Environmental and hereditary factors in the schizophrenias of age ("late paraphrenia") and their bearing on the general problem of causation in schizophrenia.
Environmental and hereditary factors in the schizophrenias of age ("late paraphrenia") and their bearing on the general problem of causation in schizophrenia.
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老年精神分裂症（“晚期精神分裂症”）的环境和遗传因素及其对精神分裂症因果关系一般问题的影响。
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发表时间：
1961
期刊：
影响因子：
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通讯作者：
M. Roth
中科院分区：
文献类型：
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作者：
D. Kay;M. Roth
1.对99例60岁以上（平均年龄70岁左右）的“晚发性妄想症”患者进行了临床随访和遗传学研究。患者分为两组，一组来自斯德哥尔摩的精神病医院（1931-1940年），另一组来自苏塞克斯郡奇切斯特的Graylingwell医院（1951-1955年）。年龄相近、入院时间相同的情感性和器质性精神障碍患者用于比较。这两种妄想症患者表现出相同的特征，可以概括如下：
㈠女性比男性多，比例约为7：1，即，大大超出预期。在两种性别中，未婚患者明显多于年龄相仿的一般人群，已婚患者较少见。已婚患者的生育率较低。
（ii）对疾病背景的研究表明，在患病时独居的妄想症患者明显多于情感障碍患者。这似乎是由几个因素造成的，即，未婚状态的频率和低生育率在精神错乱者中，他们也有更少的幸存同胞。
（iii）在独居者中，痴呆症患者比情感障碍患者在社会上“孤立”的人数要多得多。三个因素似乎是负责任的：（1）耳聋（2）性格异常（3）幸存的亲属很少。在格雷林威尔的妄想症患者中，有40%的人有不同程度的耳聋，在所有病例中，有15%的人有严重程度的耳聋，而在其他人群中，耳聋的发生率要低得多。妄想症患者和情感障碍患者的人格特征也有显著差异。在前者中，他们通常是偏执型的，并在很大程度上导致了婚姻失败，社会孤立，并可能导致精神病本身的发展。但与人格无关的因素，如没有亲戚，在决定是否发生孤立方面发挥了一定作用。
除了下文提到的一个亚组之外，临床表现非常一致，其特点是存在许多类似精神分裂症的思维、情绪和意志障碍，形式智力、人格和记忆保持得相对较好，以及明显的幻觉。在格雷林威尔的病例中，大约有20%的人完全没有幻觉，这种疾病似乎是对长期存在的偏离人格特征的一种讽刺;这些病例也许可以被视为对变老的身体和社会后果的“偏执反应”。但是，外源性因素（耳聋、孤独）或人格特征总是或多或少地存在，而且在不同的病例组之间是否真的存在任何明确的分界线是值得怀疑的。因此，在这个阶段，把“晚期妄想症”作为一个整体来对待似乎更有利。
（5）必须假定晚期妄想症的遗传倾向，但这种倾向的程度可能比发生在生命早期的精神分裂症要轻。遗传方式可能是多因素的。
（vi）大脑变性的病理程度可能与精神病的发病有关，但不超过5%。案件。正常的年龄特异性精神变化可能在更大比例的病例中导致了对先前人格异常的讽刺，并在这种程度上促成了精神病的发展。
（vii）病程往往是慢性的，精神分裂型的变化通常会变得更加突出，但有时会出现“耗尽”状态，并伴有残余缺陷。有时，这种疾病在多年后会合并成一种难以与老年痴呆症区分的状态（12%）。局灶性脑疾病的迹象，包括孤立的癫痫发作，最终出现在另外9%。平均寿命仅比正常人稍短，这一事实将晚期妄想症与预期寿命不到正常人四分之一的老年性精神病和动脉硬化性精神病明显区分开来。
2.该组的临床同质性，它与精神分裂症的关系，遗传和有机因素的影响，以及社会隔离，缺乏亲属，耳聋和异常的人格的作用进行了讨论。
3.结论：晚期妄想症应视为老年期精神分裂症的一种表现形式。因此，在晚期妄想症中发现的病因学因素可能与精神分裂症本身的病因问题有一定的相关性。人们认为，社会孤立的环境中出现高比例的妄想病例，在某种程度上是由于人格的自我隔离，对他们来说，社会接触和沟通很困难或有压力。但证据表明，隔离必须在某种程度上归因于偶然因素，如耳聋，在兄弟姐妹中的地位或幸存的关系不足。这些因素的累积效应可能是老年人最终崩溃的原因。在年轻人中，精神分裂症的发病有时可能是由于孤立，而不仅仅是孤立的原因，这些发现可能也与精神疾病的社会孤立问题有关。
1. A clinical follow-up and genetic study has been made of 99 patients aged 60 years and over (with a mean age of about 70) suffering from “late paraphrenia”. The patients consist of two groups, one from the Psychiatric Hospital, Stockholm (1931–1940)and the other from Graylingwell Hospital, Chichester, Sussex (1951–1955). Patients with affective and organic disorders of similar age and admitted during the same periods are used for comparison. Both paraphrenic groups show the same characteristics which may be summarized as follows:
( i )Females predominate over males in the ratio of about 7:1, i.e., significantly in excess of expectation. In both sexes unmarried patients are significantly more, and married patients less common than in the general population of similar age. Fertility among ever-married patients is low.
( ii )An examination of the background of the illness shows that significantly more paraphrenics were living alone at the time of falling ill than those with affective disorder. This appears to have been due to several factors, i.e., the frequency of the unmarried state and the low fertility among the paraphrenics, who also had fewer surviving sibs.
( iii )Of those living alone, many more patients with paraphrenia than with affective disorder were socially “isolated”. Three factors seem to be responsible: (1) deafness (2) abnormalities of personality (3) few surviving relatives. Deafness of some degree was found in 40 per cent. of the Graylingwell paraphrenics and of severe degree in some 15 per cent. of all cases, with a much lower incidence among the other groups. Personality traits among paraphrenics and affectives also differed markedly. Among the former they were commonly of paranoid schizoid type and contributed substantially to failure to marry, social isolation and probably to the development of the psychosis itself. But factors unconnected with the personality, such as absence of relatives, played some part in deciding whether isolation did or did not occur.
( iv )Except in one subgroup, referred to below, the clinical picture is remarkably uniform and is characterized by the presence of many schizophrenia like disorders of thought, mood and volition, by relatively good preservation of formal intellect, personality and memory, and by conspicuous hallucinations. In about 20 per cent. of the Graylingwell cases hallucinosis was entirely absent and the illness appeared to represent a caricaturing of deviating personality traits of long standing; these cases may perhaps be regarded as “paranoid reactions” to the physical and social consequences of growing old. But exogenous factors (deafness, isolation) or personality attributes are always to a greater or lesser extent in evidence, and it is doubtful if any clear lines of demarcation between groups of cases really exist. At this stage therefore it seems far more profitable to treat the “late paraphrenias” as a whole.
( v )An inherited predisposition to late paraphrenia must be postulated, but this is likely to be of lesser degree than in schizophrenia occurring early in life. The mode of inheritance is probably multifacturial.
( vi )A pathological degree of cerebral degeneration is probably related to the onset of psychosis in not more than 5 percent. of cases. Normal age specific mental changes may have been responsible in a further proportion of cases for a caricaturing of previous abnormalities of personality and to this extent have contributed to the development of the psychosis.
( vii )The course of the illness tends to be chronic and the changes of schizophrenic type usually become more prominent, but sometimes a “burnt out” state with residual defects is seen. Occasionally the illness merges after many years into a state difficult to distinguish from that of senile dementia (12 per cent.). Signs of focal cerebral disease, including isolated seizures, eventually appear in a further 9 percent. The mean life span is only very slightly shorter than normal, a fact which distinguishes late paraphrenia sharply from senile and arteriosclerotic psychoses where life expectation is less than one quarter of the normal.
2. The clinical homogeneity of the group, its relationship to schizophrenia, the influence of genetic and organic factors, and the roles of social isolation, lack of relatives, deafness, and abnormalities of the personality are discussed.
3. It is concluded that late paraphrenia has to be regarded as the mode of manifestation of schizophrenia in old age. The aetiological factors identified in late paraphrenia are therefore likely to have some relevance for the problem of causation of schizophrenia itself. It is considered that the setting of social isolation in which a high proportion of paraphrenic cases are found is due to some extent to a self-segregation of personalities for whom social contact and communication are difficult or stressful. But the evidence suggests that isolation must be attributed to some extent to accidental factors such as deafness, position in sibship or scantiness of surviving relations. The accumulating effects of such factors may account for final breakdown in old age. At younger ages also, the onset of schizophrenia is likely sometimes to be due to isolation, and not merely a cause of it. The findings perhaps also have some bearing on the general problem of social isolation in relation to mental illness.