Why is it called "schizophrenia"?

Schizophrenia is a group of mental diseases with unknown etiology. It is one of the most common mental diseases characterized by various obstacles such as perception, thinking, emotion and behavior, as well as the disharmony of mental activities and the disharmony between mental activities and the environment. Many diseases occur in young adults, usually unconscious, mentally retarded and prolonged.

Since the middle of19th century, European psychiatrists have regarded different symptoms of this disease as independent diseases. For example, Frenchman Morrel (1857) suggested that cases of mental decline in young people without external reasons are called early-onset dementia. Kahlbaum of Germany (1874) described a psychosis with special mental disorder and systemic muscle tension, called catatonia. Hecker( 187 1) called the cases that occurred in adolescence and acted absurdly and stupidly as adolescent dementia, and pointed out that this situation is more common among young people and tends to decline. From 65438 to 0896, Krepin, Germany, on the basis of long-term clinical observation and research, thought that the above different descriptions were not independent diseases, but different types of the same disease. This disease mostly happens to young people and eventually develops into a recession. Therefore, the combination of the above types is named as early-onset dementia, which is described as a disease unit for the first time.

Bruller (19 1 1), a Swiss psychiatrist in the 20th century, made a detailed clinical study of this disease, pointing out that the disorder of emotion, association and will is the primary symptom of this disease, and the central problem is the split personality, so he put forward the concept of "schizophrenia". Not all the endings of this disease end in decline, so it is suggested to name it schizophrenia. E. Bruller's concept of schizophrenia is a group of diseases, so it has a wide range of meanings.

Due to the different course of disease and prognosis, some scholars suggest that schizophrenia can be divided into process schizophrenia and schizophrenia-like reaction, including core type and peripheral type. Regarding the nature of diseases, whether schizophrenia is a disease unit or a group of diseases with the same symptoms and characteristics has been a controversial issue for a long time since Krepin was first put forward as a disease unit, which needs to be further clarified through genetics, biochemistry, brain structure and morphology, clinical and long-term follow-up observation.

epidemiology

The prevalence of this disease is the highest among mental diseases. In China, the urban prevalence rate is 7. 1 1‰, and the rural prevalence rate is 4.26‰. Cities are significantly higher than rural areas. The prevalence rate of men and women is roughly the same. The disease mostly occurs in young adults, most commonly between the ages of 15 and 35, 50% of patients between the ages of 20 and 30, and rarely before 10 (childhood schizophrenia) and after 40-50 (late onset schizophrenia). The onset age is related to clinical types, paranoid onset age is later, followed by neurotic type, youth type and simple type. The incidence of subacute and chronic diseases is mostly. The continuous progress of the course of disease can lead to the decline of social adaptability and even mental decline. If early detection and early treatment, most patients can achieve different degrees of efficacy, so the prognosis is optimistic.

Etiology and pathogenesis

The cause of schizophrenia is still unknown. Neither laboratory examination nor psychological examination has reached the level of specificity that can definitely help diagnosis. Scholars at home and abroad have accumulated a lot of valuable data around the study of etiology. From the analysis of existing data, the disease is a disease with genetic basis, and biological, psychosocial and environmental factors in the external environment can have a certain impact on the onset. Some patients' brains have changed in structure, shape and shape.

1. According to expert investigation, the prevalence rate of close relatives of patients with this disease is several times higher than that of ordinary residents, and the closer the relationship with patients, the higher the expected incidence rate of schizophrenia. The study of twins is also consistent with the study of foster children.

2. EEG study

Many scholars have studied the EEG of schizophrenic patients for many years, but the conclusions are different. It is generally believed that the patient's EEG is a non-specific change. Most patients have decreased α activity, increased slow wave and fast wave activity, and some patients have reported explosive abnormalities. In recent years, the study of EEG topographic map also shows the above findings.

3. Social and environmental factors

Schizophrenia mostly occurs in people with low economic level or social class, which is confirmed by the regional distribution characteristics of prevalence surveys at home and abroad. According to the national 1982 survey data, the prevalence rate of residents with low economic level is twice that of residents with high economic level. Some incidence survey data also found the same trend. Hollingshead et al. (1958) conducted a community survey in New Baven, and counted the incidence rate within half a year. It was found that the incidence rate of the lower class was three times that of the upper class. Giggs and Cooper (1987) reached the same conclusion based on the survey data of the incidence rate in Britain. But bipolar disorder has no such distribution characteristics. It is speculated that this may be related to the heavy psychological and social pressure load such as low economic level, low social class, poor social living environment, turbulent life and job insecurity, and it is easy to get sick on the basis of genetic quality.

4. Somatic biological factors

Schulsinger, a Danish psychiatrist, conducted a prospective survey on 166 children whose mothers had been suffering from severe schizophrenia since 1962. It is found that whether this group of high-risk people have schizophrenia when they grow up is related to birth complications such as asphyxia and eclampsia. 67% patients with schizophrenia had some complications at birth at the time of follow-up. It is suggested that under similar genetic load, whether you suffer from schizophrenia depends on environmental factors. 1957 An outbreak of influenza virus A2 occurred in Helsinki, Finland. Mednick and others examined the young people (aged 26.5 years) born from 1957+0 1 958. The results showed that the number of people whose fetuses were exposed to A2 virus epidemic in the 4th to 6th month and those who suffered from schizophrenia in adulthood was significantly higher than that in the control group. The authors speculate that this is related to the risk factors of virus infection affecting fetal nerve development.

5. Neurobiochemical pathological hypothesis

The hypothesis that schizophrenia may be caused by abnormal metabolism in the body, producing toxic intermediates and causing self-poisoning has a long history. In recent 20 years, due to brain biochemical research, monoamines and other transmitters in the central nervous system have been found to play an important role in maintaining and regulating normal mental activities. The therapeutic effect of some psychotropic drugs or antipsychotic drugs is closely related to the function of some transmitters or receptors, so various hypotheses have been put forward, such as the hypothesis of dysfunction of central 5-HT and NE channels. Among them, the hypothesis of excessive dopamine activity has received great attention. Because phenothiazine and butyryl benzene drugs can effectively control the symptoms of schizophrenia, their pharmacological effects are related to blocking the function of dopamine receptor. In addition, patients with chronic amphetamine poisoning may have some symptoms very similar to schizophrenia, and amphetamine is an activator of dopaminergic. Using isotope binding receptor method, it was found that the binding force between caudate nucleus and putamen of schizophrenia patients and the above isotope labeled nerve blockers was significantly higher than that of the control group, indicating that the postsynaptic DA receptor of schizophrenia patients was sensitized. Recently, it has been reported that PET uses positron radiation emitted by radioactive tracer to check brain biochemical metabolism and receptor function. In addition to the obvious decrease of glucose metabolism in frontal lobe, the D2 dopamine receptor in striatum of schizophrenic patients increased by as much as three times (patients who did not take antipsychotics), which supported the hypothesis that D2 receptor was over-functional. Activity determination of enzymes related to transmitter synthesis or degradation: Most reports show that the activity of platelet monoamine oxidase in patients with chronic schizophrenia is lower than that in normal control group.

6, brain structure research:

According to CT and MRI studies, about 30% ~ 40% of schizophrenic patients have ventricular enlargement or other brain structural abnormalities. Ventricular enlargement can also be seen in adolescents with early schizophrenia or children from families with high incidence of schizophrenia. It is speculated that this may be a reflection of patients with central nervous system diseases in their early years. According to the recent research data, except for ventricular enlargement, especially in the frontal angle, the corpus callosum is obviously abnormal. The clinical characteristics of these patients are obvious negative symptoms and insensitivity to treatment. According to the above data, Crow and others put forward the concepts of schizophrenia type I and type II. Type I clinical symptoms are mainly positive (hallucinations and delusions), and they respond well to the treatment of nerve blockers without mental retardation. It is speculated that the pathological basis is the increase of D2 receptor. Type ⅱ is mainly characterized by negative symptoms such as apathy and lack of initiative, with adverse reactions to nerve blockers, relatively irreversible pathological process and sometimes mental retardation.

Because D2 receptors are mainly concentrated in striatum, PET and autopsy data show that D2 receptors are very few in cortex. How to explain the disorder of thinking and will in schizophrenia is a matter of great concern to neurobiochemical and psychopathological researchers.

In recent years, according to the research data of neurophysiology and biochemistry, the following different hypotheses have been put forward.

Carlson( 1990) put forward the hypothesis that schizophrenia is due to subcortical DA hyperfunction and glutamate system dysfunction. It is based on the fact that PCP (phencyclidine) is a quasi-psychotic drug that can simulate the symptoms of schizophrenia. PCP mainly acts on glutamate receptors and is actually a non-competitive antagonist of glutamate.

Robbins et al. (1990) put forward the hypothesis of frontal lobe-striatum dysfunction in schizophrenia. According to the PET research data of FDG schizophrenia, most of them found that the glucose metabolism in frontal lobe, basal ganglia and temporal lobe was lower than that in occipital lobe, cerebellum or white matter. Other rheoencephalogram and EEG data also support the view that patients have frontal lobe dysfunction. In addition, most neuropathological changes were also reported in the frontal lobe.

It can be seen from the existing data that schizophrenia is a disease with genetic basis, and the biological, psychological and social environmental factors in the environment have certain influence on the onset. Some patients have abnormal brain structure and development. The mode of genetic transmission. The role of environmental factors and the relationship between abnormal brain structure, neurobiochemical changes and clinical characteristics need to be further clarified.

clinical picture

Typical mental symptoms

1. Association disorder

Relaxation of thinking (rambling thinking), destructive thinking, logical inversion thinking, interruption of thinking, emergence of thinking (compulsory thinking) or poor thinking content, pathological symbolic thinking.

2. Emotional disorder

Emotional apathy, dullness, emotional disharmony (inappropriate) and emotional inversion or self-smile (fake smile).

3. Will activity is weakened

Not very active, withdrawn, passive and withdrawn; Poor social adaptability and declining social function; Weird behavior and introverted personality; Wrong intentions, etc.

4. Other common symptoms

Delusion: the characteristics are mostly unsystematic, generalized and absurd; Primary delusion (delusion perception); Hallucinations, especially verbal auditory hallucinations, borderline and imperative auditory hallucinations, and other first-degree symptoms such as psychosis and tension syndrome.

(2) Common clinical types

1. paranoid schizophrenia

Also known as paranoid type, it is the most common type of schizophrenia in most parts of the world. In China, it accounts for more than 50% of inpatients and epidemiologists. Generally, the onset is slow, and the onset age is later than adolescence and neuroticism. Its clinical manifestations are relatively stable, often paranoid and delusional, often accompanied by hallucinations. However, emotional, will and speech disorders and neurological symptoms are not prominent, or "negative" symptoms such as emotional dullness and lack of will are also common, but they do not constitute the main clinical manifestations. Spontaneous remission is rare and the treatment effect is good.

2. Psychological classification of adolescents

More common. This type mostly comes from adolescence between15 and 25 years old, with acute onset and rapid development of the disease. The main symptoms are strange and incomprehensible thinking content and broken thinking. Emotional changes are prominent, joy is impermanent, expression is artificial, smirking and uncoordinated. Behavior is childish, stupid, making faces, often excited and impulsive behavior and instinctive intentions are hyperactive. Hallucinations and delusions are fragmented, and mental symptoms are rich and varied. The prognosis is poor, and the "negative" symptoms of some patients develop rapidly.

3. catatonic schizophrenia

The data of foreign developed countries and China show that this type has been greatly reduced, and the reasons are unknown. Generally, the onset is urgent, which is more common in young adults. The main clinical manifestation is that the patient's speech movement is inhibited, showing a stiff or sub-stiff state. Tension stupor can appear alternately with short-term nervous excitement. The main symptoms are speech silence, nervousness, disobedience, waxy buckling, stubbornness, passive obedience and continuous speech. Nerve excitement is manifested as sudden and short-term intense excitement and aimlessly breaking things. This type can have spontaneous remission, and the therapeutic effect is better than other types.

4. Simple schizophrenia

This type of teenagers seldom get sick, and the onset is slow, persistent and spontaneous, and they have neurasthenia-like symptoms in the early stage, but they have poor self-awareness and do not take the initiative to seek medical treatment. The main clinical manifestations are increasingly withdrawn, passive, lazy life, decreased interest, indifference and eccentric behavior. Because delusions, hallucinations and other psychotic symptoms are not obvious, it is often difficult to find them early, and it is a type that is difficult to determine the diagnosis. It is difficult to treat and insensitive to antipsychotics, and the prognosis after radiotherapy is the worst.

5. Undiagnosed schizophrenia

Clinically, it does not meet the above four types, and some symptoms coexist or are difficult to classify. Not uncommon, also known as hybrids.

6. Postschizophrenic depression

When some or most of the symptoms of schizophrenia are controlled, some patients will have depression, which will last for a long time.

7. Residual schizophrenia

The positive symptoms of schizophrenia basically disappeared, and some positive symptoms, some negative symptoms, personality changes and social functions recovered well.

8. Degenerative schizophrenia

The main clinical manifestation is mental decline, and the social function is seriously damaged, which makes it an intellectual disability that loses the ability to work.

9. Other types of schizophrenia

Those who meet the diagnostic criteria of schizophrenia but do not meet the diagnostic criteria of the above eight subtypes.

Pathogenic form, course of disease and prognosis

The onset can be acute, subacute or chronic, most of which are chronic and subacute. The course of disease can be divided into two types: persistent attack and intermittent attack. The former has a chronic course of disease and gradually appears mental decline; The latter process is in a period of mental symptoms, and the interval of remission; Some seizures will not recur for life after remission.

The prognosis is related to many factors: acute onset, obvious inducement, late onset, no obvious defects in pre-illness personality, unclear family genetic history, intermittent course of disease, dominant positive symptoms, paranoia and tense prognosis. However, chronic onset, no obvious inducement, children or adolescents onset, introversion before illness, positive family history of schizophrenia, slow progress of the course of disease, simple or adolescent type, and obvious negative symptoms have poor prognosis.

Diagnosis and differential diagnosis

The diagnosis of schizophrenia is mainly based on clinical features, and the current diagnosis is based on clinical science. Limited to phenomenological diagnosis, there is no clear experimental method to assist diagnosis.

(a) the diagnosis points are as follows

1. Including reliable medical history and mental examination, the patient showed characteristic thinking and perceptual obstacles, emotional disharmony, flat speech and lack of will activity.

2. Decline in social adaptability, including social interaction, daily life, work and study.

3. Consciousness is clear, intelligence is intact, but insight is incomplete or lost.

4. The course of disease tends to develop slowly, and the duration of psychotic symptoms in active stage is not less than 1 month, among which the symptoms in prodromal stage are not less than 3 months.

5. There are no particularly positive signs.

(2) Differential diagnosis

This disease needs to be differentiated from the following diseases:

1. neurasthenia

It is mainly differentiated from simple schizophrenia, and the main point of differentiation is that simple schizophrenia patients have no insight and no treatment requirements.

2. Compulsive neurosis

The content of obsessive-compulsive symptoms in schizophrenic patients is absurd, bizarre and changeable, and the patients' feelings about obsessive-compulsive experience are unclear, and they have incomplete self-knowledge and are not active in seeking medical treatment.

Step 3 be crazy

Adolescent psychosis with acute attack and overexcitation should be differentiated from mania. The former is mostly excited by uncoordinated speech movements; The latter is excited about coordinated mental movements.

4. Depression

The catatonic stupor of schizophrenia should be distinguished from the depressive stupor. The former is difficult to contact, with dull expression and indifferent emotion; The latter is an emotional activity of severe depression.

5. Reactive psychosis

Paranoia in schizophrenia should be distinguished from reactive delusion. The latter has mental stimulation factors. The patient's condition revolves around the mental stimulation of the onset, and the emotional response is clear. His willingness to talk about emotional experiences after trauma is sympathetic.

6. Paranoid psychosis

The delusional content of paranoid patients with this disease can be changeable or often absurd or bizarre and contradictory. Even if it is not fixed or systematic, it is often accompanied by auditory hallucinations. Paranoid mental patients, on the other hand, take systematic delusion as the main symptom, with relatively fixed content and few hallucinations. If they have short-term hallucinations, they are also closely related to delusions. Without delusions, they will not show obvious mental abnormalities.

7. Symptomatic psychosis (refers to mental disorder caused by body, infection and poisoning)

Symptomatic mental patients have common disturbance of consciousness, such as fluctuation of light day and heavy night, and horrible hallucinations, which are helpful for differential diagnosis.

8. Brain organic psychosis

Brain organic psychosis has mental retardation and corresponding positive signs of nervous system. Especially beware of sporadic encephalitis, which is more common in recent years. The main manifestation is sub-coma. In some patients, nervous system signs appeared later than mental symptoms, and EEG showed diffuse abnormality. Careful observation and analysis may lead to different degrees of consciousness disorder and urinary incontinence.

9. Schizophrenia affective psychosis

Only in the same episode of the disease, the obvious and clear symptoms of schizophrenia and emotional symptoms appear at the same time or are very close to each other, so the episode does not meet the standards of schizophrenia, depression or manic episode, and the diagnosis of schizoaffective disorder can be made.

10. Sick personality

Schizophrenia, schizophrenia, borderline and paranoid personality disorder should be differentiated from schizophrenia. Personality disorders generally have no mental symptoms, and some are even transient. It should be analyzed mainly from the patient's personality development process, and there is no natural clinical process, which is extremely important for differential diagnosis.

treat cordially

In the treatment of schizophrenia, psychotherapy is the key treatment. Supportive psychotherapy is also of great significance to improve the social psychological environment and patients' mood, and is usually combined with drug therapy when patients' condition improves. In remission stage or chronic stage, besides proper drug treatment, environment, psychotherapy and social support are very necessary, especially for patients' social rehabilitation, preventing patients from declining and improving patients' ability to adapt to society. Safe nursing in acute phase and home monitoring in chronic phase or rehabilitation phase are also necessary.

First, medication.

When choosing drugs for treatment, especially when determining the first choice of drugs, we should carefully consider the target symptoms of drugs, the clinical types and course characteristics of schizophrenia, whether the patient is in acute or chronic stage, and whether the symptoms are mainly positive or negative. We should not ignore the patient's physical condition, age characteristics and the success or failure experience and lessons of previous drug treatment.

(-) Acute phase treatment

1. chlorpromazine is suitable for all kinds of acute schizophrenia patients with psychomotor excitement and hallucinations. The therapeutic dose is 300 ~ 400 mg per day. Because of its strong sedative effect, the dosage should be gradually increased and can be taken in 2 ~ 3 times.

2. Perphenazine is suitable for elderly patients with poor physical condition. The indications are basically the same as chlorpromazine. The appropriate therapeutic dose is 20 ~ 40 ~ 60mg per day for outpatients and 40 ~ 60mg per day for inpatients. Sedative effect is lighter than chlorpromazine, and postural hypotension is rare.

3. Triflurazzine not only has anti-hallucination and delusion effect, but also has certain curative effect on negative symptoms, and it also has excitement and activation effect, but also has no sedative effect. The therapeutic dose is 20 ~ 40 mg per day, taken twice.

The indication of fluphenazine is similar to that of trifluoperazine, and the therapeutic dose is 10 ~ 30 mg per day. Fluphenazine decanoate (FD) is a long-acting preparation, which is suitable for maintenance treatment to consolidate curative effect and prevent recurrence, or for patients with obvious mental symptoms who refuse to take medicine and are uncooperative in treatment. The therapeutic dose is 25 ~ 50mg, and intramuscular injection 1 time every two weeks. The maintenance dose was 25mg, and the injection was 65438 0 times every 3 ~ 6 weeks.

Haloperidol can not only control acute excitement quickly, but also have a certain effect on chronic symptoms. The general dosage of long-acting preparation haloperidol decanoate (HD) is 50mg intramuscular injection every two weeks (or 100mg intramuscular injection every four weeks). Indications and course of treatment are the same as FD.

6. The sedative effect of clozapine is stronger than that of chlorpromazine, which can quickly control acute excitement, hallucinations and delusions, and also has a certain effect on chronic symptoms. The therapeutic dose is 300 ~ 400 mg per day, taken in 2 ~ 3 times. This medicine can reduce blood white blood cells and granulocytes, so check the peripheral white blood cells and classification every 2 ~ 3 weeks before and during treatment, and stop taking the medicine in time if found.

7. Sulpiride has exciting, activating and antidepressant effects, and is suitable for treating negative symptoms of chronic schizophrenia and schizophrenia catatonia. The therapeutic dose is 800 ~ 1200mg per day, taken in 2 ~ 3 times.

8. penfluridol This drug is a long-acting oral drug, which is suitable for schizophrenics who refuse to take it because they don't cooperate with the treatment. The therapeutic dose is 20 ~ 40 mg once a week or once every three days, and the maintenance dose can be 20 ~ 40 mg once a week.

(two) chronic or long-term maintenance treatment

It is difficult to predict whether the mental symptoms of acute attack will recur or the course will turn chronic after remission. According to DSM-ⅲ-R Ⅲ-R data, the recurrence rate of patients receiving maintenance treatment is 40% within 2 years. 80% patients were consolidated without medication. In order to prevent recurrence, the drug maintenance dose after the first attack should not be less than one year. If the patient has a second attack (that is, the first relapse), the drug maintenance amount should last for 2 ~ 3 years. If the patient has a third attack, it is not appropriate to stop taking the drug easily. The dose of maintenance therapy should be gradually reduced, and the minimum effective dose is appropriate. Generally, it is 1/4 or 1/5 of the acute therapeutic dose, and patients with high therapeutic dose can be reduced to110.

(3) Shock treatment and others

Patients with catatonic schizophrenia, schizophrenia with obvious depressive symptoms and some schizophrenia are treated with a variety of antipsychotics. Those with poor efficacy can choose electroconvulsive therapy, insulin shock therapy or hypoglycemia therapy. The general course of electroconvulsive therapy is 6 ~ 12 times. The treatment of insulin shock or hypoglycemia is generally about 40 ~ 60 times, and the number can be increased appropriately according to specific cases.

(4) Environment, psychotherapy and social support

This kind of treatment is very important for social rehabilitation of mental activities, reducing and preventing mental decline. Whether it is the inpatient environment or the community environment of discharged patients, occupational therapy, recreational therapy and group psychotherapy, properly solving family conflicts and employment, and carrying out family psychotherapy will play a positive role in reducing recurrence and social rehabilitation.

(5) Nursing care

In the acute stage, it is mainly to do a good job in patient safety nursing. In recent years, psychiatric clinical medical workers have observed that suicide or injury of schizophrenic patients is the most difficult to prevent. Therefore, both inpatients and outpatients should be vigilant to prevent patients from committing suicide and hurting others. According to DSM-ⅲ-R III-R data, 50% of schizophrenics attempted suicide, and 65,438+00% committed suicide. In the chronic stage, it is mainly to do a good job in patients' psychological nursing and family rehabilitation nursing.