Class 8 Psychotic Disorders ( 정신병적장애 )(1) 1. 정의 2. 원인과역동 (Cause & Dynamics) 3. 증상 (Symptom Charateristics ) 4. 진단분류 (Diagnostic Criteria ) 5. 관련질환 1) Schizophrenia disorder <Schizophrenia subtypes> (1) 편집형 (Paranoid Type) (2) 분열된유형 / 해체형 (Disorganized Type) (3) 긴장형 (Catatonic Type) (4) 미분화형 (Undifferentiated Type)( 감별불능형, 혼합형 ) (5) 잔류형 (Residual Type)
2) 기타정신장애 (1) 조현병적장애 / 정신분열형장애 (Schizophreniform disorder) (2) 단기정신병적장애 (Brief psychotic disorder) (3) 분열정동장애 (Schizoaffective disorder) (4) 망상장애 (Delusional disorder) (5) 공유정신병적장애 (Shared psychotic disorder) 6. 간호과정 1) 사정 2) 진단 3) 간호목적과목표 4) 계획 5) 수행 6) 평가
1. 정의 Definition - Kraepelin ; Dementia Praecox - Bleuler ; 4A(Affect, Associative looseness, Autistic thinking, Ambivalence) - Schneider : Positive Sx.
2. Cause & Dynamics Biological factor 1) 유전 - 입양연구, 쌍생아연구 2) 생화학적영향 - Neurotransmitter system : dopamin 과다가설 - serotonine 양증가, 수용체감소 - norepinephrine 결핍, 혹은 dopamin과의불균형설 3) 신경병리 - 측두엽위축, 전두엽대사활동감소, 뇌실비대, 대뇌피질위축 - 변연계 : 정서관련 - 기저신경절 : 운동기능환자들의묘한운동들 ( 어색한걸음걸이, 상동증, 얼굴찡그리기등 ( 신경과환자들중정신증상을보이는경우대개기저신경절의병소있음 )
4) 영상검사 - 뇌용량의감소 (CT, MRI) : 뇌측면, 제3뇌실확장 ( 그러나확진기준은아님 ) 전두엽, 소뇌, 변연계 ( 해마와편도 ) 위축 - PET : 인지활동중전두엽의혈류감소 ( 주의력, 계획, 의사결정관련 ) - 시상 (Thalamus) 의축소 ( 감각여과, 정보처리의문제 ) - 추체외로계 ( 기저핵 ) 의운동, 언어비정상기능과의관련성
5) 신경전달물질연구 - 조절장애가설 dysregulation hypothesis of schizophrenia : a persistent impairment in one or more neurotransmitter or neuromodulator homeostatic regulatory mechanisms causing unstable or erratic neurotransmission. 도파민의활동과다 ( 변연계 mesolimbic area) 와활동저하 ( 전전두엽 prefrontalmesocortical areas) 관찰. (1) Dopamine. * known as mind-altering drugs (such as amphetamines and cocaine) * important in responses to stress * has many connections to the limbic system. * The prefrontal cortex has few dopamine receptors of its own, but it may regulate dopamine in other circuits in the brain. * dopamine is present in high levels in the brain during late adolescence, when schizophrenia usually first appears. - Dopamine is found in three parts of the brain: Substantia nigra( 흑질운동중추로 ) : motor center, affecting movement and coordination Midbrain( 중뇌로 ) : involving emotion and memory Hypothalamic-pituitary connection( 시상하부-뇌하수체연결부로 ): involving emotional responses and stress-coping patterns
4 Dopamin major pathways in the brain 1. Mesocortical( 중뇌피질 ): innervates the frontal lobes a. Function : insight, judgment, social consciousness, inhibition, and highest level of cognitive activities (reasoning, motivation, planning, decision making) b. Negative symptoms : affective flattening or blunting, poverty of speech or speech content, blocking, poor grooming, lack of motivation, anhedonia, social withdrawal, cognitive defects, and attention deficits 2. Mesolimbic( 중뇌변연계 ): innervates the limbic system a. Function : associated with memory, smell, automatic visceral effects, and emotional behavior b. Positive symptoms : hallucinations, delusions, disorganized speech, and bizarre behavior
3. Tuberoinfundibular( 결절누두 ) : originates in the hypothalamus and projects to the pituitary a. Function : endocrine function, hunger, thirst, metabolism, temperature control, digestion, sexual arousal, and circadian rhythms b. Implicated in some of the endocrine abnormalities seen in schizophrenia and some of the side effects of antipsychotic drugs, such as hyperprolactinemia 4. Nigrostriatal( 흑질선조체 ): originates in the substantia nigra( 흑질 ) and terminates in the 미상핵 - 피각컴플렉스 (caudate nucleus putamen complex(neostriatum)) a. Function : innervates the motor and extrapyramidal systems b. Implicated in some of the movement side effects of antipsychotic drugs, such as tardive dyskinesia, akathisia, and dystonic reactions
(2) serotonin - Also has been implicated in schizophrenia. - has a modulating effect on dopamine, - the first-generation atypical antipsychotic drugs are combination serotonin/dopamine blocking agents, accounting Frontal cortex for their improved efficacy over the typical antipsychotics used in the treatment of the negative symptoms of schizophrenia. (3) Glutamate( 글루탄산염 ) - the major excitatory neurotransmitter. - Research on the effect of PCP (phencyclidine), a drug that seems to mimic the symptoms of schizophrenia in normal volunteers, has led to a better understanding of how glutamate interacts with dopamine. The function of glutamates major receptor complex, NMDA (N-methyl-D-aspartate), is interrupted by PCP. This important brain communication system is abnormal in the prefrontal cortex and thalamus in postmortem studies of patients with schizophrenia. Experimental psychotropic agents that activate the NMDA receptor complex and its coagonist site for glycine are potential future treatments for schizophrenia.
Psychosocial factor 1) 정신내적요인 - Freud : 고착, 자아기능결함 - 부모와의관계 : 자아상 2) Interpersonal factor - Sullivan; 대인관계이론, 의사소통의중요성 - G. Bateson " 이중구속의사소통 (double-bind communication)" : 어머니가아이에대해말과행동을서로상반되게줄때아이는이중으로구속된상태가되어아무것도할수없게됨. - Litz 결혼편중 (marital skew): 가족의감정이한쪽배우자에의해지배되는경우결혼분파 (marital schism): 부부사이가나빠서로고립된생활, 감정적보상을자식에게구하려하여아이는누구의편들어야할지혼돈과죄책감에빠짐 - 가족의미분화 : 구성원이서로충분히분리되지않아각자사고와감정을발달시키지못함 - 가족의 Expressed emotion 이론 (high, low)
기타요인 - 바이러스이론 : 태아기독감바이러스감염 - 자가면역이론 - 낮은사회경제적상태 - 기타증상유발인자들 - 스트레스이론
3. 증상특성 Symptom Characteristics - Positive Symptoms : Delusion, Hallucination Disorganized Thoughts - Negative Symptoms : Affective blunting, avolition, apathy, alogia(speak little). - 와해된행동 Disorganized behaviors - 인지적결함 Cognitive deficit
4. Diagnostic Criteria (DSM-IV-TR) 1) Schizophrenia disorder( 조현병 ) <Schizophrenia subtypes> (1) 편집증유형 (Paranoid Type) (2) 분열된유형 / 해체형 (Disorganized Type) (3) 긴장증유형 (Catatonic Type) (4) 미분화형 (Undifferentiated Type)( 감별불능형, 혼합형 ) (5) 잔류유형 (Residual Type) 2) 조현병적장애 (Schizophreniform disorder) ( 정신분열형장애 ) 3) 단기정신병적장애 (Brief psychotic disorder) 4) 분열정동성장애 (Schizoaffective disorder) 5) 망상장애 (Delusional disorder) 6) 공유정신병적장애 (Shared psychotic disorder)
1) Schizophrenia disorder ( 조현병 ) Subtypes (1) 편집증유형 (Paranoid Type) onset 20 대후반 30 대이후, 교육많이받은계층 증상망상 ( 피해, 과대, 관계 ), 환청, 긴장, 의심. 체계화된망상분노, 불안, 따지기, 무관심한행동 ( 언어와해나행동와해, 부적절한정서는없음 ) 행동특성 예후 피해망상으로인한분노, 난폭함대인관계어려움 ( 경계심, 의심 ), 적대적, 공격적행동 지능은이상없슴다른유형보다퇴행이덜일어남그런대로사회생활유지하는경우도있슴.
(2) 분열된유형 / 해체형 (Disorganized Type)( 파과형, hebephrenic type) onset 25 세이전, 사춘기전후 증상사고와감정의혼란극심, 인격의황폐화와퇴행이가장심한유형 thought incoherence, Disorganized speech and behaviors, Apathy, blunted affect, silly smile, inappropriate affect 망상과환각 : 지리멸렬, 내용도부적절, 단편적, 내용수시로변함 행동특성일상생활수행능력의심한장애 ( 세수, 양치, 목욕, 옷입기등 ) 기이한행동 ( 기행증 ) 병전적응력낮았던경우. 예후 나쁨
(3) 긴장증유형 (Catatonic Type) onset 증상 / 행동특성 / 예후 15-25 세정신적외상후급성으로발병 극심한정신운동장애혼미 (stupor) 와흥분 (excitement) 상태가단독또는교대. 혼미상태가더흔함 : 다양한긴장증상 ( 운동정지 ~ 장기간의강직증 ) 부동증 (catalepsy, waxy flexibility), 심한 negativism, mutism, automatism, stereotypy, mannerism, echolalia, echopraxia 흥분상태 : 강한긴장, 안절부절, 난폭, 잠안자고, 식사거부, 탈진, 사망에이름
(4) 미분류형 (Undifferentiated Type)( 감별불능형, 혼합형 ) 특징 환각, 망상의정신분열병증상이있으나복합적이어서 1), 2) 3) 의어느하나의유형으로분류할수없는경우 더 chronically ill 하고 disorganized 되는경우 (5) 잔류유형 (Residual Type) 정의정신분열병의기왕력있으면서, 양성증상이나긴장성행동은없으나 2 가지이상의음성증상이지속되는경우 증상 Blunted affect Social withdrawal, bizarre behavior illogical thought Inappropriateness 망상, 환청있을수있으나심하지않음
2) 기타정신장애 (1) 조현병적장애 (Schizophreniform disorder)( 정신분열형 ) 특징 총발병기간이 6 개월이하인경우 단기정신병적장애 ( 발병기간 1 개월이내 ) < 조현병적 < 정신분열병 (6 개월이상 ) (2) 단기정신병적장애 (Brief psychotic disorder) 특징 행동특성 증상기간이 1 일 ~1 개월이내, 흔치않음 2 주이내에한가지이상의급성적현저한스트레스가존재하는경우 불안정한정서, 기이한옷차림또는행동, 소리지르기 vs 함구주의력손상등. 정신분열병과기분장애의정신병적증상보이나대체로기분장애증상이더뚜렷
(3) 분열정동성장애 (Schizoaffective disorder) 정의 진단기준 정신분열병 + 기분장애의증상이공존하는경우 현저한기분장애의증상없이최소한 2 주이상의망상이나환각 ( 최소 1 개월이상정신분열병증세보여야진단 ) 증상 예후 특징 정신분열병 + 조증 + 우울장애등의기분장애징후함께나타남 정신분열병 < 분열정동장애 < 기분장애보다예후나쁨 갑자기발병, 빨리회복, 기능저하미미 Lithium( 항조증약물 ) 에잘반응항정신병약물 : 단기간의증상조절을위해씀가족력에기분장애많음.
(4) 망상장애 (Delusional disorder) 증상 행동특성 주증상 : 망상환각, 정신병적증상, 인격의붕괴없음망상의특징 ; 정교, 체계화, 지속적 ( 정신분열병환자보다 ) 피해, 질투, 과대, 색정, 신체망상등 일반적기능손상은없다. 대인관계나사회적기능이부분적으로유지 진단기준 발병 / 예후 괴이하지않은망상이최소 1 개월이상지속망상으로인한기능의현저한손상이없어야하고행동이뚜렷하게괴이하거나이상하지않아야함 전연령층일시적혹은지속적일수있다. < 좋은예후예측요인 > 30 세이전발병, 급성발병, 여성, 직업. 사회. 기능적적응이좋았던사람, 기혼
(5) 공유정신병적장애 (Shared psychotic disorder), 이중정신병 정의 특징 정신병적증상이있는사람과장기적인관계를유지하면서발생한정신장애 두사람 (A, AA) 의망상체계가비슷함 A : 강한성격, 나이많음, 지적 AA : 순종적, 나이어림 서로애착관계, 긴밀한삶, 그러나사회적접촉부족, 고립된삶 치료 분리치료후에발병한 (AA) 사람의증상경감가능