精神分裂症与其他精神病性障碍（schizophrenia and other psychotic disorders）课件

精神分裂症与其他精神病性障碍 (schizophrenia and other psychotic disorders) 中南大学精神卫生研究所 陈晓岗 The mental health institute of south-central university Chen Xiaogang MD.,Ph.D. *1 学习目标 1掌握精神分裂症的临床表现、诊断和鉴别诊断、 治疗和预防复发策略 2掌握精神分裂症疾病的分型、预后特征 3了解精神分裂症疾病的病因学 Date2 The definition of Schizophrenia in CCMD-3 Schizophrenia comprises a group of psychotic disorders of unknown specific etiology often presented with a gradual onset of abnormalities in perception, thought, motion and behavior since young adulthood. Consciousness is usually maintained. Intelligence is intact, but in some cases, there is some degree of cognitive impairment. The natural course of the disorder is chronic remitting but sometimes deteriorating. Date3 Epidemiology 1 Prevalence ： uPoint prevalence in China (1982): 4.75（rural area 3.42，urban 6.06 )。 uTotal prevalence in China(1982):5.69，(6.55 1999)。 uLifetime prevalence in USA（1988）13。 Date4 Epidemiology 2 nAge：the age of onset in 50% of patients is 2030 year old，over 80% of patients is 1635year old. nGender： uSchizophrenia occurs equally in men and women(in abroad) uThe prevalence in men is more than women (1.6:1) in China. uThe mean age of onset is about 2 to 5 years earlier in men than women. Date5 History（1） Schneider -first rank symptoms（首级症状） 1.thought hearing (思维化声) 2. Third-person hallucinations (争论性幻听) 3. Hallucinations in the form of a commentary(评论性 幻听) 4. thought withdrawal or insertion (思维被夺/被插入) 5. Thought broadcasting /diffusion(思维被广播或扩散) 6. Forced feeling (强加的情感) 7. forced impulsive (强加的冲动) 8. forced behavior (强加的行为) 9. somatic passivity experience (躯体被动体验) 10. delusional perception (妄想性知觉) Date6 Etiology 一、 biological factors 1genetics 2The neurodevelopmental hypothesis 3Changes in brain structure 4Biochemical abnormalities 二、personality factors 三、psycho-social factors Date7 Genetics 1 Studies Method: uFamily studies uTwin studies uAdoption studies Date8 Genetics 2 The results of family studies: uThe risk of Schizophrenia. Schizoaffective disorder, and schizotypal personality is increased in first-degree relatives of patients with Schizophrenia. uThe risk of both Schizophrenia and mood disorder is increased in first-degree relatives of patients with schizoaffective disorder. uThe risk of bipolar illness is not increased in first- degree relatives of patients with schizophrenia. Date9 Genetics 3 The results of twin studies uconcordance rates among MZ pairs is higher than that among control(35-60 times) uconcordance rates are about 50% for MZ and about 10% for DZ. It might be expected that some environmental factors relevant to etiology. uThe risk of schizophrenia in the offspring of an unaffected twin is the same as that of an affected twin. This means that an unaffected twin has the same genetic susceptibility to developing Schizophrenia, but for some reason the susceptibility is not expressed. Date10 Genetics 4 The results of adoption studies uThe rate for Schizophrenia is greater among the biological relatives of the Schizophrenia Adoptees than among the relatives of control. uThe finding supports the genetic hypothesis. Date11 Molecular genetic studies Two main approaches: 1. linkage analysis It is applied to multiply affected families(高发家系）, but no linkage markers have been clearly identified. 2. Candidate gene approaches Genes for biological mechanisms that may be involved in Schizophrenia have been localized and cloned. Using this technique, a number of genes coding for DA and 5-HT receptors have been excluded from linkage to Schizophrenia in various pedigrees（家系）. Date12 Biochemical studies The dopamine hypothesis. n5-HT hypothesis. nAmino acids in Schizophrenia Date13 Etiology studies-conclusions 1 nThere is strong evidence that schizophrenia has important genetic causes, but the mode of inheritance is not known. nThere is increasing evidence that many cases are of neurodevelopmental origin, but whether neurodevelopmental abnormalities are present in all patients is not clear. nMost believe that Sch. results from an interaction of genetic predisposition and environmental factors. nStressful life events often provoke the disorder, but non- specific events to schizophrenia. Date14 Etiology studies-conclusions 2 nSchizophrenia May be preceded by cognitive and social impairment in childhood, and that the presence of these impairment and certain kind of personality disorder are forms of expression of schizophrenia genotype n精神分裂症病人可 能在儿童期就有认 知和社会功能损害 ，这些损害及某些 人格障碍的出现是 精神分裂症基因型 表达的一种形式 Date15 Etiology studies-conclusions 3 nThe deficits of temporal and frontal structural and function are associated with non-progressive neuropsychological impairment. nDopamine receptor are blocked by drugs that control symptoms , but there is no compelling evidence at present that over-activity of DA systems is the central disorder in schizophrenia. n颞叶与额叶的功 能和结构的缺陷 与非进展性的神 经心理损害有关 n多巴胺受体阻断 能控制症状，但 尚无确信证据表 明多巴胺功能亢 进是该病的主要 原因 Date16 clinical features All of the symptoms and signs that described in chapter 4 may be seen in schizophrenic patients, but different symptoms and signs have different diagnostic value for schizophrenia. Date17 Prodromal syndrome nChanges in mood: depression, anxiety, mood swings, irritability nChanges in cognition: odd or unusual ideas, vagueness, deterioration in study or work nChanges in perception of self and the world nChanged behaviors, withdrawal and loss of interest in socializing, suspiciousness, deterioration in role function nPhysical changes: in sleep and appetite, loss of energy, reduced drive and motivation, etc. Date18 Disorders of sensation and perception 感觉障碍(disorders of sensation) 感觉过敏(hyperesthesia) 感觉减退(hypoesthesia) 内感性不适(senestopathia) 知觉障碍（disturbance of perception） 错觉(illusion) 幻觉(hallucination) 感知综合障碍(psychosensory disturbance) Date19 Disorders of sensation and perception n幻听(auditory hallucination) n幻视(visual hallucination) n幻嗅(olfactory hallucination) n幻味(gustatory hallucination) n幻触(tactile hallucination) n内脏幻觉(visceral hallucination) n功能性幻觉（functional hallucination） n反射性幻觉（reflex hallucination） Date20 Thinking disorder 思维形式障碍 (disorders of the thinking form) u思维贫乏(poverty of thought) u思维散漫( looseness of thought) u思维破裂(splitting of thought) 思维不连贯(incoherence of thought) u思维中断(blocking of thought) 思维被夺( thought deprivation)。 u思维插入(thought insertion)和强制性思维(forced thinking) u思维化声(thought hearing) u思维扩散(diffusion of thought)和思维被广播(thought broadcasting) u象征性思维(symbolic thinking) u语词新作(neologism) u逻辑倒错性思维(paralogism thinking) u强迫观念（obsessive idea） 或称强迫性思维 u内向性思维（autism） Date21 delusion 妄想(delusion) 按其起源与其他心理活动的关系可分为原 发性妄想(primary delusion)和继发性妄想(secondary delusion) u被害妄想(delusion of persecution) u关系妄想(delusion of reference) u物理影响妄想(delusion of physical influence)-被控制感。 u钟情妄想(delusion of love) u嫉妒妄想(delusion of jealousy) u被洞悉感(experience of being revealed) u夸大妄想(grandiose delusion) u罪恶妄想(delusion of guilt) u疑病妄想（hypochondriacal delusion） u虚无妄想(delusion of negation) Date22 Abnormalities of mood Three main kinds of mood are common: First, there may be sustained abnormalities of mood such as anxiety ,depression, irritability, or euphoria. Second, there may be blunting of affect. Essentially this is sustained emotional indifference（冷淡） or diminution of emotional response. Third, there is incongruity of affect. Here the expressed mood is not in keeping with situation or with the patients own feeling. Date23 Abnormalities of volition nSome acute patients are normal nOthers may present somewhat abnormalities of volition uhypobulia uabulia uParabulia（意向倒错） uambivalence uparanoid schizophrenia may present hyperbulia Date24 Abnormalities of behavior 1 nExcitement（兴奋状态）-hebephrenic excitement, catatonic excitement nStupor（木僵）-. The patient remain motionless for a long time(catatonic stupor), or maintain their limbs or trunks in unusual positions(waxy flexibilitas ) for various lengths of time. nNegativism（违拗）- refuse to cooperate (active negativism, passive negativism) nPassive obedience（被动服从） Date25 Abnormalities of behavior 2 nStereotyped act-（刻板动作）-the patient repeat various functions or gestures, or imitate other movements(echopraxia 模仿动作) nMannerism（作态） nBizarre behavior（怪异行为） nForced act ， compulsive act nViolence and suicide behavior nSome patients may cause self-induced water intoxication or avoid eating because of certain delusional beliefs. Date26 Orientation and insight nIn acute schizophrenia orientation is normal nInsight is usually impaired. Most of patient do not accept that their experiences result from illness Date27 Cognitive dysfunction 1 nCognitive dysfunction Is a cardinal(主要的） feature of schizophrenia nOn average, first diagnosed schizophrenic patients IQ is 10 points lower than control. nChildren at risk for schizophrenia have lower IQs than do control. n认知功能异常是 精分症的主要特 征 n首诊的精分症病 人较正常人IQ低 10分 n高危儿童的IQ低 于正常对照组 Date28 Cognitive dysfunction 2 nThe first episode patients exhibit impairments in attention, concentration, working memory, visual- spatial memory, semantic memory, recall memory,and executive function. nCognitive impairment is often independent of positive and negative symptoms and even of the disorganization syndrome and the course of illness n首发精分症病人 表现有注意力、 注意集中能力、 工作记忆、视-空 记忆、语义记忆 、回忆和执行功 能的异常 n认知功能损害独 立于阳性和阴性 症状，甚至独立 于解体症状和疾 病的病程。 Date29 Tab. 3 The most frequent symptoms of acute schizophrenia（急性精分症病人症状频谱） Symptom Frequency (%) Lack of insight 97 Auditory hallucinations 74 Ideas of reference 70 Suspiciousness 66 Flatness of affect 66 Delusional mood 64 Delusions of persecution 64 Thoughts spoken aloud 50 Date30 The chronic syndrome nIn contrast with the positive of the acute schizophrenia, the chronic syndrome is characterized by thought disorder and the negative symptoms. nThe most striking feature is diminished volition, that is lack of drive and initiative. n与急性精分症相 比，慢性病人以 思维障碍和阴性 症状为特征 n最突出的症状是 意志减退，缺乏 动力和始动性 Date31 Subtypes of schizophrenia Schizophrenia has also been subdivided on the basis of psychopathology ,course,and response to treatment. uHebephrenic schizophrenia uParanoid schizophrenia uCatatonic schizophrenia uSimple schizophrenia uUndifferentiated schizophrenia uOther type or unspecified of schizophrenia Date32 Simple-schizophrenia nAbout 2% of patients can diagnosed this type. nIs characterized by the insidious（隐袭 性的） development of odd behavior , social withdrawal, and declining performance at work. nClear symptoms are absent. nDifficult to identify reliably. n约2%的病人可诊 断为此型 n其临床特点为： 隐袭性起病，逐 步出现一些奇怪 的 行为、回避社 交、社会功能减 退等 n常缺乏明确的精 神病性症状 n此型常难于确诊 Date33 Hebephrenic schizophrenia nAbout 11% of patients can diagnosed this type. nIs characterized by the absence of systematized delusions and the presence of incoherence and inappropriate affect. nSilly(愚蠢） and childish in their behavior n约11%的病人可 诊断此型 n以思维联想障碍 、情感不协调、 缺乏系统性的妄 想为特征 n常伴有一些幼稚 愚蠢行为、意向 亢进或倒错 Date34 Catatonia schizophrenia nThis type is much less frequently now than in previous years. nMotor disturbance is the dominant feature, consisting of either agitated hyperactivity or a decrease in gross motor activity with stupor, rigidity, or bizarre postures n此型较以往少见 n以运动障碍为主要 特征，表现为紧张 性兴奋和紧张性抑 制（木僵、肌肉强 劲、奇怪的姿势） Date35 Paranoid schizophrenia nThis type is the most common form of the illness. nIs characterized by prominent paranoid delusion, thought processes and mood are relatively spared. The patient may appear normal until his abnormal beliefs are uncovered n此型最常见 n以妄想为主要表现， 常伴有幻觉。思维过 程和情绪常相对完好 ，在妄想未被暴露时 ，病人常被认为“正 常”。 Date36 Undifferentiated schizophrenia nThis type is the next most frequent form nDelusions and hallucinations of any type are prominent and are accompanied by incoherence and grossly of disorganized behavior. n此型为第二常见 类型 n妄想和幻觉都突 出，常伴有思维 联想障碍和行为 紊乱 n不符合以上各型 的诊断 Date37 Other type schizophrenia nConditions meeting the general symptom criteria of schizophrenia. nThe clinical feature does not satisfy the criteria of any of the subtypes mentioned above such as children schizophrenia and late-onset schizophrenia n符合精分症的症 状标准 n临床特征不符合 以上各型，如儿 童和晚发性精分 症 Date38 Post-schizophrenic depression nThe patient exhibits features of schizophrenia in the past one year. The depressive symptoms occur when the schizophrenic symptoms are in partial remission nProminent depressive symptoms have been present for at least two weeks, accompanied by residual psychotic symptoms nDepression and schizoaffective disorder are excluded. n在过去一年诊断 为精分症，抑郁 症状发生在精神 症状部分缓解后 n明显的抑郁症状 持续至少2周，且 伴随有残留的精 神症状 n排除抑郁症和分 裂情感障碍 Date39 Residual schizophrenia nSchizophrenia without complete remission for at least 2 years; nMarked improvement in mental state with partial remission of symptoms and presence of at least one of the following: uspecific positive symptom; uspecific negative symptom, such as poverty of thought, apathy, abulia or social withdrawal; upersonality change. uThe impairment of social functioning and insight are not severe; u Symptoms are relatively stable and have minimal improvement or deterioration for at least one year n患精分症至少2年 未彻底缓解 n精神症状明显改 进，但仍表现至 少以下一项： u个别阳性症状 u个别阴性症状 u人格改变 u社会功能和自 知力损害但不 严重 u症状相对稳定 至少一年 Date40 Chronic schizophrenia nSymptoms meeting the diagnostic criteria of schizophrenia; nThe course lasts for at least 2 years. Date41 Type I and type type II schizophrenia nCrow have described two syndromes in 1980 nThe feature of Type I: acute onset, positive symptoms, good social function during remissions, good response to antipsychotic drug, DA over-activity. n1980年由英国学者 Crow提出 n I 型综合征的特征 ：急性起病、阳性 症状、缓解后社会 功能良好、对药物 治疗反应良好、多 巴胺功能亢进 Date42 Type I and type type II schizophrenia nThe feature of Type II: negative symptoms, poor outcome,poor response to antipsychotic drugs, without evidence of DA over-activity, poor premorbid adjustment, an earlier age of onset, structure change in the brain. nMost of patients are a mixture of type I and type II nII 型精分症的特点： u阴性症状为主 u预后不良 u对药物治疗反应 不佳 u无多巴胺功能亢 进的证据 u病前适应不良 u起病年龄较早 u有脑结构异常 n大多数病人为一种 混合类型 Date43 The feature of Course Over a 30 year period(随访30年结果） u25% of patients recover fully u35% improve significantly and reach relative independence u15% improve but require extensive help u10% remain hospitalized and unimproved u15% die mostly as a result of suicide Date44 Diagnosis and differential diagnosis 诊断与鉴别诊断 Date45 CCMD-3 diagnostic criteria Symptom criteria（症状标准） Two of the following criteria are met. In general, mental retardation, manic-depressive episodes and delirium are excluded. There is separate diagnostic criteria for simple type of schizophrenia: 1.Repeated auditory hallucinations that are usually not mood congruent; 2. Loosening of association, derailment, incoherence in thinking or poverty of thought 3.Thought insertion or withdrawal, thought block or forced thinking Date46 CCMD-3 diagnostic criteria 4. Delusion of control, influence or passivity, thought broadcasting; 5. Primary delusions including delusional perception, delusional mood or other bizarre delusions; 6. Paralogic thinking, symbolic thought or neologism; 7. parathymia (情感倒错） or apathy; 8. Catatonic syndrome, unusual or silly behavior; 9. Avolition. Date47 Differential diagnosis Some neurosis（某些神经症） 1.the feature of insight 2.the feature of symptoms 3.some patients need to be following-up Date48 Differential diagnosis Mood disorder（心境障碍） nManic or severely depressed patients may exhibit psychotic symptoms during the peak of their disease states nAccurate historical and clinical data should help to differentiate from mania-related psychotic features in the presence of other symptoms such as: uincreased energy levels, ugrandiosity, uhypersexuality, uirritability uspeech, udistractibility. nBy the same token to differentiate depression from schizophrenia. Date49 Psychotic disorder due to a general medical or neurologic condition &substance-induced psychotic disorder 1. Carefully evaluate the chronology of symptoms in relation to the inciting cause and note whether symptoms improve or worsen in relation to such cause. 2. The feature of symptoms and course 3. Laboratory examination n仔细评估症状的 产生与促发因素 在时间上的联系 ，症状的消长与 这种促发因素的 关系 n分析症状的特征 与病程演变的特 征 n必要的实验室检 查 Date50 Personality disorder Schizotypal, schizoid, paranoid, and borderline personality disorder share some feature with schizophrenia, such as Paranoid ideation, magical thinking, social avoidance, vague speech. In personality disorder above symptoms are: 1. mild 2.present throughout the patients life 3. have no exact date of onset n分裂型、分裂样、偏 执行、及边缘型人格 障碍常具有某些精分 症的特征，如偏执观 念、社交回避，一些 奇怪的思想和言行 n但人格障碍的症状： 相对较轻，贯穿病人 的一生、无确切的发 病日期 Date51 Treatment and prevention 治疗和预防 Date52 Treatment recommendations 急性发作的药物治疗 pharmacotherapies: treatment of acute symptom episodes Date53 Treatment recommendations 1. Antipsychotic medications, should be used as the first-line treatment to reduce psychotic symptoms for persons experiencing an acute symptom episode of schizophrenia. 2. The dosage of antipsychotic medication for an acute symptom episode should be in the range of 300-800 mg CPZ equivalents per day for a minimum of 6 weeks. Outside this range should be justified. n急性发作的病人 抗精神病药物应 作为首先的治疗 方案 n药物的剂量以氯 丙嗪的效价折算 为300-700mg/天 ，至少治疗6周。 超过此剂量要做 相当的临床判断 Date54 Treatment recommendations 3。Persons experiencing their first acute symptom episode should be treated with an antipsychotic drug. but the dosage should remain in the lower end of the range (300-500mg CPZ equivalents per day) 4. Rapid neuroleptization should not be used 5. No superior efficacy of any drugs over another in the treatment positive symptoms, choice of drugs should be made on the basis patient acceptability prior individual drug response side-effect profile long-term treatment planning n首发病人剂量可适当 减量 n不应采用快速神经阻 滞化治疗 n对阳性症状的治疗各 种抗精神病药物的疗 效相当，药物的选择 主要依据以下方面： u病人的接受性、 u以前对药物的反 应、副作用大小 、 u长期治疗