全科医学中的心理健康病案研究 (七)——创伤后应激障碍

Fiona Judd，Grant Blashki，Leon Piterman(著)，杨 辉 (译)

1 病史

珍妮，35岁，她的丈夫陪她来看病。她丈夫说，自从3个月前出过一次交通事故后，珍妮就好像“变成另外一个人”。睡眠质量很差，经常“一惊一乍”的，很容易烦躁。那次出事后她不再开车。每天晚上她要喝两杯葡萄酒，说喝酒能让她平静下来。让她丈夫最无奈的是，珍妮甚至不愿意坐在副驾驶座或后座上。今天早上带她来看病，夫妻俩还为此争吵起来，珍妮不愿意坐车，还哭起来了。

2 其他病史

3个月前的那次车祸，珍妮真是非常侥幸，没受什么重伤。一辆车违反交通规则，该让路时没让路，结果撞在珍妮开的车上。那辆车的乘客当场死亡。珍妮被卡在自己的车里，2 h动弹不得，被解救出来后送到医院。珍妮在医院待了48 h，然后出院回家。刚出院的时候，珍妮有些忧伤和焦虑，其他方面倒显得正常。不过几个星期后，她不但没有感觉好些，反而感到越来越焦躁。她感觉自己好像走在悬崖边上，随时随地要“保持警觉”。她会无缘无故地发无名火，睡眠质量越来越差。

她丈夫跟你说，珍妮好像总在做噩梦，不过她没有说做过什么样的噩梦。她不愿意提起那次车祸，不愿坐车，不愿意走近出车祸的那条街道。不过令她丈夫最担心的是，感觉珍妮不再像以前那样爱他和两个孩子 (一个9岁，另一个7岁)。

3 检查

珍妮表现出明显的焦虑。当她丈夫跟你谈起她跟孩子们关系的时候，她显得很苦恼。珍妮的生命体征是正常的。

心理状态检查发现，珍妮承认自己感到焦虑，也承认经常感到忧虑。不过她否认有自残的想法。她说眼前经常闯入车祸发生时候的那些画面 (intrusive images)，她说每天夜里做梦都是自己被卡在车里。她说自己经常出现闪回 (flashback)，总感觉又要发生车祸了。

血液检查结果正常，包括全血指标、尿素、电解质、肝功能、甲状腺刺激激素都正常。缺铁指标在临界值。

4 提问

4.1 可能的精神病学诊断是什么?

4.2 应该考虑到哪些其他诊断?

4.3 怎么治疗?

4.4 珍妮的预后怎么样?

5 解答

5.1 问题1的解答:精神病学诊断 最可能的诊断是创伤后应激障碍。3个月前她经历了一次重大的交通事故，自己险些丧命，并见到对方有人死亡。这个痛苦经历通过画面闯入、噩梦、闪回等“再体验现象” (re－experiencing phenomena)一直在困扰她。她刻意和主动地逃避与那次经历有联系的刺激因素 (如:出事的那条街、开车)。她表现出情感麻木 (emotional numbing)，对丈夫和孩子表现出自身感受和情感的能力下降。她还有各种高唤醒症状 (hyperarousal)，如睡眠障碍、焦躁不安、过度警觉 (hypervigilance)。

归纳而言，再体验、逃避和情感麻木、高唤醒是创伤后应激障碍最典型的 3 个症状［2－3］。

5.2 问题2的解答:其他的诊断 做出创伤后应激障碍诊断的关键，是确定应激源 (stressor)以及应激源所导致的症状。

抑郁症是创伤后应激障碍最常见的并发心理问题。如果考虑抑郁症，则需要看病人是否有情绪低落 (low mood) 〔注:创伤后应激障碍则是感觉丧失 (loss of feelings)〕、缺乏兴趣(loss of interest)、缺乏精力 (loss of energy)、负罪想法(thoughts of guilt)、良心责备 (self－reproach)。

另外一个需要考虑的是，驾车恐惧症 (driving phobia)，因为她的症状中有害怕开车和避免开车。不过这个病人的症状并不支持驾车恐惧症的诊断。

很多创伤后应激障碍的病人，往往用酒精或镇静药来应对自己的症状。因此你还必须要辨别出病人是否本身就有物质滥用 (substance misuse)的问题。

当事件涉及法律程序的时候，病人的症状可能会持续更长时间，或表现得更加严重。

5.3 问题3的解答:怎么治疗 创伤后应激障碍的表现可谓是五花八门，每个病人的症状组合都可能有所不同，所以也没有适用于所有病人的“统一”治疗方案。要根据每个病人的特点来选择治疗方案。通常，治疗方案是心理学治疗方法与药理学治疗方法相结合的。轻型的创伤或应激障碍主要采用心理学治疗方法，比较严重的则采用心理学和药理学相结合的方法［4］。

心理学治疗的主要方法是，帮助患者克服创伤记忆的影响(confronting the traumatic memory)，改变患者对经历过事件的想法和信念。针对心理创伤的心理学干预措施包括创伤认知行为治疗方法 (CBT)和眼动脱敏再加工疗法 (eye movement desensitisation and reprocessing，EMDR)，其中包括身临其境暴露法 (in vivo exposure)。

药理学的治疗方案主要是根据患者的症状特点，对症治疗。不过通常在药物治疗方案中，加上抗抑郁药 (特别是选择性5－羟色胺再摄取抑制剂)。

5.4 问题4的解答:预后 病人之间差异较大。大部分病人的创伤后应激障碍的强度自然地降低，有相当多的病人在事件发生几年后症状消失。不过一旦病情转入慢性阶段，特别是症状持续2年以上的情况，康复率明显下降。

在顽固性症状的病人中，有些人表现为病情上下波动，时好时坏;另外一些人则表现为慢性持续恶化，伴随各种并发症，最终造成大部分心身功能残疾。

女性、儿童和老年患者的预后较差。如果创伤与战争、躯体虐待、性虐待有关，预后也很差。如果症状出现时间距创伤事件比较近、症状持续时间比较长、症状的种类比较多、情感麻木比较突出、高唤醒症状比较明显，病人的预后也比较差。另外，如果病人的社会支持差、家庭和居住条件不稳定、跟家人或同事经常产生矛盾，病人的预后也不好。所以相对来说，珍妮的预后相对来说还好。

译者注:

1 创伤后应激障碍筛查量表 (PCL):是评估创伤后焦虑症状程度的量表，有17项，可以用于筛查目的，也可以用来监测症状的严重程度和治疗效果。该量表可以从www.ncptsd.va.gov下载。

2 高唤醒症状:病人处于持续提高的警觉状态，“恐惧系统”不断地提升到越来越高的水平。警觉状态提高可以表现为一系列症状，如注意力减退、记忆力减退、焦躁不安、容易发怒、入睡困难、容易惊醒、容易受到惊吓、对危险信号或标志的过度警觉等。

3 眼动脱敏再加工疗法 (EMDR):当一个人经历一场创伤时，当时的场景、声音、思想、感觉会被“锁定”在神经系统中。在某种特定状态下，按治疗师手指移动的不同方向、速度，嘱患者眼球随之移动数十次，可以有效地解开神经系统的“锁定”状态，并使人们对创伤的经验在大脑中进行再加工。这种治疗对于抑郁、焦虑、多梦以及多种创伤后的恐惧等心理问题具有良好的治疗效果。

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.