对4734例精神分裂症患者的中医证候分布规律的多中心研究

Distribution rule of traditional Chinese medicine patterns in 4734 schizophrenia patients:a multicenter study

目的采取大样本、多中心的横断面研究方法,探讨精神分裂症患者的中医证候分布规律。方法2020年5月—2021年4月,在北京市12个分中心(北京中医药大学第三附属医院、北京市朝阳区第三医院、首都医科大学附属北京安定医院、北京回龙观医院、北京市大兴区心康医院、北京市昌平区中西医结合医院、北京市石景山区精神卫生保健所、清华大学垂杨柳医院、北京市延庆区精神病医院、北京市平谷区精神病医院、中国中医科学院广安门医院、北京中医药大学东直门医院)招募精神分裂症患者。共纳入精神分裂症患者4734例,男性2529例,女性2205例,平均年龄50.81岁。通过中医证候学量表、阳性和阴性精神症状评定量表、四诊资料,评价患者精神状态并记录症状,填写《精神分裂症中医证候观察表》。构建症状关系网络图,从中提取证候靶位及证候要素。然后将证候靶位和证候要素应证组合,形成基础证。分别通过关联规则、贝叶斯网络、聚类分析对基础证进行证候提取,最后汇总3种方法得出的证候类型,结合中医理论和专家组意见,同类合并,提取共同的证候。结果运用关联规则构建了162项症状之间的关系网络图,提取了16个基础证。关联规则提取了痰火扰神、心肝火旺、气滞血瘀、阴虚火旺、肾虚肝郁、痰蒙神窍、脾肾阳虚、心脾两虚、痰气郁结9个证候,聚类分析提取了心肝火旺、痰火伤阴、气滞血瘀、阴亏血少、脾肾阳虚、痰湿内阻、心脾两虚、肾气亏虚、胆气亏虚9个证候,贝叶斯网络提取了痰火扰神、心肝火旺、阴虚火旺、气滞血瘀、瘀热互结、肾虚肝郁、痰蒙神窍、脾肾两虚、心脾两虚、心肾不交和肝肾亏虚11个证候。经过汇总,提取了3种方法重合的痰火扰神、心肝火旺、气滞血瘀、阴虚火旺、痰蒙神窍、心脾两虚、脾肾阳虚和肾虚肝郁8个证候类型。精神分裂症的临床症状包括阴性症状(2893例,占61.11%)和阳性症状(1841例,占38.89%),前者属中医学“癫证”范畴,证候为脾肾阳虚(22.94%)、痰蒙神窍(17.79%)、心脾两虚(13.98%)、肾虚肝郁(6.40%);后者属中医学“狂证”范畴,证候为痰火扰神(12.63%)、气滞血瘀(11.03%)、阴虚火旺(10.25%)、心肝火旺(4.99%)。结论本研究探索了精神分裂症的中医证候规律,总结了常见的8个证候类型,为中医药论治精神分裂症提供了辨证基础。

Objective We aimed to find the distribution rule of traditional Chinese medicine(TCM)patterns of schizophrenia patients from the result of a large⁃sample,multicenter,cross⁃sectional study.Methods From May 2020 to April 2021,we recruited schizophrenic patients in the following 12 sub⁃centers in Beijing:The Third Affiliated Hospital of Beijing University of Traditional Chinese Medicine,The Third Hospital of Chaoyang District,Beijing Anding Hospital of Capital Medical University,Beijing Huilongguan Hospital,Daxing Xinkang Hospital,Changping Hospital of Integrated Chinese and Western Medicine,Shijingshan Mental Health Care Institute,Chuiyangliu Hospital of Tsinghua University,Yanqing District Psychiatric Hospital,Pinggu District Psychiatric Hospital,Guang'anmen Hospital of China Academy of Chinese Medical Sciences,and Dongzhimen Hospital of Beijing University of Chinese Medicine.In total,4,734 schizophrenic patients(2,529 men and 2,205 women with an average age of 50.81 years)were included,and their mental symptoms were evaluated using the TCM Pattern Scale,Positive and Negative Syndrome Scale,and the four diagnostic method(inspection,listening and smelling,inquiry,and palpation and pulse taking).After finishing the Schizophrenic TCM Pattern Observation Form,the distribution of the patients′TCM patterns was analyzed through the following steps:(Ⅰ)building a network diagram of all symptoms to extract the pattern locations and elements using association rules;(Ⅱ)combining the pattern locations with the pattern elements to form basic pattern,using the method of association rules,and Bayesian network,cluster analysis;and(Ⅲ)summarizing the patterns according to TCM theories and TCM expert consensus,and selecting the same patterns as the patterns of schizophrenia.Results Association rules were used to construct a relationship network diagram of 162 symptoms,and 16 basic TCM pattern were extracted.Among them,(Ⅰ)association rules extracted nine TCM patterns(phlegm⁃fire disturbing mind,hyperactivity of heart⁃liver fire,stagnation of qi and blood stasis,hyperactivity of fire due to yin deficiency,kidney deficiency and liver depression,spirit confused by phlegm,yang deficiency of the spleen and kidney,deficiency of both the heart and spleen,and phlegm⁃qi stagnation with binding);(Ⅱ)cluster analysis extracted nine patterns(hyperactivity of heart⁃liver fire,phlegm fire burning yin,stagnation of qi and blood stasis,yin deficiency and blood insufficiency,yang deficiency of the spleen and kidney,stagnation of phlegm⁃dampness,deficiency of both the heart and spleen,deficiency of kidney qi,and deficiency of bile qi);and(Ⅲ)the Bayesian network extracted 11 patterns(phlegm⁃fire disturbing mind,hyperactivity of heart⁃liver fire,hyperactivity of fire due to yin deficiency,stagnation of qi and blood stasis,intermingled phlegm and heat,kidney deficiency and liver depression,spirit confused by phlegm,deficiency of both the spleen and kidney,deficiency of both the heart and spleen,disharmony between the heart and kidney,and liver⁃kidney deficiency).Finally,eight common patterns were summarized,including phlegm⁃fire disturbing mind,hyperactivity of heart⁃liver fire,stagnation of qi and blood stasis,hyperactivity of fire due to yin deficiency,spirit confused by phlegm,deficiency of both the heart and spleen,yang deficiency of the spleen and kidney,and kidney deficiency and liver depression.The clinical features of schizophrenic patients included negative symptoms(2,893 cases,61.11%)and positive symptoms(1,841 cases,38.89%).The former belongs to the TCM“epilepsy syndrome”category,and the patterns of yang deficiency of the spleen and kidney(22.94%),spirit confused by phlegm(17.79%),deficiency of both the heart and spleen(13.98%),and kidney deficiency and liver depression(6.40%)are involved.The latter belongs to the TCM“manic psychosis syndrome”category,and the patterns of phlegm⁃fire disturbing mind(12.63%),stagnation of qi and blood stasis(11.03%),hyperactivity of fire due to yin deficiency(10.25%),and hyperactivity of heart⁃liver fire(4.99%)are involved.Conclusion This study may provide a reliable basis for forming plans for TCM diagnosis and treatment of schizophrenia,which can be guided by the 8 TCM patterns from 4.734 patients.