【摘要】：目的:探索軀體癥狀障礙(Somatic Symptoms Disorder,SSD)在中國(guó)三甲綜合醫(yī)院門診中的患病率,并描述軀體癥狀障礙患者的癥狀負(fù)擔(dān)、心理特征、生活質(zhì)量,探索生活質(zhì)量預(yù)測(cè)因素;驗(yàn)證軀體癥狀障礙診斷B標(biāo)準(zhǔn)量表(Somatic Symptoms Disorder-12,SSD-12)的信效度,為軀體癥狀障礙提供量化評(píng)估工具。方法:分別在消化內(nèi)科、中醫(yī)科、心理科連續(xù)納入患者,分別使用國(guó)際神經(jīng)精神科簡(jiǎn)式訪談問卷(MINI-International Neuropsychiatric Interview,M.I.N.I)進(jìn)行 ICD-10 精神與行為障礙分類(International Classification of Diseases-10 classification of mental and behavioral disorders)軀體形式障礙(Somatoform disorder,SFD)診斷、DSM-5(The Diagnostic and Statis-tical Manual of Mental Disorders,Fifth Edition,精神障礙診斷與統(tǒng)計(jì)手冊(cè),第五版)臨床定式檢查(structured clinical interview for DSM-5,research version,SCID-5)進(jìn)行軀體癥狀障礙診斷,并使用軀體癥狀嚴(yán)重程度量表(Patient Health Questionnaire-15,PHQ-15)、軀體癥狀量表-8(Somatic Symptom Scale-8,SSS-8)評(píng)估軀體癥狀嚴(yán)重程度,使用抑郁癥狀嚴(yán)重程度量表(Patient Health Questionnaire-9,PHQ-9)、廣泛性焦慮量表(General Anx-iety Disorder-7,GAD-7)評(píng)估焦慮、抑郁水平,使用健康相關(guān)焦慮評(píng)定(Whiteley-8 Scale,WI-8)評(píng)估健康焦慮,軀體癥狀障礙診斷B標(biāo)準(zhǔn)量表(Somatic Symptom Disorder-12,SSD-12)用于評(píng)估軀體癥狀障礙診斷標(biāo)準(zhǔn)的B標(biāo)準(zhǔn),使用 WHO DAS 2.0(WHO Disability Assessment Schedule 2.0)評(píng)估殘疾程度,使用 12 項(xiàng)健康調(diào)查簡(jiǎn)表(The medical outcome study 12-item short form health survey,SF-12)評(píng)估健康相關(guān)生活質(zhì)量。結(jié)果:1)三個(gè)科室各收集到50份有效問卷,22.0%的患者滿足軀體癥狀障礙診斷標(biāo)準(zhǔn),50.7%的患者滿足未分化軀體形式障礙診斷標(biāo)準(zhǔn),軀體癥狀障礙與軀體形式障礙診斷一致性不高(cohen k指數(shù)=0.217,p=0.001);2)SSD患者PHQ-15總分、PHQ-9總分、GAD-7總分、WI-8總分、SSS-8總分、SSD-12、DAS總分顯著高于僅滿足SFD的患者及一般就診人群,就診次數(shù)顯著高于其他兩組患者,就診滿意度及主觀感受的療效、PCS、MCS均顯著低于僅滿足SFD的患者及一般就診人群,三個(gè)科室的SSD患者未見顯著性差異;3)PHQ-9總分為殘疾程度的顯著預(yù)測(cè)因素,方程可解釋的變異為56.4%[F=30.842,p=0.001,VIF(variance inflation factor,方差膨脹因子)3.5];SSD-12總分、SSS-8總分、過去6個(gè)月是否治療是PCS的顯著預(yù)測(cè)因素,可解釋的變異為 50.1%(F=23.948,p=0.001,VIF3.5);已婚、GAD-7 總分、PHQ-9總分、就診次數(shù)是MCS的顯著預(yù)測(cè)因素,可解釋的變異為65.5%(F=22.513,p=0.001,VIF3.5),納入SSD-12后三個(gè)方程R2變化量均大于納入PHQ-15 時(shí)。4)SSD-12在本人群中信度高(Cronbach α=0.953),驗(yàn)證性因子分析提示SSD-12認(rèn)知、情緒、行為的三因子模型擬合度尚能接受[n=150,CFI(Comparative Fit Index)=0.990,TLI(Tucker-Lewis Index)=0.987,REMSEA(Root Mean Square Error of Approximation)=0.094,90%CI(Confidence interval)=0.072-0.116],但3個(gè)潛變量呈強(qiáng)相關(guān)性,使用SSD-12總分作為單因子模型擬合度在可接受范圍(n=150,CFI=0.989,TLI=0.987,REMSEA=0.094,90%CI=0.072-0.115),可反映總體心理困擾程度;SSD-12與軀體癥狀嚴(yán)重程度(PHQ-15,r=0.520、SSS-8,r=0.596)、健康焦慮(WI-8,r=0.781)、焦慮、抑郁水平(r=0.605及r=0.658)顯著相關(guān),區(qū)分效度欠佳;以SCID-5作為SSD診斷的金標(biāo)準(zhǔn),SSD-12作為SSD篩查工具,在本樣本人群中診斷界值為17(約登指數(shù)=0.595,敏感度=0.757,特異度=0.838),可正確診斷82.0%的患者;結(jié)論:1.綜合醫(yī)院心理科、消化科、中醫(yī)科三個(gè)科室門診患者SSD患病率為22.0%;2.軀體癥狀障礙患者軀體癥狀嚴(yán)重程度、焦慮抑郁水平、健康焦慮水平高,就診次數(shù)多,就診主觀感受差,精神健康及軀體健康相關(guān)生活質(zhì)量差,殘疾程度高;3.SSD-12信度良好,三因子模型擬合度尚能接受,但因子之間相關(guān)性太強(qiáng);量表總分能反映患者軀體癥狀困擾的嚴(yán)重程度,并預(yù)測(cè)患者的生活質(zhì)量及殘疾程度;SSD-12篩查軀體癥狀障礙界值為17;4.患者抑郁水平影響殘疾程度;SSD-12總分、近1周癥狀嚴(yán)重程度、過去6個(gè)月是否治療、焦慮抑郁水平、就診次數(shù)是健康相關(guān)生活質(zhì)量的影響因素,而軀體癥狀本身對(duì)健康相關(guān)生活質(zhì)量及殘疾程度影響不大,臨床干預(yù)應(yīng)著重于減輕患者癥狀相關(guān)的痛苦感、糾正患者對(duì)癥狀的認(rèn)知扭曲、減少就診次數(shù),改善患者生活質(zhì)量,而不僅僅是消除癥狀。
[Abstract]:Objective: To explore the prevalence of somatic symptoms disorder (SSD) in the outpatient department of the Third-Class General Hospital of China, describe the symptoms burden, psychological characteristics, quality of life of the patients with SSD, explore the predictors of quality of life, and validate the Somatic Symptoms Disorder-12 (SSD-12). Methods: ICD-10 mental and behavioral disorders were classified by the International Neuropsychiatric Interview (MINI-International Neuropsychiatric Interview, M.I.N.I) in the Department of Gastroenterology, Traditional Chinese Medicine and Psychology. Diagnosis of Somatoform disorder (SFD), DSM-5 (The Diagnostic and Statis-tical Manual of Mental Disorders, Fifth Edition, Diagnostic and Statis tical Manual of Mental Disorders, Handbook of Mental Disorders, Fifth Edition, Constructed Clinical Interview for DSM-5) 5, research version, SCID-5) for the diagnosis of somatic symptoms disorders, and use the Patient Health Questionnaire-15 (PHQ-15), Somatic Symptom Scale-8 (SSS-8) to assess the severity of somatic symptoms, using the Patient Health Questionnaire-9 (PHQ-9), a wide range of General Anx-iety Disorder-7 (GAD-7) was used to assess anxiety and depression levels, Whiteley-8 Scale (WI-8) was used to assess health anxiety, and Somatic Symptom Disorder-12 (SSD-12) was used to assess the diagnostic criteria for somatic symptomatic disorders. WHO DAS 2.0 (WHO) was used to assess the diagnostic criteria for somatic symptoms. Disability Assessment Schedule 2.0 assessed disability and health-related quality of life using 12-item short form health survey (SF-12). The diagnostic consistency between somatoform disorder and somatoform disorder was not high (cohen K index = 0.217, P = 0.001); 2) The total score of PHQ-15, PHQ-9, GAD-7, WI-8, SSS-8, SSD-12, DAS in SSD patients were significantly higher than those in SFD patients and the general population. In the other two groups, PCS and MCS were significantly lower than those who only satisfied SFD and the general population, and there was no significant difference among the SSD patients in the three departments; 3) The total score of PHQ-9 was a significant predictor of disability, and the explanatory variance of the equation was 56.4% [F = 30.842, P = 0.001, VIF (variance inflation fac) Total score of SSD-12, total score of SSS-8, whether treatment was a significant predictor of PCS in the past six months, the explanable variance was 50.1% (F = 23.948, P = 0.001, VIF3.5); married, GAD-7 total score, total score of PHQ-9, the number of visits was a significant predictor of MCS, and the explanable variance was 65.5% (F = 22.513, P = 0.001, VIF3.5) after inclusion in SSD-12. The variance of R2 in the three equations was greater than that in PHQ-15. 4) SSD-12 had a high reliability in this population (Cronbach alpha = 0. 953). Confirmative factor analysis suggested that the three-factor model of cognition, emotion and behavior of SSD-12 was acceptable [n = 150, CFI (Comparative Fit Index) = 0. 990, TLI (Tucker-Lewis Index) = 0. 987, REMSEA (Root Mean Square Error of Behavior). Roximation = 0.094,90% CI (Confidence interval) = 0.072-0.116], but the three latent variables were strongly correlated, using the total score of SSD-12 as a single factor model fit within the acceptable range (n = 150, CFI = 0.989, TLI = 0.987, REMSEA = 0.094, 90% CI = 0.072-0.115), can reflect the overall psychological distress; SSD-12 and the severity of physical symptoms (PHQ-15, r = 0.520, S = 0, S = 0.989). SS-8, r = 0.596, health anxiety (WI-8, r = 0.781), anxiety and depression levels (r = 0.605 and R = 0.658) were significantly correlated with poor discriminatory validity; with SCID-5 as the gold standard for SSD diagnosis, SSD-12 as the SSD screening tool, the diagnostic threshold value was 17 (Yorden index = 0.595, sensitivity = 0.757, specificity = 0.838) in this sample population, 82.0% of patients could be correctly diagnosed; Conclusion: 1. The prevalence of SSD was 22.0%. 2. The severity of somatic symptoms, the level of anxiety and depression, the level of health anxiety were high in patients with somatic symptoms disorders, the number of visits was high, the subjective feeling was poor, the quality of life related to mental and physical health was poor, and the degree of disability was high. The reliability was good, the three-factor model fit was acceptable, but the correlation between the factors was too strong; the total score of the scale could reflect the severity of somatic symptoms, and predict the quality of life and disability of patients; the threshold of SSD-12 screening for somatic symptoms was 17; 4. Depression level of patients affected the degree of disability; SSD-12 total score, the severity of symptoms in the past week. Severity, treatment, anxiety and depression levels, and number of visits over the past six months are the influencing factors of health-related quality of life, while physical symptoms themselves have little effect on health-related quality of life and disability. Clinical intervention should focus on alleviating symptoms-related pain, correcting cognitive distortion of symptoms and reducing visits. Number, improve the quality of life of patients, not just eliminate symptoms.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R749

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