躯体化障碍患者神经认知功能比较

躯体化障碍患者神经认知功能比较 【摘要】 目的: 探讨躯体化障碍患者神经认知功能障碍的特点。方法: 对60例符合 ICD - 10躯体化障碍诊断标准的患者给予药物治疗8周，在治疗前、后给予威斯康星卡片 分类测验(WCST)、持续操作测验(CPT)，同时测验50例正常人作为对照组。患者组的测验 结果进行自身前后比较、并分别与正常对照组进行组间比较。结果: 患者组治疗前、后WCST 的总应答数、完成分类数、持续性错误数、非持续性错误数自身比较，差异有统计学意义(P ,0.05,0.01)。患者组治疗前WCST的总应答数、完成分类数、持续性错误数、非持续性错 误数与正常对照组组间比较，差异有统计学意义(P,0.01,0.001)，治疗后与正常对照组组 间比较，差异无统计学意义(P,0.05)。患者组治疗前、后CPT 得分比较，在无干扰时差异 无统计学意义(P,0.05)，有干扰时差异有统计学意义(P,0.05)。患者组治疗前CPT 得分 与正常对照组组间比较，在无干扰时差异无统计学意义(P,0.05)，有干扰时差异有统计学 意义(P,0.05)，治疗后与正常对照组比较，差异无统计学意义(P,0.05)。结论: 躯体化 障碍患者存在神经认知功能障碍，但经过治疗可以改善。 【关键词】躯体化障碍;神经认知功能; 威斯康星卡片分类测验;持续操作测验 Comparison of neurocognitive function in patients with somatization disorder 〔Abstract〕 Objective: To explore the neurocognitive function in patients with somatization matization disorder patients who met the ICD-10 were treated for 8 disorder . Methods: sixty so weeks, they were measured with Wisconsin Card Sorting Test (WCST) and Continuous performance Test(CPT)before and after therapy. And fifty healthy peoples were measured with WCST and CPT as control group .The test results of patients group were compared before and after therapy, and they were compared with the control group respectively. Results: The significant difference in the total trials, number of completed classification, preservative errors, nor-preservative errors of WCST were observed betweem before and after therapy of patients group (P,0.05,0.01). And the same results was also found between patients group befor therapy and control group(p,0.05). And no significant difference was also found between patients group after therapy and control group(p,0.05). Compared the CPT scores between patients group of before and after therapy, the significant difference wasn’t found in no interfere stimulus( P,0.05), but they could be found in interfere stimulus (P,0.05). And the same results also be found between patients group of before therapy and control group. But no significant difference between patients group of after therapy and control group(P,0.05). Conclusion: field is downwind, brooding House separate from the breeding shed, and ... Building chicken farms must also consider the construction of chicken manure treatment facilities such as septic tanks, methane-generating pit, do not let the chicken manure directly. Five to do a disease prevention and control, do not cut corners. Built into the chicken in chicken farm, will be required to do a variety of vaccine injections and disinfection in chicken farm, do not hold the chance, and do scientific farming. Reasonable problems in building a chicken coop hen house layout, can provide a good environment for chicken, making its full productive potential, so other than in understanding the physiological characteristics of the chicken itself, and must be properly planned and constructed sheds. A chicken layout considerations 1. Sites to choose away from populated areas, traffic convenient, away from the road 2. Gaozao terrain, a lot of sunshine. Winter sun as possible, summer wind, and not after the rain water. Larger, leaving room for development 3. Abundant water resources pollution-free, easy to access, sufficient power is guaranteed 4. Building structure, the economy, saving money, and saving energy, it is facing in accordance with local environmental and physiological condition, lighting is good, easy to ventilation, easy to operate, so conducive to cooling in the summer, to insulation in winter cold 5. Layout of premises should be reasonable, do distinguish between Patients with somatization disorder have neurocognitive dysfunction, But the neurocognitive function have improved after therapy. 〔Key words〕 Somatization disorder; Neurocognitive function; Wisconsin Card Sorting Test;Continuous Performance Test 研究发现，精神分裂症、抑郁症等精神障碍患者存在神经认知功能(以下简称认知功能) [1,2]障碍，而国内外有关躯体化障碍患者认知功能的研究报道还很少。 威斯康星卡片分类测验(以下简称WCST)和持续操作测验(以下简称CPT)是常用的认知功能测评方法，本文应用WCST和CPT对躯体化障碍患者的认知功能加以探讨。 1对象与方法 1.1对象 患者组入选标准:我院2008年7月至2009年12月心身科门诊病人，符合国际 [3][4]疾病分类标准第10版(ICD-10)和中国精神疾病分类与诊断标准第3版(CCMD-3)躯体化障碍诊断标准，年龄18-60岁。排除标准:抑郁症、焦虑症、恶劣心境、应激障碍、其他神经症以及伴酒精依赖、人格障碍和严重躯体疾病者。治疗前均由家属签知情同意书。正常对照组为我院健康体检者。 1.2治疗及疗效评价方法 治疗药物为西酞普兰片(西安杨森制药有限公司，批号:080909661，每片20 mg)，平均剂量(34.38土9.54)mg/日,治疗8周。已在用药的病人先 [5]经1周清洗期。疗效评价工具为汉密尔顿抑郁量表(HAMD)24项，分别于治疗前、治疗8周末各测评1次。疗效评价方法以HAMD减分率为标准，?75%为临床痊愈，?50%为有效，,50%为无效。 1.3 WCST和CPT检测 均在计算机上完成。WCST包括4张刺激卡，128张反应卡。按颜色(红、黄、绿、蓝)、形状(三角形、十字形、圆形、五角星形)和数量(1、2、3、4)的不同而绘制。测试指导语:“请找出与反应卡图案相匹配的刺激卡，并用鼠标点中，电脑会告诉你选对了还是选错了 ,如果选错了请你不要更改，争取把下一张选对就是了”。测试过程:首先在屏幕上出现1个红三角、2个绿五角星、3个黄十字和4个蓝圆形的4张刺激卡，要求被试者根据这4张刺激卡的特点对128张反应卡进行分类，分类的顺序是按数量、形状、颜色、数量和形状依次进行，一种分类累计完成10张正确卡片，即转换成下一个分类。累计完成正确分类数6个(即60张正确卡片)或用完128张反应卡结束。操作时不把分类顺序和原则告诉被试者。WCST结果的评价:1、总应答数:范围为60-128; 2、完成分类数:范围为0-6;3、正确应答数:范围:0-60; 4、错误应答数:范围0-128;持续性错误数:指在分类原则改变后，被试者不能放弃旧的分类原则，固执地继续按原来的分类原则进行分类，非持续性错误数:即错误应答数与持续性错误数之差。 lation in winter cold 5. Layout of premises should be reasonable, do distinguish betweeno insuand physiological condition, lighting is good, easy to ventilation, easy to operate, so conducive to cooling in the summer, teed 4. Building structure, the economy, saving money, and saving energy, it is facing in accordance with local environmental free, easy to access, sufficient power is guarant-water. Larger, leaving room for development 3. Abundant water resources pollutionenient, away from the road 2. Gaozao terrain, a lot of sunshine. Winter sun as possible, summer wind, and not after the rain conv properly planned and constructed sheds. A chicken layout considerations 1. Sites to choose away from populated areas, traffic ull productive potential, so other than in understanding the physiological characteristics of the chicken itself, and must beits frming. Reasonable problems in building a chicken coop hen house layout, can provide a good environment for chicken, making required to do a variety of vaccine injections and disinfection in chicken farm, do not hold the chance, and do scientific fa ilt into the chicken in chicken farm, will begenerating pit, do not let the chicken manure directly. Five to do a disease prevention and control, do not cut corners. Bu-the construction of chicken manure treatment facilities such as septic tanks, methanefield is downwind, brooding House separate from the breeding shed, and ... Building chicken farms must also consider 2 CPT检测分为三项测验，无干扰时CPT(1) :数字连续在屏幕上一个一个出现, 每当出现“3”时按鼠标;有干扰时CPT(2):看到“3”前面任一个数字时按鼠标;另一种干扰CPT(3): 看到“3”前面一个“7”时按鼠标。最后对以上三项测验的正确反应数进行统计。 所有患者在治疗前和治疗后各测评一次。正常对照组只测评一次。 1.4统计方法 应用SPSS 10.0 for windows 统计软件进行统计分析，使用t检验等统计方法。 2结果 2.1 一般情况 患者组共入组69例，脱落9例(原因分别是疗效不好5例、不良反应2例、失访2例)。最后完成60例，其中男25例，女35例，平均年龄(41.55土9.32)岁，平均病程(4.23土2.69)年，平均受教育程度(12.68土5.74)年;正常对照组50例，男20例，女30例，平均年龄(40.56土9.49)岁，平均受教育程度(13.36土6.24)年。2组的性别，年龄，受教育程度等方面组间比较差异无统计学意义(P,0.05)。 2.2患者组治疗前、治疗后以及正常对照组的WCST结果比较 患者组治疗前、后WCST的总应答数、完成分类数、持续性错误数、非持续性错误数自身比较，差异有统计学意义(P,0.05,0.01)。患者组治疗前WCST的总应答数、完成分类数、持续性错误数、非持续性错误数与正常对照组组间比较，差异有统计学意义(P,0.01,0.001)，治疗后与正常对照组组间比较，差异无统计学意义(P,0.05)。患者组治疗前、治疗后以及正常对照组的WCST结果比较见表1。 _ 表1患者组治疗前、治疗后以及正常对照组的WCST结果比较(?s) χ WCST项目 患者组治疗前 患者组治疗后 正常对照组 (n=60) (n=60) (n=50) ac总应答数 85.86士17.54 78.94土16.89 76.66土13.31 ac完成分类数 3.95 士2.39 4.85 土1.63 5.13土1.45 正确应答数 50.31 士14.44 52.75土 12.66 53.22 土 12.83 bd持续性错误数 16.29土8.27 12.13土5.78 10.78土5.36 bd非持续性错误数 19.25士10.32 14.03土7.59 12.54土5.83 abcd注:与患者组治疗前比较，P,0.05，P,0.01，与患者组治疗前比较，P,0.01, P,0.001 2.3患者组治疗前、治疗后以及正常对照组的CPT得分结果比较 患者组治疗前、后CPT 得分比较:在无干扰时CPT(1)差异无统计学意义(P,0.05)，有干扰时CPT(2)和CPT(3)差异有统计学意义(t=1.99/2.08 ，均P,0.05)。患者组治疗前CPT 得分与正常对照组组间比较:在无干扰时CPT(1)差异无统计学意义(P,0.05)，有干扰时CPT(2)和CPT(3)差异有统计学意义(t=2.49/2.54，均P,0.05)，治疗后与正常对照组比较，差异无统计学意义(P,0.05)。患者组治疗前、治疗后以及正常对照组的CPT得分结果比较见表2。 _ 表2 患者组治疗前、治疗后以及正常对照组的CPT得分结果比较(?s) χ premgood, easy to ventilation, easy to operate, so conducive to cooling in the summer, to insulation in winter cold 5. Layout of saving money, and saving energy, it is facing in accordance with local environmental and physiological condition, lighting is free, easy to access, sufficient power is guaranteed 4. Building structure, the economy,-ment 3. Abundant water resources pollutionrrain, a lot of sunshine. Winter sun as possible, summer wind, and not after the rain water. Larger, leaving room for developo teA chicken layout considerations 1. Sites to choose away from populated areas, traffic convenient, away from the road 2. Gaoza in understanding the physiological characteristics of the chicken itself, and must be properly planned and constructed sheds. r thanng a chicken coop hen house layout, can provide a good environment for chicken, making its full productive potential, so othejections and disinfection in chicken farm, do not hold the chance, and do scientific farming. Reasonable problems in buildiilt into the chicken in chicken farm, will be required to do a variety of vaccine ingenerating pit, do not let the chicken manure directly. Five to do a disease prevention and control, do not cut corners. Bu-tment facilities such as septic tanks, methanetruction of chicken manure treafield is downwind, brooding House separate from the breeding shed, and ... Building chicken farms must also consider the consises should be reasonable, do distinguish between3 CPT得分 患者组治疗前 患者组治疗后 正常对照组 (n=60) (n=60) (n=50) 56.68土8.39 CPT(1) 53.73士8.71 55.26土8.16 aaCPT(2) 24.29士5.11 26.46土5.54 27.03土5.72 aaCPT(3) 14.72士4.59 16.54土 3.96 17.23土 5.11 a注:与患者组治疗前比较，P,0.05。 2.4患者组疗效评定 患者组治疗前、后的HAMD评分分别为34.41?10.11、11.17?4.46，疗效评定:痊愈26例，有效23例，无效11例。 3 讨论 [6]国外Niemi PM等对10位女性躯体形式障碍患者(包括躯体化障碍及未分化躯体形式障碍患者)进行记忆力、注意力、执行能力等方面的初步研究显示，患者的语义记忆能力、 [7]言语情节记忆能力、空间视觉功能及注意力均较健康对照组差。Lim SL等对重性抑郁症、恐怖症及躯体形式障碍患者进行的Stroop色词测验及外显、内隐记忆测验研究结果也表明躯体形式障碍患者存在执行功能和外显记忆能力的降低。 [8]国内马丽霞等对躯体形式障碍的事件相关电位及认知功能进行过研究。该研究结果显示，躯体形式障碍患者P300电位成分中N2、P3潜伏期延长,P3波幅降低,与对照组比较存在显著性差异，提示躯体形式障碍存在广泛的认知功能障碍。 目前国内外对躯体形式障碍的研究，已经有部分研究发现存在认知功能障碍，而躯体形式障碍包括躯体化障碍、躯体形式自主神经紊乱、躯体形式疼痛障碍、疑病症等较多病种。有鉴于此，本研究仅选择躯体化障碍加以研究，样本的一致性较高。本研究发现，躯体化障碍患者治疗前、后WCST的总应答数、完成分类数、持续性错误数、非持续性错误数自身比较，差异有统计学意义(P,0.05,0.01)。患者组治疗前WCST的总应答数、完成分类数、持续性错误数、非持续性错误数与正常对照组组间比较，差异有统计学意义(P,0.01,0.001)，治疗后与正常对照组组间比较，差异无统计学意义(P,0.05)。患者组治疗前、后CPT 得分比较，在无干扰时差异无统计学意义(P,0.05)，有干扰时差异有统计学意义(P,0.05)。患者组治疗前CPT 得分与正常对照组组间比较，在无干扰时差异无统计学意义(P,0.05)，有干扰时差异有统计学意义(P,0.05)，治疗后与正常对照组比较，差异无统计学意义(P,0.05)。说明躯体化障碍患者发病期存在认知功能障碍，但经过治疗可以改善。 躯体化障碍的症状特点和治疗方法比较接近抑郁症，而在抑郁症中，WCST和CPT可以用 [2]来反映额叶功能障碍，本研究结果是否提示躯体化障碍患者也存在额叶功能障碍，关于这个问题，值得今后进一步深入研究。 参考文献 〔1〕金魁和,王菲,丁宝坤,等.精神分裂症患者的认知功能改变的研究[J].中国心理卫生杂 water. Larger, leaving room for development 3. Abundant water resources pollutionenient, away from the road 2. Gaozao terrain, a lot of sunshine. Winter sun as possible, summer wind, and not after the rain conv properly planned and constructed sheds. A chicken layout considerations 1. Sites to choose away from populated areas, traffic ull productive potential, so other than in understanding the physiological characteristics of the chicken itself, and must beits frming. Reasonable problems in building a chicken coop hen house layout, can provide a good environment for chicken, making required to do a variety of vaccine injections and disinfection in chicken farm, do not hold the chance, and do scientific fa ilt into the chicken in chicken farm, will begenerating pit, do not let the chicken manure directly. Five to do a disease prevention and control, do not cut corners. Bu-the construction of chicken manure treatment facilities such as septic tanks, methanefield is downwind, brooding House separate from the breeding shed, and ... Building chicken farms must also consider lation in winter cold 5. Layout of premises should be reasonable, do distinguish betweeno insuand physiological condition, lighting is good, easy to ventilation, easy to operate, so conducive to cooling in the summer, teed 4. Building structure, the economy, saving money, and saving energy, it is facing in accordance with local environmental free, easy to access, sufficient power is guarant-4 志,200,15(5):347-349. 〔2〕苏晖,江开达,徐一峰,等.抑郁症首次发病患者治疗前后认知功能的研究[J].中华精神 科杂志,2006,39(1):20-22. 〔3〕范肖冬,汪向东,于欣,等.ICD-10精神与行为障碍分类[M].北京:人民卫生出版社,1993, 130. 〔4〕中华医学会精神科分会,中国精神障碍分类与诊断标准第3版(CCMD-3)[M].济南:山 东科学技术出版社,2001,4:87-88 . 〔5〕张明园主编.精神科评定量表手册[M].长沙:湖南科学技术出版社,1998:121-126. 〔6〕Niemi PM, Portin R, Aalto S, etal. Cognitive functioning in severesomatization -a pilot study. Acta Psychiatre Scand 2002,106(6): 461–463. 〔7〕Lim SL, Kim JH. Cognitive processing of emotional information in depression, panic, and somatoform disorder. J Abnorm Psychol. 2005 Feb:114(1):50-61. 〔8〕马丽霞,邱亚峰.躯体形式障碍的事件相关电位及神经认知功能研究[J].中国临床心理 学杂志,2007 (15) 1:26-27. ises should be reasonable, do distinguish betweenpremgood, easy to ventilation, easy to operate, so conducive to cooling in the summer, to insulation in winter cold 5. Layout of saving money, and saving energy, it is facing in accordance with local environmental and physiological condition, lighting is free, easy to access, sufficient power is guaranteed 4. Building structure, the economy,-ment 3. Abundant water resources pollutionrrain, a lot of sunshine. Winter sun as possible, summer wind, and not after the rain water. Larger, leaving room for developo teA chicken layout considerations 1. Sites to choose away from populated areas, traffic convenient, away from the road 2. Gaoza in understanding the physiological characteristics of the chicken itself, and must be properly planned and constructed sheds. r thanng a chicken coop hen house layout, can provide a good environment for chicken, making its full productive potential, so othejections and disinfection in chicken farm, do not hold the chance, and do scientific farming. Reasonable problems in buildiilt into the chicken in chicken farm, will be required to do a variety of vaccine ingenerating pit, do not let the chicken manure directly. Five to do a disease prevention and control, do not cut corners. Bu-tment facilities such as septic tanks, methanetruction of chicken manure treafield is downwind, brooding House separate from the breeding shed, and ... Building chicken farms must also consider the cons5