医学博士斯蒂芬·拉什
临床精神病学和行为神经科学副教授

继发性精神病

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.

通过科学家数十年和数百年的研究，我们现在可以说继发性精神病可由下图中确定的 13 种主要疾病引起。

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.

如果表现是，应怀疑精神病的潜在医学原因 非典型的 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 暂时性 症状的发生，或何时发生，应考虑精神病性症状是在身体疾病开始或摄入某种物质后出现，而当身体状况改善或物质从体内排出时症状消失。最后，因为合并症在精神分裂症患者中很常见，所以询问目前的症状是否最好是很重要的 解释 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.

参考：

Keshavan MS, Kaneko Y. 继发性精神病：更新。 世界精神病学. 2013 年；12(1)：4-15。 doi:10.1002/wps.20001

Gama Marques J. 器质性精神病导致先前诊断为原发性精神分裂症的 200 名患者中有四分之一出现继发性精神分裂症。 朴素的

Care Companion CNS 紊乱. 2020;22(2):19m02549。