Amazwana we-YBOP: Umqondo wokulutha kokuziphatha uyimpikiswano kwabanye abelaphi kanye nodokotela bezocansi. Kodwa-ke, kuyacaca kubacwaningi ukuthi ukulutha kokuziphatha kubangela ushintsho ebuchosheni olubonisa ukulutha kwezidakamizwa. Lokhu kufanele kube, njengoba konke umuthi ongakwenza ukukhulisa noma ukuvimbela indlela ejwayelekile yomzimba. Izindlela zokulutha sezivele zikhona ebuchosheni - ukubopha kuyisibonelo esiyinhloko. Ngakho-ke kunengqondo ukuthi izindlela zokuziphatha ezibandakanya ukugqugquzela okungaphezulu kwalezo zinqubo zinamandla okuholela ekuguqukeni kobuchopho obuhlobene nokulutha.
Ingemuva:
Ukuziphatha okuningana, ngaphandle kokungenisa izidakamizwa zengqondo, kukhiqiza umvuzo wesikhashana ongahle uqhubeke nokuziphatha okuqhubekayo, ngaphandle kokwazi ngemiphumela emibi, okungukuthi, ukunciphisa ukulawula ukuziphatha. Lezi zinkinga ziye zacatshangelwa ngokomlando ngezindlela eziningana. Umbono owodwa ubeka lezi ziphazamiso njengalele ngasesibonisweni sokucindezela, lapho ezinye zibhekwa njengezinkinga zokulawula umfutho. Ukunye ukucabanga okuhlukile, kepha hhayi okwehlukile, kubheka ukuphazamiseka njengezidakamizwa ezingeyona into noma "zokuziphatha". Izinhloso: Yazisa ingxoxo ngobuhlobo obuphakathi kwento esebenzayo ngokwengqondo nezidakamizwa zokuziphatha. Izindlela: Sibuyekeza idatha ekhombisa ukufana nomehluko phakathi kokuphazamiseka kokulawula umfutho noma ukulutha kokuziphatha nokulutha kwezidakamizwa. Lesi sihloko sibaluleke kakhulu ekuhlukanisweni okuphelele kwalezi zinkinga kuhlelo lwesihlanu oluzayo lwe-American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSMV). Imiphumela: Ubufakazi obukhulayo bukhombisa ukuthi umlutha wokuziphatha ufana nokuluthwa kwezidakamizwa ezindaweni eziningi, kufaka phakathi umlando wemvelo, i-phenomenology, ukubekezelelana, ukubonga, ukufaka igalelo lofuzo, izindlela ze-neurobiological, kanye nokuphendula ekwelashweni, kusekela i-DSM-V Task Force ephakamise isigaba esisha sokulutha kanye nokuphazamiseka okuhlobene kufaka phakathi ukuphazamiseka kokusetshenziswa kwezidakamizwa kanye nemikhuba yokungezona izidakamizwa. Idatha yamanje iphakamisa ukuthi lesi sigaba esihlanganisiwe singaba esifanele ukugembula kwe-pathological kanye nezinye izinto ezimbalwa ezifundwe kangcono zokuziphatha, isib, umlutha we-Intanethi. Okwamanje akukho idatha eyanele yokucacisa noma ikuphi ukufakwa kwezinye izinhlobo zokuluthwa okuhlongozwayo. Ukuphetha kanye Nokubaluleka Kwesayensi: Ukuhlukaniswa ngokufanele kokuphazamiseka kokuziphatha noma ukuphazamiseka kokulawulwa kokuthatheka kunethonya elikhulu ekwakhiweni kwamasu wokuvikela nokwelashwa athuthukisiwe.
Ukuxhumana nekheli kuDkt David A. Gorelick, 251 Bayview Boulevard, Baltimore, MD 21224, USA. I-imeyili: [i-imeyili ivikelwe] Amagama agqamile umlutha wokuziphatha, ukuhlukaniswa kwezifo, ukuxilongwa, ukuphazamiseka kokulawula okungenamsoco, ukuphazamiseka kokusebenzisa izidakamizwa
ISINGENISO
Ukuziphatha okuningana, ngaphandle kokufakwa kokuphanjiswa kwengqondo, kuveza umvuzo wesikhashana ongahle uqhubeke nokuziphatha ngaphandle kokwazi ngemiphumela emibi, okungukuthi, ukunciphisa ukulawula kokuziphatha. Ukulawulwa okwehlisiwe kungumqondo ocacile wokuncika kokuluthwa yizidakamizwa ngengqondo noma ukulutha. Lokhu kufana kuholele kumqondo wezidakamizwa ezingeyona into noma zokuziphatha ", okungukuthi, ama-syndromes afanayo nokulutha kwezidakamizwa, kepha ngokugxila kokuziphatha ngaphandle kokungeniswa kwento esebenzayo. Umqondo wokulutha kokuziphatha unenani elithile lesayensi nelomtholampilo, kepha uhlala uphikisana. Izingqinamba eziphathelene nokulutha kokuziphatha okwamanje ziyaxoxwa kumongo wokuthuthukiswa kweNcwadi Yokuhlola kanye Nezibalo Zezinkinga Zengqondo I-Fifth Edition (DSM-V) (1, 2)
Imikhuba eminingana yokuziphatha kokuziphatha icatshangelwe njengokufana nokuluthwa kwezidakamizwa. I-Diagnostic and Statistical Manual yamanje, i-Fourth Edition (DSM-IV-TR) iqoke izindlela zokuxilonga ezisemthethweni zalezi zinkinga eziningana (isib. Ukugembula kwe-pathological, i-kleptomania), ihlukanisa njengezinkinga zokulawula umthelela, isigaba esihlukile ekuphazamiseni ukusetshenziswa kwezidakamizwa. Okunye ukuziphatha (noma ukuthikamezeka kokulawula ukuphazamiseka) kubhekwe ukuthi kufakwe ekuthengeni okuzayo okuphoqelelwa yi-DSM, ukuthathwa kwesikhumba se-patologic, umlutha wezocansi (i-hypersexourse engafani neparadesi), ukusoka ngokweqile, umdlalo wekhompyuter / wevidiyo, kanye nokulutha kwe-inthanethi. Yikuphi kokuziphatha okufanele ukukufaka njengokulutha kokuziphatha kusavulekele mpikiswano (i-3). Akusikho konke ukuphazamiseka kokulawula okufakwayo, noma ukuphazamiseka okubonakala ngokuphoqelela, okufanele kubhekwe njengokulutha kokuziphatha. Yize izinkinga eziningi zokulawula umfutho (isib. Ukugembula kwe-pathological, i-kleptomania) zibonakala zabelana ngezici eziyisisekelo nokuluthwa yizidakamizwa, abanye, njengokuphazamiseka kweziqhumane ngezikhathi ezithile. Ngethemba lokuthi uzoba nengxenye kule mpikiswano, le ndatshana ibukeza ubufakazi bokufana phakathi kokuluthwa kokuziphatha kanye nokuphazamiseka kokusetshenziswa kwezidakamizwa, umehluko wabo ekuphazamisekeni okucindezelayo, futhi ikhomba izindawo zocwaningo olungaqiniseki oluzayo. Kusebenza futhi njengesingeniso emaphephandabeni alandelayo kulo magazini, abukeza ezinye izimilo zokulutha ngemininingwane eminingi.
IZIPHUMA ZE-COMMON ZOKWAMKELWA KWEMIVUZO: UBUDLELWANO BOKUTHENGA IZITOLO
Isici esibalulekile sokulutha kokuziphatha ukwehluleka ukwenqaba ukunxenxa, ukushayela, noma isilingo sokwenza isenzo esiyingozi kumuntu noma kwabanye (4). Ukulutha ngakunye kokuziphatha kubonakaliswa yiphethini ejwayelekile yokuziphatha enalesi sici esibalulekile ngaphakathi kwesizinda esithile. Ukuzibandakanya okuphindaphindayo kulezi zimo zokuziphatha kugxambukela ekusebenzeni kwezinye izizinda. Kulokhu, umlutha wokuziphatha ufana nokuphazamiseka kokusebenzisa izidakamizwa. Abantu abanokuluthwa izidakamizwa babika ubunzima ekumelaneni nesifiso sokuphuza noma sokusebenzisa izidakamizwa.
Ukulutha kwezidakamizwa nokuziphatha kunokufana okuningi emlandweni wemvelo, ku-phenomenology, kanye nemiphumela emibi. Bobabili baqale ebusheni nasebusheni obudala futhi baba namazinga aphezulu kula maqembu eminyaka yobudala kunaphakathi kwabantu abadala asebekhulile (5). Kokubili kunemilando yemvelo engakhombisa amaphethini angapheli, abuyela emuva, kepha abantu abaningi bayalulama bebodwa ngaphandle kokwelashwa okusemthethweni (okubizwa ngokuthi "ukuyeka okuzenzekelayo") (6).
Ukulutha kokuziphatha kuvame ukwandulelwa yimizwa "yokuphazamiseka noma ukuvuka ngaphambi kokwenza isenzo" kanye "nokuzijabulisa, ukwaneliseka, noma ukukhululeka ngesikhathi sokwenza leso senzo" (4). Isimo se-ego-syntonic salezi zindlela zokuziphatha sifana ngokuhlangenwe nakho kokuziphatha kokuziphatha kwezidakamizwa. Lokhu kuqhathaniswa nesimo se-ego-dystonic sokuphazamiseka okuphoqelela ngokweqile.Nokho, kokubili ukulutha kokuziphatha nezidakamizwa kungahle kube ngaphansi kwe-ego-syntonic futhi kube ne-ego-dystonic ngokuhamba kwesikhathi, njengoba isimilo (kufaka phakathi ukuthatha izinto) uqobo kuba mnandi kakhulu futhi umkhuba noma ukuphoqelelwa (2, 7), noma kukhuthazeka kancane ngokuqiniswa okuhle nokuningi ngokuqiniswa okungalungile (isb. ukukhululeka kwe-dysphoria noma ukuhoxa).
Ukulutha nokuziphatha kwezidakamizwa kunokufana okufanayo. Abantu abaningi abanokulutha kokuziphatha babika isifiso noma isimo sokulangazelela ngaphambi kokuqala isenzo, njengabantu abanezinkinga zokusebenzisa izidakamizwa ngaphambi kokusetshenziswa kwezidakamizwa. Ngokwengeziwe, lezi zimilo zivame ukwehlisa ukukhathazeka futhi ziholele esimweni esihle semizwa noma "phezulu," okufana nokudakwa kwezidakamizwa. Ukwehliswa ngokomzwelo kungasiza ekufisweni kokuphazamiseka kokuziphatha nokusetshenziswa kwezidakamizwa (8). Abantu abaningi abanokugembula kwe-pathological, i-kleptomania, indlela yokuziphatha ephoqelekile yezocansi, kanye nombiko wokuthenga ophoqelela ukwehla kwale miphumela emihle yemizwa ngokuziphatha okuphindaphindiwe noma isidingo sokwengeza ukuqina kokuziphatha ukufeza umphumela ofanayo wemizwelo, okufana nokubekezelelana (9-11) . Abantu abaningi abanalezi zilutha zokuziphatha nabo babika isimo se-dysphoric ngenkathi bebalekela ekuziphatheni, okufana nokuhoxa. Kodwa-ke, ngokungafani nokuhoxa kwezidakamizwa, ayikho imibiko yokuhoxa ngokomzimba noma ngokweqile kwezokwelapha ekuluthweni kokuziphatha.
Ukugembula kwe-pathological, okufundwe ngokuphelele mayelana nokulutha kokuziphatha, kunikeza ukuqonda okwengeziwe ebudlelwaneni bokuziphatha umlutha nokuphazamiseka kokusebenzisa izidakamizwa (bheka futhi iWareham nePotenza, lolu daba). Ukugembula kwe-pathological kuvame ukuqala ebuntwaneni noma ebusheni, kuthi abesilisa bavame ukuqala besebancane (5, 12), bebonisa iphethini yokuphazamiseka kokusebenzisa izidakamizwa. Amanani aphakeme wokugembula kwe-pathological abonwa emadodeni, ngesimo se-telescoping esibonakala kubantu besifazane (okungukuthi, abesifazane babe nokuzibandakanya kokuqala kokuziphatha komlutha, kepha babonisa isikhathi sesikhathi ukusuka ekubandakanyeni kokuqala kokulutha) (13). Into ye-telescoping ibhalwe kabanzi ebangeni lokungafani lokusebenziseka kwezidakamizwa (14).
Njengasekubandakanyekeni kokusetshenziswa kwezidakamizwa, izinkinga zezezimali nezomshado zivame kakhulu ekululeleni kokuziphatha. Abantu abanezifiso zokuziphatha, njengalabo abanokulutha izidakamizwa, bavame ukwenza izinto ezingekho emthethweni, njengokubamba, ukuzikhukhumeza, nokubhala amasheke amabi, ukuze bakhokhele ukusebenza kwabo kokulutha noma babhekane nemiphumela yokuziphatha (i-15).
Ubuntu
Abantu abanokulutha kokuziphatha nalabo abanokuphazamiseka kokusetshenziswa kwezidakamizwa bobabili baphakeme kwizinyathelo zokuzibika zokufuna ukufakwa kokunye nokufuna ukuzwa futhi ngokuvamile baphansi ngezindlela zokugwema ukulimala (i-16-20). Kodwa-ke, abantu abathile abanokulutha okuthile kokuziphatha, njengokulutha kwe-inthanethi noma ukugembula kwe-pathological, bangase futhi babike amazinga aphezulu wokugwema ukulimala (21) (bona futhi Weinstein noLejoyeux, lo magazini). Olunye ucwaningo luye lwaphakamisa ukuthi izici zokusebenzisa ingqondo, ukuxabana phakathi kwabantu, kanye nokuzibamba kungahle kudlale indima enkulu ekuluthweni kwe-inthanethi (bheka uWeinstein noLejoyeux, lo magazini). Ngokuphikisana nalokho, abantu abanokuphazamiseka okucindezelayo okucashile ngokuvamile babeka phezulu ezenzweni zokugwema ukulimala futhi baphansi ekugxambukeni (17, 21). Abantu abanezifiso zokuziphatha futhi babala kakhulu ngezindlela zokuphoqelelwa, kepha lokhu kungakhawulelwa ekuphathweni okulimazayo kwemisebenzi yengqondo nokukhathazeka ngokulahlekelwa ukulawulwa kokuziphatha kwezimoto (i-22). Kuvinjelwe okungaphenduleki kwezimpendulo zemoto (ukuphoqelela) kutholakale kubantu abanokuphazamiseka okucindezelayo okubucayi kanye nokuthathwa kwesikhumba okuvela emzimbeni (umlutha wokuziphatha onesixhumanisi esiseduze sokuphazamiseka kokuphazamiseka kwengqondo okukhona), kanti ukuguquguquka kwengqondo (kucatshangelwe ukufaka isandla ekucindezelweni) bekukhawulelwe ekubonakaleni ngokweqile ukuphazamiseka kokucindezelwa (23, 24).
ITHEBULA 1. Izilinganiso zokuphila kokuphazamiseka kokusetshenziswa kwezidakamizwa eziluthweni lokuziphatha okubi.
Ukugembula okubangelwa yi-35% -63%
I-Kleptomania 23% -50%
Ukukhetha kwe-Pathologic kwesikhumba i-38%
Ukuziphatha kobulili okuphoqelekile i-64%
Umlutha we-Intanethi 38%
Ukuthenga okuphoqelela i-21% -46% Source: (102).
I-Comorbidity
Yize izifundo eziningi ezimele ezweni lonke zingafakwanga ukuhlolwa kokuluthwa kokuziphatha, idatha ekhona yesifo esiwumshayabhuqe isekela ubudlelwano phakathi kokugembula kwe-pathological kanye nokuphazamiseka kokusetshenziswa kwezidakamizwa, ngamanani aphezulu okuvela kokuhlangana endaweni ngayinye (25, 26). Ucwaningo lwaseSt. Louis Epidemiologic Catchment Area (ECA) luthola amanani aphezulu okuvela kokuphazamiseka kokusetshenziswa kwezidakamizwa (kufaka phakathi ukuthembela kwe-nicotine) kanye nokugembula kwe-pathological, ngezilinganiso eziphakeme kakhulu ezivame ukubonwa phakathi kokugembula, ukuphazamiseka kokusebenzisa utshwala, kanye nobuntu bokuphazamiseka kobuntu ( 25). Ucwaningo lweCanada olubheka izifo eziwumngcele lucabangele ukuthi ubungozi besifo sokusebenzisa kabi utshwala bukhulisa i-3.8-fold lapho ukugembula okukhohlakele bekukhona (27). Kubantu abancike kakhulu kwezidakamizwa, ubungozi bokugembula okulinganiselwe kuya kobukhulu obukhulu bekuphindwe izikhathi ze-2.9 (28). Izilinganiso ze-Odds ezisukela ku-3.3 ziye kwi-23.1 ziye zabikwa phakathi kokuphazamiseka kwemigudu yokugembula kanye nokusetshenziswa kotshwala ezifundweni ezenzelwe abantu base-US (25, 29). Umlutha we-Intanethi ubuhlotshaniswa nokusetshenziswa kabi kwezidakamizwa okulimazayo (isilinganiso se-1.84) ocwaningweni lwabafundi basekolishi i-2,453, ngemuva kokulawula ubulili, ubudala nokudangala (30).
Amasampula omtholampilo wezinye izidakamizwa zokuziphatha aphakamisa ukuthi ukuvela kanye nokuphazamiseka kokusebenzisa izidakamizwa kuvamile (Ithebula 1). Lokhu okutholakele kusikisela ukuthi umlutha wokuziphatha ungabelana nge-pathophysiology evamile ngokuphazamiseka kokusebenzisa izidakamizwa.
Kodwa-ke, imininingwane emayelana nokusetshenziswa kwezidakamizwa i-comorbidity kumele ihunyushwe ngokucophelela ngoba noma yiziphi izinhlangano ezibandakanyekayo zingavela zisezingeni lokuziphatha (ngokwesibonelo, ukusetshenziswa kotshwala okubonisa izinhlobo ezithile zokuziphatha okungafanele, kufaka phakathi lezo ezikhonjwe njengezilutha) noma ezingeni lokuhlangana (ngokwesibonelo, a umlutha wokuziphatha uqala ngemuva kokulashwa kotshwala, mhlawumbe njengento engena esikhundleni sokuphuza). Izinkinga zokugembula ngokusetshenziswa kotshwala njalo zinobunzima obukhulu bokugembula nezinkinga zengqondo ezidalwa ukugembula kunalezo ezingenamlando wokusebenzisa utshwala (i-31), kanye nentsha eziphuza kakhulu kubabhemayo kakhulu kungenzeka ukuthi zigembula njalo kunalabo abangenayo (i-32), okuphakamisa ukusebenzisana ekuziphatheni phakathi kotshwala nokugembula. Ngokuphambene nalokho, ukutholwa okufanayo mayelana nokusebenzisa i-nicotine kusikisela ukusebenzisana kwe-syndromal, njengoba neqiniso lokuthi abantu abadala abanokugembula okuyi-pathological abangabhemi bamanje noma bangaphambilini babeba nesifiso esinamandla sokugembula (i-33). Izinkinga zokugembula ezisebenzisa ugwayi nsuku zonke zingaba nezinkinga zokusebenzisa utshwala nezidakamizwa (34).
Okunye ukuphazamiseka kwengqondo, njengokukhubazeka okukhulu, ukuphazamiseka kwengqondo okuguquguqukayo, ukuphazamiseka kwengqondo okucindezelayo, kanye nokubhekelwa phansi kwethonya lokugula, kubikwa futhi kakhulu lapho kuhlotshaniswa nemilutha yokuziphatha (i-35, 36) (bheka futhi iWeinstein noLejoyeux, lolu daba). Kodwa-ke, eziningi zalezi zifundo ze-comorbidity zazisuselwa kumasampula emitholampilo. Ukuthi lokhu okutholwayo kuvumelana kanjani namasampula omphakathi kusafanele kunqunywe.
I-Neurocognition
Imikhuba yokuziphatha okubi nokuphazamiseka kokusetshenziswa kwezidakamizwa kungenzeka kube nezici ezijwayelekile zokuqonda. Bobabili abagembuli be-pathological kanye nabantu abanezifo ezisetshenziselwa ukusetshenziswa kwezidakamizwa ngokuvamile banciphisa imivuzo ngokushesha (i-37) futhi benza ngokungathandeki emisebenzini yokwenza izinqumo (i-38) efana ne-Iowa Gossip Task, paradigm ehlola ukwenza izinqumo ngomvuzo onobungozi (i-39). Ngokuphambene, ucwaningo lwabantu abanomlutha we-Intanethi alukhombisi ukusilela okunjalo ekwenzeni izinqumo ku-Iowa Gossip Task (40). Ucwaningo olusebenzisa ibhethri eliphelele le-neurocognitive kuma-49 abasebenza ngokugembula ngezifo, izilawuli ezincike ku-48 ezitholakele, kanye nezilawuli ze-49 zithole ukuthi abagembuli nezidakwa bobabili bakhombise ukusebenza okwehlisiwe ezivivinyweni zokuvinjwa, ukuguquguquka kwengqondo okuqondayo, nemisebenzi yokuhlela, kepha bekungekho mehluko ekuhlolweni kwe ukusebenza kwe-Executive (41).
Izinqubo ezijwayelekile ze-Neurobiological
Umzimba okhulayo wezincwadi ulimaza amasistimu amaningi we-neurotransmitter (isib. I-serotonergic, i-dopaminergic, i-noradrenergic, i-opioidergic) ku-pathophysiology yokuziphatha okuluthayo nokuphazamiseka kokusebenzisa izidakamizwa (42). Ikakhulu, i-serotonin (5-HT), ebandakanyeka ekuvinjelweni kokuziphatha, kanye ne-dopamine, ebandakanyeka ekufundeni, ekugqugquzeleni, kanye nokuqina kokukhuthazeka, kufaka phakathi imivuzo, kungasiza kakhulu kulezi zisethi zokuphazamiseka (42, 43).
Ubufakazi bokubandakanyeka kwe-serotonergic ekuluthweni kokuziphatha kanye nokuphazamiseka kokusetshenziswa kwezidakamizwa kuza ngokwengxenye ezifundweni zomsebenzi we-platelet monoamine oxidase B (MAO-B), ohambelana namazinga we-cerebrospinal fluid (CSF) we-5-hydroxyindole acetic acid (5-HIAA, metabolite ye-5-HT) futhi ithathwa njengophawu lwaphesheya lomsebenzi we-5-HT. Amazinga we-CSF 5-HIAA aphansi ahambelana nezinga eliphakeme lokuxoshwa nokufuna imizwa futhi kutholakale ukugembula kwe-pathological kanye nokuphazamiseka kokusebenzisa izidakamizwa (44). Izifundo eziyinselelo ze-Pharmacologic ezilinganisa ukuphendula kwe-hormonal ngemuva kokuphathwa kwezidakamizwa ze-serotonergic zinikeza nobufakazi bokungasebenzi kahle kwe-serotonergic kukho konke ukuluthwa kokuziphatha kanye nokuphazamiseka kokusebenzisa izidakamizwa (45).
Ukusetshenziswa okuphindaphindayo kwezinto noma ukuzibandakanya ekuluthweni kokuziphatha ngokulandela isikhalazo kungakhombisa inqubo yobumbano. Ucwaningo lwe-preclinical and clinical lubonisa ukuthi inqubo esetshenziswayo eyisisekelo yezinto eziphazamisayo eziqhutshwa yisisusa ingahle ibandakanye ukucutshungulwa kokufaka komvuzo okufinyeleleka endaweni ye-ventral tegmental area / nucleus accumbens / orbital frontal cortex circ (46, 47). Indawo ye-ventral tegmental iqukethe ama-neurons akhipha i-dopamine kuma-nucleus accumbens kanye ne-orbital frontal cortex. Izinguquko ezindleleni ze-dopaminergic ziye zahlongozwa njengokucatshangelwa kokufuna kwemivuzo (ukugembula, izidakamizwa) okubangela ukukhishwa kwe-dopamine futhi kuveze imizwa yenjabulo (i-48).
Ubufakazi obunqunyelwe ovela ocwaningweni be-neuroimaging busekela i-neurocircuitry eyabiwe yokulutha kokuziphatha nokuphazamiseka kokusebenzisa izinto (7). Umsebenzi okhethiwe we-ventral medial pre prealal cortex (vmPFC) uhlotshaniswe nokwenza izinqumo okuphoqelelekayo ekuhlolweni komvuzo wobungozi kanye nokuphendula okunciphile kwezindlela zokugembula kwababhejeli be-pathological (49). Ngokufanayo, ukusebenza kwe-vmPFC okungajwayelekile kutholakale kubantu abanokuphazamiseka kokusebenzisa izidakamizwa (50). Ukwenza kusebenze kobuchopho okuhlobene nomqondo kumilutha yemidlalo ye-Intanethi kwenzeka ezifundeni ezifanayo zobuchopho (i-orbitofrontal, i-dorsolateral prefrontal, i-cterate ye-anterior, i-nucleus accumbens) njengokuqalwa kobuchopho okuhlobene nomuthi izidakamizwa kumilutha yezidakamizwa (i-51) (bona futhi Weinstein noLejoyeux, lokhu ukukhishwa).
Ucwaningo lwe-Brain imaging luphakamisa ukuthi indlela ye-dopaminergic mesolimbic esuka endaweni ye-ventral tegmental iye kuma-nucleus accumbens ingahle ibandakanyeke kuzo zombili izinkinga zokusetshenziswa kwezidakamizwa nokugembula kwe-pathological. Izihloko ezinokugembula kwe-pathological zikhombise ukusebenza okuncane kwe-ventral striatal neuronal nge-fMRI ngenkathi kwenziwa ukugembula okulingisiwe kunezifundo ezilawulwayo (52), okufana nokubhekwa ezifundweni ezincike otshwaleni lapho kucutshungulwa imivuzo yemali (53). Ukuncipha kokusebenza kwe-ventral striatal nakho kuye kwathinteka ezifisweni ezihambisana nokulutha kwezidakamizwa nokuziphatha (42). Ukubamba iqhaza emsebenzini wokugembula kubonakala kuphakamisa ukukhishwa okukhulu kwe-dopamine ku-ventral striatum kubantu abanesifo sikaParkinson's (PD) nokugembula kwe-pathological kunabantu abane-PD bodwa (54), impendulo efana naleyo etholwe yizidakamizwa noma izindlela ezihlobene nezidakamizwa eziluthweni zezidakamizwa (55).
Ukubandakanyeka kwe-Dopamine ekuluthweni kokuziphatha kubuye kuphakanyiswe nezifundo zeziguli ze-PD eziqondisiwe (56, 57). Izifundo ezimbili zeziguli ezine-PD zithole ukuthi ezingaphezu kwe-6% zithole umlutha wokuziphatha omusha wokuqalwa noma ukuthinteka kokulawulwa kokuthinteka (isib. Ukugembula kwe-pathological, umlutha wobulili), ngamanani aphakeme kakhulu phakathi kwalabo abathatha umuthi we-dopamine agonist (58, 59). Ukulingana okuphezulu kwe-levo-dopa ephezulu kwakuhlotshaniswa namathuba amakhulu okuba umlutha wokuziphatha (59). Ngokuphikisana nalokho okungase kulindelwe kusuka ekubandakanyekeni kwe-dopamine, abaphikisi ku-dopamine D2 / D3 receptors bakhuthaza izisusa ezihlobene nokugembula nokuziphatha kubantu abanga-PD ngokugembula kwe-pathological (60) futhi abanakho ukusebenza ngempumelelo ekwelapheni ukugembula kwe-pathological (61, 62) . Ucwaningo olwengeziwe lufanelekile ukucacisa iqhaza eliqondile le-dopamine ekugembeni kwe-pathological kanye nezinye izidakamizwa zokuziphatha.
Umlando Womndeni kanye nofuzo
Bambalwa kakhulu umlando womndeni / ucwaningo lofuzo lokulutha okwenziwe ngamaqembu alawulayo (i-7). Izifundo ezincanyana zomndeni wama-probands ahambisana nokugembula kwe-pathological (63), kleptomania (64), noma ukuthenga okuphoqayo (i-65) ngamunye athola ukuthi izihlobo zokuqala ze-probands zazinezilinganiso eziphakeme kakhulu zokuphila kotshwala nokunye ukuphazamiseka kokusebenzisa izidakamizwa, nokucindezelwa kanye okunye ukuphazamiseka kwengqondo, kunokuba kulawulwa yizifundo. Lezi zifundo zomndeni ezilawulwa zisekela umbono wokuthi ukuluthwa kokuziphatha kungenzeka kube nobudlelwano bezakhi zofuzo kokuphazamiseka kokusebenzisa izidakamizwa.
Amagalelo ezakhi zofuzo aqhathaniswa nemvelo ekuziphatheni ezithile nasekukhubazekeni okungalinganiswa ngokuqhathanisa amakhonsathi abo afanayo (i-monozygotic) kanye namawele ama-fraternal (dizygotic). Ocwaningweni lwamawesilisa angamaduna asebenzisa iVietnam Era Twin Registry, i-12% iye kwi-20% yokuhlukahluka kofuzo olusengozini yokugembula kwe-pathological kanye ne-3% kuya kwe-8% yokuhlukahluka kwemvelo okungabikhona kusengozini yobungozi bokugembula. izinkinga zokusebenzisa (66). Okwesithathu (i-64%) yokuvela kokuhlangana kokugembula kokudla kanye nokusetshenziswa kotshwala kubangelwe yizakhi zofuzo ezithonya zombili iziphazamiso, kuphakamisa ukunqwabelana ekuvezweni kofuzo zombili lezi zimo. Lokhu okutholakele kufana naleyo ephakamisela iminikelo ejwayelekile yofuzo kunobubanzi bokuphazamiseka kokusebenzisa izidakamizwa (67).
Zimbalwa kakhulu izifundo zokuhlolwa kwezakhi zofuzo zokulutha kokuziphatha. I-D2A1 i-allele ye-D2 dopamine receptor gene (DRD2) inyuka imvamisa ukusuka kubantu abanenkinga yokugembula kuya ekugembeni kwe-pathological kanye nokugembula okwenzeka nge-pathological kanye nokusetshenziswa kwezidakamizwa (68). Izinhlobo eziningana ze-DRD2 gene single nucleotide polymorphisms (SNPs) ziye zahlotshaniswa nezinyathelo zobuntu zokuphoqelela kanye nezindlela zokuhlola zokuvinjwa kokuziphatha kumavolontiya anempilo (i-69), kepha lokhu akuhloliswanga kubantu abanokulutha kokuziphatha. Abasebenzisi be-inthanethi abagqamile babenemvamisa ephezulu yohlobo olude lwengalo (i-SS) ye-serotonin transporter gene (5HTTLPR) kunezilawuli ezinempilo, futhi lokhu kuhlotshaniswa nokugwema ukulimala okukhulu (i-70) (bona futhi iWeinstein noLejoyeux, lolu daba).
Ukuphendula Ukwelashwa
Imilutha yokuziphatha ngokuziphatha kanye nokuphazamiseka kokusetshenziswa kwezidakamizwa kuvame ukuphendula kahle ekwelashweni okufanayo, kokubini ngokwengqondo nangokwezifo. Izindlela zokusiza ze-12-step-self-assists, ukuqiniswa kwesishukumiso, kanye nezindlela zokuziphatha zokuqonda ezivame ukusetshenziswa ekwelapheni ukusetshenziswa kwezidakamizwa zisetshenziswe ngempumelelo ukuphatha ukugembula kwe-pathological, ukuphoqelela okuphathelene nocansi, i-kleptomania, ukuthathwa kwesikhumba se-pathologic, kanye nokuthenga okuphoqayo (71-74) . Ukungenelela kwengqondo kokuthambekela kokuziphatha kanye nokuphazamiseka kokusetshenziswa kwezidakamizwa kuvame ukuthembela ekuvimbelweni kokubuyela emuva okukhuthaza ukungazikhombi ngokuhlonza amaphethini okuhlukumeza, ukugwema noma ukubhekana nezimo zobungozi obukhulu, nokwenza izinguquko zendlela yokuphila eziqinisa isimilo esihle. Ngokuphambene, izindlela zokwelapha eziphumelelayo zengqondo nezokulwa nokukhubazeka zigcizelela amasu okuveza kanye nokuphendula (i-2).
Akukho mithi evunyelwe njengamanje yokwelapha umlutha wokuziphatha, kodwa eminye imishanguzo ekhombise ukwethembisa ekwelapheni ukuphazamiseka kokusebenzisa izidakamizwa ikhombisile nokuthi ithembisa ekwelapheni imilutha yokuziphatha (i-75). I-Naltrexone, umphikisi we-mu-opioid receptor ogunyazwe i-US Food and Drug Administration ukwelashwa okuphathelene notshwala nokuncika kwe-opioid, ukhombisile ukusebenza kahle kwizivivinyo zomtholampilo ezilawulwayo zokwelapha ukugembula kwe-pathological kanye ne-kleptomania (76-79), futhi uthembisa ngokungalawulwa izifundo zokuthenga okuphoqelekile (i-80), ukuziphatha okuya ocansini okuphoqayo (i-81), umlutha we-inthanethi (82), kanye nokukhetha isikhumba se-pathologic (83). Lokhu okutholakele kusikisela ukuthi ama-mu-opioid receptors adlala indima efanayo ekuziphatheni okulimazayo njengoba enza ekuphazamiseni ukusetshenziswa kwezidakamizwa, ngokunokwenzeka ngokushintshwa kwendlela ye-dopaminergic mesolimbic. Ngokuphikisana nalokhu, i-mu-opioid receptor antagonist ye-elxone esebenza ngokufushane ibanga izimpawu ekukhubazekeni okungapheli (84).
Imithi eguqula umsebenzi we-glutamatergic nayo isetshenzisiwe ekwelapheni ukuluthwa kokuziphatha kanye nokuxhomekeka kwento. I-Topiramate, i-anticonvulsant evimba i-AMPA subtype ye-glutamate receptor (phakathi kwezinye izinto), ikhombise isethembiso ocwaningweni oluvulelekile lokugembula kwe-pathological, ukuthenga okuphoqayo, kanye nokucosha okuphoqelekile kwesikhumba (i-85), kanye nokusebenza kahle ekunciphiseni utshwala (86 ), ugwayi (87), ne-cocaine (88). I-N-acetyl cysteine, i-amino acid ebuyisela ukugxila kwe-glutamate yama-extracellular kuma-nucleus accumbens, inciphise ukunxenxa ukugembula kanye nokuziphatha ocwaningweni olulodwa lwababhejeli be-pathological (89), futhi inciphise i-cocaine craving (90) nokusetshenziswa kwe-cocaine (91) kwimilutha ye-cocaine. Lezi zifundo ziphakamisa ukuthi ukushintshashintsha kwe-glutamatergic kwethoni ye-dopaminergic ku-nucleus accumbens kungaba yindlela ejwayelekile yokulutha kokuziphatha kanye nokuphazamiseka kokusebenzisa izidakamizwa (i-92).
Izinkinga Zokuxilonga
Ukulutha kokuziphatha okulodwa kuphela, ukugembula okungokwemvelo, ukuxilongwa okwaziwayo ku-DSM-IV naku-ICD-10. Izindlela zalo zokuxilonga zifana nomqondo wokusetshenziswa kabi kwezidakamizwa / ukuncika, okungukuthi, ukukhathazeka ngokuziphatha, ukuncipha kwekhono lokulawula indlela yokuziphatha, ukubekezelelana, ukuhoxa, kanye nemiphumela emibi yengqondo. I-DSM-V Task Force iphakamise ukugembula kwe-pathological kusuka ekuhlukanisweni kwayo kwamanje njengokuphazamiseka kokulawula umfutho kuya kusigaba esisha esibizwa ngegama elithi "Umlutha Nezinkinga Ezihambisanayo," okungafaka kokubili ukuphazamiseka kokusebenzisa izidakamizwa kanye "nokulutha kokungasebenzisi izidakamizwa" (www.dsm5. org, kufinyelelwe kuFebhuwari 10, 2010). Okuwukuphela koshintsho oluhlongozwayo oluphelele kunqubo yokuxilonga ukwehla kwesimo esiphathelene nokwenziwa kwezenzo ezingekho emthethweni ukuxhasa ukugembula, okutholwe ukuthi kunokudlondlobala okuphansi futhi akunamthelela omncane ekuxilongweni.
Abanye abantu abaningi ababa umkhuba wokuziphatha bahlongoza izindlela zokuxilonga, kufaka phakathi ukuthenga okuphoqayo (i-93), umlutha we-Intanethi (i-94), umlutha wevidiyo / wekhompyutha (i-95), umlutha wezocansi (i-96), nokushuka ngokweqile (bheka uKouroush et al., Lo magazini) . Lokhu kuvame ukususelwa kunqubo ekhona ye-DSM-IV yokusebenzisa kabi izidakamizwa noma ukuthembela, isb, isikhathi esiningi esichithwa ekuziphatheni, imizamo ephindaphindwayo yokunciphisa noma yokumisa ukusebenza, inciphisa ukulawulwa kokuziphatha, ukubekezelela, ukuhoxa, kanye nokuhlukumezeka kwengqondo okubi imiphumela. Iqembu lomsebenzi we-DSM-V Substance-Related Disways group licubungula okumbalwa kwalokhu okungezona izidakamizwa ukuze kufakwe ku-DSM-V, ikhuluma ngokuqondile umlutha we-Intanethi (www.dsm5.org; kufinyelelwe uFebhu 10, 2010). Kodwa-ke, kwabaningi bokuphazamiseka, kuncane noma akukho idatha esebenzayo yalezi zindlela zokuxilonga; okwamanje ziwusizo kakhulu njengezixhobo zokuhlola ukulinganisa ukwanda kwenkinga.
Umbuzo owodwa wokuhlonza ophakanyiswe ezincwadini yilapho ukuluthwa kokuziphatha (kanye nemilutha yezithako) kuwela khona lapho kuthambekele ekunciphiseni amandla (i-97), ie, kufana nokuphazamiseka kokulawula okungathandeki noma ukuphazamiseka okucindezelayo okukhona? Abanye baphikise ukuthi le ndlela yobumbano yobumbano ingenziwa ngokweqile, futhi ukufakwa kwesisulu nokuphoqelela kumelela ubukhulu be-orthogonal, kunokuba kube nezigxobo eziphambene zesilinganiso esisodwa (98). Ngokuhambisana nengxabano yokugcina kukhona okutholakele njengokuhlukahluka okukhulu ngezinga lokuphoqelela phakathi kwabantu abanokulutha kokuziphatha, ukuhlukahluka okungahlotshaniswa nokuphendula ekwelashweni kwe-pharmacological (48, 99).
Ku-DSM-IV, ukuluthwa kwezidakamizwa (ukuphazamiseka kokusetshenziswa kwezidakamizwa) kuyisigaba esizimele, ngenkathi ukugembula kwe-pathological kubhekwa njengengozi yokulawula ukungathandeki, okufana, ngokwesibonelo, i-pyromania ne-kleptomania. I-ICD-10 ihlukanisa ukugembula kwe-pathological njengengxaki "yomkhuba kanye nokuphoqelela", kepha iyaqaphela ukuthi "le ndlela yokuziphatha ayiphoqeleli ngomqondo wezobuchwepheshe," noma ngezinye izikhathi ibizwa ngokuthi "ukugembula okuphoqayo."
Udaba oluhlobene nobumbano, noma ukuhlangana, uma kukhona, phakathi kwezidakamizwa ezihlukile zokuziphatha. Ukuhlaziywa kweqoqo lokuhlukahluka kwabantu kanye nokwelashwa ezigulini ezingama-210 ezinezifo eziyimpoqo eziyimpoqo ezivelele kukhombe amaqoqo amabili ahlukene eziguli ezinokulutha kokuziphatha (100): iziguli ezinokugembula okungokwemvelo noma ukulutha ngokocansi ("ubungqingili") zazineminyaka yobudala yokuqala futhi zazinamathuba amaningi okuqala. owesilisa, uma kuqhathaniswa neziguli ezinokuthenga okucindezelayo. Ucwaningo olwengeziwe luyadingeka ukuqinisekisa nokwandisa lokhu okutholakele. Enye indlela yokucwaninga engaba nomthelela omkhulu emkhakheni kungaba ukuhlolwa okuphelele kweqembu elikhulu, eliyingqayizivele, elihloniphekile labantu abanezidakamizwa ezihlukahlukene zokuziphatha nezidakamizwa ngokwezinto ezihlukile zokungabi namandla kanye nokuphoqeleka kokubili kwengqondo (ukuqonda) nokuziphatha ( motor) izizinda, isb., ukuzwela kokuvuza ukubambezeleka (ukwehliswa kwesikhashana somvuzo), ukwenza izinqumo zomvuzo wobungozi, ukuqina komqondo, ukuphendula okulindelwe ngaphambi kwesikhathi, ukuphendula okuphikelelayo, ukuvinjelwa kwempendulo nokufunda okuphindayo.
SUMMARY AND CONCLUSIONS
Ubufakazi obukhulayo bukhombisa ukuthi ukulutheka kokuziphatha kufana nokulutha kwezidakamizwa ezizindeni eziningi, kufaka phakathi umlando wemvelo (inkambo engapheli, ebuyela emuva enezinga eliphakeme nokwanda kwentsha nasebekhulile), i-phenomenology (ukuthanda ngokweqile, ukudakwa [“okuphezulu”], nokuhoxa), ukubekezelelana , comorbidity, okweqile ukunikela kwezofuzo, izindlela ze-neurobiological (ezinendima yobuchopho be-glutamatergic, opioidergic, serotonergic, kanye ne-dopamine mesolimbic systems), kanye nokuphendula ekwelashweni. Kodwa-ke, imininingwane ekhona ibanzi kakhulu ekugembuleni kwe-pathological (bona iWareham nePotenza, le nkinga), enemininingwane elinganiselwe yokuthenga okuphoqelelwe (bona iLejoyeaux ne-Weinstein, le nkinga), ukulutha kwe-inthanethi (bona uWeinstein noLejoyeaux, lolu daba), futhi ukulutha komdlalo wevidiyo / wekhompyutha (bona uWeinstein, lolu daba), futhi cishe akukho datha yezinye izilingo zokuziphatha ezinjengokulutha ngokocansi (bona uGarcia noThobaut, lolu daba), umlutha wothando (bona uReynaud, le nkinga), ukukha isikhumba se-pathologic (bona U-Odlaug noGrant, lo magazini), noma ukushuka ngokweqile (bona uKouroush et al., Le nkinga).
Kunobufakazi obanele bokugunyazwa ukubheja ukugembula komzimba njengento engeyona into noma eyokuziphatha; I-DSM-V Task Force ihlongoze ukuhambisa ukuhlukaniswa kwayo ku-DSM-V kusuka enkingeni yokulawula ukuthatheka iye ekuluthweni nasekuphazamisweni okuhlobene nakho (isigaba esisha esihlanganisa kokubili okuluthayo nokungafanele okuphathelene nezinto). Esimweni samanje solwazi, ikakhulukazi uma kungekho zinqubo eziqinisekisiwe zokuxilonga kanye nezifundo ezinokwenzeka, kusesenesikhathi ukubheka ezinye izidakamizwa zokuziphatha njengokuphazamiseka okuzimele okugcwele, kungabalwa kakhulu kufana nokuluthwa kwezidakamizwa, kunokuba njengokuphazamiseka kokulawula okungafanele. Ucwaningo lwekusasa olubalulekile, kufaka phakathi izifundo zabantu nezilwane (i-101), luyadingeka ukuletha ulwazi lwethu lokuluthwa kwezinga lokuziphatha kuleveli yalokho kokulutha kwezidakamizwa, ikakhulukazi kwizizinda zofuzo, i-neurobiology (kufaka phakathi ukucabanga kobuchopho), nokwelashwa.
Ukuvuma
Isekelwa yi-Intramural Research Programme, Izikhungo ZikaZwelonke Zesayensi Yezempilo, Isikhungo Sikazwelonke Sezokuxhashazwa Kwezidakamizwa (i-DAG); I-NIH (NIDA) isiza i-R01 DA019139 (MNP) ne-RC1 DA028279 (JEG); kanye neZikhungo ZaseMinnesota kanye neYale of Excellence Ekucwaningweni Kokugembula, ezesekelwa yiSikhungo Sikazwelonke Sokubhekelela Ukugembula Isikhungo Sayo Sokucwaninga Ngezinkinga Zokugembula. UDkt Weinstein usekelwa yi-Israel National Institute for Psychobiology. Okuqukethwe kulo mbhalo wesandla kungumsebenzi wababhali kuphela futhi akumelwe kuveze imibono esemthethweni yeSikhungo Sikazwelonke Sokubhekelela Ukudlala noma Isikhungo Sokucwaninga Ngezinkinga Zokugembula noma ezinye izinhlangano ezixhasa imali.
Isimemezelo Sentshisekelo
Bonke ababhali babike akukho kungqubuzana kwenzalo maqondana nokuqukethwe yile ndatshana. UDkt Grant uthole izibonelelo zokucwaninga kwa-NIMH, NIDA, National Center for Responsible Gaming kanye nesikhungo sayo esixhumene neSikhungo Sokucwaninga Ngezinkinga Zokugembula, kanye ne-Forest Pharmaceuticals. UDkt Grant uthola isinxephezelo sonyaka kwaSpringer Publishing ngokusebenza njengoMhleli-Oyinhloko we-Journal of Gossip Studies, wenze izibuyekezo zesibonelelo se-NIH kanye ne-Ontario Gossip Association, ithole imali evela e-Oxford University Press, e-American Psychiatric Publishing, Inc. , I-Norton Press, kanye noMcGraw Hill, bathole i-honaria kusuka e-Indiana University Medical School, University of South Florida, Mayo Medical School, California California of Addiction Medicine, State of Arizona, State of Massachusetts, State of Oregon, Isifundazwe seNova Scotia, kanye nesiFundazwe sase-Alberta. UDkt Grant uthole isinxephezelo njengomeluleki wamahhovisi ezomthetho mayelana nezinkinga eziphathelene nokuphazamiseka kokulawulwa kokuthinteka. UDkt Potenza uthole ukwesekwa ngokwezezimali noma isinxephezelo ngokulandelayo: umeluleki kanye nomeluleki ku-Boehringer Ingelheim; izintshisakalo zezezimali eSomaxon; ukusekelwa kokucwaninga okuvela kwizikhungo zikazwelonke zezempilo, uMnyango wezamaVeterans, i-Mohegan Sun Casino, Isikhungo Sikazwelonke Sokubhekelela Imidlalo Yezemidlalo kanye Nesikhungo Sayo Esisebenzayo Sokucwaninga Ngezinkinga Zokugembula, kanye namaLabhoratri Amahlathi; ubambe iqhaza ocwaningweni, ekubhaleni ngeposi noma ekuxhumaneni ngocingo okuhlobene nokuluthwa yizidakamizwa, ukuphazamiseka kokulawula okungafanele, noma ezinye izihloko zezempilo; uthintane namahhovisi ezomthetho mayelana nezinkinga eziphathelene nokulutha noma ukuphazamiseka kokulawula ukuthatheka; uhlinzekele ukunakekelwa kwemitholampilo eMnyangweni Wezinsizakalo Zokugembula Wezinsizakalo Nokulutheka; futhi ukhiqize izincwadi noma izahluko zencwadi zabashicileli bemibhalo yezempilo yengqondo. UDktWeinstein uthole izibonelelo zokucwaninga ezivela kwa-Israeli Anti-Drug Authority, kwa-Israel National Institute for Psychobiology, the Chief Scientist of the Israeli Ministry of Health, kanye neRashi Trust (Paris, France) nezimali zezinkulumo zokuluthwa kwezidakamizwa ezivela Umnyango Wezemfundo wakwa-Israyeli. UDkt Gorelick ubika ukuthi akukho mali yangaphandle noma ukushayisana kwezintshisekelo.
IZINDAWO ZOLWAZI
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