精神分裂症与其他精神病性障碍

1、精神分裂症与其他精神病性障碍9/26/20221第1页，共74页，2022年，5月20日，9点1分，星期二学习目标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9/26/20222第2页，共74页，2022年，5月20日，9点1分，星期二The definition of Schizophrenia in CCMD-3Schizophrenia comprises a group of psychotic disorders of unknown specific etiology often presented

2、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

3、 deteriorating.9/26/20223第3页，共74页，2022年，5月20日，9点1分，星期二Epidemiology 1 Prevalence ：Point prevalence in China (1982): 4.75（rural area 3.42，urban 6.06 )。Total prevalence in China(1982):5.69，(6.55 1999)。Lifetime prevalence in USA（1988）13。9/26/20224第4页，共74页，2022年，5月20日，9点1分，星期二Epidemiology 2Age：the age of

4、 onset in 50% of patients is 2030 year old，over 80% of patients is 1635year old.Gender：Schizophrenia occurs equally in men and women(in abroad)The prevalence in men is more than women (1.6:1) in China.The mean age of onset is about 2 to 5 years earlier in men than women.9/26/20225第5页，共74页，2022年，5月20

5、日，9点1分，星期二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 impuls

6、ive (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) 9/26/20226第6页，共74页，2022年，5月20日，9点1分，星期二Etiology 一、 biological factors1genetics2The neurodevelopmental hypothesis3Changes in brain structure4Biochemical abnormalities二、personality factors三、p

7、sycho-social factors9/26/20227第7页，共74页，2022年，5月20日，9点1分，星期二Genetics 1 Studies Method: Family studiesTwin studies Adoption studies9/26/20228第8页，共74页，2022年，5月20日，9点1分，星期二Genetics 2 The results of family studies:The risk of Schizophrenia. Schizoaffective disorder, and schizotypal personality is increas

8、ed in first-degree relatives of patients with Schizophrenia.The risk of both Schizophrenia and mood disorder is increased in first-degree relatives of patients with schizoaffective disorder.The risk of bipolar illness is not increased in first-degree relatives of patients with schizophrenia.9/26/202

9、29第9页，共74页，2022年，5月20日，9点1分，星期二Genetics 3The results of twin studiesconcordance rates among MZ pairs is higher than that among control(35-60 times)concordance rates are about 50% for MZ and about 10% for DZ. It might be expected that some environmental factors relevant to etiology.The risk of schizo

10、phrenia 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.9/26/202210第10页，共74页，2022年，5月20日，9点1分，星期二Genetics 4The r

11、esults of adoption studiesThe rate for Schizophrenia is greater among the biological relatives of the Schizophrenia Adoptees than among the relatives of control.The finding supports the genetic hypothesis.9/26/202211第11页，共74页，2022年，5月20日，9点1分，星期二Molecular genetic studiesTwo main approaches: 1. linka

12、ge 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

13、and 5-HT receptors have been excluded from linkage to Schizophrenia in various pedigrees（家系）.9/26/202212第12页，共74页，2022年，5月20日，9点1分，星期二Biochemical studies The dopamine hypothesis.5-HT hypothesis.Amino acids in Schizophrenia9/26/202213第13页，共74页，2022年，5月20日，9点1分，星期二Etiology studies-conclusions 1There i

14、s strong evidence that schizophrenia has important genetic causes, but the mode of inheritance is not known.There is increasing evidence that many cases are of neurodevelopmental origin, but whether neurodevelopmental abnormalities are present in all patients is not clear.Most believe that Sch. resu

15、lts from an interaction of genetic predisposition and environmental factors.Stressful life events often provoke the disorder, but non-specific events to schizophrenia.9/26/202214第14页，共74页，2022年，5月20日，9点1分，星期二Etiology studies-conclusions 2Schizophrenia May be preceded by cognitive and social impairme

16、nt in childhood, and that the presence of these impairment and certain kind of personality disorder are forms of expression of schizophrenia genotype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9/26/202215第15页，共74页，2022年，5月20日，9点1分，星期二Etiology studies-conclusions 3The deficits of temporal

17、and frontal structural and function are associated with non-progressive neuropsychological impairment.Dopamine 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.颞叶与额叶的功能和结构的缺陷

18、与非进展性的神经心理损害有关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9/26/202216第16页，共74页，2022年，5月20日，9点1分，星期二clinical featuresAll 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.9/26/202217

19、第17页，共74页，2022年，5月20日，9点1分，星期二Prodromal syndromeChanges in mood: depression, anxiety, mood swings, irritabilityChanges in cognition: odd or unusual ideas, vagueness, deterioration in study or workChanges in perception of self and the worldChanged behaviors, withdrawal and loss of interest in sociali

20、zing, suspiciousness, deterioration in role functionPhysical changes: in sleep and appetite, loss of energy, reduced drive and motivation, etc.9/26/202218第18页，共74页，2022年，5月20日，9点1分，星期二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(senes

21、topathia) 知觉障碍（disturbance of perception）错觉(illusion)幻觉(hallucination) 感知综合障碍(psychosensory disturbance) 9/26/202219第19页，共74页，2022年，5月20日，9点1分，星期二Disorders of sensation and perception幻听(auditory hallucination)幻视(visual hallucination)幻嗅(olfactory hallucination)幻味(gustatory hallucination)幻触(tactile ha

22、llucination)内脏幻觉(visceral hallucination)功能性幻觉（functional hallucination） 反射性幻觉（reflex hallucination）9/26/202220第20页，共74页，2022年，5月20日，9点1分，星期二Thinking disorder 思维形式障碍 (disorders of the thinking form) 思维贫乏(poverty of thought) 思维散漫( looseness of thought) 思维破裂(splitting of thought) 思维不连贯(incoherence of t

23、hought)思维中断(blocking of thought) 思维被夺( thought deprivation)。思维插入(thought insertion)和强制性思维(forced thinking) 思维化声(thought hearing) 思维扩散(diffusion of thought)和思维被广播(thought broadcasting) 象征性思维(symbolic thinking) 语词新作(neologism) 逻辑倒错性思维(paralogism thinking) 强迫观念（obsessive idea） 或称强迫性思维内向性思维（autism） 9/26

24、/202221第21页，共74页，2022年，5月20日，9点1分，星期二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)被害妄想(delusion of persecution) 关系妄想(delusion of reference) 物理影响妄想(delusion of physical influence)-被控制感。钟情妄想(delusion of love) 嫉妒妄想(delusion of jealousy) 被洞悉感(experience of bein

25、g revealed)夸大妄想(grandiose delusion)罪恶妄想(delusion of guilt)疑病妄想（hypochondriacal delusion）虚无妄想(delusion of negation)9/26/202222第22页，共74页，2022年，5月20日，9点1分，星期二Abnormalities of moodThree main kinds of mood are common:First, there may be sustained abnormalities of mood such as anxiety ,depression, irritab

26、ility, 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.9/26/202223第23页，共7

27、4页，2022年，5月20日，9点1分，星期二Abnormalities of volitionSome acute patients are normal Others may present somewhat abnormalities of volitionhypobulia abulia Parabulia（意向倒错） ambivalenceparanoid schizophrenia may present hyperbulia 9/26/202224第24页，共74页，2022年，5月20日，9点1分，星期二Abnormalities of behavior 1Excitement

28、（兴奋状态）-hebephrenic excitement, catatonic excitementStupor（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.Negativism（违拗）- refuse to cooperate (active negativism, passive nega

29、tivism)Passive obedience（被动服从）9/26/202225第25页，共74页，2022年，5月20日，9点1分，星期二Abnormalities of behavior 2Stereotyped act-（刻板动作）-the patient repeat various functions or gestures, or imitate other movements(echopraxia 模仿动作)Mannerism（作态）Bizarre behavior（怪异行为）Forced act ， compulsive actViolence and suicide beh

30、aviorSome patients may cause self-induced water intoxication or avoid eating because of certain delusional beliefs.9/26/202226第26页，共74页，2022年，5月20日，9点1分，星期二Orientation and insightIn acute schizophrenia orientation is normalInsight is usually impaired. Most of patient do not accept that their experie

31、nces result from illness9/26/202227第27页，共74页，2022年，5月20日，9点1分，星期二Cognitive dysfunction 1Cognitive dysfunction Is a cardinal(主要的） feature of schizophreniaOn average, first diagnosed schizophrenic patients IQ is 10 points lower than control.Children at risk for schizophrenia have lower IQs than do con

32、trol.认知功能异常是精分症的主要特征首诊的精分症病人较正常人IQ低10分高危儿童的IQ低于正常对照组9/26/202228第28页，共74页，2022年，5月20日，9点1分，星期二Cognitive dysfunction 2The first episode patients exhibit impairments in attention, concentration, working memory, visual- spatial memory, semantic memory, recall memory,and executive function.Cognitive impa

33、irment is often independent of positive and negative symptoms and even of the disorganization syndrome and the course of illness.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。9/26/202229第29页，共74页，2022年，5月20日，9点1分，星期二Tab. 3 The most frequent symptoms of acute schizop

34、hrenia（急性精分症病人症状频谱）Symptom Frequency (%) Lack of insight 97Auditory hallucinations 74Ideas of reference 70Suspiciousness 66Flatness of affect 66Delusional mood 64Delusions of persecution 64Thoughts spoken aloud 509/26/202230第30页，共74页，2022年，5月20日，9点1分，星期二The chronic syndromeIn contrast with the posit

35、ive of the acute schizophrenia, the chronic syndrome is characterized by thought disorder and the negative symptoms.The most striking feature is diminished volition, that is lack of drive and initiative.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最突出的症状是意志减退，缺乏动力和始动性 9/26/202231第31页，共74页，2022年，5月20日，9点1分，星期二Subtypes

36、of schizophreniaSchizophrenia has also been subdivided on the basis of psychopathology ,course,and response to treatment.Hebephrenic schizophreniaParanoid schizophreniaCatatonic schizophreniaSimple schizophrenia Undifferentiated schizophrenia Other type or unspecified of schizophrenia9/26/202232第32页

37、，共74页，2022年，5月20日，9点1分，星期二Simple-schizophreniaAbout 2% of patients can diagnosed this type.Is characterized by the insidious（隐袭性的） development of odd behavior , social withdrawal, and declining performance at work.Clear symptoms are absent.Difficult to identify reliably.约2%的病人可诊断为此型其临床特点为：隐袭性起病，逐步出现

38、一些奇怪的 行为、回避社交、社会功能减退等常缺乏明确的精神病性症状此型常难于确诊9/26/202233第33页，共74页，2022年，5月20日，9点1分，星期二Hebephrenic schizophreniaAbout 11% of patients can diagnosed this type.Is characterized by the absence of systematized delusions and the presence of incoherence and inappropriate affect.Silly(愚蠢） and childish in their b

39、ehavior 约11%的病人可诊断此型以思维联想障碍、情感不协调、缺乏系统性的妄想为特征常伴有一些幼稚愚蠢行为、意向亢进或倒错9/26/202234第34页，共74页，2022年，5月20日，9点1分，星期二Catatonia schizophreniaThis type is much less frequently now than in previous years.Motor disturbance is the dominant feature, consisting of either agitated hyperactivity or a decrease in gross m

40、otor activity with stupor, rigidity, or bizarre postures 此型较以往少见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）9/26/202235第35页，共74页，2022年，5月20日，9点1分，星期二Paranoid schizophreniaThis type is the most common form of the illness.Is characterized by prominent paranoid delusion, thought processes and mood are rela

41、tively spared. The patient may appear normal until his abnormal beliefs are uncovered此型最常见以妄想为主要表现，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”。9/26/202236第36页，共74页，2022年，5月20日，9点1分，星期二Undifferentiated schizophreniaThis type is the next most frequent form Delusions and hallucinations of any type are promi

42、nent and are accompanied by incoherence and grossly of disorganized behavior.此型为第二常见类型妄想和幻觉都突出，常伴有思维联想障碍和行为紊乱不符合以上各型的诊断9/26/202237第37页，共74页，2022年，5月20日，9点1分，星期二Other type schizophreniaConditions meeting the general symptom criteria of schizophrenia.The clinical feature does not satisfy the criteria

43、of any of the subtypes mentioned above such as children schizophrenia and late-onset schizophrenia符合精分症的症状标准临床特征不符合以上各型，如儿童和晚发性精分症9/26/202238第38页，共74页，2022年，5月20日，9点1分，星期二Post-schizophrenic depressionThe patient exhibits features of schizophrenia in the past one year. The depressive symptoms occur w

44、hen the schizophrenic symptoms are in partial remissionProminent depressive symptoms have been present for at least two weeks, accompanied by residual psychotic symptomsDepression and schizoaffective disorder are excluded.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明显的抑郁症状持续至少2周，且伴随有残留的精神症状排除抑郁症和分裂情感障碍9/26/202239第3

45、9页，共74页，2022年，5月20日，9点1分，星期二Residual schizophreniaSchizophrenia without complete remission for at least 2 years;Marked improvement in mental state with partial remission of symptoms and presence of at least one of the following:specific positive symptom;specific negative symptom, such as poverty of

46、thought, apathy, abulia or social withdrawal;personality change.The impairment of social functioning and insight are not severe; Symptoms are relatively stable and have minimal improvement or deterioration for at least one year患精分症至少2年未彻底缓解精神症状明显改进，但仍表现至少以下一项：个别阳性症状个别阴性症状人格改变社会功能和自知力损害但不严重症状相对稳定至少一年

47、9/26/202240第40页，共74页，2022年，5月20日，9点1分，星期二Chronic schizophreniaSymptoms meeting the diagnostic criteria of schizophrenia;The course lasts for at least 2 years.9/26/202241第41页，共74页，2022年，5月20日，9点1分，星期二Type I and type type II schizophreniaCrow have described two syndromes in 1980The feature of Type I:

48、acute onset, positive symptoms, good social function during remissions, good response to antipsychotic drug, DA over-activity.1980年由英国学者Crow提出 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9/26/202242第42页，共74页，2022年，5月20日，9点1分，星期二Type I and type type II schizophreniaThe feature of Type II: negative

49、 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.Most of patients are a mixture of type I and type II II 型精分症的特点：阴性症状为主预后不良对药物治疗反应不佳无多巴胺功能亢进的证据病前适应不良起病年龄较早有脑结构异常大多数病人为

50、一种混合类型9/26/202243第43页，共74页，2022年，5月20日，9点1分，星期二The feature of Course Over a 30 year period(随访30年结果）25% of patients recover fully35% improve significantly and reach relative independence15% improve but require extensive help10% remain hospitalized and unimproved 15% die mostly as a result of suicide9

51、/26/202244第44页，共74页，2022年，5月20日，9点1分，星期二Diagnosis and differential diagnosis 诊断与鉴别诊断9/26/202245第45页，共74页，2022年，5月20日，9点1分，星期二CCMD-3 diagnostic criteriaSymptom criteria（症状标准）Two of the following criteria are met. In general, mental retardation, manic-depressive episodes and delirium are excluded. The

52、re 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 thought3.Thought insertion or withdrawal, thought block or forced thinking9/26/202

53、246第46页，共74页，2022年，5月20日，9点1分，星期二CCMD-3 diagnostic criteria4. 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） o

54、r apathy;8. Catatonic syndrome, unusual or silly behavior;9. Avolition.9/26/202247第47页，共74页，2022年，5月20日，9点1分，星期二Differential diagnosis Some neurosis（某些神经症）1.the feature of insight2.the feature of symptoms3.some patients need to be following-up9/26/202248第48页，共74页，2022年，5月20日，9点1分，星期二Differential dia

55、gnosisMood disorder（心境障碍）Manic or severely depressed patients may exhibit psychotic symptoms during the peak of their disease statesAccurate historical and clinical data should help to differentiate from mania-related psychotic features in the presence of other symptoms such as:increased energy leve

56、ls,grandiosity, hypersexuality, irritabilityspeech, distractibility.By the same token to differentiate depression from schizophrenia. 9/26/202249第49页，共74页，2022年，5月20日，9点1分，星期二Psychotic disorder due to a general medical or neurologic condition &substance-induced psychotic disorder1. Carefully evaluat

57、e 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 course3. Laboratory examination 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分析症状的特征与病程演变的特征必要的实验室检查9/26/202250第50页，共74页，2022年，5月20日，9点1分，星期二Per

58、sonality disorderSchizotypal, 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. mild2.present throughout the patients life3. have no

59、exact date of onset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9/26/202251第51页，共74页，2022年，5月20日，9点1分，星期二Treatment and prevention 治疗和预防9/26/202252第52页，共74页，2022年，5月20日，9点1分，星期二Treatment recommendations急性发作的药物治疗pharmacotherapies: treatment of acute symptom episod

60、es9/26/202253第53页，共74页，2022年，5月20日，9点1分，星期二Treatment recommendations1. 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