躯体症状障碍患者的心理行为特征

发布时间：2018-09-04 16:10

【摘要】：目的:探索躯体症状障碍(Somatic Symptoms Disorder,SSD)在中国三甲综合医院门诊中的患病率,并描述躯体症状障碍患者的症状负担、心理特征、生活质量,探索生活质量预测因素;验证躯体症状障碍诊断B标准量表(Somatic Symptoms Disorder-12,SSD-12)的信效度,为躯体症状障碍提供量化评估工具。方法:分别在消化内科、中医科、心理科连续纳入患者,分别使用国际神经精神科简式访谈问卷(MINI-International Neuropsychiatric Interview,M.I.N.I)进行 ICD-10 精神与行为障碍分类(International Classification of Diseases-10 classification of mental and behavioral disorders)躯体形式障碍(Somatoform disorder,SFD)诊断、DSM-5(The Diagnostic and Statis-tical Manual of Mental Disorders,Fifth Edition,精神障碍诊断与统计手册,第五版)临床定式检查(structured clinical interview for DSM-5,research version,SCID-5)进行躯体症状障碍诊断,并使用躯体症状严重程度量表(Patient Health Questionnaire-15,PHQ-15)、躯体症状量表-8(Somatic Symptom Scale-8,SSS-8)评估躯体症状严重程度,使用抑郁症状严重程度量表(Patient Health Questionnaire-9,PHQ-9)、广泛性焦虑量表(General Anx-iety Disorder-7,GAD-7)评估焦虑、抑郁水平,使用健康相关焦虑评定(Whiteley-8 Scale,WI-8)评估健康焦虑,躯体症状障碍诊断B标准量表(Somatic Symptom Disorder-12,SSD-12)用于评估躯体症状障碍诊断标准的B标准,使用 WHO DAS 2.0(WHO Disability Assessment Schedule 2.0)评估残疾程度,使用 12 项健康调查简表(The medical outcome study 12-item short form health survey,SF-12)评估健康相关生活质量。结果:1)三个科室各收集到50份有效问卷,22.0%的患者满足躯体症状障碍诊断标准,50.7%的患者满足未分化躯体形式障碍诊断标准,躯体症状障碍与躯体形式障碍诊断一致性不高(cohen k指数=0.217,p=0.001);2)SSD患者PHQ-15总分、PHQ-9总分、GAD-7总分、WI-8总分、SSS-8总分、SSD-12、DAS总分显著高于仅满足SFD的患者及一般就诊人群,就诊次数显著高于其他两组患者,就诊满意度及主观感受的疗效、PCS、MCS均显著低于仅满足SFD的患者及一般就诊人群,三个科室的SSD患者未见显著性差异;3)PHQ-9总分为残疾程度的显著预测因素,方程可解释的变异为56.4%[F=30.842,p=0.001,VIF(variance inflation factor,方差膨胀因子)3.5];SSD-12总分、SSS-8总分、过去6个月是否治疗是PCS的显著预测因素,可解释的变异为 50.1%(F=23.948,p=0.001,VIF3.5);已婚、GAD-7 总分、PHQ-9总分、就诊次数是MCS的显著预测因素,可解释的变异为65.5%(F=22.513,p=0.001,VIF3.5),纳入SSD-12后三个方程R2变化量均大于纳入PHQ-15 时。4)SSD-12在本人群中信度高(Cronbach α=0.953),验证性因子分析提示SSD-12认知、情绪、行为的三因子模型拟合度尚能接受[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个潜变量呈强相关性,使用SSD-12总分作为单因子模型拟合度在可接受范围(n=150,CFI=0.989,TLI=0.987,REMSEA=0.094,90%CI=0.072-0.115),可反映总体心理困扰程度;SSD-12与躯体症状严重程度(PHQ-15,r=0.520、SSS-8,r=0.596)、健康焦虑(WI-8,r=0.781)、焦虑、抑郁水平(r=0.605及r=0.658)显著相关,区分效度欠佳;以SCID-5作为SSD诊断的金标准,SSD-12作为SSD筛查工具,在本样本人群中诊断界值为17(约登指数=0.595,敏感度=0.757,特异度=0.838),可正确诊断82.0%的患者;结论:1.综合医院心理科、消化科、中医科三个科室门诊患者SSD患病率为22.0%;2.躯体症状障碍患者躯体症状严重程度、焦虑抑郁水平、健康焦虑水平高,就诊次数多,就诊主观感受差,精神健康及躯体健康相关生活质量差,残疾程度高;3.SSD-12信度良好,三因子模型拟合度尚能接受,但因子之间相关性太强;量表总分能反映患者躯体症状困扰的严重程度,并预测患者的生活质量及残疾程度;SSD-12筛查躯体症状障碍界值为17;4.患者抑郁水平影响残疾程度;SSD-12总分、近1周症状严重程度、过去6个月是否治疗、焦虑抑郁水平、就诊次数是健康相关生活质量的影响因素,而躯体症状本身对健康相关生活质量及残疾程度影响不大,临床干预应着重于减轻患者症状相关的痛苦感、纠正患者对症状的认知扭曲、减少就诊次数,改善患者生活质量,而不仅仅是消除症状。
[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.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R749

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