慢性思覺失調症患者核心症狀和心智理論能力對臨床病識感的影響

研究目的：思覺失調症患者的臨床病識感是預後的重要指標，但長久以來臨床工作者在其慢性化的復原歷程中卻難以撼動臨床病識感，約50-80％的思覺失調症患者在治療多年後仍是部分或完全缺乏病識感。然而，目前對於如何改變慢性思覺失調症患者臨床病識感的機制尚存有分歧，其中核心症狀和心智理論能力被認為可能是影響患者臨床病識感的重要因子。因此，本研究旨在探索慢性思覺失調症患者的核心症狀和心智理論能力對臨床病識感（包含：精神疾病之覺察、藥物效果之覺察、社會影響之覺察三向度）的影響，以及臨床穩定度在其中是否存在著調節作用。研究方法：本研究採橫斷式設計，共納入90位罹病三年以上的慢性思覺失調症患者，依據臨床狀態分為臨床穩定組60人和臨床不穩定組30人。以症狀嚴重度評分表、中文版心智理論量表、以及中文版精神疾病覺知障礙量表做為資料收集的評估工具，並進行研究變項的相關分析，以及將臨床病識感總分和分向度分別作為依變項，再將與依變項有顯著相關的核心症狀和心智理論能力作為預測變項來進行多元迴歸分析。研究結果：慢性思覺失調症患者在不同的臨床狀態中，臨床病識感與其三向度顯示有各自獨特的機制。對於不穩定的慢性患者而言，情感性心智理論能力有助於整體臨床病識感和精神疾病之覺察；認知性心智理論能力則有助於社會影響之覺察。然而，對於穩定的慢性患者而言，當核心症狀中的負性症狀嚴重度下降則有助於藥物效果之覺察。結論與建議：由於慢性思覺失調症患者的臨床病識感與三向度受心智理論能力和負性症狀的影響，且臨床穩定度從中扮演著調節變項的角色。因此，臨床工作者在治療計畫上，不僅需留意患者的臨床穩定度，也可透過提升心智理論能力或減低負性症狀嚴重度的治療策略，以促進不同狀態的慢性思覺失調症患者之臨床病識感。

關鍵字

慢性思覺失調症；臨床病識感；核心症狀；認知性心智理論能力；情感性心智理論能力；臨床穩定度

並列摘要

Objective: The present study aimed to explore the influence of symptoms and theory of mind on overall insight and its three components (i.e., awareness of mental disorder, achieved effect of medicine, and social influences) of people with chronic schizophrenia. Methods: A total of 90 persons with chronic schizophrenia were recruited in a cross-sectional study. 60 subjects were classified as clinically stable group and 30 were classified as unstable group. All subjects were assessed with the Chinese version of Theory of Mind Scale, and Scale to assess Unawareness of Mental Disorder (SUMD). In addition, Dimensions of Psychosis Symptom Severity in the DSM-5 was administered through a semi-structured interview to assess the severity of symptoms. Results: As far as persons with chronic schizophrenia in an unstable clinical condition were concerned, affective theory of mind contributed to overall insight and their awareness of mental disorder; cognitive theory of mind contributed to awareness of the social influences. However, as far as persons with chronic schizophrenia in stable clinical condition were concerned, negative symptoms contributed to poor awareness of the achieved effect of medication. Conclusions and Suggestion: Our findings suggest that different dimensions of clinical insight may require contributions from different components of theory of mind as well as symptoms. Moreover, the stability of clinical conditions plays the role as a moderator. Therefore, it is recommended that: 1) clinicians pay attention to the patient’s stability of clinical condition, and 2) treatment strategies that improve theory of mind or reduce the severity of negative symptoms, thus helping people with chronic schizophrenia to improve clinical insight.