【作者】 林昭宇；

【导师】 李洁；

【作者基本信息】 广州医学院 ， 精神病学， 2010， 硕士

【摘要】 背景我国是世界上的人口大国,而计划生育工作是我国的一项重要国策。自从上世纪70年代全面开展计划生育工作以来,我国人口增长得到了有效的控制。但是,目前的人口形势依然严峻,至2006年末全国总人口为131448万人,比上年末增加692万人。2006年全年出生人口1584万人,出生率为12.09‰;死亡人口892万人,死亡率为6.81‰;人口自然增长率为5.28‰。可见,今后计划生育工作仍须继续贯彻执行。作为一种行之有效的避孕手段,绝育术(Sterilization)是我国控制人口增长的重要计划生育措施,包括男性的输精管结扎术(Vasoligation)和女性的输卵管结扎术(Tubal ligation)。近40年来,随着医护人员素质的提高和手术技术的改进,绝育术后脏器损伤、出血、感染及异物残留腹腔等各种躯体并发症的发生率及严重程度已经明显下降,但仍有少部分受术者出现一些与手术损伤无关或没有任何可证实器质性病理基础的症状,如性功能下降、月经紊乱、食欲减退、情绪低落、持续疼痛、心悸、头晕、肌肉无力甚至瘫痪等,称为绝育术后心身反应(Psychosomatic Reaction after Sterilization)。部分受术者认为这些术后出现的症状完全是由绝育术导致的,于是向法院提起诉讼要求赔偿。而其中相当部分提起赔偿诉讼的个案经过鉴定后诊断为赔偿神经症(Compensation Neurosis)。绝育术后心身反应的发生对计划生育工作的负面影响很大:造成群众对绝育术的误解,严重妨碍绝育术的推广和开展。尤其是赔偿神经症患者,其诉讼耗费大量的时间和资源,而此类诉讼人多数存在明显的补偿心态,故缺乏治疗能动性与自信性,使病程迁延,影响其社会功能和生活质量,给家庭带来沉重负担。因此,有必要对绝育术后人群心理卫生状况进行调查,分析其中各种精神障碍的患病率、各种心理症状的发生率和分布状况、易患因素(Predisposing factor)等,这对今后开展有针对性的干预研究(Intervention study),减少绝育术后心身反应发生,颇为重要。西方国家人口增长率低,政府不限制生育,故国外针对绝育术后人群的研究较少。国内既往研究大多限于输精管结扎术或输卵管结扎术中的一种受术人群,未见两者心理卫生状况相互比较的报道。我们在实际的临床工作中发现,绝育术后心身反应患者中未生育男孩的占相当大的比例,考虑到生育子女情况可能是影响绝育术后心身反应发生的因素之一,而目前也未见针对绝育术人群中有生育男孩受术者与未生育男孩受术者的心理卫生状况进行比较的研究。本研究调查两种绝育术受术者的心理卫生状况,并对男女受术者进行比较,以及有生育男孩与未生育男孩受术者之间的比较,为绝育术后心身反应乃至心身疾病的防治工作提供科学依据,以利于计划生育政策的顺利实施。目的调查输精管结扎术和输卵管结扎术两种绝育术受术者人群各种精神障碍的患病率、各种心理症状的的发生及分布状况、受术人群的生命质量及人格特征,通过分组比较探讨其易患因素,探索如何预防绝育术后心理症状、精神障碍的发生,并减少因绝育术后心身反应引起的赔偿纠纷或诉讼。为今后开展有针对性的心理社会干预(Psychosocial interventions, PIs)奠定基础。通过本研究促使我国计划生育工作得以更为有力地开展,使有限的社会资源得到更有效、合理的使用。方法1.从广东省人口和计划生育委员会数据库中随机抽到阳山县及辖下13个乡镇作为调查地区,并调出该地区2009年4月1日至2009年6月30日所有行绝育术的居民名单。调查员按名单到当地面访受术者,填写问卷。2.调查工具有:自编一般资料问卷,DSM-IV轴I障碍用临床定式检查(SCID-I),症状自评量表(SCL-90),汉密顿抑郁量表17项(HAMD-17),汉密顿焦虑量表(HAMA),健康状况问卷(SF-36),艾森克人格问卷(EPQ)。3.调查员为从事精神科工作5年以上的医师,调查同时有从事计划生育专科工作5年以上的医师在场协助。4.资料输入计算机,采用SPSS13.0统计软件包,根据资料性质进行分析。计量资料采用t检验或秩和检验;计数资料采用χ2检验。结果1.阳山县绝育术受术者精神障碍时点患病率为12.8%,排前三位的分别为焦虑障碍5.2%、物质使用障碍4.4%、心境障碍2.0%;精神障碍终身患病率为15.2%,排前三位的分别为物质使用障碍5.6%、焦虑障碍5.2%、心境障碍3.2%。2.绝育术后3个月有49.5%的男性和66.7%的女性出现心身症状。男性SCL-90的焦虑、人际关系因子分与全国常模有显著性差异( t焦=1.996,t人=2.130,P<0.05),而女性的躯体化、抑郁、焦虑因子分与全国常模有显著性差异(t躯=4.264,t抑=4.419,t焦=8.537,P<0.001),男女受术者之间躯体化、抑郁、焦虑因子分均有显著性差异(t躯=2.216,t抑=2.381,t焦=3.306,P<0.05)。女性心身症状的发生率比男性高(χ2=7.465,P=0.006)。无生育男孩受术者的SCL-90各因子分和心身症状的发生率均高于有生育男孩的受术者(χ2=36.076,P<0.001)。3. HAMD-17评分结果为重度抑郁5例(2.0%),中度抑郁32例(12.8%),轻度抑郁48例(19.2%),无抑郁165例(66.0%)。4. HAMA评分结果为严重焦虑4例(1.6%),明显焦虑16例(6.4%),肯定有焦虑58例(23.2%),可能有焦虑84(33.6%),无焦虑88例(35.2%)。5. SF-36结果显示总结扎人群、现患组、仅有症状组的8个因子得分均低于常模,且差异有显著性(P<0.01);正常组的躯体疼痛、总体健康因子得分低于常模,差异有显著性(P<0.01),而活力因子显著高于常模(P<0.05)。6. EPQ结果显示心身症状的发生率在情绪稳定性不同的受术者间有显著性差异(χ2=45.897,P<0.001),其中情绪不稳定型的发生率是情绪稳定型受术者的6倍。见表9。而有心身症状组与无心身症状组的4个分量分均值比较,均有显著性差异。其中有心身症状组的精神质P量分、神经质N量分均高于无心身症状组(P<0.01),内外向E量分小于无心身症状组(P<0.05)。提示有心身症状的受术者以情绪不稳、内向、固执的人格居多。结论1.绝育术后部分受术者会出现心理症状,出现症状的受术者生命质量有一定程度的下降。2.男性输精管结扎术受术者与女性输卵管结扎术受术者比较,男性受术者术后心身症状的发生率和程度均比女性受术者低。3.有生育男孩的受术者与未生育男孩的受术者比较,有生育男孩的受术者术后心身症状的发生率和程度远远低于未生育男孩的受术者。4.人格为情绪稳定型的受术者,术后心身症状的发生率低于情绪不稳定型的受术者。5.对需要做绝育术的已育夫妇,推荐施行男性输精管结扎术为宜。对高危人群如女性、未生育男孩或情绪不稳定型人格的受术者,应注意做好解释安抚工作,必要时请心理卫生专业人员进行心理辅导,以减少绝育术后心身症状的发生。更多还原

【Abstract】 BackgroundAs the world’s most populous country, family planning is an important national policy in China. And the population growth has been effectively controlled since the work of a comprehensive family planning beginning in the 70s of 20th century. However,the current population situation is still grim. In 2006, there were 15.84 million births and 892 million deaths in China. A birth rate of 12.09‰and a mortality rate of 6.81‰; and the natural growth rate was 5.28‰. Till the end of 2006, the total population was 1,314,480,000,an increase over the previous year 6.92 million. So, it will be necessary to continue the family planning work in future.Sterilization, an effective and viable means of contraception, including tubal ligation and vasoligation, is an important population control measure in China. During the past 40 years, with improvements in surgical techniques and the quality of personnel, the incidence and severity of various physical complications after sterilization, such as organ injury, bleeding, infection and foreign body left abdominal, have decreased significantly. But there are still a small part of patients developing symptoms after sterilization, which has nothing to do with surgical injury or no demonstrable organic pathological evidence, including decreased sexual function, menstrual disorders, loss of appetite, depression, persistent pain, palpitations, dizziness, muscle weakness, even paralysis, called Psychosomatic Reaction after Sterilization. A part of the patients believe that these symptoms are entirely caused by the sterilization and claims to the courts for compensation. And a significant proportion of cases filed compensation lawsuits were diagnosed as compensation neurosis after been identified.Psychosomatic reaction after sterilization impedes the implementation and promotion of sterilization since it will cause misunderstanding, especially for those with compensation neurosis: they spend a lot of time and resources in litigation for compensation, and it will prolong the course, affect social function and quality of life, and increase the family burden due to lack of initiative and self-confidence of treatment. Therefore, it’s necessary to investigate the mental health status of those after sterilization, analyze the incidence, clinical characteristics, and risk factors, so as to reduce the occurrence of psychosomatic action after sterilization.Western countries don’t need a family planning since the low rates of population growth, and there are few similar studies for the peoples after sterilization. Most domestic studies focus on the mental health status after either vasoligation or tubal ligation while few reports compare both of them. It’s found in our clinical work that patients with psychosomatic reaction after sterilization who did not give birth to a boy account for a large proportion, however, there are few studies comparing mental health status of them and those who did. So we investigated and compared the mental health status after vasoligation and tubal ligation, also including the comparison of people in sterilization who gave birth to a boy and those who did not, To provide evidence for the prevention and treatment of psychosomatic reaction after sterilization, and facilitate the implementation of family planning policy.Objective To investigate the incidence and clinical characteristics of mental disorders inthe two groups of people who have been in sterilization (vasoligation or tubal ligation), explore the risk factors and discover how to prevent mental disorder after sterilization, reduce the compensation disputes or litigation due to mental disorders after sterilization, lay the foundation to carry out intervention, be helpful with carrying out China’s family planning work more smoothly and better, and achieve a more rational use of the limited social resources. Methods1. Yangshan County and its 13 townships had been randomly got from the database of Population and Family Planning Commission of Guangdong Province as survey area, and the list of people who are in sterilization during April 1, 2009 to June 30, 2009 in the area was transferred out. Then, investigators interviewed the people by the list and complete the questionnaires.2. The tools included: General Information Questionnaire, SCID-I, SCL-90, HAMD-17, HAMA, SF-36, EPQ.3. Investigators: 2 psychiatrists working more than 5 years and 2 family planning specialist working more than 5 years.4. Computer data entry, then data were analyzed according to the nature, using SPSS13.0 package.Results1. The point prevalence rate of mental disorders after sterilization was 12.8% in Yangshan County, 5.2% for anxiety disorders, 4.4% for substance abuse disorder and 2.0% for mood disorder; while the lifetime prevalence was 15.2%, 5.6% for substance abuse disorder,5.2% for anxiety disorders and 3.2% for mood disorder.2. Three months after sterilization, psychosomatic symptoms appeared in 49.5% of the males and 66.7% of the females. There was significant difference in anxiety and interpersonal sensitivity factor points of SCL-90 between male recipients and national norm (ta=1.996,ti=2.130,P<0.05). The same difference also exist between female group and national norm in the score of somatization, depression and anxiety(ts=4.264,td=4.419,ta=8.537,P<0.001). Between men and women, the score of somatization, depression and anxiety showed significant difference(ts=2.216,td=2.381,ta=3.306,P<0.05). The incidence of psychosomatic symptoms in women is higher than men(χ2=7.465,P=0.006).To the subjects who didn’t have a male offspring, they had higher factor scores of SCL-90 and incidence of psychosomatic symptoms compare with those who have a male offspring(χ~2=36.076,P<0.001).3. According to the results of HAMD scale, there were 5 (2.0%) cases with severe depression, 32 (12.8%) cases with moderate depression, 48 (19.2%) cases with mild depression and 165 (66%) cases with no depression.4. The results of HAMA scale indicated that severe anxiety accounts for 4 (1.6%),significant anxiety for 16 (6.4%), certain anxiety for 58 (23.2%), possible anxiety for 84 (33.6%) and 88 (35.2%) with no anxiety。5. There were significant differences in all of the 8 factors of SF-36 between the persons after sterilization, the group of mental disorder, the group of symptom and the national norm (P<0.01). The subjects who didn’t have mental disorder or symptom, they had lower scores of BP and GH factors of SF-36 and higher score of VL factor compare with the national norm (P<0.001).6. Between the people with variant types of emotional stability in EPQ, significant difference was found in the incidence of psychosomatic symptoms (χ~2=45.897, P<0.001).Conclusion1. A part of patients develop psychosomatic symptoms after sterilization, and the quality of life has decreased to some extent.2. The incidence and severity of psychosomatic symptoms after sterilization are lower in men compare to women.3. The subjects who have a male offspring show significant lower incidence of psychosomatic symptoms compare to the subjects who don’t.4. The subjects with stable emotion personality show lower incidence and severity of psychosomatic symptoms after vasoligation compare to the subjects with unstable emotion personality.5. For the procreated couples, vasoligation is recommended to the males. To reduce the incidence of psychosomatic symptoms after sterilization, it is necessary to explain the work to high-risk groups, such as those who are women, have a male offspring or have an emotion stable personality. Sometimes, professional psychological intervention may be essential.更多还原