The term psychosis was first used in the medical literature by Ernest von Feuchtersleben in his textbook Principles of Medical Psychology (1847). Originally, the concept was defined broadly to include any impairment of the higher mental functions. Starting in the late 1800s, psychopathologists such as Emil Kraepelin, Eugen Bleuler, and Kurt Schneider began to differentiate specific psychotic disorders on the basis of their symptomatology and course. According to contemporary views, psychotic disorders are psychopathological conditions characterized primarily by profound disturbances in cognition, perception, emotion, and volition that result in severe psychosocial dysfunction, including inability to meet the demands of daily life, and impaired reality testing.
精神病的症状
精神病疾病实际上包括数十个症状,其中许多症状具有多种不同的表现。症状不是具体的,偶尔可以在其他疾病中观察到,包括认知障碍和情绪障碍。根据功能领域,可以将精神病症状分为四个类别。
认知障碍
这些可以分为思想内容的干扰(即,一个人的想法或谈论)与思想形式的干扰(即,一个人的思维或说话方式)。与思想内容有关的症状包括妄想(确定的信念明显是错误的和文化异常)和构想(过高的信念)。Specific symptoms that occur with some frequency include thought insertion (others are placing thoughts in the person’s head), thought withdrawal (thoughts are being taken out of the person’s head), thought broadcasting (others can hear the person’s thoughts), misidentification (others are impersonating the person’s loved ones), and thoughts of reference (ordinary occurrences have a special meaning or were arranged just for the person). Disturbances of thought content are often characterized according to thematic content (e.g., persecutory, grandiose, erotomanic, jealous, somatic, or nihilistic) or according to whether they are bizarre (strange and impossible, totally implausible), fixed (stable over time), and systematized (complex and internally coherent).
与思想形式相关的症状包括宽松的联想(从主题到主题迅速跳跃),切向性(不断徘徊在主题上),间接性(语音仅与所讨论的主题间接相关),出轨(完全失去了主题),坚持不懈(不断返回同一主题),思想阻碍(突然停止说话),新词(构成新的单词),叮当声(言语充满押韵),压力很大(快速而大声),不稳定(语音是不可能的)和Echolalia(其他人所说的重复单词)。
感知的干扰
这些也可以分为两种主要类型。首先,幻觉是在没有外部刺激的情况下感觉到的。它们可能以任何感官方式发生。The most common are auditory (e.g., hearing voices that other people can’t hear, often several people conversing in negative terms with or about the person or telling the person what to do) and visual (e.g., seeing things that other people can’t see, such as lurking strangers, ghosts, or visions). Second, depersonalization and derealization are abnormalities in perception of self and the environment, respectively. Depersonalization often involves “out-of-body” experiences (e.g., people perceive that their minds have left their bodies and are floating around the room or that they no longer have control over the movement of their own bodies). Derealization, in contrast, often involves the perception that the outside world is unreal or a sham (e.g., other people are automatons).
情绪的干扰
这些涉及不存在正常影响或异常影响的存在。第一种类型的症状包括情感的钝性或贫穷(情绪表现的范围和深度),Anhedonia(愉悦感的失去)和平坦的情感(几乎完全没有情感)。第二种症状包括困惑(关于正在发生的事情的困惑或不确定性),暴风雨影响(激烈和不稳定的情绪),不一致(显然与讨论主题的语气相反的情感展示)和情感影响(情感上的影响)(与所讨论的主题无关的显示,通常被视为不成熟或少年)。
意志的干扰
这些涉及自愿行为的困难。与制定计划问题和执行目标指导活动有关的症状包括Abulia或Avolition(不活动),冷漠(矛盾或兴趣丧失),Anergia(能源丧失),自闭症或社交戒断(未能与他人互动),self-neglect (neglect of one’s own health and hygiene), negativism (ignoring the directions of others, resisting attempts to be moved by maintaining a rigid posture), and alogia or mutism (not speaking at all). Symptoms related to disturbance of behavioral tone, also known as catatonic symptoms, include hypertonia (overactivity, such as moving a lot or moving quickly) and hypotonia or catalepsy (underactivity, such as moving rarely, moving slowly, and waxy flexibility). Disturbances of purposeful activity include mannerisms (strange gestures or movements, such as walking on tiptoe or wiggling the fingers), stereotypies (repetitive, tic-like movements or vocalizations, such as constantly rubbing one’s head or barking like a dog), grimaces, posturing (assuming strange poses, such as standing with one leg in the air or sitting with arms extended), echopraxia (repeating the movements of others), and bizarre behavior (e.g., masturbating in public, eating inedible substances, playing with feces).
症状簇
临床观察和研究发现,某些精神病症状经常同时发生。至少有三种不同的综合症(即症状簇)。积极的症状是由于它们的存在是病理性的,例如妄想,幻觉,暴风雨的情感和举止。阴性症状因缺乏而成为病理。例子是言语的贫困,情感的贫困和社会戒断。混乱的症状反映了基本心理功能调节或协调的损害,例如,不连贯,愚蠢的情感和怪异的行为。
当代精神病分类
精神病的分类基于症状,过程和病因。在美国精神病学协会的第四版中,精神障碍或DSM-IV的诊断和统计手册,精神病障碍分组为“精神分裂症和其他精神病性疾病”的标题,并包括许多特定疾病。
精神分裂症
精神分裂症的特征是进行性或阴险的发作(前驱阶段),在此期间负面症状占主导地位。在几个月甚至几年之后,急性加重(活动阶段)持续了一个月或更长时间,在此期间,积极和混乱的症状占主导地位。在大多数(约80%)的情况下,该病程是慢性的,其特征是至少一些持续的负面症状(残留阶段)以及偶尔出现阳性或混乱症状的复发。症状的总持续时间(Promal Plus活跃加残留阶段)应至少6个月。症状应在没有明显的抑郁症或躁狂症症状的情况下发生,不应是毒液,戒断或一般医疗状况的结果。已经根据其主要症状学(包括偏执型(突出的妄想或幻觉),catatonic类型(明显的意志干扰),混乱的类型(突出的混乱症状),突出的负症状(突出的负症状)(突出的负面症状),基于偏执型(突出的妄想或幻觉),已经鉴定出许多普遍发生的精神分裂症亚型。), and Undifferentiated Type (doesn’t fit one of the other types). Age of onset is typically between 15 and 45 years; onset is about 5 years earlier in males than in females. Schizophrenia can have a debilitating affect on social adjustment, including impaired occupational functioning; failure to establish intimate relationships and reduced fertility; increased mortality owing to suicide, accident, and illness; and elevated risk of serious violence. In about 50% of cases, there is little or no improvement in social adjustment over time; in about 30%, there is substantial improvement; and in about 20%, there is good recovery or remission. Good prognosis is associated with having achieved adequate social functioning prior to onset of the disorder (e.g., absence of premorbid personality disorder), acute onset (e.g., short prodromal phase, onset following experience of a major life stressor), the presence of abnormal affect (e.g., stormy affect, perplexity, confusion), the absence of blunted or flat affect, and the absence of a family history of schizophrenia. Early detection and treatment may also be associated with good prognosis.
精神分裂症
这与精神分裂症有关,仅在其课程方面。精神分裂症的总症状总持续时间至少为6个月,而精神分裂症疾病至少为1个月但少于6个月。两种亚型被识别,有或没有良好的预后特征。前者可能与迎接前的社会功能完全恢复有关,而后者可能会发展为成熟的精神分裂症(如果精神病症状持续或反复出现)。
简短的精神病
这与精神分裂症和精神分裂症疾病不同,因为所有阶段的总症状持续时间均小于1个月,随后又回到了前的社会和职业功能。识别出三种亚型:根据症状发作是否在不久和显然响应压力性生命事件的情况下发生症状发作以及显然发生的两个亚型,具有和没有明显的压力源;第三次出现产后发作,当症状发作在分娩后4周内发生时,在女性中被诊断出来。
精神分裂症
这与精神分裂症有所不同,仅在疾病的活跃阶段的某个时候,该人还患有抑郁或躁狂症的突出症状(即符合主要抑郁,躁狂或混合发作的标准),但有一段时间在没有情绪症状的情况下存在妄想或幻觉至少2周。根据情绪症状的性质,可以识别两种亚型:如果情绪障碍至少包括一些躁狂症症状和抑郁型,如果情绪障碍仅限于抑郁症状,则两种亚型。与精神分裂症相比,精神分裂症的长期预后相关,尽管预后比主要抑郁症或双相情感障碍等情绪障碍更差。
妄想障碍
这特征是持续至少1个月的突出的非义务妄想。该人还可能表现出与妄想内容有关的著名嗅觉或触觉幻觉。妄想应该在没有明显的听觉或视觉幻觉以及没有突出的情绪症状的情况下发生,并且不应是物质中毒,戒断或一般医疗状况的结果。基于妄想的主要主题,可以认识到七个子类型:狂热,宏伟,嫉妒,迫害,躯体,混合和未指定的类型。妄想障碍可能仅导致对社会心理功能的有限或限制干扰。
共同的精神病
当该人发展出类似于患有精神病障碍的亲密相识的妄想时,这是诊断出来的。妄想应在没有突出的情绪症状的情况下发生,不应是物质中毒,戒断或一般医疗状况的结果。
由于一般疾病而导致的精神病障碍
This is characterized by prominent delusions or hallucinations that arose during or shortly after and apparently in response to the physiological result of a general medical illness, which has been confirmed by history, physical examination, or laboratory findings. The symptoms should not occur only during periods of clouded consciousness (i.e., delirium). Two subtypes are recognized, With Delusions and With Hallucinations, based on which psychotic symptoms are predominant.
物质诱导的精神病
This is identical to Psychotic Disorder Due to a General Medical Condition, except that history, physical examination, or laboratory findings indicate that the symptoms arose during or shortly after and apparently in response to substance intoxication or withdrawal. Two subtypes are recognized, With Onset During Intoxication and With Onset During Withdrawal.
精神病流行病学
普通人群中精神病的终生患病率约为3%至4%;最常见的精神病是精神分裂症,终生患病率约为1%至2%。精神病症状的发生频率更高;孤立的幻觉妄想的终身患病率可能高达4%至8%,任何精神病症状的终生患病率可能高达10%至20%。精神病的患病率显然在各个国家之间显然几乎没有变化,尽管在各个国家内,在民族文化少数群体和最近移民中,可能会更经常被诊断出来。有证据表明性别差异很小,男性的比率略高于女性。
心理疾病的病因
大量的研究表明,神经生物学因素在精神病的病因中的重要性,最有可能是脆弱性或诱发因素。行为遗传研究表明,精神病,尤其是精神分裂症,基本上是可遗传的。然而,分子遗传研究尚未成功地分离哪些基因,甚至涉及哪些染色体。遗传贡献的强度似乎随着精神分裂症类型的函数而变化,其遗传负荷与阴性和混乱症状有关。许多行为遗传学家都同意,尽管多因素模型也有一些支持,在多因素模型中,特定基因产生了重大影响,而多基因对特定基因的作用进行了增强或隔离。其他研究发现,精神病与妊娠和出生并发症的史有关,包括妊娠中期母体流感率提高,吸烟和营养剥夺以及怀孕期间的母子RH不兼容;分娩过程中的产科并发症;和先天性异常,可见后明显。神经影像学和验尸研究发现,精神病患者以及其一级生物依赖性(包括心室和硫磺空间肿大)的结构性脑异常率提高。大脑体积减少,尤其是在额叶和颞区,丘脑,杏仁核和海马; reduced inter-region connectivity; cytohistological abnormalities in the prefrontal and temporal regions, thalamus, hippocampus, and parahippocampal gyrus; and changes in regional activity during performance of cognitive tasks. Pharmacological studies indicate that disturbances of the dopaminergic neurotransmitter system in the brain (e.g., elevated frequency and activity of dopamine receptors) may be related to positive psychotic symptoms, whereas the serotonergic and glutamate systems may be related to both positive and negative symptoms.
Psychosocial factors may also be important in the etiology of psychotic disorders, most likely as triggers or precipitating factors. Life event studies indicate that active phases of psychotic disorders—both first episodes and recurrences—may occur shortly after, and apparently in reaction to, major life stressors. Also, a high level of negative expressed emotion in close per-sonal relationships is associated with increased risk for development of psychotic disorders, as well as the recurrence of active phases. Both these factors, however, may be of limited importance in the absence of a neurobiological vulnerability or predisposition.
精神病治疗
在精神病的活跃阶段,药理治疗已使用了50多年。在1950年代至1970年代,抗精神病药的作用机理(例如苯噻嗪,丁烷酮,硫甘氨酸)是D2多巴胺受体的封锁。这些“典型”的抗精神病药导致大约60%的病例降低了正症状(并且在较小程度上是混乱的症状),大约30%的病例减少了,大约有10%的病例没有反应。维持剂量还有助于减少活动阶段的复发。但是,典型的抗精神病药对负面症状的影响很小,并且与严重的副作用(包括镇静和运动障碍)相关。在1980年代,引入了“非典型”抗精神病药(例如,氯氮平,氨基甲苯)。它们的作用机理比典型的抗精神病药更普遍。除多巴胺能系统外,它们还会影响5-羟色胺能和肾上腺素能系统。非典型抗精神病药至少与典型的抗精神病药一样有效(即使在典型的抗精神病药无效的情况下),它们也可能减少负面症状。但是,它们也具有严重的负面影响,并且非常昂贵。 The effectiveness of pharmacological treatment has greatly reduced the use of other, more invasive somatic treatment, such as electroconvulsive therapy and prefrontal lobotomy; it has also greatly reduced the frequency of long-term institutionalization.
社会心理干预措施经常用于管理主动症状,减少对药理治疗难治性的主动症状,在活动阶段后改善社交功能,并降低复发的风险。当难以在社区中提供适当的服务以及自杀或暴力的风险很严重时,就会使用制度化或暂托护理。针对患者及其家人的心理教育计划用于提高对其他疗法的依从性并降低复发率。认知行为疗法用于管理主动精神病症状,例如妄想和幻觉,并提高对其他治疗的依从性。“双重疾病”或“同时出现的疾病”计划用于治疗也患有精神病患者的药物使用障碍症状。康复和社交技能计划用于改善人际关系和职业功能。
大多数情况下,精神病的治疗是长期的和多模式的:与一种或多种社会心理干预结合使用的药理学干预措施。使用自信案例管理技术协调时,服务提供最有效。
精神病的法医相关性
在法律中,做出重要决定的能力通常要求该人可以准确地感知环境,合理地操纵有关环境的信息,并向他人传达欲望和意图。这些特定的决策能力可能会因精神病症状,尤其是阳性和混乱症状而受到损害。因此,精神病障碍在裁决能力的心理评估中尤为重要(例如,立场审判,放弃律师权,供认)和在犯罪环境中的罪魁祸首和其他能力的评估(例如,同意治疗,作证,遗嘱,遗嘱,遗嘱,,在民事环境中的签署合同)。例如,对裁决能力和罪魁祸首的研究表明,在合法无能或不可污染的人中,多达80%至90%的人可能患有精神病或其他疾病(例如,认知或情绪障碍)患有精神病患者(例如,具有杰出的精神病)症状。
关于控制自己行为的能力,法律通常要求该人可以自由形成适合这种情况的目标或意图;制定实现这些目标的计划;并根据需要实施,评估和修改这些计划。这些特定的能力也可能因各种类型的精神病症状而损害。在犯罪环境中,精神疾病可能在对罪犯的精神障碍评估以及对其他能力的民事问题评估中(例如,同意治疗,作证,遗嘱,签署合同)。在犯罪和民事环境中,特别关注的问题是与精神病症状有关的严重暴力,尤其是积极和迷失的症状。在某些情况下,精神病症状的性质与暴力直接相关(例如,遭受迫害妄想的人袭击了他认为正在试图毒害他的人);在其他情况下,精神病症状与其他因素(例如,使用物质)相互作用,通常会破坏社会调整并增加可能导致暴力的人际冲突。研究表明,精神病疾病会导致一个人参与严重暴力的几率增加。
参考:
- Jibson,M。D.,Glick,I。D.和Tandon,R。(2004)。精神分裂症和其他精神病。焦点,2,17-30。
- 利伯曼(J. A.(2006)。美国精神分裂症的美国精神病出版教科书。华盛顿特区:美国精神病出版。
Return to犯罪行为概述。