【作者】 张朝辉；

【导师】 张亚林；

【作者基本信息】 中南大学 ， 精神病与精神卫生学， 2008， 博士

【摘要】 第一部分躯体化障碍与抑郁症的对比研究目的从社会人口学、临床特征、心理学以及认知功能方面比较躯体化障碍和抑郁症之间的异同,旨在澄清躯体化障碍是抑郁症的特殊表现形式,还是不同于抑郁症的一个独立疾病。方法1.对同期入组的72例躯体化障碍和84例抑郁症患者,采用自编的一般资料调查表、主诉不适症状调查表和汉密顿抑郁量表(HAMD)比较二者的人口学和临床特征。2.选取年龄、性别、受教育程度相近的躯体化障碍和抑郁症患者各56例,完成心理评估,包括症状自评量表(SCL-90)、艾森克人格问卷(EPQ)、多伦多述情障碍量表(TAS-20)、社会支持量表(SSRS)、特质应对方式问卷(TCSQ)。3.对小学以上文化程度、视力正常、右利手及性别、年龄相近的52例躯体化障碍和54例抑郁症进行认知能力筛查测验(CASI)。结果1.躯体化障碍患者的起病年龄明显早于抑郁症组(P＜0.01);其农村人口构成比明显大于抑郁症组(P＜0.05);职业构成与抑郁症组有显著不同(P＜0.01);对家庭经济状况的主观评价明显差于抑郁症组(P=0.001);病程明显长于抑郁症组(P＜0.01);躯体化障碍为缓慢起病、持续性病程,而抑郁症多为亚急性起病、发作性病程。躯体化障碍组承认社会心理诱因的人口构成比及其抑郁症家族史的阳性率均明显小于抑郁症组(P＜0.01)。2.躯体化障碍组的主诉不适症状的数目及所涉及的系统数均远远高于抑郁症组(P＜0.01);二者在症状构成上也有显著性差异(P＜0.05)。3.躯体化障碍组的HAMD总分及体重、认知障碍、阻滞分明显低于抑郁症组:焦虑/躯体化分高于抑郁症组(P＜0.05或P＜0.01)。4.躯体化障碍组SCL-90总均分、躯体化、强迫、偏执因子、EPQ-E、EPQ-L、TAS总分、F1、F3、SSRS客观分、支持利用度高于抑郁症组;人际敏感、抑郁、恐怖以及精神病因子、EPQ-P、消极应对均低于抑郁症组(P＜0.05或P＜0.01)。5.躯体化障碍组的CASI总分、注意、心算、新、旧记忆分均高于抑郁症组;言语和概念判断分低于抑郁症组(P＜0.05)。结论躯体化障碍与抑郁症在社会人口学和症状特点方面存在明显的差异;在心理学以及认知功能上也有显著性差别。显示躯体化障碍是不同与抑郁症的一个独立疾病。第二部分躯体化障碍的临床特征及相关因素的分析目的从社会人口学、临床、心理学以及认知功能方面探讨躯体化障碍的特征及其相关因素;为躯体化障碍的识别和诊断提供一些思路,并为其早期预防和心理干预提供一些理论依据。方法1.采用自编一般资料调查表和主诉不适症状调查表探讨躯体化障碍的社会人口学和临床特征。2.采用半定式访谈的方法对56例躯体化障碍患者和50名正常对照组进行心理评估,包括SCL-90、EPQ、TAS-20、SSRS、TCSQ、父母教养方式评价量表(EMBU)、生活事件量表(LES)。3.采用韦氏成人智力量表(WAIS-RC)、威斯康星卡片分类测验(WCST)、言语流畅性测试(VFT)、注意划销测试以及事件相关电位P300测定认知功能。4.采用交感神经皮肤反应(SSR)评价植物神经功能。结果1.躯体化障碍的社会人口学特征:女性患病人数明显多于男性,男女之比为1:1.7;农村患者明显多于城镇(P＜0.01);以中等受教育程度、体力劳动者为主。家庭经济状况中等者最多,占57.7%。2.躯体化障碍的临床特征:病程平均为(8.12±7.19)年;否认有心理诱因者显著多于承认有心理诱因者;缓慢起病者显著多于急性或亚急性起病者。症状数为(8.50±1.47),涉及的系统为(4.51±0.87)。3.躯体化障碍组SCL-90总均分和各因子分(除敌对因子外)明显高于对照组(P＜0.01或P＜0.05),病程超过一定时期、症状多于一定数目时SCL-90总分有减少的趋势,躯体化因子分随着症状数目的增多呈增高的趋势;EPQ-E、EPQ-N、EPQ-L及TAS总分、F1、F2、F3、LES总分、负性LES、家庭LES、社交LES分均明显高于对照组(P＜0.01或P＜0.05);父亲的F1、母亲的M1、M2、M5及SSRS总分、主观支持分均低于对照组(P＜0.05);消极及积极应对分别高于、低于对照组(P＜0.001)。4.起病形式、家庭经济状况、病程、症状数目以及发病次数对躯体化障碍有显著性预测意义。心理学危险因素有神经质人格、述情障碍、较多的负性及家庭LES、较少的主观支持、较多的消极应对、缺乏母亲温暖、理解和父亲较多的过分干涉。5.认知功能特征(1)躯体化障碍组在领悟、数字广度、词汇、编码、填图、图片排列因子方面都比对照组明显差(P＜0.05);WCST总次数、持续错误数、VFT重复数及划销测验漏划数明显多于对照组,VFT总数和划销测验总行数明显少于对照组(P＜0.05);较对照组相比,P300电位的N2、P3波潜伏期延长,N2、P3波幅降低(P＜0.01)。(2)躯体化障碍患者的病程与P300电位中P2、P3潜伏期呈正相关、与N2、P2、P3波幅呈负相关(P＜0.05);症状数目与N2、P3潜伏期呈正相关、与N1、P3波幅呈负相关(P＜0.05或P＜0.01)。6.躯体化障碍组较对照组SSR波潜伏期延长、波幅降低(P＜0.05)。SSR潜伏期与躯体化因子分及消化、呼吸循环、皮肤、泌尿生殖系统症状的严重程度呈正相关;波幅与病程、症状总数目及神经、呼吸循环、皮肤、泌尿生殖系统症状的严重程度呈负相关、与SCL-90总均分呈正相关(P＜0.05或P＜0.01)。结论1躯体化障碍的特征为:1.1多发生于女性,多发生于社会经济地位较差的人群;1.2缓慢起病、病程长且呈持续性病程;1.3症状多,累及系统广,以消化系统、神经系统、肌肉骨骼系统的症状最多见;且患者大多否认社会心理压力与疾病的关系;1.4躯体化障碍患者存在神经质、外倾的个性特征以及述情障碍;1.5躯体化障碍患者存在认知功能障碍和植物神经功能障碍;P300可以反映躯体化障碍患者的认知功能,SSR可以反映躯体化障碍患者的植物神经功能,这两个电生理指标对躯体化障碍的诊断有一定的参考价值。2家庭教养方式、较多的负性生活事件尤其是与家庭有关的生活事件、较差的社会支持以及消极应对方式与躯体化障碍的形成有关,在心理干预时应该注意这些因素。更多还原

【Abstract】 ObjectiveTo investigate the relationship between somatization disorder and depression from various aspects of research, such as demography, clinical feature, psychology and cognitive function in China.Methods1. 72 patients with somatization disorder and 84 depression patients enrolled during a same period were investigated with self-design questionnaires of demography and complaint symptoms and Hamilton depression rating scale(HAMD). ICD-10 and CCMD-3 diagnostic criteria were assigned by consensus after the interviews were evaluated by three independent psychiatric doctors.2.Symptom Checklist-90(SCL-90), Eysenck’s Personality Questionnaire(EPQ), Tornto Alexithymia Scale(TAS-20) , Trait Coping Style Questionnaire(TCSQ),Social Supporting Rating Scale( SSRS)were administered to 56 patients with somatization disorder and 56 age-, sex-education-matched depression patients.3. 52 patients with somatization disorder and 54 age-, sex-, education-matched depression patients, who were above primary school education and right handedness, were tested with Cognitive AbilitiesScreening Instrument(CASI) .Results1. The onset age of somatization disorder group was obvious earlier than that of depression group. The constituent ratio of rural population in somatization group was higher than that in depression group. The subjective evaluation to family’s economic status in somatization group was lower than that in depression group. The course of somatization disorder was longer than that of depression group. The constituent ratio of rural population of denying psychological reasons in patients with somatization disorder was lower than that in depression patients. The percentage of depression family history in patients with somatization disorder was lower than that in depression patients. All the difference had significant(P<0.05 or P<0.01).2. The systems involved in and total number of complaints in patients with somatization disorder were obvious higher than those in depression patients(P<0.01). The order of complains in patients with somatization disorder was stomach discomfort(10.8%), aches of muscle and articulus(10.4%), skin discomfort(9.9%); while in depression patients was sleep disorder(13.7%), hypodynamia (13.4%), anepithymia and athrepsy(12.1%), the difference were significant(P<0.05).3. The total score of HAMD in patients with somatization disorder was obvious lower than that in depression group(P<0.05). The scores of anxiety/somatization factor and body weight, cognitive handicap hysteresis in patients with somatization disorder was obvious higher or lower than those in depression group respectively(P<0.01).4. Compared with depression group, the scores of total SCL-90, somatization, obsess-compulsion and paranoid factor was obvious higher and interpersonal relationship, depression, phobia and sypchosis factor were lower in patients with somatization disorder, there were significant difference(P<0.05).There were significant difference in EPQ, TAS-20, SSRS and TCSQ between somatization disorder and depression group(P<0.01). The total score and scores of attention, mental arithmetic, new memory and old memory were higher and the scores of language and concept judgement were lower in somatization disorder group than in depression group(P<0.05).ConclusionsSomatization disorder is difference with depression in social demography, clinical trait, psychology and cognition. Somatization is an independent disease. ObjectiveTo explore the clinical characteristic and related factors in patients with somatization disorder on demography, clinical characteristic, psychology and cognitive function. In order to provide some guidance to recognize and diagnose somatization disorder, and provide some theoretical basis for the early prevention and mental intervention of somatization disorder.Methods1. Self-design questionnaires of demography and complaint symptoms were administered to investigate the demography and clinical characteristic of somatization disorder.2. 56 somatization disorder patients and 50 normal controllers took psychological assessment, including SCL-90, EPQ, TAS-20, TCSQ, Life Event Scale(LES), Egma minnen av bardndosnauppforstan(EMBU).3. Wechsler Adult Intelligence Scale(WAIS-RC), Wisconsin Card Sorting Test(WCST), Verbal Fluency task(VFT), attention-canceling test and event-related potentials -P300 test were used to study the cognitive function.4. Sympathetic skin response(SSR) was administered to understand the autonomic nerve function.Results1. The demography characteristic of somatization showed that female patients were more than male ones significantly, the ratio was 1:1.7. Ural patients were more than urban ones, there were significant difference(P<0.01). The patients were main middle-education(45.8%) and physical workers(72.9%). Subjective evaluation of family economic status was middle level(57.7%).2. The clinical feather of somatization disorder showed that its course was 8.12±7.19 years on average, majority patients denied mental motivation, they were main slow-moving onset. The number of symptoms and involved systems was 8.50±1.47 and 4.51±0.87 on average respectively. The symptom of skeletal musculature system, digestive system and nervous system was 72.9%, 71.2% and 62.7% respectively.3. The total score and each factor’s scores of SCL-90 except hostility factor in somatization disorder group were obvious higher than those in control group(P<0.01 or P<0.05). The scores of EPQ-E, EPQ-N, EPQ-L and F1, F2, F3 and total score of TAS-20 in somatization disorder group were obvious higher than those in control group(P<0.01 or P<0.05). The scores of parental warmth and understanding factor and the mother’s over-intervention and overprotection factor in somatization disorder group were obvious lower than those in control group(P<0.05). Compared with control group, the total score and the scores of negative, family and social intercourse life event in somatization disorder group were obvious higher, the total score and subjective social supporting were lower. The scores of negative and positive coping style in somatization disorder group were higher and lower than those in control group respectively(P<0.01).4. The style of onset, family economic status, course of disease, the number of symptoms and onset had forecasting meaning for somatization disorder. The psychological risk factors of somatization disorder were neurotic personality, TAS-F1, TAS-F2, more negative and family life events, less subjective social supporting , more negative coping style and less mother’s warmth and more father’s over-intervention.5. The results of cognitive function showed(1) Compared with control group, the patients with somatization disorder had lower scores of comprehension, numeral scope, words, encoding, completion of drawing and pictures arrange (P<0.05), had more total test number and persist error number of WCST, had less total VFT and attention-canceling test and more repeat number of VFT and leakage number of attention-canceling test. There were significant difference(P<0.05). The latency of N2 and P3 of P300 were longer and the amplitude of N2 and P3 of P300 lower in somatization disorder group than in normal control group(P<0.01).(2) The course of disease of somatization disorder was positive correlation with latency of P2, P3, and negative correlation with N2, P2 and P3. The number of symptoms in somatization disorder group was positive correlation with the latency of N2 and P3, negative correlation with N1 and P3. The latency of N2,P3 were positive correlation with the total score and somatization factor of SCL-90, the amplitude of P3 was negative correlation with the total score and somatization factor, the latency of N1 and P2 were positive correlation with somatization factor and total score respectively, the amplitude of N2 was negative with total score . All of them had significant difference(P<0.05 or P<0.01).6. Compared with control group, the latency and amplitude of SSR in somatization disorder group prolonged and decreased respectively(P<0.05). The latency of SSR was negative somatization factor of SCL-90, the amplitude of SSR was negative correlation with the course and number of symptoms and positive correlation with total score of SCL-90(P<0.01). The latency of SSR was positive correlation with the serous degree of symptoms of digestive system, respiration and circulation system, skin and genitourinary system. The amplitude of SSR was negative correlation with the serous degree of symptoms of nervous system, respiration and circulation system, skin and genitourinary system(P<0.05 or P<0.01). Conclusions1 The characteristics of somatization disorder shows as following:1.1 The female patients are more, and majority patients are poor social and economic status.1.2 Onset of the disease is slow, the course is long and persisting.1.3 The symptoms of somatization disorder are more, and the systems involved are wide. Majority patients deny social psychological causes.1.4 Somatization disorder patients have nervousness and extraversion personality trait and alexithymia.1.5 The patients with somatization disorder have cognitive functional disturbance and dysautonomia. P300 and SSR have certain reference value to diagnose somatization disorder.2 The parental rearing style, negative life events especially family life event, poor social supporting and negative coping style are related with development of somatization disorder.更多还原