《The Medical Republic》案例分享——X 线正常可能不等于复原: 从创伤后应激障碍学到的

Leon Piterman(著)，邱珊娇(译)，黄文静(译)，杨辉(译)

·世界全科医学工作瞭望·

《The Medical Republic》案例分享
——X 线正常可能不等于复原: 从创伤后应激障碍学到的

Leon Piterman(著)1，邱珊娇(译)2，黄文静(译)2，杨辉(译)1

全科医生；应激障碍，创伤后；心理疗法

PITERMAN L.X线正常可能不等于复原——从创伤后应激障碍学到的[J].邱珊娇，黄文静，杨辉，译.中国全科医学，2017，20(14)：1663-1665.[www.chinagp.net]

PITERMAN L.Normal X-rays may not heal——a study in PTSD[J].QIU S J,HUANG W J,YANG H,translators.Chinese General Practice,2017，20(14)：1663-1665.

当我第一次见到鲍里斯，他是孤独和绝望的样子。

他今年45岁，可看起来却像65岁。他像中年发福一样的超重，面色红润，迈着缓慢和有目的的步态，很高兴能逮住机会，把自己陷在我对面的病人椅子上。是他的老板把他送到我诊所的，是为了评估在他病休6个月后重新回去工作的可能性。我知道，给他看病要花很长时间，但愿不要花的时间太长；或者，可能要给他看好几次病。

以前，鲍里斯在我们诊所附近的印刷厂担任下午班或晚班经理。

他出生在保加利亚，20岁之后就一直住在澳大利亚。他跟一位小他12岁的女子结婚，生了两个儿子，分别是8岁和6岁。他以往一直坚持锻炼身体，40岁之前一直在踢足球。他为自己健美的身材和阳刚气概感到骄傲。

所有这一切在6个月前的一个晚上被完全改变了。鲍里斯在工作时遇到了事故。当时，他正在工厂里修理一个墙上的电灯开关，一辆叉车冲着他倒车过来，并停车，把他挤压在墙上，动弹不得。他感到被压扁了，心想自己死定了。

虽然重启叉车只用了几分钟，但感觉像是用了几个小时。这段时间，鲍里斯一直保持着警觉，虽然他的胸部、背部和骨盆疼痛难忍。有人叫了急救车，鲍里斯被紧急送到了当地的教学医院。医院给他做了体检，照了X线，做了扫描检查，并在留观室留观了24 h。医生告诉他仅是擦伤，没有骨折，这些问题会在短时间内得到恢复，然后把他送回家，并给他预约了2周后的骨科门诊。去骨科门诊复诊的路上他感到很痛苦，然后又在候诊室忍受了漫长的等待，结果得到的是很短暂的专家接诊。骨科医生告诉他没有严重的损伤，给他开了2周的病假证明，让他再看病的话去找全科医生。

然而，鲍里斯并没有如期恢复。他的疼痛一直持续着，而且噩梦不断。他梦到自己被压扁或淹死，并经常在冷汗中惊醒。这些噩梦和闪回变成了他生活常态。他的妻子经常被他吵醒，所以把他打发到另一个空房间去。

医生给他开了安眠药，并让他继续休息1个月，但他发现自己越来越抑郁和焦虑。他无法忍受汽车噪声和喇叭声。他有几次回到自己工作的地方，但一看到叉车就感到无比害怕。他开始每天喝烈酒，而且和妻子的关系也变得恶化。他甚至怀疑妻子可能有外遇。

在持续5个月无法工作后，他被精神病专家确诊为创伤后应激障碍(PTSD)，开始使用选择性血清素再吸收抑制剂(SSRI)类药物(5-羟色胺再摄取抑制剂)治疗，并转诊去做心理治疗。

现在，PTSD已经是我们的字典中广泛使用的术语，因为在日常生活中不断目睹各种各样的创伤性事件。

对于PTSD最早的系统描述，称为“炮弹休克”，是1917年第一次世界大战期间发明的新词。有1/7的部队士兵受到PTSD的折磨，总共8万名英军士兵接受治疗，其中有很多人不是前线部队的。

在伊拉克和阿富汗战争中，25万美国士兵受到PTSD影响。参加这些战争的3 000多名澳大利亚士兵也受到相似的折磨。

很多参加世界大战和越南战争的退伍军人在沉默中忍受痛苦，然后转向酗酒、吸毒和暴力行为，或者直接变得长期焦虑和抑郁。我们对PTSD的认识，意味着通过早期干预，并采用一系列传统和新的治疗方法，能让他们得到更好的健康结果。

当然，PTSD不仅影响经历过战争的人。其可以影响直接地或间接地暴露于被认为是威胁生命的创伤事件的任何人。包括交通事故、与工作相关的事故(如鲍里斯的案例)、自然灾害、犯罪或恐怖主义行为、儿童虐待和家庭暴力。

遭受PTSD的人可能不是创伤的直接受害者，但可能是目睹了其可怕结果的人。尤其影响急救服务人员和健康工作者，甚至影响仅是旁观的人，正如最近发生的墨尔本市中心悲剧(注：2017年1月，一个人驾车冲进墨尔本繁华的市中心，造成4人死亡，数十人受伤)。

据估计，澳大利亚PTSD终生流行率是7.2%，12个月流行率是4.4%。真不敢想象，在叙利亚PTSD会是什么情况！

PTSD有一系列的临床表现，包括：反复重现创伤性体验、噩梦、失眠、症状闪回、负面的想法和自我懊恼；在遇到与当时场景有关的线索时，出现诸如出汗、心悸、胸痛等生理反应；易激惹(如对噪声的反应)、逃避行为、攻击行为、兴趣低下和注意力不集中。

其中有些症状也明显表现为抑郁和焦虑。

PTSD的治疗方法包含心理治疗和药物治疗。一般来说，早期干预会有较好的结果。

心理治疗包含认知行为疗法、延长暴露疗法(谈论和再度体验痛苦的回忆)、眼动脱敏与再加工疗法(即当想到痛苦回忆的时候，专注于其他活动如眼球运动和用手敲击)。

药物治疗包括SSRI的使用，这些药物也用于治疗抑郁和焦虑。

并不是每个暴露于创伤的人均会发展成PTSD。例如，在阿富汗和伊拉克服役的200万名美军士兵中，约有10%的人有PTSD。这种现象促使研究者提出关于个人易感性的研究问题。对PTSD的神经生物学研究，是一个新的研究方向，可能有助于我们识别出哪些人有患PTSD高风险，并开发出更有针对性的治疗方法。

经过治疗后，鲍里斯在病休6个月后能够回到岗位做兼职工作，9个月后能够做全职工作。

我一直在推演某种情形，如果医院急诊和骨科门诊对他的情况有更深刻的了解，并在此了解的基础上给他治疗，那么他的预后会不会大不相同呢。

如果有人告诉你：“你的X线检查正常，所以你没有大问题”，这种说法可能既不代表你躯体没病，也不说明你心理无恙。给患者做更具有同情心的评估，再加上意识到危及生命的事件可能带来长期的心理并发症，那么就可能有助于帮到诸如鲍里斯这样的患者，让其免受PTSD带来的损害。

我最近参加了一个PTSD的研讨会，详情参阅：www.traumaandmentalhealthconference.org.

Boris cut a lonely despondent figure when I first met him.

He was 45 years old,but looked more like 65.He was overweight with a large middle-aged spread,ruddy complexion,slow purposeful gait and relished the opportunity to sink into the patient′s chair.He had been sent to see me by his employer to assess the possibility of a return to work after a six-month absence.I knew this would be a long,if not very long,consultation-or maybe several consultations.

Boris had been the afternoon/evening manager in a print works that operated near our clinic.

He was born in Bulgaria but had lived in Australia since the age of 20.He was married to a woman 12 years his junior and had two sons,aged eight and six.He had been physically active,playing football until the age of 40,and had been proud of his fitness and virility.

This all changed one evening six months ago,when Boris was involved in an accident at work.He was fixing a light switch on the wall in the factory when a forklift reversed,stalled and trapped him against the wall.He felt crushed and was sure he was going to die.

It only took several minutes to restart the forklift,but it seemed like hours.Boris was alert during this time although the pain in his chest,back and pelvis was excruciating.An ambulance was called and Boris was rushed to the local teaching hospital.He was examined,had X-rays and scans and kept in for 24 hours in the short- stay unit.

He was informed that there were no fractures,just bruising,which would settle in time,and sent home with an outpatient orthopaedic appointment two weeks later.This turned out to be short consultation after a painful car trip and long stint in the waiting room.He was told that there no serious damage,given a certificate for two weeks off work,and told to see his GP.

Boris did not recover.His pain persisted and so did his nightmares.He dreamed he was being crushed or drowned.He frequently awoke in a cold sweat.These dreams and flashbacks became the norm.His wife was woken repeatedly and he was relegated to the spare room.

He was given sleeping tablets and another month off work but found himself becoming increasingly depressed and anxious.Car noises and sirens were intolerable.He visited his workplace on several occasions but the sight of the forklifts terrified him.He began drinking spirits on a daily basis and his relationship with his wife deteriorated.He even suspected she might be having an affair.

After a five-month absence from work he was seen by a psychiatrist who diagnosed post traumatic stress disorder (PTSD),started him on an SSRI and referred him for psychological treatment.

PTSD is a term now widely used in our lexicon as we continue to witness a wide variety of traumatic events on a daily basis.

The earliest systematic description of this disorder was "shell shock",a term coined in 1917 in the midst of the First World War to describe what we now know as PTSD.This afflicted one in seven troops and a total of 80,000 British troops were treated for the condition,many of them not front-line troops.

PTSD has affected 250,000 US troops who have fought in Iraq and Afghanistan and more than 3 000 Australian troops involved in these conflicts have been similarly afflicted.

While many of our world war and Vietnam veterans suffered in silence,turned to alcohol,drugs and violent behaviour,or simply became chronically anxious or depressed,the recognition of this syndrome has meant that early intervention,using a range of established and novel treatments,is improving outcomes.

Of course,PTSD is not confined the those serving in theatres of war.It can affect anyone exposed directly or even vicariously to trauma which is perceived to be life threatening.This includes traffic and work-related accidents,as in Boris′s case,natural disasters,criminal and terrorist acts,child abuse and domestic violence.

Those afflicted may not be the direct victims of the trauma but may have witnessed its horrific outcomes.This particularly affects emergency-services personnel and health workers,but may also affect bystanders,as has just happened tragically in the Melbourne CBD.

It is estimated that the lifetime prevalence rate of PTSD in Australia is 7.2% with a 12-month rate of 4.4%.One shudders to think what it might be in Syria！PTSD has a range of clinical manifestations.These include:recurrent intrusive memories,nightmares,poor sleep,flashbacks,negative thoughts and feelings of self blame,physiological reactions such as sweats,palpitations,chest pains on exposure to cues,exaggerated startle response (for example to loud noise),avoidance behaviour,aggressive behaviour,loss of interest and poor concentration.

Some of these symptoms are also manifestations of depression and anxiety.

Treatment of PTSD includes both psychological as well as pharmacological approaches.Early intervention generally provides better outcomes.

Psychological treatments include cognitive behavioural therapy;prolonged exposure therapy,which involves talking about and reliving painful memories;and eye-movement desensitisation processing,i.e.,while thinking about painful memories focus on other activities such as eye movements and hand-tapping.

Drug treatment includes the use of SSRIs which are also used to treat depression and anxiety.

Not everyone exposed to trauma will develop PTSD.For example,of the two million US troops who served in Afghanistan and Iraq,around 10% developed PTSD.This raises interesting research questions regarding individual susceptibility.A better understanding of the neurobiology of PTSD is emerging which may help identify those most at risk,as well as developing targeted therapies.

Boris was able to return to part-time work after a six-month absence,and to full-time work after nine months.

I have continued to speculate if his outlook would have been very different if he had been treated with more understanding in the ED and in the orthopaedic outpatient clinic.

Being told:"You have normal X-rays so there is nothing seriously wrong" may not heal body nor soul.A more sympathetic assessment,coupled with awareness of the possible long-term psychological complications of a life-threatening event,may have helped prevent the damage caused by PTSD in Boris′s case.

I have recently been involved in convening a conference on PTSD.For details,please check:www.traumaandmentalhealthconference.org.

(本文编辑：贾萌萌)

Normal X-rays May Not Heal——a Study in PTSD

General practitioners;Stress disorders,post-traumatic;Psychotherapy

R 197 R 749.72

A

10.3969/j.issn.1007-9572.2017.14.002

2017-03-31)

【编者按】 澳大利亚的全科医生具有行业自律性，体现在其自行制定行业标准、自主进行资质考核及自主执业等方面，也体现在《The Medical Republic》这一共享平台上。Leon Piterman是Monash University的副校长、全科医学教授，从事全科医学临床服务近40年，其建议我国的全科医生应培养“共和”思想，以为全科医学领域提供更多的平等交流机会。目前Piterman教授定期为《The Medical Republic》撰写文章，本刊深受“医学共和”思想的启发，特邀本刊编委Monash University杨辉教授对Piterman教授的文章进行编译，并将进行连载刊登，希望对我国的全科医生有所帮助和启发！本文中，Piterman教授讲述了自己管理的一例经历创伤后，X线检查正常，未再进行更细致检查，从而确诊为创伤后应激障碍(PTSD)患者，建议医生接诊遭遇危及生命事件的患者时，给予更具同情心的评估，并意识到可能带来的心理并发症，从而减少PTSD的发生，敬请关注！

1.3168 Monash University,Melbourne,Australia

2.518003 广东省深圳市，罗湖医院集团黄贝岭社区健康服务中心

注：本文首次刊登于《The Medical Republic》