【作者】 张明；

【导师】 徐志伟；

【作者基本信息】 广州中医药大学 ， 中医基础理论， 2009， 博士

【摘要】 黄褐斑,中医称为“黧黑斑”、“肝斑”等,是一种获得性面部对称色素沉着皮肤病,为临床常见而难治的一种损容性皮肤病。本病多发于中青年女性,它不仅损害患者容貌,而且造成了一定的心理问题和社会压力,严重影响患者的日常生活与工作;而不良情绪又促进了病情发展。本病发病机理复杂,至今中西医治疗方法均难以获得满意的疗效。随着“生物-心理-社会”医学模式的提出,现代研究表明精神因素与黄褐斑发病密切相关,因此,从社会心理方面深入研讨黄褐斑的病因及病变机制,确为切实可行之举。一、目的证治规律研究:运用文献学研究的方法,对历代中医文献中有关黄褐斑资料进行全面系统地归纳整理,建立相关数据库,运用现代统计学分析方法,力求揭示中医黄褐斑有关情志方面的方药证治规律,为黄褐斑的中医临床科研提供新的思路和方法。临床研究:采用现代心理学的问卷测量技术,对黄褐斑患者进行大样本调查,通过分析心理学量表指标与黄褐斑中医证候的相关性,探讨社会心理因素在黄褐斑发病中所起的作用,从心理学角度阐释黄褐斑的发病机制,为黄褐斑的中医情志致病机理研究提供新的思路,为提高中医防治黄褐斑的疗效提供社会心理的病因学依据。二、内容与方法文献综述:整理中医文献资料中有关黄褐斑病名沿革、病因病机、证治规律、理法方药等方面资料,归纳总结黄褐斑与中医情志因素相关的内容;研究现代医学文献资料,对黄褐斑病因、致病机理、治法方药及其进展等方面进行分析综述,对黄褐斑患者心理的现代研究成果进行归纳整理。证治规律研究:以大型电子图书《中华医典》为载体,以黄褐斑的古代多种病名为检索词,以有确切药物用量的方药为研究对象,并规范药物功效、主治、计量单位等,建立古代黄褐斑相关方药数据库。借助于spss分析软件的帮助,主要采用频数分析、因子分析、R型(指标)聚类分析等方法对数据进行统计学处理,结合历代对黄褐斑的认识,运用中医药理论分析统计结果。临床研究:以黄褐斑患者为研究对象,采用Zung焦虑自评量表(SAS)、Zung抑郁自评量表(SDS)、艾森克个性问卷(EPQ)、特质应对方式(TCSQ)和社会支持量表(PSSS),对黄褐斑病人进行调查,所收集到的资料均用SPSS统计软件包进行统计学处理。通过观察各量表指标与黄褐斑中医证候的相关性,探讨社会心理因素在黄褐斑发病中所起的作用,力求深入阐释黄褐斑的发病机制及病变机制。三、结果与结论(一)证治规律研究1.通过对黄褐斑中医历代文献资料的系统整理,从整体上认识了黄褐斑病辨证论治的发展规律,归纳总结黄褐斑与中医情志因素相关的内容,为今后的研究奠定文献学基础。2.采用古代文献与统计学分析相结合的方法,从黄褐斑方药使用的角度,研究了古代文献中黄褐斑的方药证治状况。结果显示现代中医对黄褐斑的认识和古代黄褐斑的方药证治的思路是一脉相承的。古今医家均认为其病因为:内因七情及饮食劳倦失宜,以致肝、脾、肾虚损;外因感受风邪,且兼夹湿、热、寒邪,以及病理产物瘀血、痰湿等,诸种因素内外合邪而成;病位在肝、脾、肾三脏;为本虚(肝、脾、肾)邪实(六淫、瘀血、痰湿)之证。3.本研究遵循中医理论及方法,通过对黄褐斑证诒方药统计分析,证实了情志失调在黄褐斑的发病过程中有重要影响。黄褐斑与肝脏关系尤为密切,肝气郁结是黄褐斑基本病机的主要环节。4.女子“以血为本”、“以肝为先天”,肝脏藏血、主疏泄的功能对女子生殖机能具有重要的调节作用。肝失疏泄,气血失和,冲任失调,直接与面部色泽的加深有关。对于青中年女性患者,在临床诊治中尤其应重视疏肝和血、调理冲任。5.运用统计学的因子分析和聚类分析,以方药频数分析结果为基础,挖掘并总结出黄褐斑临床主要证型的治疗方药。(二)临床研究1.本研究的黄褐斑患者主要人群特征、黄褐斑发病相关常见因素以及黄褐斑的皮损特征表现方面符合黄褐斑发病的一般规律性。主要人群特征为:女性,年龄在30-39岁,已婚,具有高等学历,工作不稳定,收入中等。较常见发病相关因素为家族史,伴随病症、慢性疾病史、妇科疾病、精神因素、季节、化妆品过敏史等。皮损特征临床表现以蝴蝶型、特发型、皮损呈淡褐色或深褐色、皮肤类型呈混合型、皮肤弹性和色泽评定为一般者居多。2.在一般社会特征中,高等学历是焦虑水平的影响因素,而高收入是抑郁水平的影响因素。发病相关因素中的病程、伴随病症、服用避孕药、化妆品过敏和精神因素是抑郁、焦虑水平的影响因素。临床分型中的蝴蝶型、面上型是抑郁、焦虑水平的影响因素;病因分型中的继发型是抑郁、焦虑水平的影响因素;皮损颜色呈淡褐色和深褐色是抑郁、焦虑水平的影响因素。3.黄褐斑艾森克人格特征中的内外倾与情绪性得分均明显低于正常人群,导致应激反应水平较正常人群偏高,使抑郁或焦虑水平也相应偏高。人格特质因素中的内外倾及精神质维度与抑郁、焦虑障碍的产生有着密切的关系,即内倾性越强和精神质倾向明显的患者越是容易产生抑郁、焦虑障碍。4.黄褐斑患者的应对方式与正常人群比较偏于消极应对,故其应激反应水平较常人偏高,使抑郁、焦虑水平也相应偏高。但应对方式对黄褐斑抑郁、焦虑水平的影响不具有显著性,这可能与群体个性特质有关,不能反应应对活动的全貌。从人格特质来看,性格越偏于内向、人格越不稳定其消极应对方式得分越高;个性过于精神质会也引起消极应对方式的增加,过于循规蹈矩则积极应对方式分值也降低。5.对于缺乏社会支持的黄褐斑患者,多采取消极应对。但领悟社会支持程度对黄褐斑抑郁、焦虑水平的影响不具有显著性。可能本研究所针对的人群的社会支持水平还不足以达到与抑郁、焦虑水平相关的程度,但这并不意味着可以忽视社会支持。6.伴随抑郁障碍的黄褐斑患者达80%,伴随焦虑障碍的患者则将近1/3。说明黄褐斑患者总体的心理承受压力大,个体的心身健康水平偏低,抑郁和焦虑是黄褐斑患者的主要情绪障碍。7.黄褐斑中医证型以肝气郁结证多见,并且其抑郁、焦虑水平明显高于脾虚湿阻和肾阴不足两型。说明此病病变机制以情志致病为主,并且肝气郁结患者的心理健康水平低于其他两种证型,证实了情志因素是黄褐斑病变的重要影响因素。8.黄褐斑中医各证型与本研究中的社会心理因素存在相关性:肝气郁结证与焦虑水平之间存在明显的正性相关,脾虚湿阻证与焦虑水平之间存在明显的负性相关,肾阴不足证与抑郁水平之间存在明显的负性相关;瘀血阻络兼证的患者往往具有内倾性人格特质,与消极应对之间存在负相关。可据此作为今后临床诊断及采取相应防治措施的心理学依据。四、结语本课题运用文献整理和临床调研相结合的方法,从理论和临床两方面来研究黄褐斑与情志致病因素的相关性。结果证实了心理社会因素与黄褐斑的发病密切相关,抑郁和焦虑是黄褐斑患者的主要情绪障碍,在病变过程中起着重要的作用,并且黄褐斑各中医证型与社会心理因素存在相关性。提示医者在进行诊治过程中应重视社会心理因素的影响,把握情志失调引起机体气机紊乱的特点,重视肝气不疏的病变机制。尝试在临床实践中将心理学问卷的测量及评定与中医辨证论治相结合,充分考虑患者的心理因素、情境因素及药物功效,在进行药物治疗的同时,给予心理疏导和心理治疗,以调畅情志,减少精神因素导致的色素沉着,提高黄褐斑中医预防和治疗水平。更多还原

【Abstract】 The chloasma,which is caused by pigmentation and presents itself into facial symmetry,is a kind of skin disease of face department.Traditional Chinese medicine (TCM) calls it as "Li black spot" or "liver spot".As a damage holding disease,it is one of the most difficult cure dermatitis in clinical treatment.Cholasma,which attacked to young and middle-aged women mainly,is not only influences appearance,but also affects the patient’s daily life and work seriously.Besides,it brings a great deal of psychological problems and social stress.Furthermore,these bad effects will accelerate the disease worse. Although both TCM and western medicine have diverse methods and already get some therapeutic effects,they are still not satisfactory.As presenting the medical model of "biology-psychology-society",people begin to focus on the effect of psychological factor to the patients.Based on this,this article will analyze the etiology and lesion mechanism of cholasma from the aspect of social psychology.ObjectiveResearch on Law of syndromes and therapies:We have study and summarize all cases about cholasma in TCM comprehensively by using literature research method,and meantime,build the relevant database.And then,use the method of statistics to dig out the objective law of cholasma relating to emotion which conforms to pharmacology of TCM,in order to reveal the law of syndromes and therapy cholasma.As a result,put forward a new method and an ideal to the TCM clinical scientific research.Research of clinic:Through the introduction of the modern psychology questionnaire measurement,cholasma patients were choose as the object of study,and then in view of the object,make a large sample survey.On the basis of statistics analysis,observe the relevance between Psychology Scale targets and TCM Syndromes.Hereby,explore the role of socio-psychological factors in Cholasma incidence intended to illuminate the lesion mechanism of cholasma.Accordingly,give a new idea in the emotional pathogenic mechanism of TCM,hope that raising therapeutic efficiency of TCM and providing sufficient socio-psychological foundation based on etiology.MethodsResearch of literature:First of all,researching cholasma medicine record information on TCM,Collate and analyze generally the disease history of cholasma,such as the evolution of the disease name,etiology and pathogenesis,treatment of the law and prescription and so on.Simultaneity,consult a number of books and documents about this subject on Western Medicine.Then,make a systemic summary of the cholasma history from both TCM and wester medicine angles.In a word,find out the law of cholasma.Research on law of syndromes and therapies:The medical cholasma database was built up by using Encyclopedia of TCM,the large-scale e-book,as the elementary reference to retrieval all kinds of words which related with chloasma’s name in ancient time, selecting the exact amount of prescription drugs as the object of study and regulating the drug’s efficacy,indications,measuring unit.Meanwhile,with the help of analysis software SPSS,do data processing and data analysis,including Frequency analysis,Factor analysis, and R-type(target) cluster analysis.Based on this processing result,combined the knowledge of ages of Cholasma and TCM Theory,analyze and check out the statistical and clinical significance.Research of clinic:Choose cholasma patient as the object of study,survey them by questionnaire.These forms consist of Zung self-rating depression scale(SDS),Zung self-rating anxiety scale(SAS),Eysenck Personality Questionnaire(EPQ),Trait Coping Style Questionnaire(TCSQ) and Perceived Social Support Scale(PSSS).By observing the relevance between the target scale and Cholasma TCM Syndrome,explore the role of the socio-psychological factors in the pathogenesis of Cholasma.Aim at explaining cholasma pathogenesis and disease mechanisms from a psychological point.All of the data were processed bySPSS statistics package.Results and Conclusion1.Research on law of syndromes and therapies(1)Selecting cholasma medicine record of TCM information by using philology research,Collect and analyze generally the disease history of cholasma,such as the evolution of the disease name,etiology and pathogenesis,treatment of the law and prescription and so on.To realize the processing law in diagnosis and treatment based on an overall analysis of signs and symptoms about cholasma,and make a systemic summary of culprits.There are a lot of different classifications about chloasma.According to clinical experience,there are 2 kinds of style like butterfly type and surface type.As a type of secondary-type,the disease symptom is that the impaired skin is light brown or dark brown. Obviously,this type is resulted from depression and anxiety.(3)The person’s disposition like introversion and extroversion is highly related to emotion like depression and anxiety.Those patients who are introversion are less inclined to be gloomy and anxious,whereas those who are extroversion are more apt to slip into depression and anxiety.(4)Chloasma patients are always prone to adopt passive coping style,so their level of stress reaction is higher than normal person.Thus their level of depression and anxiety is higher accordingly.Coping style,however,is not significant correlation with the level of depression and anxiety.Besides,the questionnaire is related to the traits of social groups.In consideration of this,the result of survey can not stand for general trait.Therefore,it is more suitable for a research subject about all kinds of health problems.(5)The degree of perceived social support has no correlation with the level of depression and anxiety.On account of the sample selection,it is hard to include all kinds of people.Despite of this,we can no ignore social support.(6)It is demonstrated from both overall cases and sub-card-type statistics that most of chloasma patient has serious depression and anxiety.About 80%of those patients are depressive,most of the rest have some anxiety symptom.The results show deafly that chloasma patients suffer prodigious stress and have ill-natured physical and mental health. So it can not be ignored that psychological factors plays a critical role in the chloasma pathogen process.(7)The syndrome’s style of the stagnancy of liver-Qi is appeared mostly.A lot of research indicates that the group of stagnancy of liver-Qi has higher level of depression and anxiety than the group of deficiency of spleen and the group insufficiency of kidney-Yin. This means that the emotional disorder is main pathogen of chloasma.The standard of psychological health in the syndrome of stagnancy of liver-Qi is lowest than the others(the syndrome of deficiency of spleen and the syndrome of insufficiency of kidney-Yin])(8)Through quantitative and qualitative analysis,we can discover that there is relativity between the types of chloasma in TCM and socio-psychological factors referred in this dissertation.The sample has been divided into stagnancy of liver-Qi group(group 1), deficiency of spleen group(group2) and insufficiency of kidney-Yin group(group 3).From the diagram of the correlation between stagnancy of liver and anxiety,they show strong positive correlation.The relationship between dampness evidence spleen deficiency and the cholasma association with emotional factors in order to lay the foundations of philology.(2)Combining the method of ancient literature and statistical analysis,research and analyze the law of cholasma’ treatment in ancient medical literature.The result shows that the modern and ancient of Chinese medicine have the same medical idea about syndromes and therapy of chloasma.The ancient doctors believe that chloasma is caused by both endopathic and exopathic factor.The endopathic factors are included by emotional injuries, improper diet,maladjustment of work and rest,which led to deficiency of three organs-liver,spleen and kidney.The exopathic factors are included by exogenous wind-heat seemingly,companying by evil of dampness,heat and cold frequently,and pathological producers which are blood stasis,phlegm stains.The chloasma,which pathogenic site is located in liver,spleen and kidney,belongs to syndromes of deficiency of vital qi with excessive pathogenic factors.(3)Abide by TCM theory and method to analysize the medicines of chloasma,accord with the statistic result;it is proved that emotional disorder was considered as an important pathogen.There is a closer relevance between Chloasma and liver.The stagnancy of liver-qi is a main link in the chain of basic pathogenic mechanism of chloasma.(4)It were said that "women are taken blood as body’s basis" and "the liver is viewed as congenital of women’s life".Liver’s function about storing blood and smoothing and regulating the flow of viral energy and blood could play an important role in regulating the reproduction of women.The liver’s dysfunction,which could cause the disorder of qi and blood and lose balance of chong-ren,led to facial dark.This illustrates that we should devote much attention to removing stagnancy of vital energy of the liver in order to harmony the blood and adjusts function of chong-ren in clinical diagnosis and treatment for young and middle-aged women especially.(5)Utilizing factor analysis and cluster analysis in statistics,generalize the ancient treatment prescription based on the result of frequency of prescription to dig out and summarize treating recipes about main style of syndromes and signs.2.Research of clinic(1)This dissertation finds that there is a consistency among chloasma patients dominating characteristic,the incidence of the more common factors related to chloasma and the performance of the clinical diagnostic.(2)In the modern word,high-education is the leading element to induce anxiety, simultaneity,high-income gives birth to depression directly.Among those factors referred before,course of the disease,companying diseases and mental factors are the primary anxiety is a clear negative correlation.So does insufficiency of kidney-yin.Overall the result,we can discover that the patient who has blood stasis is more introversion.The patient’s response will be more negative with the worse of the illness.According to this, combined psycho-questionnaires with TCM Differential Treatment,give adequate socio-psychological foundations in order to raise the clinical efficiency of chloasma and provide some precautionary methods.This dissertation uses the method of Document Research and Clinical Research to study chloasma from both theoretical and clinical aspects.Furthermore,explores the relevance between chloasma and pathogenic factors of emotion.The results show that the psycho-social factors are closely related to the incidence of chloasma.Depression and anxiety are the major mood problem of chloasma patients and play an important role to the course of the disease.Besides,there is relativity between the types of chloasma in TMC and socio-psychological factors.So,firstly,the doctor should pay more attention on the psycho-social factors while in the course of medical treatment.Secondly,understand the characteristics of emotional disorder and its bad effects.Thirdly,disperse the depressed liver-energy for patient in the treatment.This dissertation tries to combine with psychological results in the questionnaires and TCM treatment in the clinical practice. Finally,give some advice to doctor for chloasma patient who should take full account of the psychological factors,situational factors and the drug’s efficacy,while in drug treatment and psychological counseling and psychotherapy.So adjust their emotion in order to reduce pigmentation for spirit factors and improve the prevention and treatment of chloasma the level of Chinese medicine.更多还原