《The Medical Republic》案例分享——跨越几代人的创伤：孩子的过错？

，周海铃(译)，邱珊娇(译)，黄文静(译)，杨 辉(译)

·世界全科医学工作瞭望·

【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是医学学士，医学博士，教育学硕士，英国医生学会会员，澳大利亚全科医生学会会员，Monash University副校长、全科医学教授，从事全科医学临床服务近40年；研究兴趣为慢性病管理、心理健康、医学教育；曾获澳大利亚勋章，医学部医学教育奖，澳大利亚全科医生学会研究奖，香港全科医生学会研究奖等；获多项澳大利亚卫生和医学研究理事会等大型研究项目，发表科学文章和著作章节120余篇，是《全科医学中的精神病学》合作著者。Piterman教授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，并进行连载刊登！本期Piterman教授为我们讲述了一例为遭受创伤性事件家庭提供医疗服务的案例，指出全科医生应该为居民提供“以家庭为单位”的照顾，不仅要关心家庭成员的躯体疾病，也要重视家庭成员的身-心关联，重视代际间情感和关系互动的家庭社会史和家庭心理史。敬请关注！

《The Medical Republic》案例分享
——跨越几代人的创伤：孩子的过错？

LeonPiterman1，周海铃(译)2，邱珊娇(译)2，黄文静(译)2，杨 辉(译)1

注：本文首次刊登于《TheMedicalRepublic》

全科医生；应激障碍，创伤性

PITERMAN L.跨越几代人的创伤：孩子的过错？[J].周海铃，邱珊娇，黄文静，等，译.中国全科医学，2017，20(31)：3847-3849.[www.chinagp.net]

PITERMAN L.Transgenerational trauma:the sins of the child?[J].ZHOU H L,QIU S J,HUANG W J,et al,translators.Chinese General Practice，2017，20(31)：3847-3849.

全科医生需要面对的，可能是由于创伤性事件触发的大范围内家庭成员在健康方面的级联影响。

全科医生需要提供“以家庭为单位”的照顾，这种照顾常常会跨越家庭中的两代、三代甚至是四代人。影响某一代人的事件，如疾病，通常也会影响其他几代人。核心家庭内的结构与关系，使得各家庭成员不可避免地要共同受到创伤性事件的影响。或许我们应该感激这些事件的发生，因为这也意味着家庭成员间可以相互支持和帮助，只有必要的时候会需要医务人员的帮助，当然最重要的还是全科医生。

作为全科医生，我们经常会遇到一些家庭被不明原因的创伤性事件极度困扰。我们经常会觉得困惑，为什么这个家庭会遭受如此不幸的折磨？什么地方出了错？他们做了什么才会遭受如此惩罚？怎么去预防？全科医生应该以一种什么样的定位来为家庭提供干预和支持，以尽量减少创伤性事件带来的危害？一次意外事故、一场严重疾病、一段关系破裂，都可能是一连串事件的创伤触发点，接下来要讲述的故事中的“孩子迷失”也是一个触发点。创伤性事件对其他家庭成员的影响，可能不仅在于心理上的(抑郁、焦虑、失眠、创伤后应激障碍)，也可能是躯体上的，这一现象强调了心身联系的重要意义。

我第一次见到亚历克萨是在她3岁的时候，当时她的外公乔治65岁、外婆索菲亚63岁，我已经照顾了他们10年。乔治有肥胖症、高血压、2型糖尿病病史，索菲亚有高血压、肾病史，考虑为IgA肾病。乔治和索菲亚直到最近还在郊区经营着一家水果店，但现在他们已经卖掉水果店，高兴地开始退休生活了。

二十世纪六十年代初，乔治和索菲亚同许多希腊家庭一起移民到澳大利亚，他们为通过自己努力所得到的成就感到自豪。乔治和索菲亚有一个女儿，叫安娜，现在是化工专家，安娜的丈夫是会计师迈克尔。两位老年人非常宠爱他们唯一的外孙女亚历克萨，现在他们退休了，可以有更多的时间在安娜和迈克尔工作的时候照顾亚历克萨。

安娜带亚历克萨来我这里就诊。亚历克萨有过敏史，表现为湿疹和哮喘。同时，亚历克萨有严重的过敏家族史，特别是迈克尔那侧的家庭。此次的就诊原因为上呼吸道疾病诱发的哮喘加重。安娜和迈克尔均为35岁左右，身体健康。

在接下来的十年里，我频繁地为这个家庭的三代人提供服务。乔治的健康状况逐渐变差，70来岁的时候患了缺血性心脏病。不幸的是，索菲亚的身体也逐渐变差，需要接受透析治疗。安娜和迈克尔的健康状态保持良好。亚历克萨十几岁时，仅伴有偶尔的哮喘发作，她成绩优异，看起来适应得很好。但在15岁那年，事情似乎变得非常糟糕，亚历克萨拒绝使用预防哮喘的药物，花很长时间在网络群里聊天，拒绝参加家庭活动。学习成绩也下滑，而且有明显的逃课现象，教师怀疑她吸毒，遭到了她的坚决否认。有时候晚上和周末，亚历克萨会谎称自己在同学家，之后被发现在和一名22岁的辍学大学生交往。而这名辍学大学生和一些有奇怪宗教信仰的吸毒者住在一个房子里。16岁时，亚历克萨离家出走，几个星期没有与父母联系。

以上的大部分信息都是亚历克萨的家人转达给我的。在这1年中他们出现了严重的健康问题。迈克尔出现了便血和腹泻，检查结果提示为溃疡性结肠炎；乔治出现了多次短暂性脑缺血发作，最终发生卒中，遗留轻度左侧肢体偏瘫；索菲亚错过了几次透析，需要在重症监护室治疗肾衰竭和心脏并发症；安娜疲于工作，尽最大努力保持着家庭的完整。

我们都很清楚心理压力与躯体疾病之间的关联。然而，我很少看到仅在几个月内就有这么多不幸同时发生在一个家庭里。我需要照顾三名家庭成员的身体，同时也试着给第四名家庭成员提供情感支持，希望这一切可以让亚历克萨回归家庭，保持家庭的完整。家人，尤其是父母，会非常包容孩子的过错。他们最关心的是孩子的幸福，并且愿意做任何事情确保孩子的茁壮成长。这个案例的最终结局是宽容、理解以及和睦共处，但这耗费了两年的时间，并且在这期间留下了不可弥补的创伤。

译者注：跨代创伤(transgenerational trauma)：原意是指遭受创伤的第一代幸存者，将创伤传递到第二代甚至更后辈，使他们也遭受创伤的折磨，其机制是创伤后应激障碍在代际上的延伸，即第一代的创伤后应激障碍直接或间接地传递给了下一代或几代，造成“继发创伤”。既往研究发现，二战大屠杀幸存者的孩子会更多地寻求医疗服务，幸存者的孙辈接受儿童心理治疗的比例是其他儿童的3倍。澳大利亚的殖民者将土著人的孩子从家中强行带走去接受教育感化，给土著人家庭及其数代人造成了严重的跨代创伤，澳大利亚总理也因此郑重地向土著人道歉。在普通家庭中，也存在跨代创伤问题，如家境贫困、家庭暴力、性侵犯、被奴役、关系破裂等。跨代创伤不仅是从上至下的代际传递，正如Piterman教授在上述案例中讲述的故事，其也可以逆向地从晚辈传递到上辈，或者说是代际互动。虽然上辈的躯体问题可能具有“偶然性”或是在亚历克萨出现青春期叛逆的时间段中加重，但家庭各成员的身-心关联(body-mind link)是“为什么这个家庭会遭受如此不幸的折磨”的部分原因。Piterman教授隐藏在故事里的另一个线索，是这个家庭属于上世纪60年代的希腊移民。二战后，希腊爆发了内战，16万希腊人为逃避战火而来到澳大利亚(主要是维多利亚州)，这些第一代移民(如故事中的乔治和索菲亚)在澳大利亚的工厂和农场做劳工，生活非常艰难，直到他们的第二代(如故事中的安娜)生活才有起色。在我国，重大的历史事件(大历史)、社区的过往和文化事件(小历史)、大家庭和核心家庭内的重要事件，均有可能会影响到几代人的身心健康，这也是全科医生可以发现健康问题的“触发点”。全科医学关注家庭的真正意义，不仅包括狭义的疾病遗传家族史，还包括反映出代际间情感和关系互动的家庭社会史和家庭心理史。

志谢：特别感谢原文出版者《The Medical Republic》同意将此文编译后刊登于《中国全科医学》。

GPs can be faced with the cascading impact on the health of a wide range of family members triggered by a traumatic event.

GPs care for families.That care often occurs across two,three or sometimes four generations.Events including illnesses affecting one generation may often have an impact on other generations.The composition and relations within nuclear families is such that sharing the impact of traumatic events is inescapable.Perhaps we should be grateful that this still takes place as it also means that support can be offered within families by family members helping one another,assisted only where necessary by health professionals,including,most importantly,GPs.

As GPs,we often witness traumatic events plaguing certain families which,for apparently unexplained reasons,appear excessive and out of the norm.We are left wondering why should so much misfortune afflict this family? What went wrong? What did they do to deserve this? What could have been done to prevent it? And now that it has happened,what interventions and support can we as GPs put in place to minimise the harm caused by these traumatic events?

The traumatic trigger for the cascade of events that follow may be an accident,a serious illness,relationship breakdown or,as in the case described here,a child "gone missing".

The impact on other family members may not only be psychological(depression,anxiety,insomnia,post-traumatic stress disorder) but we also witness the sudden emergence of physical illnesses which serves to emphasise the significance of the mind-body nexus.

I first met Alexa when she was three years old.At that stage,I had looked after her grandparents George and Sofia for 10 years.George was aged 65 and Sofia was aged 63.

George had a history of obesity,hypertension and type 2 diabetes.Sofia had a history of hypertension,set against a background of renal disease thought to be IgA nephropathy.George and Sofia had until recently run a suburban fruit shop which they sold and were now happy to be retired.

Along with many other Greek families,they had migrated to Australia in the early 1960s and were proud of their achievements,having raised a daughter,Anna,who was now an industrial chemist and married to Michael,an accountant.Naturally they doted over their only granddaughter Alexa,and now that they were retired,they spent more time looking after her while Anna and Michael were at work.

Anna brought Alexa to see me.She had a history of atopy,which included eczema and asthma.There was a strong family history of atopy,especially on Michael′s side of the family.The reason for the visit was an upper respiratory illness which had triggered an exacerbation of the asthma.Both Anna and Michael were in good health and in their mid-30s.

Over the next decade I saw the three generations of this family on a multitude of occasions.

George′s health deteriorated and he developed ischaemic heart disease in his early 70s.Sadly Sofia′s health took a similar course and she needed dialysis.Anna and Michael remained well and as Alexa reached her teens she would have only the occasional asthma attack.She was a high-achieving student and seemed well adjusted.

Things seemed to go very wrong when she turned 15.Over the ensuing 12 months she refused to take her asthma preventers,spent long hours on internet chat groups,refused to attend family functions,and school reports showed deteriorating performance as well as notable absences from class.Parent-teacher interviews raised suspicions about drug use which Alexa vehemently denied.

In the months that followed there were nights and weekends that Alexa said she was spending at her school friend′s house,but this was not confirmed.It then emerged she was in a relationship with a 22-year-old university dropout who lived in a share-house with a number of drug addicts who belonged to a strange religious cult.Eventually,at the age of 16,she left home and made no contact with her parents for weeks on end.

Much of this information was relayed to me by family members as they began to suffer serious health problems over this 12-month period.

Alexa′s father,Michael,presented with rectal bleeding and diarrhoea.Investigations revealed ulcerative colitis.Alexa′s grandfather had a series of transient ischaemic attacks culminating in a stroke which left him with a mild left hemiplegia.Alexa′s grandmother missed some of her dialysis sessions and required treatment in intensive care for renal failure with cardiac complications.Anna struggled to keep working and to keep the family together.

We are well aware of the link between stress and physical illness.However,rarely had I seen such devastation occurring in one family in the course of several months.

I was left to coordinate care for three family members,while trying to provide emotional support to the fourth and hoping throughout all of this that Alexa would make an effort to restore family unity.

Family,and particularly parents,can be very forgiving of their children′s misdemeanours.Ultimately they are concerned for the wellbeing of their children and will do anything to ensure their children thrive.

Tolerance,understanding and rapprochement prevailed in this case,but it took two years and left much irreparable damage along the way.

TransgenerationalTrauma:TheSinsofTheChild?

General practitioners;Stress disorders,traumatic

1.3168MonashUniversity,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

R 749.72

A

10.3969/j.issn.1007-9572.2017.31.003

2017-09-11)

(本文编辑：王凤微)