基于“已病防变”理论从肺论治儿童抽动障碍的临床研究

【作者】 夏桂选；

【导师】 徐荣谦；

【作者基本信息】 北京中医药大学 ， 中医儿科学， 2011， 博士

【摘要】 儿童抽动障碍是以运动性抽动伴或不伴发声性抽动,以及伴随的心理行为症状为特征的一种儿童常见神经精神疾病。近年来本病的发病率有上升趋势。目前对本病病因病机研究有所进展。在传统的神经递质学说方面,已在基因水平开展遗传易感基因的相关研究,范围也已扩展到合并症的基因研究；神经免疫学发病机制是近年来研究的热点,主要涉及A组乙型溶血性链球菌、肺炎支原体等相关微生物感染后的免疫损伤与发病关系的研究；在临床上,心理因素的研究越来越广泛。在治疗方面,提倡在生物-心理-社会医学模式下,以心理治疗为基础,在解除环境因素的情况下,配合长期服用有效低副作用药物的综合治疗。患儿的行为问题、生活质量、自我意识等开始受到广泛关注。近年来,中医研究儿童抽动障碍的报道越来越多。研究内容涉及流行病学、中医病因学、中医药对本病相关神经递质表达的影响、中医药对本病神经免疫机制的影响、临床治疗思路与辨证论治经验、中医药对本病动物模型的影响等诸多方面。众多文献显示,中医药治疗儿童抽动障碍的疗效较高,而副作用则相对较低。由于儿童抽动障碍的影响因素较多,不同地区存在环境差异,临床表现和中医证候也不尽相同。因此,中医对本病病因病机的认识有很大差异,治疗思路也很广泛。但无论怎么认识总不离“肝风”。关于本病的治则治法,从大量文献报道中可以看出,有从上焦心肺论治者,有从中焦脾胃论治者,有从下焦肝肾论治者。从上焦心肺论治者,其证候多与外感相关；从中焦脾胃论治者,其证候多与脾虚肝亢有关；从下焦肝肾论治者,证候多以肝肾不足、阴虚风动为主。本病临床症状呈从上到下逐渐发展的过程,是否存在上焦-中焦-下焦的自然传遍过程仍有待进一步研究。但从三焦论治儿童抽动障碍已在临床中广泛应用,并见于大量临床文献报道,是儿童抽动障碍的共同治疗原则。各种治法在三焦治则中的位置有所不同。从肺论治抓住本病发病的始动环节,通过截断外风引动内风的过程,防患于未然,具有已病防变的治未病思想；从脾论治抓住后天之本,刘弼臣教授称之为医中王道；从肝肾论治抓住本病根本,治病必求于本,三者辨证统一五脏是一个有机统一体,病理因素作用于五脏,虽可出现各种不同的证候表现,但最终都会影响及肝,导致肝风内动,出现抽动、秽语和情志方面的症状。因此,我们认为可将本病各种病因病机认识统一于“肝风内动”。即“肝风内动”是本病的基本病机,外感因素是诱发“肝风内动”的始动病机。因此,所有针对始动病机的治疗法则都是辅助“平肝熄风”的,“平肝熄风”是本病的基本治则。其他治法都统一于“平肝熄风”这一基本治则。因此,笔者认为临床辨证应该灵活从三焦论治,将三者有机结合,统一于平肝熄风。刘弼臣教授提出从肺论治儿童抽动障碍的学术思想和临证经验。本病以肢体上部,尤其是头面部抽动为主,发声抽动以清嗓子等咽喉部怪声为主,且本病常由外感引发或加重,这些都与肺肝两脏关系密切。小儿肺常不足,“肺为娇脏”,“风邪上受,首先犯肺”,气机不利,津液停滞为痰。肺受外邪,病首发于上焦,引发肝风,“高巅之上,唯风可至”,故见以头面部等肢体上部抽动为主。痰阻经隧,则在上表现为异常发声。因此,本病证属肝风,肺受外邪是发病的始动环节,由外风引发内风而发病。因此,应从肺论治,通过调肺利窍、疏邪祛表,截断外风引发内风的过程,达到治疗本病的目的。在病因病机方面,根据《素问·阴阳应象大论》：“风胜则动”；《素问·风论》“风者,善行而数变”；《素问·至真要大论》：“诸风掉眩皆属于肝”；《素闻·宣明五气篇》：“五气所病……肝为语”；《灵枢·九针论》：“五脏气……肝主语”等论述,结合本病全身肌肉迅速、反复、不规则地交替抽动及秽语等特征,刘弼臣教授认为儿童抽动障碍“本源在肝”,属中医“肝风”证。以肺主一身之气,调节全身气机的升降出入运动。若风邪袭肺,肝气郁于表,则在里之气机更加紊乱,故内传他脏,内生风痰,症状迭起,刘弼臣教授称之为“病发在肺”。因此,刘弼臣教授抓住了本病外感诱发的始动环节,提出从肺论治儿童抽动障碍。在外感急性期,及时干预,截断外风引动内风的发病过程；在外感缓解期,亦可防邪入侵,防患于未然,体现了“已病防变”的“治未病”思想。我们临床基于“已病防变”理论,在国家“十一五”科技支撑项目的基础上,从“调肺”与“治肝”两个角度研究“从肺论治”临证经验对儿童抽动障碍的治疗作用。研究表明刘弼臣教授从肺论治临证经验治疗儿童抽动障碍,具有调肺祛邪与平肝熄风的双重作用。在儿童抽动障碍发病之初,着眼于上焦,根据安内必先攘外的原则,在平肝熄风的同时,突出从肺论治。在疾病早期及时从肺论治,避免其进一步向中、下焦发展,从而控制症状,缩短病程,取得了较好的临床疗效,体现了“已病防变”的“治未病”思想。更多还原

【Abstract】 Children tic disorder is a common childhood neuropsychiatric disorders characterized by campaign tic disorder,with or without audible tic disorder and associated psychological and behavioral symptoms.Recently, the incidence of the disease is on the rise and the pathogenesis of the disease gets some progress.In terms of classical neurotransmitter theory,the research on genetic susceptibility gene is carrying out,and the scope of the study has also been extended to genetic studies of complications.Pathogenesis of Neuro-immunology is the research focus in recent years.The research on psychological factors is more and more extensive in clinical.In terms of treatment, comprehensive treatment based on the psychotherapy to take low side effects and effective drug in long-term under the Bio-Psycho-Social medical model is advocated.The behavior problems, quality of life and self-consciousness of tic disorder children is getting widespread attention.In recent years,chinese researchs in child tic disorders has been reported increasingly.The study covers the epidemiology of child tic disorders,TCM etiology,Traditional Chinese Medicine on the impact of the expression of disease-related neurotransmitters,Traditional Chinese Medicine on the impact of the neural-immune mechanisms of the disease,clinical treatment idea and diagnosis or treatment experience,Traditional Chinese Medicine on the impact of the disease animal model and other aspects.Large literature shows that the effect of Chinese medicine treatment to child tic disorders is high and the side effects are relatively low.There are many influence factors of child tic disorders.Environmental differences are significant in different regions, clinical manifestations and Chinese syndromes are not always the same to each other.TCM etiology and pathogenesis of the disease are very different,the treatment ideas are also very extensive.But gan-feng is the most basic pathogenesis.Reports from the large number of documents can be seen that there are many kind of treatment ideas,some based on theoretical of cardiopulmonary,some based on theoretical of the spleen and stomach,others based on theoretical of the liver and kidney. Whether there are process of natural spread from upper to middle and lower burner is looking forward to further study.But the treatment idea based on the upper, middle and lower burner have been widely used in clinical which is found in a large number of clinical literature. And it is the basic principle of treatment of child tic disorders.The characteristics of treatment principle based on the theory of triple burner are different.The treatment idea based on the theory of lung seizes the beginning of the disease dynamic link; The treatment idea based on the theory of spleen seizes the acquired fundamental; The treatment idea based on the theory of liver and kidney focus on the disease fundamental.Five zang-organs is an organic unity。The Pathological factors act on five zang-organs first, leading to all sorts of different syndromes performance, affect the liver eventually, Causing Gan-Feng dynamic,and arise symptoms such as tic, tourette and sentiment related symptoms. We propose that GanFeng dynamic is the basic pathogenesis of the disease. Infection is the tumor-initiating pathogenesis which inducing GanFeng dynamic.And to extinguish the liver wind is the basic treatment law of the disease. Treat the disease based on the theory of triple burner flexibly is looking forward to extinguish the liver wind.Professor LiuBiChen proposed the academic thoughts and clinical experience of treating child tic disorders based on the theory of lung. The head and facial tic is the primarily symptoms for the disease. Pure throat is the common vocal tics symptoms. Infection causes the disease. Pulmonary and liver are important for the disease.Professor Liu Bichen proposed the academic thoughts of treatment idea based on the theory of lung,which has double action between eliminating pathogenic from lung and extinguishing the wind from liver,revealing Treatment role of pre-sickness from changing.更多还原