全科醫學中的心理健康病案研究 (七)——創傷后應激障礙

Fiona Judd，Grant Blashki，Leon Piterman(著)，楊 輝 (譯)

1 病史

珍妮，35歲，她的丈夫陪她來看病。她丈夫說，自從3個月前出過一次交通事故后，珍妮就好像“變成另外一個人”。睡眠質量很差，經?！耙惑@一乍”的，很容易煩躁。那次出事后她不再開車。每天晚上她要喝兩杯葡萄酒，說喝酒能讓她平靜下來。讓她丈夫最無奈的是，珍妮甚至不愿意坐在副駕駛座或后座上。今天早上帶她來看病，夫妻倆還為此爭吵起來，珍妮不愿意坐車，還哭起來了。

2 其他病史

3個月前的那次車禍，珍妮真是非常僥幸，沒受什么重傷。一輛車違反交通規則，該讓路時沒讓路，結果撞在珍妮開的車上。那輛車的乘客當場死亡。珍妮被卡在自己的車里，2 h動彈不得，被解救出來后送到醫院。珍妮在醫院待了48 h，然后出院回家。剛出院的時候，珍妮有些憂傷和焦慮，其他方面倒顯得正常。不過幾個星期后，她不但沒有感覺好些，反而感到越來越焦躁。她感覺自己好像走在懸崖邊上，隨時隨地要“保持警覺”。她會無緣無故地發無名火，睡眠質量越來越差。

她丈夫跟你說，珍妮好像總在做噩夢，不過她沒有說做過什么樣的噩夢。她不愿意提起那次車禍，不愿坐車，不愿意走近出車禍的那條街道。不過令她丈夫最擔心的是，感覺珍妮不再像以前那樣愛他和兩個孩子 (一個9歲，另一個7歲)。

3 檢查

珍妮表現出明顯的焦慮。當她丈夫跟你談起她跟孩子們關系的時候，她顯得很苦惱。珍妮的生命體征是正常的。

心理狀態檢查發現，珍妮承認自己感到焦慮，也承認經常感到憂慮。不過她否認有自殘的想法。她說眼前經常闖入車禍發生時候的那些畫面 (intrusive images)，她說每天夜里做夢都是自己被卡在車里。她說自己經常出現閃回 (flashback)，總感覺又要發生車禍了。

血液檢查結果正常，包括全血指標、尿素、電解質、肝功能、甲狀腺刺激激素都正常。缺鐵指標在臨界值。

4 提問

4.1 可能的精神病學診斷是什么?

4.2 應該考慮到哪些其他診斷?

4.3 怎么治療?

4.4 珍妮的預后怎么樣?

5 解答

5.1 問題1的解答:精神病學診斷 最可能的診斷是創傷后應激障礙。3個月前她經歷了一次重大的交通事故，自己險些喪命，并見到對方有人死亡。這個痛苦經歷通過畫面闖入、噩夢、閃回等“再體驗現象” (re－experiencing phenomena)一直在困擾她。她刻意和主動地逃避與那次經歷有聯系的刺激因素 (如:出事的那條街、開車)。她表現出情感麻木 (emotional numbing)，對丈夫和孩子表現出自身感受和情感的能力下降。她還有各種高喚醒癥狀 (hyperarousal)，如睡眠障礙、焦躁不安、過度警覺 (hypervigilance)。

歸納而言，再體驗、逃避和情感麻木、高喚醒是創傷后應激障礙最典型的 3 個癥狀［2－3］。

5.2 問題2的解答:其他的診斷 做出創傷后應激障礙診斷的關鍵，是確定應激源 (stressor)以及應激源所導致的癥狀。

抑郁癥是創傷后應激障礙最常見的并發心理問題。如果考慮抑郁癥，則需要看病人是否有情緒低落 (low mood) 〔注:創傷后應激障礙則是感覺喪失 (loss of feelings)〕、缺乏興趣(loss of interest)、缺乏精力 (loss of energy)、負罪想法(thoughts of guilt)、良心責備 (self－reproach)。

另外一個需要考慮的是，駕車恐懼癥 (driving phobia)，因為她的癥狀中有害怕開車和避免開車。不過這個病人的癥狀并不支持駕車恐懼癥的診斷。

很多創傷后應激障礙的病人，往往用酒精或鎮靜藥來應對自己的癥狀。因此你還必須要辨別出病人是否本身就有物質濫用 (substance misuse)的問題。

當事件涉及法律程序的時候，病人的癥狀可能會持續更長時間，或表現得更加嚴重。

5.3 問題3的解答:怎么治療 創傷后應激障礙的表現可謂是五花八門，每個病人的癥狀組合都可能有所不同，所以也沒有適用于所有病人的“統一”治療方案。要根據每個病人的特點來選擇治療方案。通常，治療方案是心理學治療方法與藥理學治療方法相結合的。輕型的創傷或應激障礙主要采用心理學治療方法，比較嚴重的則采用心理學和藥理學相結合的方法［4］。

心理學治療的主要方法是，幫助患者克服創傷記憶的影響(confronting the traumatic memory)，改變患者對經歷過事件的想法和信念。針對心理創傷的心理學干預措施包括創傷認知行為治療方法 (CBT)和眼動脫敏再加工療法 (eye movement desensitisation and reprocessing，EMDR)，其中包括身臨其境暴露法 (in vivo exposure)。

藥理學的治療方案主要是根據患者的癥狀特點，對癥治療。不過通常在藥物治療方案中，加上抗抑郁藥 (特別是選擇性5－羥色胺再攝取抑制劑)。

5.4 問題4的解答:預后 病人之間差異較大。大部分病人的創傷后應激障礙的強度自然地降低，有相當多的病人在事件發生幾年后癥狀消失。不過一旦病情轉入慢性階段，特別是癥狀持續2年以上的情況，康復率明顯下降。

在頑固性癥狀的病人中，有些人表現為病情上下波動，時好時壞;另外一些人則表現為慢性持續惡化，伴隨各種并發癥，最終造成大部分心身功能殘疾。

女性、兒童和老年患者的預后較差。如果創傷與戰爭、軀體虐待、性虐待有關，預后也很差。如果癥狀出現時間距創傷事件比較近、癥狀持續時間比較長、癥狀的種類比較多、情感麻木比較突出、高喚醒癥狀比較明顯，病人的預后也比較差。另外，如果病人的社會支持差、家庭和居住條件不穩定、跟家人或同事經常產生矛盾，病人的預后也不好。所以相對來說，珍妮的預后相對來說還好。

譯者注:

1 創傷后應激障礙篩查量表 (PCL):是評估創傷后焦慮癥狀程度的量表，有17項，可以用于篩查目的，也可以用來監測癥狀的嚴重程度和治療效果。該量表可以從www.ncptsd.va.gov下載。

2 高喚醒癥狀:病人處于持續提高的警覺狀態，“恐懼系統”不斷地提升到越來越高的水平。警覺狀態提高可以表現為一系列癥狀，如注意力減退、記憶力減退、焦躁不安、容易發怒、入睡困難、容易驚醒、容易受到驚嚇、對危險信號或標志的過度警覺等。

3 眼動脫敏再加工療法 (EMDR):當一個人經歷一場創傷時，當時的場景、聲音、思想、感覺會被“鎖定”在神經系統中。在某種特定狀態下，按治療師手指移動的不同方向、速度，囑患者眼球隨之移動數十次，可以有效地解開神經系統的“鎖定”狀態，并使人們對創傷的經驗在大腦中進行再加工。這種治療對于抑郁、焦慮、多夢以及多種創傷后的恐懼等心理問題具有良好的治療效果。

1 Shi Tieying，Jiang Chao，Jia Shuhua，et al.Post－traumatic stress disorder and related factors following the severe acute respiratory syndrome［J］ .Chinese Journal of Clinical Rehabilitation，2005，9(44):9 －12.

2 Australian guidelines for the treatment of adults with acute stress disorder and post－traumatic stress disorder［Z］.Australian Centre for Posttraumatic Mental Health，2007.

3 Li Lingjiang，Yu Xin.Chinese treatment and prevention guideline of post－ traumatic stress disorder ［J］ .Beijing:People's Health Publisher，2010.

4 Blashki G，Judd F，Piterman L.General practice psychiatry［Z］.McGrawHill，2007.

【Introduction of the Column】 The Journal presents the Column of Case Studies of Mental Health in General Practice，with academic support from Australian experts in general practice，psychology and psychiatry from Monash University and the U-niversity of Melbourne.The Column's purpose is to respond to the increasing needs of mental health services in China.Through study and analysis of mental health cases，we hope to improve understanding of mental illnesses in Chinese primary health settings，and to build capacity of community health professional in managing of mental illnesses in general practice.Patient－centred and whole－person approach in general practice is the best way to maintain and improve the physical and mental health of residents.Our hope is that these case studies will lead new wave of general practice and mental health development both in practice and academic research.A number of Australian experts from the disciplines of general practice，mental health and psychiatry will contribute to the Column.You will find A/Professor Blashki，Professor Judd and Professor Piterman are authors of General Practice Psychiatry.The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinese mental health in primary health care will step up to a new level under this international cooperation.

Affiliation:Melbourne University，Victoria 3010，Australia(Fiona Judd，Grant Blashki);Monash University(Leon Piterman)

【Introduction of the case study】 After the fatal earthquake in Sichuan in 2008(more than 460 thousand people died or were missing)，a'new term'of post－traumatic stress disorder(PTSD)came into the vocabulary of Chinese health professionals and general people［1］.PTSD may develop after exposure to an extremely traumatic event，such as war，torture，rape， physical assault， being kidnapped，terrorism，natural disaster，major car accident，being diagnosed with a potentially fatal illness，finding the body of someone who has committed suicide or been murdered，etc.The potentially traumatic events(PTEs)may involve large numbers of the public(e.g.earthquake)or an individual(e.g.major car accident).Annually，according to the Ministry of Civil Affairs，about 200 million people are affected by natural disasters(flooding，bushfire，earthquake).In 2008，more than 100 thousand people died in car accidents，as reported by the Ministry of Public Security.In Australia，the most commonly reported PTEs are witnessing death or injury to others， accidents， natural disasters， and physical assaults.Approximately 15%～25%of people exposed to PTEs later develop PTSD.Over a quarter of a million Australians experience PTSD in any one year.Without effective management，PTSD can become a chronic and debilitating condition.It carries a higher suicide risk than any other anxiety disorder.As a general practitioner，you should be aware of the possibility of PTSD among people who are involved in PTEs.And they might be your patients in your clinic.Therefore，being able to recognize typical symptoms，to understand diagnostic and screening strategies，and to know options of appropriate management are necessary as part of your professional development and enable you to be ready to help people who experience traumatic events.

1 History

Jenni Chan，a 35 year－old woman is brought to see you by her husband.He reports she is'not the same person'since a motor vehicle accident 3 months ago.He describes that since the accident，she has been sleeping poorly，is very jumpy and irritable and has refused to drive the car.She has been having 2 glasses of wine at night which she says is helping her to feel calm.Further，he is frustrated because she is even reluctant to get into the car as a passenger，and bringing her to the surgery today caused an argument and tears.

2 Other history

Jenni was lucky to escape serious physical injury in the accident 3 months ago.Her car was hit when a driver failed to give way，and a passenger in the other car was killed.Jenni was pinned inside her vehicle for 2 hours before being freed and taken to hospital.She stayed in hospital for 48 hours.Following discharge home she was distressed and anxious but otherwise seemed to be coping.However，after a couple of weeks rather than feeling better she felt increasingly anxious，on edge and'on alert'，was uncharacteristically irritable and had increasing difficulty sleeping.

Her husband described that she seems to have nightmares，although does not talk to him about them，that she won't discuss the accident，won't go out in the car and does not want to go near the street where the accident occurred.However，his greatest concern is that Jenni seems'less loving'towards him and their two children who aged 9 and 7 years old.

3 Examination

Jenni is obviously anxious，and becomes quite distressed as her husband talks about her interaction with her children.Vital signs are normal.A basic set of blood tests was unremarkable－normal FBE，U/E and LFT and TSH and a borderline iron deficiency.On mental state examination she acknowledges that she feels anxious and at times depressed.She denies thoughts of self harm.She describes intrusive images of the accident，and admits that she dreams of being trapped in the car every night.She also reports flashbacks，with a feeling that the crash is about to happen.

4 Questions

4.1 What is the probability psychiatric diagnosis?

4.2 What other diagnoses should be considered?

4.3 How can the disorder be treated?

4.4 What is Jenni's prognosis?

5 Answers

5.1 What is the probability psychiatric diagnosis? The most likely diagnosis is post－traumatic stress disorder(PTSD).She is now 3 months post a major life threatening trauma;she is describing re－experiencing phenomena(flashbacks，nightmares，intrusive images);avoidance of stimuli associated with the trauma(the street，driving car)，emotional numbing(less ability to show feelings to husband and children)and symptoms of hyperarousal(sleep disturbance，irritability，hypervigilance)［2－3］.

5.2 What other diagnoses should be considered? Important features in making the diagnosis of PTSD are the stressor，and the onset of symptoms following the stressor.Depression is a common cooccurring disorder with PTSD.Thus enquiry should be made about low mood(compared with'loss of feelings"in PTSD)，loss of interest，loss of energy，thoughts of guilt and self－reproach).Another diagnosis to consider in light of her fear and avoidance of driving is the possibility of a driving phobia;but the accompanying symptoms would not be explained by this diagnosis.Many people with PTSD attempt to cope with the symptoms using alcohol or sedative medications;thus co－occurring substance misuse must also be excluded.Sometimes if legal proceedings are likely to occur these can prolong or exacerbate the symptoms.

5.3 How can the disorder be treated? Full blown PTSD presents in different ways with different combinations of symptoms，so no treatment approach is likely to be applicable to all patients.Decisions about choice of treatment need to take into account the characteristics of each patient and usually involve a combination of various types of psychological and pharmacological treatment.Severity of PTSD is only a rough guide to choice of treatment－mild psychological，more severe both psychological and pharmacological treatments［4］.

The cornerstone of psychological treatment involves confronting the traumatic memory and addressing thoughts and beliefs associated with the experience.Trauma focussed psychological interventions include trauma focussed cognitive behavioural therapy(CBT)and eye movement desensitisation and reprocessing(EMDR)that includes in vivo exposure.

Pharmacological treatment is based on predominant type of symptoms，but antidepressants，particularly the SSRIs，are usually considered the treatment of choice.

5.4 What is Jenni's prognosis? The course varies from one person to another.There is a tendency for the disorder to spontaneously decrease in intensity and disappear in a substantial number of patients within a few years of onset.However，recovery rates decrease sharply once the disorder has become chronic，and in particular once symptoms have been present for＞2 years.

For those with persistent symptoms，some have a fluctuating course with exacerbation and partial remission，whilst other have a chronic deteriorating course with various complications and lasting impairment in most areas of functioning.

Poor prognosis is more likely if amongst female，children and the elderly;if the trauma is related to war，or to physical or sexual assault;if there are early onset symptoms，long duration symptoms，greater number of symptoms，prominent numbing and hyperarousal symptoms;and if there is poor social support，unstable home/family situation，conflict at home or in the workplace.Thus，Jenni's prognosis is relatively good.

Note:

1 The posttraumatic stress disorder checklist(PCL):is a 17－item scale designed to assess the extent to which patients experience symptoms of anxiety related to certain trauma experiences.The scale can be used as a'screen'for PTSD and as a means of monitoring severity of symptoms and response to treatment.Copy available from www.ncptsd.va.gov.

2 Hyperarousal:the patient experiences ongoing increased arousal，as though the'fear system'has been recalibrated to a higher idling level.Increased arousal is evident in a range of symptoms such as poor concentration and memory，irritability and anger，difficulty in falling and staying asleep，being easily startled，and being constantly alert to signs of danger(hypervigilance).

3 Eye movement desensitization reprocessing(EMDR):the person is asked to focus on trauma－related imagery，negative thoughts and body sensations while simultaneously moving their eyes back and forth，following the movement of the therapist's fingers across their field of vision，for 20～30 seconds or more.It is proposed that this dual attention facilitates the processing of the traumatic memory into existing knowledge networks.

1 Shi Tieying，Jiang Chao，Jia Shuhua，et al.Post－traumatic stress disorder and related factors following the severe acute respiratory syndrome［J］ .Chinese Journal of Clinical Rehabilitation，2005，9(44):9 －12.

2 Australian guidelines for the treatment of adults with acute stress disorder and post－traumatic stress disorder［Z］.Australian Centre for Posttraumatic Mental Health，2007.

3 Li Lingjiang，Yu Xin.Chinese treatment and prevention guideline of post－ traumatic stress disorder ［J］ .Beijing:People's Health Publisher，2010.

4 Blashki G，Judd F，Piterman L.General practice psychiatry［Z］.McGrawHill，2007.