利用者:Anesth Earth/作業場3
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| 自律神経失調症 | |
|---|---|
| 別称 | Autonomic failure, Autonomic dysfunction |
 | |
| The autonomic nervous system | |
| 概要 | |
| 診療科 | 神経学、精神医学 心身医学 |
| 症状 | Anhidrosis or hyperhidrosis, blurry vision, tunnel vision, orthostatic hypotension, constipation, diarrhea, anxiety, dysphagia, bowel incontinence, urinary retention or urinary incontinence, dizziness, Brain Fog, exercise intolerance, insomnia, tachycardia, vertigo, weakness and pruritus.[1] |
| 原因 | Inadequacy of sympathetic, or parasympathetic, components of autonomic nervous system[2] |
| 危険因子 | Alcoholism and Diabetes[3] |
| 診断法 | Ambulatory Blood pressure, as well as EKG monitoring[より良い情報源が必要][4] |
| 治療 | Symptomatic and supportive[2] |
| 分類および外部参照情報 | |
| ICD-10 | G90 |
| ICD-9-CM | 337.9 |
| MeSH | D001342 |
自律神経不全とはしばしば混同されるが[5]、自律神経失調症とは体位性頻脈症候群（postural tachycardia syndrome: PoTS）や神経調節性失神（neurally mediated syncope: NMS）など，交感神経または副交感神経機能，あるいはその双方が亢進を示す病態であり、自律神経不全症とは、シャイ・ドレーガー症候群など，交感・副交感神経機能の 双方が機能低下を示す病態である、と埼玉医科大学神経内科の田村直俊は述べている[5][6]。第二次世界大戦前、自律神経学の中心テーマは自律神経失調症であったが戦後は潮流が一変して自律神経不全症が主要テーマになり、自律神経失調症は“junk disease”とみなされるようになった[5]。1992年からの欧米でのPoTSの概念提唱は田村自らが「自律神経失調症の概念のリバイバル」[5]と言うように、自律神経失調症そのものは、神経内科領域全体で疾患概念としては再確立されたとは言えない現状を表すものである。
機序
[編集]目前に捕食動物が現れたり、敵との闘争が必要な状況下になると、副腎髄質よりアドレナリンなど神経伝達物質が分泌され、交感神経を興奮させる。交感神経は脈拍や呼吸数の増加、体温の上昇などの反応を引き起こし、身体を予想される激しい活動に備えた状態にする[7]。このため交感神経は「闘争と逃走の神経」などとも呼ばれる。
一方で副交感神経は、睡眠や休息を行う時に活性化し、脈拍や呼吸数の低下、身体の弛緩など、身体をリラックスさせ、休息に適した状態にする[7]。睡眠や安静には、副交感神経の活動が必須である[要出典]。
健康な状態では、これら相反する２つの神経活動の綱引きのバランスが保たれ、身体は問題なく休息と活動のそれぞれに適した状態に移行できる。しかしなんらかの理由により、これらの神経活動の調和が崩れ、休息し入眠したいのに交感神経が活性化し、異常な興奮や発汗で眠れない、また全く正反対に、副交感神経が過剰に活発化し、活動が必要な状況で極端な無気力・無反応になるなどの症状が現れたものが自律神経失調症である[要出典]。
人体ではおよそ12時間交代でこの二つの神経の優位が入れ替わるとされているが、過労、ストレスなどで脳を休める時間が減ると自律神経が興奮し、結果的に交感神経と副交感神経の優位入れ替わりのバランスが崩れ、自律神経失調症となるとされている[要出典]。
自律神経の中枢は脳の視床下部というところにあり、この場所は情緒、不安や怒り等の中枢とされる辺縁系と相互連絡していることから、こころの問題も関わってくる[要出典]。
治療
[編集]多くの患者は内科ではなく心療内科や神経科に通院する[要出典]。治療には抗不安薬やホルモン剤を用いた薬物療法や、睡眠の周期を整える行動療法などが行われている[要出典]。最近では体内時計を正すために強い光を体に当てる、見るなどの療法もある[要出典]。
西洋医学での改善が認められない場合は、鍼灸・整体・マッサージ・カウンセリングなどが有効な場合もある[要出典]。
成長時の一時的な症状の場合、薬剤投入をしないで自然治癒させる場合もある。また、自ら自律訓練法を用いて心因的ストレスを軽減させ、症状を改善させる方法もある。薬物療法において、自律神経を調整する作用を持つトフィソパムの投与が有効であったとする報告例がある[8]。
漢方薬
[編集]漢方薬の場合、若年から老年まで幅広い年齢に適用できる[9]。漢方で副作用が既往に生じたものは原則として適応外[10]。
症状と所見を元にした頻用処方を以下に示す（主訴→随伴症状の順）[10]。
- めまい・たちくらみ
- 動悸
- 頭痛・頭重
- 全身倦怠感
- 不定愁訴
xxx（英: Dysautonomia）
Dysautonomia, autonomic failure or autonomic dysfunction is a condition in which the autonomic nervous system (ANS) does not work properly. This may affect the functioning of the heart, bladder, intestines, sweat glands, pupils, and blood vessels. Dysautonomia has many causes, not all of which may be classified as neuropathic.[11] A number of conditions can feature dysautonomia, such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies,[12] Ehlers–Danlos syndromes,[13] autoimmune autonomic ganglionopathy and autonomic neuropathy,[14] HIV/AIDS,[15] pure autonomic failure, autism and postural orthostatic tachycardia syndrome.
The diagnosis is achieved through functional testing of the ANS, focusing on the affected organ system. Investigations may be performed to identify underlying disease processes that may have led to the development of symptoms or autonomic neuropathy. Symptomatic treatment is available for many symptoms associated with dysautonomia, and some disease processes can be directly treated. Depending on the severity of the dysfunction, dysautonomia can range from being nearly symptomless and transient to disabling and/or life-threatening.[16]
Signs and symptoms
[編集]The symptoms of dysautonomia, which are numerous and vary widely for each individual, are due to inefficient or unbalanced efferent signals sent via both systems.[要出典医学] The primary symptoms in individuals with dysautonomia include:
Causes
[編集]
Dysautonomia may be due to inherited or degenerative neurologic diseases (primary dysautonomia)[11] or it may occur due to injury of the autonomic nervous system from an acquired disorder (secondary dysautonomia).[1][18] The most common causes of dysautonomia include:
- アルコール依存症[17]
- アミロイドーシス[より良い情報源が必要][4]
- 自己免疫疾患, such as シェーグレン症候群 or 全身性エリテマトーデス (lupus), and autoimmune autonomic ganglionopathy[要出典]
- Craniocervical instability[17]
- Diabetes[17]
- ランバート・イートン症候群[要出典医学]
- エーラス・ダンロス症候群[19]
- ギラン・バレー症候群[17]
- HIV and AIDS[17]
- Long COVID[20]
- 多発性硬化症[17]
- 腫瘍随伴症候群[21]
- 脊髄損傷[17] or 外傷性脳損傷[22]
- シヌクレイノパチー, a group of neurodegenerative diseases including dementia with Lewy bodies, multiple system atrophy, and Parkinson's disease[12]
- Surgery or injury involving the nerves[17]
- Toxicity (vincristine)[23]
In the sympathetic nervous system (SNS), predominant dysautonomia is common along with fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis, raising the possibility that such dysautonomia could be their common clustering underlying pathogenesis.[24]
In addition to sometimes being a symptom of dysautonomia, anxiety can sometimes physically manifest symptoms resembling autonomic dysfunction.[25][26][27] A thorough investigation ruling out physiological causes is crucial, but in cases where relevant tests are performed and no causes are found or symptoms do not match any known disorders, a primary anxiety disorder is possible, but should not be presumed.[28] For such patients, the anxiety sensitivity index may have better predictivity for anxiety disorders, while the Beck Anxiety Inventory may misleadingly suggest anxiety for patients with dysautonomia.[29]
Mechanism
[編集]The autonomic nervous system is a component of the peripheral nervous system and comprises two branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS). The SNS controls the more active responses such as increasing heart rate and blood pressure. The PSNS slows down the heart rate and aids in digestion, for example. Symptoms typically arise from abnormal responses of either the sympathetic or parasympathetic systems based on situation or environment.[11][30][22]
Diagnosis
[編集]
The diagnosis of dysautonomia depends on the overall function of three autonomic functions – cardiovagal, adrenergic, and sudomotor. A diagnosis should, at a bare minimum, include measurements of blood pressure and heart rate while lying flat, and after at least 3 minutes of standing. The best way to achieve a diagnosis includes a range of testing, notably an autonomic reflex screen, tilt table test, and testing of the sudomotor response (ESC, QSART or thermoregulatory sweat test).[31]
Additional tests and examinations to determine a diagnosis of dysautonomia include:
- Ambulatory blood pressure and EKG monitoring[より良い情報源が必要][4]
- Cold pressor test[31]
- Deep breathing[31]
- Electrochemical skin conductance[要出典]
- Hyperventilation test[31]
- Nerve biopsy for small fiber neuropathy[1]
- Quantitative sudomotor axon reflex test (QSART)[31]
- Testing for orthostatic intolerance[31]
- Thermoregulatory sweat test[31][22]
- Tilt table test[31]
- Valsalva maneuver[31][22]
Tests to elucidate the cause of dysautonomia can include:
- Evaluation for acute (intermittent) porphyria[1]
- Evaluation of cerebrospinal fluid by lumbar puncture[1]
Vegetative-vascular dystonia
[編集]Particularly in the Russian literature,[32] a subtype of dysautonomia which particularly affects the vascular system has been called vegetative-vascular dystonia.[33] The term "vegetative" reflects an older name for the autonomic nervous system: the vegetative nervous system.[要出典]
A similar form of this disorder has been historically noticed in various wars, like the Crimean War and American Civil War and among British troops who colonized India. This disorder was referred to as "irritable heart syndrome" (Da Costa's syndrome) in 1871 by American physician Jacob DaCosta.[34]
Management
[編集]
The treatment of dysautonomia can be difficult; since it is made up of many different symptoms, a combination of drug therapies is often required to manage individual symptomatic complaints. Therefore, if an autoimmune neuropathy is the case, then treatment with immunomodulatory therapies is done, or if diabetes mellitus is the cause, control of blood glucose is important.[1] Treatment can include proton-pump inhibitors and H2 receptor antagonists used for digestive symptoms such as acid reflux.[35]
For the treatment of genitourinary autonomic neuropathy medications may include sildenafil (a guanine monophosphate type-5 phosphodiesterase inhibitor). For the treatment of hyperhidrosis, anticholinergic agents such as trihexyphenidyl or scopolamine can be used, also intracutaneous injection of botulinum toxin type A can be used for management in some cases.[36]
Balloon angioplasty, a procedure referred to as transvascular autonomic modulation, is specifically not approved in the United States for the treatment of autonomic dysfunction.[37]
Prognosis
[編集]The prognosis of dysautonomia depends on several factors; individuals with chronic, progressive, generalized dysautonomia in the setting of central nervous system degeneration such as Parkinson's disease or multiple system atrophy have a generally poorer long-term prognosis. Consequently, dysautonomia could be fatal due to pneumonia, acute respiratory failure, or sudden cardiopulmonary arrest.[11]Autonomic dysfunction symptoms such as orthostatic hypotension, gastroparesis, and gustatory sweating are more frequently identified in mortalities.[38]
脚注
[編集]- ^ a b c d e f g h i j k l m “Autonomic Neuropathy Clinical Presentation: History, Physical, Causes”. emedicine.medscape.com. 2016年2月21日閲覧。
- ^ a b “Dysautonomia Information Page | National Institute of Neurological Disorders and Stroke”. www.ninds.nih.gov. 2 January 2018閲覧。
- ^ “Dysautonomia | Autonomic Nervous System Disorders | MedlinePlus” (英語). NIH. 2 January 2018閲覧。
- ^ a b c d e f g h i j k l [より良い情報源が必要]“Autonomic Neuropathy. Information about AN. Patient | Patient”. Patient info. 2016年2月21日閲覧。
- ^ a b c d 田村直俊 (2015). “自律神経失調症と自律神経不全症”. 自律神経 52: 2.
- ^ 田村直俊，山元敏正，中里良彦ら (2007). “自律神経失調症の歴史的展望”. 自律神経 44: 171-179.
- ^ a b “自律神経失調症”. e-ヘルスネット 情報提供. 2023年10月7日閲覧。
- ^ 田中文雄、赤木成子、藤本政明 ほか、「めまい、耳鳴に対するトフィソバムの臨床的検討」 『耳鼻と臨床』 1994年 40巻 5号 p.851-856, doi:10.11334/jibi1954.40.5_851
- ^ 精神疾患・発達障害に効く漢方薬―「続・精神科セカンドオピニオン」の実践から (精神科セカンドオピニオン) 内海 聡 (著)
- ^ a b c d e f g h i j k 日本医師会『漢方治療のABC』医学書院〈日本医師会生涯教育シリーズ〉、1992年、129-132頁。ISBN 4260175076。
- ^ a b c d e “Dysautonomia”. NINDS. 2016年12月2日時点のオリジナルよりアーカイブ。2012年4月3日閲覧。
- ^ a b “Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies”. Mov Disord 33 (3): 372–90. (March 2018). doi:10.1002/mds.27344. PMC 5844369. PMID 29508455.
- ^ “Neurological manifestations of Ehlers-Danlos syndrome(s): A review”. Iranian Journal of Neurology 13 (4): 190–208. (October 2014). PMC 4300794. PMID 25632331.
- ^ “Ganglionic Acetylcholine Receptor Antibodies and Autonomic Dysfunction in Autoimmune Rheumatic Diseases”. Int J Mol Sci 21 (4): 1332. (February 2020). doi:10.3390/ijms21041332. PMC 7073227. PMID 32079137.
- ^ “A meta-analysis of HIV and heart rate variability in the era of antiretroviral therapy”. Clin Auton Res 26 (4): 287–94. (August 2016). doi:10.1007/s10286-016-0366-6. PMID 27395409.
- ^ “Efficacy of immunotherapy in seropositive and seronegative putative autoimmune autonomic ganglionopathy”. Neurology 72 (23): 2002–8. (June 2009). doi:10.1212/WNL.0b013e3181a92b52. PMC 2837591. PMID 19506222.
- ^ a b c d e f g h i MedlinePlus Encyclopedia Autonomic neuropathy
- ^ “Dysautonomia after pediatric brain injury”. Developmental Medicine and Child Neurology 54 (8): 759–64. (August 2012). doi:10.1111/j.1469-8749.2012.04322.x. PMC 3393822. PMID 22712762.
- ^ “Dysautonomia and its underlying mechanisms in the hypermobility type of Ehlers-Danlos syndrome”. Seminars in Arthritis and Rheumatism 44 (1): 93–100. (August 2014). doi:10.1016/j.semarthrit.2013.12.006. PMID 24507822.
- ^ Paliwal, V. K.; Garg, R. K.; Gupta, A.; Tejan, N. (2020). “Neuromuscular presentations in patients with COVID-19”. Neurological Sciences 41 (11): 3039–3056. doi:10.1007/s10072-020-04708-8. PMC 7491599. PMID 32935156.
- ^ “Paraneoplastic syndromes of the nervous system”. Mayo Clinic. 13 September 2016閲覧。
- ^ a b c d Acob, Lori Mae Yvette. (2021). Autonomic Nervous System Dysfunction – Concussion Alliance. Retrieved 21 September 2021, from https://www.concussionalliance.org/autonomic-nervous-system-dysfunction
- ^ “Orthostatic hypotension possibly caused by vincristine”. Neurology and Clinical Neuroscience 9 (4): 365-366. (May 2021).
- ^ “Sympathetic nervous system dysfunction in fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis: a review of case-control studies”. Journal of Clinical Rheumatology 20 (3): 146–50. (April 2014). doi:10.1097/RHU.0000000000000089. PMID 24662556.
- ^ “Postural orthostatic tachycardia syndrome (POTS): a diagnostic dilemma.”. British Journal of Cardiology 17 (1): 36–9. (2010).
- ^ Ackerman, Kurt; DiMartini, Andrea F. (2015) (英語). Psychosomatic Medicine. Oxford University Press, Incorporated. ISBN 9780199329311
- ^ Carr, Alan; McNulty, Muireann (2016-03-31) (英語). The Handbook of Adult Clinical Psychology: An Evidence Based Practice Approach. Routledge. ISBN 9781317576143
- ^ Tasman, Allan; Kay, Jerald; First, Michael B.; Lieberman, Jeffrey A.; Riba, Michelle (2015-03-30) (英語). Psychiatry, 2 Volume Set. John Wiley & Sons. ISBN 9781118845479
- ^ “Psychiatric profile and attention deficits in postural tachycardia syndrome”. Journal of Neurology, Neurosurgery, and Psychiatry 80 (3): 339–44. (March 2009). doi:10.1136/jnnp.2008.144360. PMC 2758320. PMID 18977825.
- ^ “Autonomic Nervous System — National Library of Medicine”. PubMed Health. National Center for Biotechnology Information. 2016年2月21日閲覧。
- ^ a b c d e f g h i “Dysautonomia: perioperative implications”. Anesthesiology 116 (1): 205–15. (January 2012). doi:10.1097/ALN.0b013e31823db712. PMC 3296831. PMID 22143168.
- ^ Loganovsky, Konstantin (1999). “Vegetative-Vascular Dystonia and Osteoalgetic Syndrome or Chronic Fatigue Syndrome as a Characteristic After-Effect of Radioecological Disaster”. Journal of Chronic Fatigue Syndrome 7 (3): 3–16. doi:10.1300/J092v07n03_02.
- ^ “[State-of-the-art corrective and diagnostic technologies in medical rehabilitation of patients with vegetative vascular dystonia]”. Voprosy Kurortologii, Fizioterapii, I Lechebnoi Fizicheskoi Kultury (1): 4–7. (2008). PMID 18376477.
- ^ Halstead, Megan (2018-01-01). “Postural Orthostatic Tachycardia Syndrome: An Analysis of Cross-Cultural Research, Historical Research, and Patient Narratives of the Diagnostic Experience”. Senior Honors Theses & Projects.
- ^ “H2 Blockers. Reducing stomach acid with H2 Blockers. | Patient” (英語). Patient. 2016年2月21日閲覧。
- ^ “Diabetic Autonomic Neuropathy”. Template:Cite webの呼び出しエラー：引数 accessdate は必須です。
- ^ “Safety Alerts for Human Medical Products — Balloon angioplasty devices to treat autonomic dysfunction: FDA Safety Communication — FDA concern over experimental procedures” (英語). fda.gov. 5 December 2020閲覧。
- ^ “Diabetic autonomic neuropathy”. Diabetes Care 26 (5): 1553–79. (May 2003). doi:10.2337/diacare.26.5.1553. PMID 12716821.
関連項目
[編集]
- Dopamine beta hydroxylase deficiency
- Familial dysautonomia
- Reflex syncope
- Postural orthostatic tachycardia syndrome
- Orthostatic intolerance
- 神経症
- メンタルケア
- 心理療法の一覧
参考文献
[編集]関連文献
[編集]
- Brading, Alison (1999). The autonomic nervous system and its effectors. Oxford: Blackwell Science. ISBN 978-0632026241
- Goldstein, David (2016). Principles of Autonomic Medicine (free online version ed.). Bethesda, Maryland: National Institute of Neurological Disorders and Stroke, National Institutes of Health. ISBN 9780824704087
- Jänig, Wilfrid (2008). Integrative action of the autonomic nervous system : neurobiology of homeostasis (Digitally printed version. ed.). Cambridge: Cambridge University Press. ISBN 978-0521067546
- “Dysautonomia due to reduced cholinergic neurotransmission causes cardiac remodeling and heart failure”. Molecular and Cellular Biology 30 (7): 1746–56. (April 2010). doi:10.1128/MCB.00996-09. PMC 2838086. PMID 20123977.
- Schiffer, Randolph B.; Rao, Stephen M.; Fogel, Barry S. (2003-01-01) (英語). Neuropsychiatry. Lippincott Williams & Wilkins. ISBN 9780781726559
外部リンク
[編集]- 知って得する病気の知識 自律神経失調症(精神科・心療内科)[リンク切れ] — 日本医師会によるサイト
- 心療内科Q＆A - 日本心療内科学会