1、精神分裂癥與其他精神病性障礙9/26/20221第1頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二學(xué)習(xí)目標(biāo)1掌握精神分裂癥的臨床表現(xiàn)、診斷和鑒別診斷、治療和預(yù)防復(fù)發(fā)策略2掌握精神分裂癥疾病的分型、預(yù)后特征3了解精神分裂癥疾病的病因?qū)W9/26/20222第2頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二The definition of Schizophrenia in CCMD-3Schizophrenia comprises a group of psychotic disorders of unknown specific etiology often presented

2、with a gradual onset of abnormalities in perception, thought, motion and behavior since young adulthood. Consciousness is usually maintained. Intelligence is intact, but in some cases, there is some degree of cognitive impairment. The natural course of the disorder is chronic remitting but sometimes

3、 deteriorating.9/26/20223第3頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Epidemiology 1 Prevalence ：Point prevalence in China (1982): 4.75（rural area 3.42，urban 6.06 )。Total prevalence in China(1982):5.69，(6.55 1999)。Lifetime prevalence in USA（1988）13。9/26/20224第4頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Epidemiology 2Age：the age of

4、 onset in 50% of patients is 2030 year old，over 80% of patients is 1635year old.Gender：Schizophrenia occurs equally in men and women(in abroad)The prevalence in men is more than women (1.6:1) in China.The mean age of onset is about 2 to 5 years earlier in men than women.9/26/20225第5頁，共74頁，2022年，5月20

5、日，9點(diǎn)1分，星期二History（1）Schneider -first rank symptoms（首級癥狀）1.thought hearing (思維化聲)2. Third-person hallucinations (爭論性幻聽)3. Hallucinations in the form of a commentary(評論性幻聽)4. thought withdrawal or insertion (思維被奪/被插入)5. Thought broadcasting /diffusion(思維被廣播或擴(kuò)散)6. Forced feeling (強(qiáng)加的情感)7. forced impuls

6、ive (強(qiáng)加的沖動)8. forced behavior (強(qiáng)加的行為)9. somatic passivity experience (軀體被動體驗(yàn))10. delusional perception (妄想性知覺) 9/26/20226第6頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Etiology 一、 biological factors1genetics2The neurodevelopmental hypothesis3Changes in brain structure4Biochemical abnormalities二、personality factors三、p

7、sycho-social factors9/26/20227第7頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Genetics 1 Studies Method: Family studiesTwin studies Adoption studies9/26/20228第8頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Genetics 2 The results of family studies:The risk of Schizophrenia. Schizoaffective disorder, and schizotypal personality is increas

8、ed in first-degree relatives of patients with Schizophrenia.The risk of both Schizophrenia and mood disorder is increased in first-degree relatives of patients with schizoaffective disorder.The risk of bipolar illness is not increased in first-degree relatives of patients with schizophrenia.9/26/202

9、29第9頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Genetics 3The results of twin studiesconcordance rates among MZ pairs is higher than that among control(35-60 times)concordance rates are about 50% for MZ and about 10% for DZ. It might be expected that some environmental factors relevant to etiology.The risk of schizo

10、phrenia in the offspring of an unaffected twin is the same as that of an affected twin. This means that an unaffected twin has the same genetic susceptibility to developing Schizophrenia, but for some reason the susceptibility is not expressed.9/26/202210第10頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Genetics 4The r

11、esults of adoption studiesThe rate for Schizophrenia is greater among the biological relatives of the Schizophrenia Adoptees than among the relatives of control.The finding supports the genetic hypothesis.9/26/202211第11頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Molecular genetic studiesTwo main approaches: 1. linka

12、ge analysis It is applied to multiply affected families(高發(fā)家系）, but no linkage markers have been clearly identified.2. Candidate gene approaches Genes for biological mechanisms that may be involved in Schizophrenia have been localized and cloned. Using this technique, a number of genes coding for DA

13、and 5-HT receptors have been excluded from linkage to Schizophrenia in various pedigrees（家系）.9/26/202212第12頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Biochemical studies The dopamine hypothesis.5-HT hypothesis.Amino acids in Schizophrenia9/26/202213第13頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Etiology studies-conclusions 1There i

14、s strong evidence that schizophrenia has important genetic causes, but the mode of inheritance is not known.There is increasing evidence that many cases are of neurodevelopmental origin, but whether neurodevelopmental abnormalities are present in all patients is not clear.Most believe that Sch. resu

15、lts from an interaction of genetic predisposition and environmental factors.Stressful life events often provoke the disorder, but non-specific events to schizophrenia.9/26/202214第14頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Etiology studies-conclusions 2Schizophrenia May be preceded by cognitive and social impairme

16、nt in childhood, and that the presence of these impairment and certain kind of personality disorder are forms of expression of schizophrenia genotype精神分裂癥病人可能在兒童期就有認(rèn)知和社會功能損害，這些損害及某些人格障礙的出現(xiàn)是精神分裂癥基因型表達(dá)的一種形式9/26/202215第15頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Etiology studies-conclusions 3The deficits of temporal

17、and frontal structural and function are associated with non-progressive neuropsychological impairment.Dopamine receptor are blocked by drugs that control symptoms , but there is no compelling evidence at present that over-activity of DA systems is the central disorder in schizophrenia.顳葉與額葉的功能和結(jié)構(gòu)的缺陷

18、與非進(jìn)展性的神經(jīng)心理損害有關(guān)多巴胺受體阻斷能控制癥狀，但尚無確信證據(jù)表明多巴胺功能亢進(jìn)是該病的主要原因9/26/202216第16頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二clinical featuresAll of the symptoms and signs that described in chapter 4 may be seen in schizophrenic patients, but different symptoms and signs have different diagnostic value for schizophrenia.9/26/202217

19、第17頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Prodromal syndromeChanges in mood: depression, anxiety, mood swings, irritabilityChanges in cognition: odd or unusual ideas, vagueness, deterioration in study or workChanges in perception of self and the worldChanged behaviors, withdrawal and loss of interest in sociali

20、zing, suspiciousness, deterioration in role functionPhysical changes: in sleep and appetite, loss of energy, reduced drive and motivation, etc.9/26/202218第18頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Disorders of sensation and perception 感覺障礙(disorders of sensation) 感覺過敏(hyperesthesia)感覺減退(hypoesthesia) 內(nèi)感性不適(senes

21、topathia) 知覺障礙（disturbance of perception）錯覺(illusion)幻覺(hallucination) 感知綜合障礙(psychosensory disturbance) 9/26/202219第19頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Disorders of sensation and perception幻聽(auditory hallucination)幻視(visual hallucination)幻嗅(olfactory hallucination)幻味(gustatory hallucination)幻觸(tactile ha

22、llucination)內(nèi)臟幻覺(visceral hallucination)功能性幻覺（functional hallucination） 反射性幻覺（reflex hallucination）9/26/202220第20頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Thinking disorder 思維形式障礙 (disorders of the thinking form) 思維貧乏(poverty of thought) 思維散漫( looseness of thought) 思維破裂(splitting of thought) 思維不連貫(incoherence of t

23、hought)思維中斷(blocking of thought) 思維被奪( thought deprivation)。思維插入(thought insertion)和強(qiáng)制性思維(forced thinking) 思維化聲(thought hearing) 思維擴(kuò)散(diffusion of thought)和思維被廣播(thought broadcasting) 象征性思維(symbolic thinking) 語詞新作(neologism) 邏輯倒錯性思維(paralogism thinking) 強(qiáng)迫觀念（obsessive idea） 或稱強(qiáng)迫性思維內(nèi)向性思維（autism） 9/26

24、/202221第21頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二delusion 妄想(delusion) 按其起源與其他心理活動的關(guān)系可分為原發(fā)性妄想(primary delusion)和繼發(fā)性妄想(secondary delusion)被害妄想(delusion of persecution) 關(guān)系妄想(delusion of reference) 物理影響妄想(delusion of physical influence)-被控制感。鐘情妄想(delusion of love) 嫉妒妄想(delusion of jealousy) 被洞悉感(experience of bein

25、g revealed)夸大妄想(grandiose delusion)罪惡妄想(delusion of guilt)疑病妄想（hypochondriacal delusion）虛無妄想(delusion of negation)9/26/202222第22頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Abnormalities of moodThree main kinds of mood are common:First, there may be sustained abnormalities of mood such as anxiety ,depression, irritab

26、ility, or euphoria.Second, there may be blunting of affect. Essentially this is sustained emotional indifference（冷淡） or diminution of emotional response.Third, there is incongruity of affect. Here the expressed mood is not in keeping with situation or with the patients own feeling.9/26/202223第23頁，共7

27、4頁，2022年，5月20日，9點(diǎn)1分，星期二Abnormalities of volitionSome acute patients are normal Others may present somewhat abnormalities of volitionhypobulia abulia Parabulia（意向倒錯） ambivalenceparanoid schizophrenia may present hyperbulia 9/26/202224第24頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Abnormalities of behavior 1Excitement

28、（興奮狀態(tài)）-hebephrenic excitement, catatonic excitementStupor（木僵）-. The patient remain motionless for a long time(catatonic stupor), or maintain their limbs or trunks in unusual positions(waxy flexibilitas ) for various lengths of time.Negativism（違拗）- refuse to cooperate (active negativism, passive nega

29、tivism)Passive obedience（被動服從）9/26/202225第25頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Abnormalities of behavior 2Stereotyped act-（刻板動作）-the patient repeat various functions or gestures, or imitate other movements(echopraxia 模仿動作)Mannerism（作態(tài)）Bizarre behavior（怪異行為）Forced act ， compulsive actViolence and suicide beh

30、aviorSome patients may cause self-induced water intoxication or avoid eating because of certain delusional beliefs.9/26/202226第26頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Orientation and insightIn acute schizophrenia orientation is normalInsight is usually impaired. Most of patient do not accept that their experie

31、nces result from illness9/26/202227第27頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Cognitive dysfunction 1Cognitive dysfunction Is a cardinal(主要的） feature of schizophreniaOn average, first diagnosed schizophrenic patients IQ is 10 points lower than control.Children at risk for schizophrenia have lower IQs than do con

32、trol.認(rèn)知功能異常是精分癥的主要特征首診的精分癥病人較正常人IQ低10分高危兒童的IQ低于正常對照組9/26/202228第28頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Cognitive dysfunction 2The first episode patients exhibit impairments in attention, concentration, working memory, visual- spatial memory, semantic memory, recall memory,and executive function.Cognitive impa

33、irment is often independent of positive and negative symptoms and even of the disorganization syndrome and the course of illness.首發(fā)精分癥病人表現(xiàn)有注意力、注意集中能力、工作記憶、視-空記憶、語義記憶、回憶和執(zhí)行功能的異常認(rèn)知功能損害獨(dú)立于陽性和陰性癥狀，甚至獨(dú)立于解體癥狀和疾病的病程。9/26/202229第29頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Tab. 3 The most frequent symptoms of acute schizop

34、hrenia（急性精分癥病人癥狀頻譜）Symptom Frequency (%) Lack of insight 97Auditory hallucinations 74Ideas of reference 70Suspiciousness 66Flatness of affect 66Delusional mood 64Delusions of persecution 64Thoughts spoken aloud 509/26/202230第30頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二The chronic syndromeIn contrast with the posit

35、ive of the acute schizophrenia, the chronic syndrome is characterized by thought disorder and the negative symptoms.The most striking feature is diminished volition, that is lack of drive and initiative.與急性精分癥相比，慢性病人以思維障礙和陰性癥狀為特征最突出的癥狀是意志減退，缺乏動力和始動性 9/26/202231第31頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Subtypes

36、of schizophreniaSchizophrenia has also been subdivided on the basis of psychopathology ,course,and response to treatment.Hebephrenic schizophreniaParanoid schizophreniaCatatonic schizophreniaSimple schizophrenia Undifferentiated schizophrenia Other type or unspecified of schizophrenia9/26/202232第32頁

37、，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Simple-schizophreniaAbout 2% of patients can diagnosed this type.Is characterized by the insidious（隱襲性的） development of odd behavior , social withdrawal, and declining performance at work.Clear symptoms are absent.Difficult to identify reliably.約2%的病人可診斷為此型其臨床特點(diǎn)為：隱襲性起病，逐步出現(xiàn)

38、一些奇怪的 行為、回避社交、社會功能減退等常缺乏明確的精神病性癥狀此型常難于確診9/26/202233第33頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Hebephrenic schizophreniaAbout 11% of patients can diagnosed this type.Is characterized by the absence of systematized delusions and the presence of incoherence and inappropriate affect.Silly(愚蠢） and childish in their b

39、ehavior 約11%的病人可診斷此型以思維聯(lián)想障礙、情感不協(xié)調(diào)、缺乏系統(tǒng)性的妄想為特征常伴有一些幼稚愚蠢行為、意向亢進(jìn)或倒錯9/26/202234第34頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Catatonia schizophreniaThis type is much less frequently now than in previous years.Motor disturbance is the dominant feature, consisting of either agitated hyperactivity or a decrease in gross m

40、otor activity with stupor, rigidity, or bizarre postures 此型較以往少見以運(yùn)動障礙為主要特征，表現(xiàn)為緊張性興奮和緊張性抑制（木僵、肌肉強(qiáng)勁、奇怪的姿勢）9/26/202235第35頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Paranoid schizophreniaThis type is the most common form of the illness.Is characterized by prominent paranoid delusion, thought processes and mood are rela

41、tively spared. The patient may appear normal until his abnormal beliefs are uncovered此型最常見以妄想為主要表現(xiàn)，常伴有幻覺。思維過程和情緒常相對完好，在妄想未被暴露時，病人常被認(rèn)為“正?！?。9/26/202236第36頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Undifferentiated schizophreniaThis type is the next most frequent form Delusions and hallucinations of any type are promi

42、nent and are accompanied by incoherence and grossly of disorganized behavior.此型為第二常見類型妄想和幻覺都突出，常伴有思維聯(lián)想障礙和行為紊亂不符合以上各型的診斷9/26/202237第37頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Other type schizophreniaConditions meeting the general symptom criteria of schizophrenia.The clinical feature does not satisfy the criteria

43、of any of the subtypes mentioned above such as children schizophrenia and late-onset schizophrenia符合精分癥的癥狀標(biāo)準(zhǔn)臨床特征不符合以上各型，如兒童和晚發(fā)性精分癥9/26/202238第38頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Post-schizophrenic depressionThe patient exhibits features of schizophrenia in the past one year. The depressive symptoms occur w

44、hen the schizophrenic symptoms are in partial remissionProminent depressive symptoms have been present for at least two weeks, accompanied by residual psychotic symptomsDepression and schizoaffective disorder are excluded.在過去一年診斷為精分癥，抑郁癥狀發(fā)生在精神癥狀部分緩解后明顯的抑郁癥狀持續(xù)至少2周，且伴隨有殘留的精神癥狀排除抑郁癥和分裂情感障礙9/26/202239第3

45、9頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Residual schizophreniaSchizophrenia without complete remission for at least 2 years;Marked improvement in mental state with partial remission of symptoms and presence of at least one of the following:specific positive symptom;specific negative symptom, such as poverty of

46、thought, apathy, abulia or social withdrawal;personality change.The impairment of social functioning and insight are not severe; Symptoms are relatively stable and have minimal improvement or deterioration for at least one year患精分癥至少2年未徹底緩解精神癥狀明顯改進(jìn)，但仍表現(xiàn)至少以下一項(xiàng)：個別陽性癥狀個別陰性癥狀人格改變社會功能和自知力損害但不嚴(yán)重癥狀相對穩(wěn)定至少一年

47、9/26/202240第40頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Chronic schizophreniaSymptoms meeting the diagnostic criteria of schizophrenia;The course lasts for at least 2 years.9/26/202241第41頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Type I and type type II schizophreniaCrow have described two syndromes in 1980The feature of Type I:

48、acute onset, positive symptoms, good social function during remissions, good response to antipsychotic drug, DA over-activity.1980年由英國學(xué)者Crow提出 I 型綜合征的特征：急性起病、陽性癥狀、緩解后社會功能良好、對藥物治療反應(yīng)良好、多巴胺功能亢進(jìn)9/26/202242第42頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Type I and type type II schizophreniaThe feature of Type II: negative

49、 symptoms, poor outcome,poor response to antipsychotic drugs, without evidence of DA over-activity, poor premorbid adjustment, an earlier age of onset, structure change in the brain.Most of patients are a mixture of type I and type II II 型精分癥的特點(diǎn)：陰性癥狀為主預(yù)后不良對藥物治療反應(yīng)不佳無多巴胺功能亢進(jìn)的證據(jù)病前適應(yīng)不良起病年齡較早有腦結(jié)構(gòu)異常大多數(shù)病人為

50、一種混合類型9/26/202243第43頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二The feature of Course Over a 30 year period(隨訪30年結(jié)果）25% of patients recover fully35% improve significantly and reach relative independence15% improve but require extensive help10% remain hospitalized and unimproved 15% die mostly as a result of suicide9

51、/26/202244第44頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Diagnosis and differential diagnosis 診斷與鑒別診斷9/26/202245第45頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二CCMD-3 diagnostic criteriaSymptom criteria（癥狀標(biāo)準(zhǔn)）Two of the following criteria are met. In general, mental retardation, manic-depressive episodes and delirium are excluded. The

52、re is separate diagnostic criteria for simple type of schizophrenia:1.Repeated auditory hallucinations that are usually not mood congruent;2. Loosening of association, derailment, incoherence in thinking or poverty of thought3.Thought insertion or withdrawal, thought block or forced thinking9/26/202

53、246第46頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二CCMD-3 diagnostic criteria4. Delusion of control, influence or passivity, thought broadcasting;5. Primary delusions including delusional perception, delusional mood or other bizarre delusions;6. Paralogic thinking, symbolic thought or neologism;7. parathymia (情感倒錯） o

54、r apathy;8. Catatonic syndrome, unusual or silly behavior;9. Avolition.9/26/202247第47頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Differential diagnosis Some neurosis（某些神經(jīng)癥）1.the feature of insight2.the feature of symptoms3.some patients need to be following-up9/26/202248第48頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Differential dia

55、gnosisMood disorder（心境障礙）Manic or severely depressed patients may exhibit psychotic symptoms during the peak of their disease statesAccurate historical and clinical data should help to differentiate from mania-related psychotic features in the presence of other symptoms such as:increased energy leve

56、ls,grandiosity, hypersexuality, irritabilityspeech, distractibility.By the same token to differentiate depression from schizophrenia. 9/26/202249第49頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Psychotic disorder due to a general medical or neurologic condition &substance-induced psychotic disorder1. Carefully evaluat

57、e the chronology of symptoms in relation to the inciting cause and note whether symptoms improve or worsen in relation to such cause.2. The feature of symptoms and course3. Laboratory examination 仔細(xì)評估癥狀的產(chǎn)生與促發(fā)因素在時間上的聯(lián)系，癥狀的消長與這種促發(fā)因素的關(guān)系分析癥狀的特征與病程演變的特征必要的實(shí)驗(yàn)室檢查9/26/202250第50頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Per

58、sonality disorderSchizotypal, schizoid, paranoid, and borderline personality disorder share some feature with schizophrenia, such as Paranoid ideation, magical thinking, social avoidance, vague speech.In personality disorder above symptoms are:1. mild2.present throughout the patients life3. have no

59、exact date of onset分裂型、分裂樣、偏執(zhí)行、及邊緣型人格障礙常具有某些精分癥的特征，如偏執(zhí)觀念、社交回避，一些奇怪的思想和言行但人格障礙的癥狀：相對較輕，貫穿病人的一生、無確切的發(fā)病日期9/26/202251第51頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Treatment and prevention 治療和預(yù)防9/26/202252第52頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Treatment recommendations急性發(fā)作的藥物治療pharmacotherapies: treatment of acute symptom episod

60、es9/26/202253第53頁，共74頁，2022年，5月20日，9點(diǎn)1分，星期二Treatment recommendations1. Antipsychotic medications, should be used as the first-line treatment to reduce psychotic symptoms for persons experiencing an acute symptom episode of schizophrenia.2. The dosage of antipsychotic medication for an acute symptom