儿童精神分裂症5年预后及社会功能康复影响因素的前瞻性研究

发布时间：2018-05-28 04:12

本文选题：儿童精神分裂症 + 预后　；参考：《山东大学》2017年博士论文

【摘要】：目的:采用标准化测评工具对儿童精神分裂症患者进行为期5年的前瞻性随访研究,分别在入组后第3个月、第1年、第2年、第3年、第4年、第5年进行随访,观察儿童精神分裂症的症状缓解和社会功能康复状况,探索影响儿童精神分裂症患者社会功能康复的预测因素,为儿童精神分裂症的诊断、治疗、预防提供科学依据。方法:从2008年6月1 日到2010年5月31日在山东省精神卫生中心儿童青少年病区收集的小于14岁的儿童首发精神分裂症住院患者81例作为研究对象,基线时采用自制患者一般情况调查量表、病前社会适应能力评估量表(Promorbid Adjustment Scale,PAS)、阳性症状与阴性症状量表(The Positive and Negnitive Syndrome Scale,PANSS)、儿童期逆境问卷(The Questionnaire of Adverse Childhood Experiences,ACEs)、个人和社会功能量表(The Personal and Social Performance Scale,PSP)、韦氏儿童智力量表(Wechsler Intelligence Scale for Children,WISC),收集儿童精神分裂症患者的人口学资料、病前社会适应能力、发病前就诊情况、临床特征如起病年龄、起病形式、DUP(未经抗精神病药物治疗的时间)、家族史、症状特点等各项指标,采用自制门诊随访情况调查表,前瞻性定期随访5年,收集儿童精神分裂症患者的服药依从性、服用抗精神病药物的种类、服药剂量、合并用药、换药情况、再住院情况、PANSS因子得分及早期阳性症状缓解情况、随访结束时患者的阳性症状累计缓解月数、阴性症状累计缓解月数、个人和社会功能得分等指标,数据录入SPSS22.0并进行统计分析,采用生存分析、t检验、X2检验、重复测量方差分析、多元线性回归分析、logistic回归分析、路径分析,探索儿童精神分裂症的5年预后及社会功能康复的影响因素。结果:1.儿童精神分裂症患者中,男性的起病年龄为7-14岁,平均11.0±1.8岁,女性的起病年龄为6-12.5岁,平均10.6±1.4岁,通过Kaplan-Meier生存分析,发现起病年龄有性别差异(logrank=4.99, P0.05),女性起病年龄较男性早。儿童精神分裂症患者家族史阳性者占50.0%,病前社会适应能力差的比例占55.9%,慢性起病者的比例占61.8%,住院前因情绪、行为问题就诊的患者比例占22.2%,未经抗精神病药物治疗的时间平均为8.33个月,高逆境得分的患者比例为47.1%。2.81例患者中,8例患者因各种原因失访,5例患者在随访过程中更改诊断,68例完成随访,诊断的稳定性为93.2%(68/73)。随访期间住院次数为1-5次,5年内复发再入院的比例为58.8%,服药依从性好的患者比例为48.5%,用药种类以第二代抗精神病药物为主。至随访结束时,仅有3例患者处于未服药状态,占4.4%; 15例患者患者单用一种抗精神病药物治疗,占23.1%,40例患者合并两种抗精神病药物治疗.占61.5%; 13例合并三种抗精神病药物治疗,占15.4%。合并情感稳定剂、抗抑郁药物、苯二氮卓类药物的患者分别为12例、16例、5例,占l7.6%、23.5%、5.9%; 一直沿用出院时治疗方案的患者人数为10例,仅占14.7%,更换过二种及以上治疗方案的患者人数为34例,占50.0%。3.随访结束时,儿童精神分裂症患者PANSS阳性因子(12.78±2.92VS14.88±3.38.t=-4.35,P0.05)、焦虑抑郁因子(12.78±2.92VS14.88士3.38,t=-4.35,P0.05)、兴奋敌对因子(11.90±3.12VS15.44±3.91, t=-5.93,P0.05)得分较基线时明显下降,差异有统计学意义(P0.05),阴性因子得分(30.32±7.35vs24.10±6.08,t=6.21,P0.05)较基线时明显升高,差异有统计学意义(P0.05);认知因子与基线相比变化不大(25.15±7.33vs26.57±6.25,t=-1.91,P0.05),差异无统计学意义。PSP得分较基线时明显升高(40.06±11.02vs20.96±5.37),差异有统计学意义(P0.05)。获得早期阳性症状缓解的患者例数为27例,早期阳性症状缓解率为34.6%,阳性症状处于缓解状态的累计月数平均为18.78±7.18月,最短为6个月,最长为38月,阴性症状处于缓解状态的累计月数平均为17.51±3.69月,最短为7个月,最长为24个月。以PSP得分作为社会功能康复情况的指标,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分之间的有54人,占79.4%。4.多因素线性回归、logistic回归分析显示,阳性症状是否早期缓解的预测因素是起病形式,急性及亚急性起病者获得早期缓解的可能性大约是慢性起病者的5倍;阳性症状缓解时间的预测因素是病前社会适应能力得分、服药依从性和基线时韦氏智力测验得分,三者共解释变异的44.4%;阴性症状缓解时间的预测因素是未经抗精神病药物治疗的时间(Duration of Untreated Psychosis DUP)、基线时阴性因子得分,两者共解释因变量变异的54.5%。PSP得分的预测因素是DUP、病前社会适应能力得分、早期阳性症状是否获得缓解及阴性症状的缓解时间,四者共解释变异的39.7%。中介效应分析的结果显示,阳性症状的缓解时间在病前社会适应能力与PSP得分之间其部分中介作用,中介作用的效应为24.1%;阴性症状的缓解时间在DUP与PSP得分之间起完全中介作用。结论:1.本研究中女性儿童的起病年龄较男性儿童早。儿童精神分裂症患者中家族史阳性者居多,占50.0%,慢性起病者居多,占61.8%,病前社会适应能力差的比例及遭受不良生活事件的比例较高,分别占55.9%、47.1%。2.儿童精神分裂症的诊断稳定性较高,服药依从性相对较好,但合并应用抗精神病药物的比例较高,更换治疗方案的比例高。3.随访结束时,与基线相比,阳性症状、兴奋敌对症状、焦虑抑郁症状明显减轻,阴性症状明显加重,认知损害症状变化不大,个人和社会功能明显改善,但均表现社会功能低下及不同程度的受损,显示预后不良。4.影响儿童分裂症社会功能恢复的因素是多方面的,急性及亚急性起病的患者容易获得阳性症状的早期缓解;病前社会适应能力差、服药依从性差、认知功能差是患者阳性症状缓解时间短的危险因素;较长的DUP、基线时阴性症状重是患者阴性症状缓解时间短的危险因素。较长的DUP、病前社会适应能力差、早期阳性症状未获得缓解及阴性症状缓解时间短是患者社会功能恢复不良的危险因素。病前社会适应能力即能直接影响社会功能结局,也能通过阳性症状的缓解时间间接影响社会功能结局;DUP不直接影响社会功能的结局,它是通过阴性症状的缓解时间来影响社会功能的结局的。我们应该重视这些影响预后的危险因素,尽可能采取各种措施,缩短从发病到抗精神病药物服用的时间,早发现,尽早治疗和干预,定期跟踪随访和监测,对家属普及儿童精神卫生知识的教育,提高服药依从性,进而延长阳性症状和阴性症状缓解的时间,从而达到减轻社会功能损害、改善预后的目的。
[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.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R749.3

【参考文献】