스티븐 러시, MD
임상 정신과 및 행동 신경과학 부교수

이차 정신병

Psychotic experiences are common in those who are diagnosed with schizophrenia.  In fact, the presence of psychotic symptoms can lead to the diagnosis of this brain disorder if both delusions and hallucinations are present for six months, including one month of persistent symptoms.  In other medical specialties a diagnosis is often made after a physical exam, imaging (X-Rays or CT Scans) and bloodwork that are crucial to determining a diagnosis and appropriate treatment.  In psychiatry, however, this same diagnostic process does not often yield much useful information except in the case of secondary psychosis (caused by other medical disorders).

Secondary psychosis is a term more frequently used in recent decades as there is a growing realization that it is vital to understand when symptoms such as delusions and hallucinations are due to a known medical illness or substance.  Previously referred to as “functional” when having a psychological origin and “organic” when there was an identifiable biological origin, the shift to “primary” and “secondary” reflects an understanding that every psychiatric condition and symptom has a biological component. This understanding first appeared in the revised version of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) in 2000.  Any substance, prescribed drug or medical condition that affects the central nervous system can result in psychiatric symptoms including psychosis and, unfortunately, we continue to see cases where a presumptive diagnosis of schizophrenia is made before a thorough medical evaluation confirms the absence of a source of secondary psychosis.

In a 2016 article published in The Primary Care Companion to CNS Disorders, Dr João Gama Marques studied how often patients initially diagnosed with schizophrenia had an underlying source of secondary psychosis that was not recognized.  This retrospective analysis of 250 patients in Portugal demonstrated that 25% of patients diagnosed with schizophrenia actually had an underlying medical condition causing psychotic symptoms. And further, the average delay in correct diagnosis was 12 years.  The consequences of such a delay in diagnosis can have devastating consequences to patients and their loved ones.

수십 년, 수백 년에 걸친 과학자들의 연구를 통해 우리는 이제 이차 정신병이 다음 그림에서 확인된 13가지 주요 장애 그룹에서 발생할 수 있다고 말할 수 있습니다.

How do clinicians determine if a psychotic disorder is “primary” or “secondary”?  First, the causative  substance or medical condition must be identified.  Then, the relationship between a medical condition or substance used and the psychotic symptoms should be identified.  In doing so, clinicians should consider three key aspects of the patient’s symptoms: atypicality, temporality and explicability.

증상이 다음과 같은 경우 정신병의 근본적인 의학적 원인을 의심해야 합니다. 전형적인 아닌 in regards to the age of onset and the type of symptoms observed.  For example, the presence of multiple types of hallucinations (auditory, visual, tactile, and olfactory) is not typical in schizophrenia and increases the likelihood of a secondary psychotic disorder such those seen in dementia or some types of epilepsy.  The 세속적 소유물 정신병적 증상이 의학적 질병의 시작 또는 물질 섭취 후 발생하고 의학적 상태가 호전되거나 물질이 신체에서 제거되면 해결될 때 증상의 발생 또는 발생 시기를 고려해야 합니다. 마지막으로, 동반이환 의학적 질병은 정신분열증이 있는 사람들에게 매우 흔하기 때문에 현재 증상이 최선인지 물어보는 것이 중요합니다. 설명 by a primary or a secondary psychotic disorder.  For example, in a patient with a strong family history of schizophrenia in their parents and siblings, longstanding psychotic symptoms, even in the context of a co-occurring medical illness, may be most accurately explained by schizophrenia given the genetic predisposition present.

In April of 2018 the University of Cincinnati Medical Center instituted the First Episode Evaluation and Services (FEELs) program.  This includes a multidisciplinary team of physicians, nurses, social workers, pharmacists, psychologists, occupational and recreational therapists who work together to rule out secondary causes of psychosis in patients within the first 2 years of symptom onset while on a psychiatry inpatient unit.  This work-up includes thorough bloodwork, imaging, review of any medications taken and substances and psychological testing.  This evaluation helps the treatment team to identify the most likely cause of psychosis in any given patient and guide treatment.  If a medical condition is identified, clinicians who specialize in the treatment of that condition then become involved in treatment.  This protocol was inspired by working with patients whose secondary psychotic disorders were not identified early in their illness, leading to long-term negative consequences.  While many academic medical centers have similar procedures there is still a lack of awareness about the identifiable causes of secondary psychosis in many places around the world.  Physicians, patients, and family members alike must be educated about these issues and advocate for standard assessment of secondary causes of psychosis to further our common goal of healing through correct diagnosis and treatment.

참조:

Keshavan MS, Kaneko Y. 이차 정신병: 업데이트. 세계정신과. 2013;12(1):4-15. 도이:10.1002/wps.20001

Gama Marques J. 이전에 원발성 정신분열증으로 진단받은 200명의 환자 코호트 중 1/4에서 이차성 정신분열증을 유발하는 기질적 정신병. 꼼꼼한

간병 동반자 CNS 장애. 2020;22(2):19m02549.