(西南大學(xué)認(rèn)知與人格教育部重點(diǎn)實(shí)驗(yàn)室;西南大學(xué)心理學(xué)院,重慶 400715)

1 引言

神經(jīng)性厭食(Anorexia nervosa,AN),又稱(chēng)厭食癥,是由心理因素引起的一種慢性進(jìn)食障礙,指?jìng)€(gè)體通過(guò)節(jié)食等手段,有意造成并維持體重明顯低于正常標(biāo)準(zhǔn)為特征的進(jìn)食障礙。其主要癥狀表現(xiàn)在生理、心理及行為三方面。

生理異常主要表現(xiàn)為極度消瘦(Sm ith,Joiner,&Dodd,2014),常伴隨營(yíng)養(yǎng)不良、代謝、內(nèi)分泌障礙(嚴(yán)春曉,陳學(xué)軍,鄭偉,楊建華,2009)和睡眠障礙(Cinosietal.,2011;Samara,2009;傅旭明,2014)等一系列癥狀。

心理異常主要表現(xiàn)為體像障礙(body image distortion)(Tovée,Benson,Emery,Mason,&Cohen-Tovée,2003;付丹丹,王建平,陳薇,畢玉,2005)、內(nèi)感受器紊亂、惡劣心境如抑郁(Abbate-Daga etal.,2011;Godartetal.,2007;李亞玲等,2012)、焦慮、恐懼等。共病情感障礙多見(jiàn)于該患者(Godard,Grondin,Baruch,&Lafleur,2011;Soléetal.,2011),且雙相情感障礙患者更多地發(fā)生于年輕女性中,具有更高程度的自殺傾向(M cElroy etal.,2016)。

行為異常主要表現(xiàn)為限制或拒絕進(jìn)食、偏食挑食、行為退縮、人際交往減少等特征(申景進(jìn),陳向一,2008),患者除存在不健康飲食行為之外,還常存在其他危險(xiǎn)行為,如自殺(Preti,Rocchi,Sisti,Camboni,&M iotto,2011)、自傷(Svirko&Haw ton,2007)及物質(zhì)濫用(Baker,M itchell,Neale,&Kendler,2010;Root,Pinheiro etal.,2010;Root,Pisetsky etal.,2010)等。

除生理、心理及行為異常外,厭食癥患者的神經(jīng)結(jié)構(gòu)及功能也發(fā)生著相應(yīng)的變化。有研究者對(duì)厭食癥患者品嘗不同口味食物后腦島的反應(yīng)進(jìn)行了觀(guān)察,實(shí)驗(yàn)設(shè)置饑餓和飽腹?fàn)顟B(tài)兩組被試,讓其均飲用巧克力牛奶,結(jié)果顯示,饑餓狀態(tài)下的厭食癥患者腦島激活程度低于對(duì)照組(Vocks,Herpertz,Rosenberger,Senf,&Gizew ski,2011)。此外,通過(guò)CT和MRI,人們發(fā)現(xiàn)部分厭食癥患者的腦溝、腦回、腦室、大腦灰質(zhì)白質(zhì)體積均有相應(yīng)變化。體重過(guò)輕的患者表現(xiàn)出灰質(zhì)體積(grey matter volume,GMV)減少和腦脊液(cerebrospinal fluid,CSF)的增加(Kerem&Katzman,2003;van den Eynde etal.,2012)。除了灰質(zhì),患者的海馬、中腦及腦橋體積也顯著減少(Connan et al.,2006;Neum?rker,Bzufka,Dudeck,Hein,&Neum?rker,2000)。將腦影像學(xué)技術(shù)應(yīng)用到厭食癥的研究上在厭食癥的研究范疇內(nèi)具有里程碑的意義。

美國(guó)一項(xiàng)對(duì)13~18周歲女性和男性的調(diào)查發(fā)現(xiàn)該病的終生患病率為0.3%(Swanson,Crow,Le Grange,Swendsen,&Merikangas,2011)。在英國(guó)兒童調(diào)查研究中發(fā)現(xiàn),13歲以下的孩子患病率為0.01%(Nicholls,Lynn,Viner,&2011),中年及老年女性的患病率相對(duì)較低(Lapid et al.,2010)。該病多見(jiàn)于年輕女性,雖在過(guò)去10年中總發(fā)病率保持穩(wěn)定,但15~19歲的女孩作為該病的高風(fēng)險(xiǎn)群體其發(fā)病率有著顯著增加(Sm ink,van Hoeken,&Hoek,2012)。一項(xiàng)對(duì)女性進(jìn)食障礙患者長(zhǎng)達(dá)11年隨訪(fǎng)研究報(bào)告指出：厭食癥的女性患者死亡率為7.4%,其中4/10死于自殺(Franko etal.,2004;Keel et al.,2003),該病死亡率在所有精神疾病中死亡率最高(Arcelus,M itchell,Wales,&Nielsen,2011)。

最新修訂《精神障礙診斷與統(tǒng)計(jì)手冊(cè)(第五版)》(DSM-5)(2015)對(duì)厭食癥的診斷標(biāo)準(zhǔn)做了部分修改,提出厭食癥診斷的主要標(biāo)準(zhǔn)：限制能量攝入,目的是將體重保持在與其年齡、性別、發(fā)育水平及軀體健康狀況相對(duì)而言非常低的體重值;即使已有體重過(guò)低,仍極度害怕體重增加或變胖,表現(xiàn)出明顯的阻礙體重增加的持續(xù)性行為;患者對(duì)自己體重或者體形的感受紊亂,自我評(píng)價(jià)不當(dāng),否認(rèn)目前嚴(yán)重的體重過(guò)低。

另一方面,世界各地的研究人員在探討厭食癥的影響因素上花了諸多精力,隨著現(xiàn)代醫(yī)學(xué)模式的轉(zhuǎn)變,生物—心理—社會(huì)整體醫(yī)學(xué)模式指導(dǎo)下的病因?qū)W研究愈來(lái)愈受到重視。

2 厭食癥的生物?心理?社會(huì)模型

20世紀(jì)50年代以來(lái),生物?心理?社會(huì)整體醫(yī)學(xué)模式成為詮釋健康和疾病的主流,人們?cè)诮忉尲膊r(shí)不僅要看到其生物學(xué)因素,還要重視引發(fā)疾病的心理和社會(huì)因素。厭食癥作為一種進(jìn)食障礙,其成因極其復(fù)雜,受到生物、心理及社會(huì)文化因素的共同影響。遺傳基因?qū)е碌膮捠嘲Y易感個(gè)體在社會(huì)文化因素(“瘦”文化、家庭關(guān)系)與心理因素(人格特質(zhì)、肥胖恐懼感及應(yīng)激因素)共同作用下更容易引發(fā)患病(圖1)。

圖1 厭食癥發(fā)生發(fā)展病因模式圖(資料來(lái)源：陳玨,2013)

2.1 生物學(xué)因素

2.1.1 遺傳學(xué)研究

家系研究、雙生子研究及寄養(yǎng)子研究均已表明遺傳因素在厭食癥的發(fā)病中起著相當(dāng)重要的作用。

早期研究就已表明厭食癥在家庭結(jié)構(gòu)中具有交叉?zhèn)鞑ゼ熬奂蕴攸c(diǎn)(Strober,Lampert,Morrell,Burroughs,&Jacobs,1990)。Steinhausen,Jakobsen,Helenius,Munk-J?rgensen 和 Strober(2015)的一項(xiàng)大數(shù)據(jù)研究也為厭食癥患者的家庭聚集性提供了有利證據(jù)。此外,遺傳因素與其他各環(huán)境因素一樣(Jacobietal.,2011)會(huì)增加厭食癥患病風(fēng)險(xiǎn)(Trace,Baker,Pe?as-Lledó,&Bulik,2013)。研究者對(duì)瑞典1993~1998年出生的雙胞胎的父母進(jìn)行關(guān)于多動(dòng)癥、自閉癥及飲食問(wèn)題的訪(fǎng)談,通過(guò)相關(guān)和結(jié)構(gòu)方程模型評(píng)估遺傳和環(huán)境因素的影響,結(jié)果發(fā)現(xiàn)飲食問(wèn)題的患病率為0.6%,顯著高于多動(dòng)癥和自閉癥,在飲食問(wèn)題中,遺傳因素占總變異的44%(R?stam etal.,2013)。一項(xiàng)早期寄養(yǎng)子研究顯示兒童身體指數(shù)與親生父母有顯著相關(guān),與養(yǎng)父母并沒(méi)有密切關(guān)系(Stunkard etal.,1986)。由此說(shuō)明遺傳在本病的發(fā)生中起一定作用。

在此基礎(chǔ)上,Chen等人(2015)采用對(duì)照組設(shè)計(jì)探討血清素轉(zhuǎn)運(yùn)體連接的啟動(dòng)子區(qū)域(5-HTTLPR)多態(tài)性與中國(guó)漢族厭食癥群體易感性及嚴(yán)重性間的可能聯(lián)系。實(shí)驗(yàn)對(duì)198例厭食癥患者和225例健康對(duì)照組進(jìn)行基因分型和關(guān)聯(lián)分析,發(fā)現(xiàn)5-HTTLPR基因多態(tài)性與中國(guó)漢族人群厭食行為之間存在關(guān)聯(lián),且S等位基因的出現(xiàn)頻率顯著高于對(duì)照組,5-HTTLPR基因多態(tài)性與中國(guó)漢族人易患厭食癥有顯著相關(guān)。

2.1.2 生物化學(xué)研究

關(guān)于厭食癥的生物化學(xué)研究主要集中在中樞神經(jīng)遞質(zhì)對(duì)厭食行為的影響,研究較多的包括5-羥色胺(5-HT)、去甲腎上腺素及神經(jīng)肽Y等(Scherma,Satta,Fratta,&Fadda,2015)。

一項(xiàng)肥胖老鼠實(shí)驗(yàn)發(fā)現(xiàn)增加突觸間隙中5-HT的活性或直接激活5-HT受體可減少攝食量(Bano,Akhter,&Haleem,2012)。研究者在對(duì)焦慮、強(qiáng)迫與抑郁患者的治療中發(fā)現(xiàn),5-羥色胺再攝取抑制劑(SSRIs)和5-HT特異性藥物是治療厭食癥的有效方式(Vaswani,Linda,&Ramesh,2003)。然而,SSRIs通過(guò)抑制突觸前膜5-HT再攝取,從而增加突觸間隙中5-HT的濃度。故上述SSRIs類(lèi)藥物的作用表明,患者中5-HT濃度可能很低。近年來(lái)有研究顯示,5-HT與懲罰和行為抑制機(jī)制有關(guān),即當(dāng)體內(nèi)5-HT濃度很低時(shí),個(gè)體激勵(lì)動(dòng)機(jī)降低(Sanders,Hussain,Hen,&Zhuang,2007;Cools,Roberts,&Robbins,2008;Hebart&Gl?scher,2015), 攝食減少。這與Bano,Akhter和Haleem的結(jié)論不一致。Bano等人的研究建立在動(dòng)物實(shí)驗(yàn)的基礎(chǔ)上,認(rèn)為上調(diào)5-HT可以減少攝食;Vaswani等人的研究建立在對(duì)患者治療的結(jié)果基礎(chǔ)上,臨床上對(duì)患者進(jìn)食的改善不僅僅依賴(lài)于5-HT系統(tǒng),還可能源于兩個(gè)原因：(1)情緒癥狀的改善導(dǎo)致消化道癥狀的改善;(2)情緒癥狀的改善導(dǎo)致進(jìn)食行為的改變。而情緒癥狀的改善是可通過(guò)突觸間隙5-HT濃度的增加實(shí)現(xiàn)。

多巴胺在中樞神經(jīng)系統(tǒng)調(diào)節(jié)食物攝入量方面起著重要作用(M irmohammadsadeghi,Elyasi,&Haghparast,2015)。多巴胺受體拮抗劑可減少基于活動(dòng)的厭食癥(activity-based anorexia,ABA)患者的體重?fù)p失,并大大提高患者的存活率(K lenotich,Ho,M cmurray,Server,&Dulawa,2015)。Anderberg,Anefors,Bergquist,Nissbrandt和 Skibicka(2014)通過(guò)評(píng)估老鼠杏仁核內(nèi)多巴胺受體的激活對(duì)攝食量及蔗糖操作行為的影響,結(jié)果發(fā)現(xiàn),多巴胺信號(hào)通過(guò)攝食行為及腦腸肽GLP-1得到激活,杏仁核多巴胺D2受體的激活對(duì)于改變攝食行為具有必要性。這向我們展示了一種調(diào)節(jié)食物攝入量及獎(jiǎng)勵(lì)的新的神經(jīng)生物學(xué)機(jī)制。

2.2 心理因素

2.2.1 人格特質(zhì)

有研究報(bào)道人格特征和厭食癥有著顯著相關(guān)(Youssef et al.,2004),精神病態(tài)和抑郁更為突出(李亞玲等,2012),例如,限食型厭食癥與癔癥、精神病態(tài)等人格特征密切相關(guān),而暴食/清除型厭食癥與精神衰弱、恐懼等人格特征密切相關(guān)?；颊咄哂袃和瘹赓|(zhì)和個(gè)性特征,如焦慮,強(qiáng)迫觀(guān)念及完美主義(Kaye,Wierenga,Bailer,Simmons,Wagner etal.,2013;Kaye,Wierenga,Bailer,Simmons,&Bischoff-Grethe,2013)。Schulze,Calame,Keller和Mehler(2009)對(duì)入院治療的23例兒童和青少年厭食癥患者進(jìn)行臨床評(píng)估,發(fā)現(xiàn)類(lèi)似結(jié)果,飲食障礙與特質(zhì)焦慮存在顯著相關(guān)。有學(xué)者認(rèn)為強(qiáng)迫型人格障礙(obsessive-compulsive personality disorder)作為最常見(jiàn)的人格障礙之一(Starcevic&Brakoulias,2014)與厭食癥具有顯著關(guān)聯(lián)(Bulik,Sullivan,Fear,&Joyce,1997)。另有學(xué)者采用對(duì)照組設(shè)計(jì)探討厭食癥患者童年強(qiáng)迫特質(zhì)(childhood obsessive-compulsive)的發(fā)生率,結(jié)果患者較健康組報(bào)告了更多的童年強(qiáng)迫特質(zhì)和精神病態(tài)等人格特征,如體像障礙(Degortes,Zanetti,Tenconi,Santonastaso,&Favaro,2014)。

2.2.2 肥胖恐懼

厭食癥患者可在節(jié)食中找到自我感及身份感?；颊邔?duì)成熟有極度的恐懼,包括體重增加、青春期和性,厭食能夠預(yù)防這些恐懼事件的發(fā)生,減少恐懼感、低自我效能感,從而獲得安全感。在DSM-Ⅳ中,“肥胖恐懼”一直被認(rèn)為是厭食癥的“核心”病理心理。然而,不斷增長(zhǎng)的跨國(guó)文獻(xiàn)表明,并非所有厭食癥患者均表現(xiàn)出脂肪恐懼癥的核心診斷癥狀。在香港,一項(xiàng)對(duì)70例華人厭食癥患者的分析顯示,有41例(59%)患者在疾病的整個(gè)過(guò)程中未出現(xiàn)任何肥胖恐懼,另外,日本一項(xiàng)1011例厭食癥患者大樣本研究中有269例(26.6%)患者無(wú)肥胖恐懼(Lee,1995)。近年來(lái),一項(xiàng)對(duì)香港113名脂肪恐懼厭食癥患者和28名非脂肪恐懼厭食癥患者的研究結(jié)果也表現(xiàn)出與核心恐懼癥狀不一致(Lee,Ng,Kwok,Thomas,&Becker,2012)。為什么會(huì)出現(xiàn)這樣的現(xiàn)象？文化作為一種差異變量可能是出現(xiàn)這種不一致的原因。要求的“一致性”并不保證每一病人的體驗(yàn)相同。在表現(xiàn)上同為厭食的部分個(gè)體在應(yīng)激因素的影響下,會(huì)尋求緩解壓力疏導(dǎo)焦慮的方式,通過(guò)食物來(lái)獲得安慰,來(lái)表達(dá)眾多難以釋?xiě)训那楦小?/p>

2.2.3 應(yīng)激因素

不良生活事件作為精神障礙的危險(xiǎn)因素(Beardsetal.,2013)與厭食癥存在密切聯(lián)系。研究者認(rèn)為不良生活事件可預(yù)測(cè)青春期或成年早期個(gè)體體重的波動(dòng)、節(jié)食及飲食失調(diào)現(xiàn)象(Akkermann etal.,2012)。也有研究得出類(lèi)似結(jié)論,心理社會(huì)應(yīng)激是體重增加的一個(gè)危險(xiǎn)因素(Wardle,Chida,Gibson,Whitaker,&Steptoe,2011)。個(gè)體在經(jīng)受劇烈驚嚇后、對(duì)新環(huán)境適應(yīng)不良、工作學(xué)習(xí)過(guò)度緊張或壓力知覺(jué)過(guò)高均可成為此病誘因。在一項(xiàng)壓力對(duì)食物攝入和丘腦外側(cè)區(qū)(LHA)神經(jīng)活動(dòng)的影響研究中,研究者發(fā)現(xiàn)壓力情境下個(gè)體攝食量減少(Shim izu,Oomura,&Kai,1989)。然而,近年來(lái)有研究顯示,急性或慢性生活壓力與食物攝入量的增加有顯著相關(guān),尤其是高脂肪和高糖分的食物(Torres&Nowson,2007)。也有國(guó)外研究發(fā)現(xiàn),在壓力情境下,人們即使沒(méi)有感覺(jué)到饑餓仍然會(huì)大量進(jìn)食(Rutters,Nieuwenhuizen,Lemmens,Born,&Westerterp-Plantenga,2009)。前后研究的結(jié)果雖不一致,但可以肯定的是應(yīng)激因素與攝食行為存在著某種聯(lián)系,這種聯(lián)系可能是間接的,它通過(guò)某些中介變量(如自卑感、應(yīng)對(duì)方式)影響攝食行為。

2.3 社會(huì)文化因素

2.3.1 “瘦”文化

經(jīng)過(guò)媒體的大肆宣揚(yáng)及時(shí)尚界的標(biāo)榜,當(dāng)下社會(huì)文化觀(guān)念崇尚以瘦為美,女性更是深深認(rèn)同這樣的文化觀(guān)念,將“苗條”標(biāo)榜為自己的理想體形,追求苗條的身姿,隨處可見(jiàn)的減肥廣告、媒體宣傳更加給女性施加了“瘦文化”的壓力。美國(guó)學(xué)者蘇珊?鮑爾多(Bordo,2009)在她的《不能承受之重——女性主義、西方文化與身體》(Unbearable Weight;Fem im ism,Western Culture,and the Body)一書(shū)中提到女性的節(jié)食現(xiàn)象,那種非意識(shí)形態(tài)的饑餓,體現(xiàn)主流文化媒體與消費(fèi)主義共謀的本質(zhì),成為女性自我約束教育中重要的一個(gè)環(huán)節(jié)。大眾媒體作為新興媒介,可傳播健康、積極的信息內(nèi)容,可促使人們思想的進(jìn)步,而消極、不健康、虛假的信息則對(duì)社會(huì)風(fēng)氣產(chǎn)生負(fù)面影響(劉念維,2015)。Dakanalis和Riva(2013)認(rèn)為大眾媒體促使個(gè)體將美的文化標(biāo)準(zhǔn)及如何提升吸引力的方式內(nèi)化,進(jìn)一步影響著飲食失調(diào)現(xiàn)象的發(fā)展(Smolak,1996)。在苗條文化的帶領(lǐng)下,為了追趕“瘦”潮流,女性即使深知減肥會(huì)給自身身體機(jī)能造成不利影響,仍孤注一擲,采用各種方式,如盲目采用減肥產(chǎn)品、過(guò)度節(jié)食等方法,保持“瘦”身姿。這種病態(tài)的瘦文化使得原本屬于標(biāo)準(zhǔn)體形的女性產(chǎn)生歪曲的自我認(rèn)知,造成嚴(yán)重的飲食失調(diào)現(xiàn)象。

2.3.2 家庭關(guān)系

家庭是一個(gè)有眾多維度的復(fù)雜動(dòng)態(tài)組織,是一個(gè)可以從各種方式加以研究的復(fù)雜現(xiàn)象(Liu,Zhang,&Yeh,2011)。許多研究發(fā)現(xiàn),厭食癥具有家族傾向,患者家族成員中有較多人表現(xiàn)出類(lèi)似行為。這一方面表明與遺傳相關(guān),另一方面表明可能與家庭關(guān)系如父母沖突、親子沖突、父母離異,家庭進(jìn)食觀(guān)念如母親對(duì)進(jìn)食的態(tài)度和行為影響其子女(陳清剛,2006)。家庭關(guān)系影響兒童期自我認(rèn)同的發(fā)展,進(jìn)而出現(xiàn)厭食這一退縮性行為。家庭關(guān)系表現(xiàn)出極端親密和極端疏遠(yuǎn)兩極性,M inuchin提出的“糾纏”(enmeshed)概念是進(jìn)食障礙家庭研究中最穩(wěn)定的發(fā)現(xiàn)之一(Tom iyama&Mann,2008),“糾纏”指一種極端形式的親密和高強(qiáng)度的家庭互動(dòng),家人之間沒(méi)有清晰明確的界限。父母的過(guò)度保護(hù)會(huì)減慢孩子個(gè)體化 (individualization)的過(guò)程,并阻礙其整體心理社會(huì)功能的發(fā)展,“糾纏”作為進(jìn)食障礙家庭關(guān)系的主要特點(diǎn)在厭食癥患者中更為明顯。家庭關(guān)系紊亂破壞家庭組織結(jié)構(gòu)功能,使子女處于不良的生活環(huán)境中,不利于子女身心發(fā)展,易形成易感性心理素質(zhì),對(duì)于生活中的應(yīng)激性事件,他們更傾向于選擇厭食這一行為作為自己防衛(wèi)傷害的方式。家庭系統(tǒng)理論也認(rèn)為,厭食被看做孩子為維護(hù)家庭穩(wěn)定而做出的一種“防衛(wèi)”機(jī)制。

3 問(wèn)題與展望

厭食癥這一概念最先于19世紀(jì)在法國(guó)提出(Pineles&M inken,2005),隨后愈來(lái)愈受到重視。研究者結(jié)合心理、生理、社會(huì)文化因素多維度地揭示了厭食癥的病因、預(yù)防及治療,并取得了豐碩的成果。雖然研究者不懈地努力,不斷的在驗(yàn)證與充實(shí)已有的結(jié)論成果,但仍然存在一些不足之處。

一方面,對(duì)其神經(jīng)內(nèi)分泌研究的探討。厭食癥與許多內(nèi)分泌軸的適應(yīng)性變化相關(guān),這些變化包括性腺功能、獲得性生長(zhǎng)激素水平、高皮質(zhì)醇血癥、改變脂肪細(xì)胞因子和調(diào)節(jié)食欲的荷爾蒙的分泌(M isra&K libanski,2016)。神經(jīng)內(nèi)分泌學(xué)研究主要集中在下丘腦功能異常。下丘腦?垂體?腎上腺軸(hypothalam ic-pituitary-adrenal axis,HPA)的研究最多,其持續(xù)激活與厭食癥及異常體重的調(diào)節(jié)有關(guān)。厭食癥患者往往伴隨著HPA軸活性的改變(Taksande,Chopde,Umekar,&Kotagale,2015),并報(bào)告出各種內(nèi)分泌失調(diào),如皮質(zhì)醇(cortisol)持續(xù)增多癥(Hari Kumar&Baruah,2012)。雖然閉經(jīng)不再作為厭食癥的診斷標(biāo)準(zhǔn),但月經(jīng)紊亂仍然是該病的常見(jiàn)癥狀。下丘腦?垂體?性腺軸(hypothalam icpituitary-gonadal axis,HPG)功能紊亂也是厭食癥的一大癥狀。在此意義上,神經(jīng)內(nèi)分泌紊亂可作為厭食癥引發(fā)的結(jié)果。然而,促腎上腺皮質(zhì)激素釋放因子(corticotropin-releasing factor,CRF)是機(jī)體調(diào)節(jié)應(yīng)激反應(yīng)的關(guān)鍵因子,且與多種精神疾病有關(guān)。CRF分泌亢進(jìn)將導(dǎo)致某些精神障礙,如抑郁癥、焦慮癥和厭食癥;CRF分泌不足則會(huì)導(dǎo)致神經(jīng)退行性疾病。在此意義上,神經(jīng)內(nèi)分泌紊亂可作為厭食癥的病因。在未來(lái)研究中應(yīng)更加明確二者的因果關(guān)系,為更好的預(yù)防、干預(yù)及治療該病提供明確的理論基礎(chǔ)。

另一方面,對(duì)該病的預(yù)防、干預(yù)及治療。除了探討厭食癥及相關(guān)心理健康問(wèn)題外,還要關(guān)注厭食癥的預(yù)防、干預(yù)及治療等方面。厭食癥患者內(nèi)在的心理紊亂外化到進(jìn)食行為問(wèn)題上,其病因和發(fā)病機(jī)制涉及生物、心理及社會(huì)文化等多因素,因此針對(duì)不同的患者應(yīng)采取不同的心理治療,從個(gè)體及更大的系統(tǒng)角度上進(jìn)行干預(yù)。生物性治療方式包括支持治療、營(yíng)養(yǎng)治療及藥物治療等。目前對(duì)厭食癥的治療多采用SSRI(5-HT再攝取抑制劑)及非典型抗精神病類(lèi)藥物(Flament,Bissad,&Spettigue,2012;M cElroy,Guerdjikova,Mori,&Keck,2015),但其療效并不十分肯定。病情嚴(yán)重時(shí),精神科藥物基本無(wú)效,5%~15%的患者死于營(yíng)養(yǎng)耗竭,部分患者可因重度抑郁自殺(張小小,孫伯民,李殿友,占世坤,曹春燕,2014)。

厭食癥的心理治療包括認(rèn)知行為治療(cognitivebehavioral therapy,CBT)、精神動(dòng)力性心理治療、家庭治療。近年很多研究證實(shí)CBT對(duì)嚴(yán)重厭食癥患者具有明顯療效(Touyz etal.,2013)?！霸鰪?qiáng)型”認(rèn)知行為治療(enhanced cognitive behaviour therapy,CBT-E)作為一種以家庭為基礎(chǔ)的治療方式在厭食癥患者的治療中十分有效(Dalle Grave,Calugi,Doll,&Fairburn,2013;Fairburn et al.,2013;Zipfel et al.,2014)。相當(dāng)多厭食癥患者的家庭氣氛充滿(mǎn)敵對(duì)、沖突,缺乏良好的教育環(huán)境,導(dǎo)致患者產(chǎn)生孤獨(dú)感甚至長(zhǎng)期抑郁。家庭治療是一種把關(guān)注的焦點(diǎn)置于人際關(guān)系上的心理治療范式,需要對(duì)家庭中不利于患者身心康復(fù)的因素進(jìn)行干預(yù),通過(guò)引入新的觀(guān)點(diǎn)或做法,來(lái)改變與病態(tài)行為相互關(guān)聯(lián)的認(rèn)知態(tài)度。一項(xiàng)以家庭為基礎(chǔ)對(duì)青少年厭食癥進(jìn)行治療的試驗(yàn)得到了很好的療效(Isserlin&Couturier,2012),且試驗(yàn)結(jié)果也發(fā)現(xiàn)家庭治療比個(gè)人焦點(diǎn)式治療更有效(Le Grange et al.,2012)。在對(duì)厭食癥患者進(jìn)行心理治療時(shí)應(yīng)根據(jù)患者的具體病因采取不同的治療方式。

除藥物和心理治療外,對(duì)社會(huì)環(huán)境的正向引導(dǎo)同樣十分重要。大眾傳媒要倡導(dǎo)個(gè)體形象的多樣性,以防“以瘦為美”的局限性思維。青少年是厭食癥的主要發(fā)病群體,基于此,對(duì)青少年進(jìn)行學(xué)校家庭健康教育、社會(huì)文化及媒體引導(dǎo)尤為重要,學(xué)校、家庭應(yīng)該采取相應(yīng)措施進(jìn)行干預(yù)。此外,對(duì)正確的健康“美”的教育也必不可少。傳媒和時(shí)尚界要宣傳健康“美”,使當(dāng)下女性認(rèn)識(shí)到過(guò)分消瘦是一種自虐行為。對(duì)厭食癥的干預(yù)有多種多樣的形式,在以后的研究中,要盡可能多地完善和開(kāi)發(fā)新的干預(yù)方式。

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