intermittent psychosis
Introduction
Introduction to intermittent psychosis Intermittent psychosis is a legal concept, not a psychiatric concept. Intermittent mental patients refer to mental patients whose mental state is not always in a state of confusion and completely lost recognition or unable to control their own behavior. Medical psychosis can have varying degrees of remission. Complete relief, mental symptoms have completely disappeared, can be considered normal, assessed as full responsibility; although in remission, there are residual symptoms or personality changes, mental state is not completely normal, when harmful behavior occurs, its identification or Control ability can be significantly reduced and should be assessed as limiting liability. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: anxiety
Cause
Cause of intermittent psychosis
Schizophrenia is a very complex disease, both biologically and methodologically. The etiology, pathogenesis, treatment and prevention of schizophrenia have been the central topic of psychiatric research. The traditional medical model emphasizes the cause of biological. According to this view, schizophrenia is a disease of unknown cause. Because, since the discovery of pathogenic microorganisms, people are accustomed to regard the cause of various diseases as a single factor. If a single cause cannot be found, it is considered "the cause is unknown." Many common diseases can be considered as unknown causes, such as high blood pressure and gastric ulcer. Schizophrenia certainly belongs to this category. However, this traditional concept has changed, reflecting the changes in disease patterns since the 1970s, from the original biomedical model to the bio-psycho-social model. This means that for most diseases, the onset of the disease is not absolutely dependent on a single factor. For example, after infection with M. tuberculosis, it is not necessary to have tuberculosis (in fact, most of them do not have tuberculosis). Whether or not the disease is determined depends on the spirit of the time. And physical condition, which in turn is closely related to its environmental conditions. As far as schizophrenia is concerned, some people think that it is also caused by a combination of many factors. Some even believe that even in the future, it is impossible to find a single consensus factor that can explain all schizophrenia. Therefore, the etiology studies described in this paper will cover clinical genetics, molecular genetics, brain imaging neurodevelopment and psychosocial factors.
As a complex organ with a tightly protected structure, the human brain is also very complex; in research, it is generally difficult to obtain a large number of living brain specimens; and patients with schizophrenia are either impaired in cognitive ability or unable to follow the requirements and research. Cooperating with personnel; in addition to long-term use of antipsychotic drugs, the biochemical status of the brain changes, which in turn affects the structure, function or other aspects of the brain; stopping the drug can lead to repeated mental symptoms; the diversity of symptoms is also a difficult point of research. Like a patient, symptom fluctuations occur at different times; in addition, symptom diversity and volatility are not easily identifiable due to the use of antipsychotic drugs, etc., all of which together constitute the complexity of schizophrenia research. It is because of the complexity of these studies that it is difficult to study the etiology of schizophrenia. So far, the cause of the disease has not been fully elucidated.
Genetic factors: The results of population genetics studies prove that schizophrenia is a complex disease with multiple genes, and its heritability is 60%-80%. Therefore genetic factors are the most likely quality factor for schizophrenia. The earliest family studies found that relatives of schizophrenia patients had a higher probability of suffering from the disease than the general population, and the prevalence increased with the close relationship of the blood relationship; the more serious the proband, the higher the probability of relatives. Kallmann (1938) counted the incidence of 1,087 relatives of schizophrenia probands, with a Morbidity risk rate of 4.3% to 16.4% among all relatives, with the highest number of children, siblings and parents. In Shanghai (1958), a survey of 54,576 family members of 1198 patients with schizophrenia had the highest prevalence of schizophrenia among parents and siblings. Studies of schizophrenia twins have found that the same rate of single-oval twins is 4-6 times that of twins (Kallmann, 1946; Kringlen, 1967). The twin and foster child studies conducted to rule out the environmental factors of the disease found that the same twins (MZ) were three times more common than the twins (DZ); parents were schizophrenia patients, their children The prevalence after being fostered is the same as that of the unfostered person, which is significantly higher than the normal foster child. Heston (1966) raised 47 children of the mother of the patient from childhood, raised by healthy parents, and compared with the children of 50 parents. After adulthood, 5 patients in the experimental group suffered from schizophrenia, 22 patients had pathological personality; in the control group, there were no patients with schizophrenia, and 9 patients had pathological personality, and the difference was significant. Prompt the importance of genetic factors in schizophrenia.
In the 1980s, Sherrington conducted a linkage analysis of the corresponding chromosomal regions (Sherrington R, 1988), suggesting that there is a dominant gene in schizophrenia on the long arm of chromosome 5. A year later, the Sherrington team withdrew the hypothesis after conducting a large-scale sample study. At present, most authors believe that it is almost impossible to find a specific gene that controls the onset of schizophrenia. A large number of experimental studies suggest that schizophrenia may be polygenic, caused by the superposition of several genes.
Prevention
Intermittent psychosis prevention
1. Understand the patient and solve the happy knot: Some patients have had unreasonable words and deeds with their relatives during the onset of illness. The family members feel very wronged and the patients feel very guilty. At this time, they should explain to each other so that they can understand each other and actively communicate. The feelings of each other make the condition long-term stable and ready.
2, exercise patients, resilience: Because schizophrenia requires a long period of consolidation treatment, so the hospital stay usually takes several months, plus some side effects of taking antipsychotic drugs, many patients always feel powerless, It is easy to get tired and feel unfamiliar to the outside world. I am afraid that I cannot adapt to my future work and life. At this time, the family should encourage patients to participate in various activities, such as doing some light and safe labor, enriching the life content of patients, and gradually cultivating their social adaptability.
3, caring for patients, caring for patients: in the face of patients should avoid high-level people, to treat patients with modesty, enthusiasm, affectionately, avoid discrimination, satire, tease patients. To protect the patient, you should not take the pathological words and deeds of the disease period as the content of the jokes, so that it can create a sense of trust and security.
4, respect the patient, considerate the patient: due to the patient's psychological burden is heavier, the mood is not good, prone to emotional excitement, treat people violently, and even jealous of others. In this case, you should stay calm and avoid disputes. To comfort and understand them, the reasonable demands of patients should be satisfied as much as possible. The things that cannot be done should be explained patiently, avoid forced orders, and do not wish and deceive patients.
Complication
Intermittent psychiatric complications Complications
Main hazards:
1. The patient may have an unfounded wrong idea. It is suspected that someone will harm him. He is always suspicious: the important thing is not to trust his instincts, not to trust other people, but to suffer.
2. Patients with schizophrenia should not marry until the condition has not been completely relieved, as this will increase the risk of aggravating or worsening the condition. In addition, from the perspective of eugenics, schizophrenic patients who are breast-feeding try to avoid breastfeeding.
3. The attempt to commit suicide in schizophrenia patients can reach 40%, and the most common cause of death in patients with schizophrenia is suicide. When a person with schizophrenia develops, it is prone to cause severe depression and easy suicide. If the patient lacks care or poor care, it may cause suicidal tendencies. In the case of hallucinations, patients with schizophrenia hear someone order him to commit suicide or feel that someone is around. To harm him, he can only commit suicide without a pass.
4, the patient's emotional inversion; affectionate indifference; stubborn in a certain idea can not be changed; life self-care ability is low, lack of speech, not with people. Onset, irritability, paranoia, depression, fear and anxiety, auditory hallucinations, sensitivity and suspiciousness, forced irritability, confusion, gibberish, slamming things, impulsive wounds, unable to control themselves.
Symptom
Intermittent Psychiatric Symptoms Common Symptoms Interrupted Thinking Mandatory Thinking Emotions Inverted Illusory Thinking Disorders Persecution Perception
The spirit is normal, sometimes not normal. In the normal state of mind, the mind is awake, capable of recognizing or controlling one's own behavior. At the time of onset, it loses the ability to identify right and wrong and control one's behavior, that is, its mental illness is In a state of intermittent seizures. Based on this characteristic of intermittent psychiatric patients, the criminal law stipulates that intermittent mental patients who commit criminal acts stipulated by criminal law when they are in normal spirits should be criminally liable for causing harmful consequences, because at this time he has the same characteristics as normal people. The ability to act; and the criminal act stipulated in the criminal law is implemented when the loss of identification and right and the ability to control oneself during the onset of the disease, and the result of the harm is not criminally liable. Judging whether a person is an intermittent mental patient, and whether he is in a mentally normal state or a mental illness state when implementing socially harmful behaviors must also be authenticated in accordance with the provisions of the Criminal Law and the Criminal Procedure Law.
The characteristic mental symptoms are as follows:
1, will decline in activity
Less movement, solitude, passiveness, retreat; poor social adaptability and decline in social function; behavior is bizarre, introverted; intentional inversion.
2, Lenovo barriers
Relaxed thinking (sloppy thinking), ruptured thinking, logically inverted thinking, interrupted thinking, emerging thinking (mandatory thinking) or lack of thinking content and pathological symbolic thinking.
3, affective disorder
Apathy, dullness, emotional dissonance (inappropriate), and emotional inversion or self-smiling (smirking).
4, other common symptoms
Delusion: Features are mostly unsystematic, generalized, ridiculous and bizarre; primary delusions (destination perception); hallucinations, more common in verbal illusory auditory, critical, imperative auditory hallucinations, other mental symptoms such as mental disorders Stress syndrome, etc.
Examine
Intermittent psychiatric examination
There is no specific laboratory test for this disease. When complications such as infections occur, laboratory tests show positive results of complications.
Since the concept of schizophrenia has been proposed, brain morphological changes and some toxic metabolites have been studied from various aspects, and no positive results have been obtained. Until the past two or three decades, some positive results have been discovered due to advances in inspection techniques. As a result, brain imaging technology research has found that the disease has an organic basis. In the past 20 years, imaging technology has provided a convenient way for people to understand the function and structure of living brain, and the research on brain abnormalities in schizophrenia is mainly Involved in three aspects, first, through CT or MRI to find the site of brain damage that increases susceptibility to schizophrenia; second, using functional imaging techniques such as PET, SPECT, fMRI, to observe local neuronal activity To establish the interrelationship between neurological dysfunction and the clinical features of schizophrenia. Third, through the molecular structure of brain tissue, to clarify the nature of the pathological process of neuronal deficits, such as PET, SPECT observation of neurotransmitters Receptors, or MRS to detect changes in neurochemistry.
1. Structural imagery
The reduction of the whole brain volume of schizophrenia and the enlargement of the ventricle are relatively consistent, and the volume reduction of gray matter is more obvious. CT found that the ventricles of patients with schizophrenia are enlarged and the volume of brain tissue is reduced, and the parts of brain tissue shrinking are different. Some believe that in the temporal lobe, especially the left temporal lobe, some believe that there is a general size reduction, and the amount of sputum, sacral occipital lobe is obvious, ventricular enlargement can be detected early in the disease, and pre-operative functional impairment , negative symptoms, poor treatment and cognitive impairment, no significant correlation with the course of the disease, although CT abnormalities have clinical significance, but no diagnostic specificity, because the same abnormalities can also be seen in patients with AD and alcoholism, Some patients with schizophrenia have enlarged ventricles, while others with active symptoms use dopamine blockers with good efficacy. These phenomena make Crow (1980) propose the hypothesis of two types of pathological processes of schizophrenia, which are type I and type II. Schizophrenia, Crow believes that negative symptoms are associated with brain tissue loss and ventricular enlargement, but CT does not provide evidence in this regard, most studies Studies have shown that ventricular enlargement is associated with clinical cognitive function and neuropsychological deficits. Other scholars have sought to find specific cognitive impairments and brain tissue loss. For example, Raine et al. (1992) found that frontal volume was reduced. In the neuropsychological test, the scores of frontal lobe function tests were correlated, and plasma high vanillic acid levels were used as indicators of dopaminergic activity. Breier et al. (1993) found that patients with schizophrenia had abnormally increased dopaminergic activity under drug-induced stress. It is also believed that the magnitude of the dopaminergic response is inversely related to the frontal lobe volume.
The advantage of MRI is that it can distinguish gray matter and white matter, can measure the size of special brain regions, and make the study of brain structural abnormalities in schizophrenia from general structural abnormalities to study specific regions. However, despite schizophrenia There are more possible brain regions, but there are fewer positive regions. The earliest MRI study found that patients with schizophrenia have selective frontal lobe, total brain volume and intracranial volume, suggesting that the above abnormalities are related to imperfect neurodevelopment. Instead of future degenerative changes.
The change of frontal lobe is one of the focuses of many studies. Because the prefrontal lobe performs more cortical function, these functions are obviously damaged in schizophrenia patients, including executive function, abstract thinking and working memory ability. There have been many studies in this area. In recent years, studies have found that there are atrophy of frontal lobe in chronic and first-episode patients, as well as thalamic, amygdala, hippocampus, basal ganglia and temporal lobe atrophy, in which the volume of the upper iliac crest is reduced and auditory hallucinations Related, Andreasen is the first to use MRI to study and report the reduction of frontal lobe. Many studies have confirmed this. For example, the results of the prefrontal cortex suggest that the area of the dorsolateral cortex of the prefrontal cortex is negative. Related, domestic researchers in the study of 38 cases of schizophrenia and 34 cases of control group MRI found that Hastelloy value of schizophrenia, lateral ventricle body index, third ventricle, left frontal sulcus, corpus callosum The anteroposterior diameter and area were significantly different from the control group, suggesting that there is lateral ventricle in schizophrenia, especially the lateral anterior horn and third ventricle, left frontal lobe The expansion of the sulcus and the reduction of the corpus callosum once again indicate the significance of changes in the structure of the frontal lobe in schizophrenia. The study also found that the anterior horn of the lateral ventricle, the third ventricle and the left frontal lobe in patients with type II schizophrenia In patients with sulcus larger than type I, the anteroposterior diameter and area of the corpus callosum are smaller than type I, indicating that the negative symptoms are related to brain atrophy. There is no difference in brain structure abnormalities between patients <30 years old and those >30 years old, suggesting early years Neurodevelopmental disorders may be responsible for abnormal brains and subsequent schizophrenia.
The temporal lobe-edge system has an unusual significance for mental activity. A large number of studies have confirmed that this part of schizophrenia patients also has atrophy, and the volume is reduced by about 8%, which is more obvious on the left side. In addition, the change of the upper back It is closely related to positive symptoms such as auditory hallucinations and thinking disorders, and it is worthy of further study.
2, functional image
The SPECT study found that cerebral blood flow in patients with schizophrenia changes stepwise from front to back. The most serious damage occurs in the frontal lobe, the left side is heavier than the right side, and the blood of almost every region of interest and any other region of interest. There is a significant correlation between flow perfusion, and there is only a correlation between specific regions in normal people. This result suggests that the interaction between various regions of the brain varies between schizophrenia and normal people. As a signal for cerebral neurological changes and disorders in schizophrenia.
Compared with cerebral blood perfusion in patients with schizophrenia at rest and activation, it was found that at rest, the blood flow in the dorsal prefrontal cortex was significantly reduced. In the activated state, the blood flow perfusion in the normal person increased. The patient did not increase, and the schizophrenic patients who had not been treated with the drug had a higher prefrontal perfusion than the normal person at rest; in the activated state, the perfusion of the part would not increase, while the normal person would increase significantly, suggesting the spirit. Patients with schizophrenia have prefrontal dysfunction at the time of onset, consistent with findings from structural imaging.
Domestic researchers have suggested that the abnormality of cerebral blood perfusion in schizophrenia is mainly in the frontal lobe, and coincides with the abnormality of the visual evoked potential P300 amplitude. Therefore, it can be considered that schizophrenia has abnormality in frontal lobe integration, which is closely related to its negative symptoms. The SPECT examination before and after cognitive activation was performed on the first-episode schizophrenia patients, and the changes of SPECT images before and after activation were compared. The result was that the patients in the resting state had perfusion changes of temporal and frontal lobe compared with normal people; The amount of patients with negative symptoms was not significantly increased, but the blood flow perfusion of the patients with positive symptoms was significantly higher than that of negative symptoms. The lighter the symptoms, the more obvious the increase.
The characteristics of late-onset and early-onset schizophrenia are different. The former manifests as a decrease in bilateral frontal and temporal lobes, a decrease in the perfusion ratio between the left hemisphere and the right hemisphere, and a decrease in perfusion of the left temporal lobe. The most sensitive of the control group, the latter also showed low perfusion of the frontal lobe, the left amount was more obvious, but the blood flow perfusion of the temporal lobe was not obvious.
The study of cerebral blood perfusion characteristics of various symptom groups of schizophrenia showed that the thinking form disorder and exaggerated delusion were positively correlated with bilateral frontal and temporal sacral perfusion; delusional concept, hallucinatory behavior and suspicion and bilateral frontal lobe, cingulate gyrus, There was a negative correlation between left temporal lobe and left thalamic perfusion; negative thinking was negatively correlated with left frontal lobe, left temporal lobe and left parietal perfusion. After drug treatment and clinical symptoms improved, residual positive symptoms and brain local blood There was no correlation between flow perfusion, and negative symptoms were inversely correlated with bilateral frontal lobe, temporal lobe, cingulate gyrus, basal ganglia and hindbrain perfusion.
SPECT technology is used as a means to study the mechanism of action of drugs. The research in this area mainly includes the effects of antipsychotics on regional cerebral blood perfusion and its relationship with clinical efficacy, as well as changes in receptor binding rate at specific sites before and after drug treatment. The results of studies on perfusion are not consistent, suggesting that antipsychotic effects act on specific receptors and neurotransmitters to some extent, rather than by altering the effects of regional cerebral perfusion, neurotransmitter studies have found that The D2 receptor density index of patients with schizophrenia is higher than that of normal people, and the variation is larger. The ligand binding rate of patients taking drugs decreases, indicating that the D2 receptor occupancy rate is increased. The striatum D2 is taken by typical antipsychotics. The body occupation rate is higher than that of those who do not take drugs or take atypical antipsychotics. The incidence of extrapyramidal adverse reactions is also high. There is no difference in D2 receptor utilization between patients and healthy people in the basic state. D2 of patients after amphetamine is used. Receptor utilization is significantly reduced, and excessive dopamine release is associated with aggravation of certain symptoms in patients, schizophrenic patients who have never used medication, medication 3 After the day, the change of the ratio of ligand binding rate between the basal ganglia and the frontal lobe was significantly correlated with the efficacy and extrapyramidal adverse reactions: the curative effect was good, the ratio of patients with small adverse reactions decreased, and the ratio of patients with poor efficacy and large adverse reactions increased. It is suggested that antipsychotics can cause up-regulation of D2 receptors in the basal ganglia of the latter type of patients.
PET can more clearly observe the activation status of the brain under different stimuli, the activation of the brain by certain drugs, the receptor occupancy rate of the specific central part, the dynamic changes of various related parts, and the blood concentration and clinical efficacy of the drug. Relationships, etc., PET receptor studies have shown that 5HT2 receptors in schizophrenia patients are not reduced, patients with extrapyramidal adverse reactions are associated with D2 receptor occupancy, the latter is dose-dependent, and with patients Age related.
The fMRI study of schizophrenia is often associated with cognitive deficit symptom studies. Cognitive function studies have found that cognitive deficit symptoms in patients with schizophrenia involve multiple areas, such as memory, attention, executive function, and integration. Scholars have used different fMRI cognitive research models for these different cognitive deficits. Among them, memory (especially working memory) has the most fMRI studies, and fMRI findings of working memory in patients with schizophrenia are inconsistent. More studies support schizophrenia. Patients (including high-risk offspring) have low activation of the dorsolateral dorsolateral (DLFC) and posterior lobes, but there are some opposite conclusions that lead to increased frontal lobe activation. In addition, Fletcher et al. found that with verbal working memory capacity Increased, DLFC activation increased in the control group, while activation of the above-mentioned parts of schizophrenia patients decreased with increasing capacity; Stevens et al and Barch found that speech working memory is more obvious than non-verbal working memory activation, possibly The defects that reflect the verbal working memory of patients with schizophrenia are more obvious. As for the treatment before treatment There are very few fMRI studies. Wexler et al. used a series of word position memory tests to study the effects of cognitive training on cognitive function. Eight patients with stable disease received a 10-week memory training and found that patients with schizophrenia after cognitive training left. The activation of the lateral forearm was significantly stronger than that before training; Wykes et al. used the reciprocal n test (n=2) to study the changes before and after cognitive therapy in patients with schizophrenia, and found that patients with schizophrenia after cognitive therapy were related to working memory. The activation of brain regions (especially frontal lobe) was significantly increased. Domestic Liu Dengtang and Jiang Kaida also used fMRI to study patients with first-episode schizophrenia. The digital homework test was used as the stimulation mode, and the digital homework test was mainly used to measure the subjects. The maintenance of linguistic material information, with selective attention and executive control of cognitive component participation, the study found that the left DLFC (mainly the left frontal gyrus) of the first schizophrenia patient before treatment, the left frontal lobe The activation of the lateral (VLFC) and the posterior lower part of the left parietal lobe (the upper left lobule and the left rim of the left side) is low, which is basically consistent with the above known findings. It shows that patients with schizophrenia have defects in working memory (mainly verbal working memory) at the early stage of the disease. After treatment with risperidone or chlorpromazine for 2 months, fMRI was reviewed and risperidone treatment was found. The activation of the left upper frontal and left lower frontal gyrus was significantly improved. After chlorpromazine treatment, the left upper frontal and left lower frontal gyrus of schizophrenia patients also improved, and risperidone There were no significant differences in the changes of brain regions between the group and the chlorpromazine group before and after treatment. Further analysis of the causes may be related to the first schizophrenia with positive symptoms in the study. The positive symptoms of the patients were significantly improved, and the symptoms of cognitive impairment associated with positive symptoms were also improved. If further follow-up, there may be differences between the two groups.
(1) Research on resting state of the brain: The study of brain function in resting state of patients with certain diseases is often the beginning of imaging studies of such diseases, and the results of the research are mostly used as baseline data. Used to compare results with other non-resting states.
There was no difference in the regional cerebral blood flow between the schizophrenia patients and the healthy control group at rest. The difference was that the frontal lobe did not increase in activity relative to the posterior brain region, but this characteristic was more obvious in the healthy control group. Especially in the prefrontal cortex area, although some studies do not support this conclusion, the proposed "low frontal function" of schizophrenia has become the classic theory of schizophrenia so far. Since then, the same results have been found using SPECT and PET techniques, particularly in the prefrontal and left frontal cortex, and another important finding for resting studies in patients with schizophrenia is an increase in basal ganglia activity, which appears to be The follow-up findings after antipsychotic treatment were consistent with the increase in the activity of the putamen after a single dose of antipsychotic drugs in the healthy control group.
The biggest problem encountered in the interpretation of the above results is that it is difficult to determine the cognitive activity of the subject under the so-called "resting state", because in the "resting state", the patient still has emotional and cognitive activity Different from person to person, this difference causes different functional states in the corresponding brain regions. The researchers have even confirmed different "resting states" (closed eyes, thunder, closed eyes and ears), healthy people will show Different brain functional states, they therefore think that "resting state" is an inappropriate name, however, the study of "resting state" provides a basis for partial mental disorders of mental disorders, which is to further study these The nature of the disease provides a baseline for comparison, and how to make the resting state a true rest is already a new direction of exploration in the field.
(2) Research on brain function under cognitive activation: Using cognitive activation tasks to measure the brain function status of subjects when completing tasks is one of the most used imaging methods in mental disease research, which is online. Assessment of brain function provides a pathway for studying cognitive function in schizophrenia using cognitive tasks that activate the prefrontal cortex. These cognitive tasks include continuous work tests, Wisconsin card classification tests, and Raven's progressive model tests. And working memory tests, etc., the level of prefrontal activation is lower in patients with schizophrenia than in the control group. Because of the low level of behavioral responses and response levels in patients with schizophrenia, problems with such studies Yes, it is not certain whether the subject is being "online" or "immediately imaged" while performing cognitive tasks, and it is not possible to determine that low levels of prefrontal activation are the cause of schizophrenia response and low response levels. Still the result, in order to answer the latter question, the researchers designed such a scheme, that is, Patients with Huntington's disease (HD) with low response and response patterns similar to those with schizophrenia undergo a Wisconsin card classification test, but HD patients do not exhibit low levels of frontal activation, which at least to some extent indicate that low amounts cannot be Leaf activation levels are simply attributed to low response levels.
The H215O PET technique was used to examine the blood flow of the prefrontal cortex when completing a multi-level memory task. When the task was to recall a few words, the patient completed the task and the activation of the prefrontal cortex were similar to the control group. When the number of words requiring recall increases, the patient's completion of the task becomes worse, and the clinical manifestation and the patient's prefrontal blood flow cannot be increased correspondingly with the increase of the cognitive task load, suggesting that the patient's prefrontal lobe is cognizant. The decline in responsiveness of a task may only appear when the patient is unable to complete the cognitive task.
In addition, the abnormality of prefrontal activation in patients with schizophrenia presents different conditions due to the different characteristics of cognitive activation tasks used. For example, patients exhibit low pre-frontal activation levels when completing fluency tasks, and complete semantic tasks. This phenomenon does not occur at the time, although both tasks are subject to word processing tasks and are related to prefrontal activation, the former requires vocabulary based on prompts, while the latter requires classification of external stimuli, so it is speculated The low activation level of the prefrontal lobe in patients with schizophrenia is associated with a defect in its endogenous synthetic ability.
(3) Research on mental symptoms:
1 Study on the relationship between symptom group and local brain function: There are 3 groups of characteristic clinical symptoms in patients with schizophrenia, namely negative symptoms, thinking disorders and positive symptoms (ie hallucinations and delusions), with PET A method for examining regional cerebral blood flow was found to have a negative correlation with negative prefrontal blood flow; thought disorder was associated with cingulate gyrus function; and hallucinations and delusions were associated with blood flow in the central cortex of the temporal lobe.
If the symptoms of depression were divided into 3 groups, the same method was used to study depression, and the anxiety symptoms were positively correlated with the blood flow in the posterior and parietal cortex of the cingulate gyrus; psychomotor retardation and Depression was negatively correlated with blood flow in the left frontal prefrontal and parietal cortex; cognitive function was positively correlated with cortical blood flow in the left prefrontal cortex. In addition, it was found that both single-phase and bipolar depression, patient's abdomen The lateral cortical area has a functional abnormal decline with respect to the corpus callosum; while in the biphasic mania, the function of this part is increased. This phenomenon suggests that the functional status of the area may be emotionally state-dependent, that is, with the emotional state. Change and change.
2 Immediate brain function study at the onset of symptoms: Some researchers believe that patients with a diagnosis of the same disease with a certain symptom at the time and without symptoms of the brain function is a more direct way to reveal the symptoms, they compared The brain function of patients with schizophrenia with auditory hallucinations and those without auditory hallucinations found that patients with auditory hallucinations had relatively lower levels of metabolism in the lateral part of the temporal lobe, while those in the lower right frontal lobe were relatively more metabolically Gao, another study compared the brain function of the same group of patients in the presence of rich auditory hallucinations and the relief of auditory hallucinations. For patients with auditory hallucinations, they were required to move their fingers while hearing auditory hallucinations, and the testers saw them. At the time of finger movement, brain function imaging was performed. It was found that the local blood flow in the left lower frontal area of the patient with auditory hallucinations was higher than that in the patients without auditory hallucinations. The blood flow in the left anterior cingulate gyrus and temporal lobe cortex was also relative. Higher, when other researchers repeated the above test, the requirement to move the finger was changed to the button, and the results suggest the function of auditory hallucinations and striatum, the central cortex of the thalamus and temporal lobe. turn off.
These trials all aim to "capture" brain function changes at the time of the onset of symptoms, but there is a deficiency that mental symptoms are often a subjective experience, and the quality of the test data will ultimately depend on the credibility of the patient's reported symptoms. Faithfulness, and the process of marking symptoms, such as moving a finger or a button, may also affect the functional state of the brain.
A cross-sectional study of psychiatric symptoms refers to the study of the same type of symptoms that occur in different diseases. This method is especially applicable to psychiatric subjects because, for example, delusions, depression and hallucinations often occur in different mental illnesses, a series of studies The association between depression and neuroimaging function secondary to HD and Parkinson's disease (PD) was compared. Some results suggest that bilateral ankle, prefrontal and anterior temporal cortex are low-metabolism in both groups; There are also some studies supporting PD patients with depressive symptoms showing low metabolic levels in the bilateral frontal lobes and anterior cingulate cortex. Although the results are different, they all suggest that the depressive symptoms themselves may be independent of the disease they are associated with. The frontal lobe, temporal cortex, and striatum neural pathways are functionally related, and functional deficits in this neural pathway may lead to primary depression, or other diseases associated with the basal ganglia, and, in addition, poor mental activity A comparative study of schizophrenia and depression with psychomotor retardation revealed a decrease in the function of these symptoms and the left frontal prefrontal cortex (DLPFC). Related to, regardless of the disease associated with it, from the above studies, there are certain specific structural regions or neural pathways in the brain. Some mental symptoms may be related to the function of these parts, and what kind of symptoms occur. Mental illness has nothing to do.
3. Research on neurotransmitter theory of schizophrenia by neuroreceptor imaging technique
Schizophrenia is one of the most complete neurotransmitter theories in many mental disorders. It mainly involves two major transmitter systems, dopamine and 5-HT. The focus of molecular imaging studies on this aspect is also concentrated in this study. The main design patterns can be divided into two categories: one is called clinical research, which aims to understand the neurochemical abnormalities of mental diseases such as neurotransmitters and receptors, and to further understand the pathophysiological mechanisms of diseases; the other is Receptor occupancy studies are used to better understand the mechanisms and pathways of action of drugs.
The central dopamine receptors are mainly located in the cortex and striatum. Due to the late development and development of radioligands suitable for cortisol dopamine receptors, there are many studies on striatum dopamine receptors. Clinical studies have confirmed that the spirit The striatum has a higher density of dopamine D2 receptors in the striatum than in the normal control group. Amphetamine is used to stimulate the release of dopamine. The peak of release is clearly related to the transient psychiatric symptoms caused by amphetamine. The phenomenon has nothing to do with whether the patient has used antipsychotics in the past; moreover, the above phenomenon occurs only when the patient's disease is aggravated, and disappears after the symptoms are relieved. The most common explanation for this phenomenon is that the patient's dopamine release is caused by amphetamine stimulation. In addition, another explanation is the increased affinity of the patient's D2 receptor for dopamine.
The defect in the amphetamine stimulation test is that the change in dopamine in the synaptic cleft is due to non-physiological stimuli, and the trial fails to provide data on the baseline concentration of dopamine in the synaptic cleft, using A-methyl-terptyrosine (AMPT). To inhibit dopamine synthesis and to assess the baseline level of dopamine inhibition in the presynaptic gap and its binding to the postsynaptic D2 receptor by an increase in the binding rate of the ligand to the postsynaptic D2 receptor due to the above ligands The increased rate of binding to the postsynaptic D2 receptor occurs only in in vivo assays and does not occur in in vitro assays, suggesting that this phenomenon is not related to receptor upregulation, but rather due to endogenous dopamine depletion and originally bound by dopamine. The D2 receptor is re-dissociated. It is confirmed by the above test that the rate of D2 receptor binding to dopamine is higher in patients with schizophrenia than in healthy controls, which is related to the high dopamine level in patients with synaptic cleft. Consistent.
In addition, studies of dopa decarboxylase and dopamine transporters using specific radiolabeled ligands have also confirmed increased dopamine levels in patients with schizophrenia.
The current "receptor occupancy study" is mainly used for the study of the mechanism of action of drugs on drugs and the comparison of classic and non-classical antipsychotic drugs. The D2 receptor occupancy rate of classical antipsychotic drugs is 70% to 89%. The clozapine occupancy rate is 28% to 63%, even if the former dose is added to the upper limit of the clinical use dose, the latter uses the lower limit of the clinical use dose, and their respective receptor occupancy rates remain in the original range. Internally, it suggests that the D2 receptor occupancy rate is not related to the drug dose, but an indicator of drug properties, which can be used to distinguish between classic and non-classical antipsychotics. However, for two types of non-classical antipsychotics, risperidone and olanzapine. The findings do not support this claim because both D2 receptor occupancy rates increase with increasing dose.
There is no major breakthrough in the clinical study of 5-HT because of its high non-specific binding rate, low labeling/interference rate, difficulty in measuring free radicals in plasma, low clearance rate in the brain, and receptor occupancy. The results indicate that the antagonism of 5-HT2A receptor is a feature of non-classical antipsychotic drugs that is different from classical antipsychotic drugs. However, the improvement of clinical symptoms caused by 5-HT2A receptor blockade is still the direction of future research.
4. Changes in brain evoked potentials in schizophrenia
(1) P300: Foreign studies on schizophrenia P300 have the following findings:
1 volatility decline, schizophrenia P300 amplitude is significantly reduced, may be the obstacles to the active processing of information and the results of passive attention to the defect, recent research found that the high-risk children with schizophrenia P300 amplitude reduction, that P300 can be used as a pre-onset Forecast indicator
2 The incubation period is prolonged, and the P300 latency of patients with schizophrenia is prolonged by more than 2 standard deviations in 20% to 30% of schizophrenia; and the P300 latency of children at high risk of schizophrenia is significantly shortened;
3P300 is distributed in different brain regions, and P300 in patients with schizophrenia is deficient in the left middle and posterior temporal region of the scalp.
Olichney (1998) reported the relationship between P300 amplitude and senile schizophrenia with a late onset of age, and found that the amplitude of auditory P300 was lower in schizophrenia patients with earlier onset age, but not in older schizophrenia with a later onset age. With similar changes, the study found that there was no difference in the amplitude of N100 and N200 in auditory P300 between schizophrenia patients with early onset age and late onset age; P300 amplitudes in patients with early onset of schizophrenia were higher than normal. The violent decline in the schizophrenia patients with late onset of age was mostly within the normal range, indicating that patients with earlier onset schizophrenia had more serious information processing defects.
Weir (1998) described the P300 latency and topographic map distribution of schizophrenia and depression. According to the DSM-III-R diagnostic criteria, 19 patients with right-handed positive schizophrenia and 14 patients with right-handed depression were tested. P300 topographic map of the patient and 31 normal people found that the left central region of patients with schizophrenia was significantly deficient, while the depression of the right side of the P300 topographic map was defective. The latency of schizophrenia patients was 22 ms longer than that of normal people. There was a significant difference in the analysis of the study; the latency of depression was 10 ms longer than that of the normal person, and there was no significant difference in statistical analysis.
Buchsbaum et al. believe that the increase or decrease of N100 amplitude reflects the degree of opening and closing of the "valve structure" that regulates the sensory afferent pathway of the cerebral cortex. The amplitude of N100 increases with the increase of light stimulation intensity, and the N100 amplitude is not only stimulated. In addition to the influence of personality factors, they also found that the spirometry patients with P300 N100 ~ P200 amplitude decreased; chronic schizophrenia N100 amplitude changes and acute schizophrenia, the former increased, while the latter decreased, N100 was It is considered to be related to selective attention.
The decline in P3 amplitude of schizophrenia P300 is consistent with the findings of domestic and international research reports. The decrease of target P3 amplitude in P300 may be one of the attributes of schizophrenia, because this variation can be seen in patients in remission and some high-risk groups.
(2) CNV: Ruiloba found that CNV in patients with schizophrenia has the following changes:
1 The basic waveform has large variation and no regularity;
2 The highest peak potential decreased, the average amplitude decreased, and patients with mental symptoms such as auditory hallucinations, depression, delusions, etc., the CNV amplitude was lower;
3CNV extended time;
4 The error of the operation reaction test is increased; E. The time course (PINV) of the negative change after the stimulation is extended.
5, problems in imaging studies of schizophrenia, whether it is structural or functional imaging studies, there is such a problem that the lack of attention to the heterogeneity of schizophrenia, positive and negative, with Cognitive and non-cognitive deficits are subtypes that are already known, but there must be subtypes that are unknown, so any study should first determine the subtype to be studied in order to purify the sample. A reliable conclusion is obtained. In addition, the functional and structural defects of the frontal lobe are the most noteworthy imaging findings of schizophrenia, but this seems to be more closely related to negative symptoms. As for the positive symptoms, is there any part corresponding to it? Is the frontal problem a characteristic or stateful indicator of schizophrenia? These questions can be understood after studying the brain condition of the patient before and after the disappearance of the symptoms, but at least the current answer is still unknown.
In short, the relationship between different subtypes or symptom groups of schizophrenia and rCBF in different regions of the brain is complicated. Because different researchers use different research methods, the results are different, and it is necessary to use uniform standards and methods for research. In order to clarify the relationship between subtypes of schizophrenia or changes in psychopathological symptoms and changes in imaging indicators.
Diagnosis
Diagnosis of intermittent psychosis
According to the clinical manifestations of the medical history and laboratory tests can be diagnosed.
