中国神经性厌食症诊疗专家共识

doi:10.12114/j.issn.1007-9572.2023.0728

中国全科医学 ›› 2024, Vol. 27 ›› Issue (05): 509-520.DOI: 10.12114/j.issn.1007-9572.2023.0728

中国神经性厌食症诊疗专家共识

中华医学会心身医学分会进食障碍协作学组, 中华医学会精神医学分会进食障碍研究协作组, 陈涵¹, 陈妍¹, 韩慧琴¹, 李雪霓², 张岚³, 孔庆梅², 乔慧芬⁴, 匡桂芳⁵, 孙建琴⁶, 虞阳⁶, 金富锐⁷, 蒋晶晶⁸, 张大荣², 栗克清⁹, 王振¹^,^*(), 陈珏¹^,^*()

1．200030　上海市，上海交通大学医学院附属精神卫生中心
2．100091　北京市，北京大学第六医院　北京大学精神卫生研究所　国家卫生健康委员会精神卫生学重点实验室（北京大学）　国家精神心理疾病临床医学研究中心（北京大学第六医院）
3．610041　四川省成都市，四川大学华西医院心理卫生中心
4．210024　江苏省南京市，南京医科大学附属脑科医院
5．266034　山东省青岛市，青岛大学附属妇女儿童医院
6．200040　上海市，复旦大学附属华东医院
7．200030　上海市，中国福利会国际和平妇幼保健院
8．200032　上海市，复旦大学附属中山医院
9．071000　河北省保定市，河北省精神卫生中心

收稿日期:2023-08-10 修回日期:2023-10-25 出版日期:2024-02-15 发布日期:2023-11-21
通讯作者: 王振, 陈珏
基金资助:
国家自然科学基金项目面上项目(82071545); 上海市科学技术委员会医学创新研究专项项目(20Y11906500); 上海市卫生健康委员会面上项目(202140092); 医工交叉重点项目(YG2022ZD026); 上海市精神心理疾病临床医学研究中心(19MC1911100)

Chinese Expert Consensus on the Diagnosis and Treatment of Anorexia Nervosa

Eating Disorders Coordination Group of the Psychosomatic Medicine Society of the Chinese Medical Association, Eating Disorders Research Collaboration Group of the Psychiatric Medicine Society of the Chinese Medical Association, CHEN Han¹, CHEN Yan¹, HAN Huiqin¹, LI Xueni², ZHANG Lan³, KONG Qingmei², QIAO Huifen⁴, KUANG Guifang⁵, SUN Jianqin⁶, YU Yang⁶, JIN Furui⁷, JIANG Jingjing⁸, ZHANG Darong², LI Keqing⁹, WANG Zhen¹^,^*(), CHEN Jue¹^,^*()

1. Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
2. Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing 100091, China
3. Mental Health Center, West China Hospital, Sichuan University, Chengdu 610041, China
4. Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210024, China
5. Women and Children's Hospital, Qingdao University, Qingdao 266034, China
6. Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
7. International Peace Maternity & Child Health Hospital of China Welfare Institute, Shanghai 200030, China
8. Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China
9. Hebei Mental Health Center, Baoding 071000, China

Received:2023-08-10 Revised:2023-10-25 Published:2024-02-15 Online:2023-11-21
Contact: WANG Zhen, CHEN Jue

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摘要/Abstract

摘要： 神经性厌食症是以自我饥饿、体质量显著减轻和营养不良为特征的一类进食障碍。在所有精神疾病中，神经性厌食症死亡率最高，其会导致严重的精神病理症状和危及生命的医疗并发症。然而，目前在中国，对于神经性厌食症不能早期识别和诊治，导致病程迁延。因此，在中华医学会心身医学分会进食障碍协作学组的组织下，联合中华医学会精神医学分会进食障碍研究协作组，由16名医学专家基于循证医学证据、国内外指南与专家共识、专家经验等制定本专家共识，以期提高国内专业人员对神经性厌食症的识别和诊治水平。

关键词: 神经性厌食, 营养治疗, 心理治疗, 药物治疗, 专家共识

Abstract:

Anorexia nervosa (AN) is a type of eating disorders characterized by self-starvation, significant loss of body mass, and malnutrition. AN has the highest mortality rate among all psychiatric disorders, leading to severe psychopathologic symptoms and life-threatening medical complications. However, AN cannot be recognized and diagnosed early in China, resulting in a prolonged course of the disease. Therefore, under the organization of the Eating Disorders Coordination Group of the Psychosomatic Medicine Society of the Chinese Medical Association, together with the Eating Disorders Research Collaboration Group of the Psychiatric Medicine Society of the Chinese Medical Association, this expert consensus was formulated by 16 medical experts based on evidence-based medical evidence, domestic and international guidelines and expert consensus, expert experience, etc., in order to improve the recognition, diagnosis and treatment of AN among domestic professionals.

Key words: Anorexia nervosa, Nutrition therapy, Psychotherapy, Pharmacotherapy, Expert consensus

中华医学会心身医学分会进食障碍协作学组,中华医学会精神医学分会进食障碍研究协作组,陈涵,等. 中国神经性厌食症诊疗专家共识[J]. 中国全科医学, 2024, 27(05): 509-520. DOI: 10.12114/j.issn.1007-9572.2023.0728.
Eating Disorders Coordination Group of the Psychosomatic Medicine Society of the Chinese Medical Association,Eating Disorders Research Collaboration Group of the Psychiatric Medicine Society of the Chinese Medical Association,CHEN Han, et al. Chinese Expert Consensus on the Diagnosis and Treatment of Anorexia Nervosa[J]. Chinese General Practice, 2024, 27(05): 509-520. DOI: 10.12114/j.issn.1007-9572.2023.0728.

图/表 5

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推荐强度	证据级别	病因、治疗、预防
A	1a	多个同质随机对照研究的系统综述
	1b	单个随机对照研究
	1c	"全或无"证据
B	2a	同质性队列研究的系统综述
	2b	单一的队列研究（包括低质量的随机对照研究，如随访率<80%）
	2c	结局性研究
	3a	同质性病例对照研究的系统综述
	3b	单独的病例对照研究
C	4	病例系列
D	5	没有严格评价的专家意见，或完全基于生理学和基础研究

推荐强度	证据级别	病因、治疗、预防
A	1a	多个同质随机对照研究的系统综述
	1b	单个随机对照研究
	1c	"全或无"证据
B	2a	同质性队列研究的系统综述
	2b	单一的队列研究（包括低质量的随机对照研究，如随访率<80%）
	2c	结局性研究
	3a	同质性病例对照研究的系统综述
	3b	单独的病例对照研究
C	4	病例系列
D	5	没有严格评价的专家意见，或完全基于生理学和基础研究

分类	躯体症状
营养不良：与能量摄入不足有关的特征	在身高、体质量和体质量指数图表上与既往的生长轨迹有偏差
	异常的生命体征：静息状态下心率或血压降低；直立时心率增加（>20次/min）或血压下降（<10 mmHg）；体温过低
	情绪平淡或焦虑
	皮肤苍白、干燥；胡萝卜素血症（特别是手掌和脚底）
	恶病质：面部消瘦，皮下脂肪减少，肌肉量减少
	毛发稀疏
	心脏杂音（1/3伴有左房室瓣脱垂），四肢冰凉，手足发绀
	左下腹粪便团块
	青春期发育的延迟：乳房小，阴道干燥；睾丸小
与清除有关的特征	生命体征异常：直立时心率增加（>20次/min）或血压下降（<10 mmHg）
	牙釉质腐蚀、口角炎、上腭部划痕
	Russell's征（自我催吐导致指关节磨损或结茧）
	唾液腺肿大（腮腺和下颌下腺）
	上腹部压痛
	脊柱挫伤或擦伤（与过度运动或仰卧起坐有关）

分类	躯体症状
营养不良：与能量摄入不足有关的特征	在身高、体质量和体质量指数图表上与既往的生长轨迹有偏差
	异常的生命体征：静息状态下心率或血压降低；直立时心率增加（>20次/min）或血压下降（<10 mmHg）；体温过低
	情绪平淡或焦虑
	皮肤苍白、干燥；胡萝卜素血症（特别是手掌和脚底）
	恶病质：面部消瘦，皮下脂肪减少，肌肉量减少
	毛发稀疏
	心脏杂音（1/3伴有左房室瓣脱垂），四肢冰凉，手足发绀
	左下腹粪便团块
	青春期发育的延迟：乳房小，阴道干燥；睾丸小
与清除有关的特征	生命体征异常：直立时心率增加（>20次/min）或血压下降（<10 mmHg）
	牙釉质腐蚀、口角炎、上腭部划痕
	Russell's征（自我催吐导致指关节磨损或结茧）
	唾液腺肿大（腮腺和下颌下腺）
	上腹部压痛
	脊柱挫伤或擦伤（与过度运动或仰卧起坐有关）

编号	条件
1	BMI≤相应年龄和性别青少年BMI中位数的75%
2	脱水
3	电解质紊乱（低钾血症、低钠血症、低磷血症）
4	心电图异常（如QTc延长）
5	生理上的不稳定性：严重心动过缓（日间心率<50次/min；夜间心率<45次/min）低血压（<90/45 mmHg）低体温（<35.6 ℃）体位性脉搏增加（>20次/min）或体位性血压降低（收缩期>20 mmHg或舒张期>10 mmHg）
6	生长发育受阻
7	门诊治疗失败
8	严重拒食
9	无法控制的暴饮暴食和清除行为
10	营养不良导致的急性并发症（晕厥、癫痫发作、心力衰竭、胰腺炎等）
11	因共病其他精神障碍或躯体疾病导致无法门诊治疗（如严重抑郁、自杀意念、强迫性障碍、1型糖尿病）

中国神经性厌食症诊疗专家共识

Chinese Expert Consensus on the Diagnosis and Treatment of Anorexia Nervosa

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心理治疗类型	治疗目标	推荐疗程	推荐强度/证据级别
FT	通过调整家庭的互动模式，使家庭系统具有更好的功能来支持个体康复，从而改善患者症状	1次/周，持续数月	A/1b
FBT	通过赋能予父母负责青少年体质量恢复，逐步调整为适当控制、最终帮助青少年独立发展	6个月，20次访谈	A/1a
CBT-E	聚焦于改变患者对于体质量体形的歪曲认知，纠正或改善异常的进食行为	4~6个月，20~40次访谈	B/2a
DBT	通过一系列技巧训练，帮助患者认识自我，学会调整情绪，建立良好的人际关系以及学会承受生活中不可避免的痛苦	6个月，每周1次个体访谈和1次技能团体	C/4
其他（PDT、 IPT等）	帮助患者理解饮食行为症状背后的潜意识动机、冲突，或人际关系模式等，帮助患者发展更加灵活及具有适应性的应对方式	4~12个月，15~50次访谈不等	D/5

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心理治疗类型	治疗目标	推荐疗程	推荐强度/证据级别
CBT-E	聚焦于改变患者对于体质量体形的歪曲认知，纠正或改善异常的进食行为	4~6个月，20~40次访谈	A/1a
PDT	帮助患者理解饮食行为症状背后的潜意识动机、冲突、防御方式等，帮助患者发展更加灵活及具有适应性的应对方式	约1年，50次访谈	B/2a
DBT	通过一系列技巧的训练，帮助患者认识自我，学会调整情绪，建立良好的人际关系以及学会承受生活中不可避免的痛苦	6个月，1次/周个体访谈和1次技能团体	B/2b
IPT	聚焦于识别和改变导致进食问题发生、发展和持续的人际关系背景	4~5个月，15~20次访谈	B/2b

心理治疗类型	治疗目标	推荐疗程	推荐强度/证据级别
CBT-E	聚焦于改变患者对于体质量体形的歪曲认知，纠正或改善异常的进食行为	4~6个月，20~40次访谈	A/1a
PDT	帮助患者理解饮食行为症状背后的潜意识动机、冲突、防御方式等，帮助患者发展更加灵活及具有适应性的应对方式	约1年，50次访谈	B/2a
DBT	通过一系列技巧的训练，帮助患者认识自我，学会调整情绪，建立良好的人际关系以及学会承受生活中不可避免的痛苦	6个月，1次/周个体访谈和1次技能团体	B/2b
IPT	聚焦于识别和改变导致进食问题发生、发展和持续的人际关系背景	4~5个月，15~20次访谈	B/2b