本文選題：兒童精神分裂癥 + 預(yù)后��； 參考：《山東大學(xué)》2017年博士論文

【摘要】：目的:采用標(biāo)準(zhǔn)化測(cè)評(píng)工具對(duì)兒童精神分裂癥患者進(jìn)行為期5年的前瞻性隨訪研究,分別在入組后第3個(gè)月、第1年、第2年、第3年、第4年、第5年進(jìn)行隨訪,觀察兒童精神分裂癥的癥狀緩解和社會(huì)功能康復(fù)狀況,探索影響兒童精神分裂癥患者社會(huì)功能康復(fù)的預(yù)測(cè)因素,為兒童精神分裂癥的診斷、治療、預(yù)防提供科學(xué)依據(jù)。方法:從2008年6月1 日到2010年5月31日在山東省精神衛(wèi)生中心兒童青少年病區(qū)收集的小于14歲的兒童首發(fā)精神分裂癥住院患者81例作為研究對(duì)象,基線時(shí)采用自制患者一般情況調(diào)查量表、病前社會(huì)適應(yīng)能力評(píng)估量表(Promorbid Adjustment Scale,PAS)、陽性癥狀與陰性癥狀量表(The Positive and Negnitive Syndrome Scale,PANSS)、兒童期逆境問卷(The Questionnaire of Adverse Childhood Experiences,ACEs)、個(gè)人和社會(huì)功能量表(The Personal and Social Performance Scale,PSP)、韋氏兒童智力量表(Wechsler Intelligence Scale for Children,WISC),收集兒童精神分裂癥患者的人口學(xué)資料、病前社會(huì)適應(yīng)能力、發(fā)病前就診情況、臨床特征如起病年齡、起病形式、DUP(未經(jīng)抗精神病藥物治療的時(shí)間)、家族史、癥狀特點(diǎn)等各項(xiàng)指標(biāo),采用自制門診隨訪情況調(diào)查表,前瞻性定期隨訪5年,收集兒童精神分裂癥患者的服藥依從性、服用抗精神病藥物的種類、服藥劑量、合并用藥、換藥情況、再住院情況、PANSS因子得分及早期陽性癥狀緩解情況、隨訪結(jié)束時(shí)患者的陽性癥狀累計(jì)緩解月數(shù)、陰性癥狀累計(jì)緩解月數(shù)、個(gè)人和社會(huì)功能得分等指標(biāo),數(shù)據(jù)錄入SPSS22.0并進(jìn)行統(tǒng)計(jì)分析,采用生存分析、t檢驗(yàn)、X2檢驗(yàn)、重復(fù)測(cè)量方差分析、多元線性回歸分析、logistic回歸分析、路徑分析,探索兒童精神分裂癥的5年預(yù)后及社會(huì)功能康復(fù)的影響因素。結(jié)果:1.兒童精神分裂癥患者中,男性的起病年齡為7-14歲,平均11.0±1.8歲,女性的起病年齡為6-12.5歲,平均10.6±1.4歲,通過Kaplan-Meier生存分析,發(fā)現(xiàn)起病年齡有性別差異(logrank=4.99, P0.05),女性起病年齡較男性早。兒童精神分裂癥患者家族史陽性者占50.0%,病前社會(huì)適應(yīng)能力差的比例占55.9%,慢性起病者的比例占61.8%,住院前因情緒、行為問題就診的患者比例占22.2%,未經(jīng)抗精神病藥物治療的時(shí)間平均為8.33個(gè)月,高逆境得分的患者比例為47.1%。2.81例患者中,8例患者因各種原因失訪,5例患者在隨訪過程中更改診斷,68例完成隨訪,診斷的穩(wěn)定性為93.2%(68/73)。隨訪期間住院次數(shù)為1-5次,5年內(nèi)復(fù)發(fā)再入院的比例為58.8%,服藥依從性好的患者比例為48.5%,用藥種類以第二代抗精神病藥物為主。至隨訪結(jié)束時(shí),僅有3例患者處于未服藥狀態(tài),占4.4%; 15例患者患者單用一種抗精神病藥物治療,占23.1%,40例患者合并兩種抗精神病藥物治療.占61.5%; 13例合并三種抗精神病藥物治療,占15.4%。合并情感穩(wěn)定劑、抗抑郁藥物、苯二氮卓類藥物的患者分別為12例、16例、5例,占l7.6%、23.5%、5.9%; 一直沿用出院時(shí)治療方案的患者人數(shù)為10例,僅占14.7%,更換過二種及以上治療方案的患者人數(shù)為34例,占50.0%。3.隨訪結(jié)束時(shí),兒童精神分裂癥患者PANSS陽性因子(12.78±2.92VS14.88±3.38.t=-4.35,P0.05)、焦慮抑郁因子(12.78±2.92VS14.88士3.38,t=-4.35,P0.05)、興奮敵對(duì)因子(11.90±3.12VS15.44±3.91, t=-5.93,P0.05)得分較基線時(shí)明顯下降,差異有統(tǒng)計(jì)學(xué)意義(P0.05),陰性因子得分(30.32±7.35vs24.10±6.08,t=6.21,P0.05)較基線時(shí)明顯升高,差異有統(tǒng)計(jì)學(xué)意義(P0.05);認(rèn)知因子與基線相比變化不大(25.15±7.33vs26.57±6.25,t=-1.91,P0.05),差異無統(tǒng)計(jì)學(xué)意義。PSP得分較基線時(shí)明顯升高(40.06±11.02vs20.96±5.37),差異有統(tǒng)計(jì)學(xué)意義(P0.05)。獲得早期陽性癥狀緩解的患者例數(shù)為27例,早期陽性癥狀緩解率為34.6%,陽性癥狀處于緩解狀態(tài)的累計(jì)月數(shù)平均為18.78±7.18月,最短為6個(gè)月,最長(zhǎng)為38月,陰性癥狀處于緩解狀態(tài)的累計(jì)月數(shù)平均為17.51±3.69月,最短為7個(gè)月,最長(zhǎng)為24個(gè)月。以PSP得分作為社會(huì)功能康復(fù)情況的指標(biāo),PSP得分平均40.06±11.02分,最低21分,最高68分,小于30分的有14人,占20.6%,30分到70分之間的有54人,占79.4%。4.多因素線性回歸、logistic回歸分析顯示,陽性癥狀是否早期緩解的預(yù)測(cè)因素是起病形式,急性及亞急性起病者獲得早期緩解的可能性大約是慢性起病者的5倍;陽性癥狀緩解時(shí)間的預(yù)測(cè)因素是病前社會(huì)適應(yīng)能力得分、服藥依從性和基線時(shí)韋氏智力測(cè)驗(yàn)得分,三者共解釋變異的44.4%;陰性癥狀緩解時(shí)間的預(yù)測(cè)因素是未經(jīng)抗精神病藥物治療的時(shí)間(Duration of Untreated Psychosis DUP)、基線時(shí)陰性因子得分,兩者共解釋因變量變異的54.5%。PSP得分的預(yù)測(cè)因素是DUP、病前社會(huì)適應(yīng)能力得分、早期陽性癥狀是否獲得緩解及陰性癥狀的緩解時(shí)間,四者共解釋變異的39.7%。中介效應(yīng)分析的結(jié)果顯示,陽性癥狀的緩解時(shí)間在病前社會(huì)適應(yīng)能力與PSP得分之間其部分中介作用,中介作用的效應(yīng)為24.1%;陰性癥狀的緩解時(shí)間在DUP與PSP得分之間起完全中介作用。結(jié)論:1.本研究中女性兒童的起病年齡較男性兒童早。兒童精神分裂癥患者中家族史陽性者居多,占50.0%,慢性起病者居多,占61.8%,病前社會(huì)適應(yīng)能力差的比例及遭受不良生活事件的比例較高,分別占55.9%、47.1%。2.兒童精神分裂癥的診斷穩(wěn)定性較高,服藥依從性相對(duì)較好,但合并應(yīng)用抗精神病藥物的比例較高,更換治療方案的比例高。3.隨訪結(jié)束時(shí),與基線相比,陽性癥狀、興奮敵對(duì)癥狀、焦慮抑郁癥狀明顯減輕,陰性癥狀明顯加重,認(rèn)知損害癥狀變化不大,個(gè)人和社會(huì)功能明顯改善,但均表現(xiàn)社會(huì)功能低下及不同程度的受損,顯示預(yù)后不良。4.影響兒童分裂癥社會(huì)功能恢復(fù)的因素是多方面的,急性及亞急性起病的患者容易獲得陽性癥狀的早期緩解;病前社會(huì)適應(yīng)能力差、服藥依從性差、認(rèn)知功能差是患者陽性癥狀緩解時(shí)間短的危險(xiǎn)因素;較長(zhǎng)的DUP、基線時(shí)陰性癥狀重是患者陰性癥狀緩解時(shí)間短的危險(xiǎn)因素。較長(zhǎng)的DUP、病前社會(huì)適應(yīng)能力差、早期陽性癥狀未獲得緩解及陰性癥狀緩解時(shí)間短是患者社會(huì)功能恢復(fù)不良的危險(xiǎn)因素。病前社會(huì)適應(yīng)能力即能直接影響社會(huì)功能結(jié)局,也能通過陽性癥狀的緩解時(shí)間間接影響社會(huì)功能結(jié)局;DUP不直接影響社會(huì)功能的結(jié)局,它是通過陰性癥狀的緩解時(shí)間來影響社會(huì)功能的結(jié)局的。我們應(yīng)該重視這些影響預(yù)后的危險(xiǎn)因素,盡可能采取各種措施,縮短從發(fā)病到抗精神病藥物服用的時(shí)間,早發(fā)現(xiàn),盡早治療和干預(yù),定期跟蹤隨訪和監(jiān)測(cè),對(duì)家屬普及兒童精神衛(wèi)生知識(shí)的教育,提高服藥依從性,進(jìn)而延長(zhǎng)陽性癥狀和陰性癥狀緩解的時(shí)間,從而達(dá)到減輕社會(huì)功能損害、改善預(yù)后的目的。
[Abstract]:Objective: a 5 year prospective follow-up study of children with schizophrenia was followed up for third months, first years, second years, third years, fourth years and fifth years, respectively, to observe the symptoms and social functions of children with schizophrenia, and to explore the influence of children's schizophrenia. The predictors of functional rehabilitation provide a scientific basis for the diagnosis, treatment and prevention of schizophrenia. Methods: from June 1, 2008 to May 31, 2010, 81 cases of primary schizophrenic residents in children younger than 14 years old were collected at the children's sick area of the mental health center of Shandong province. The general situation questionnaire, the Promorbid Adjustment Scale (PAS), the positive symptom and negative symptom scale (The Positive and Negnitive Syndrome Scale, PANSS), the childhood adversity questionnaire, the personal and social function scale, were made. Rsonal and Social Performance Scale, PSP), Wechsler's child intelligence scale (Wechsler Intelligence Scale for Children, WISC), collection of demographic data of children with schizophrenia, pre - onset social adaptation, pre onset visits, clinical features such as onset age, onset form, (without antipsychotic medication time), Family history, symptom characteristics and other indicators, using homemade outpatient follow-up questionnaire, prospectively followed up for 5 years, collecting the compliance of children with schizophrenia, taking antipsychotic drugs, taking drugs, taking medication, combining medication, changing medication, living in hospital, PANSS factor scores and early positive symptoms relief. At the end of the visit, the cumulative remission months of the positive symptoms, the cumulative remission months of the negative symptoms, the scores of individual and social function, the data entered SPSS22.0 and statistical analysis, using survival analysis, t test, X2 test, repeated measurement of variance analysis, multiple linear regression analysis, logistic regression analysis, path analysis, and exploration of children essence. The 5 year prognosis of schizophrenia and the influence factors of social function rehabilitation. Results: in 1. children with schizophrenia, the age of the male is 7-14 years old, the average age is 11 + 1.8 years old. The onset age of the female is 6-12.5 years old, and the average age is 10.6 + 1.4 years old. The age of onset is logrank=4.99, P0.05, women's onset age (P0.05), female The age of the onset was earlier than that of the male. The family history of children with schizophrenia was 50%, the proportion of poor social adaptation was 55.9%, the proportion of chronic onset persons accounted for 61.8%, the proportion of patients who were hospitalized with emotion, behavior problems were 22.2%, the average time of treatment without antipsychotic drugs was 8.33 months, and the high adversity score was Among the patients with 47.1%.2.81, 8 patients lost their visits for various reasons, 5 patients changed the diagnosis during follow-up, 68 cases were followed up, the stability of the diagnosis was 93.2% (68/73). The number of hospitalized times was 1-5 times during the follow-up period, the rate of relapse and readmission in 5 years was 58.8%, the proportion of patients with good compliance was 48.5% and the type of medication was second. At the end of the follow-up, only 3 patients were in the untreated state, accounting for 4.4%, 15 patients were treated with an antipsychotic drug, 23.1%, and 40 patients with two antipsychotic drugs. 61.5%, 13 combined with three antipsychotic drugs, with 15.4%. with emotional stabilizers, and antidepressants. There were 12, 16, 5, 16, 5, l7.6%, 23.5%, 5.9%, respectively. The number of patients who had been discharged at discharge was 10, only 14.7%, and 34 patients were replaced by two or more treatments, accounting for the PANSS positive factor of schizophrenia in children (12.78 + 2.92VS1) at the end of the follow-up. 4.88 + 3.38.t=-4.35, P0.05), the anxiety and depression factors (12.78 + 2.92VS14.88, 3.38, t=-4.35, P0.05), the scores of excitatory antagonistic factors (11.90 + 3.12VS15.44 + 3.91, t=-5.93, P0.05) were significantly lower than those of the baseline, and the difference was statistically significant (P0.05). The negative factors (30.32 + 7.35vs24.10 + 6.08, t=6.21, P0.05) were significantly higher than those at the baseline, and the differences were significantly higher than those at the baseline. Statistical significance (P0.05); cognitive factors were not significantly different from baseline (25.15 + 7.33vs26.57 + 6.25, t=-1.91, P0.05), and there was no statistically significant difference in.PSP scores (40.06 + 11.02vs20.96 + 5.37). The difference was statistically significant (P0.05). The number of patients with early positive symptoms remission was 27, and the early positive symptoms were relieved. The rate was 34.6%. The average cumulative months of the positive symptoms in remission were 18.78 + 7.18 months, the shortest was 6 months and the longest was 38 months. The cumulative months of the negative symptoms were 17.51 + 3.69 months, the shortest was 7 months and the longest was 24 months. The PSP score was used as the index of social function rehabilitation. The average PSP score was 40.06 + 11.02 points. The lowest 21 points, the highest 68 points, less than 30 points, 14, 20.6%, 30 to 70, accounted for 79.4%.4. multiple factor linear regression. Logistic regression analysis showed that the predictors for early remission of positive symptoms were the form of onset, and the possibility of early remission of the acute and subacute patients was about 5 times that of the chronic onset. The predictors of the time for remission of positive symptoms were the score of social adaptation before the disease, the compliance of the medicine and the score of the Wechsler's intelligence test at the baseline, and the three explained 44.4% of the variation; the predictive factors for the time of remission of negative symptoms were the time of Duration of Untreated Psychosis DUP without the antipsychotic treatment, and the negative factors at the baseline were obtained. The predictors for the 54.5%.PSP score of variable variation were DUP, the score of social adaptation before the disease, and whether the early positive symptoms were relieved and the time of remission of the negative symptoms. The results of the four interpretations of the variant 39.7%. mediator effect showed that the positive symptomatic remission time was the social adaptation ability and PSP before the disease. The mediating effect was 24.1% between the scores and the mediating effect was 24.1%, and the time for the remission of the negative symptoms was completely mediated by the PSP score. Conclusion: in 1. studies, the onset age of the female children is earlier than that of the male children. The majority of the children with schizophrenia in the children, accounting for 50%, the majority of the chronic onset, the 61.8%, the disease. The proportion of poor social adaptation and the proportion of poor life events were higher, accounting for 55.9% respectively. The diagnostic stability of 47.1%.2. children's schizophrenia was higher and the compliance was relatively good, but the proportion of anti psychotic drugs was higher, and the ratio of replacement therapy was high in.3. follow-up, and the positive symptoms were compared with the baseline. The symptoms of excitatory hostility, anxiety and depressive symptoms were obviously reduced, negative symptoms were obviously aggravated, cognitive impairment was not changed, personal and social function was obviously improved, but all the social dysfunction and degree of impairment were manifested, and the factors that affected the function recovery of children with schizophrenia with poor prognosis.4. were multifaceted, acute and subacute Patients with the onset of disease were prone to early remission of positive symptoms, poor social adaptability before the disease, poor compliance and poor cognitive function as a risk factor for the short duration of remission of the positive symptoms of the patients; longer DUP, the negative symptoms of the baseline were the risk factors for the short duration of remission of the negative symptoms of the patients. Longer DUP, and poor social adaptability before the disease, The unremission of early positive symptoms and the short remission time of negative symptoms are the risk factors for the poor social function recovery. The social adaptation ability before the disease can directly affect the social functional outcome and can indirectly influence the social functional outcome through the time of remission of positive symptoms; DUP does not directly affect the outcome of social function, it is through Yin. The time of remission of sexual symptoms affects the outcome of social function. We should pay attention to the risk factors that affect the prognosis and take all possible measures to shorten the time from onset to antipsychotic drugs, early discovery, early treatment and intervention, regular follow-up and monitoring, and education for family members to popularize the knowledge of mental health for children, Objective to improve the compliance of taking medicine and prolong the time of relieving positive symptoms and negative symptoms, so as to reduce the damage of social function and improve the prognosis.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R749.3

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本文編號(hào)：1945226