YBOP Iingxelo: Umxholo wokuziphatha gwenxa uphikisana nabanye abanyangi kunye noochwephesha kwezesondo. Nangona kunjalo, kuyacaca kubaphandi ukuba iindlela zokuziphatha ezibangela ukutshintsha kwengqondo ezibonisa iziyobisi. Oku kufanele ukuba, njengoko zonke iziyobisi zinokukwenza ukwandisa okanye ukuthintela indlela eqhelekileyo yomzimba. Iindlela zokulutha sele zikho kwingqondo-ukubopha ngumzekelo ophambili. Ke kuyacaca ukuba indlela yokuziphatha ebandakanya ukukhuthaza okungaphezulu kwezo ndlela zinamandla okukhokelela kutshintsho olunxulumene nomlutha.
imvelaphi:
Iindlela zokuziphatha ezininzi, ngaphandle kokungenisa iziyobisi ngengqondo, zivelisa umvuzo wexesha elifutshane onokubangela ukuqhubeka kokuziphatha, ngaphandle kolwazi lweziphumo ezibi, okt ukunciphisa ulawulo lokuziphatha. Ezi ngxaki ziye zacaciswa ngeendlela ngeendlela. Olunye uluvo lubeka ezi ngxaki njengokulala ecaleni kokunyanzelwa, kwaye ezinye zichazwa njengokuphazamiseka kolawulo. Enye into, kodwa ingavumelani ngokukodwa, ukuqwalasela kuthathela ingqalelo ukuphazamiseka njengezinto ezingezizo okanye zokuziphatha. Iinjongo: Yazisa ingxoxo ngobudlelwane phakathi kwento esebenzayo yengqondo kunye nokuziphatha kweziyobisi. Iindlela: Siphonononga idatha ebonisa ukufana kunye numahluko phakathi kokuphazamiseka kulawulo lokuziphatha okanye isimilo sokuziphatha kunye neziyobisi. Esi sihloko sibaluleke ngokukodwa kuluhlu olufanelekileyo lwezi ngxaki kuhlelo lwesihlanu oluzayo lweAmerican Psychiatric Association Diagnostic kunye neNcwadi yeNgxelo yeNgxelo yeNgxaki yeNgqondo (DSMV). Iziphumo: Ubungqina obukhulayo bunika ukuba iziyobisi ziziphatha kakubi zifana neziyobisi kwimimandla emininzi, kubandakanya imbali yendalo, ubugqi, ukunyamezelana, ubugqwirha, igalelo lemfuzo, iinkqubo ze-neurobiological, kunye nempendulo kunyango, ukuxhasa iDSM yeVenkile yoMsebenzi ophakanyisiweyo kubandakanya zonke iingxaki zokusebenzisa iziyobisi kunye neziyobisi. Idatha yangoku icebisa ukuba eli nqanaba lidibeneyo lingakulungele ukungcakaza kwendalo kunye nezinye iindlela zokuziphatha ezifundwe ngcono, umzekelo, iziyobisi kwi-Intanethi. Okwangoku akukho lwazi lwaneleyo lokucacisa nakuphi na ukwahlulwa kolunye uhlobo lokuziphatha okucetyiweyo. Iziphetho kunye neNzululwazi yeNzululwazi: Ukufakwa ngokwamanqanaba ngendlela efanelekileyo kwendlela yokuziphatha okanye ukuphazamiseka kolawulo kunokuchaphazela kakhulu ukuphuculwa kweendlela zokuthintela nokunyanga.
Imbalelwano kwidilesi kaGqr David A. Gorelick, 251 Bayview Boulevard, Baltimore, MD 21224, USA. I-imeyile: [imeyile ikhuselwe] Amagama aphambili ukuchasana nokuziphatha, ukwahlula-hlula, isifo, ukujongana nokuphazamiseka, ukusetyenziswa kweziyobisi
INTSHAYELELO
Iindlela zokuziphatha ezininzi, ngaphandle kokungena ngaphakathi kweziyobisi ngokwengqondo, zivelisa umvuzo wexesha elifutshane onokubangela ukuqhubeka kokuziphatha ngaphandle kolwazi lweziphumo ezibi, okt ukunciphisa ulawulo lokuziphatha. Ukuncitshiswa kolawulo sisiseko esichazayo sokuxhomekeka kweziyobisi kwikhoboka leziyobisi. Oku kufana kukhokelele kwinto yokuba iziyobisi azikho iziyobisi okanye iindlela zokuziphatha, oko kukuthi, ii-syndromes ezinxulumene nokukhotyokiswa ziziyobisi, kodwa kugxilwe ekuziphatheni ngaphandle kokungenisa into yengqondo. Umxholo wokuziphatha gwenxa unexabiso elithile kwisayensi nakwiklinikhi, kodwa uhlala uphikisana. Imicimbi ejikeleze isimilo sokuziphatha ngoku iyaxoxwa kwimeko yokuphuhliswa kweNgcaciso kunye neNcwadi yeNgxelo yeNgxelo yeNgxaki yesiHlanu yokuPhazamiseka kwengqondo (DSM-V) (1, 2)
Iimpawu zokuziphatha ezininzi ziye zafakwa kwiimpawu zokuziphatha ezifanayo. Incwadana yangoku yokuNxibelelanisa kunye neNcwadi yeenkcukacha-manani, uHlelo lweSine (i-DSM-IV-TR) ichonge indlela yokuhlola esisifo kwezi ngxaki zingako (umz: ukugembula kwe-pathological, kleptomania), ukubabeka njengophazamiso lolawulo lwezinto ezingafunekiyo, udidi olwahlukileyo kunengxaki yokusetyenziswa kweziyobisi. Eminye imilo yokuziphatha (okanye impembelelo yokuphazamiseka kolawulo) iye yaqwalaselwa ukuze ifakwe kuthengiso oluzayo lwe-DSM, ukuthathwa kwesikhumba, ukuthambekisa ngokwesini (ukungabinantloni), ukusoka kakhulu, umdlalo wekhompyuter / wevidiyo, kunye nomlutha we-intanethi. Yeyiphi indlela yokuziphatha yokubandakanya njengezinto zokuziphatha ezikhobokisayo ezisavulekileyo kwingxoxo-mpikiswano (3). Ayizizo zonke iingxaki zokuphazamiseka, okanye ukuphazamiseka okuphawulwa kukungxamiseki, ekufuneka kuthathelwe ingqalelo njengeziyobisi. Nangona uninzi lwezinto ezinokubangela impembelelo yokungalawuleki (umzekelo, ukungcakaza ngokwendalo, i-kleptomania) zibonakala zabelana ngeempawu eziphambili kunye neziyobisi, abanye, njengokuphazamiseka kwesiqhushumbo, abanakukwenza oko. Ngethemba lokufaka igalelo kule ngxoxo-mpikiswano, eli nqaku lihlolisisa ubungqina bokufana phakathi kweziyobisi kunye nokuphazamiseka kokusetyenziswa kweziyobisi, umahluko wabo ekungafezekiseni okunyanzelekileyo, kwaye uchonge iindawo ezinokungaqiniseki zophando lwexesha elizayo. Ikwasebenza njengentshayelelo kumanqaku alandelayo kulo mbandela, ophononongwa kwezinye zeendlela zokuziphatha ezingekho mthethweni ngakumbi.
IMIQATHANGO YOKUGQIBELA YOLWAZI LOKUGQIBELA
Into ebalulekileyo yezigqibo zokuziphatha kukusilela ukumelana nokuphembelela, ukuqhuba, okanye isilingo sokwenza into eyenzakalisayo emntwini okanye kwabanye (4). Isimo ngasinye sokuzibonakalisa siphawuleka ngephethini eqhelekileyo yokuziphatha enenqaku elibalulekileyo ngaphakathi kwesizinda esithile. Ukuzibandakanya okuphindaphindiweyo kwezi zinto zokuziphatha ekugqibeleni kuphazamisa ukusebenza kweminye imimandla. Ngokuphathelele koku, iziyobisi ekuziphatheni zifana nokuphazamiseka kokusetyenziswa kweziyobisi. Abantu abaziyobisi iziyobisi baxela ubunzima ekuxhathiseni umnqweno wokusela okanye ukusebenzisa iziyobisi.
Ukuziphatha kunye neziyobisi zikho ukufana okuninzi kwimbali yendalo, i-phenomenology, kunye neziphumo ezibi. Zombini ziqale kwinqanaba lokufikisa kunye nokuba mdala nokuba ngumdala kwaye amazinga aphezulu kula maqela mabudala kunabantu abadala (5). Zombini zineembali zendalo ezinokuthi zibonise iipatheni ezingapheliyo, ezibuyayo, kodwa abantu abaninzi bayazifumana ngokwabo ngaphandle konyango olusesikweni (okubizwa ngokuba "kukuyeka") (6).
Iziyobisi ngokuziphatha zihlala zilandelwa ziimvakalelo "zovuselelo okanye inkanuko ngaphambi kokwenza isenzo" kunye "nolonwabo, ukwaneliseka, okanye isiqabu ngexesha lokwenza isenzo" (4). Uhlobo lwe-ego-syntonic kwezi ndlela zokuziphatha lufana namava okuziphatha kokusetyenziswa kweziyobisi. Oku kwahlukile kubume be-ego-dystonic yesifo esinganyanzelekanga, nangona kunjalo, isimilo nokuziphatha gwenxa kweziyobisi kunokuba yinto encinci ye-syntonic kunye ne-ego-dystonic ekuhambeni kwexesha, njengoko isimilo (kubandakanya ukuthatha iziyobisi) ngokwaso kuye kungathandeki kwaye ngakumbi umkhwa okanye ukunyanzelwa (2, 7), okanye ukhuthazeka kancinci ngokuqiniswa okuhle nangakumbi ngokuqiniswa okungalunganga (umzekelo, ukukhululeka kwedysphoria okanye ukurhoxa).
Ukuziphatha kunye neziyobisi zikho ukufana okufana noko. Uninzi lwabantu abanokuziphatha gwenxa baxela inkanuko okanye imeko yokulangazelela ngaphambi kokuqala indlela yokuziphatha, njengabantu abanengxaki yokusebenzisa iziyobisi ngaphambi kokusetyenziswa kweziyobisi. Ukongeza, ezi ndlela zokuziphatha zihlala zinciphisa uxinzelelo kwaye zikhokelela kwimeko entle yemeko okanye "phezulu," ngokufana nokunxila kweziyobisi. Ukudakumba ngokweemvakalelo kunokufaka isandla kwiminqweno kuzo zombini iindlela zokuziphatha kunye nokusetyenziswa kweziyobisi (8). Uninzi lwabantu abanengxaki yokungcakaza, i-kleptomania, indlela yokuziphatha ngokwesondo, kunye nengxelo yokuthenga okunyanzelekileyo yokwehla kwezi mpembelelo zintle ngokuziphatha okuphindaphindiweyo okanye isidingo sokwandisa ubungqingqwa bokuziphatha ukufezekisa imeko efanayo, efana nokunyamezelana (9-11) . Uninzi lwabantu olunale ndlela yokuziphatha yokuziphatha ikwachaza imeko yedysphoric ngelixa lishiya ihambo, efana nokurhoxa. Nangona kunjalo, ngokungafani nokurhoxiswa kweziyobisi, azikho iingxelo zokuchaphazeleka komzimba ngokwasemzimbeni okanye ngokurhoxa kakhulu kwezonyango.
Ukungcakaza okungapheliyo, okufundwe ngokucokisekileyo kukuziphatha okubonakalayo, kunika ulwazi oluthe kratya malunga nolwalamano lokuziphatha gwenxa kunye nokuphazamiseka kokusebenzisa iziyobisi (jonga iWareham kunye nePotenza, lo mbandela). Ukungcakaza okungapheliyo ngokwasendleleni kuvame ukuqala ebuntwaneni okanye ebusheni, kunye neemazi ezijonge ukuqala kubudala obudala (i-5, 12), zikhombise iipatheni zokuphazamiseka kokusetyenziswa kweziyobisi. Amanqanaba aphakamileyo okungcakaza kwe-pathological abonwa emadodeni, ngento ye-telescoping eye yaqwalaselwa kwabasetyhini (okt., Abantu basetyhini babandakanyeka okokuqala kwisenzo sokulutha, kodwa bafanekisela ixesha lexesha ukusuka ekubandakanyekeni kokuqala ukuya kulutywala) (13). Into ye-telescoping ibhalwe ngokubanzi kwiimeko ezahlukeneyo zokuphazamiseka kokusetyenziswa kweziyobisi (14).
Njengakwimeko yokusetyenziswa gwenxa kweziyobisi, iingxaki zemali kunye nomtshato zixhaphakile kwiindlela zokuziphatha. Abantu abaphembelela ekuziphatheni, ezinjengezo zinakho iziyobisi, baya kuhlala besenza izinto ezingekho mthethweni, ezinjengobusela, ubusela, kunye nokubhala iitsheki ezimbi, ukuxhasa indlela abaziphethe ngayo okanye ukujongana neziphumo zokuziphatha (i-15).
isimo
Abantu abaphembelela ekuziphatheni kwaye abo banengxaki yokusebenzisa iziyobisi bobabini banamanqaku aphezulu kumanqaku enkqubo yokuzifaka kunye nokufuna imvakalelo kwaye ngokubanzi baphantsi kumanyathelo okuphepha ukonzakala (16-20). Nangona kunjalo, abantu abathile abanokuziphatha okuthile, njengokulutha kwi-intanethi okanye ukugembula kwe-pathological, banokuxela amanqanaba aphezulu okuphepha ekulimaleni (21) (jonga ne-Weinstein kunye neLejoyeux, ngalo mbandela). Olunye uphando licebisile ukuba iinkalo zengqondo, ukungqubana phakathi kwabantu, kunye nokuzilawula kungadlala indima kwi-intanethi (jonga u-Weinstein noLejoyeux, lo mbandela). Ngokwahlukileyo, abantu abanesiphazamiso sokunyanzeliswa okubonakalayo ngokubanzi banamanqaku aphezulu kumanyathelo okuphepha ukulimala kwaye baphantsi kwi-impulsivity (17, 21). Abantu abaziphetheyo baziphethe njengamazinga okunyanzelwa, kodwa ezo zinto zinokukhawulelwa kulawulo olungalunganga kwimisebenzi yengqondo kunye nexhala malunga nokulahleka kolawulo kwiindlela zokuziphatha (i-22). Uthintelo olungalunganga lweempendulo zemoto (ukuqhuba) lufunyenwe kubantu abanesiphazamiso sokunyanzeliswa okungafunekiyo kunye nokuchola ulusu (ulwalamano lokuziphatha kunye nonxibelelwano olungemnandanga lokusondela kwimeko yengozi) ukuphazamiseka kokunyanzelwa (i-23, 24).
ISICATSHULWA 1. Ixesha lonke lokuqikelelwa kokusetyenziswa kweziyobisi kukuphazamiseka kwendlela yokuziphatha.
Ukungcakaza okungapheliyo kwe-35% -63%
Kleptomania 23% -50%
Ukuthathwa kwesikhumba kwePathologic 38%
Ukuziphatha ngokwesondo okunyanzelekileyo i-64%
Iziyobisi kwi-Intanethi 38%
Ukuthenga okunganyanzelekanga kwe-21% -46% Umthombo: (102).
Ukunyibilika
Nangona uninzi kwizifundo ezimele ilizwe lonke lungabandakanyi kuvavanyo lokuziphatha okubi, idatha ekhoyo yezifo ezikhoyo zixhasa ubudlelwane phakathi kokungcakaza kwe-pathological kunye nokuphazamiseka kokusetyenziswa kweziyobisi, ngamaxabiso aphezulu okwenzeka ngokubambisana kwicala ngalinye (25, 26). Isifundo se-St. Louis Epidemiologic Catchment Area (ECA) safumanisa amazinga aphezulu okuhlangana kweziphazamiso zokusetyenziswa kweziyobisi (kubandakanya ukuxhomekeka kwe-nicotine) kunye ne-pathological ukugembula, kunye nemilinganiselo ephezulu yokuphawulwa okubonwa ngokubanzi phakathi kokungcakaza, ukuphazamiseka kotywala, kunye nokuphazamiseka kobuntu. 25). Uhlolisiso lwesifo seCanada esivelele ukuba umngcipheko wokuphazamiseka kwesifo sokusebenzisa utywala unyuke nge-3.8-fold xa ukungcakaza okungalunganga kwakukhona (27). Phakathi kwabantu abaxhomekeke kwiziyobisi, umngcipheko wokumodareyitha ukuya kwinqanaba eliphakamileyo lokungcakaza kwakuluxesha le-2.9 ngaphezulu (28). I-Odds ratios ukusuka kwi-3.3 ukuya kwi-23.1 iye yaxelwa phakathi kokungcakaza kwe-pathological kunye nokuphazamiseka kokusetyenziswa kotywala kwizifundo ezisekelwe kubemi base-US (25, 29). Ukulutha kwe-Intanethi kwakudityaniswa nokusetyenziswa kotywala obunobungozi (umlinganiso we-1.84) kwisifundo sabafundi bekholeji i-2,453, emva kokulawula isini, ubudala kunye nokudakumba (30).
Iisampulu zeklinikhi zezinye izinto ezikhobokisayo zibonisa ukuba ukubakho ngokudibeneyo kokuphazamiseka kokusetyenziswa kweziyobisi kuyinto eqhelekileyo (iTheyibhile 1). Ezi ziphumo zibonisa ukuba ukubhekisa ngokuziphatha kunokukwabelana nge-pathophysiology eqhelekileyo kunye nokuphazamiseka kokusebenzisa iziyobisi.
Nangona kunjalo, idatha malunga nokusetyenziswa kwesiyobisi i-comorbidity kufuneka itolikwe ngononophelo kuba nayiphi na imibutho enokubangela ibangele inqanaba lokuziphatha (umzekelo, ukusetyenziswa kotywala kunento yokwenza neendlela zokuziphatha ezingalunganga, kubandakanya nezo zichongiweyo njengezikhobokisayo) okanye kwinqanaba lolungelelwaniso (umzekelo, Imikhwa yokuziphatha okubi iqala emva konyango olunxilisayo, njengokuthatha indawo yokusela). Ingxaki yokungcungcuthekiswa kukusetyenziswa rhoqo kotywala kunobuzaza bokungcakaza kunye neengxaki zengqondo eziphuma ekungcakazeni kunalezo zingabinayo imbali yokusetyenziswa kotywala (31), kunye nolutsha oluzisela isiselo esinxilisayo esikhulu basengozini yokungcakaza rhoqo kunabo bengekho (i-32), Ukucebisa intsebenziswano yokuziphatha phakathi kotywala nongcakazo. Ngokwahlukileyo koko, ukufumanisa okufanayo ngokubhekisele ekusebenziseni i-nicotine kucebisa ukusebenzisana, njengoko nenyaniso yokuba abantu abadala abanokungcakaza kwethambo abo bangoku okanye ababhemayo bangaphambi kwexesha babenomnqweno onamandla wokungcakaza (i-33). Abaneengxaki zokungcakaza abasebenzisa icuba mihla le kunokwenzeka ukuba babe neengxaki zokusebenzisa utywala neziyobisi (34).
Olunye uphazamiseko lwengqondo, njengokuphazamiseka kwengcinezelo, ukuphazamiseka kwengqondo, ukuphazamiseka kwengqondo, kunye nengxaki yokuchaphazeleka kwengqondo, zihlala zixelwa ngokudibeneyo nokuziphatha (i-35, 36) (jonga iWeinstein noLejoyeux, lo mbandela). Nangona kunjalo, uninzi lwezi zifundo ze-comorbidity lwalusekwe kwiisampulu zeklinikhi. Ubungakanani bezi zinto zifunyanwayo ngokubanzi kwiisampulu zoluntu zihlala zimisiwe.
Ukunxibelelana
Ukuziphatha okubi kunye nokuphazamiseka kokusebenzisa iziyobisi kunokuba neempawu eziqhelekileyo zokuqonda. Zombini iindlela zokungcakaza kunye nabantu abanengxaki yokusebenzisa iziyobisi ngokufuthi zincitshisa imbuyekezo ngokukhawuleza (i-37) kwaye zenze ngokungathandekiyo kwimisebenzi yokwenza izigqibo (i-38) enjenge-Iowa Gossip Task, iparigigm evavanya ukwenziwa kwezigqibo ngomngcipheko wokuthatha izigqibo (39). Ngokuchasene noko, uphando lwabantu abanomlutha we-intanethi abukhombisi nakuphi na ukusilela ekwenzeni izigqibo kwi-Iowa Gask Task (40). Isifundo esisebenzisa ibhetri ebanzi ye-neurocognitive kwi-49 i-pathological gambler, i-48 engafunekiyo kwizifundo ezixhomekeke kwiziselo ezinxilisayo, kunye nokulawulwa kwe-49 kufumanise ukuba ukungcakaza kunye notywala bobabini kubonise ukunciphisa ukusebenza kwimvavanyo yokuzinqanda, ukuguquguquka kwengqondo, kunye nemisebenzi yokucwangcisa, kodwa kwakungekho mahluko kuvavanyo ukusebenza kolawulo (41).
Iinkqubo eziqhelekileyo ze-Neurobiological
Umzimba okhulayo woncwadi ubeka iinkqubo ezininzi ze-neurotransmitter (umzekelo, i-serotonergic, idopaminergic, i-noradrenergic, i-opioidergic) kwi-pathophysiology yokuziphatha kweziyobisi kunye nokuphazamiseka kokusebenzisa iziyobisi (42). Ngokukodwa, i-serotonin (5-HT), ebandakanyeka kuthintelo lokuziphatha, kunye ne-dopamine, ebandakanyeka nokufunda, inkuthazo, kunye nokuqina kwesimo, kubandakanya nemivuzo, inokuba negalelo elikhulu kuzo zombini iiseti zokuphazamiseka (42, 43).
Ubungqina bokubandakanyeka kwe-serotonergic kwizikhuzo zokuziphatha kunye nokuphazamiseka kokusetyenziswa kweziyobisi kuza ngokwenxalenye evela kwizifundo zomsebenzi we-platelet monoamine oxidase B (MAO-B), ehambelana nenqanaba le-cerebrospinal fluid (CSF) ye-5-hydroxyindole acetic acid (5-HIAA, metabolite ye-5-HT) kwaye ithathwa njengophawu lomsebenzi we-5-HT. Amanqanaba asezantsi e-CSF 5-HIAA alungisa amanqanaba aphezulu okunyanzeliswa kunye nokukhangela kwimvakalelo kwaye afunyenwe ekungcakazeni kwe-pathological kunye nokuphazamiseka kokusebenzisa iziyobisi (44). Izifundo ze-Pharmacologic mngeni ezivavanya ukuphendula kwehomoni emva kokuphathwa kwamachiza e-serotonergic zikwabonelela ubungqina bokungasebenzi kakuhle kwe-serotonergic kuzo zombini iziyobisi ezinokuziphatha kunye nokuphazamiseka kokusebenzisa iziyobisi (45).
Ukuphindaphinda ukusetyenziswa kwezinto okanye ukubandakanyeka kwisimo sokuziphatha ngokulandela isibongozo kunokubonakalisa inkqubo yobumbano. Izifundo zangaphambili kunye nezonyango zibonisa ukuba indlela esekelezelwe kwimeko yokuphazamiseka kwengcinezelo inokubandakanya ukulungiswa kokungeniswa kwembuyekezo yendawo ye-ventral tegmental ndawo / i-nucleus accumbens / orbital frontal cortex yesekethe (46, 47). Indawo ye-ventral tegmental iqulethe ii-neurons ezikhupha i-dopamine kwi-nucleus accumbens kunye ne-orbital frontal cortex. Utshintsho kwindlela ye-dopaminergic iye yacetyiswa njengokuqhubeka komvuzo (ukugembula, iziyobisi) okubangela ukukhutshwa kwe-dopamine kwaye kuvelise imvakalelo yolonwabo (48).
Ubungqina obunqamlekileyo obuvela kwizifundo ze-neuroimaging exhasa i-neurocircuitry ekwabelwana ngayo malunga nokuziphatha kunye nokuphazamiseka kokusetyenziswa kweziyobisi (7). Umsebenzi otyholwayo we-cralex yangaphambili ye -ralral preialal cortex (vmPFC) idibene nokwenza izigqibo okungxamisekileyo kwiimvavanyo zomvuzo womngcipheko kunye nokuphendula okucothayo kwimidlalo yokungcakaza kubagembuli be-pathological (49). Ngokufanayo, ukusebenza kwe-vmPFC engaqhelekanga kufunyenwe kubantu abanengxaki yokusebenzisa iziyobisi (50). Ukwenza umdlalo ohambelana nobuchopho obunxulumene nomdlalo kwi-Intanethi iziyobisi kwimidlalo ye-Intanethi kwenzeka kwimimandla efanayo yobuchopho (i-orbitofrontal, i-dorsolateral prefrontal, i-anterior cingulate, i-nucleus accumbens) njengesiyobisi se-cue-inxulumene nokusebenza kwengqondo ekusebenzeni iziyobisi iziyobisi (i-51) (jonga nakwi-Weinstein kunye neLejoyeux, oku khupha).
Uphando lobungqina beBongo lubonisa ukuba indlela ye-dopaminergic mesolimbic ukusuka kwindawo yokwahlulahlula ukuya kwindawo ye-nucleus accumbens inokuba nenxaxheba kuzo zombini iingxaki zokusetyenziswa kweziyobisi kunye nongcakazo lwe-pathological. Izifundo ezinokungcakaza kwe-pathological zibonakalise ukungaphantsi kwe-ventral ye-striatal neuronal ye-fMRI ngelixa iqhuba ukungcakaza okungafaniyo nezifundo zolawulo (52), ngokufanayo nokuqwalaselwa kwizifundo ezixhomekeke kwiziselo ezinxilisayo xa kusenziwa imbuyekezo yemali (53). Ukuncitshiswa kokusebenza kwestriatal kwangaphakathi kuye kwachaphazeleka kwiminqweno ehambelana neziyobisi kunye nokuziphatha okuluthayo (42). Ukuthatha inxaxheba emsebenzini wokungcakaza kubonakala ngathi kukhupha ukukhutshwa kwe-dopamine enkulu kwi-ventral striatum kubantu abanesifo sika-Parkinson (PD) kunye nongcakazo lwe-pathological kunabantu abane-PD bodwa (54), impendulo efana naleyo yenziwa ngamachiza okanye iziyobisi ezinxulumene neziyobisi kwikhoboka leziyobisi. Izimvo eziyi-55.
Ukubandakanyeka kwe-Dopamine kwizikrelemnokuziphatha kukwaphakanyiswa nezifundo zezigulana ezinamayeza e-PD (56, 57). Izifundo ezibini zezigulana ezine-PD zifumanise ukuba ngaphezulu kwe-6% yahlangabezana nokuziphatha okutsha kokuziphatha okanye ulawulo lwezinto ezingafunekiyo (umzekelo, ukugembula nge-pathological, umlutha wesini), ngamanani aphezulu phakathi kwabo bathatha amayeza e-dopamine agonist (58, 59). Ukufana kwe-levo-dopa yeyona ndlela iphakamileyo inxulunyaniswa nomngcipheko omkhulu wokuba nesifo sokuziphatha (i-59). Ngokuchasene noko kunokulindeleka ukubandakanyeka kwe-dopamine, abachasi kwi-dopamine D2 / D3 receptors baphucula inkuthazo enxulumene nokungcakaza kunye nokuziphatha kubantu abangenanto ye-PD ngokungcakaza kwe-pathological (60) kwaye abanakho ukusebenza kakuhle kunyango lokungcakaza kwe-pathological (61, 62) . Uphando olongezelelekileyo lufanelekile ukucacisa indima eyiyo ye-dopamine kuhambo lokungcakaza lwendalo kunye nezinye iindlela zokuziphatha.
Imbali yosapho kunye ne-genetics
Bambalwa kakhulu imbali yosapho / izifundo zofuzo zohlobo lokuziphatha eziyilwe ngamaqela olawulo afanelekileyo (7). Izifundo ezincinci zosapho ze-probands ezinomngcipheko we-pathological (63), kleptomania (64), okanye ukuthenga okunyanzelekileyo (i-65) nganye ifumene ukuba izihlobo zokuqala zeprotheyini zinamazinga aphezulu obomi kotywala kunye nokunye ukuphazamiseka ukusebenzisa iziyobisi, kunye noxinzelelo kunye Olunye uphazamiseko lwengqondo, kunokulawula izifundo. Ezi zifundo zentsapho ezilawulwayo zixhasa umbono wokuba iziyobisi ekuziphatheni zinokuba nobudlelwane bemfuza kuphazamiso lokusebenzisa iziyobisi.
Igalelo lohlobo lokuchasana nemeko yokusingqongileyo kwindlela ethile yokuziphatha kunye nokuphazamiseka kunokuqikelelwa ngokuthelekisa ikhonkrithi yabo ngokuchanekileyo (i-monozygotic) kunye namabini ama-dizygotic). Kuphononongo lwamawele angamadoda asebenzisa iVietnam ye-Era Twin Registry, i-12% ukuya kwi-20% yokwahluka kwemfuza emngciphekweni wokungcakaza kwe-pathological kunye ne-3% ukuya kwi-8% yantlukwano yokungalingani emngciphekweni kwaba semngciphekweni wokuba semngciphekweni wotywala. ukusetyenziswa kwengxaki yokuphazamiseka (66). Isibini kwisithathu (64%) sengozi eyenzeka phakathi kokungcakaza kwe-pathological kunye nokusetyenziswa kotywala kunxulunyaniswe nobume obuphembelela ukuphazamiseka, ukucebisa ukuxhaphaka kokungaphaya kwemfuza kwezi meko zombini. Ezi zinto zifunyanisiweyo ziyafana nezo ziphakamisa igalelo lemfuzo oluqhelekileyo kuluhlu lweengxaki zokusebenzisa iziyobisi (67).
Zimbalwa kakhulu izifundo zenzululwazi yemfuza malunga nokuziphatha. I-D2A1 i-allele ye-D2 dopamine receptor gene (i-DRD2) inyusa isantya esivela kubantu abanengxaki yokungcakaza ukuya ekungcakazeni kwe-pathological kunye nonyango olusebenzayo lokungcakaza kunye nokusetyenziswa kweziyobisi (68). Iqela le-DRD2 gene single nucleotide polymorphisms (SNPs) zidibene nemilinganiselo yobuntu yokunyanzeliswa kunye nokuvavanywa kwamanyathelo okuziphatha kokuzinikela okunempilo (i-69), kodwa oku akuvavanywanga kubantu abanokuziphatha okubi. Abasebenzisi be-intanethi abagqithisileyo babenamaqondo aphezulu e-alle (i-SS) ye-serotonin transporter gene (5HTTLPR) kunolawulo olusempilweni, kwaye oku bekudityaniswa nokuthintelwa kokulimala kakhulu (70) (jonga kwakhona iWeinstein noLejoyeux, lo mbandela).
Ukuphendula kunyango
Ukuziphatha okubi kunye nokuphazamiseka kokusetyenziswa kweziyobisi kuhlala kuphendula ngokuchanekileyo kunyango olufanayo, kokubini ngokwengqondo nangokwezonyango. I-12-inyathelo lokuzinceda ngokwayo, ukunyusa amandla okunyusa, kunye neendlela zonyango zokuziphatha eziqhele ukusetyenziswa ukunyanga ingxaki yokusebenzisa iziyobisi zisetyenziswe ngempumelelo ekunyangeni ukugembula komzimba, ukunyanzeliswa kwezesondo, kleptomania, ukuthathwa kwesikhumba, kunye nokuthenga okunyanzelekileyo (71-74) . Ungenelelo lweengqondo kunye nokuziphatha kweziyobisi zombini kunye nokuphazamiseka kokusetyenziswa kweziyobisi bahlala bexhomekeke ekunciphiseni kwakhona ukuthintela ukukhusela ngokuchonga iipateni zokuxhatshazwa, ukunqanda okanye ukujongana neemeko ezinobungozi obukhulu, kunye nokwenza utshintsho lwendlela eqinisa indlela yokuziphatha efanelekileyo. Ngokwahlukileyo, unyango oluyimpumelelo lwe-psychosocial for diagnostivecompulsive disorder gxininisa ubuchule bokuchaza kunye neendlela zokuthintela impendulo (i-2).
Akukho mayeza avunyiweyo okwangoku ukuba anyangwe ngokuziphatha, kodwa amanye amayeza abonise isithembiso ekunyangeni ukuphazamiseka kokusetyenziswa kweziyobisi ikwabonisa isithembiso ekunyangeni ukuba likhoboka lokuziphatha (i-75). I-Naltrexone, i-mu-opioid receptor antagonist evunywe yi-US Food and Drug Administration kunyango lotywala kunye nokuxhomekeka kwe-opioid, ibonakalise ukusebenza ngokulingeneyo kwizilingo zeklinikhi ezilawulwayo kunyango lokungcakaza kwe-pathological kunye ne-kleptomania (76-79), kwaye isithembiso ngokungalawulwa izifundo zokuthenga okunyanzelekileyo (i-80), indlela yokuziphatha yezesondo ezinyanzelekileyo (i-81), umlutha we-intanethi (82), kunye nokukhetha ulusu lwesifo sephepha (83). Ezi ziphumo zibonisa ukuba ii-receptors ze-mu-opioid zidlala indima efanayo kwizimo zokuziphatha njengoko zisenza kwinto yokusetyenziswa kweziyobisi, ngokunokwenzeka ekuguqukeni kwendlela ye-dopaminergic mesolimbic. Ngokuchasene noko, i-mu-opioid receptor antagonist eyi-elacone eyi-elfoneid ikhulisa iimpawu ezibonakalayo kwisifo sokungakhathali (i-84).
Amayeza atshintsha utshintsho lwe-glutamatergic ikwasetyenziselwa ukunyanga ukubakho kweziyobisi kunye nokuxhomekeka kwento. I-Topiramate, i-anticonvulsant evimba i-AMPA subtype ye-glutamate receptor (phakathi kwezinye izinto), isibonisile isithembiso kwizifundo ezivulekileyo zelebhu yokungcakaza, ukunyanzela ukuthenga, nokunyanzela ulusu (85), kunye nokusebenza ngempumelelo ekunciphiseni utywala (86 ), icuba (87), kunye necocaine (88). I-N-acetyl cysteine, i-amino acid ebuyisela uxinzelelo lwe-glutamate ye-extracellular kwi-nucleus accumbens, inciphise iminqweno yokungcakaza kunye nokuziphatha kwisifundo esinye sabaphembuli be-pathological (89), kunye nokunciphisa i-cocaine craving (90) kunye nokusetyenziswa kwe-cocaine. Olu phononongo lubonisa ukuba ukumodareyitha kweglacamergic ithoni ye-dopaminergic kwi-nucleus accumbens kunokuba yindlela eqhelekileyo kwizimo zokuziphatha kunye nokuphazamiseka kokusebenzisa iziyobisi (91).
Imicimbi yokuqonda
Inye kuphela indlela yokuziphatha, ukungcakaza okungapheliyo, kukuchongwa okwaziwayo kwiDSM-IV nakwi-ICD-10. Iikhrayitheriya zayo zokuchonga ziyafana ngokufana nokusetyenziswa gwenxa kweziyobisi / ukuxhomekeka, okt, ukuzibandakanya nokuziphatha, ukunciphisa ukubanakho ukulawula indlela yokuziphatha, ukunyamezelana, ukurhoxa, kunye neziphumo ezibi zengqondo. I-DSM-V Task Force iphakamise ukugembula kwe-pathological ukungcola kulwahlulo lwangoku njengokuphazamiseka kolawulo kuhlobo olutsha olubizwa ngokuba yi "Addiction and Related Disorders," ezingabandakanya ukuphazamiseka kokusetyenziswa kweziyobisi kunye "neziyobisi ezingalawulekiyo" (www.dsm5. org, ifikelele ngoFebruwari 10, 2010). Olona tshintsho lucetywayo kwiindlela zokuchonga kukushiya imeko malunga nokugwetywa kwezenzo ezingekho mthethweni zokuxhasa ukungcakaza ngemali, eyafunyanwa inezinga eliphantsi lokuchaphazeleka.
Ezinye iindlela zokuziphatha zicebise ngovavanyo lokuqonda, kubandakanya ukuthenga okunyanzelekileyo (i-93), umlutha we-Intanethi (i-94), ividiyo / umlutha womdlalo wecompyuter (95), iziyobisi ngokwesondo (i-96), kunye nokuxhuzula kakhulu (jonga uKouroush et al., Ngalo mbandela) . Ezi zihlala zihlala kusekwe kumgaqo okhoyo we-DSM-IV wokusetyenziswa gwenxa kweziyobisi okanye ukuxhomekeka, umzekelo, ixesha elininzi elichithwa ekuziphatheni, ukuphinda-phinda imizamo engaphumeleliyo yokusika okanye ukuyekisa isimilo, ukunciphisa ulawulo malunga nokuziphatha, ukunyamezelana, ukurhoxa, kunye nokuphambana kwengqondo iziphumo. Iqela lokuphazamiseka kwi-DSM-V ye-Dis-Disstance-Associated Disfall group lijonga inani lezi ziyobisi ezingekho phantsi kweziyobisi ukuze zibandakanywe kwi-DSM-V, ikhankanya ngokuthe gabalala iziyobisi kwi-Intanethi (www.dsm5.org; ezifikelelweyo ngoFeb. 10, 2010). Nangona kunjalo, kuninzi lokuphazamiseka, akukho lwazi luncinci okanye akukho datha eqinisekisiweyo kwezi ndlela zokuqonda; Okwangoku ziluncedo njengezixhobo zokuphanda ukuqikelela ubukho bengxaki.
Umbuzo omnye wokuqonda ophakanyiswe kuncwadi apho ukuziphatha kokuziphatha (kunye neziyobisi) kuwela kwisilinganiselo sokunyanzeliswa (i-97), okt, ngaba kufana nokungahambi kakuhle kolawulo okanye ukuphazamiseka okunyanzelekileyo? Abanye baphikise ukuba le ndlela yobumbano yobumbano iyinto elula kakhulu, kwaye ukunyanzeliswa nokunyanzelwa kumelele imilinganiselo ye-orthogonal, kunokuba izibonda ezichaseneyo zobukhulu obunye (98). Ngokuhambelana nengxoxo yokugqibela ziziphumo ezinje ngokuhlukahluka okukhulu kwinqanaba lokunyanzeliswa kwabantu abanokuziphatha okuchaseneyo, ukwahluka okunokuthi kunxulunyaniswe nokuphendula kunyango lwe-pharmacological (48, 99).
Kwi-DSM-IV, iziyobisi (iziyobisi ukusetyenziswa kweziyobisi) luluhlu oluzimeleyo, ngelixa ukugembula komzimba kuthathwa njengokuphazamisayo kolawulo, okufana, umzekelo, i-pyromania kunye ne-kleptomania. I-ICD-10 ichaza ukungcakaza okwenzekileyo njengesiqhelo "nokuziphatha okunyanzelekileyo", kodwa iyaqonda ukuba "indlela yokuziphatha ayinyanzelekanga kwimeko yezobuchwephesha," nangona ngamanye amaxesha ibizwa ngokuba "kukungcakaza okunyanzelekileyo."
Umcimbi onxulumene noko ngumbutho, okanye ukudityaniswa, ukuba kukho nayiphi na, phakathi kweziyobisi ezahlukeneyo zokuziphatha. Uhlalutyo lwamaqela kunye nokuhlukahluka kweklinikhi kwizigulana ezingama-210 ezinesifo esisisinyanzelo esinyanzelekileyo sachaza amaqela amabini ahlukeneyo ezigulana ezinokuziphatha (100): izigulana ezinengxaki yokungcakaza kwezesondo okanye iziyobisi ngokwesini ("hypersexuality") zazineminyaka yokuqala kwaye zazinokwenzeka eyindoda, xa kuthelekiswa nezigulana ezinokuthenga okunyanzelekileyo. Uphando oluqhubekayo luyafuneka ukuqinisekisa nokwandisa oku kufunyanisiweyo. Enye indlela yophando enokuthi ibenegalelo elibonakalayo ebaleni iya kuba kuvavanyo olubanzi lweqela elikhulu, elinobungqingqwa, elibonakala kakuhle labantu abaneendlela ezahlukeneyo zokuziphatha kunye neziyobisi ngokubhekisele kwizinto ezinganyanzelekanga zokunyanzeliswa kunye nokunyanzelwa kokubini kwengqondo (kwengqondo) kunye nokuziphatha ( iimoto), umzekelo, ubuntununtunu bokulibaziseka komvuzo (ukuphungulwa komvuzo okwexeshana), ukuthatha izigqibo zomngcipheko, ukuqina kwengqondo, ukuphendula kwangaphambili, ukuphendula ngokuzingisileyo, ukuthintela impendulo kunye nokuguqula ukufunda.
ISISHWANKATHELO NEMIGQUBO
Ubungqina obukhulayo bubonisa ukuba iindlela zokuziphatha ezinjengeziyobisi zifana neziyobisi kwimimandla emininzi, kubandakanya nembali yendalo (engapheliyo, ekhokelela ekubuyeleni kwimeko eneziganeko eziphezulu kunye nokuxhaphaka kulutsha nakubantu abadala abancinci), i-phenomenology (ukuthanda ukuzimela, ukunxila ["phezulu"], kunye nokurhoxa), ukunyamezelana , comorbidity, overlapping gene, igalelo le-neurobiological (kunye nendima yengqondo ye-glutamatergic, opioidergic, serotonergic, kunye ne-dopamine mesolimbic systems), kunye nempendulo kunyango. Nangona kunjalo, idatha esele ibanzi kakhulu yokungcakaza kwe-pathological (jonga iWareham kunye nePotenza, lo mbandela), inedatha encinci yokuthenga okunyanzelekileyo (jonga iLejoyeaux kunye ne-Weinstein, lo mbandela), umlutha we-intanethi (jonga uWeinstein noLejoyeaux, lo mbandela), kwaye ividiyo / umlutha womdlalo wekhompyuter (jonga uWeinstein, lo mbandela), kwaye phantse akukho datha yezinye iindlela zokuziphatha ezinje ngeziyobisi zesondo (jonga uGarcia noThobaut, lo mbandela), uthando lweziyobisi (jonga uReynaud, lo mbandela), ukukhetha ulusu lwezifo (jonga Odlaug kunye noGrant, lo mbandela), okanye ukushuka okugqithileyo (jonga uKouroush et al., Lo mbandela).
Kukho ubungqina obaneleyo bokugunyazisa ukungcakaza kwendalo njengento engeyiyo eyakho into okanye eyokuziphatha; I-DSM-V Task Force iye yacebisa ukususa ukubekwa kwayo kwiDSM-V ukusuka kuphazamiso lolawulo lwesiphazamiso ukuya kubugwenxa kunye nokuphazamiseka okunxulumene noko (udidi olutsha olubandakanya zombini iziyobisi ezichasene nezinto ezingezozamachiza). Kwimeko yangoku yolwazi, ngakumbi ukungabikho kweendlela zokuvavanya okuqinisekisiweyo kunye nezifundo ezinokubakho, izifundo ezinde, kusengaphambi kokuba zithathele ingqalelo ezinye iindlela zokuziphatha njengokuphazamiseka okuzimeleyo okugcweleyo, ubukhulu becala zibahlukanise bonke ngokufana neziyobisi, endaweni yokuba njengokuphazamiseka kolawulo. Uphando lwexesha elizayo olubalulekileyo, kubandakanywa nezifundo zabantu kunye nezilwanyana (i-101), luyafuneka ukuzisa ulwazi lwethu malunga nokuziphatha kwinqanaba lezinto zokusetyenziswa kweziyobisi, ngakumbi kwimimandla ye-genetics, neurobiology (kubandakanya nengqondo yokucinga), kunye nonyango.
AMAKHODI
Ixhaswe yiNkqubo yoPhando lwe-Intramural, amaZiko eSizwe e-Health, iZiko leSizwe kuZokusetyenziswa gwenxa kweziyobisi (i-DAG); I-NIH (NIDA) izibonelelo i-R01 DA019139 (MNP) kunye ne-RC1 DA028279 (JEG); kunye namaZiko eMinnesota kunye neYale aGqwesileyo kuPhando loNgcakazo, axhaswe liZiko leSizwe loThengiso oluThembekileyo kunye neZiko lakhe loPhando kwiNgcakazo yokuNgcakaza. UGqirha Weinstein uxhaswa yi-Israel National Institute for Psychobiology. Iziqulatho zombhalo wesandla ziluxanduva lwababhali kuphela kwaye akufuneki zimele izimvo ezisemthethweni zeZiko leSizwe leNtlalontle eliDala okanye iZiko loPhando kwiNgcakazo yokuNgcakaza okanye nayiphi na enye arhente yokuxhasa ngemali.
Isibhengezo somdla
Bonke ababhali baxele ukuba akukho kungqubana komdla malunga nokuqulathwe leli nqaku. Ugqirha Grant ufumene izibonelelo zophando kwi-NIMH, NIDA, iZiko leLizwe leMidlalo elinoXanduva kunye neZiko eliDibeneyo loPhando ngeNgcakazo yokuNgcakaza, kunye nezaMithi zamaHlathi. UGqr Grant ufumana imbuyekezo yonyaka evela kuSpringer Shicilela ngokusebenza njengoMhleli-kwiNtloko yeJenali yeziFundo zoNgcakazo, wenza uhlolo lwesibonelelo se-NIH kunye noMbutho woNgcakazo i-Ontario, ufumene ubukhosi kwiOxford University Press, kwiAmerican Psychiatric Publishing, Inc. , I-Norton Press, kunye neMcGraw Hill, ifumene i-honaria kwi-Indiana University Medical School, kwiYunivesithi yaseSouth Florida, iMayo Medical School, kwiCalifornia Society of Addiction Medicine, i-State of Arizona, ilizwe laseMassachusetts, ilizwe lase-Oregon, Iphondo laseNova Scotia, kunye nePhondo laseAlberta. UGqr Grant ufumene imbuyekezo njengomcebisi weeofisi zomthetho kwimiba enxulumene nokuphazamiseka kolawulo. UGqr Potenza ufumene inkxaso yemali okanye imbuyekezo koku kulandelayo: umcebisi kunye nomcebisi ku-Boehringer Ingelheim; umdla wemali eSomaxon; Inkxaso yophando evela kumaZiko ezeMpilo eSizwe, iSebe leMicimbi yeVeterans, kwiMidlalo yeMidlalo yaseLangeni iMougan, iZiko leLizwe leMidlalo elinoXanduva kunye neZiko eliDibeneyo loPhando kwiNgcakazo yokuNgcakaza, kunye neeLabhoratri zamahlathi; Uthathe inxaxheba kuphando, ukuthunyelwa ngeposi okanye ukubonisana ngefowuni okunxulumene neziyobisi, ukuphazamiseka kolawulo, okanye ezinye izihloko zezempilo; Ubonisane neeofisi zomthetho kwimiba enxulumene nokulutha okanye ukuphazamiseka kolawulo; unike ukhathalelo lweklinikhi kwiCandelo le-Connecticut lezeMpilo yeNgqondo kunye neeNkonzo zeeNkozo zoNgcakazo ngeNgozi; kwaye wavelisa iincwadi okanye izahluko zeencwadi zabapapashi bezicatshulwa zempilo yengqondo. Ugqirha Weinstein ufumene izibonelelo zophando kwi-Israeli anti-Drug Authority, i-Israel National Institute for Psychobiology, iNjingalwazi eyi-Ministry of Health yase-Israel, kunye ne Rashi Trust (Paris, France) kunye nemirhumo yokufunda malunga nokusetyenziswa kweziyobisi. Icandelo loMphathiswa Wezemfundo wase-Israeli. UGqr Gorelick unika ingxelo yokuba akukho nkxaso mali ingaphandle okanye ukungqubana kwemidla
IZALATHISO
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