【作者】 薛强；

【导师】 郭涛； 李淑敏； 韩明华； 赵玲； 刘中梅； 杨西云；

【作者基本信息】 昆明医学院 ， 内科学， 2008， 硕士

【摘要】 目的了解埋藏式心律转复除颤器(ICD)患者中心理障碍的发病率,探讨心理障碍的病因与发病学机制,评价标准心理干预项目与综合治疗即“拼盘治疗”的疗效。方法选取从1998年～2007年12月在昆明医学院第一附属医院行ICD/CRT-D植入术的患者以及在外院植入而到本院随访的患者88人(男78人,女10人,平均年龄60.8岁),所有患者均接受中国生活事件量表(LES)、适应不良自评量表、防御方式问卷(DSQ)、症状自评量表(SCL-90)、社会支持评定量表(SSRS)、ICD与回避行为问卷、汉密尔顿抑郁量表(HRSD)和汉密尔顿焦虑量表(HAMA)进行心理状态评估,并选取昆明医学院部分在校研究生51例作为正常对照组(健康人群),采用相同量表进行心理状态评估,与ICD患者进行对比分析。选取2006年8月～2007年8月进行手术的病人分为两组,一组仅予以简单的健康教育,另一组予以ICD相关信息的全面健康教育;所有手术病人于术前1周和术后1周、1月、3月、6月及9月分别采用上述量表进行心理状态评估。对于除外上述提及的手术患者中未接受ICD放电的随访病例,发现存在心理障碍的患者予以综合治疗即“拼盘治疗”并在治疗后1周、2周、4周、6周和10周再次进行心理状态评估,与此同时采用病情严重程度(SI)与疗效总评(GI)两项指标进行疾病严重程度和疗效评价。病例追踪随访采用门诊复查、住院观察、电话随访及上门随访等方式进行,患者心理评估采用观察法、问卷法及半结构式晤谈法进行。结果本研究过程中失访两例,均为男性死亡病例(具体死因不详),总共完成随访292例次。研究发现ICD患者的心理健康状况较差其中42%存在心理障碍,明显高于健康对照组差异具有显著统计学意义(P＜0.01),其中以焦虑(包括惊恐发作和广泛性焦虑)、睡眠障碍、适应不良和抑郁为主要表现。本研究表明以SCL-90作为ICD患者是否出现心理障碍的衡量指标,其中以躯体化、焦虑与恐怖是最有意义的预测因子;应用HARD作为抑郁的评判指标,ICD患者抑郁状态以焦虑/躯体化、绝望感、睡眠障碍、迟缓和认知障碍作为预测指标;应用HAMA作为焦虑的评判指标,ICD患者焦虑状态中精神性与躯体性症状具有同等重要的意义,均是其发生的有力预测因素。在手术组患者的对照研究中采用SCL-90、HAMA、HRSD作为评价指标,实施经验心理健康教育干预组的患者术后心理障碍程度明显重于标准心理健康干预组的患者,心理障碍恢复时间也明显长于后者,两组患者之间的差异具有统计学意义(P＜0.05);标准干预组心理障碍发作高峰明显提前,严重程度也有所减轻;并且两组患者均表现出心理障碍会随时间消退的趋势。在应用综合治疗疗法治疗ICD患者心理障碍的研究中,治疗前后以适应不良自评量表、SCL-90、HAMA、HRSD、SI和GI作为评价指标,结果证明该疗法能够明显改善患者心理障碍的严重程度(P＜0.05),并在患者接受治疗的第二周开始显现疗效(P＜0.05)。本研究发现ICD放电与心理防御方式是ICD患者心理障碍的强烈预测因素。由本研究揭示的心理障碍病因及其他研究的成果推论ICD患者心理障碍发病的可能潜在机制为经典条件反射理论、学习无助理论和认知评价理论所解释。结论1.ICD患者心理障碍的发病率显著高于健康人群,不仅严重损害了患者的生活质量,甚至降低了患者的生存率,并且长期未受到应有重视。2.ICD患者心理障碍的症状随时间呈现山峦状消退趋势。3.本研究发现ICD患者心理障碍发病高危预测因素为:ICD放电、心理防御方式。4.ICD患者心理障碍发病的潜在机制可能为经典条件反射理论、学习无助理论和认知评价理论所解释。5.标准心理健康教育干预措施能够最大限度地减少ICD患者心理障碍症状的发生,减轻心理障碍的严重程度,更快的恢复到正常生活。6.综合治疗即“拼盘治疗”对存在心理障碍的ICD患者能够发挥上佳的治疗效果,并在治疗第二周开始发挥疗效。7.ICD患者的常规随访中应定期进行心理状态评估和心理咨询,及时对ICD患者的心理障碍发挥早发现、早治疗的一、二级预防作用。更多还原

【Abstract】 Objective The study was designed to understand the rate of psychological disturbances in patients with implantable cardioverter defibrillator(ICD) retrospectively,to explore the etiological factor and psychopathogenesis and to evaluate the therapeutic effect of standard educational interventions program and comprehensive therapy likewise called "combination therapy".Method The study enrolled 88 patients(78 male,10 female,mean age of 60.8 years),who accepted the implantation of ICD/CRT-D in The First Affiliated Hospital of Kunming Medical College during 1998～december 2007 and receive a medical or physical examination in our hospital after implanted in other hospitals.All patients were assessed by life event scale of china(LES)、maladaptation self-rating scale、defense style questionnaire(DSQ)、symptom checklist 90(SCL-90)、social support rating scale(SSRS)、avoidance behaviors of ICD、Hamilton depression rating scale for depression(HRSD)and Hamilton anxiety scale(HAMA),and then a part of post-graduates(81 persons)in the Kunming medical college selected as the control group(heath persons)were appraised in the such ways.Both of results were compared after data were collected.ICD recipients were randomly divided into two groups from august 2006 to October 2007.The one received a set of experimental educational interventions about health and the other received a series of comprehensive educational interventions related to ICD.Psychological assessment of all operation-patients were executed before 1 week and 1 week、1 month、3 months、6 months、9months after implantation.Among all patients except operation-patients without shock in the former study,patients who suffered with psychological disturbances accepted a comprehensive therapy likewise called "combination therapy" and psychological assessment of such patients were carried out 1 week、2weeks、4weeks、6weeks and 10weeks after treatment;Severity of illness(SI)and global improvement(GI)were thought as index suggesting severity of diseases and therapeutic effect at the same time.Out-patient clinical examination、in-patient observation、care by telephone and drop-in investigation were adopted in the Follow-up period.Observation、questionnaire and semi-structured interview were employed in the progress of psychological assessment.Result 86 patients were enrolled and 292 cases were eligible in the study due to two male death(death causes were unknown).The research indicated that the mental health was poor in ICD patients and 42%of patients suffered psychological disturbances,the most frequent problems of which included anxiety(containing panic attack and generalized anxiety)、sleep disorder、adjustment disorder and depression, which is obviously statistical significance compared with the heath crowds(P＜0.01).The study found that somatization、anxiety and photic anxiety could reasonably predict the psychological status when SCL-90 was considered as a predictor stating whether the mental heath is well or not;that anxiety/somatization、hopelessness、sleep disturbances、retardation and congnitive disturbance was believed as predictors for depression when the depression standard was HARD;and that somatic anxiety and psychic anxiety were equally meaningful predictors when HAMA was adopted to demonstrate existence of anxiety.SCL-90、HAMA and HRSD were applied for appraisal indexes in the control research about operation-patients,the severity of mental disorder in patients receiving the experimental educational intervention was far more than that in patients receiving the comprehensive educational intervention and rehabilitation time of the former was apparently longer than that of the latter statistically(P＜0.05);the mental disorder attacked ahead of time and the severity of illness reduced in the standard intervention group,compared to the results of the simple intervention group;the psychological disturbances of ICD patients might gradually vanished with time in both groups.In the therapeutic effect concerning the comprehensive therapy pilot study,SCL-90、maladaptation self-rating scale、HAMA、HRSD、SI and GI were deemed indexes of therapeutic effect,which were measured before and 1 week、2 weeks、4 weeks、6 weeks、10 weeks after treatment. The study concluded that the treatment strategies could substantially improve the severity of psychological disturbances,which was statistical significance(P＜0.05), and discovered that the therapeutic effect emerged after the second week.The psychopathogenesis of psychological disturbances might be explained altogether by the classical conditioning theory、the learned helplessness theory and the cognitive appraisal theory,according to the research achievements we gained and the outcomes a handful studies found.Conclusion 1.The attack rate of psychological disturbances exceeds that of the heath crowds and the phenomenon is easily ignored in the long run.2.The symptoms of psychological disturbances may gradually vanish with time,the process of which is described as the mountain.3.The retrospective study finds that the high-risk predictors for psychological disturbances in ICD recipients are ICD shock and mental defense mechanism.4.The classical conditioning theory、the learned helplessness theory and the cognitive appraisal theory have been altogether invoked to conceptualize these psychological disturbances in ICD patients.5.The standard educational intervention may utmost reduce incidence of psychological disturbances, relieve the severity of psychological disturbances in ICD recipients and quickly regain the normal life after implantation.6.The comprehensive therapy also called "combination therapy" may significantly relieve the symptoms of psychological disturbances in patients with ICD,which achieves the optimal therapeutic effect and produces a marked effect in the second week.7.The study implies that it is vital that patients attend the routine psychological assessment and psychological consultation, in order to detect and treat psychological disturbances of ICD patients in the early stage,which contributes to the primary or secondary prevention.更多还原