張 琴 賀國斌 劉 平 向 佳 向 霞

宣漢縣人民醫(yī)院消化內(nèi)科1(636150) 川北醫(yī)學(xué)院附屬醫(yī)院消化內(nèi)科2

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·短篇論著·

功能性消化不良不同亞型患者心理因素的比較研究

張 琴1賀國斌2*劉 平1向 佳1向 霞1

宣漢縣人民醫(yī)院消化內(nèi)科1(636150) 川北醫(yī)學(xué)院附屬醫(yī)院消化內(nèi)科2

背景：焦慮、抑郁、軀體化是影響功能性消化不良(FD)患者生活質(zhì)量的重要因素，但與FD各亞型之間的關(guān)系尚不完全清楚。目的：探索焦慮、抑郁和軀體化對FD各亞型患者的影響。方法：應(yīng)用焦慮自評量表(GAD-7)、抑郁自評量表(PHQ-9)、軀體化癥狀自評量表(PHQ-15)、悉尼消化不良指數(shù)簡表(NDI)和消化不良癥狀嚴(yán)重度量表(DSS)分別評估223例FD患者的焦慮、抑郁、軀體化、生活質(zhì)量和消化不良嚴(yán)重度，并分析焦慮、抑郁、軀體化對FD各亞型生活質(zhì)量和消化不良的影響。結(jié)果：EPS、PDS和EPS與PDS重疊組的GAD-7、PHQ-9、PHQ-15、NDI、DSS評分相比差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。FD各亞型患者的生活質(zhì)量與焦慮、抑郁和軀體化均相關(guān)(P<0.05)，而消化不良嚴(yán)重度僅與軀體化相關(guān)(P<0.05)。抑郁和軀體化是影響FD各亞型患者生活質(zhì)量的因素(P<0.05)，軀體化是影響各亞型患者消化不良的因素(P<0.05)。結(jié)論：EPS與PDS癥狀重疊患者的焦慮、抑郁、軀體化較EPS、PDS患者嚴(yán)重，對生活質(zhì)量和消化不良的影響亦更大。

功能性消化不良； 焦慮； 抑郁； 軀體化

功能性消化不良(FD)是最常見的功能性胃腸疾病，分為上腹痛綜合征(epigastric pain syndrome, EPS)、餐后不適綜合征(postprandial distress syndrome, PDS)[1]。FD可能的病理生理機(jī)制包括胃感覺運(yùn)動功能障礙、幽門螺桿菌(Hp)感染、精神心理因素等[2-3]，且精神心理因素和軀體化為影響FD患者生活質(zhì)量和癥狀嚴(yán)重度的重要因素[4]，但與FD各亞型之間的關(guān)系仍存在爭議。瑞典的一項(xiàng)研究[5]表明焦慮而非抑郁與PDS相關(guān)，與EPS無關(guān)；臺灣的一項(xiàng)研究[6]表明精神心理應(yīng)激特別是抑郁、軀體化、恐懼與PDS相關(guān)，與EPS無關(guān)；而Fischler等[7]的研究表明精神心理因素和軀體化與EPS相關(guān)。本研究通過研究焦慮、抑郁、軀體化等危險(xiǎn)因素與FD各亞型之間的關(guān)系，旨在為今后進(jìn)一步指導(dǎo)FD不同亞型患者的臨床治療提供一定的依據(jù)。

對象與方法

一、一般資料

選取2014年1月—2015年6月宣漢縣人民醫(yī)院消化內(nèi)科門診符合羅馬Ⅲ標(biāo)準(zhǔn)[1]的擬診斷FD患者264例。納入標(biāo)準(zhǔn)：①年齡18～65歲；②性別不限；③排除器質(zhì)性疾病。排除標(biāo)準(zhǔn)：①胃鏡檢查發(fā)現(xiàn)存在器質(zhì)性病變?nèi)缦詽?、腫瘤、出血、食管炎或血管病變等；②同時(shí)合并有糖尿病、惡性腫瘤、嚴(yán)重肝腎功能疾?。虎塾屑谞钕偌膊?、精神病史、腹部手術(shù)史；④有腹痛伴排便頻率與性狀改變等腸易激綜合征為主要表現(xiàn)者；⑤最近2周內(nèi)服用過抗膽堿藥、解痙藥、阿司匹林以及其他非甾體消炎藥；⑥年齡<18歲。因FD患者常合并焦慮或抑郁且兩者相互影響[2,4]，故本研究未排除伴有焦慮或抑郁的患者。入選者均簽署知情同意書。

二、研究方法

應(yīng)用廣泛性焦慮障礙量表(GAD-7)[8]、患者健康問卷抑郁癥狀群量表(PHQ-9)[9]、患者健康問卷軀體化癥狀群量表(PHQ-15)[10]、悉尼消化不良指數(shù)簡表(NDI)[11]、消化不良癥狀嚴(yán)重度量表(DSS)[12]分別對FD患者焦慮、抑郁、軀體化、生活質(zhì)量和消化不良嚴(yán)重度進(jìn)行評估。

三、統(tǒng)計(jì)學(xué)分析

結(jié) 果

一、一般情況

共223例FD患者入選，其中男63例，女160例；年齡18～65歲，平均(43.4±9.0)歲；病程6～360個(gè)月，中位病程24個(gè)月(8～60個(gè)月)；EPS患者69例，PDS患者44例，EPS與PDS重疊者110例。

二、FD不同亞型患者評分結(jié)果

不同亞型FD患者的性別構(gòu)成和年齡相比差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，而焦慮、抑郁、軀體化、生活質(zhì)量和消化不良評分相比差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表1)。

三、相關(guān)性分析結(jié)果

不同F(xiàn)D亞型患者的生活質(zhì)量與焦慮、抑郁和軀體化均相關(guān)(P<0.05)。

EPS患者消化不良與軀體化相關(guān)(P<0.05)，PDS患者消化不良與抑郁和軀體化相關(guān)(P<0.05)，EPS與PDS重疊患者消化不良與焦慮、抑郁、軀體化均相關(guān)(P<0.05)。

四、回歸分析結(jié)果

抑郁和軀體化是影響FD患者生活質(zhì)量的因素(P<0.05)，而非焦慮。軀體化是影響FD患者消化不良嚴(yán)重度的因素(P<0.05)，而非焦慮和抑郁。

討 論

根據(jù)羅馬Ⅲ標(biāo)準(zhǔn)FD分為以上腹部疼痛或燒灼感為主要特征的EPS和以餐后飽脹或早飽為主要特征的PDS，但這種分類標(biāo)準(zhǔn)是基于羅馬Ⅱ標(biāo)準(zhǔn)的流行病學(xué)和病理生理機(jī)制的研究結(jié)果，缺乏直接的科學(xué)證據(jù)[1,13]。FD的治療策略包括檢測和根除Hp、應(yīng)用PPI以及促胃腸動力藥物、抗抑郁藥物，但這些治療策略僅對部分患者有效[13]。了解精神心理因素和軀體化對FD不同亞型患者的影響，有益于提高治療療效。

本研究中，EPS、PDS以及癥狀重疊患者的焦慮、抑郁、軀體化、生活質(zhì)量和消化不良評分相比差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，且癥狀重疊患者的評分高于EPS和PDS患者；相關(guān)性分析結(jié)果顯示軀體化對FD患者生活質(zhì)量和消化不良的影響較焦慮、抑郁更大，且抑郁對生活質(zhì)量和消化不良的影響大于焦慮，而焦慮、抑郁、軀體化對癥狀重疊患者生活質(zhì)量、消化不良的影響程度強(qiáng)于EPS和PDS患者；回歸分析結(jié)果顯示抑郁和軀體化是影響不同亞型患者生活質(zhì)量的因素，軀體化是影響不同亞型患者癥狀嚴(yán)重度的因素。

本研究所納入的患者均來自三級醫(yī)院，其中49.3%的患者為EPS與PDS癥狀重疊患者。Vakil等[14]的研究中癥狀重疊患者所占的比例為66%。以人群為基礎(chǔ)的研究中，F(xiàn)D患者更易于區(qū)分為EPS和PDS，而以醫(yī)院為基礎(chǔ)的研究中，存在明顯的EPS與PDS重疊患者[13]，表明癥狀重疊患者的病情可能更嚴(yán)重。本研究亦發(fā)現(xiàn)癥狀重疊患者與抑郁的相關(guān)性最強(qiáng)，與Clauwaert等[15]和Fang等[16]的研究結(jié)果相似。病理生理的研究表明PDS患者較EPS患者存在更普遍的胃容受性受損[13]，與抑郁相關(guān)的自主功能障礙可能會損傷胃的容受性從而導(dǎo)致PDS[17]，推測PDS患者應(yīng)用抗抑郁藥物的效果更佳。軀體化和抑郁是影響各亞型FD患者生活質(zhì)量和消化不良癥狀嚴(yán)重度的因素，與Van Oudenhove等[2,4]和Jones等[18]的研究結(jié)果相一致。然而，癥狀重疊患者的焦慮、抑郁、軀體化較EPS、PDS更嚴(yán)重的病因仍尚不清楚，需在今后的病因?qū)W研究中進(jìn)一步探索。

表1 FD各亞型的人口統(tǒng)計(jì)學(xué)特征以及焦慮、抑郁、軀體化、生活質(zhì)量和消化不良評分

*與EPS組比較，P﹤0.001；與EPS與PDS重疊組比較，#P﹤0.05，△P﹤0.01

綜上所述，EPS與PDS癥狀重疊患者的焦慮、抑郁、軀體化較EPS、PDS患者嚴(yán)重，對生活質(zhì)量和消化不良的影響亦更大，有助于今后指導(dǎo)不同亞型FD患者的治療，但仍需進(jìn)一步研究證實(shí)。

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(2015-11-03收稿；2016-01-01修回)

Comparative Study on Psychological Factors in Subgroups of Patients with Functional Dyspepsia

ZHANGQin1,HEGuobin2,LIUPing1,XIANGJia1,XIANGXia1.

1DepartmentofGastroenterology,People’sHospitalofXuanhanCounty,Dazhou,SichuanProvince(636150);2DepartmentofGastroenterology,theAffiliatedHospitalofNorthSichuanMedicalCollege,Nanchong,SichuanProvince

HE Guobin, Email: heguob@163.com

Functional Dyspepsia; Depression; Anxiety; Somatization

10.3969/j.issn.1008-7125.2016.09.010

*本文通信作者，Email: heguob@163.com

Background: Anxiety, depression and somatization are important influencing factors of quality of life in patients with functional dyspepsia (FD), but the relationship with subgroups of FD remains not fully clear. Aims: To explore the influence of anxiety, depression and somatization on subgroups of FD patients. Methods: Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Patient Health Questionnaire-15 (PHQ-15), Nepean Dyspepsia Index (NDI) and Dyspepsia Symptoms Score (DSS) were used to evaluate anxiety, depression, somatization, quality of life and dyspepsia of 223 FD patients, respectively. The influences of anxiety, depression and somatization on quality of life and dyspepsia in subgroups of FD were analyzed. Results: Significant differences in score of GAD-7, PHQ-9, PHQ-15, NDI, DSS were found among EPS group, PDS group and EPS-PDS overlapping group (P<0.05). Quality of life in subgroups of FD was correlated with anxiety, depression and somatization (P<0.05), and dyspepsia was correlated with somatization (P<0.05). Depression and somatization were the determinants of quality of life in subgroups of FD patients (P<0.05), and somatization was the determinant of dyspepsia in subgroups of FD patients (P<0.05). Conclusions: Anxiety, depression and somatization in EPS-PDS overlapping patients are more severe than those in EPS and PDS patients, and the influence of these three risk factors on quality of life and dyspepsia are more severe.