精神科身體症狀診斷的心理及心率變異性特徵研究

精神科的身體症狀診斷是一群具有身體症狀表現，同時心理議題亦扮演一定角色的疾患。在不同系統中，本群診斷有不同名稱，包括身體型疾患、身體症狀障礙症(somatic symptom disorder，SSD)等，其亦與非精神科定義的功能性身體症候群(如纖維肌痛症)有所重疊。本類診斷於臨床上並不罕見，惟診治方式存在歧異性；在台灣，「自律神經失調」一詞常用於和民眾溝通，但此一名稱並非當代系統的正式診斷，此類疾患是否具有自律神經活性的生理基礎，亦有待闡明。本系列4類主題13個研究的目標，即是探索台灣身體症狀診斷個案的心理與自律神經活性特徵，以心率變異性(heart rate variability，HRV)做為自律神經活性的評估工具。第一類主題是「應用心理工具於篩檢或診斷本群問題的臨床可行性」。於研究一，幾種量表應用於評估DSM-IV系統、DSM-5系統身體症狀診斷的適用性，被加以評估；診斷分佈狀況亦被檢視。結果顯示，幾種自填量表應用於DSM-5身體症狀及相關障礙症的適用性，都高於DSM-IV身體型疾患。結合病人健康問卷-15、健康焦慮問卷，分別以3/4和16/17為切點，可對SSD做較佳的判斷。在精神科場域，DSM-5的SSD會比DSM-IV的未分化身體型疾患更常見。研究二探討的是SSD嚴重度標註的臨床意義。分析結果指出，不同的嚴重度層級，並非來自生理或精神科共病之干擾。以嚴重度的界面而論，中度-重度的界面會比輕度-中度界面更能反映身體症狀診斷精神病理特徵的差異，也較能反映共存的憂鬱、焦慮程度之差別。研究三是使用心身醫學診斷準則的概念，對SSD加以分群。最終可分為5群，具有較高分群影響力的概念包括煩躁易怒情緒、對健康狀態的焦慮感、士氣低落、A型性格等。其中，以煩躁易怒情緒為特徵的群體，有較為複雜的精神病理，臨床上的共病問題可能需要較高的關注。第二類主題為「本群問題共病憂鬱焦慮與潛在性格特徵的影響」。於研究四，身體型疾患與憂鬱、焦慮的關聯性被加以檢驗。結果顯示，身體型疾患個案與恐慌症個案的憂鬱焦慮程度大致相當。幾種不同的身體型疾患，憂鬱焦慮的程度並無顯著區別。當鬱症、廣泛性焦慮症個案合併身體型疾患時，會比未合併身體型疾患者有更高的焦慮程度。身體型疾患與憂鬱、焦慮程度的高關連性，在校正人口學因子、其他共病的影響後，仍然存在。研究五的目的是比較身體型疾患個案與健康人的性格特徵，並分析一些性格因子與精神病理現象的關聯性。結果為，相較於健康族群，身體型疾患個案有新異追尋偏低、傷害迴避偏高、酬賞依賴偏低的性格特徵，與強迫型人格有最高的相似性。偏高的傷害迴避與持續度和較強的身體不適感受、慮病意念、憂鬱焦慮程度都存在顯著關連。在研究六，SSD個案的生活品質與功能被加以探討。與健康人相比，SSD個案的所有生活品質與功能面向都欠佳。而和較差的生活品質與功能有關的心理因子，最重要的是共存的憂鬱程度，其次為對健康和疾病的認知。此結果支持處理憂鬱共病為提高SSD個案生活品質與功能的重要策略。第三類主題是「坊間常見的HRV量度做法對於診斷/評估SSD是否具有意義」。研究七的主旨在比較SSD個案與健康人的靜息狀態HRV特徵，並分析各種心理現象與靜息狀態HRV的關係。副交感專一的指標高頻功率(high-frequency power，HF)在SSD個案與健康人並未呈現顯著組間差異。若對性別年齡分層，僅有低高頻功率比(ratio of low-frequency power to high-frequency power，LF/HF)在年長女性的組間差異達到顯著。此外，HF在男性個案與憂鬱程度的相關性，更高於其與身體不適症狀的相關性。研究八為統合分析，對於精神科身體症狀診斷、功能性身體症候群個案與健康人的HRV進行比較。若以階序觀點綜合各研究的HRV指標，所有身體症狀診斷、功能性身體症候群個案的靜息狀態HRV，顯著低於健康人；效果量為中等。若區分不同診斷，組間差異的效果量以纖維肌痛症為最大。如考慮不同HRV指標，standard deviation of normal to normal RR intervals (SDNN)最能呈現組間差異。研究九的目的在檢視身體症狀診斷個案的常用藥物是否會影響靜息狀態HRV。抗憂鬱劑、苯二氮平類藥物、常用於鬱症輔助治療的抗精神病藥物quetiapine被納入考慮。結果顯示，所有藥物中僅quetiapine與偏低的HRV有關；此發現在校正人口學因子、心理狀態特徵後仍存在。第四類主題是「如何看待HRV提供的訊息，及使用HRV於評估此群個案應注意哪些事項」。研究十的標的是瞭解SSD個案的HRV反應性特徵。受試者觀看健康焦慮、慢性疼痛、憂鬱、中性主題的圖文故事，過程中量測HRV。結果為，當觀看慢性疼痛主題圖文時，女性SSD個案的HF顯著低於女性健康人；此差異比靜息狀態HRV更明顯。但男性並沒有類似的特徵。在研究十一，SSD和心身醫學診斷準則的持續性的身體化症狀(persistent somatization，PS)與靜息狀態HRV的關係被加以比較。校正可能的干擾因子後，PS與HF、SDNN的關係都達到顯著，但SSD則否。SSD的準則較強調心理建構，PS則重視生理建構，並有自律神經症狀的相關陳述；這可能是造成差異的原因。研究十二是在僅考慮SSD個案的情況下，分析HRV是否有應用於評估此群個案症狀嚴重度與共病的機會。結果顯示，LF在女性個案，有機會對不同SSD嚴重度進行區辨；root mean square of successive differences (RMSSD)則可區分男性SSD個案是否合併臨床上有意義的憂鬱問題。在研究十三探討的是接受各種Stroop tasks的過程中，能否呈現SSD個案與健康人的HRV差異。Stroop tasks可觀察受試者在干擾資訊下的表現，此與SSD的精神病理有類似之處。研究結果為，情緒文字干擾的emotion Stroop，女性SSD個案與健康人的認知測驗表現與過程中的HF都存在顯著差異。這對於和emotion Stroop相關的腦區與自律神經活性的關連，提供了可能的線索。本系列研究顯示了台灣精神科身體症狀診斷的心理與生理特徵，對於臨床評估與治療應有參考價值。若欲在本群個案應用HRV，性別、憂鬱共病、抗精神病藥物、不同的身體症狀診斷、採用靜息狀態HRV或HRV反應性設計、反應性設計的心理刺激內容等，都可能影響量測結果，在臨床與研究上需加以考慮。

關鍵字

精神科身體症狀診斷；身體型疾患；身體症狀障礙症；自律神經系統；心率變異性；憂鬱焦慮共病；性別差異

並列摘要

Somatic symptom diagnoses in psychiatry are disorders with both somatic presentations and psychological features. The terminology of this group of disorders is different in distinct diagnostic systems, such as somatoform disorders, somatic symptom disorder (SSD); they are overlapping with functional somatic syndromes (such as fibromyalgia) in non-psychiatric fields. The somatic symptom diagnoses are common; but the principles of management are quite different in clinical situations. In Taiwan, “autonomic dysfunction” is often used to communicate with the patients; this name is informal, whether the somatic symptom diagnoses have autonomic basis are not clear. The aims of the 13 studies in this series were to investigate the psychological and autonomic features of the somatic symptom diagnoses in Taiwan. Heart rate variability (HRV) was adopted for measuring the autonomic activity. Aim 1 was to examine whether questionnaires could be used for diagnosing somatic symptom diagnoses. Several self-administered questionnaires were more suitable for evaluating DSM-5 somatic symptom diagnoses than DSM-IV ones. Combining Patient Health Questionnaire-15 and Health Anxiety Questionnaire (setting 3/4 and 16/17 as cutoff respectively) provided acceptable estimation to SSD. Aim 2 was to explore the clinical meaning of the “severity” specifier of SSD. The different levels of severity were not biased by psychiatric or physical comorbidities. The moderate-severe interface could reflect more difference of psychopathologies than mild-moderate interface. Aim 3 was to group SSD with Diagnostic Criteria for Psychosomatic Research (DCPR). Five clusters were generated; irritable mood, health anxiety, demoralization, type A behavior were influential for the grouping. The cluster with irritable mood tended to have complicated psychopathologies. Aim 4 was to investigate the association between somatoform disorders and depression/anxiety. The level of depression/anxiety in patients with somatoform disorders and panic disorder were similar. When patients with major depressive disorder and generalized anxiety disorder were comorbid with somatoform disorders, their level of anxiety increased. Aim 5 was to compare personality features in SSD patients and healthy individuals. Comparing with health population, SSD patients revealed lower level of novelty seeking, higher level of harm avoidance, and lower level of reward dependence. Harm avoidance and persistence were positively associated with somatic and emotional psychopathologies. Analyzing quality of life and functioning in SSD patients was aim 6. SSD patients showed poorer quality of life and functioning than healthy individuals in all domains. Comorbid depression was a key factor affecting the quality of life and functioning in SSD patients. Aim 7 was to investigate resting state HRV in SSD patients. Considering all subjects, high-frequency power (HF) in SSD patients and in healthy people was not significantly different. After stratification with sex and age, only elder women revealed significantly lower ratio of low-frequency power to high-frequency power (LF/HF) than controls. The high association between the level of depression and HF in men was noteworthy. Aim 8 was to perform a meta-analysis for comparing HRV between patients with somatic symptom diagnoses/functional somatic syndromes and healthy individuals. Resting state HRV in patients with somatic symptom diagnoses/functional somatic syndromes (especially fibromyalgia) was significantly lower than in healthy individuals. Standard deviation of normal to normal RR intervals (SDNN) could present the highest difference. Aim 9 was to analyze the potential influence of antidepressants, benzodiazepines and quetiapine on HRV. After correcting potential confounders, only quetiapine is associated with reduced HRV. Aim 10 was to apply HRV reactivity in SSD patients. HRV was measured when the subjects watched stories; 4 types of stories (health anxiety, chronic pain, depression, neutral) were designed. During watching the chronic pain story, SSD women showed significantly lower HF than healthy women; a similar pattern was not observed in men. Aim 11 was to compare the associations between resting state HRV-SSD and HRV-persistent somatization (PS) of DCPR. After correcting cofounders, PS, but not SSD, was significantly associated with HF and SDNN. Aim 12 was to examine the possibility of applying HRV on evaluating the severity and comorbidity when only SSD patients were included. LF in women was able to discriminate SSD patients with different severity; whereas root mean square of successive NN interval differences (RMSSD) was helpful to detect male patients with comorbid depression. Stroop tasks can reflect the subjects’ cognitive function under interference, which is associated with a candidate mechanism of SSD; this topic was explored as aim 13. Female SSD patients revealed worse performance in emotion Stroop than healthy women; besides, they also showed significantly lower HF than healthy women during this task. This finding provided possible connection between brain areas and autonomic function. The psychological and autonomic features of the somatic symptom diagnoses in psychiatry were investigated in detail in this series of research; the findings may provide insights to the clinical evaluation and management. Sex, comorbid depression, taking antipsychotics, different somatic constructs, adopting resting state HRV or HRV reactivity, the content of psychological challenging in HRV reactivity design, may affect the results of HRV measurement; they should be considered in future studies.

並列關鍵字

somatic symptom diagnoses in psychiatry ； somatoform disorders ； somatic symptom disorder ； autonomic nervous system ； heart rate variability ； comorbid depression and anxiety ； sex difference

參考文獻

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精神科身體症狀診斷的心理及心率變異性特徵研究

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