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1、精神分裂症与其他精神病性障碍2023/2/271第一页，本课件共有74页学习目标1掌握精神分裂症的临床表现、诊断和鉴别诊断、治疗和预防复发策略2掌握精神分裂症疾病的分型、预后特征3了解精神分裂症疾病的病因学2023/2/272第二页，本课件共有74页Thedefinition of Schizophrenia definition of Schizophrenia inin CCMD-3 CCMD-3Schizophrenia Schizophrenia comprises comprises a a group group of of psychotic psychotic disorder
2、s disorders of of unknown unknown specific specific etiology etiology often often presented presented with with a a gradual gradual onset onset of of abnormalities abnormalities in in perception,perception,thought,thought,motion motion and and behavior behavior since since young young adulthood.adul
3、thood.Consciousness Consciousness is is usually usually maintained.maintained.Intelligence Intelligence is is intact,intact,but but in in some some cases,cases,there there is is some some degree degree of of cognitive cognitive impairment.impairment.The The natural natural course course of of the th
4、e disorder disorder is is chronic chronic remitting remitting but but sometimes sometimes deteriorating.deteriorating.2023/2/273第三页，本课件共有74页Epidemiology1 Prevalence：uPoint prevalence in China(1982):4.75（rural area 3.42，urban 6.06 )。uTotal Total prevalence prevalence in in China(1982):5.69China(1982)
5、:5.69，(6.551999)。uLifetime prevalence in USA（1988）13。2023/2/274第四页，本课件共有74页Epidemiology2nAge：the ageof onset in 50%of patients is2030 2030 year year oldold，over80%80%of of patients patients is is 1635year old.1635year old.nGender：uSchizophrenia occurs equally in men and women(in abroad)uThe prevalen
6、ce in men is more than women(1.6:1)in China.1.6:1)in China.uThe The mean mean age age of of onset onset is is about about 2 2 to to 5 5 years earlier in men than women.years earlier in men than women.2023/2/275第五页，本课件共有74页HistoryHistory（1 1）SchneiderSchneider-first rank symptoms-first rank symptoms（
7、首级症状）（首级症状）1.thought hearing(1.thought hearing(思维化声思维化声)2.2.Third-person hallucinationsThird-person hallucinations(争论性幻听争论性幻听)3.3.Hallucinations in the form of a commentaryHallucinations in the form of a commentary(评论性幻评论性幻听听)4.thought withdrawal 4.thought withdrawal or insertionor insertion(思维被夺思维被
8、夺/被插入被插入)5.5.Thought broadcastingThought broadcasting/diffusion(/diffusion(思维被广播或扩散思维被广播或扩散)6.Forced feeling(6.Forced feeling(强加的情感强加的情感)7.forced impulsive(7.forced impulsive(强加的冲动强加的冲动)8.forced behavior(8.forced behavior(强加的行为强加的行为)9.somatic passivity experience(9.somatic passivity experience(躯体被动体
9、验躯体被动体验)10.delusional perception(10.delusional perception(妄想性知觉妄想性知觉)2023/2/276第六页，本课件共有74页Etiology 一、biological factorsbiological factors1 1geneticsgenetics2 2The neurodevelopmental hypothesisThe neurodevelopmental hypothesis3 3Changes in brain structureChanges in brain structure4 4Biochemical abno
10、rmalitiesBiochemical abnormalities二、二、personality factorspersonality factors三、三、psycho-social factorspsycho-social factors2023/2/277第七页，本课件共有74页Genetics 1 Studies Method:Studies Method:uFamily studiesFamily studiesuTwin studies Twin studies uAdoption studiesAdoption studies2023/2/278第八页，本课件共有74页Gene
11、tics 2 The results of family studies:uThe risk of Schizophrenia.Schizoaffective disorder,and schizotypal personality is increased in first-degree relatives of patients with Schizophrenia.uThe risk of both Schizophrenia and mood disorder is increased in first-degree relatives of patients with schizoa
12、ffective disorder.uThe risk of bipolar illness is not increased in first-degree relatives of patients with schizophrenia.2023/2/279第九页，本课件共有74页Genetics 3The results of twin studiesuconcordance rates among MZ pairs is higher than that among control(35-60 times)uconcordance rates are about 50%for MZ a
13、nd about 10%for DZ.It might be expected that some environmental factors relevant to etiology.uThe risk of schizophrenia 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,bu
14、t for some reason the susceptibility is not expressed.2023/2/2710第十页，本课件共有74页Genetics 4The results of adoption studiesuThe rate for Schizophrenia is greater among the biological relatives of the Schizophrenia Adoptees than among the relatives of control.uThe finding supports the genetic hypothesis.2
15、023/2/2711第十一页，本课件共有74页Molecular genetic studiesTwo main approaches:1.linkage analysis It is applied to multiply affected families(高发家系）,but no linkage markers have been clearly identified.2.Candidate gene approaches Genes for biological mechanisms that may be involved in Schizophrenia have been loc
16、alized and cloned.Using this technique,a number of genes coding for DA and 5-HT receptors have been excluded from linkage to Schizophrenia in various pedigrees（家系）.2023/2/2712第十二页，本课件共有74页Biochemicalstudies The dopamine hypothesis.n5-HT hypothesis5-HT hypothesis.nAmino acids in Schizophrenia2023/2/2
17、713第十三页，本课件共有74页Etiology studies-conclusions 1nThere is strong evidence that schizophrenia has important genetic causes,but the mode of inheritance is not known.nThere is increasing evidence that many cases are of neurodevelopmental origin,but whether neurodevelopmental abnormalities are present in
18、all patients is not clear.nMost believe that Sch.results from an interaction of genetic predisposition and environmental factors.nStressful life events often provoke the disorder,but non-specific events to schizophrenia.2023/2/2714第十四页，本课件共有74页Etiology studies-conclusions 2nSchizophrenia May be prec
19、eded by cognitive and social impairment in childhood,and that the presence of these impairment and certain kind of personality disorder are forms of expression of schizophrenia genotypen精神分裂症病人可能在儿童期就有认知和社会功能损害，这些损害及某些人格障碍的出现是精神分裂症基因型表达的一种形式2023/2/2715第十五页，本课件共有74页Etiology studies-conclusions 3nThe
20、deficits of temporal and frontal structural and function are associated with non-progressive neuropsychological impairment.nDopamine 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 schizoph
21、renia.n颞叶与额叶的功能和结构的缺陷与非进展性的神经心理损害有关n多巴胺受体阻断能控制症状，但尚无确信证据表明多巴胺功能亢进是该病的主要原因2023/2/2716第十六页，本课件共有74页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.2023/2/
22、2717第十七页，本课件共有74页Prodromal syndromenChanges in mood:depression,anxiety,mood swings,irritabilitynChanges in cognition:odd or unusual ideas,vagueness,deterioration in study or worknChanges in perception of self and the worldnChanged behaviors,withdrawal and loss of interest in socializing,suspiciousne
23、ss,deterioration in role functionnPhysical changes:in sleep and appetite,loss of energy,reduced drive and motivation,etc.2023/2/2718第十八页，本课件共有74页Disorders of sensation and perception 感觉障碍(disorders of sensation)感觉过敏(hyperesthesia)感觉减退(hypoesthesia)内感性不适(senestopathia)知觉障碍（disturbance of perception）错
24、觉(illusion)幻觉(hallucination)感知综合障碍(psychosensory disturbance)2023/2/2719第十九页，本课件共有74页Disorders of sensation and perceptionn幻听(auditory hallucination)n幻视(visual hallucination)n幻嗅(olfactory hallucination)n幻味(gustatory hallucination)n幻触(tactile hallucination)n内脏幻觉(visceral hallucination)n功能性幻觉（function
25、al hallucination）n反射性幻觉（reflex hallucination）2023/2/2720第二十页，本课件共有74页Thinking disorder思维形式障碍思维形式障碍(disordersofthethinkingform)u思维贫乏(poverty of thought)u思维散漫(looseness of thought)u思维破裂(splitting of thought)思维不连贯(incoherence of thought)u思维中断(blocking of thought)思维被夺(thought deprivation)。u思维插入(thought
26、insertion)和强制性思维(forced thinking)u思维化声(thought hearing)u思维扩散(diffusion of thought)和思维被广播(thought broadcasting)u象征性思维(symbolic thinking)u语词新作(neologism)u逻辑倒错性思维(paralogism thinking)u强迫观念（obsessive idea）或称强迫性思维u内向性思维（autism）2023/2/2721第二十一页，本课件共有74页delusion 妄妄想想(delusion)按其起源与其他心理活动的关系可分为原发性妄想(primary
27、 delusion)和继发性妄想(secondary delusion)u被害妄想(delusion of persecution)u关系妄想(delusion of reference)u物理影响妄想(delusion of physical influence)-被控制感。u钟情妄想(delusion of love)u嫉妒妄想(delusion of jealousy)u被洞悉感(experience of being revealed)u夸大妄想(grandiose delusion)u罪恶妄想(delusion of guilt)u疑病妄想（hypochondriacal delus
28、ion）u虚无妄想(delusion of negation)2023/2/2722第二十二页，本课件共有74页Abnormalitiesofmood Three main kinds of mood are common:Three main kinds of mood are common:nFirst,there may be sustained abnormalities of mood such as anxiety,depression,irritability,or euphoria.nSecond,there may be blunting of affect.Essentia
29、lly this is sustained emotional indifference（冷淡）（冷淡）or diminution of emotional response.nThird,there is incongruity of affect.Here the expressed mood is not in keeping with situation or with the patients own feeling.2023/2/2723第二十三页，本课件共有74页AbnormalitiesofvolitionnSome acute patients are normal nOth
30、ers may present somewhat abnormalities of volitionuhypobulia uabulia uParabulia（意向倒错）（意向倒错）uambivalenceuparanoid schizophrenia may present hyperbulia 2023/2/2724第二十四页，本课件共有74页Abnormalitiesofbehavior1nExcitement（兴奋状态）-hebephrenic excitement,catatonic excitementnStupor（木僵）-.The patient remain motionle
31、ss for a long time(catatonic stupor),or maintain their limbs or trunks in unusual positions(waxy flexibilitas)for various lengths of time.nNegativism（违拗）-refuse to cooperate(active negativism,passive negativism)nPassive obedience（被动服从）2023/2/2725第二十五页，本课件共有74页Abnormalitiesofbehavior2nStereotyped act
32、-（刻板动作）（刻板动作）-the patient repeat various functions or gestures,or imitate other movements(echopraxia 模仿动作模仿动作)nMannerism（作态）（作态）nBizarre behavior（怪异行为）（怪异行为）nForced act，compulsive actnViolence and suicide behaviornSome patients may cause self-induced water intoxication or avoid eating because of cer
33、tain delusional beliefs.2023/2/2726第二十六页，本课件共有74页Orientation and insightnIn acute schizophrenia orientation is normalnInsight is usually impaired.Most of patient do not accept that their experiences result from illness2023/2/2727第二十七页，本课件共有74页Cognitive dysfunction 1nCognitivedysfunctionIsacardinal(主
34、要的）主要的）featureofschizophrenianOnaverage,firstdiagnosedschizophrenicpatientsIQis10pointslowerthancontrol.nChildrenatriskforschizophreniahavelowerIQsthandocontrol.n认知功能异常是精分症的主要特征n首诊的精分症病人较正常人IQ低10分n高危儿童的IQ低于正常对照组2023/2/2728第二十八页，本课件共有74页Cognitive dysfunction 2nThefirstepisodepatientsexhibitimpairment
35、sinattention,concentration,workingmemory,visual-spatialmemory,semanticmemory,recallmemory,andexecutivefunction.nCognitiveimpairmentisoftenindependentofpositiveandnegativesymptomsandevenofthedisorganizationsyndromeandthecourseofillness.n首发精分症病人表现有注意力、注意集中能力、工作记忆、视-空记忆、语义记忆、回忆和执行功能的异常n认知功能损害独立于阳性和阴性症状
36、，甚至独立于解体症状和疾病的病程。2023/2/2729第二十九页，本课件共有74页Tab.3 The most frequent symptoms of acute schizophrenia（急性精分症病人症状频谱）Symptom Frequency(%)Lack of insight 97Auditory hallucinations 74Ideas of reference 70Suspiciousness 66Flatness of affect 66Delusional mood 64Delusions of persecution 64Thoughts spoken aloud
37、502023/2/2730第三十页，本课件共有74页The chronic syndromenIncontrastwiththepositiveoftheacuteschizophrenia,thechronicsyndromeischaracterizedbythoughtdisorderandthenegativesymptoms.nThemoststrikingfeatureisdiminishedvolition,thatislackofdriveandinitiative.n与急性精分症相比，与急性精分症相比，慢性病人以思维障慢性病人以思维障碍和阴性症状为特碍和阴性症状为特征征n最突
38、出的症状是意最突出的症状是意志减退，缺乏动力志减退，缺乏动力和始动性和始动性 2023/2/2731第三十一页，本课件共有74页Subtypes of schizophreniaSchizophrenia has also been subdivided on the basis of psychopathology,course,and response to treatment.uHebephrenic schizophreniauParanoid schizophreniauCatatonic schizophreniauSimple schizophrenia uUndifferent
39、iated schizophrenia uOther type or unspecified of schizophrenia2023/2/2732第三十二页，本课件共有74页Simple-schizophrenianAbout 2%of patients can diagnosed this type.nIs characterized by the insidious（隐隐袭袭性性的的）development of odd behavior,social withdrawal,and declining performance at work.nClear symptoms are abs
40、ent.nDifficult to identify reliably.n约约2%的病人可诊的病人可诊断为此型断为此型n其临床特点为：其临床特点为：隐隐袭性起病，逐步出袭性起病，逐步出现一些奇怪的现一些奇怪的 行行为、回避社交、社为、回避社交、社会功能减退等会功能减退等n常缺乏明确的精神常缺乏明确的精神病性症状病性症状n此型常难于确诊此型常难于确诊2023/2/2733第三十三页，本课件共有74页Hebephrenic schizophrenianAbout 11%of patients can diagnosed this type.nIs characterized by the abse
41、nce of systematized delusions and the presence of incoherence and inappropriate affect.nSilly(愚蠢）愚蠢）and childish in their behavior n约约11%的病人可诊的病人可诊断此型断此型n以思维联想障碍、以思维联想障碍、情感不协调、缺乏情感不协调、缺乏系统性的妄想为特系统性的妄想为特征征n常伴有一些幼稚愚常伴有一些幼稚愚蠢行为、意向亢进蠢行为、意向亢进或倒错或倒错2023/2/2734第三十四页，本课件共有74页Catatonia schizophrenianThis typ
42、e is much less frequently now than in previous years.nMotor disturbance is the dominant feature,consisting of either agitated hyperactivity or a decrease in gross motor activity with stupor,rigidity,or bizarre postures n此型较以往少见此型较以往少见n以运动障碍为主要以运动障碍为主要特征，表现为紧张特征，表现为紧张性兴奋和紧张性抑性兴奋和紧张性抑制（木僵、肌肉强制（木僵、肌肉强劲
43、、奇怪的姿势劲、奇怪的姿势）2023/2/2735第三十五页，本课件共有74页Paranoid schizophrenianThis type is the most common form of the illness.nIs characterized by prominent paranoid delusion,thought processes and mood are relatively spared.The patient may appear normal until his abnormal beliefs are uncoveredn此型最常见此型最常见n以妄想为主要表现，
44、以妄想为主要表现，常伴有幻觉。思维过常伴有幻觉。思维过程和情绪常相对完好，程和情绪常相对完好，在妄想未被暴露时，在妄想未被暴露时，病人常被认为病人常被认为“正常正常”。2023/2/2736第三十六页，本课件共有74页Undifferentiated schizophrenianThistypeisthenextmostfrequentformnDelusionsandhallucinationsofanytypeareprominentandareaccompaniedbyincoherenceandgrosslyofdisorganizedbehavior.n此型为第二常见类此型为第二常见
45、类型型n妄想和幻觉都突出，妄想和幻觉都突出，常伴有思维联想障常伴有思维联想障碍和行为紊乱碍和行为紊乱n不符合以上各型的不符合以上各型的诊断诊断2023/2/2737第三十七页，本课件共有74页Other type schizophrenianConditions meeting the general symptom criteria of schizophrenia.nThe clinical feature does not satisfy the criteria of any of the subtypes mentioned above such as children schizo
46、phrenia and late-onset schizophrenian符合精分症的症状符合精分症的症状标准标准n临床特征不符合以临床特征不符合以上各型，如儿童和上各型，如儿童和晚发性精分症晚发性精分症2023/2/2738第三十八页，本课件共有74页Post-schizophrenic depressionnThe patient exhibits features of schizophrenia in the past one year.The depressive symptoms occur when the schizophrenic symptoms are in partia
47、l remissionnProminent depressive symptoms have been present for at least two weeks,accompanied by residual psychotic symptomsnDepression and schizoaffective disorder are excluded.n在过去一年诊断为在过去一年诊断为精分症，抑郁症状精分症，抑郁症状发生在精神症状部发生在精神症状部分缓解后分缓解后n明显的抑郁症状持明显的抑郁症状持续至少续至少2周，且伴周，且伴随有残留的精神症随有残留的精神症状状n排除抑郁症和分裂排除抑郁症
48、和分裂情感障碍情感障碍2023/2/2739第三十九页，本课件共有74页Residual schizophrenianSchizophrenia without complete remission for at least 2 years;nMarked improvement in mental state with partial remission of symptoms and presence of at least one of the following:uspecific positive symptom;uspecific negative symptom,such as
49、poverty of thought,apathy,abulia or social withdrawal;upersonality change.uThe impairment of social functioning and insight are not severe;u Symptoms are relatively stable and have minimal improvement or deterioration for at least one yearn患精分症至少患精分症至少2年年未彻底缓解未彻底缓解n精神症状明显改进，精神症状明显改进，但仍表现至少以下但仍表现至少以下
50、一项：一项：u个别阳性症状个别阳性症状u个别阴性症状个别阴性症状u人格改变人格改变u社会功能和自知社会功能和自知力损害但不严重力损害但不严重u症状相对稳定至症状相对稳定至少一年少一年2023/2/2740第四十页，本课件共有74页Chronic schizophrenianSymptoms meeting the diagnostic criteria of schizophrenia;nThe course lasts for at least 2 years.2023/2/2741第四十一页，本课件共有74页Type I and type type II schizophrenianCro