认知矫正治疗对慢性精神分裂症患者临床症状和社会功能的影响

Effects of cognitive remediation therapy on improving clinical symptoms and social functions in patients with chronic schizophrenia

目的:观察认知矫正治疗对慢性精神分裂症患者临床症状和社会功能的改善作用。方法:选择2003-01/08在北京回龙观医院住院的慢性精神分裂症患者104例。均符合CCMD-Ⅲ及DSM-Ⅳ关于精神分裂症诊断标准;年龄25～55岁;病程≥2年;病情稳定,处于迁延、残留或部分缓解状态;药物治疗状况稳定,近期无换药打算;纳入对象或家属同意入组并签署知情同意书。应用随机数字表法将患者分认知矫正治疗组和对照组,每组52例。在相近药物治疗的基础上,认知矫正治疗组以Ann Delahunty和Rodney Morice等制定的神经认知矫正手册(汉化)为治疗工具,在治疗师的指导下进行认知作业练习,内容包括认知灵活性、工作记忆、计划执行功能3大功能模块。对照组予以相同时间的工娱治疗,主要包括有治疗师指导的操作性音乐治疗和舞蹈治疗。治疗前后两组患者分别进行PANSS、住院精神患者社会功能缺陷量表和护士观察量表的评定。结果:实验共纳入慢性精神分裂症患者104例,认知矫正治疗组44例,对照组46例进入结果分析,14例脱落。①治疗前后两组患者PANSS量表总分以及阴性症状量表、复合量表、一般精神病理量表、反应缺乏量表4个分量表的评分均有下降,组内比较差异有显著性意义(t=2.12～4.59,P<0.05);减分情况在两组间差异不明显(P>0.05)。②两组患者的社会功能缺陷量表总分在治疗后均有下降,与治疗前比较,差异有显著性意义(t=3.89,2.04,P<0.05);两组间比较,差异无显著性意义(P>0.05)。认知矫正治疗组治疗后护士观察量表的总病情以及总消极、迟滞2个分量表评分下降,与治疗前比较差异有显著性意义(t=1.49,1.19,2.81,P<0.05);其中迟滞项的减分在两组间比较,差异具有显著性意义(F=4.97,P<0.05)。③社会功能量表的改善与词语流畅性的改善呈正相关(R2=0.36,P<0.05),护士观察量表中总病情与积极两项评分的改善也与言语流畅性测验的改善正相关(R2=0.37,0.34,P<0.05)。结论:认知矫正治疗能在一定程度上改善精神分裂症患者的社会功能,并与部分认知功能的改善相关,但对临床症状无明显改善作用。

AIM： To explore the efficiency of cognitive remediation therapy （CRT） on improving the clinical symptoms and social functions in patients with chronic schizophrenia. METHODS： A total of 104 chronic schizophrenic inpatients with stable clinical state were recruited from Beijing Huilongguan Hospital from January to August in 2003. They, aged 25-55 years, all accorded with the diagnosis standard of schizophrenic by CCMD-Ⅲ and DSM-Ⅳ. Their course of disease was more than 2 years at protraction, residue or partial remission. The curative effect of drug treatment was stable and unvaried, informed consents were obtained from the subjects or their relatives. All the patients were divided into CRT group and control group at random （n =52）, and were pretreated with antipsychotic agent therapy. CRT manual （Chinese version） derived from Neurocognitive Remediation Manual 2000 designed by Ann Delahunty and Rodney Morice et al, which included three models of cognitive flexibility, working memory and planning execution. In control group, the subjects received occupation recreational therapy of operatic music therapy and dancing therapy instructed by therapists. Pre- and post-treatment, positive and negative syndrome scale （PANSS）, social functional disability scale for psychiatnc inpatients, and nurse observation scale for inpatient evaluation （NOSIE） were administered to all subjects. RESULTS： Totally 104 chronic schizophrenia patients were involved in the study, and 44 ones in CRT group and 46 one in control group entered the result analysis, except 14 lost. （1）A significant decrease occurred in PANSS total score, negative symptom score, compound scale score, general psychopathology score and reaction retardation score in both groups （t =2.12-4.59, P 〈 0.05）. But there was no significant difference in these decreases between two groups （P 〉 0.05）. （2）The total score of social functional disability scale for psychiatric inpatients was significantly declined in both groups after treatment （t =3.89, 2.04, P 〈 0.05）, and no significant difference appeared between two groups （P 〉 0.05）. NOSIE general illness score, general negative score, and retardation score all decreased significantly after treatment in CRT group （t =1.49, 1.19, 2.81, P 〈 0.05）, with retardation score decreased significantly between two groups （F=4.97, P 〈 0.05）. （3）There was a positive correlation between social functional improvement and verbal fluency improvement （R^2 =0.36, P 〈 0.05）. Another positive correlation occurred between two NOSIE subscales （general illness and positive score） and verbal fluency （R ^2=0.37, 0.34, P 〈 0.05）. CONCLUSION： CRT can improve the social function of patients with schizophrenia moderately, and is correlated with some cognitive function enhancements. There is no obvious prompting effect of CRT on clinical symptoms.