創(chuàng)傷后應激障礙綜述

目錄1.概述 21.1基本概念 21.2流行病學研究 21.3臨床體現(xiàn) 32.致病因素 32.1創(chuàng)傷事件 42.2易感因素 43.診療與評定 53.1診療 53.2評定 64.治療與防止 74.1心理治療 74.2藥品治療 84.3防止 8參考文獻 9

創(chuàng)傷后應激障礙綜述社會沖突、自然災害給人類造成了嚴重的生理和心理傷害。創(chuàng)傷后應激障礙(posttraumaticstressdisorder,PTSD)已經(jīng)成為影響創(chuàng)傷救治整體水平的重要因素之一，嚴重干擾了人民生活和社會秩序。許多人產(chǎn)生了焦慮、抑郁、恐懼、重復不能忘記痛苦、出現(xiàn)回避行為等癥狀。這就使得對創(chuàng)傷后應激障的研究越發(fā)顯得重要。1.概述1.1基本概念創(chuàng)傷后應激障礙是一種由非同尋常的威脅或災難性事件所引發(fā)的強烈的恐懼感、無助或厭惡等嚴重的心理反映ADDINZOTERO_ITEMCSL_CITATION{"citationID":"q4BoNLVo","properties":{"formattedCitation":"(Nolen,)","plainCitation":"(Nolen,)"},"citationItems":[{"id":295,"uris":[""],"uri":[""],"itemData":{"id":295,"type":"book","title":"變態(tài)心理學與心理治療","publisher":"世界圖書出版公司","edition":"第三版","author":[{"family":"Nolen","given":"s"}],"issued":{"date-parts":[[""]]}}}],"schema":""}(Nolen,)，最少會持續(xù)一種月，其特性為創(chuàng)傷或災難性事件后長久存在的焦慮反映，重要癥狀為持續(xù)的警惕性增高癥狀群、重復發(fā)生的闖人性再體驗癥狀群、反映性麻木癥狀群ADDINZOTERO_ITEMCSL_CITATION{"citationID":"54ckeaxe","properties":{"formattedCitation":"(David,n.d.)","plainCitation":"(David,n.d.)"},"citationItems":[{"id":296,"uris":[""],"uri":[""],"itemData":{"id":296,"type":"book","title":"心理障礙臨床手冊","edition":"第三版","author":[{"family":"David","given":"BarlowH."}]}}],"schema":""}(David,n.d.)。PTSD可引發(fā)明顯的職業(yè)、心理和社會功效殘疾，對個體的社會功效、家庭生活和身心健康造成長久的破壞性影響，也給患者及其家庭乃至社。1.2流行病學研究據(jù)美國精神病協(xié)會(AmericanPsychiatryAsso-ciation，APA)統(tǒng)計，美國PTSD的人群總體患病率為1至14%，平均為8%，個體終身患病危險性達3至58%，女性PTSD患者終身患病率高于男性，約是男性的2倍ADDINZOTERO_ITEMCSL_CITATION{"citationID":"qmdoqqmr7","properties":{"formattedCitation":"(Breslau,)","plainCitation":"(Breslau,)"},"citationItems":[{"id":297,"uris":[""],"uri":[""],"itemData":{"id":297,"type":"article-journal","title":"Theepidemiologyofposttraumaticstressdisorder:whatistheextentoftheproblem?","container-title":"JournalofClinicalPsychiatry","source":"谷歌Scholar","URL":"","shortTitle":"Theepidemiologyofposttraumaticstressdisorder","author":[{"family":"Breslau","given":"Naomi"}],"issued":{"date-parts":[[""]]},"accessed":{"date-parts":[["",6,12]]}}}],"schema":""}(Breslau,)，因素在于傷害女性的暴力攻擊的發(fā)生更為普遍，如，性侵犯、身體傷害。普通人群中50%以上的人一生中最少有一次曾暴露于創(chuàng)傷事件，并不是全部的創(chuàng)傷幸存者都會發(fā)展為PTSD，普通人群中PTSD的患病率為7.8%。女性創(chuàng)傷暴露率為51.2%,PTSD的患病率為10.4%；男性創(chuàng)傷暴露率為60.7%,PTSD的患病率為5.0%。普通說來，不同的人群或個體，不同應激事件所致P'TSD的患病危險性亦不相似。調(diào)查發(fā)現(xiàn)，經(jīng)歷過滿足診療原則的創(chuàng)傷性事件的人，患有P'TSD的比率以下：強奸，32%；其它性攻擊，31%；軀體攻擊，39%；家人或朋友被殺，22%；其它犯罪的受害者，26%；非犯罪類的創(chuàng)傷(天災人禍，事故，受傷等等)，9%ADDINZOTERO_ITEMCSL_CITATION{"citationID":"CFj8GR0G","properties":{"formattedCitation":"(Gilliland&James,1998)","plainCitation":"(Gilliland&James,1998)"},"citationItems":[{"id":298,"uris":[""],"uri":[""],"itemData":{"id":298,"type":"book","title":"Theoriesandstrategiesincounselingandpsychotherapy","publisher":"Allyn&Bacon","source":"谷歌Scholar","author":[{"family":"Gilliland","given":"BurlE."},{"family":"James","given":"RichardK."}],"issued":{"date-parts":[["1998"]]}}}],"schema":""}(Gilliland&James,1998)。我國軍隊醫(yī)務工作者的流行病學調(diào)查，成果顯示軍人PTSD患病率為0,485%，其中，陸、海、空軍和學員的P'TSD患病率分別為0.484%,0.58%,0.84%和0.227%，特殊兵種或在執(zhí)行抗災任務后的軍人P'TSD發(fā)病率明顯高于和平時期軍人P'TSD橫斷面調(diào)查的成果ADDINZOTERO_ITEMCSL_CITATION{"citationID":"e5nHpRCp","properties":{"formattedCitation":"{\\rtf(\\uc0\\u29579{},\\uc0\\u23828{},&\\uc0\\u38472{},1996)}","plainCitation":"(王,崔,&陳,1996)"},"citationItems":[{"id":299,"uris":[""],"uri":[""],"itemData":{"id":299,"type":"article-journal","title":"中國軍人心理創(chuàng)傷后應激障礙的流行病學調(diào)查","container-title":"中華神經(jīng)科雜志","page":"69-72","issue":"29","author":[{"family":"王","given":"煥林"},{"family":"崔","given":"庶"},{"family":"陳","given":"繼軍"}],"issued":{"date-parts":[["1996"]]}}}],"schema":""}(王,崔,&陳,1996)?，F(xiàn)在，我國由自然災難和突發(fā)事故引發(fā)的心理創(chuàng)傷已引發(fā)心理學界重視。有些流行病學研究報告的數(shù)據(jù)，如張本等ADDINZOTERO_ITEMCSL_CITATION{"citationID":"FB1Pb6UE","properties":{"formattedCitation":"{\\rtf(\\uc0\\u24352{},\\uc0\\u29579{},&\\uc0\\u23385{},)}","plainCitation":"(張,王,&孫,)"},"citationItems":[{"id":300,"uris":[""],"uri":[""],"itemData":{"id":300,"type":"article-journal","title":"唐山大地震所致孤兒心理創(chuàng)傷后應激障礙的調(diào)查","container-title":"中華精神科雜志","page":"111-114","issue":"33","author":[{"family":"張","given":"本"},{"family":"王","given":"學義"},{"family":"孫","given":"賀祥"}],"issued":{"date-parts":[[""]]}}}],"schema":""}(張,王,&孫,)對唐山大地震所致孤兒的P'TSD的調(diào)查顯示發(fā)病率為23%。徐唯等的研究表明，特大爆炸事故后P'TSD的發(fā)生率高達78.6%。1.3臨床體現(xiàn)PTSD的重要臨床體現(xiàn)可分為三組ADDINZOTERO_ITEMCSL_CITATION{"citationID":"xDAzudfY","properties":{"formattedCitation":"(Nietzel&Wakefield,1996)","plainCitation":"(Nietzel&Wakefield,1996)"},"citationItems":[{"id":301,"uris":[""],"uri":[""],"itemData":{"id":301,"type":"article-journal","title":"AmericanPsychiatricAssociationDiagnosticandStatisticalManualofMentalDisorders","container-title":"CONTEMPORARYPSYCHOLOGY","page":"642–651","volume":"41","source":"谷歌Scholar","author":[{"family":"Nietzel","given":"M.T."},{"family":"Wakefield","given":"J.C."}],"issued":{"date-parts":[["1996"]]}}}],"schema":""}(Nietzel&Wakefield,1996)：第一組為重復體驗創(chuàng)傷性事件，如，侵人性的回想和重復出現(xiàn)的惡夢；第二組為保護性的反映，如，回避與創(chuàng)傷有關(guān)的刺激和情感麻木；第三組為高度警惕的癥狀，如，驚跳反映和過分警惕。2.致病因素2.1創(chuàng)傷事件PTSD最初來源于戰(zhàn)爭創(chuàng)傷后，其因素普通為異乎尋常的戰(zhàn)斗事件。后來戰(zhàn)爭創(chuàng)傷的概念擴展到其它事件，如，大的災難、軀體的攻擊、暴力性侵害等。成為病因的壓力能夠是來自軀體的或情感的，能夠是單獨的或重復的，范疇能夠從自然災害、事故到刑事暴力、虐待、戰(zhàn)爭，這種壓力既能夠是直接經(jīng)歷，如，被打傷，也能夠是間接經(jīng)歷ADDINZOTERO_ITEMCSL_CITATION{"citationID":"YHSpG8Jw","properties":{"formattedCitation":"(Nolen,)","plainCitation":"(Nolen,)"},"citationItems":[{"id":295,"uris":[""],"uri":[""],"itemData":{"id":295,"type":"book","title":"變態(tài)心理學與心理治療","publisher":"世界圖書出版公司","edition":"第三版","author":[{"family":"Nolen","given":"s"}],"issued":{"date-parts":[[""]]}}}],"schema":""}(Nolen,)，如親眼目睹別人死亡或受傷。而有關(guān)癥狀能夠立刻出現(xiàn)，也能夠延遲發(fā)作，如在事件發(fā)作最少6個月以上才出現(xiàn)ADDINZOTERO_ITEMCSL_CITATION{"citationID":"15ob0n1nme","properties":{"formattedCitation":"(Butcher,Mineka,Hooley,&others,)","plainCitation":"(Butcher,Mineka,Hooley,&others,)"},"citationItems":[{"id":302,"uris":[""],"uri":[""],"itemData":{"id":302,"type":"book","title":"Abnormalpsychology","publisher":"PearsonBoston,MA","source":"谷歌Scholar","URL":"","author":[{"family":"Butcher","given":"JamesNeal"},{"family":"Mineka","given":"Susan"},{"family":"Hooley","given":"JillM."},{"family":"others","given":""}],"issued":{"date-parts":[[""]]},"accessed":{"date-parts":[["",6,16]]}}}],"schema":""}(Butcher,Mineka,Hooley,&others,)。尚有某些人經(jīng)歷了長時間的精神痛苦，在沒有特殊事件發(fā)生時也會出現(xiàn)PTSD。近年來個體的主觀反映和發(fā)生在所愛之人身上的事件也可成為PTSD的應激源。另外，在目擊或急救該事件的過程中也會產(chǎn)生PTSD的應急源ADDINZOTERO_ITEMCSL_CITATION{"citationID":"1gfvl2ivns","properties":{"formattedCitation":"(Yehuda,Halligan,&Bierer,)","plainCitation":"(Yehuda,Halligan,&Bierer,)"},"citationItems":[{"id":304,"uris":[""],"uri":[""],"itemData":{"id":304,"type":"article-journal","title":"RelationshipofparentaltraumaexposureandPTSDtoPTSD,depressiveandanxietydisordersinoffspring","container-title":"Journalofpsychiatricresearch","page":"261–270","volume":"35","issue":"5","source":"谷歌Scholar","author":[{"family":"Yehuda","given":"Rachel"},{"family":"Halligan","given":"SarahL."},{"family":"Bierer","given":"LindaM."}],"issued":{"date-parts":[[""]]},"accessed":{"date-parts":[["",6,16]]}}}],"schema":""}(Yehuda,Halligan,&Bierer,)。DSM一W對應激源重新定義后增加了體驗到的應激事件的數(shù)目，許多醫(yī)學事件，如，孕婦生產(chǎn)、流產(chǎn)、患癌癥或住院等也可造成PTSD。尚有某些人經(jīng)歷了長時間的精神痛苦，在沒有特殊事件發(fā)生時也會出現(xiàn)PTSD。2.2易感因素常見的易感因素有:精神障礙的家族史與既往史，家庭社會因素，性格內(nèi)向及有神經(jīng)質(zhì)傾向，職業(yè)特性等。這些因素均增加了個體在創(chuàng)傷后患應激障礙的可能性ADDINZOTERO_ITEMCSL_CITATION{"citationID":"VcvAXmwC","properties":{"formattedCitation":"{\\rtf(\\uc0\\u39532{},\\uc0\\u29579{},&\\uc0\\u35885{},)}","plainCitation":"(馬,王,&譚,)"},"citationItems":[{"id":306,"uris":[""],"uri":[""],"itemData":{"id":306,"type":"article-journal","title":"應激障礙的危險因素分析","container-title":"臨床精神醫(yī)學雜志","page":"257-258","volume":"5","issue":"14","author":[{"family":"馬","given":"磊"},{"family":"王","given":"家同"},{"family":"譚","given":"慶榮"}],"issued":{"date-parts":[[""]]}}}],"schema":""}(馬,王,&譚,)。研究表明，PTSD患者家族史中精神障礙發(fā)病率是經(jīng)歷同樣事件未發(fā)病或無此經(jīng)歷者的三倍ADDINZOTERO_ITEMCSL_CITATION{"citationID":"he170lu6l","properties":{"formattedCitation":"(Xianetal.,)","plainCitation":"(Xianetal.,)"},"citationItems":[{"id":307,"uris":[""],"uri":[""],"itemData":{"id":307,"type":"article-journal","title":"Geneticandenvironmentalinfluencesonposttraumaticstressdisorder,alcoholanddrugdependenceintwinpairs","container-title":"Drugandalcoholdependence","page":"95–102","volume":"61","issue":"1","source":"谷歌Scholar","author":[{"family":"Xian","given":"Hong"},{"family":"Chantarujikapong","given":"SunantaI."},{"family":"Scherrer","given":"JeffreyF."},{"family":"Eisen","given":"SethA."},{"family":"Lyons","given":"MichaelJ."},{"family":"Goldberg","given":"Jack"},{"family":"Tsuang","given":"Ming"},{"family":"True","given":"WilliamR."}],"issued":{"date-parts":[[""]]},"accessed":{"date-parts":[["",6,16]]}}}],"schema":""}(Xianetal.,)。在雙胞胎研究中，PTSD患者的同胞較創(chuàng)傷后未患PTSD的同胞PTSD發(fā)病率增高ADDINZOTERO_ITEMCSL_CITATION{"citationID":"al5pg02vr","properties":{"formattedCitation":"(Trueetal.,1993)","plainCitation":"(Trueetal.,1993)"},"citationItems":[{"id":309,"uris":[""],"uri":[""],"itemData":{"id":309,"type":"article-journal","title":"Atwinstudyofgeneticandenvironmentalcontributionstoliabilityforposttraumaticstresssymptoms","container-title":"Archivesofgeneralpsychiatry","page":"257–264","volume":"50","issue":"4","source":"谷歌Scholar","author":[{"family":"True","given":"WilliamR."},{"family":"Rice","given":"John"},{"family":"Eisen","given":"SethA."},{"family":"Heath","given":"AndrewC."},{"family":"Goldberg","given":"Jack"},{"family":"Lyons","given":"MichaelJ."},{"family":"Nowak","given":"Justina"}],"issued":{"date-parts":[["1993"]]},"accessed":{"date-parts":[["",6,16]]}}}],"schema":""}(Trueetal.,1993)。童年期創(chuàng)傷使PTSD的發(fā)病率增高ADDINZOTERO_ITEMCSL_CITATION{"citationID":"2i12spc7d4","properties":{"formattedCitation":"(Baker&Shalhoub-Kevorkian,1999)","plainCitation":"(Baker&Shalhoub-Kevorkian,1999)"},"citationItems":[{"id":311,"uris":[""],"uri":[""],"itemData":{"id":311,"type":"article-journal","title":"Effectsofpoliticalandmilitarytraumasonchildren:thePalestiniancase","conta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表(TraumaticStressSchedule)、創(chuàng)傷性事件問卷(TraumaticEventsQuestionnaire)、創(chuàng)傷后應激診療量表(ThePosttraumaticStressDiagnos-ticScale)、戰(zhàn)爭暴露量表(CombatExposureScale)、潛在應激事件訪談量表(ThePotentialStressfulEventsInterview),PTSD臨床監(jiān)測量表(TheDSM-WversionoftheClinician-AdministeredPTSDScale)。國內(nèi)學者在參考國外有關(guān)文獻和評定量表的基礎(chǔ)上，編制了創(chuàng)傷后應激障礙自評量表(post-traumaticstressdisorderself-ratingscale,PTSD-SS)，經(jīng)檢查含有較好的信度和效度ADDINZOTERO_ITEMCSL_CITATION{"citationID":"1vpj6k4d19","properties":{"formattedCitation":"{\\rtf(\\uc0\\u21016{},\\uc0\\u39532{},&\\uc0\\u21016{},1998)}","plainCitation":"(劉,馬,&劉,1998)"},"citationItems":[{"id":317,"uris":[""],"uri":[""],"itemData":{"id":317,"type":"article-journal","title":"心理創(chuàng)傷后應激障礙自評量表的編制和信度效度研究","container-title":"中國行為醫(yī)學科學","page":"93-96","volume":"2","issue":"7","author":[{"family":"劉","given":"賢臣"},{"family":"馬","given":"登岱"},{"family":"劉","given":"連啟"}],"issued":{"date-parts":[["1998"]]}}}],"schema":""}(劉,馬,&劉,1998)。4.治療與防止4.1心理治療心理治療是治療PTSD的重要辦法，比精神藥品治療更為有效。干預過程中根據(jù)正?；f(xié)同化、個性化原則，干預的形式能夠多樣化，一對一的面談、電話咨詢、團體輔導等方式可根據(jù)實際狀況靈活采用。常見的治療辦法涉及：應激免疫訓練(StressInoculationTrain-ing,SIT)、系統(tǒng)脫敏療法、延長暴露(prolongexposure,PE)和視覺暴露治療、認知加工治療(CognitiveProcessingTherapy,CPT)、眼動脫敏和再加工(EyeMovementDesen-situationandReprocessing,EDMR)4.2藥品治療PTSD的藥品治療能緩和某些癥狀，減少患者的痛苦體驗，普通作為心理治療的輔助方法，增加患者對心理治療的依從性?，F(xiàn)在重要是使用選擇性5-經(jīng)色胺再攝取克制劑類抗抑郁藥品，它能夠明顯緩和抑郁、焦慮癥狀，改善睡眠質(zhì)量，減少回避癥狀。在我國還嘗試性應用了中西藥結(jié)合治療創(chuàng)傷后應激障礙，成果顯示起效快，副反映少，患者的依從性高。另外，軀體癥狀的改善能夠影響到個體情緒的變化，因此創(chuàng)傷事件發(fā)生后，應針對個體的軀體癥狀及時予以藥品對癥治療。4.3防止早期干預的目的應針對不同的個體、社區(qū)、文化需要和特性而制訂，精神衛(wèi)生人員應被納人到重大事故或災難解決小組中，使精神衛(wèi)生服務整合到災難解決的計劃之中。對職業(yè)衛(wèi)生領(lǐng)域PTSD核心在于防止，重要方法在于加強安全教育和保護，防患于未然。完善職業(yè)環(huán)境的組織系統(tǒng)、社會支持系統(tǒng)、加強個體及群體心理素質(zhì)的培養(yǎng)，提高對創(chuàng)傷應激事件的心理承受力也是其中核心環(huán)節(jié)。

參考文獻ADDINZOTERO_BIBL{"custom":[]}CSL_BIBLIOGRAPHYBaker,A.,&Shalhoub-Kevorkian,N.(1999).Effectsofpoliticalandmilitarytraumasonchildren:thePalestiniancase.ClinicalPsychologyReview,19(8),935–950.Breslau,N.().Theepidemiologyofposttraumaticstressdisorder:whatistheextentoftheproblem?JournalofClinicalPsychiatry.RetrievedfromButcher,J.