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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Within the economics context, disbelieving in secrets results in the conclusion that markets are utterly environment friendly.
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{Tôi đã rất hài lòng để tìm thấy trang web tuyệt vời này. Tôi cần cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thưởng thức từng một chút nó và tôi đã đánh dấu trang để xem điều mới trong trang web của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để khám phá một người mà thực sự hiểu họ là gì thảo luận trên web. Bạn chắc chắn nhận ra cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa thực sự cần đọc điều này và hiểu khía cạnh này câu chuyện của bạn. Tôi đã ngạc nhiên rằng bạn không nổi tiếng hơn vì bạn chắc chắn nhất sở hữu món quà.|Xuất sắc bài viết trên blog. Tôi hoàn toàn yêu thích trang web này. Tiếp tục làm tốt!|Thật gần như không thể tìm thấy những người hiểu biết về điều này, tuy nhiên, bạn nghe có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn cần là một phần của một cuộc thi dành cho một blog trên mạng tốt nhất. Tôi chắc chắn sẽ Rất khuyến nghị trang web này!|Một cuộc thảo luận thú vị chắc chắn đáng giá bình luận. Không còn nghi ngờ gì nữa rằng bạn nên xuất bản thêm về chủ đề này, nó có thể không là một điều cấm kỵ vấn đề nhưng thường xuyên mọi người không nói về những chủ đề những điều này. Đến phần tiếp theo! Chúc mừng!|Xin chào! Tôi chỉ muốn đề nghị rất cho thông tin tuyệt vời bạn có ở đây trên bài đăng này. Tôi sẽ là trở lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu bình luận tôi có vẻ như đã nhấp hộp kiểm -Thông báo cho tôi khi có bình luận mới- và từ bây giờ mỗi lần được thêm vào tôi nhận được 4 email có cùng nội dung. Có lẽ có một phương tiện bạn có thể xóa tôi khỏi dịch vụ đó không? Kudos.|Lần sau nữa Tôi đọc một blog, Tôi hy vọng rằng nó không thất bại nhiều như bài này. Ý tôi là, Tôi biết điều đó là sự lựa chọn của tôi để đọc, tuy nhiên tôi thực sự tin bạn sẽ có điều gì đó thú vị để nói về. Tất cả những gì tôi nghe được là một loạt rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi nghiêm túc cảm thấy trang web này cần nhiều hơn nữa sự chú ý.
{Tôi khá hài lòng để tìm thấy trang web tuyệt vời này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thực sự thích từng của nó và tôi đã đánh dấu trang để xem thông tin mới trên trang web của bạn.|Tôi có thể chỉ nói rằng thật thoải mái để khám phá một người thực sự hiểu họ là gì đang nói về trên internet. Bạn chắc chắn nhận ra cách đưa một vấn đề ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa phải kiểm tra điều này và hiểu khía cạnh này của. Thật ngạc nhiên bạn không nổi tiếng hơn vì bạn chắc chắn có món quà.|Xuất sắc bài đăng. Tôi chắc chắn yêu thích trang web này. Tiếp tục viết!|Thật khó tìm những người có kinh nghiệm về điều này, tuy nhiên, bạn nghe có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên là một phần của một cuộc thi dành cho một blog trên web hữu ích nhất. Tôi sẽ Rất khuyến nghị trang web này!|Một cuộc thảo luận thú vị chắc chắn đáng giá bình luận. Tôi nghĩ rằng bạn cần viết thêm về vấn đề này, nó có thể không là một điều cấm kỵ vấn đề nhưng nói chung mọi người không nói về chủ đề như vậy. Đến phần tiếp theo! Chúc mọi điều tốt đẹp nhất!|Xin chào! Tôi chỉ muốn cho bạn một rất cho thông tin xuất sắc bạn có ở đây trên bài đăng này. Tôi sẽ là trở lại blog của bạn để biết thêm thông tin sớm nhất.|Sau khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp hộp kiểm -Thông báo cho tôi khi có bình luận mới- và bây giờ bất cứ khi nào có bình luận được thêm vào tôi nhận được 4 email cùng chính xác một bình luận. Có một cách bạn có thể xóa tôi khỏi dịch vụ đó không? Kudos.|Lần sau Tôi đọc một blog, Hy vọng rằng nó không làm tôi thất vọng nhiều như bài này. Rốt cuộc, Vâng, đó là sự lựa chọn của tôi để đọc hết, dù sao thì tôi thực sự nghĩ bạn sẽ có điều gì đó hữu ích để nói. Tất cả những gì tôi nghe được là một loạt rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi hoàn toàn tin rằng trang web này cần nhiều hơn nữa sự chú ý.
{Tôi đã cực kỳ hài lòng khám phá trang web này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thưởng thức từng của nó và tôi đã lưu làm mục ưa thích để xem điều mới trên blog của bạn.|Tôi có thể chỉ nói rằng thật thoải mái để khám phá một người thực sự biết họ là gì đang nói về trên internet. Bạn chắc chắn nhận ra cách đưa một vấn đề ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa cần phải đọc điều này và hiểu khía cạnh này câu chuyện của bạn. Tôi đã ngạc nhiên bạn không nổi tiếng hơn vì bạn chắc chắn nhất có món quà.|Xuất sắc bài viết. Tôi chắc chắn đánh giá cao trang web này. Tiếp tục viết!|Thật gần như không thể tìm thấy những người có kinh nghiệm về điều này, nhưng bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên tham gia một cuộc thi dành cho một trang web trên internet có chất lượng cao nhất. Tôi sẽ Rất khuyến nghị blog này!|Một động lực chắc chắn đáng giá bình luận. Tôi tin rằng bạn nên xuất bản thêm về chủ đề này, nó có thể không là một điều cấm kỵ chủ đề nhưng thường xuyên mọi người không thảo luận chủ đề như vậy. Đến phần tiếp theo! Chúc mọi điều tốt đẹp nhất!|Xin chào! Tôi chỉ muốn đề nghị rất to cho thông tin tuyệt vời bạn có ngay tại đây trên bài đăng này. Tôi sẽ là quay lại trang web của bạn để biết thêm thông tin sớm nhất.|Sau khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp hộp kiểm -Thông báo cho tôi khi có bình luận mới- và bây giờ mỗi lần được thêm vào tôi nhận được 4 email có cùng nội dung. Có lẽ có một phương pháp dễ dàng bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm ơn rất nhiều.|Lần sau Tôi đọc một blog, Hy vọng rằng nó sẽ không thất bại nhiều như bài này. Rốt cuộc, Vâng, đó là sự lựa chọn của tôi để đọc, tuy nhiên tôi thực sự nghĩ bạn sẽ có điều gì đó hữu ích để nói về. Tất cả những gì tôi nghe được là một loạt phàn nàn về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thực sự nghĩ trang web này cần nhiều hơn nữa sự chú ý.
{Tôi cực kỳ hài lòng khám phá trang web này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thưởng thức từng một chút nó và tôi đã đánh dấu trang để xem những thứ mới trên trang web của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để tìm thấy một người mà thực sự hiểu họ là gì đang nói về trên internet. Bạn chắc chắn biết cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa cần phải kiểm tra điều này và hiểu khía cạnh này câu chuyện của bạn. Thật ngạc nhiên bạn không nổi tiếng hơn vì bạn chắc chắn nhất sở hữu món quà.|Tốt bài viết. Tôi chắc chắn đánh giá cao trang web này. Tiếp tục với nó!|Thật gần như không thể tìm thấy những người có học thức về điều này, nhưng bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn cần tham gia một cuộc thi dành cho một trang web trực tuyến tốt nhất. Tôi chắc chắn sẽ Rất khuyến nghị trang web này!|Một hấp dẫn đáng giá bình luận. Tôi nghĩ rằng bạn cần viết thêm về chủ đề này, nó có thể không là một điều cấm kỵ vấn đề nhưng thường xuyên mọi người không nói về những chủ đề như vậy. Đến phần tiếp theo! Chúc mọi điều tốt đẹp nhất!|Xin chào! Tôi chỉ muốn cho bạn một rất to cho thông tin tuyệt vời bạn có ở đây trên bài đăng này. Tôi đang quay lại blog của bạn để biết thêm thông tin sớm nhất.|Sau khi tôi ban đầu bình luận tôi có vẻ như đã nhấp hộp kiểm -Thông báo cho tôi khi có bình luận mới- và bây giờ mỗi lần được thêm vào tôi nhận được bốn email có cùng nội dung. Phải có một phương tiện bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm kích.|Lần sau Tôi đọc một blog, Hy vọng rằng nó sẽ không làm tôi thất vọng nhiều như bài này. Ý tôi là, Tôi biết điều đó là sự lựa chọn của tôi để đọc hết, dù sao thì tôi thực sự nghĩ bạn sẽ có điều gì đó hữu ích để nói về. Tất cả những gì tôi nghe được là một loạt tiếng rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thực sự cảm thấy trang web này cần nhiều hơn nữa sự chú ý.
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