刑事案件精神病鉴定的诊断与既往精神病诊断的一致性

目的:探讨刑事案件中司法精神病鉴定的诊断(简称鉴定诊断)与既往精神病诊断(简称既往诊断)的一致性,从人口学特征、病史资料的角度分析相关影响因素。方法:本研究为期限两年的纵向研究,于2016年1月至2017年12月连续纳入既往有精神病诊断的刑事责任能力鉴定的案例173例,以两年观察期内鉴定诊断与既往诊断不一致作为结局事件,采用Cox回归模型的方法分析与诊断不一致相关的独立风险因素并计算各因素的风险比(HR)。结果:诊断一致组85例(49.1%),诊断不一致组88例(50.9%)。两组在吸毒、前科、刑事责任能力上的差异有统计学意义(P0.01)。鉴定诊断与既往诊断的一致性较差(Kappa=0.372,P0.001)。鉴定诊断以精神分裂症(25.4%)、精神活性物质所致精神障碍(24.9%)、人格障碍(22.5%)较多见。既往诊断以精神分裂症(52.0%)、心境障碍(22.5%)较多见。鉴定诊断与既往诊断的分布差异有统计学意义(Z=-3.325,P=0.001)。Cox回归分析显示,前科(HR=1.832,P=0.033)与吸毒史(HR=3.642,P0.001)是预测诊断不一致的主要因素。结论:刑事案件精神病鉴定的诊断与既往精神病诊断常不一致;前科、吸毒史等病史资料的补充是两种诊断产生差异的主要因素。     

某医院187例伤害案件的司法精神病学鉴定资料分析

目的探讨精神障碍患者故意伤害案件的特征及刑事责任能力评定问题。方法采用自制的故意伤害案件司法鉴定资料调查表,运用回顾性调查方法,收集2009-2012年合肥市精神病医院司法鉴定科187例故意伤害案例完整鉴定材料,对被鉴定人人口学特征、临床特征、作案前监护情况、治疗情况、刑事责任能力以及不同鉴定申请者所申请的鉴定结论进行分析,比较精神分裂症及其他精神障碍患者犯罪学特征。结果由司法机关申请的其鉴定结论为无责任26例(50%),由被鉴定人本人、代理人或家属申请的其鉴定结论为完全或限定责任88例(73.3%)(χ2=9.191,P0.05)。诊断为精神分裂症的案例中伤害亲属、同事等熟悉人和陌生人者分别为59例(56.73%)和45例(43.27%)。诊断为癫痫、神经症等其它精神障碍者伤害熟悉人和陌生人分别为19例(32.20%)和40例(67.80%)(χ2=9.075,P0.05)。作案为病理性动机、现实动机、混合性动机的精神分裂症患者分别为80例、24例和0例。其他精神疾病患者分别为14例、42例、3例(χ2=45.277,P0.01)。精神分裂症患者突然作案63例,其他精神疾病患者20例(χ2=10.721,P0.05)。在公共场所或在家中作案58例为精神分裂症患者,其他精神疾病患者21例(χ2=6.135,P0.05)。163例精神障碍患者中,63例(38.6%)从未到任何医院就诊,76例(46.6%)因各种原因无人监管。结论故意伤害案多发生于男性、受教育程度低以及体力劳动者和无业者,年龄以30岁左右多见;司法机关申请鉴定的案例其鉴定结论为无责任,高于由被鉴定人本人、代理人或家属申请的案件;实施故意伤害的精神障碍患者治疗不充分及得不到有效监护情况较多。     

法医精神病学鉴定中未成年人及老年人责任能力鉴定案件分析

目的 探讨法医精神病学鉴定中,涉嫌违法犯罪的未成年人及老年人责任能力鉴定案件的特征.方法 对116例未成年人及107例老年人的刑事案件鉴定资料进行回顾性分析.结果 未成年组的女性（6.0％）比例低于老年组（16.8％）,差异有统计学意义（χ^2=6.508,P＜0.05）.未成年组的小学及以下文化程度58例（50.0％）,老年组90例（84.1％）.两组职业均以农民及无业为主,分别占81.0％和87.8％.涉嫌犯罪类型排前3位的在未成年组为抢劫/盗窃（31.0％）、杀人（21.6％）、强奸/猥亵（19.8％）,在老年组为杀人（43.0％）、故意伤害（24.3％）、其他（18.5％）,两组差异有统计学意义（χ^2=38.324,P＜ 0.01）.受害者在未成年组以陌生人（56.9％）为主,老年组以邻居/朋友等熟人（48.6％）为主,两组差异亦有统计学意义（χ^2=28.993,P＜0.01）.鉴定诊断排前三位在未成年组为精神发育迟滞（40.5％）、无精神病（17.2％）和精神分裂症（12.9％）,在老年组为精神分裂症（49.5％）、待分类精神障碍（15.0％）和无精神病（12.1％）,差异有统计学意义（χ^2=74.343,P＜0.01）.未成年组与老年组中的精神分裂症及无精神病的涉嫌犯罪类型均以杀人为主,差异均无统计学意义.结论 法医精神病学鉴定中,涉嫌违法犯罪的未成年人及老年人均以男性、文化程度偏低、农民及无业者为主;两组涉嫌的犯罪类型、受害者及鉴定诊断均有显著差异.     

不同精神鉴定申请者与刑事案件性质及鉴定意见的关系

目的:探讨精神鉴定中不同鉴定申请者与刑事案件性质及鉴定意见的关系。方法:对271例精神鉴定的刑事案件按精神鉴定申请者分为家属申请组(155例,57.2%)、办案机关申请组(95例,35.1%)、本人申请组(21例,7.7%);采用自行设计的调查表,收集被鉴定的犯罪嫌疑人一般情况、案由、诊断和结论,并进行比较和分析。结果:3组被鉴定者既往精神疾病史(χ~2=5.424,P0.05)、诊断为精神疾病的比率(χ~2=14.807,P0.01)、鉴定责任能力的分布(χ~2=9.584,P0.01)差异有统计学意义。肇事案与家属申请的关联明显;放火案、强奸猥亵案与办案机关申请的关联明显;毒品案与本人申请的关联明显(χ~2=30.596,P0.05)。家属申请组与诊断品行障碍、人格障碍的关联明显;办案机关申请组与诊断精神发育迟滞的关联明显;本人申请组与诊断无精神病的关联明显(对应分析χ~2=33.158,P0.05)。回归分析发现男性、无精神病史、有前科、本人申请鉴定者较多鉴定为完全刑事责任能力。结论:精神鉴定中不同鉴定申请者其相关的刑事案件性质及鉴定意见均不同,本人申请者其结论多为无精神疾病及完全刑事责任能力。     

23例男性服刑人员服刑能力鉴定

目的了解男性服刑人员的服刑能力,为监狱管理工作提供依据。方法于2012年3月采用自编服刑能力调查表收集23例由四川省雅安监狱医院委托进行服刑能力鉴定的男性服刑人员资料,对其一般情况及病种进行比较分析。结果被鉴定者受教育程度在初中及以下者共20例(86.96%),无服刑能力者占65.20%,均为精神分裂症。鉴定为有服刑能力且符合精神障碍诊断标准的占26.09%,其中癫痫所致精神障碍8.70%,精神分裂症4.35%,酒精所致精神障碍4.35%,待分类的精神障碍4.35%,持续性心境障碍4.35%,无精神障碍者占8.70%。结论在被鉴定男性服刑人员中,以无服刑能力者为主,均为精神分裂症患者,近三分之一的被鉴定者有服刑能力但仍符合精神障碍诊断标准。     

司法鉴定诊断为拘禁性精神障碍65例随访观察

目的了解服刑能力鉴定中拘禁性精神障碍的医学转归。方法对65例服刑能力鉴定诊断为拘禁性精神障碍者进行第二次医学诊断,通过现场随访、复习病史以及精神检查,进行诊断。结果维持原诊断27例,修改诊断为精神分裂症28例,心境障碍6例,癔症3例,经前紧张症1例。结论拘禁性精神障碍的诊断有扩大化倾向,应制定操作性诊断标准。     

不同种类精神障碍患者暴力犯罪特征研究

目的：探讨各类精神障碍患者暴力犯罪行为的特征。方法：235例司法精神病鉴定暴力犯罪案例分成3组。A组135例,其中器质性精神障碍11例,精神分裂症85例,其他精神病性障碍25例,心境障碍14例;B组34例,其中精神活性物质所致精神障碍10例,神经症4例,轻度精神发育迟滞13例,人格障碍7例;C组66例,为无精神病或伪装精神病。分析3组被鉴定者人口学特点和犯罪行为学特征。结果：在人口学特点上,A、B及C组均以年轻无业男性、低教育水平者居多,但3组间差异无显著性。在犯罪特征上,C组有现实动机（X^2=128．87,P=0．00）、有预谋性（X^2=76．176,P=0．00）、有隐蔽性（X2=80．652,P=0．00）、有自我保护（x2=83．714,P=0．00）及完全责任能力（x^2=170．437,P=0．00）,与A组、B组存在显著差异（P〈0．01）。结论：不同种类精神障碍患者的犯罪行为学特征及司法精神病学鉴定特点不同。     

不同时期司法凶杀案件鉴定比较

目的：探讨不同时期司法精神病鉴定凶杀案件的特征。方法：采用自编司法精神病鉴定案例调查表,对1990年至1999年期间256例（前期组）和2000年至2007年期间179例（后期组）司法鉴定的凶杀案件进行比较。结果：与前期组比较,后期组凶杀案比率减少（χ2=35.55,P〈0.01）;无业者增多（χ2=24.91,P〈0.05）;农民减少（χ2=53.37,P〈0.05）;外省人员增多（χ2=24.30,P〈0.05）;由家属举鉴者增多（χ2=35.55,P〈0.05）;作案手段残忍者增多（χ2=26.65,P〈0.01）;鉴定为无精神病者增多（χ2=74.00,P〈0.01）;而精神分裂症减少（χ2=16.3,P〈0.05）;评定为完全刑事责任能力者增多（χ2=30.44,P〈0.01）。结论：新时期司法精神病鉴定凶杀案件的特征存在显著变化,值得引起重视。     

抑郁症和躁狂症患者违法行为的犯罪学特征及对照分析

目的探讨抑郁症和躁狂症患者的犯罪学特征,为更好地从事司法精神病学服务提供客观、科学的依据。方法收集近8年以来我室有关情感性精神障碍的司法鉴定资料,对符合纳入标准的73例案例整理、归纳后进行犯罪学特征、刑事责任能力评定的描述性统计和相关性分析,对抑郁症和双相情感障碍躁狂相的违法行为做比较分析。结果情感性精神障碍患者的犯罪学特征:作案前有动机共43例(58.90%),无动机30例(41.10%)(χ2=4.630,P=0.031)。作案前有准备45例(61.60%),没有准备28例(38.40%)(χ2=7.918,P=0.005)。作案后反侦察27例(37.00%),自杀以及其他精神异常表现46例(63.00%)(χ2=9.923,P=0.002)。刑事责任能力评定:有责任能力21例(28.80%),无责任能力18例(24.70%),部分责任能力43例(46.60%)(χ2=6.154,P=0.046)。其中抑郁症患者43例(58.90%),双相情感障碍躁狂相患者30例(41.10%)(χ2=4.630,P=0.031)。抑郁症患者在作案前有准备28例(65.10%),无准备15例(34.90%)(χ2=7.860,P=0.005),作案时间有选择28例(65.10%),没有选择15例(34.90%)(χ2=7.860,P=0.005),作案后有自杀等精神异常表现34例(79.10%),无异常反应9例(20.90%)(χ2=29.070,P=0.000)。双相障碍躁狂相患者在作案有动机20例(66.70%),无动机10例(33.30%)(χ2=6.667,P=0.001),作案时间有选择9例(30.00%),无选择21例(70.00%)(χ2=9.600,P=0.002);双相情感障碍与抑郁症患者在作案时间选择(χ2=8.718,P=0.003)、作案后表现(χ2=11.574,P=0.001)方面存在着显著差异。结论情感性精神障碍患者违法行为常常具有作案有动机、作案前有准备、案发后出现自杀和其他精神异常表现居多的特点。其中抑郁症较躁狂症多见,其作案常常具有事前有准备,作案时间有选择,作案后自杀及其他精神异常表现突出等特点。双相障碍躁狂相患者作案常常具有案发前有作案动机、作案时间选择少等特点。两组对照研究发现,抑郁症患者比躁狂症患者作案前更有准备,作案后更多出现自杀以及其他精神异常表现。     

精神病混合家系GRIK2基因多态性的关联研究

目的　在中国汉族人群混合家系中探讨GRIK2基因多态性与精神分裂症、心境障碍是否 关联。方法　采用PCR RFLP技术对GRIK2基因多态性rs6922753(T/C)和rs2227283(G/A)分型,进行 传递不平衡检验(TDT)。结果　(1)rs6922753多态性与精神分裂症(χ2=3.13,P>0.05)或心境障碍 (χ2=3.20,P>0.05)无关联,但在发病年龄≤25岁的患者中与两组疾病均相关联(P<0.05);(2) rs2227283多态性与精神分裂症(χ2=9.85,P<0.01)、心境障碍(χ2=13.50,P<0.01)呈显著关联;(3) 双位点TDT提示单体型TG、CA与精神分裂症、心境障碍相关联(P<0.05)。结论　在中国汉族人群 中GRIK2基因或邻近基因可能是精神分裂症和心境障碍的共同易患基因之一,并可能影响发病年龄。     

X线摄片在脑部疾病诊断中的应用

目的:探讨X线摄片技术在脑部疾病诊断和鉴别诊断中的应用价值。方法:报道1年内我科住院患者中见到的4例较典型病例,依赖CT和MRI误诊神经系统疾病。结果:4例病人分别诊断为面肌痉挛脑梗塞的paget′s病例,初诊意识障碍原因待诊-代谢性脑病?脑干梗死?的多发性骨髓瘤病例;诊断帕金森病的股骨颈骨折病例;诊断脑梗死的肺癌病例。结论:CT和MRI决不能替代以症状和体征为基础的临床诊断学,X线摄片技术在脑部疾病诊断和鉴别诊断仍具有重要价值。     

Time to diagnosis of intraspinal tumors

The aim of this study was to assess the time to diagnosis in patients with intraspinal tumors and to assess factors contributing to a long delay in some patients. Patients who were admitted at our hospital over a 15-year period (1986-2000) with an intraspinal (either intradural or extradural) tumor were included. Records of patients were studied for variables such as sex, age, diagnosis, date of diagnosis, initial symptoms, symptoms at diagnosis, level of tumor, original diagnosis and diagnostic technique [CT-myelography, CT-caudography or magnetic resonance imaging (MRI)]. The median time to diagnosis of 108 patients with an intraspinal tumor was 12.3 months (range: 4 days-14.4 years). Most common initial symptoms were back and/or neck pain, pain radiating to one extremity and walking disturbances. There was no distinctive clinical pattern between intramedullary and extramedullary tumors regarding initial symptoms. At the time of diagnosis, patients presented with moderate to severe neurological deficits: weakness in one extremity in 26%, sphincter disturbance (20%) and paraparesis (12%). Improved imaging of the spinal cord by MRI did not result in earlier detection of the intraspinal tumor. The time to diagnosis is explained by non-specific and slowly progressing signs and symptoms. A high rate of clinical suspicion should be present to diagnose an intraspinal tumor at an early stage.     

Diagnosis of dementia. II—Diagnostic methods: A survey of current consultant practice and review of the literature

Inaccuracy in the diagnosis of the dementia syndrome is widely reported. In a postal survey which asked hospital specialists about their use of diagnostic criteria and explored their knowledge of the aetiology of the syndrome, clear differences between research findings and clinical practice emerged. Clinicians are unlikely to use research diagnostic criteria and about half of the respondents consider the results of investigations to be essential in the diagnosis of the dementia syndrome. The frequency of contact with new patients with the dementia syndrome influenced some aspects of knowledge of its aetiology.     

容易误诊漏诊的硬脑膜动静脉瘘9例分析

目的 提高对容易误诊漏诊的硬脑膜动静脉瘘(dural arteriovenous fistula,DAVF)的诊断水平.方法 回顾性总结9例DAVF的临床资料,结合文献进行分析.结果 9例主要临床表现及误诊情况分别为:视朦或视力下降4例,无颅内高压症状,误诊为视神经炎、颅内结核感染或特发性颅内压增高;记忆力下降1例,误诊为病毒性脑炎;双下肢无力1例,误诊为急性脊髓炎、神经鞘瘤;反复头痛1例,误诊为偏头痛、特发性颅内压增高;反复抽搐1例,误诊为正常颅内压脑积水;饮水呛咳、吞咽困难1例,误诊为脑梗死.3例满足于静脉窦血栓的诊断而忽略了DAVF.所有病例影像学均漏诊,但如仔细观察仍可发现细微的血管形态改变,提示动静脉畸形.结论 DAVF临床表现缺乏特异性,加上临床及放射科医师对本病认识不足,诊断思路狭窄,造成本病误诊、漏诊率高.     

Diagnosis of atypical forms of chronic inflammatory demyelinating polyradiculoneuropathy: a practical overview based on some case studies

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare disease and the diagnosis is complicated by heterogeneity of the variant forms. Underdiagnosis is undesirable as effective treatments exist. Conversely, overdiagnosis can lead to inappropriate and expensive treatment and delay the initiation of appropriate treatment. Summary: The European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) diagnostic criteria are used widely in clinical trials and clinical practice. A limitation of the criteria is the requirement for at least one demyelinating parameter as there are certain situations (e.g. proximally located demyelinating process, secondary axonal loss, predominant involvement of sensory fibers) where this criterion may be not apparent; this can lead to misclassification of the neuropathy as axonal. To prevent this situation, the French CIDP Study Group has proposed a set of clinical and electrophysiological signs that are atypical for chronic idiopathic axonal polyneuropathy and suggestive for CIDP. Greater use of supportive diagnostic tools such as magnetic resonance imaging in clinical practice is not only extending the boundaries of CIDP but also contributing to over-representation of some variants, such as those involving the plexus, and sensory or minimal forms of CIDP. Many misdiagnoses can be avoided by adapting the diagnostic strategy to the clinical phenotype of CIDP. Key Messages: Early and accurate diagnosis of CIDP facilitates the selection of appropriate therapy to improve prognosis. Understanding the limitations of diagnostic criteria and adapting the diagnostic strategy to clinical phenotype can enhance precision and avoid diagnostic pitfalls.     

The relative importance of history and symptoms in child psychiatric diagnosis

Summary This study analyzed the relationship between case history and reported symptoms and child psychiatric diagnosis in a sample of 928 cases. In addition sex, age, socioeconomic status and intelligence were considered. In general, symptoms were more important than case history data and background factors. Antisocial symptoms contained by far the most information for diagnosis. However, the highest information gained by a combination of different variables was only 20%. Overall, case history data represent an nonspecific factor of vulnerability in child psychiatric disorders which are primarily determined by symptoms.     

Neurosis from the Viewpoint of DIS (Diagnostic Interview Schedule)

Abstract: We examined the relationship between clinical and DIS-Lifetime diagnoses given independently on 106 psychiatric patients clinically diagnosed as suffering from neurosis. They had many coexisting DIS diagnoses, and some of them had no DIS diagnosis. The key to the coexistence relationships in DIS diagnosis was a major depressive episode, and the subjects were classified into four types by the DIS coexistence relationships; Type I: 28 cases (26.4%) had coexisting diagnoses belonging to anxiety disorders or somatoform disorders, in addition to a major depressive episode. They were suffering from clinically severe neurosis accompanied by borderline personality disorder. Type II: 30 cases (28.3%) belonged to anxiety disorders or somatoform disorders without a major depressive episode, and had clinically symptomatic neurosis. Type III: 18 cases (17.0%) had a major depressive episode without anxiety disorders or somatoform disorders, and had clinically depressive neurosis or depressive episode with less distortion of the personality. Type IV: 30 cases (28.3%) were other than Type I-III, and were clinically similar to symptomatic neurosis.     

体表孤立性神经鞘瘤与神经纤维瘤的超声诊断和鉴别诊断

目的探讨体表孤立性神经鞘瘤与神经纤维瘤的超声诊断和鉴别诊断。方法统计分析2012-11—2014-03我院收治的116例体表孤立性良性神经源性肿瘤患者的临床资料。结果 116例患者中,超声诊断表明神经鞘瘤55例,神经纤维瘤43例,脂肪瘤8例,皮脂腺囊肿4例,脂膜炎3例,腱鞘囊肿3例;病理诊断表明64例为神经鞘瘤,52例为神经纤维瘤。超声对神经鞘瘤诊断的符合率为70.9%,神经纤维瘤的符合率为65.1%,神经源性肿瘤的符合率为84.5%,误诊率为15.5%;体表孤立性神经鞘瘤和神经纤维瘤包膜的回声检出率差异无统计学意义(χ~2=0.74,Ρ0.05)。结论临床在运用超声鉴别诊断体表孤立性神经鞘瘤和神经纤维瘤的过程中可以依据二者与周围神经的关系。