会话分析在鉴别诊断痫性发作与心因性非痫性发作中的作用

目的明确会话分析能否用于汉语患者中痫性发作与心因性非痫性发作的鉴别诊断。方法对2014—2016年就诊于北京协和医院的12例日常使用汉语并疑诊痫性发作或心因性非痫性发作的患者，采用标准化开放性提问流程进行访谈，由语言学家和神经内科医生使用英语、德语患者中总结的17项互动、话题和语言学特征评分表，分别对患者作出诊断，并与最终临床诊断进行对比。结果语言学家和神经内科医生仅依据会话特征，均有10/12患者诊断正确。痫性发作患者的会话特征平均得分为8.00分（语言学家）和6.75分（神经内科医生），心因性非痫性发作患者平均得分则为－5.75分（语言学家）和－7.88分（神经内科医生）。2名研究者单项评分的一致性较高（一致项目占81.86%，167/204）。并以1例额叶癫痫患者与1例心因性非痫性发作患者为例，对比了两组患者的会话特征。结论会话分析可作为汉语患者中鉴别痫性发作与心因性非痫性发作的一种方法。

Psychogenic non‑epileptic seizures (PNES)in the context of concurrent epilepsy-making the right diagnosis

Epilepsy is a risk factor for the development of psychogenic non-epileptic seizures(PNES)and comorbid epilepsy is recognized as a comorbidity in about 10–30%of patients with PNES.The combination of epileptic and nonepileptic seizures poses a particular diagnostic challenge.In patients with epilepsy,additional PNES may be suspected on the basis of their typical semiology.The possibility of additional PNES should also be considered if seizures fail to respond to antiepileptic drug treatment,in patients with frequent emergency admissions with seizures and in those who develop new types of seizures.The description of semiological details by patients and witnesses can suggest additional PNES.Home video recordings can support an initial diagnosis,however,especially in patients with mixed seizure disorders it is advisable to seek further diagnostic confirmation by capturing all habitual seizure types with video-EEG.The clinical features of PNES associated with epilepsy are similar to those in isolated PNES disorders and include longer duration,fluctuating course,asynchronous movements,pelvic thrusting,side-to-side head or body movement,persistently closed eyes and mouth,ictal crying,recall of ictal experiences and absence of postictal confusion.PNES can also present as syncope-like episodes with unresponsiveness and reduced muscle tone.There is no unique epileptological or brain pathology profile putting patients with epilepsy at risk of additional PNES.However,patients with epilepsy and PNES typically have lower educational achievements and higher levels of psychiatric comorbidities than patients with epilepsy alone.Psychological trauma,including sexual abuse,appears to be a less relevant aetiological factor in patients with mixed seizure disorders than those with isolated PNES,and the gender imbalance(i.e.the greater prevalence in women)is less marked in patients with PNES and additional epilepsy than those with PNES alone.PNES sometimes develop after epilepsy surgery.A diagnosis of‘known epilepsy’should never be accepted without(at least brief)critical review.This narrative review summarises clinical,electrophysiological and historical features that can help identify patients with epilepsy and additional PNES.

医疗人员对心因性非痫性发作的观点研究:基于定性与定量研究的系统回顾

近期一篇关于心因性非痫性发作(Psychogenic nonepileptic seizures,PNES)的系统分析表明,该类患者总是会有不愉快的就医经历,因此详细了解其中相互关系至关重要。文章旨在探究医疗人员对PNES的态度与看法。系统性检索截至到2017年11月前发表在3个主要数据库的文章(Web of Science、PubMed、CINAHL),并回顾1997年以后发表的定性或定量的方法学研究。基于扎根理论来解释数据,使用Mixed Methods Appraisal Tool进行质量评价。总共30篇独立文章,其中包含了至少3 900名专业人员的观点。在分析中出现了5个解释性概念:①不确定性,医疗人员表示他们对PNES的许多方面都感到不确定,包括诊断和治疗;②理解,医疗人员对PNES的理解是基于二元论,他们认为PNES与心理精神因素的关系极大;③挫折感与挑战性,对PNES患者的诊断治疗被认为是有挑战性的,并令人感到沮丧的;④责任,医疗人员对于"谁应该为PNES患者的治疗负责"是有争论的;⑤预后与残疾,与癫痫相比,医疗人员普遍认为PNES症状相对较轻,致残率也没有癫痫高,并且与自身的自制力有关。尽管有一些医师对PNES有较深刻的理解,但是仍有一部分医师的观点需要更新和提高。有一部分研究在调查中是直接询问医师"对PNES疾病的观点",这样的研究存在局限性。此外,有一些学科专业的医师并没有被研究调查(如精神健康专业医师)。研究还表明,对医师们进行PNES额外教学训练是有必要的,但同时也需要改变医师们对PNES的态度。