【学位级别】医学博士
【论文完成日期】2004-05-1
【论文中文题名】北京市高中学生人格障碍的流行病学研究
【论文外文题名】An
epidemiology study of personality disorder among senior high school
students in Beijing
【论文著者】黄悦勤
【中文文摘】
目的
通过流行病学现况调查的方法描述北京市高中学生人格偏离和人格障碍的流行强度；通过病例对照研究广泛筛选人格障碍在青春期的生物遗传学和社会心理学可疑危险因素，建立人格障碍的遗传和环境病因假设，并通过队列研究进行检验，同时观察和描述青少年人格偏离的自然史；通过社区干预试验，建立社区青少年人格障碍的心理健康教育的干预模式，并进行效果评价。
方法
应用系列的流行病学研究方法——现况调查、病例对照研究、队列研究、社区干预试验的方法，按照ICD-10和DSM-IV的标准，采用人格诊断问卷第四版（PDQ-4）、国际人格障碍检查表（IPDE）、父母养育方式问卷（EMBU）和一般情况问卷，调查北京市10039名高中学生及其父母，并随访三年，进行精神卫生健康教育。采用现代流行病学单因素和多因素的分析方法分析资料。
结果
一、现况调查 （1）高一学生PDQ-4量表总分为25.38±9.64，男性明显高于女性，乡村明显高于城市，学校类型由高至低依次为普通高中、区重点高中、市重点高中，差异有显著性。人格偏离现患率为8.3%，男性明显高于女性，乡村明显高于城市，学校类型由高至低依次为普通高中、区重点高中、市重点高中，差异有显著性。学生填EMBU父母相同因子得分高度相关；因子分析获得四个公因子。（2）高三学生PDQ-4量表总分为23.10±10.20，量表总分男性明显高于女性。人格偏离现患率为5.8%。总体人格障碍患病率为1.8%；父母填EMBU因子得分相关系数均有显著性；因子分析获得四个公因子；总体人格障碍的父亲和母亲遗传度分别为0.71和0.72，各组人格障碍的遗传度多数大于0.6。
二、病例对照研究
（1）高一学生资料的单因素分析筛选出危险因素有男性、乡村居住地区、父母关系不良、家庭收入低、独生子女、非重点高中、乡村学校、年龄大、与父母居住年限短、父母的否认拒绝型、过度保护型、偏爱型和非情感温暖型养育方式。Logistic回归分析筛选出总体人格偏离的危险因素有父母关系不良、学校所在区县、父母的过度保护型、偏爱型、否认拒绝型和非情感温暖型养育方式、与父母同住年限短和男性。各组人格偏离的分析结果类似。（2）高三学生资料的单因素分析筛选出危险因素有父母关系不良、家庭收入低、父母的否认拒绝型和过度保护型养育方式。Logistic回归分析筛选出总体人格偏离的危险因素有父母关系不良、父母的过度保护型、否认拒绝型、偏爱型和非情感温暖型养育方式。Logistic回归分析筛选出总体人格障碍的危险因素有父母关系不良、父母的否认拒绝型和过度保护型养育方式。各组人格障碍的分析结果类似。经计算总体人格障碍的父亲和母亲遗传度分别为0.84和0.85，各组人格障碍的遗传度多数大于0.6。
三、队列研究
（1）单因素分析人格偏离发病率差异有显著性的暴露因素有性别、父母的情感温暖型、过度保护型、否认拒绝型和偏爱型养育方式。父母否认拒绝型和过度保护型养育方式的RR分别为2.60和2.31，女性的RR为0.64。Logistic回归分析总体人格偏离的危险因素有父母关系不良、父母的否认拒绝型和过度保护型养育方式；各组人格偏离的分析结果类似。（2）单因素分析人格障碍发病率差异有显著性的暴露因素有父母的否认拒绝型和过度保护型养育方式。父母否认拒绝型和过度保护型养育方式的RR分别为2.45和2.80。Logistic回归分析总体人格障碍的危险因素有父母的否认拒绝型和过度保护型养育方式。各组人格障碍的分析结果类似。（3）人格偏离和人格障碍的自然转归：非干预组的结果是高一时人格偏离者三年自愈率为71.0%，非人格偏离者三年人格偏离的新发率为4.0%；高一时人格偏离者至高三时人格偏离维持阳性率是无人格偏离者人格偏离新发率的7.25倍。高一时非人格偏离者三年后人格障碍的发病率为1.1%；高一时人格偏离者至高三时人格障碍的发病率是无人格偏离者发病率的9.6倍。
四、社区干预试验 （1）干预组与非干预组高一时PDQ-4量表总分、各组量表分和人格障碍现患率差异均无显著性，高三时干预组量表分明显低于非干预组，但人格偏离现患率差异无显著性。（2）高三PDQ-4量表分和人格偏离现患率较高一明显下降，高一与高三人格偏离和人格障碍的OR分别为1.54和1.46。（3）干预组和非干预组发病率单因素配对比较差异无显著性，Logistic回归分析总体人格障碍的危险因素有父母关系不良、父母的否认拒绝型和过度保护型养育方式；各组人格障碍分析的结果类似。（4）干预组人格偏离新发率为3.4%，低于非干预组新发率4.0%；但差异无显著性。干预组人格障碍发病率为0.8%，低于非干预组新发率1.1%；但差异无显著性。（5）干预前后横断面比较PDQ-4量表总分高一时干预组与非干预组差异无统计学意义，高三时干预组明显低于非干预组；纵向比较干预组和非干预组PDQ-4量表分三年后均明显下降，成组和配对比较差异均有高度显著性。高一阴性至高三维持阴性组中干预组三年前后PDQ-4量表总分下降的差值明显大于非干预组三年前后差值。干预前后横断面比较总体人格偏离现患率高一时干预组与非干预组差异无显著性；高三时人格偏离现患率差异仍然无统计学意义；纵向比较干预组和非干预组率的总体人格偏离现患率三年后均明显下降。在各组人格偏离现患率中干预组C组和偏执型、自恋型、边缘型人格偏离的新发率低于非干预组，干预效果较好。
结论
（1）首次调查了北京市高中生人格偏离和人格障碍流行强度，结果是北京市高中学生人格偏离的现患率低于国外患病率，且随年龄增长而下降，有明显自愈趋势；人格障碍的患病率和发病率亦处于较低水平；高一出现人格偏离者高三时人格障碍发病率明显高于人格正常者。（2）建立并检验了人格障碍遗传和环境病因假设，证实对于人格障碍的发生，广义遗传因素的作用约占85%；人格障碍的家庭环境危险因素是父母关系不良和否认拒绝型及过度保护型养育方式。（3）建立了青少年心理健康教育的干预模式并评价了干预效果，证实社区人群预防人格障碍发生的青春期心理健康教育的干预模式对青少年是行之有效的，可以促进高中学生群体精神卫生水平的提高。
关键词
人格障碍
流行病学
青少年
干预
健康教育
【外文文摘】
Objective
To describe personality disorders (PD) among senior high school students
in Beijing, to explore genetic and environmental risk factors of PD, and
to establish an intervention model of mental health education for
adolescents in community.
Method
Using cross-sectional study,
case-control study, cohort study, and community intervention trial,
10039 senior high school students were investigated with Personality
Disorder Questionnaire-fourth edition (PDQ-4), EMBU, General Information
Questionnaire, and International
Personality Disorder Examination (IPDE)
to diagnose PD according to the criteria of ICD-10 and DSM-IV. The subjects were followed up for three years to
observe the dynamic change of personal disorder and to evaluate
the effect of intervention measure of mental health education. The single
and multivariate analysis methods were applied for data processing.
Results
(A) Cross-sectional study: a)
Among first grade students, the mean score of PDQ-4 was 25.38±9.64
with different distributions by gender, residential area, and rank of
school. The prevalence rate of personality dysfunction was 8.3% with different distributions by gender, residential area, and rank of school.
b) Among third grade students, the mean score of PDQ-4
was 23.10±10.20 with different distributions by gender. The
prevalence rates of personality dysfunction and PD were 5.8%
and 1.83%,
respectively. The
inheritability of overall PD of father and mother were 0.71and
0.72, respectively. The heritability of each PD cluster was higher than
0.6. (B) Case-control study: a) Among first grade students, the risk
factors of PD were poor parental relationship, rural residential area,
parental rejection, over- protection, favoring subject, non-emotional
warmth, less years of living with parents, and male. b) Among third grade
students, the risk factors of PD were poor parental relationship, parental
rejection and over-protection. The heritability of overall PD of father
and mother were 0.83 and 0.85, respectively. The
heritability of each PD cluster was higher than 0.6. (C) Cohort study: a)
The risk factors of personality dysfunction were poor parental
relationship, parental rejection and over-protection. b) The risk factors
of PD were parental rejection and over-protection. c) The dynamic changes
of personality dysfunction and PD: the self-recovering rate of personality
dysfunction was 71.0%,
and the incidence rate of personality dysfunction was 4.0%. The prevalent
rate of personality dysfunction among students with personality
dysfunction at the first grade was 7.25 times higher than that of the
students without personality dysfunction. The incidence rate of PD was
1.1%. At meantime, the incidence rate among students with personality
dysfunction at the first grade was 9.6 times higher than that of the
students without personality dysfunction. (D) Community intervention
trial: a) PDQ-4 scores of the intervention group were significantly lower
than those of the non-intervention group. b) PDQ-4 scores and incidence
rates of PD at the third grade were significantly lower than those at the
first grade. The ORs of personality dysfunction and PD were 1.54 and 1.46.
c) Logistic regression
analysis yielded risk factors of overall PD including poor parental
relationship, parental rejection and over-protection. d) The incidence
rate of personality dysfunction was 3.4% in the intervention group, and 4.0% in the
non-intervention group. The incidence rate of PD
was 0.8%
in the intervention group, and 1.1% in the non-intervention group, but no
statistical differences were found among them. e) The mean score of PDQ-4
in intervention group was significantly lower than that in
non-intervention group. The PDQ-4 score showed significant decline during
three years. But the prevalence rates had no statistical difference
between intervention and non-intervention groups. Moreover, the prevalence
rates of personality dysfunction significantly decreased after three
years. The incidence rates of cluster C, as well as paranoid, narcissistic
and borderline PD were statistically decreased by intervention.
Conclusions
(A) The prevalence of personality dysfunction in Beijing, China is lower
than those in other countries, and it declines with growing up. The
incidence and prevalence rates of personality disorder are relatively low
as well. There is a self-recovery tendency of personality dysfunction. The
students with personality dysfunction at the first grade are more liable
to be diagnosed as personality disorder at the third grade compared with
the students without personality dysfunction. (B) The genetic factor plays an important role in the development of PD.
Family environmental risk factors include poor parental relationship,
parental rejection and over-protection. (C) The mental health
education during adolescence contributes to promotion of mental health for
adolescents.
Key words
Personality disorder, epidemiology, adolescent, intervention, health education