분열형 인격장애

3. 진단

분열형 인격장애는 일반적으로 정신건강 전문가가 환자의 증상, 병력, 생활사 등을 종합적으로 평가하여 진단한다. 확진을 위한 특정 검사는 없으며, 기분 장애, 불안장애, 정신병적 사고 유무 등을 통해 다른 정신질환과 감별한다.

DSM-IV-TR 진단 기준은 다음과 같다.^[227]

• 관계망상적 사고 - 분명한 관계망상은 제외한다.
• 행동에 영향을 미치고 하위문화의 기준에 부합되지 않는 기이한 믿음이나 마술적 사고(예 : 미신, 천리안에 대한 믿음, 텔레파시나 육감, 아동이나 청소년에게서 보이는 기이한 환상이나 집착)
• 신체적 착각을 포함한 유별난 지각 경험
• 기이한 사고와 언어 (예 : 모호하고 우회적이고 은유적이고 지나치게 자세하게 묘사하거나 혹은 상동증적인 사고와 언어)
• 의심이나 편집증적인 사고
• 부적절하거나 메마른 정동
• 기이하고 엉뚱하거나 특이한 행동이나 외모
• 직계 가족 외에는 가까운 친구나 마음을 털어놓을 수 있는 사람이 없다.
• 자신에 대한 부정적인 판단보다는 편집증적인 두려움과 연관되어 있는, 친밀해져도 줄어들지 않는 과도한 사회적 불안.

• 관계적 사고 (관계 망상은 아님)
• 기이한 믿음^영어 또는 마술적 사고 (예: 초자연적 현상)
• 특이한 지각 경험 (목소리 들림, 해리 경험, 착각 등)
• 기이한 사고와 언어 (예: 한 주제에서 다른 주제로 건너뜀)
• 괴상한 행동 및/또는 외모
• 편집증적 사고
• 서로 일치하지 않거나 상황에 맞지 않는 기분과 표정
• 친밀한 지지자가 거의 없음 또는 없음
• 익숙한 사람과 있어도 지속되는 과도한 사회 불안

다음 장애와의 감별 진단도 고려해야 한다.

• 정신병적 증상을 동반한 다른 장애: (예: 조현병, 양극성 장애 또는 정신병적 특징이 있는 우울 장애)
• 편집성, 분열성 또는 회피성 인격 장애
• 해리성 정체성 장애
• 의사소통 장애

3. 1. DSM-IV-TR 진단 기준

• 관계적 사고 (관계 망상은 아님)
• 기이한 믿음 또는 마술적 사고 (예: 초자연적 현상 또는 가해자와의 특별한 관계 또는 유대감)
• 특이한 지각 경험 (목소리 들림, 해리 경험, 착각 등)
• 기이한 사고와 언어 (예: 한 주제에서 다른 주제로 건너뜀)
• 괴상한 행동 및/또는 외모
• 편집증적 사고
• 서로 일치하지 않거나 상황에 맞지 않는 기분과 표정
• 친밀한 지지자가 거의 없음 또는 없음
• 익숙한 사람과 있어도 지속되는 과도한 사회 불안

3. 2. ICD-10 진단 기준

• 관계적 사고 (관계 망상은 아님)
• 기이한 믿음^영어 또는 마술적 사고 (예: 초자연적 현상)
• 특이한 지각 경험 (목소리 들림, 해리 경험, 착각 등)
• 기이한 사고와 언어 (예: 한 주제에서 다른 주제로 건너뜀)
• 괴상한 행동 및/또는 외모
• 편집증적 사고
• 서로 일치하지 않거나 상황에 맞지 않는 기분과 표정
• 친밀한 지지자가 거의 없음 또는 없음
• 익숙한 사람과 있어도 지속되는 과도한 사회 불안

3. 3. 감별 진단

다음 장애와의 감별 진단도 고려해야 한다.

• 정신병적 증상을 동반한 다른 장애: (예: 조현병, 양극성 장애 또는 정신병적 특징이 있는 우울 장애)
• 편집성, 분열성 또는 회피성 인격 장애
• 해리성 정체성 장애
• 의사소통 장애

4. 원인

분열형 인격장애의 원인은 명확하게 밝혀지지 않았지만, 유전적 요인과 환경적 요인이 복합적으로 작용하는 것으로 추정된다.

== 유전적 요인 ==

분열형 인격장애는 환경적 요인 외에도 유전적 요인이 크게 작용하는 것으로 알려져 있다.^{[105][106][107]} 분열형 인격장애는 기분 장애,^[108] 조현병 등과 유전적 연관성이 높다.^{[109][107][110]}

COMT Val158Met 다형성과 그 Val 또는 Met 대립 유전자는 분열성 성격 장애와 관련이 있는 것으로 추정된다.^{[111][112][113][114]} 이 유전자들은 뇌 내 도파민 생산에 영향을 미치는데,^{[115][116][117]} 이는 분열형 특성과 관련된 신경 화학 물질로 여겨진다.^[118][119] CACNA1C 유전자의 rs1006737 다형성 또한 분열형 증상에 관여하는 것으로 여겨지는데,^[126] 이는 뇌의 코르티솔 각성 반응을 통해 스트레스에 대한 생리적 반응을 증가시킨다.^{[127][128][129][130]} 아연 핑거 단백질 ZNF804A는 분열형 인격장애의 편집증, 불안 및 관계 망상 수준에 영향을 줄 수 있다.^{[134][135][136]} NOTCH4는 조현병 스펙트럼 장애와 관련이 있는 것으로 생각되며,^[139][140] 후두 피질의 교란을 일으켜 분열형 증상으로 이어질 수 있다.^[141] GLRA1과 p250GAP 유전자 또한 분열형 인격장애와 관련이 있을 수 있다.^{[142][143][144]}

분열형 인격장애는 22번 염색체의 이상에서 비롯될 수 있다는 연구 결과도 있다.^{[149][150][151]} 다른 성격 장애보다 유전적 요소가 강하며, 조현병과 유사한 유전자 요인을 가지면서도 어떤 요인으로 인해 발병하지 않은 상태로 일반적으로 여겨진다.^[287]

== 신경학적 요인 ==

임신 23주차의 인플루엔자 노출이나 소아기의 불량한 영양 상태는 뇌 발달 과정을 변화시켜 분열형 인격장애(StPD) 발병에 영향을 줄 수 있다.^[152] 뇌 내의 높은 도파민 수치,^[153][154] 특히 D1 수용체가 StPD의 발달에 관여할 수 있으며,^{[155][156][157]} 선조체에서 증가된 도파민 활성과 관련이 있다.^{[158][159][160][161]} 또한 높은 전 시냅스 도파민 방출이 증상을 유발할 수 있다.^{[162][163][164][165]} StPD 환자는 꼬리핵에서 회백질 또는 백질의 부피가 감소할 수 있으며,^[166][167] 이는 언어 능력의 어려움으로 이어질 수 있다.^{[168][169][170][171]} 측두엽, 특히 좌반구의 부피 감소는 부정적 증상과 관련될 수 있다.^[175] 상측두이랑 또는 가로측두이랑의 회백질 또는 백질 부피 감소는 언어,^{[98][176][177][178]} 기억력, 환각 문제와 관련이 있다.^[179][180] 측두엽과 전전두피질의 회백질 부피 결함은 인지 능력, 감각 처리, 언어, 집행 기능, 의사 결정, 정서 처리의 손상과 관련이 있을 수 있다.^[181][182] 정보를 대뇌 피질로 전달하는 내포 감소,^{[183][184][185][186]} 변연계의 일부를 연결하는 갈고리다발의 손상도 StPD 증상에 영향을 줄 수 있다.^[187] 중간 전두이랑과 브로드만 영역 10에서 회백질 수치가 감소하지만, 조현병 환자만큼 감소하지는 않아 조현병 발병을 막을 수도 있다.^[188][189] 소뇌에 의한 이랑의 증가된 굴곡은 뇌의 연결성 이상, 따라서 분열형 증상으로 이어질 수 있다.^[190][191] 과소 반응성^[192] 또는 과잉 반응성 편도체,^[193] 과다 활성 뇌하수체와 미상핵을 가질 수 있다.^[194][195] 사전 펄스 억제 능력 저하,^{[196][197][198][199]} 호모바닐산 농도 증가,^[200] 투명 중격강의 이상이 나타날 수도 있다.^[201] 조현병 스펙트럼 장애 발병 경향이 있는 사람은 대마초를 섭취하면 StPD 또는 정신병적 증상이 있는 다른 장애가 유발될 수 있다.^{[202][203][204][205]}

== 환경적 요인 ==

독특한 환경적 요인들은 형제간 공유되지 않는 경험과는 다르며, 분열형 인격장애(StPD)와 그 증상의 발달에 영향을 미치는 것으로 밝혀졌다. 양육 방식, 이른 시기의 분리, 아동기 외상, 아동기 방임이 분열형 성격 특성의 발달로 이어질 수 있다는 증거가 있다.^{[206][207][208]} 아동기의 방임, 학대, 스트레스,^[209] 외상,^{[210][211][212]} 또는 가족 기능 장애는 분열형 성격장애 발병 위험을 증가시킬 수 있다.^{[213][214][215]} 또한 산전 기간 동안의 뇌 발달 장애가 StPD의 발달에 영향을 미칠 수 있음을 시사하는 증거도 있다.^[216]

시간이 지남에 따라 아이들은 사회적 신호를 해석하고 적절하게 반응하는 법을 배우지만, 알 수 없는 이유로 이 과정이 이 장애를 가진 사람들에게는 제대로 작동하지 않는다.^[217] 아동기 동안, StPD를 가진 사람들은 부모로부터 감정 표현을 거의 보지 못했을 수 있다. 또 다른 가능성은 그들이 과도하게 비판을 받았거나 끊임없이 위협을 느끼는 듯한 느낌을 받았을 수 있으며,^[218] 잠재적으로 사회적 불안, 이상한 사고 패턴,^[219] 그리고 StPD에 나타나는 둔마된 정동의 발병으로 이어질 수 있다.^{[220][219][221]} 사회적 상황에서의 어려움은 결국 개인이 대부분의 사회적 상호 작용에서 물러나게 하여 비사회성으로 이어질 수 있다.^[222] 분열형 증상을 보이는 아이들은 보통 내적 환상에 더 탐닉하고,^[223] 더 불안하고, 사회적으로 고립되며, 비판에 더 민감하다.^[224] StPD가 가장 심한 사람들은 보통 아동기 외상과 그들의 상태에 대한 유전적 근거를 함께 가지고 있다.^[225][226]

4. 1. 유전적 요인

4. 2. 신경학적 요인

4. 3. 환경적 요인

5. 치료 및 관리

분열형 인격장애는 임상 현장에서 주된 치료 대상으로 드물게 나타나지만, 불안장애나 우울장애 등 다른 정신 질환과 함께 진단되는 경우가 흔하다.^[291] 약물치료를 받게 되는 경우 할로페리돌 등의 조현병치료제가 쓰이게 되는 경우가 많다. 미국의 정신과의 폴 마르코비츠(Paul Markovitz)는 환자를 2가지 케이스로 분류했는데, 환자가 인식의 이상 등 거의 조현병에 가까운 증세를 보이는 경우 (또한 이것이 오랜 기간 지속되었으며 신경이완제가 효과적이지 않을 경우) 항정신병제를, 환자가 자신의 신념이나 행동에 강박적인 모습을 보이는 경우 SSRI를 쓰는 것이 더 효과적일 것이라고 하였다.^[291]

전체 인구의 3%가 분열형 장애의 경향을 보인다는 연구가 있으며, 이에 따르면 여성보다는 남성에게서 조금 더 흔하다.^[292] 조현병과의 유전적, 생리학적 관계가 있다고 예상되어 조현 스펙트럼(schizophrenia spectrum)에 포함되며, 실제로 조현병으로 발전하는 경우도 존재한다.

5. 1. 약물 치료

5. 2. 심리 치료

6. 역학

분열형 인격장애는 전체 인구의 3%가 분열형 장애의 경향을 보인다는 연구가 있으며, 여성보다는 남성에게서 조금 더 흔하다.^[292] 지역 사회 연구에서 보고된 분열형 인격 장애 유병률은 노르웨이 표본에서 1.37%에서 미국 표본에서 4.6%에 이르기까지 다양하다.^[87] 미국의 대규모 연구에 따르면 평생 유병률은 3.9%이며, 남성(4.2%)이 여성(3.7%)보다 다소 높았다.^[10] 임상 집단에서는 드물 수 있으며, 최대 1.9%의 유병률이 보고되었다.^[87] 일반 인구의 최대 5.2%에서 유병률이 있는 것으로 추정된다.^[88] 2008년 뉴욕 연구에 따르면 다른 A군 인격 장애와 함께, 드롭인 센터에 나타나는 노숙자에게도 매우 흔하게 나타난다.^[89] 분열형 장애는 러시아 및 기타 구소련 국가에서 과잉 진단될 수 있다.^[90]

7. 예후

분열형 인격장애 증상은 보통 어린 시절부터 나타나며,^[91] 시간이 지남에 따라 비교적 일관되게 나타나는 경향이 있다.^[92][93] 그러나 증상의 심각성과 안정성은 크게 변동할 수 있다.^[94][95] DSM은 분열형 인격장애를 관계 망상, 기이하거나 마술적인 믿음, 사회 불안, 친한 친구가 없음, 기이하거나 괴상한 행동, 기이한 언어, 특이한 지각, 의심, 분열-강박 행동^[96] 및 정동 둔마의 9가지 주요 증상으로 특징짓는다.^[97]

분열형 인격장애가 있는 남성과 여성의 증상에는 성별 차이가 있을 수 있다.^[98] 이 장애가 있는 여성은 덜 심각한 인지 결손, 더 심각한 사회 불안 및 마술적 사고를 가질 가능성이 높다.^{[99][100][101]} 분열형 인격장애가 있는 사람들은 고등학교만 졸업하고 실업 상태이며,^[102] 상당한 장애를 겪을 가능성이 더 높다.^[103] 편집증과 비정상적인 경험은 변할 가능성이 가장 낮은 두 가지 특징이다.^[95]

분열형 인격장애가 없는 사람에 비해, 이 장애가 있는 청소년은 인터넷 사교에 더 많은 시간을 보내고, 직접 사교에는 더 적은 시간을 보낸다.^[104] 강박 장애 (OCD) 행동 치료 및 약물 치료에 저항하는 사람들은 분열형 장애가 공존할 수 있다.^[96]

8. 같이 보기

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