ndi kukhalapo kwa GD yopanda AUD.26

AUD ndi DUD ndiwofala kwambiri pakati pa omwe amafuna njuga kuposa anthu ambiri, omwe ali ndi kuchuluka kwa kukumana kwa 41% nthawi yayitali AUD ndi 21% kukumana kwama SUDs osamwa mowa kuphatikiza kudalira kwa chikonga.27 Comorbid DUD imapangitsa zotsatira za kutchova njuga kuti iwo omwe alibe mbiri ya moyo wa DUD ali ndi nthawi za 2.6 kuti akwaniritse nyengo ya 3 ya miyezi yambiri ya juga poyerekeza ndi omwe ali ndi DUD yonse.28 Ofufuza29 akuwonetsa kuti ngakhale mwa omwe ali ndi moyo wa AUD / DUD, ambiri (58%) kwa iwo omwe akufuna kulandira njuga akugwiritsa ntchito moledzera kapena zinthu zosayenera mchaka chovomerezeka asanavomere. Mwamwayi, kugwiritsa ntchito mankhwala osokoneza bongo omwe ali pachiwopsezo chachikulu (zakumwa zoonjezera za 14 / sabata kapena 4 / tsiku kwa amuna; zoposa zakumwa za 7 / sabata kapena zakumwa za 3 / tsiku kwa akazi) zimawoneka ngati zikuchepa panthawi ya chithandizo cha juga.30 ndipo kuchepetsedwa kwachilengedwe kumeneku pakugwiritsira ntchito mowa kumatha kuthandizidwa ndikuphatikizidwa kwa njira zachidule za zakumwa zochiritsira njuga. Chithandizo choterechi chitha kuchepetsa mwayi woti mungamwe mowa pang'ono, kukhalapo komwe kumalumikizidwa ndikuyambiranso kutchova juga.28 Kusintha komweku pakamodzi pa kumwa mowa ndi kutchova juga kumatsimikizira kuti izi zimatha kukhudzana pakapita nthawi.

Poganizira kuchuluka kwambiri kwa zovuta ndi zotsatira za comorbid DUD ndi AUD pazotsatira zamtundu wa juga, kuphatikiza njira zowunikira za AUD ndi DUD muzochitika zamankhwala ndizovomerezeka kwa odwala omwe ali ndi GD. Kusinthananso, kuwonera njuga yovuta pakati pa omwe amafuna kugwiritsa ntchito mankhwala osokoneza bongo, ndikofunikira. Pafupifupi, 15% ya omwe amafunafuna chithandizo cha AUD / DUD amafuna kukwaniritsa njira za GD ndi 11% amakwaniritsa zomwe ali nazo masiku ano a GD.31 Mwa odwala omwe ali ndi opioid omwe amalowa m'malo mwanjira imeneyi, mitengo ya GD ikhoza kukhala yapamwamba kwambiri,31 ndipo njuga yamavuto imalumikizidwa ndi yankho losauka la mankhwala osokoneza bongo pakati pa odwala.32 Kuphatikizidwa kwa kuwonerera njuga ndi njira zoperekera mankhwala osokoneza bongo kumatha kuwongolera osati zovuta zanjuga zokha, komanso zotsatira za chithandizo cha AUD / DUD. Kuphatikiza apo, anthu ambiri omwe ali ndi AUD / DUD amatha kukwanitsa kuledzera komanso kugwiritsa ntchito mankhwala osokoneza bongo, koma akulephera kuwongolera njuga zawo,29 Kungonena kuti ndi chindapusa kapena chothandizira kuphatikizidwa.

GD diathesis

Kapangidwe ka chibadwa cha munthu kumatha kupereka chiwopsezo chachikulu pakupanga SUD ndi GD. Gawo la kusinthika chifukwa cha majini kumachokera ku 0.39 ya hallucinogens mpaka 0.72 ya cocaine.33 Kuchulukitsa kwa GD kuli mkati mwa izi ku 0.50-0.60 ndipo ndiwofanana ndi ziwengo za heritability za mowa ndi opiates.34 Ntchito zamakono35 pakukula kuchokera pakubwera mpaka kukhala chizolowezi chosonyeza kuti zopereka zamtunduwu zimagwira gawo lalikulu pamasiku omaliza a chizolowezi (mwachitsanzo, kulephera kuwongolera), pomwe zochitika zachilengedwe zimawoneka ngati zikuyambitsa kuwonetsedwa koyambirira komanso kuyesa.36,37 Zomwe zimathandizira pazachilengedwe pakuchepa kwakutukuka kwa GD zimanenedwa chifukwa cha 38% –65% ya kusiyana mumikhalidwe yovuta ya njuga38 ndikuyimira chinthu chofunikira kuti timvetsetse vuto ili. Zina mwazomwe zimadziwika kuti ndizoyambitsa GD zimaphatikizapo kuzunza ana,39 Khalidwe la njuga kwa makolo40-42 chikhalidwe kuvomereza njuga,40 ndi zinthu zake monga kupezeka kosavuta kwa mayendedwe a njuga ndi maphwando.43

Chiwopsezo chachikulu cha kusuta kwa mankhwala osokoneza bongo ndizosagwirizana komanso kugawana zinthu. Chiwopsezo chogawidwirachi mwina chimachitika chifukwa chakuwonekera kwakukulu komanso kukhudzidwa koyipa, komwe kumayambitsa chibadwa ndipo kungakhale pangozi yogwiritsa ntchito zinthu.44 Osangokhala zoopsa zomwe zimachitika chifukwa chosakhudzidwa komanso kusakhudzidwa zimakhudzidwa ndi zinthu zomwe zimadulidwa, koma buku lomwe limaoneka ngati lingaliro limanenanso kuti izi ndi zinthu zomwe zingayambitse zovuta zina zakunja, kuphatikizapo GD.34,45 Mwachitsanzo, phunziroli lingakhale lachitukuko24 adanenanso kuti 1) kusokonekera kwa unyamata kumayambitsa kukula kwa njuga komanso zovuta zapa, ndikuti 2) zizindikilo ziwiri izi zimathandizira wina ndi mnzake kutha kwa unyamata ndi ukalamba. Kuphatikiza apo, pankhani yofufuza zamakina, kupezeka kwa Taq A1 alile wa dopamine receptor D2 polymorphism yalumikizidwa ndi onse GD ndi AUD.46 Izi zothandizira zalumikizidwa ndi kuwonjezereka kwa ntchito ya mitsempha,47 ndikuwonetsa kuti mwina gawo limodzi la magawidwe ogawana pakati pa GD ndi kudalira mowa (12% –20%)48 ndi chifukwa cha chibadwa chomwe chimayambitsa zovuta.

Kuphatikizidwa pamodzi, izi zimapereka chithandiziro cha mtundu wa kusuta kwa chizolowezi, chomwe chimapangitsa kuti zinthu zosiyanasiyana zosokoneza bongo zigwirizane kwambiri ndi diatheses komanso sequelae.37 Ngakhale zotsatira zomaliza zimakhala zosiyanasiyana (mwachitsanzo, njuga yosalamulika motsutsana ndi kugwiritsidwa ntchito kosalamulirika kwa heroin), magwiridwe antchito omwe amapezeka amakhala akuwonjezereka, akuwonetsa chodabwitsa cha kuphatikizika, momwe anthu omwe ali ndi maziko ofananawo pazovuta ndi zotetezera amakumana ndi zotsatira zakutukuka zosiyana.49

Neurobiology

Njira yochokera ku majini kupita pamakonzedwe ndi yodziwika bwino, yobwereza, ndipo imasinthidwa pamlingo wapakatikati ndi neural circry, yomwe imapangidwa mochuluka ndi njira ya chibadwa ndipo imagwira ntchito kuwongolera zochitika za phenotypic. Mwachitsanzo, njira ya mesocorticolimbic dopamine modulates mtengo wamtengo wapatali wa zinthu zowonjezera ndi zizolowezi zake.35 Kafukufuku angapo a GD ndi DUD adasinthira zopereka zamtunduwu panjira zosiyanasiyana, kuphatikizapo kupsinjika kwa ma D2 receptors komanso kukula kwa kutulutsidwa kwa dopamine, zomwe zimaneneratu kuyanjika kwa hedonic.50

Monga momwe ma genetic operekera machitidwe amakhala ophatikizidwa, chodabwitsa chakusokoneza bongo ndizovuta kwambiri kuti chitha kuphatikizidwa ndi neurocircuit imodzi. Ma network ena omwe akhudzidwa ndi chizolowezichi amaphatikizapo njira yolowera,51 axoralamic-pituitary-adrenal (HPA) axis,52 insula,53 ndi zigawo zingapo za preortal cortex (PFC).54 Monga mtundu waukulu wamankhwala osokoneza bongo, Koob ndi Le Moal36 adalemba kukhalapo kwa onse a 1) mkati mwa ma-neuroadaptations, omwe amadziwika ndi gawo lokwezeka la mphotho (mwachitsanzo, kulolerana) komwe kumayendetsedwa ndi kuchepetsedwa mu zochitika za dralamine ya ventral, komanso 2) pakati pa machitidwe a neuroadaptations machitidwe (mwachitsanzo, olamulira a HPA, amygdala owonjezereka) amathandizidwa kwambiri, ndikupangitsa mkhalidwe woyipa (mwachitsanzo, kudzipatula, kulakalaka) pakalibe chinthu / chikhalidwe. Kusintha kwamakono kotereku kumagwirizana ndi malingaliro osiyanasiyana akuti chiphunzitsochi chimalimbikitsa kusuta35 ndipo ikhoza kuphatikizidwa pakusunthika kwakanthawi kogwirizana ndi kakamizidwe komwe koyamba kuchita machitidwe achizolowezi kumachitika chifukwa cha chikhumbo choyendetsedwa ndi zotsatira zoyipa za hedonic. Khalidwe lotsatira likutsatira kukulira kwa kulolerana ndi kusintha kwakonsekonse mu mitsempha yayikulu, ndipo, mosiyana ndi chibwenzi choyamba, chimayendetsedwa ndi chizolowezi, chokakamiza chofuna kuthana ndi nkhawa komanso zovuta zoyipa (mwachitsanzo, kuchepetsa kukhumba, kupewa kuchoka). Umboni ukusonyeza kuti kugwiritsa ntchito mankhwala osokoneza bongo kumawonongetsa maukadaulo a PFC ovuta kwambiri kusintha mawonekedwe, kuchepetsa kuthekera kokhala ndi kudziletsa koyenera kuti pakhale kudziletsa.55 Zowonongeka zotsalazo zingathandizenso kufotokozera chifukwa chomwe zizolowezi zina zomwe zimakonda kumatha kubereka pambuyo poti zasiya kuchita zomwe zimapangitsa kuti zibwererenso nthawi yayitali pomwe GD ikugwidwa ndi DUD.

Koob ndi Le Moal's36 module amatembenuka mothandizidwa ndi oyamba ndi othandizira olimbirana panjira yogwiritsa ntchito mankhwala oyambilira, kenako ndikuwonjezereka kwa dorsal striatum modular monga momwe zikhalidwe zimayambira kupitirira mphotho ya hedonic monga chofunikira chothandizira kuchita.56 Munkhaniyi, anthu amakhala ndi zokonda zotsatizana zazomvera (mwachitsanzo, "mowa" wa mowa zingachitike) ndi zizolowezi zowonjezera (mwachitsanzo, kumwa mowa), pogwirira ntchito pakapangidwe kabwino. Pamapeto pake, kugwiritsidwa ntchito kwa mayiko obwerera m'mbuyo (mwachitsanzo, kulakalaka, kusiya) komwe kumalumikizana ndi chizolowezi chomasankha kumakhala kofunikira poyendetsa mchitidwewu. Chosangalatsa ndichakuti kuwonongeka kwa gawo logona, lomwe limayang'anira mawonekedwe amkati ndi malingaliro, limathetsa zomwe zimachitika pakulakalaka.57

Kuphatikiza pa insula, gawo lina la ma neurobiological module la anti-malipo dongosolo ndi HPA axis. Njira iyi ya neuroendocrine imasokonezeka ndikuwonetsa pang'onopang'ono zinthu, komanso nthawi yomwe mukuchita juga.58 omwe amasintha kuthekera kwake kugwira ntchito moyenera komanso moyenera.52 Kusintha kwa axis ya HPA chifukwa chogwiritsa ntchito mobwerezabwereza kumaphatikizanso kuwonjezeka kwa kusintha kwa adrenocorticotropic timadzi ndi corticosterone. Kusintha kumeneku kumapangitsa anthu omwe ali ndi vuto losokoneza bongo kukhala ndi nkhawa kwambiri komanso kwa nthawi yayitali kuposa ena36 ndipo zimawonjezera kuwonjezereka kwanthaŵi yayitali pakuwonjezera kwawo zovuta zoyipa za kupsinjika.59 Kuphatikiza apo, kusintha koteroko ku nkhwangwa ya HPA kumawerengedwa ngati njira pakati pamakina ogwiritsira ntchito mankhwalawa, popeza kugwidwa kwa kayendedwe ka kupanikizika uku kumathandizira pang'ono kudziwa komwe kungafunikire komanso kulosera.59

Ngakhale a Koob ndi a Le Moal36 mtundu unapangidwa mozungulira zinthu, maumboni omwe akutuluka amalumikizana ndi maupangiri ofunikira pakudalira kwa mankhwala ndi GD komanso. Mwachitsanzo, kusintha kosafunikira komwe kumachitika mu DUD kumachitikanso mu GD.60 Kuphatikiza apo, pamamolekyulu, umboni umawonetsa kuti ma dopamine D2 receptors amachititsa chidwi cha mphotho ku njuga zonse61 ndi kugwiritsa ntchito mankhwala.62 Pokhudzana ndi kukopa kwa dopaminergic pa GD, dopamine agonists, yomwe imagwiritsidwa ntchito ngati mankhwala a Parkinson komanso matenda osakhazikika mwendo, imatha kuyambitsa zochitika zokhudzana ndi hedonic monga hypersexourse ndi njuga, makamaka kudzera pakamwa pa mphotho ya dopamine.63 Momwemonso, pharmacotherapy yokhala ndi dopamine antagonists yawonetsa kuchita bwino pothandizira kudalira mowa,64 ngakhale umboni ulibe umboni wotsimikizira kuti njirayi ili mu GD.65,66 Pomaliza, monga DUD, kulephera kwa anthu omwe ali ndi GD kuti awonetse kuwongolera koyenera kumatha kuchitika chifukwa cha kuwonjezeka kwa kuwonjezeka kwa machitidwe amanjenje omvera pa njuga,67 kuphatikiza ndi machitidwe oopsa othinana,58 komanso kuchepetsedwa kutseguka mu ma network ofunikira a PFC.68

Ngakhale atapita patsogolo kwambiri pakuwongolera kutsimikiza kwa ma neurobiological a GD ndi DUD, pali ntchito yambiri yofunika kuti ichitike. Ngakhale zidachitika kuti kuphatikiza GD ikhale mitundu ya DUD, mabuku a GD akusowabe pakumvetsetsa kwathunthu pokhudzana ndi gawo la dopamine pakukula kwa vutoli, komwe kumalepheretsa kuphatikizidwa kwathunthu mu mitundu yotchuka iyi .35-36 Komanso, zikuwonekeratu kuti ma neurotransmitters pambali pa dopamine amathandizira kwambiri pantchito yowonjezera,54 koma umboni wopatsa chidwi wokhudzana ndi serotonin, norepinephrine, ndi glutamate ku GD ndiwofalikira.69

Kuzindikira

Matenda osokoneza bongo nthawi zambiri amagwirizanitsidwa ndi kuchepa kwa kuzindikira, ngakhale pali kusiyanasiyana kwakukulu pazotsatira zomwe zimatengera zomwe zimagwiritsidwa ntchito molakwika, komanso kuchuluka ndi kugwiritsidwa ntchito kwakukulu. Mwa anthu omwe ali ndi zakumwa zoledzeretsa, zoperewera zimachitika m'maboma a akuluakulu (EFs) ndi luso lakuwona, pomwe maluso ena monga malankhulidwe ndi magalimoto akulu satha.70 Mwamwayi, izi zowonongeka chifukwa chogwiritsa ntchito kwambiri zimatha kukometsedwa pang'ono ndi kudziletsa kwanthawi yayitali. Anthu omwe ali ndi GD amawonetsanso zoperewera mu EFs,71 kuphatikiza kupanga zisankho,72 kudziletsa73 ndi kusinthasintha kwa malingaliro;74 komabe, palibe maphunziro pano omwe adawunikapo kuyeserera kwa kupewa kutchova juga kwakanthawi pazinthu izi. Funso lina lomwe silinayankhidwe m'mabukuwa limakhala ngati kuchepa kwa mitsempha ya mankhwalawa kulipo posakhalitsa kapena ngati zikuyimira mtsogolo zotsatira zakusintha kwa thupi chifukwa chamakhalidwe olowerera. Kafukufuku wambiri mu GD komanso kudalira kwa mowa nthawi zambiri amathandizira kupezeka kwa kukakamizidwa kwa anthu ambiri omwe ali ndi vuto lodzaza, ngakhale zambiri kuchokera pazofufuza izi zimasonyezanso kusokonezeka kwakukulu mu EFs monga kukumbukira kukumbukira pakati pa anthu omwe amadalira mowa, poyerekeza ndi omwe ali ndi GD,75 Mwinanso kungonena kuti kuperewera kwa ethanol mosamala kumawononga kayendedwe ka PFC. Kuphatikiza apo, zomwe zimasinthidwa ndi zomwe zimapezeka mu mitsempha, zotsatira za malipoti zimawonetsa kuti kukhudzika kumakonda kukwezedwa mu GD, kupereka umboni wodziyimira pawokha wodziyimira pawokha wazovuta zowonjezera zovuta zowonjezera.73,76

Pazonse, zomwe zapezeka pazakuchepa kwa mitsempha mu GD ndizothandiza, makamaka pokhudzana ndi kufufuza komwe GD imagwiritsidwa ntchito ngati chida chaukadaulo pofuna kuthana ndi mafunso ena ofufuza.75 Komabe, chofunikira kwambiri chomwe chakupitilirabe m'mabukuwa ndi kupezeka kwa zinthu zakale zomwe zimagwiritsidwa ntchito polemba, zomwe zimapangitsa kufananiza mwachindunji komanso kusanthula kwakukulu.77 Mosoweka, mzere wofufuzirawu udakali wakhanda, ndipo pamene ukupitiliza kukula, kufananizidwa kolondola kwa mapangidwe a mitsempha kumatha kupangidwa pakati pa anthu omwe ali ndi GD ndi omwe amamwa zinthu monga mowa. Kutembenuza zomwe zapezedwa pantchito zofananira ndikuchita zofanizira zazitali74 ithandizanso kumvetsetsa kwathu mosafunikira komanso zinthu zina zofunika kuzindikira monga zimagwirizirana ndi GD ndi DUD.

chithandizo

Pafupifupi, gawo limodzi mwa magawo atatu a anthu omwe ali ndi GD komanso pafupifupi kotala imodzi ya iwo omwe amadalira mowa adzachira mwachilengedwe osafunikira chithandizo.78,79 Ena atembenukira kunjira zamankhwala monga kuphatikiza kudzithandiza ndi kuthandizidwa ndi anzawo, kulowererapo mwachidule ndi zolimbikitsa, ndi chidziwitso pochita masewera olimbitsa thupi (CBT) kuti ayambenso kuwongolera machitidwe awo osokoneza bongo. Njira zamtunduwu zamtundu wa juga zimadalira kwambiri zomwe zimapangidwa kuti azigwiritsa ntchito mankhwala osokoneza bongo, ndipo kafukufuku amafotokoza kuti otchova juga,80 monga iwo omwe ali ndi zosokoneza bongo.81 pindulani ndi izi. Komabe, chithandizo cha njuga sichimapezeka ponseponse. Mu gawo lotsatira, tikambirana mwachidule njira zomwe zimachitika povutikira ndi zovuta za mankhwala ndi njuga.

Pulogalamu yochiritsa ya 12-Step

Alcoholics Anonymous (AA) ndi gulu lotsogozedwa ndi anzanu kwa iwo omwe ali ndi mavuto amowa. Misonkhano ya AA imapezeka kwambiri ku US ndipo kafukufuku akuwonetsa kuti kutenga nawo mbali kumakhala kofala komanso kumalumikizidwa ndi zotsatira zabwino. Kelly et al82 adatsata odwala omwe amadalira mowa omwe adalimbikitsidwa kuti azichita nawo magulu othandizira atachoka pakulandila chithandizo champhamvu ndipo 79% idalowa m'magulu amenewa chaka choyamba. Kutenga nawo gawo kunatsika koma kunakhalabe kofunikira patatha zaka zachiwiri (54%) ndi lachitatu (54%) zotulukapo ndipo zimalumikizidwa ndi zotsatira zabwino zakumwa. Maphunziro ena83,84 akuwonetsa kuti phindu la kutenga nawo gawo kwa AA litha kukhala lokwanira pomwe odwala akuchita nawo AA mogwirizana ndi chithandizo cha akatswiri komanso kuti kutenga nawo gawo kwa AA kungakhale kofunikira pakuchira kwanthawi yayitali.

Ochita kutchova juga osadziwika (GA) zachokera pa malingaliro a 12 omwe amapangidwa ndi AA, ndipo amathandizira mfundo zambiri zopezeka mu AA, kuphatikiza kungoyeserera zokhazokha, kulandira chitsanzo cha matenda osokoneza bongo, komanso lingaliro lokonda kusuta kudwala. GA ikuwoneka kuti ipindulitsa iwo omwe ali ndi zovuta kwambiri,85 koma zomwe tafotokozazi (mwachitsanzo, kudziletsa) zitha kuchepetsa kukopa kwake anthu ena. Pali zambiri zochepa pa GA ngati chithandizo chokha, koma maphunziro omwe alipo85-87 akuwonetsa kuti mapindu a GA monga kungolowerera pakokha ndi ocheperako, mwina chifukwa chothamangitsa mitengo. Komabe, kutenga nawo gawo kwa GA pokambirana ndi akatswiri pazamankhwala kumawoneka kuti kumawonjezera zotsatira za chithandizo,88 ndipo amakhalanso othandizira popereka chithandizo moyenera.89

Zodzithandiza

Chithandizo chodzithandizira chimapereka zabwino zambiri zomwe sizipezeka mumisonkhano yatsatanetsatane ya 12 kapena njira zoperekedwa mwaukadaulo monga chinsinsi, kusunga ndalama, kupezeka mosavuta, komanso kupezeka.90 Bibliotherapy yamavuto amowa imapanga kukula kocheperako mpaka pang'ono poyerekeza ndi njira zina zochizira, kungakhale kothandizanso monga kuchitira kwina zambiri, ndikuwoneka kuti kukuwongolera pakupeza chithandizo kwakanthawi yayitali.91 Bibliotherapy yawonedwanso njuga zamavuto ndipo imapindulitsa kwa otchova juga omwe amagwirizana ndi omwe amasankhidwa kuti azidikira.92 Komabe, yesero lolamulidwa mwachisawawa (RCT)93 ndi kutsatira kwawo kwa mwezi wa 2494 Fotokozerani kuti kulumikizana kwa akatswiri ochepa mphamvu kungakhale gawo lofunikira pakukhudzana ndi mavutowa.

Zochita zothandizira

Kuyambitsa kuchitapo kanthu kungakhale njira zabwino kwa iwo omwe ali ndi vuto lakumwa omwe ali ndi chidwi chofuna kusintha momwe angagwirire kapena kulandira chithandizo. Kusanthula kwa Meta kwa 55 kosasinthika kapena kafukufuku wokhazikika yemwe adatsimikiza kuti kulowererapo kwa omwe ali ndi AUD / DUD kumabweretsa kutsika kwakukulu pakumwa komanso kugwiritsa ntchito mankhwala osokoneza bongo pazotsatira zopanda njira zochizira komanso zotsatira zofananira ndi zina.95 Momwemonso, njira zothandizira ndizothandiza kulimbana ndi mavuto a juga. RCT idawonetsa kuti gawo limodzi lokonzekera gawo limodzi la 75 limatha kukhala lothandiza pakati pa otchova njuga kuti achepetse kuchuluka kwa njuga ndi madola omwe amalandilidwa poyerekeza ndi kuyankhulana kwaposachedwa, zotsatira zake zikupitilira chaka chotsatira kulowererapo.96 Mitundu yambiri yokhala ndi nthawi yochulukirapo (mwachitsanzo, mphindi za 10-15), kuphatikiza upangiri wachidule komanso mayankho pamachitidwe anu, iwonetsani lonjezo lakusintha machitidwe ena otchova njuga kwa omwe ali ndi vuto kapena otchova njuga.97,98 Chosangalatsa ndichakuti mitundu yambiri (monga, magawo anayi) yolimbikitsira yolimbikitsidwa ndi CBT sikuti imasintha zotsatira zokhudzana ndi mafotokozedwe achidule kapena amtundu umodzi mu RCTs ya anthu omwe ali ndi vuto kapena osokoneza njuga omwe amalemba pagulu98 ndi wophunzira waku koleji99 anthu. Izi zitha kuchitika chifukwa chophatikizidwa ndi otchova njuga m'maphunzirowa, omwe mwina safuna kapena kufuna chithandizo chambiri. Kwa ena, makamaka omwe ali ndi GD, chithandizo chamankhwala chotenga nthawi yayitali chitha kukhala chofunikira pakusintha kwamakhalidwe.

Njira zozindikira komanso / kapena zamakhalidwe

Ophunzitsidwa bwino, owongoleredwa omwe amatsogozedwa ndi malangizo a Bungwe la Bungwe la BP amathandizira kukonza zotsatira zokhudzana ndi GA kapena zolemba zokha zozimira pa iwo omwe ali ndi GD mu RCTs.86,88 Komabe, mu RCT100 zomwe zimaphatikizapo ochita masewera ovuta a koleji ovuta, 4- mpaka 6-gawo la CBT sizinapange zotsatira zabwino zogwirizana ndi gawo limodzi la mayankho. Kafukufuku wina wowunika mtundu (gulu motsutsana payekha) kapena kuyerekezera kwa CBT ndi othandizira ena othandizira nthawi zambiri samapeza kusiyana pakati pamagulu oyerekeza.101-103 Izi zakupeza umboni kuchokera ku chithandizo chodalira mowa.104

Ngakhale CBT yokhudza juga ndi yofanana kwambiri ndi CBT yothandizira mankhwalawa, njira zochizira zomwe zimayang'ana mwachindunji pazidziwitso zopotoka zokhudzana ndi juga ndizapadera pazambiri. Njira zamtunduwu nthawi zambiri zimaphatikizana ndi othandizira ena (mwachitsanzo, mpaka magawo a 20) ndikuwonetsa mapindu olimbikitsidwa ndi kuwongolera mndandanda.105,106 Komabe, zotsatirazi zikuyenera kuchitika mobwerezabwereza pogwiritsa ntchito zitsanzo zazikuru ndikugwiritsa ntchito kusanthula kwakanthawi, monga maphunziro awa105,106 kupatula anthu omwe adasiya kulandira chithandizo chifukwa chakukwera kwamankhwala. Zofanana ndi maphunziro ena omwe amapeza kusiyana pang'ono pakati pa njira zamtundu wa juga,101 ndi RCT107 omwe anayerekezera chidziwitso chamankhwala othandizika ndi njira zina zogwiritsira ntchito (mwachitsanzo, kufunsa kwamphamvu, kugwiritsa ntchito njira) ndikuwunikira pazomwe zimagwiritsidwa ntchito pozindikira sizinapeze kusiyana kwakukulu pakubwera kwa njuga pakati pa mankhwalawa.

Pafupifupi, kafukufuku wa AUD / DUD ndi mayendedwe a juga mpaka pano akuwonetsa kuti palibe mtundu kapena njira imodzi yabwino. M'malo mwake, zikuwoneka kuti chithandizo chambiri ndizothandiza, kusiyana pang'ono komwe kumakhalapo pakati pa othandizira. Chifukwa chake, anthu omwe ali ndi chizolowezi chomwa mankhwala osokoneza bongo omwe amafuna kulandira chithandizo ali ndi njira zingapo zomwe angapezeke potengera zomwe amakonda, zosowa zawo, komanso mwina mwamphamvu zovuta zawo. Kupita patsogolo, njira zochiritsira zingafunike kuwonjezera zomwe zikukhudza kuthana kwambiri pakati pa GD ndi mavuto ena amisala, kuphatikizapo, nkhawa, kusunthika, umunthu, mowa, komanso mavuto osokoneza bongo.22 Umboni ukusonyeza kuti zizindikiro zamagulu amisala zimamvomera ndikuwongolera panthawi yolandila njuga.108 Komabe, malo opititsa patsogolo malingaliro amisala amisala adakali pakati pa omwe ali ndi mafotokozedwe owopsa.109 kutanthauza kuti anthu awa amafunika zinthu zapadera komanso zophatikizika kuti athane ndi zochitika za comorbid.

Kutsiliza

Chovuta chachikulu pakuwunikira kwathunthu zolumikizira ndi zowopsa pa GD ndi AUD / DUD zimafanana ndi chikhalidwe cha asymmetrical ofufuza pazovuta zokhudzana ndi kusokoneza bongo komwe GD ndi gawo lamaphunziro lofunsa ndi kusowa kwa ndalama poyerekeza ndi zina.110 Komabe, kufufuza kwaposachedwa kwayamba kufotokoza bwino momwe GD ikukula,111 kutanthauza kuti etiology ya GD ndi yovuta, epigenetic, ndipo imaphatikizaponso zolosera zam'tsogolo. Kuphatikiza apo, zitsanzozi ndizofanana mwachilengedwe kwa zitsanzo za chitukuko cha psychopathology za AUD / DUD, ndikuwonetsa kuchulukira kwakukuru ndi zinthu zomwe zili pachiwopsezo. Umboni ukawonjezereka, timatha kuphatikiza kafukufuku wazaka makumi ambiri kukhala mitundu yayikulu, yophatikiza ya kusuta37 zomwe zimaphatikizapo zizolowezi zakakhalidwe monga GD.

Kafukufuku wofunsa mafunso monga zovulaza komanso mtengo wachuma wokhudzana ndi kutchova juga kwaulere komanso ngati otchova njuga angadziwe zotsatira zoyipa malinga ndi mitundu yofatsa ya AUD / DUD ikufunika. Maphunzirowa ndi ofunikira kuwunikiranso mtsogolo mwa DSM pokhudzana ndi zisankho zokhudzana ndi mtundu wa njira za GD komanso zopumira kwambiri kwa iwo a AUD / DUD. Chofunikira china chofufuzira ndikusanthula njira zamankhwala, makamaka zophatikiza zomwe zimathetsa vuto la comorbid kapena magwiridwe antchito (mwachitsanzo, kuperewera). Mitengo yayikulu ya comorbidity ikuwonetsa kuti chithandizo chophatikizika choterechi ndi malo osowa kwambiri ndipo ali ndi kuthekera kwakukulu. Tsoka ilo, mabuku azachipatala a GD samapangidwa bwino pamenepa kuposa ena.

Pankhani ya machitachita azachipatala, timalimbikitsa kuwunika zokhudzana ndi zovuta zamagetsi zomwe siziri njuga pakati pa omwe akufuna chithandizo cha mavuto a njuga. Kuunikanso njira zamavuto amisala pakati pa omwe amafuna chithandizo chamatendawa kungathandize odwala kupeza chithandizo chofunikira cha matenda a comorbid mwachangu ndipo amatha kuthekera poyankha ku GD komanso vuto la comorbid pamene chithandizo chotere chimaperekedwa munthawi imodzi kapena m'njira zophatikizika. Kuphatikiza apo, m'makliniki azachipatala a AUD / DUD, kuchuluka kwambiri kwa vuto la kutchova njuga pakati pa anthuwa kukuwonetsa kuti kuwunika mwadongosolo mavuto a njuga kuyenera.31,112

GD, monga chizolowezi choyipa chamakhalidwe, chimayika bala kuti lingaganizire zovuta zina ngati zizolowezi zam'tsogolo. Zowunikiridwa, GD imagawana magawo ambiri m'madilesi ambiri ndi AUD / DUD, kutsogolera ofufuza ena37 kukhazikitsa mtundu wamalingaliro osokoneza bongo, womwe umawunikira kuwonekera kwazinthu zambiri pazokopa zosiyanasiyana (mwachitsanzo, njuga yosalamulirika, kumwa mowa, kapena kugwiritsa ntchito mankhwala osokoneza bongo a cocaine). Ofufuzawo ndi asing'anga onse amafunikira kuwonjezereka kwakukulu pamikhalidwe imeneyi pochita conceptualizing psychopathology pazifukwa zosiyanasiyana pakupanga kafukufuku wofufuza, kuwunika kwa matenda a diagnostic, ndi kukonza chithandizo.

Kuvomereza

Kukonzekera kwa lipotili kunathandizidwa mothandizidwa ndi zopereka za NIH: P60-AA003510, R01-AA021446, R21-DA031897, R01-DA-033411-01A1, ndi National Center for Responsible Ganced.

Kuwulura

Olembawo amanena kuti palibe zovuta zokhudzana ndi ntchitoyi.

 

Zothandizira

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