統合失調症と関する事項について
統合失調症
人口の約1％が罹患する精神疾患であり、精神科入院の理由として最多となっている。陽性症状・陰性症状・認知機能障害(記憶力・集中力・判断力の低下)を認める。モノアミン(ドパミン・ノルアドレナリン・アドレナリン・セロトニンなどの神経伝達物質の総称)の働きが発症に関与しているとされている。
統合失調症の症状
統合失調症の陽性症状は健康な頃にはなかったものを指し、陰性症状は健康な頃にはあったが失われたものを指す。
中脳辺縁系でドパミン機能が亢進すると陽性症状が出現して、中脳皮質系でセロトニン機能亢進によってドパミン機能が低下すると陰性症状が出現する。
このようにして陽性症状と陰性症状という一見相反した症状同士が併存しているのである。
統合失調症の陽性症状
陽性症状では妄想・幻覚・思考障害(思路障害・自我意識の障害)という症状が出る。
妄想について
妄想に関して、統合失調症では一次妄想も二次妄想も見られるが一次妄想は統合失調症に特徴的である。
二次妄想は妄想の形成機序が了解可能(理解可能)であるものを指し、一次妄想は妄想の形成機序が了解不能(理解不能)であるものを指す。
一次妄想には妄想気分・妄想知覚・妄想着想があり、二次妄想には被害妄想(統合失調症に良く見られる)・罪業妄想(うつ病に良く見られる)などがある。
一次妄想は妄想○○で、二次妄想は○○妄想であると覚えれば良い。
妄想気分では「いつもとは何か違って不気味な感じがする」というようなことが感じられる。
妄想知覚は「知覚された事実に了解不能の意味が加わる」ことであり、例えば「(隣家を見て)あの玄関の形は明日自分が死ぬことを意味している」などと考える。
妄想着想は「突然に了解不能の考えを着想して確信してしまう」ことであり、例えば「(突然)自分は聖徳太子の子孫であると分かった」などと考える。
115C33:統合失調症の一次妄想と考えられる患者の言葉はどれか。3つ選べ。
出典:第115回医師国家試験問題
- 「(突然）自分は聖徳太子の子孫であるとわかった」
- 「（食事の途中で）誰かが自分の食事に毒を盛っている」
- 「（漠然と）何か恐ろしいことが起こりそうでひどく怖い」
- 「（電車の客が会話する様子を見て）自分の悪口を話している」
- 「（隣家を見て）あの玄関の形は明日自分が死ぬことを意味している」
解答:1,3,5
幻覚について
幻覚に関して、統合失調症の幻覚では「テレビから自分の悪口が放送される」というような幻聴が多い。
思考障害について
思考障害に関して、思路障害によって思考の流れが突然遮断される「思考途絶」→関連のない様々なことが思い浮かんでは遮断される「連合弛緩」→思考のまとまりがない「滅裂思考」→言葉が無意味に混ざる「言葉のサラダ」となる。
他の思考障害として、考想伝播(自分の考えが周囲の人間に知れ渡ってしまうと考える)・思考奪取(自分の考え抜き取られる)・思考吹入(他人の考えが吹き込まれる)などの自我意識の障害が起きて「自分の思考が他者によって操られているように感じる」させられ体験(作為体験)をすることが挙げられる。
統合失調症の陰性症状
陰性症状では「感情表出に乏しくなる」感情の平板化(感情鈍麻)や思考の貧困によって「口数が少なくなる」といったような「意欲の欠如」の症状が生じて「社会的引きこもり」となる。
統合失調症の治療
統合失調症の治療は薬物治療と休養・環境調整と心理社会的療法という3本柱で行う。
薬物治療
従来型抗精神病薬である定型抗精神病薬は強力なドパミン抑制作用を持ち中脳辺縁系に対して働くと陽性症状の顕著な改善が得られる。しかし、中脳皮質系に対しても働くことで陰性症状を強めてしまうという副作用があった。
そこで、ドパミンだけではなくセロトニンなどのモノアミンに対しても作用を持つ新規抗精神病薬である非定型抗精神病薬が開発された。 非定型抗精神病薬は陰性症状に対しても効果が得られることがある。
「統合失調症の発症にはモノアミン(ドパミン・ノルアドレナリン・アドレナリン・セロトニンなどの神経伝達物質の総称)が関わっている」ということを押さえておく必要がある。
心理社会的療法
心理社会的療法は心理教育とリハビリテーションからなるものであり、治療を円滑に進めて患者を社会復帰させやすくすることを目的として行われる。
心理教育とは精神障害やAIDSの患者に対して行うもので、患者に病気や治療について学んでもらうことで治療を前向きに主体的に取り組んで頂くことを目的とする。
統合失調症の予後予測因子
急性発症vs緩徐発症
急性発症は早期に治療を開始できるので予後良好であるのに対して、緩徐発症は治療が遅れるので予後不良である。
統合失調症を含む精神障害は「早期発見・早期治療」の重要性が言われており、症状に気づいてから治療を開始するまでの期間が短い方が予後が良いと報告されているので「発病初期の積極的な治療介入」が求められる。
発症が思春期かどうか
統合失調症は思春期に発症すると症状が慢性化して患者の人柄が変わってしまうことが多く、予後不良である。
発症における誘因があるかどうか
発症における心理的契機が明瞭であった場合は予後良好である。
発症前の社会適応レベルと病前性格
病前の良好な社会適応は予後良好因子である。
病前性格が循環気質的傾向(社交的で人情味があり、親しみやすい好人物)であった場合は予後良好である。
家族歴
統合失調症に限ったことではなく、うつ病・双極性障害などを含める主要な精神障害は40－90%の高い遺伝率を示す多因子遺伝疾患であり、病態には多数の遺伝子が関わっている。精神障害において家族歴は発症の重要なリスク因子であり、家族歴を有する患者は家族歴を有しない患者に比べて症状の重症化リスクが大きいことが知られている。
統合失調症に関する医師国家試験問題
111I29:統合失調症について正しいのはどれか。2つ選べ。
出典:第111回医師国家試験問題
- 発症率は国によって大きく異なる。
- 家族歴がある場合には罹患率が高い。
- 脳内の異常蛋白の蓄積が原因である。
- 治療の開始時期によって予後が異なる。
- 陰性症状には選択的セロトニン再取り込み阻害薬(SSRI)が有効である。
解答:2,4
解説:1.←日本における発症率は約1%である。発症率は国によって多少違うが大きく異なるわけではない。
2.←精神障害は家族歴が重要である。
3.←モノアミンが発症に関与しているとされる。
4.←「発病初期の積極的な治療介入」が求められる。
5.←陰性症状に対してSSRIは逆効果である。陰性症状に対しては非定型抗精神病薬が有効である。
投影法
曖昧な視覚的又は言語的な刺激を与えて、それに対する被検査者からの自由な連想や反応から性格特性を把握するために行われる性格検査を指す。
ロールシャッハテスト(Rorschach test)
患者に対してインクの滲みで作られた10枚の図版を順番に提示して質問することで、患者の反応から性格や精神状態を明らかにする心理・精神機能検査である。
10枚の図版は無彩色(グレー)のものと有彩色(カラー)のものがある。
Rorschachテストは2時間程度を要するテストであり、主な目的は被検査者の性格特性を把握するためのテストであるので精神疾患のスクリーニングには適さない。ただし、統合失調症の患者は比較的分かりやすい異常回答をするので心理検査の中では統合失調症の診断に最も有用となる。
文章完成法テスト(SCT)
文章の前半のみが書いてある「刺激文」を提示して、被検査者にそこから意味の通る文を自由に記述させることで、被検査者の知能や性格などのパーソナリティ全体を推測していく心理検査であり、投影法に分類される。
絵画統画テスト(TAT)
人物や景色を含む様々な状況が描かれたカードを提示して、被検査者にそれから連想した自由なストーリーを語ってもらうことで、パーソナリティ全体を推測していく心理検査であり投影法に分類される。
妄想性障害
1ヶ月以上持続する「事実ではないことを確信してしまい訂正することができない」妄想が存在して、統合失調症などの他の精神疾患が除外される場合に診断される。
もともとあった妄想性パーソナリティ障害に起因して高齢(60代以降)になってから発症することが多い。
幻覚やまとまりのない発語や陰性症状を伴うことがないので、この点から統合失調症と鑑別する。
問題文では「患者は表情が明るく抑うつ気分を認めず、疎通性も良好である」というような具合で陰性症状を否定するように形容されており、このような文から統合失調症と鑑別すると良い。
例えば「隣の人がいつも自分を監視している」と確信する被害型妄想や「配偶者が不倫をしている」と確信する嫉妬型妄想などを認める。
緊張病症候群
統合失調症・気分障害(うつ病・躁うつ病)などの精神疾患、感染症や脳炎などの脳器質疾患といった身体疾患において出現することがある。特徴的な症状を認めて診断する。
受動的にとらされた姿勢を重力に拮抗したまま保持する「カタレプシー」を認める。「カタレプシー」では、例えば「診察時に手を挙上させるとそのままの姿勢を保持する」というようになる。
重力に抗った奇妙な姿勢を自発的に維持し続ける「姿勢保持」を認める。
指示に対して反対したり、質問しても反応しない「拒絶症」を認める。
他人の言葉を真似たり動作を真似る「反響言語・反響動作」を認める。
意識障害を伴わないが、心身ともに自己表現をせず外部とつながれなくなる「昏迷」を認める。
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James Goose Creek Parish (now a part of Berkeley County, South Carolina) to William Johnson Sr., a blacksmith who moved to South Carolina from New York, and Sarah Johnson, née Nightingale.
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Countries with fewer capital controls and greater trade with the United States also invest more in U.S.
The NYA additionally arrange its personal excessive faculties, completely separate from the public faculty system or academic colleges of education.
April 3, 2020 OTIS Otis Worldwide United Applied sciences spun off Otis and Provider and acquired Raytheon Firm.
The Standard & Poor’s Guide to Measuring and Managing Credit Risk.
In the secondary market, the securities are simply assets held by one investor selling them to another investor, with the money going from one investor to the other.
In forex trading the most popular currency pair is the EUR/USD, and regarding the Euro currency there have been some very interesting fundamental developments.
Other than those there are various MMFs just like prime funds, first-tier MMFs etcetera.
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Halaby not only took on the title of queen, but a new name as properly.
More and more companies are starting to increase their use of direct injection, but it has yet to become the standard.
ARMs that permit destructive amortization will usually have cost changes that occur much less ceaselessly than the interest rate adjustment.
As of 2018, share prices of Credit Suisse and different Swiss banks including UBS remained principally stagnant or flat since the 2008 monetary disaster.
Mutual Fund industry is a maze through which one has to find his way out to the opportunities, but they can be easily found if they are approached with wisdom.
However, it is best to still take additional warning as soon as you discover your dream house — think about how you’ll feel as soon as the honeymoon part’s over.
This contains reaching 100 battery electric car (BEV) gross sales for passenger vehicles in Europe and 50 BEV sales for passenger vehicles and gentle-obligation trucks in the United States by 2030.
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