Litšobotsi tse qobelloang ka ho lemalla boitšoaro: boemo ba papali ea papali ea chelete (2012)

a. Ho na le phetoho e susumetsang?

Mefuta e mengata ea bokhoba ba tlhekefetso e hatisa mohopolo ho tloha tlhotlheletsong ho ea ho khothalo, phetoho ho tloha ho khothaletso e ntle ea tšusumetso ho ea ho lits'ebetso tse mpe tsa morao-rao le mekhoa ea boiketsetso (9;17-21). Ho ka ba le ts'oaetso ea ho ikatisa e ka hlahang, e hlahisang likarolo tsa ts'epahalo, ka maikutlo a seng monate (mohlala, dysphoria, ho tšoenyeha, ho teneha) ha ho fihlella ts'ebeliso ea lithethefatsi kapa lithethefatsi. Boemo bona bo seng botle bo ka tlatsetsang ho qobelloang ka matlafatso e mpe (9;20;22).

b. Dichotomy ea "ego-syntonic / ego-dystonic" e fapane hakae?

Le ha ho ka ba le likarolo tse tšoanang tse qobelloang ho PG, OCD, le bokhoba ba lithethefatsi, ho boetse ho na le phapang. Ho lemalla bokhoba ba lithethefatsi le litloaelo tsa boits'oaro bo tšoanang le PG li hlalositsoe e le sebopeho sa "ego", ho bolelang hore hangata li etelletsoa pele ke maikutlo a "menyaka, ho ikholisa kapa ho phomola ka nako ea ho etsa ketso eo" (8). Ho OCD, boits'oaro bo qobelloang hangata bo phethoa ho hatella kapa ho khelosa maikutlo le ho fokotsa tsitsipano le matšoenyeho a amanang le ho tebela maikutlo (8). Liphetso tsena ka tloaelo li nkuoa e le li-ego-dystonic ka tlhaho. Kahoo, sepheo se khothalletsang boits'oaro bo bobebe ho litumelo le OCD li ka fapana. Leha ho le joalo, litloaelo tse lemalloang li ka fokola ka sebopeho sa 'mele oa motho le ho feta ha nako e ntse e feta, kaha boits'oaro kapa litlamorao tsa ntho li sa khahlise ebile li tloaetse ho feta kapa li qobella (9;20;22-24). Ka mokhoa o ts'oanang, ho bua ka lintho tse qobelloang ho OCD joalo ka ha li "sa thabise" ho ka se be joalo kamehla, joalo ka bongoaneng OCD, kapa batho ba liphallelo ba ka fumana kamora ho "hloekisa hantle" kapa khotsofalo e hlophiselitsoeng ho hlophisa ho fihlela "mosebetsi o phethoe"25).

c. Ho mamella le ho tlohela

Ho ba teng ha mamello e kanna ea tšoana e 'ngoe lipakeng tsa bokhoba ba lithethefatsi, PG, le OCD, ka sepheo sa ho eketsa botebo ba boits'oaro bo phetoang ha nako e ntse e feta (26;27). Khothatso kapa takatso ha o ntse o qoba boits'oaro e kanna ea ts'oana le litakatso nakong ea ho khaotsa lithethefatsi bokhobeng ba lithethefatsi (1). Phetoho ea ts'ebeliso ea lithethefatsi ho lemalla e boetse e nahanne le mabapi le neuroplasticity, moo ho pepesehelang lithethefatsi tsa tlhekefetso boemo bo khothalletsang "ho batla", bo amanang le ts'ebeliso e qobelloang, bo nkang karabo ea "ho rata" kapa ea hedonic (28).

a. Li-Neurotransmitters

Lisebelisoa tse ngata tsa li-neurotransmitter li kenya letsoho ho lemeng ha lithethefatsi le PG, tse ngata li amehile ho OCD; le ha ho le joalo, datha e bonts'a phapang ea mofuta oa ho kenya letsoho ha lits'ebetso tsena ho PG le OCD (23).

Serotonin (5-HT) e kenya letsoho ho sitiseng boitshwaro le dopamine (DA) ho ithuteng, ho susumetsang, le boiketlo ba ho susumetsa, ho kenyeletsa le meputso (29). Liphephetso tsa meriana ea 5-HT le dopamine system (30-34) fana ka maikutlo a phapang ea mofuta oa ho kenya letsoho ha lits'ebetso tsena ho OCD ha e bapisoa le PG le SUDs. Ho latela phephetso ka serotonergic agonist joalo ka pakane ea bona-chlorophenyl piperazine (m-CPP), bakuli ba OCD ba tlaleha ho eketseha ha matšoao a OC (33). Batho ba nang le PG ba na le monyetla oa ho tlaleha karabo e kholo kapa e "phahameng" ho m-CPP, e ts'oanang le likarabo tse bonoang lithutong tse itjelletseng ka joala (31).

b. Neurocircuitry

Lintlha tsa Neuroimaging li ts'ehetsa li-neurocircuitry tse arolelanoang tsa litloaelo tsa boits'oaro le lithethefatsi tse hlahang ka mokhoa o fapaneng ho OCD (20). Frontostriatal circry e etsa hore ho be le khetho e kenelletseng litabeng tsa bokhoba ba lithethefatsi (18) le PG (35;36). Ho se sebetse hantle ha litšupa-nako tsa "striato-thalamo-cortical circry"37).

Li-circuits tsa Frontal-striatal li na le tšusumetso ho OCD, ICD ho lefu la Parkinson (PD), le boits'oaro bo batlang cocaine (38). Ka mohlala o le mong (38), sistimi e ka pele ea pele e amanang le lintlha tse khahlisang e sebetsana le tsamaiso e sebetsang ea dorsal pele. Ho li-ICD ho PD, ho se lekane pakeng tsa tsamaiso ea methapo le methapo ea methapo, karolong e amanang le PD pathology le / kapa litlhare tsa DA tse sebelisitsoeng ho phekola lefu lena, li ka ba teng (39). Bokhobeng ba lithethefatsi, ho se leka-lekane ha li-system tsa ventral le tsa motor li ka fetoha habonolo ka nako, ho tloha ho kenya letsoho ha ventral ho ea ho dorsal circry (40-42).

Litakatso tsa lithahasello tsa lithethefatsi le litloaelo tsa boits'oaro li amahantsoe le ts'ebeliso e mpe ea ts'ebetso ea moea oa ts'ebetso ea moea.43), e ts'oanang le liphumano nakong ea ts'ebetso ea moputso kapa papali ea chelete ea papali ea chelete ka hara PG le bokhoba ba tahi (44;45). Ho nka karolo ha mosebetsi oa papali ea chelete ho ka etsa hore DA e lokolloe maemong a phahameng bathong ba nang le PD le PG ho feta ho batho ba nang le PD feela (46), karabelo e ts'oanang le e hlahisitsoeng ke lithethefatsi kapa likotsi tse amanang le lithethefatsi ho batho ba lemaletseng lithethefatsi (47) kapa lithutong tsa PD tse sebelisang lithethefatsi tse nkang DA ka mokhoa o feteletseng (48). Ts'ebetso e ntseng e eketseha ea potoloho ea pele e bonoe ka mor'a ho pepesetsoa ha cue ho OCD (49), athe ts'ebetso e fokotsehile e bonoe ho PG (50), e totobatsa tlhoko ea tlhahlobo e ts'oanang ea PG, OCD, lithuto tse amanang le lithethefatsi le taolo (23).

Koob le Volkow (9) ba pheha khang ea hore ho susumetsa ho laola maemo a pele a bokhoba, 'me ho susumetsa ho kopantsoeng le ho qobelloa ho busa maemong a kamorao. Ba hlahisa methati e meraro ea potoloho ea bokhoba ba ho lematsa: 'ho itlopa joala / ho tahoa', 'ho khaola / ho ama hampe', le 'ho nahanisisa' (ho lakatsa). Ka mohlala oa bona, sebaka se kenellang sethaleng le ho kenella linthong tse tahang li kenya letsoho haholo molemong oa ho itlopa lijo tse tahang kapa tse tahang, li-amygdala tse atolositsoeng (ho kenyeletsoa libaka tsa amygdala, stria terminalis le li-nucleus) tse tlatsetsang haholo sethaleng sa ho ama / ho se sebe, le ho lebella / ho lebella / ho lebella sethala se kenyelletsa marang-rang a phatlalalitsoeng ka bongata a amanang le orbitof Pambal cortex-dorsal striatum, preortalal cortex, basolateral amygdala, le hippocampus. Insula e tlatsetsa ho lakatseng, gingus, cingrate gorsus, dorsolateral pre-preal, le inferior frontal cortices ho mafutsana a thibelo a thibelo ea taolo, le lefu la ho itlhahisa le nang le tšusumetso e mpe le mmuso ho ama maemo a ho hloka matla (9;22).

Ho nahanoa ka ho khaola ho tsubelletseng ho PG hoa utloahala kaha ho tlalehiloe ho khaola ha kelello ho PG (1;51). Ntle le moo, papali ea chelete mabapi le khatello ea maikutlo (24) le ho sebetsana le khatello ea maikutlo ho boletsoe e le litlatsetso tsa ho kenya letsoho ho PG (52). Ka mokhoa o ts'oanang, ho ts'oara lithethefatsi bokhobeng ba lithethefatsi le boits'oaro bo qobelloang ho OCD ho ka etsoa ho fokotsa khatello ea maikutlo (8).

Lubman et al. (53) tlhokomeliso, hore leha ho na le ho ts'oana ho likarolo tsa bongaka le bofokoli ba boits'oaro bo amanang le taolo ea thibelo ho tšebeliso ea lithethefatsi le OCD, ts'ebetso e sebetsang libakeng tse sa thibelang e bonahala e sa lumellane, e bonts'ang phapang lits'ebetsong tsa tlhokomeliso ea mantlha e amanang le pherekano e 'ngoe le e' ngoe (53-56). Ts'ebetso e tlasa ts'ebetso ea ts'ebetso ea inhibitory bokhobeng e kanna ea amahanngoa le tlhokomelo e fokolang ea bokamoso le ho fokotseha bokhoni ba ho hanela ho etsa lintho tse amanang le lithethefatsi, athe ho OCD, ts'ebetso e kanna ea sebetsa haholo, mohlomong hobane batho ba amehile haholo ka litlamorao tsa nako e tlang. (53).

c. Ho ba kotsing ea liphatsa tsa lefutso le endophenotypes

Boithuto ba mofuta oa motho ea khethiloeng oa PG bo fana ka khokahano le li-SUD le taolo e fokolang ea taolo (23). Boithuto bo bong empa eseng lithuto tse ling bo ts'oaretse polymorphism ea Taq-A1 ea gene e kenyang receptor ea DA D2 (57-59). Mefuta e fapaneng ea mofuta oa 5HT transporter e kentse letsoho ho OCD le PG, empa mofuta oa mekhatlo e fapaneng (23), le allele e telele e fumanoeng ho kopantsoe le OCD le alamo e khuts'oane e fumanoeng e le kopanong le PG (60;61).

Ho ts'ehetsa li-OCSDs, tlhahlobo ea lihlotšoana e entsoeng ho bakuli ba OCD ba bonts'itse lihlopha tsa 3 tse arohaneng (62). Mekhahlelo e ne e bitsoa: khaello ea moputso (ho kenyeletsoa le trichotillomania, bothata ba Tourette, papali ea papali ea kelello, le lefu la hypersexual); ho hloka matla (ho kenyeletsoa ho ea mabenkeleng a qobelloang, kleptomania, mathata a ho ja, ho intša kotsi le ho phatloha ho hoholo ha lintho); le somatic (ho kenyelletsa le dysmorphic disorder le hypochondriasis). Ha ho tse amanang le mofuta o itseng oa liphatsa tsa lefutso tse ithutoang. Patlisiso ea liphatsa tsa lefutso ea bokamoso e lokela ho nka boholo ba boits'oaro (boits'oaro le ho qhekella) le endophenotypes (63). Endophenotypes e na le bokhoni ba ho lekanya matšoao a tšobotsi ao ho leng bonolo ho a lekola ho feta mafu a rarahaneng a boitšoaro kapa a ka emelang litlatsetso tse amanang haholo le tlholeho ea tlhaho ea mathata a kelello (64). Hobane lipatlisiso tsa endophenotype ho tsa mafu a kelello li sa le ncha, ho na le lintlha tse fokolang (65).

Ho bonoa ts'ebetso e sa tloaelehang ea libaka tse 'maloa tsa cortical, ho kenyelletsa le orbitofrontal cortex nakong ea ho ithuta ho feto-fetoha ho bakuli ba OCD le beng ka bona ba haufi ba sa sebetseng. Phuputsong e lekolang li-inhibitory controlprocesses, li-OCD probands le beng ka li-degree tse sa sebetseng li bonts'itse ts'oaetso (extradimensional set change) le motor impulsivity (linako tsa karabelo ea ho emisa-lets'oaetso). Lits'oaetso tsena li ka emela endophenotypesfor OCD le maemo a amanang (65;66).

Ka motor inhibition paradigm (mosebetsi oa ho emisa - SST), bakuli ba OCD ka bobeli le beng ka bona ba sa sebetseng ba ile ba bonts'a taolo e sa sebetseng ea makoloi, e tšoaelitsoeng ke latency e telele ea nako ea ho emisa lets'oao la ho emisa (SSRT), le latency e telele e ne e amahanngoa ka bobeli ba tsona bo fokotsehileng ka bophahamo ba orbitofrontal cortex le ka ho le letona le ka tlase bokong bo ka pele (libaka tse tloahelehileng tse amanang le ts'ebetso ea OCD le SST, ka ho latellana) le ho eketsa molumo oa taba ea bohlooho libakeng tsa striatum, cingulate le parietal cortex (67). Liphetho tsena li pheha khang bakeng sa tšebeliso ea pele ea sebopeho sa MRI endophenotype ea lelapa, mme mohlomong le liphatsa tsa lefutso, kotsi bakeng sa ho qhekelloa ho amanang le OCD. Datha e fana ka maikutlo a hore mofuta o joalo oa endophenot o ka sebetsa le ho PG le SUDs (24).

a. Mehato ea kelello

Batho ba nang le OCD ba ipabola maemong a thibelo ea likotsi (68;68), athe ba nang le PG ba lekanya haufi-ufi ba nang le li-SUDs, ba ipabola maemong a ho susumetsa le ho batla lintho tse ncha (20;50;69). Leha ho le joalo, batho ba bang ba nang le OCD ba bonts'a boemo bo phahameng ba ho lemoha (70), mme batho ka bomong ba nang le PG kapa OCD ba bonts'itse maemo a phahameng a ho qoba ho potlaka le ho qoba likotsi, ho fana ka maikutlo a kamano e rarahaneng lipakeng tsa ho susumetsoa le ho qobelloa (23;71). Ka har'a li-OCSD, Hollander le Wong (72) e hlahisitse kopane ea ho hlophisa (sebopeho se kopaneng-se qobelloang) moo mathata a kelello a robetseng setšoantšong le OCD nakong ea khatello le bohlasoa ba botho bo fetelletseng. Leha ho le joalo, ho ba teng ha tšusumetso le ho ts'oaroa ka tšohanyetso maemong a mangata a lemalloang ho phephetsa khang ena. Phuputso ea PG le OCD (71) e khothalelitse hore ho senoloe sekhahla sa "Impulsive-Compulsive spectrum" maemong a mabeli a orthogonal, se hlahisang libaka tse tharo tsa psychopathological: haholo ts'usumetso, ho qobelloa pele (OCD), le khatello e sa qobelloang (PG).

Ho etsa liqeto ho bohlokoa ho PG, OCD, le SUDs (23). Phapang e ts'oanang le ea ho nka liqeto e bonts'a botebo ba ho khetha likhetho tse mpe nakong ea ts'ebetso ea papali ea papali ea chelete e fumanoe lipakeng tsa lithuto tsa taolo le tse nang le PG (73), OCD (74), le li-SUD (75). Leha ho le joalo, lithuto tse ling li fumane hore ho nka liqeto ho tiile ho OCD le ha e sitisoa ke mesebetsi e meng (76;77). Ho haella ha ho kopanyetsano liphumisong tsena ho ka bonts'a botsitso ba OCD, mme lipatlisiso tse ling hape lia hlokahala ho etsa lipatlisiso mabapi le ho qobelloa le ho etsa liqeto.

b. Mathata a hlahang

Mehlala ea Clinical le ea sechaba e bonts'a hore PG e sebetsa hammoho ka mathata a mangata a I le a II, ka likamano tse matla le SUDs (78-81). Ka bomalimabe, liteko tsa tlhahlobo ea OCD ha lia ka tsa fumaneha kamehla. Phuputsong ea St. Louis Epidemiologic Catchment Area (ECA), athe litekanyetso tse phahameng tsa menahano (li-ORs) li ile tsa bonoa lipakeng tsa bothata / papali ea methapo ea methapo le li-SUDs, OR e senoloang ea 0.6 e ile ea bonoa lipakeng tsa bothata / papali ea li-pathological le OCD (82).

Leha PG le OCD ba kanna ba se na khokahano e matla, ba arolelana li-comorbidities. Tlalehong ea Naha ea Sechaba ea Comorbidity Survey, tlhahlobo ea ba arabileng ea 2073 e ile ea hlahlojoa bakeng sa OCD (83). Batho ba fetang kotara e le 'ngoe ba arabetseng ba tlaleha ho hloloa kapa ho qobelloa nako eohle ea bophelo, empa ke palo e nyane feela ea ba arabelitsoeng e fihletseng litekanyetso tsa DSM-IV tsa bophelo bohle (2.3%) kapa 12-khoeli (1.2%) OCD. OCD e ne e amahanngoa le comorbidity e kholo, le litloaelano tse matla le mathata a ho kenella hare (ho tšoenyeha le ho sithabela) le menyako e phahameng bakeng sa li-ICD le li-SUDs. Ka kopanelo, liphumano tsena li bonts'a tlhokeho ea mehato ea OCD, PG, le litlatsetso tse ling tsa boitšoaro le boits'oaro lithutong tsa baahi le lipatlisiso tse ling tsa likamano tsa bona.

a. Lithethefatsi

Le ha ho se na lithethefatsi tse bonts'itsoeng ka semmuso bakeng sa PG, ho fumanoe litlelase tse tharo tse ka sehloohong: bahanyetsi ba opioid, maikutlo a ho feto-fetoha ha maikutlo le serotonin reuptake inhibitors (SRIs) (84;85). Batho ba hanyetsang Opioid ba joalo ka naltrexone ba fokotsa khafetsa ho nooeng le monyetla oa ho khutlela ho joala haholo (86;87). Bohanyetsi ba opioid le bona bo bonahala bo sebetsa hantle kalafong ea PG (1;88-90). Ha karabelo kalafo ea mohanyetsi oa opioid e bonahala e matla haholo bathong ba nang le nalane ea lelapa ea joala (91) Ho khothaletsoa tlhahiso ea endophenotype e amanang le bokhoba bo amanang le kalafo.

Ho ts'oana ho amanang le kalafo lipakeng tsa PG le SUDs ho ts'oana le liphetho tsa OCD. Naltrexone ha e susumetse ho teba ha OCD (92) hape e ka mpefatsa matšoao a (93;94). Mekhoa e metle ea methapo e kang lithium e ka ba molemo ho phekoleng PG (95-97) empa eseng OCD (98). Lithethefatsi tsa antipsychotic tse sebelisang DA D2-receptors (haloperidol, risperidone le olanzapine) li bonts'itse ts'ebetso e le baemeli ba matlafatsang ho OCD (99), empa li bontšitse liphumano tse mpe litekong tse laoloang ke placebo ho PG (100-102) le ho eketsa lits'oants'o tsa ho becha ho PG (103).

Ho bontšoa li-SRI bakeng sa ho phekola OCD (99) empa ba bile le liphetho tse kopaneng bakeng sa PG le SUDs (23). Liteko tse ling tsa taolo e sa reroang li fumane fluvoxamine le paroxetine li phahame ho feta placebo kalafo ea PG (104;105), mme ba bang ha ba (106;107). Litlamorao tse fapaneng tsa pharmacotherapy ho PG li fana ka maikutlo a tobileng ho mathata a hlahang a amanang le ona, joalo ka matšoenyeho (108), ha u phekola PG (79;109), 'me ho fokotseha ka nako e tšoanang ho PG ka bobeli le libaka tse hlahang li se li bonoa (96;108).

Phuputso e se nang mahlo a mabeli, e laoloang ke sebaka, e hanyetsanang le boithuto ba atypical (modafinil) ho PG e khothalelitse lihlopha tse peli tse nyane (103). Lintho tse nang le tšusumetso e phahameng li bontšitse ho fokotseha hoa tšusumetso ea ho becha, ho etsa liqeto tse kotsi, ho se ts'oaroe, le karabelo litekong tse amanang le papali ea chelete. Ba nang le khatello e tlase ba bontšitse ho eketseha ha maemo mehatong ena kaofela, ho fana ka maikutlo a phello ea modafinil e khethollang lipakeng tsa batho ba phahameng le ba tlase ba nang le PG. Seo ba se fumaneng se fana ka maikutlo a heterogeneity ho PG, e ka hlalosang sephetho se bonahalang ekare sea lumellana. Lintlha tse ling li fana ka maikutlo a hore ho potlaka ho ka emela sepheo sa bohlokoa sa kalafo ho PG (110;111). Lintlha tse hlahang hape li fana ka maikutlo mabapi le likarolo tsa kalafo ea glutamatergic kalafong ea OCD, PG, le SUDs (99;112;113), mohlomong ka ho shebella mehato e amanang le ho qobella (mohlala, ho se khonehe ha kelello)114), leha sephetho se lokela ho hlalosoa ka mokhoa o hlokolosi.

b. Ho kenella ka mekhoa ea boits'oaro

Mekgwa ya kalafo ya boitshwaro e sebetsang hantle kalafong ya SUDs e ka ba molemo ho PG le OCD (115;116). Mekhoa ea boikoetliso e mabapi le boits'oaro le tšusumetso, e kenyelletsoang ho khothaletsa lipuisano (MI) le Cognitive Behahlangu Therapy (CBT) li atlehile ho phekola li-SUDs le PG (85;117-120). Ho ba teng ho Gambler Anonymous (GA), e hlahisitsoeng kamora Alcoholics Anonymous (AA), ho amahantsoe le sephetho se betere bakeng sa batho ba nkang karolo ho tsa bongaka kalafi (121). OCD e tloaetse ho alafshoa ka mekhoa ea thibelo ea ho itlhahisa / ho thibela karabo (122;123), le mekhoa e tšoanang ea ho nahana ka takatso e tšoanang e na le ts'ehetso ho PG (124-127).

Pampiri ena e qapiloe ka thuso ea thuso ea ho etela e tšehelitsoeng ke Setsi sa Lipapali sa Alberta mme karolo e ts'ehelitsoe ke lithuso tsa NIH R01 DA019039, R01 DA020908, RL1 AA017539, RC1 DA028279, le P20 DA027844, VA VISXEC le National Center ea National. bakeng sa Papali e nang le Boikarabello le Setsi sa eona sa Patlisiso mabapi le Mathata a Papali ea Chelete.

Polelo ea Khopolo: Ho kenyelletsa ho ameha ha khatello litlamong tsa taolo ea tšusumetso (haholo-holo papali ea papali ea kelello), pherekano e kenelletseng le litheko tsa lithethefatsi li hlahlojoa. Ha ts'ebetso ea endophenotypic ea impulsivity e ntse e hlahlojoa le ho hlalosoa mabapi le mathata ana, ho qobelloa ha ho ithutoe hantle. Litlamorao tsa neurobiological le tsa bongaka li tšohloa.

Phatlalatso ea Thahasello:

Dr. Nady el-Guebaly ha a na likhohlano tsa chelete ho tsetela mabapi le litaba tse ngotsoeng ka letsoho.

Tanya Mudry ha a na likhohlano tsa lichelete tsa phaello ea ho tlaleha mabapi le litaba tsa buka ena e ngotsoeng ka letsoho.

Dr. Zohar o amohetse chelete ea ho etsa lipatlisiso le litefiso tsa ho bua ho tsoa Lundbeck hammoho le chelete ea lipatlisiso le litefiso tsa tlhahlobo ho tsoa ho Servier.

Dr. Tavares o fumane tšehetso ea lipatlisiso ho tsoa ho Cristalia, Roche, le Sandoz karolong ea hae e le Mopresidente oa Mokhatlo oa Naha oa Brazil mabapi le Kameho ea Pherekano le Mathata a Bangata a Taolo.

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