DIENDAN Y HOC
Nghien ciJu khoa hp<
Nghien ciJu tac dong cua ao thanh ra lenh doi vdi cam xuc - hanh vi d benh nhan tam than phan Net
Nguyin Kim Viet*
TOM TAT
Ao thanh ra lenh (ATRL) la tieu chuin chin doan tam thin phan Het (TTPL) theo ICD-10. ATRL cd lien quan ro ret din cac hanh vi bao luc cua benh nhan. 6 Viet Nam chua cd nghien ciiu he thdng nao vi vin di nay IVIuc tieu; danh gia ty le ATRL trong sdcac benh nhan TTPL cd cac hanh vi bao luc. Xac djnh cac yiu tianh hudng din su tuan thu va cac phudng thiic dii phd cua benh nhan vdi ATRL. Bo'i tifong; nghien ciiu 65 benh nhan dap ling tieu chuin chin doan tam thin phan Het theo ICD. 10 cd ao thanh vao diiu tn trong 5 thang lien tuc tai Vien Siic khoe Tam thin va Vien Giam djnh phap y Tam thin Trung Udng. Phugng phap; tiin ciiu, md ta lam sang, dua tren cac tieu chuin chin doan cua ICD-10. Ki{ qua: ATRL odd 53,8%
benh nhan. Su tuan thu menh lenh cd d 62,8% cac benh nhan. ATRL cd ngi dung bao luc cd d 52,4% cac benh nhan. Tiin sir cd rdi loan hanh vi cd d 63,6% benh nhan. Su kit hgp hoang tudng cd d 77,2% benh nhan. Phuang thiic dii phd bang vai lay cd d 7/13 benh nhan. Ke't luan: ATRL la kha phd biin va chi phii rd ret cac hanh vi bao luc cua cac benh nhan TTPL. TiSn sd rii loan hanh vi va cd su kit hgp cac hoang tudng la nhOng yiu td thiic diy su tuan thu menh lenh cua AT. Phuang thiic ddi phd phd biin la cac hanh vi cd tinh nghi li, ton giao...
I. DAT VAN DE
Ao thanh (AT) la rdi loan khi phd biin trong benb tam thin phan liet (TTPL), dac biet AT binh pham ve birth vi tu each cua benh fihln. Ao thanh ra lenh (ATRL) dugc coi la mdt
trong nhiing tieu chuan dae biet d i chan doan TTPL theo ICD-10. Theo y van [1] 1/3 sd bgnh nhan cd ao giac II cd ATRL. Nhiiu tic gia [2][4] eho rang ATRL cd lien quan rd ret din cam xuc, hinh vi ciia benh nhin TTPL, dae biet la cac hanh vi nguy hiem, cd dnh bao lire, chdng ddi xa hdi, giet ngudi, tu sit... Roger va edng su cho ring 5,8% benh nhan loan thin da thtrc hien cic hanh vi pham tdi do tic dgng ciia ATRL. Mot nghien eiiu khlc [5] cho thly
* Vien Sdc khoe Tam than
43,6% cic ddi tugng cd lien quan din gilm djnh phip y tam thin (GDPYTT) ed AT.
Su tuan thii ele ATRL dugc thly cd lien quan voi nhieu yeu td. Kasper va edng su eho ring hlu bet ele benh nhin tuan thu theo cac menh lenh eua AT ke ca cae menh lenh ed tinh bag lire hay khdng va khdng le thugc vao ngudn goc eiia AT.
O Viet Nam, eac nghien cthi vi linh vuc nay mdt each he thdng chua nbilu. Nghien cuu cua chiing tdi nham mot sd mue tiSu sau dly:
- Danh gil budc dau ty le ATRL trong sd cae benh nhin TTPL cd ao thanh.
- Xlc djnh ele yeu td cd anh hudng den sir tuan thii ATRL.
- CIc phuang thuc ddi phd ciia benh nhan vdi ATRL.
48 IY HOC LAM SANG Sd 43 (Thang 08/2009)
DIENDAN Y HOC
Nghien cu'u khoa hpc
II. DOI TirgNG VA PHirCTNG PHAP NGHIEN CUU - Ddi tugng la cae benh nhin dugc chan doln TTPL theo tieu chuan ICD-10, cd AT, duge diiu trj tai Vien SKTT va Vien GDPYTTTW tir thing 10 nam 2008 din thing 3 nam 2009. Loai trir cac benh nhan lam dung ehit, ed benh than kinh vl eo the kem theo. Benh nhin duge theo ddi trong qui trinh dieu trj, ddng thai hci cuu benh sir ve ele rdi loan hinh vi (tu gay thuang tdn, tu sat, bao lue, vi pham luat le xa hdi...).
CIc hanh vi bao luc duac xlc dinb II moi hanh
vi thd bao, tan cdng, ham hiep hoac de dga hinh hung ngudi khlc...
- CIc AT duge dinh gil II cd ra lenh, thiic ep, dieu khien banh vi, cam xuc ciia benh nhan hay khdng. Yeu cau benh nhan md ta ngi dung, ngudn goc eiia AT...
- ATRL dugc phan loai la eac menh lenh cd bao luc hay khdng, benb nhan da thuc hien menh lenh hay du djnh thuc hien song bi can trd bdi hoan canh ben ngoai. Cac phuong thtic ma benb nhan diing de ddi phd, chdng lai ele menh lenh...
- Xii ly sd lieu theo truong trinh Epi. Info 6.01.
III. KET QUA NGHIEN CUU
Bang 1. Dac diem ehung nhdm benh nhdn nghien ciiu STT
1 2 3 4 5 .
Cdc dgc tnmg Nam
NO-
Tuoi trung binh khi vao vien Tuoi vao vien Ian dau So lan nam vien trung binh Thai gian bi benh
CdATRL 19(54,2%) 16(48,5%)
30,5 26,2 3,3 6,3
Khong ATRL
16 14 32,6 27,3 4,7 7,4
Benh nhdn cd AT 35 30
65 31.5 26,8 4 6,9
Nhdn xet: lo thanh ra lenh ed d 35 berth nhan (19 nam va 16 nii), chiim ti le 53,8% trong sd 65 benh nhan tam than phan liet ed ao thanh.
Bdng 2. Dac diim nhdm BN cd ATRL (35/65 - 53,8%) STT
So trudng hop Tyle%(n=35)
Siftudn thd Co
22 62,8
Khong 13 37,2
Noi dung ATRL Bao luc
19 54,2
Khac 16 5,8
Doi tirong gay ATRL Ngudi n6i
24 66,8
Sieu nhan 11 28,7
Nhdn xet: sir tuan thii menh lenh lo thanh cd d 62,8% ele benh nhan vl chii yeu la do ele l o thanh ra lenh la tieng ngudi ndi (66,8%).
Bdng 3. Dac diem nhdm BN tuan thu menh lenh AT (22/35 - 62,8%) STT
SL
%
Tien sir bao lire Co
14 63,6%
Khong 8 34,4%
Hoang tieong ket hop Co
17 77,2%
Khong 5 22,8%
Muc tieu bao lire Ban than
7 27,3%
Nguo'i xung quanh 15 72,7%
Nhdn xet: hdang tudng ket bgp cd d hau bet cdc benh nhdn (77,2%). Da sd cac benh nhan dd cd ele hanh vi bao luc trong tien sir (63,6%).
So43(ThangCS/2009) Y HOC LAM SANG I 4 9
DIEN DAN Y HOC
Nghien CL?u khoa hpc
Nhdn xet: hoang tuong ket bgp cd d bau bet cac benb nhan (77,2%). Da sd ele benh nhan dd cd ele hanh vi bao lire trong tien su (63,6%).
Bdng 4. Cdc phuong thuc ddi phd & nhom BN khdng tudn thu menh lenh cdc AT (13/35 benh nhdn)
STT 1 2 3 4
Phuong thuc thudng dung Bit tai
Ndi cbuyen, eai nhau vdi AT Vli lay
KhIe (nghe nhac, xem truyen binh...)
Sd trudng hop 4 3 7 6
Nhdn xet; phuong thiic ddi phd vdi ATRL blng ele le nghi tdn gilo (vli lay) cd d 7/13 BN
IV. BAN LUAN
Trong sd 65 benh nhin TTPL ed AT va dieu trj (bang 1), chiing tdi thay mdt ty le kha cao cae benh nhan ed ATRL (35BN): 53,8%. Trong dd cd 19 BN la nam (54,2%) vl 16 BN la nir (45,8%). Ddng thdi ehiing tdi cung nhan thay ty le cao ele benh nhin tuan thii theo menh lenh ciia AT (22 BN):
62,8%. Trong khi ty le tuan thii menh lenh ciia AT d nghien ciru ciia ele tie gil khlc II 39%
(Junginger I, Gillis FB, Tunner RE, Frise-Smith T) din 84,8% (Kasper MS, Roger R, Adam PA)
[1][3].
Chiing tdi cling nhan thly (bang 2) la ele benh nhan tuan thii nhieu hon vdi ele menh lenh cd tinh bao lue (54,2%). Dieu nay bgp vdi nhan xet trong ngbiert eiiu ciia Kasper va edng su la 67% benh nhan da tuan thii cac ATRL cd tinh thd bao vdi chinh ban than cua minh. Me Niel xlc nhan cd mot mdi tuong quan rd ret giira ndi dung, tinh chat AT ra lenh vdi eac hanh vi bao luc. Trong sd 103 BN nghien cuu, cac tie gil tbly 22% cac BN tuan thii cac menh lenh gay thuang tdn eho ngudi khlc, va nguy CO ed hanh vi thd bao, kich dgng, tin edng...
cao gap hai lan d nhdm cd ATRL vdi ngi dung bao luc so vdi nhdm cd cic AT khlc [1][4]. Tuy nhien, su khlc biet ve ty le giira cac nghien eiiu khae nhau duge ele tic gia eho la khd giai thich do ele nghien eiiu dugc tien hanh tren nhiing quIn the benh nhin khlc nhau (vi du d ele Benh vien Tam than bay co sd gilm dinh), hole khlc nhau ve phuong phap nghien cuu, tieu chuan chan doln, tien sir lam dung chat va cd the cd ca sukhac biet ve van hda xa hdi...
Yeu td khac Inh budng den sir tuan thu dugc nhiiu nghien eiiu xae nhan la ngudn gde ciia ATRL. Trong nghien eiiu ciia chiing tdi AT la tiing ngudi ndi ra lenh
thay d 24 BN (66,8%), cae AT cd ngudn gde sieu nhin (thin thanh, ma quy, ngudi ngoai vu tru...) ehi thay d 28,7% eac benb nhin. Junginger cung nhan thay eac ddi tugng cd AT cd ngudn gde la tieng ngudi ndi thudng tuan thu menh lenh nhieu hon so vdi AT cd ngudn gde khlc. Beck-Sander va cdng sunhan xet:
sir tin tudng ciia BN ddi vdi tieng ndi ao giac cd y nghia quan trgng trong viec tuan thii menh lenh eiia hg. Neu tieng ndi la eua ngudi quen biet (ngudi than, ban be, ddng nghiep...) BN thudng tuan thii nhieu ban ele tieng ndi xa la, mo hd [5]. Rudnick trong khi tdng quan bdn ngbiert cdu khac nhau ciing nhan thly ed mdi lien quan true tiep giiia viee tuan thii menh lenh AT vdi ea hai yeu td la su nhart biet rd rtdi dung va tinh quen thude ciia tieng ndi ao giac [2].
Tir bang 3 chiing tdi nhan thay cd mdi lien quan giira tien sir da tiing ed ele hanh vi thd bao (63,6%) va viec tuan thii ATRL. Nhirng ngudi cd tien sir rdi loan hanh vi hoac de cd ele xung dgng khdng kiem che dugc... duge coi la mdt td chit sinh hgc bat thudng, llm tang tinh nhay cam eiia bg vdi ele menh lenh cd ndi durtg thd bao va viec thuc hien ele AT dd.
Ciing tir bang 3, cbimg tdi nhan thay d 77,2%
sd benb nhan tuan thii merth lenh AT la ed hoang tudng ket hgp de tao nen mdt benb einh Paranoid dien hinh. Cac hoang tudng thudng gap vdi ele ndi dung bj truy hai, bj tic dgng vat ly, bj chi phdi... CIc hoang tudng nay cd the la nguyen phIt hoac thii phIt sau khi xuat hien ao gilc. Diiu nay phii hgp vdi rtban xet ciia nhieu tie gil [2][4][5]:
ele hoang tudng cd vai trd quan trgng trong viee cbi phdi hanh vi, elm xiic cua ele benb nhan, nhat la viec tuan thii ele menh lenh ciia ao giac d ele benb nhan TTPL.
5 0 j Y HOC LAM SANG So 43 (Thang 08/2009)
DIEN DAN Y HOC
Nghien ciiu khoa hpc
Trong sd benh nhan nghien ciiu eiia chiing tdi cd tdi 72,7% benb nhan thuc hien ele hanh vi thd bao, tan cdng ngudi than hole ngudi xung quanh. Theo Roger vl cdng su [4] thi ty le ele benh nhan cd cic hanh vi tu gly thuang tdn lai gap nhiiu ban (60%). Su khlc biet nly cd le vi ehung tdi nghien eiiu ca ele benb nhin trong ele CO sd giam dinh pblp y tam than.
Vdi cac benh nhanN khdng tuan thii menh lenh ciia AT, ele phuang thiic ddi phd ciia bg rlt da dang. Mdt benh nhan cd the sir dung nhieu phuang thirc de chdng ddi lai AT d ele thdi diem khae nhau. Vli lay dugc thay II phuong thirc phd bien hon (7/13). CIc tic gia [5] cho rang day dudng nhu II cleh d i p ling ciia nhirng BN coi AT la gigng ndi eua chua trdi, than phat hay ciia ma quy... Trong nghien ciru eiia Tepper vl cdng su [6] cd 80% ele benh nhan sir dung ele hanh vi cd tinh le nghi tdn gilo de ddi phd vdi cic trieu chiing benh ly tam than eiia minh va vli lay la hinh vi thudng gap nhat. Nhiiu nghien eiiu khlc [1][5] ggi y: vdi ele benh nhan TTPL tu chdi udng thude hoac khIng tbudc, lieu phip nhan thtrc hanh vi nhiiu khi lai cd bieu qua dang ke vdi cac trieu chiing loan than.
Cd phuang thiic nhlm lam gilm bat su thdi thiic hoac che md tie ddrtg ciia ao thanh nhu nghe nhac, xem truyen hinh, ndi chuyen vdi ngudi khac cung duge sir dung d 6/13 benb nhan. Theo Tarrier va cdng su, viee nhan biet va khuyin khieh ele phuong thirc ddi phd rieng eiia mdi benb rtban se lam tang dang ke hieu qua chdng lai tic ddng ehi phdi eua ATRL [5] [6].
V. KET LUAN
Tren co sd nghien ciru 65 benh nhin TTPL cd AT ehiing tdi nhan thay ATRL la trieu chirng khi phd biin (53,8%). Viec tuan thu ATRL thiy d 62,8% berth nhan, nhat II cic l o thanh vdi ndi dung bao lire (52,4%) va ao thanh II nhtrng tiing ndi quen thude (66,8%). Tien sir cd ele rdi loan hanh vi cd tirth bao luc (63,6%) va sir kit hgp vdi ele hoang tudng (77,2%) la nhihig yiu td llm tang su nhay cam vl tuIn thii menh lenh eua ao thanh.
CIc hinh vi cd tinh nghi le tdn gilo (vli lay) duge cho II phuong thuc ddi phd phd bien eiia benh nhan vdi menh lenh cua ao thanh (7/13BN) • TAI LIEU THAM KHAO
1. Kasper ME, Roger R, Adam PA (1996).
Dangerousness and command hallucination; an investigation of psychotic inpatients. Bull Am Acad psychiatry Law. No.3. page 219 - 224.
2. Rudnick A (1999) Relation between command hallu- cination and dangerous behaviour J. Am Acad psy- chitry Law. No.2. page 253 - 257.
3. Junginger J (1990). Predicting compliance with com mand hallucination. Am J psychiatry. No.6.
page 245 - 247.
4. Rogers R. Gillis JR, Turner RE, Frise-smith (1990) The clinical presentation of command hallucinations in
forensic Population. Am, J Psychiatry page 304 - 307.
5. Beck-Sander A. Birchwood M. Chadwick P. (1997).
Acting on command hallucination; a cognitive approach Br J. Clin, psychol. No.4. page 139-148.
6. Tepper L, Roger SA. Coleman EM. Malony HN (2001). The prevalance of religious coping among persons with persistent. Mental illness. Psychiatry services. No.4. page 660 - 665.
SUMMARY
COMMAND HALLUCINATION IN SCHIZOPHRENIA PATIENTS
Command Hallucination (CH) is a diagnostic criteria of schizophrenia according to ICD-10. CH.
affect strongly to violent act of patients. So far in Vietnam there arent systematic study on this field.
Objective: to establish the prevalence of CH among schijophrenia patient with violent behaviour and to identify the factors that affect compliance with the command, together with patients coping methods.
Methods: perspective study, clinical description were based on criteria of ICD-10.
Results: 65 patients met researching criteria. CH were 53.8%. Compliance with command were 62.8%.
CH having violence contents were on 52.4% patients. History of behavioral disorders were on 63.6%, delusion coexisted on 72.7% patients. Praying to cope with command were seen on 7/13 patients.
Conclusion: CH are very common and they affected strongly on violent acts of schizophrenic patient.
History of behavioral disorder and coexistance ofdellusion are factors that actuate compliance with the command. Most frequent method to cope with command are religious retuals.
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