職場心理衛生
國泰醫院
精神科
邱偉哲 醫師
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課程大綱
Mental Illness 分類
壓力與職場常見壓力
與職場相關之精神疾病
直接壓力相關
間接壓力相關
自殺
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Mental Illness 分類
Organic or Substance related
Psychosis(精神病)
Schizophrenia, bipolar disorder, major
depressive disorder, delusional disorder
Neurosis(精神官能症)
Anxiety disorder, panic disorder, OCD, PTSD,
Adjustment disorder
Psychosis 與 Neurosis主要分別在現實感
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Stress
壓力的特性
失掉控制力
不可預期性
失去發洩管道
壓力源包括下列五者：
(一)環境壓力源
(二)災變事件
(三)生活改變
(四)日常瑣事
(五)心理因素
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壓力不解除會如何?
壓力源(短期，長期)

耗竭

體質或基因的脆弱性

精神疾病
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職場上常見壓力
急性
面臨或目睹重大傷害
工作失敗
工作量增加
強迫退休
降職
升職
調派
性騷擾
與同事糾紛
慢性
長時間工作
長期睡眠剝奪
輪班
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輪班制度注意事項
順時針方向的輪班方式較易調適。
換班頻率不宜過快。
早班交接時間不宜太早。
剛換班時可以容許彈性工時。
光照療法
曝曬於照明度達7000－30000燭光的強光下一小時。
可有效調整約日節奏。
下班後應避免其他光源的曝曬
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Mental Illness related to the Stress
Adjustment disorder
Acute stress disorder
PTSD
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Adjustment Disorder
Maladaptive reaction within three months
of onset of stressor/s
Distress in excess of normal reaction
Not manifestation of personality disorder
Symptoms resolve within 6 months of
termination of stressor
Acute versus Chronic
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Adjustment Disorder
Coded Symtom Subtype
With Depressed Mood
With Anxiety
With Anxiety and Depressed Mood
With Disturbance of Conduct
With Mixed Disturbance of Emotions
and Conduct
Unspecified
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Acute Stress Disorder
New to DSM-IV (1994)
Symptoms 2 days to 4 weeks following
traumatic event
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PTSD的定義
依DSM-IV 1993的定義如下:
一個人經歷極度的創傷壓力事件而且出現害
怕、無助感、或恐怖感的反應;這樣的壓力事
件如戰爭經驗、天災及強暴;隨後表現下列三
大類症狀:
此創傷壓力事件經由夢境或回憶持續被再體驗
對創傷相關的刺激產生逃避及對一般反應麻木
持續升高警覺性
若以上的症狀造成人際社會功能受損,而且持
續一個月以上,則稱為PTSD。
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Symptoms Categories (PTSD)
Intrusive
distressing recollections
dreams
flashbacks
psychological trigger reactions
physiological trigger reactions
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Symptoms Categories (PTSD)
Avoidance
avoid thoughts, feelings or discussions
avoid activities, places
memory blocks
anhedonia (without pleasure)
numb
alexithymia (emotions unknown)
feeling of doom
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Symptom Categories (PTSD)
Hyperarousal Symptoms
sleep disturbance
anger problems
concentration
startle response
“on guard” hypervigilence
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PTSD的流行病學
以急性壓力症(ASD),及PTSD為主(兩者之
區別為症狀之出現及持續時間,ASD為兩
天以上,一個月以下,而PTSD為一個月以
上)
在各種創傷後發生PTSD的機率為5-75%,
而在數年後的盛行率通常小於10%
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PTSD的病因
Stressor:並不一定要現場經歷,一般是指下述
任何一種情境
 直接經驗到真實的或具威脅性的死亡、 嚴重傷害、 或對自己
或他人身體的完整性造成威脅
 目睹關於死亡、 受傷、 或對他人身體完整性產生威脅
 知悉關於不可預期或暴力性的死亡、 嚴重的傷害、 或親近的
人感受到死亡或傷害的威脅
Biological factors:
 Sympathetic activity:sympathetic tone
 Neuroendocrine functions:hypothalamo-pituitaryadrenal axis dysfunction
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DSM-IV Diagnostic Criteria for Panic
Attack
A discrete period of intense
fear or discomfort, in which
four (or more) of the following
symptoms developed abruptly
and reached a peak within 10
minutes:
Palpitations, pounding heart,
or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of
breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady,
lightheaded, or faint
Derealization (feelings of
unreality) or depersonalization
(being detached from oneself)
Fear of losing control or going
crazy
Fear of dying
Paresthesias (numbness or
tingling sensations)
Chills or hot flashes
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Panic Disorder
Recurrent, unexpected panic attacks
Persistent concern
Preoccupation with having another attack
Worry about consequences of attack
Significant behaviour change in response
to attacks
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Panic Disorder
Often accompanied by avoidance
behaviours (agoraphobia)
Onset around late adolescence, early
adulthood
More women than men
High rates of service utilization, poor
quality of life
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Specific Phobia – Diagnostic
features
Types –marked and persistent fear and
avoidance of specific stimulus
Situation interfere significantly with
person’s life
Excessive or unrealistic
ANS arousal
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Phobia - subtype
animal
environmental
blood, injury, injection
specific situation – elevators, flying
other
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Specific phobia
Prevalence rates from 7-11%
Often emerge during adolescence, usually
earlier than age 25
Tend to be chronic, but may fluctuate over
life course
Self-report
Conditioning theories or systematic
desensitization
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Major Depressive Disorder
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DSM-IV-TR Diagnostic Criteria
for Major Depressive Disorder
≥5 of the following have
been present during the
same 2-week period and
are a change from previous
function
Depressed mood
Decreased interest in
pleasure
Significant weight loss
or gain (>5% in 1 month)
Hypersomnia or
insomnia
Fatigue or loss of
energy
Psychomotor agitation
or retardation
Feelings of
worthlessness or
excessive/inappropriate
guilt
Diminished ability to
think or concentrate
Recurrent thoughts of
death or suicidal
ideation
At least one of the
symptoms is depressed
mood or loss in interest or
pleasure
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Washington, DC: American Psychiatric Association; 2000.
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Disease Course of Major
Depressive Disorder (MDD)
Remission
“Normalcy”
Recovery
Response
Symptoms
Syndrome
Relapse
Treatment phases
Acute
Continuation
Recurrence
Maintenance
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Adapted from Kupfer DJ. J Clin Psychiatry. 1991;52(suppl 5):28-34.
Bipolar Disorder
Bipolar I – Depression & Mania
At least one Manic episode
Bipolar II – Depression & hypomania
At least one hypomanic eipsode
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Dx for Manic Episodes (DSM-VI)
A. Duration more than 1 week （期間大於一星期）
B. Three (or more) of the following symptoms :
下列症狀大於 3 項或以上:
(1) inflated self-esteem or grandiosity 自信心增高
(2) decreased need for sleep 睡眠需求減少
(3) more talkative than usual or pressure to keep talking 多話
(4) flight of ideas or subjective racing thoughts 跳躍性思考
(5) distractibility 易分心
(6) increase in goal-directed activity or psychomotor agitation
增加目的性行為或激躁不安
(7) excessive involvement in pleasurable activities that have a
high potential for painful consequences 增加享樂性行為
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Dx for Manic Episodes (DSM-VI)
C. Do not meet criteria for a mixed episode.
D. Cause marked impairment in occupational
functioning or in usual social activities or
relationships with others, or to necessitate
hospitalization to prevent harm to self or others, or
there are psychotic features.
E. Not due to the direct physiological effects of a
substance or a general medical condition (e.g.,
hyperthyroidism).
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PSYCHOTIC FEATURES
PSYCHOTIC FEATURES
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Suicide
Suicidal ideation
Suicidal threatening
Suicidal behavior
Commit Suicide
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Suicide, suicide attempt and mood
disorder
Mood
disorder
Suicide
attempt
15%suicide
10% suicide within
10 years
Suicide
45-70% with mood
disorder
19-24% had previous
suicide history
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精神疾病與自殺
大部分（97%）自殺者生前罹患精神疾病
重鬱症（89%）
物質濫用（酒癮）（45%）
情緒不穩之性格障礙
(為前三名之精神疾病)
憂鬱症合併物質濫用是最常見的共病狀態
超過90%的自殺者生前罹患憂鬱症
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(鄭泰安，1995)
自殺的危險因子
失落的生活事件
一等親有自殺行為
重鬱症
情緒不穩人格障礙
（鄭泰安，2000）
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過勞與自殺
工作型態有關：臺灣人和日本人常像是工蜂一樣
整日勞碌
相關疾病
憂鬱症
耗竭症候群（burn out syndrome）
慢性疲勞症候群
檢測量表
簡易壓力量表網路版
勞研所
勞工職業壓力量表
職場疲勞量表 台大衛生政策與管理研究所鄭雅文老
師
羅士翔2007
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工作相關心理壓力事件引起精神疾病認定
疾病之證據
精神科醫師出具之診斷書註記為ICD-10中F0至
F9之診斷
暴露之證據與時序性
「工作場所心理壓力評估表」
醫學文獻之佐證
其他致病因之考量
「非工作造成心理負荷評估表」
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報告完畢
敬請指教
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