創傷後壓力心理障礙症

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目前已翻译5%，原文在en:Post-traumatic stress disorder。

創傷後壓力心理障礙症（Post-traumatic stress disorder；PTSD）指人在遭遇或對抗重大壓力後，其心理狀態產生失調之後遺症。這些經驗包括生命遭到威脅、嚴重物理性傷害、身體或心靈上的脅迫。有時候被稱之為創傷後壓力反應（post-traumatic stress reaction）以強調這個現象乃經驗創傷後所產生之合理結果，而非病患心理狀態原本就有問題。

又譯創傷後壓力症、創傷後壓力症候群、創傷後精神緊張性障礙、重大打擊後遺症。

[编辑] 序論

PTSD的主要症狀包括惡夢、性格大變、情感分离、麻木感（情感上的禁欲或疏離感）、失眠、逃避會引發創傷回憶的事物、易怒、过度警觉、失憶和易受驚嚇。

可能會造成這些症狀的經驗包括：

孩童時期遭受身體或心理上的性虐待
成人經驗強姦、戰爭、打鬥（後兩者常稱為戰鬥壓力反應combat stress reaction）
暴力攻擊
嚴重的車禍
目睹愛人的突然死亡
自然災難，如地震、海嘯
難產

在精神疾病诊断与统计手册 中指出，個體也有可能在經驗創傷後並沒有出現全部創傷後壓力症候群的症狀。
大部份人對創傷事件的情感會在幾個月後淡去。如果其持續過長的時間，就有可能導致精神上的失調。大部份經驗創傷事件的人並不會產生PTSD。PTSD是一種焦慮性失常，不應和一般的悲傷或創傷後之調適混淆，此疾病也有可能伴隨著其他精神失調（合併症comorbidity）包括重度憂鬱（major depression）、一般性焦慮失調（general anxiety disorder）、和各種成癮性。

PTSD的發病時間可能會延遲數年甚至數十年。創傷記憶有時候會被貯存在程序記憶（procedural memory）中，當病患做了某一特定身體動作時，便觸發了創傷後壓力症。延遲發病的PTSD也有可能在另一個壓力事件下浮出檯面，如家人或親密朋友之死亡、或被診斷患有重大疾病。
臨床研究指出，曾罹患PTSD之幼童，在成年後比起沒有PTSD的人有更高的犯罪傾向。

[编辑] 歷史背景

創傷後心理障礙是在西元前1900年由埃及人提出，以形容些對於創傷斯抵裡的反應(Veith 1965). 一世紀前，歇斯底里也和"遺留的創傷"相關(Janet 1901). 當時，佛洛伊德的學生，Kardiner, 是第一位形容這種不久後以"創傷後心理壓力失調症狀"知名的現象。(Lamprecht & Sack 2002).

Hippocrates 使用 homeostasis 理論來解釋為何疾病漢壓力總是被定義為一種對威脅一個系統的平衡或生理平衡的狀況的反應。(Antonovsky 1981). 引起這種壓力的狀況被定義為"施壓者"，而非壓力的反應，而非壓力危害生理平衡。(Aardal-Eriksson 2002). 因此，根據壓力的理論，創傷後壓力被視為一種"神經傳遞的化學不平衡"。

然而，創傷後壓力心理障礙症 per se 是一個相較之下在精神病學較新的診斷，第一次出現在1980年的"精神疾病診斷和統計手冊"[Diagnostic and Statistical Manual of Mental Disorders](DSM)據說創傷後壓力心理障礙症概念的發展有部分社會`經濟和政治上的暗示。(Mezey & Robbins 2001). 戰場老兵被[神智疾病|精神疾病]所苦,包含越戰後的創傷後心理壓力。然而，他們很難得到經濟上的補償因為沒有足以證明他們可要求賠償的有效精神科診斷書

在近二十年里，这种情况有所改变，PTSD现已成为美国能够证明那些战场老兵是否能够得到赔偿的精神科诊断书之一(Mezey & Robbins 2001)。然而，这种测试只是在美国复审。 This situation has changed during the last two decades, and PTSD is now one of several psychiatric diagnoses for which a veteran can receive compensation, such as a war veteran indemnity pension, in the US (Mezey & Robbins 2001). However this practice is under review in the United States. In 2005, the US Department of Veterans Affairs Veterans Benefits Administration began a review of claims after it noted a reported 30% increase in PTSD claims in recent years. Because of the negative affect on the budget and the apparent inconsistency in the rate of rewards by different rating offices of the Department, they undertook this review. There was broad political backlash from veterans rights groups and some highly publicized suicides by veterans who feared loss of their benefits (which served often as their only source of income). In response to these events, on November 10, 2005, the Secretary of the US Department of Veterans affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..."

However the feeling of reprieve experienced by some veterans and veteran advocates was short-lived. Soon thereafter, the Department of Veterans Affairs announced that it had contracted with the Institute of Medicine (IOM) to conduct a[nother] study on Post-Traumatic Stress Disorder (PTSD). The Committee will review and comment on the objective measures used in the diagnosis of PTSD and known risk factors for the development of PTSD. The committee will also "review the utility and objectiveness of the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and will comment on the validity of current screening instruments and their predictive capacity for accurate diagnoses." The committee will also "review the literature on various treatment modalities (including pharmacotherapy and psychotherapy) and treatment goals for individuals with PTSD [and] ... comment on the prognosis of individuals diagnosed with PTSD and existing comorbidities." Some veteran advocates expressed concern that this was merely a backdoor method of reducing benefits to veterans who have served and currently service in Iraq and the Persian Gulf. On the other hand, conservative groups such as psychiatrist Sally Satel, who is affiliated with the conservative American Enterprise Institute, say "an underground network advises veterans where to go for the best chance of being declared disabled." The institute organized a recent meeting to discuss PTSD among veterans. Read more on the politics of PTSD at [1]

In sum, the diagnosis is highly controversial because of the strong connection with compensation seeking behavior and efforts and the uncertainty about the affect of this on objective diagnosis of those who may have been subjected to trauma. See recent article at [2]

While PTSD-like symptoms were recognized in combat veterans following many historical conflicts, the modern understanding of the condition dates to the 1980s. Reported OEF/OIF cases of combat-PTSD incidents are currently being compiled in ePluribus Media's PTSD Timeline: [3]

[编辑] 診斷標準

The diagnostic criteria for PTSD, according to Diagnostic and Statistical Manual of Mental Disorders -IV (DSM-IV), are stressors listed from A to F.

Due to copyright issues and editorial concerns the reference to the DSM-IV-TR is outlinked. The current diagnostic criteria for the PTSD published in the Diagnostic and Statistical Manual of Mental Disorders may be found here:

DSM-IV-TR Diagnostic Criteria: Post-traumatic stress disorder

Notably, the stressor criterion A is divided into two parts. The first (A1) requires that "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV A criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience." Since the introduction of DSM-IV, the number of possible PTSD-traumas has increased, and one study suggests that the increase is around 50% (Breslau & Kessler 2001).

[编辑] 臨床症狀及其可能之解釋

Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment, or nightmares. A potential symptom is the memory loss about an aspect of the traumatic event. Amplification of other underlying psychological conditions may also occur. Young children suffering from PTSD will often enact aspects of the trauma through their play, and may often have nightmares that lack any recognizable content.

One patho-psychological way of explaining PTSD is by viewing the condition as secondary to deficient emotional or cognitive processing of a trauma (Cordova 2001). This view also helps to explain the three symptom clusters of the disorder (Shalev 2001):

Intrusion: Since the person cannot process difficult emotions in a normal way, he/she is plagued by recurrent nightmares, or daytime flashbacks, while he/she realistically re-experiences the trauma. These re-experiences are characterized by high anxiety levels, and make up one part of the PTSD symptom cluster triad called intrusive symptoms.

Hyperarousal: PTSD is also characterized by a state of nervousness with the organism being prepared for "fight or flight". The typical hyperactive startle reaction, characterized by "jumpiness" in connection with high sounds or fast motions, is typical for another part of the PTSD cluster called hyperarousal symptoms, and could also be secondary to an incomplete processing.

Avoidance: The hyperarousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything, and everyone, even to his/her own thoughts, that can arouse memories of the trauma and thus cause the intrusive and hyperarousal states to go on. He/She isolates him/herself, being detached in his/her feelings with a restricted range of emotional response, and can experience so-called emotional detachment ("numbing"). This avoidance behavior is the third and most important part of the symptom triad that makes up the PTSD criteria.

[编辑] 生物學

[编辑] 神經化學

PTSD displays biochemical changes in the brain and body, which are different from other psychiatric disorders such as major depression.

In PTSD patients, the dexamethasone cortisol suppression is strong, while it is weak in patients with major depression. In most PTSD patients the urine secretion of cortisol is low, at the same time as the catecholamine secretion is high, and the norepinephrine/cortisol ratio is increased. Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. There is also an increased sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis, with a strong negative feedback of cortisol, due to a generally increased sensitivity of cortisol receptors (Yehuda, 2001).

The response to stress in PTSD is abnormal with long-term high levels of norepinephrine, at the same time as cortisol levels are low, a pattern associated with facilitated learning in animals. Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response (Yehuda 2002). With this deduction follows that the clinical picture of hyperreactivity and hyperresponsiveness in PTSD is consistent with the sensitive HPA-axis.

Swedish United Nations soldiers serving in Bosnia with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels (Aardal-Eriksson 2001).

Another possible factor in PTSD is that a persistence of depressive symptoms may be caused by an underlying biochemical disorder, associated with insulin resistance (dysglycemia), that can be treated by a hypoglycemic diet.

[编辑] 神經解剖學

In animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.

[编辑] 普及

PTSD may be experienced following any traumatic experience, or series of experiences which satisfy the criteria, and that do not allow the victim to readily recuperate from the detrimental effects of stress. It is believed that of those exposed to traumatic conditions between 5% (life threatening disease such as cancer) and 80% (rape) will develop PTSD depending on the severity of the trauma and personal vulnerability.

In peacetime, 30% of those that suffer will go on to develop a chronic condition; in wartime, the levels of disorder are believed to be higher.

In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, as well as the September 11, 2001 attacks on the World Trade Center and The Pentagon, may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as The Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.

Other agencies, such as the National Meditation Center for World Peace [4], have created special programs. The NMC trains agencies such as crisis centers NGOs and works with international agencies to prevent trauma to children.

[编辑] 癌症引起之PTSD

PTSD is normally associated with trauma such as violent crimes, rape, and war experience. However, there have been a growing number of reports of PTSD among cancer survivors and their relatives (Smith 1999, Kangas 2002). Most studies deal with survivors of breast cancer (Green 1998, Cordova 2000, Amir & Ramati 2002), and cancer in children and their parents (Landolt 1998, Stuber 1998), and show prevalence figures of between five and 20%. Characteristic intrusive and avoidance symptoms have been described in cancer patients with traumatic memories of injury, treatment, and death (Brewin 1998). There is yet disagreement on whether the traumas associated with different stressful events relating to cancer diagnosis and treatment actually qualify as PTSD stressors (Green 1998). Cancer as trauma is multifaceted, includes multiple events that can cause distress, and like combat, is often characterized by extended duration with a potential for recurrence and a varying immediacy of life-threat (Smith 1999).

[编辑] 治療方法

There have been scores of treatments suggested for the treatment of PTSD. One technique specifically targeted at the disorder is Eye Movement Desensitisation and Reprocessing (EMDR) ^[5]. Traumatic Incident Reduction is another, more controversial targeted method of treatment.

PTSD is usually treated by a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and psychotropic drug therapy (antidepressant or atypical antipsychotics, e.g. brand names such as Prozac (fluoxetine), Effexor (venlafaxin), Zoloft (sertraline), Remeron (mirtazapine), Zyprexa (olanzapine), or Seroquel (quetiapine)). Talk therapy may prove useful, but only insofar as the individual sufferer is enabled to come to terms with the trauma suffered and successfully integrate the experiences in a way that does not further damage the psyche. Forbes, et al, (2001) ^[6] have shown that a technique of "rewriting" the content of nightmares through imagery rehearsal so that they have a resolution can not only reduce the nightmares but also other symptoms. The US Food and Drug Agency (FDA) recently approved a clinical protocol that combines the drug MDMA ("Ecstasy") with talk therapy sessions.

Basic counseling for PTSD includes education about the condition and provision of safety and support (Foa 1997). Cognitive therapy shows good results (Resick 2002), and group therapy may be helpful in reducing isolation and stigma (Foy 2002).

Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD.[7]

PTSD is often co-morbid with other psychiatric disorders such as depression, substance abuse and other addictive behaviors. Currently under scrutiny is the inclusion of Complex Post Traumatic Stress in the 2006 revision of the DSM-IV-TR. This is a variant of PTSD that includes the breakthrough of Borderline Personality traits.

[编辑] 法規

If the acts and omissions of an individual suffering from PTSD result in consequences that breach the criminal law, there may be levels of confusion that prevent the formation of the relevant mens rea (the Latin for "guilty mind") so mistake or reasonable excuse may be a defence. In more extreme cases, the defence of automatism may be available, with particular conditions discussed at automatism (case law). But there is a danger that although the initial cause of the disorder will be external, it may produce an internal defect of reason or an abnormality of mind within the meaning of the M'Naghten Rules (redefined as a mental disorder defence in some criminal jurisdictions) that define insanity as an excuse. The difference is that whereas defences that negate the mens rea and automatism result in an acquittal, insanity or mental disorder leaves the "offender" available for sentencing by the court. In the event that a death has resulted, diminished responsibility may be available as an alternative to insanity. This defence reduces what would otherwise have been murder to manslaughter. For a detailed discussion of a sometimes related condition, see battered woman syndrome and, more generally, the abuse defense in the U.S.

[编辑] 被認為患有PTSD之歷史人物

Karel Kinsky, a prince from the Austro-Hungarian empire, was believed to have suffered from PTSD after serving extensively on the Russian front during World War I.

Audie Murphy, the most decorated American soldier in history at the time of World War II (he received thirty-three awards, including the Congressional Medal of Honor), Hollywood actor (he starred as himself in the 1955 film version of his autobiography To Hell and Back, in addition to films such as 1951's The Red Badge of Courage, 1957's Night Passage, and 1960's The Unforgiven), and songwriter (he wrote songs for Dean Martin, among others), suffered from PTSD as a result of his experience in WWII. According to his first wife, actress Wanda Hendrix, he suffered terrible nightmares and always slept with a gun under his pillow. Murphy was one of the first people to actually speak out publically about PTSD, and during the Vietnam War he called for more government funding to care for the returning veterans and to research the condition.

Marshal Ney, one of Napoleon Bonaparte's most notable commanders, is believed to have suffered from symptoms of PTSD. The decisions he made towards the end of his career were questionable, including those made during the Battle of Waterloo. It is suspected by most scholars that his exposure to extreme combat conditions eventually began to erode his mental capacities. He gained his biggest notoriety for leading rearguard actions during Napoleon's retreat from Moscow in 1812.

[编辑] 參見

Acute stress reaction
Amnesia
Betrayal
Biological psychiatry
Chemical imbalance theory
Invasion and occupation of Iraq casualties Civilian casualties section
Mental health
Survivor guilt
Survivor syndrome
Trauma model of mental disorders

[编辑] 相關創作

[编辑] 非小說類

Spike Milligan: Mussolini: His Part in My Downfall. In this war diary Milligan, one of Britain's greatest post-war comedians, details his descent into madness during the Italian campaign of World War II. The sequel, Where Have All the Bullets Gone? describes the unsympathetic treatment he received at the hands of military doctors.

[编辑] 小說類

Tim O'Brien: The Things They Carried
Pat Barker: Regeneration
William Somerset Maugham: The Razor's Edge
Frederik Pohl: Gateway
Philip Roth: The Human Stain
Rebecca West: The Return of the Soldier
Leslie Marmon Silko: Ceremony
David Morrell: First Blood
The Rights of Numbers - This Sci-Fi eBook was written to include several characters with trauma issues.
David Drake: Redliners
Solid Snake: Metal Gear series
Hideo Kuze: Ghost in the Shell: Standalone Complex 2nd Gig

[编辑] 電影

First Blood (1982)
The Razor's Edge (1984)
Fearless (1993)
Jacknife (1989)
The Deer Hunter (1978)
Apocalypse Now (1979)
The Hunted: Benicio Del Toro
12 O'clock High A black/white film about the air war over Germany during WW2, starring Gregory Peck. This was considered the first film to depict PTSD, and was controversial for doing so.
The Beast
Behind the Lines (1997) based on the book 'Regeneration' (1991) about PTSD treatment of WW I veterans
Saving Private Ryan Several characters in the film exhibit signs and symptoms of PTSD. Most notable is the character of Captain John Miller, played by the actor Tom Hanks. He suffers from a noticeable shaking of his left hand which only occurs when he is not in combat conditions. Throughout the film the decisions he makes regarding the actions of his squad become increasingly suicidal and his men start to question his rationale. Cpt. Miller orders an assault on an isolated machine gun nest which (as pointed out by his Sgt. and the other soldiers) could be avoided, and had apparently been done previously when the Captain's Company had encountered some German 88's. Cpt. Miller's decision to assault the nest indicates that his constant exposure to combat conditions is beginning to override his decision-making skills. The group spends some time debating the assault's necessity, and Miller is the only one in favor of it. When the discussion becomes heated, Miller verbally redresses his Sgt. by telling him to shut up. Inevitably, one of the soldiers in the squad is killed during the attack.
Don't Say a Word (2001)
The Thin Red Line (1998 film) by Terence Malick

[编辑] 電視節目

Josh Lyman experiences PTSD in "Noel," episode 210, of West Wing
Malcolm Reynolds experiences PTSD in "Serenity," the pilot episode, of Firefly
David Fisher experiences PTSD in the last two seasons of Six Feet Under.
The Number Six clone "Gina" exhibited PTSD symptoms on the Battlestar Galactica television series. The actress researched the disorder to incorporate it into her character's behavior.

[编辑] 參考資料

^ David Satcher etal. (1999). "Chapter 4.2", Mental Health: A Report of the Surgeon General.

^ Forbes, D. et al. (2001) "Brief report: treatment of combat-related nightmares using imagery rehearsal: a pilot study", Journal of Traumatic Stress 14 (2): 433-442

^ Devilly, G. J., & Spence, S. H. (1999). "The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post traumatic stress disorder". Journal of Anxiety Disorders, 13, 131–157.