post-traumatic stress disorder
Introduction
Introduction to post-traumatic stress disorder Posttraumatic stress disorder (PTSD), also known as delayed psychogenic reaction, is a delayed response caused by a stressful event or situation. PTSD is a delayed and/or persistent response to unusually threatening, catastrophic events. Traumatic events are necessary for the diagnosis of PTSD, but not sufficient conditions for PTSD to occur. Although most people experience varying degrees of symptoms after traumatic events, studies have shown that only some people eventually become PTSD patients. basic knowledge The proportion of sickness: 0.002% - 0.006% Susceptible people: no specific people Mode of infection: non-infectious Complications: psychosis, reactive psychosis
Cause
Causes of post-traumatic stress disorder
Stress events (40%):
PTSD is caused by stressful events or situations. The occurrence of PTSD is associated with many factors, including natural disasters and family and psychosocial factors (such as gender, age, race, marital status, economic status, social status, work status). , education level, stressful life events, personality characteristics, defense methods, childhood trauma, domestic violence, war, social support, etc.) and biological factors (such as genetic factors, neuroendocrine factors, neurobiochemical factors, etc.). Among them, major traumatic events are the basic conditions for the onset of PTSD and are extremely unpredictable.
Man-made disasters (40%):
War, serious accidents, witnessing the tragic death of others, torture, victims of terrorist activities, rape and other factors may cause post-traumatic stress disorder.
Other factors (20%):
If there are predisposing factors, personality disorder or history of neurosis, it can reduce the defense against stressors or aggravate the disease process.
Prevention
Prevention of post-traumatic stress disorder
The purpose of PTSD crisis intervention is to prevent disease, relieve symptoms, reduce comorbidity, prevent prolongation, and crisis intervention has short-term, timely and effective characteristics (4~5). Therefore, the main focus of intervention is prevention of disease and symptom relief. Interventions are cognitive behavioral methods, psychological relief, severe stress inducement treatment, imaginary recall therapy and other comprehensive use of psychotherapy techniques. Relevant cognitive behavioral methods have been systematically introduced and clinically applied in the past 10 years. .
1. psychological debriefing (PD) and severe stress stress debriefing (CISD)
Chemtob had a cross-over study of PD intervention in the population after the Hawaiian storm disaster. After 6 months of intervention, the IES (impact of event scale) and BSI (brief symptom inventory) were used to evaluate the results. Post-traumatic PD intervention was effective and feasible. Campfield et al. randomly assigned 77 patients who were robbed to the immediate PD treatment group (within 10 h) and the delayed PD treatment group (after 48 h), and collected 4 groups of scores: 2 days after the evacuation, 4 days after the evacuation, and 2 weeks after the robbery, it was found that there was no difference in the frequency and severity of the symptoms between the two groups, but the scores of the subsequent three points were immediately compared. The delay group score is low, that is, the frequency and severity of symptoms decrease with time, but the decrease of the delay group is not obvious. This result supports immediate evacuation of victims of robbery.
Myow et al. studied inpatients after traffic accidents, and used IES and BSI to control patients who received PD intervention and non-intervention before enrollment, 3 months after intervention, and 3 years after intervention. The results showed post-traumatic intervention in the intervention group. The annual BSI score, travel anxiety, pain, physical illness, overall level of social function, and living capital problems were worse than those of the control group who did not receive intervention. Intrusive symptoms and avoidance symptoms still exist after intervention. Symptoms of patients who did not receive intervention disappeared. Bisson et al randomly assigned 136 burn patients to the PD intervention group and the uninterventional control group. The 110 patients (83%) who were followed up were traumatized for 3 months and 13 months. After IES and BSI assessment, 16 patients (26%) received PD with PTSD after 13 months, and only 4 patients (9%) in the control group, suggesting that early administration of psychological relief to help traumatic stress is not satisfactory. It is worth noting that the initial symptom scores of the patients in the intervention group were higher, and the severity of the burns was higher than that of the control group. The presence of this interference factor would affect the reliability of the conclusions of this test. Rose et al. For the development of mental disorders, two short interventions, psychological treatments for missions and psychological relief (missions explain normal PTSD responses, and venting to explore victimization) to test whether short interventions can prevent violent crimes from suffering. The adverse emotional response of the person.
In this trial, 157 victims were randomly assigned to the mission group, the mission and psychological evacuation group, and the control group for general medical examination only. For 138 victims who were followed for 6 months, the symptoms of 92 victims were followed for 11 months. Analysis showed that the mental symptoms improved over time, but there was no significant difference between the groups. This result does not support the hypothesis that short interventions for victims of violence can prevent the occurrence and development of PTSD. In addition, Deahl et al used randomized controls. The trial conducted PD and CISD interventions on British soldiers in the Bosnian peacekeeping force. The results showed that the risk of alcohol abuse was reduced in the PD intervention group. In addition, physical illness was also a traumatic event. Neel et al found that crisis intervention can help implant the defibrillator. Patients adapted to postoperative life and relieved their affliction. Suzanna et al. conducted a meta-analysis of published literature and searched for relevant literature on interviews with patients who suffered trauma within 1 month. Interventions included various forms of emotional management. Encourage the normalization of memories or emotional reactions. As a result, in the 11 documents that meet the criteria, 2 conclusions are completely opposite. The results show that the single talks can not alleviate psychological pain or prevent PTSD, that is, one-time relief can not reduce anxiety or depression, the prevalence of psychological disorders, Rose and Bisson also conducted a similar systematic literature review, There were only 6 randomized controlled trials on the efficacy of short-term early intervention trauma. The results were 2 effective, 2 no significant differences, and 2 ineffective.
2. Imagine rehearsal therapy (IRT)
Barrey et al. randomized 168 women with PTSD after DSM-IV-related sexual trauma in Mexico. They were randomized to receive IRT (n=88) and non-IRT (n=80). After 3 treatments, follow-up 3~ After 6 months, the results showed that the number of nightmares and weekly nightmare days in the treatment group was significantly improved compared with the control group, and 65% of the treatment group had improved PTSD symptoms, while 69% of the control group did not improve or the symptoms worsened. , suggesting that IRT may be effective in treating patients with comorbid sleep disorders.
3. Other psychotherapy techniques
There was a case study of 19 survivors of the Holocaust Church in South Africa. As a result, the survivors described the killings with religious beliefs. Their cognition was mainly influenced by religion, suggesting that they used religious beliefs. Survivors of certain beliefs may be a treatment direction. Everly believes that the pastor's community has a powerful function of restoring trauma, crisis intervention for abnormal stress events such as terror, natural disasters and man-made disasters, and a series of comfort activities by pastors. As one of the crisis intervention strategies may be effective, Everly et al believe that as with any other effort to change human behavior, crisis intervention is also at risk, one of which is immature intervention, not only wasting valuable resources, but also It also interferes with the natural recovery process of some victims' traumas. Therefore, it is necessary to first clarify the nature of the crisis, then consider whether intervention is needed, how to intervene and estimate the consequences of the help, and avoid imperfect crisis interventions such as quick success and enthusiasm for the crisis. , psychological evacuation treatment is currently used to help One of the most common methods of trauma and crisis individuals, it needs to be carefully considered, but the good therapeutic relationship between doctors and patients in PTSD intervention is very important, it can reduce the possibility of adverse consequences of intervention, therefore, how the treatment physician It is especially important for patients to build trust and partnerships to facilitate early intervention.
However, the risk of PTSD caused by different stress groups in different populations, different individuals, and different stress events is not exactly the same, and PTSD can hinder the normal and healthy development of children's psychology. PTSD can be associated with mental illness such as anxiety, depression, and substance dependence. Comorbid hypertension, bronchial asthma and other physical diseases, comorbid depression increases the risk of suicide in patients, and the suicide rate of PTSD is 19%. The main interventions for PTSD are cognitive behavioral therapy techniques including PD, and current research indicates The psychological crisis intervention effect of PTSD is not certain. The possible influencing factors are: lack of experience of PTSD crisis intervention, that is, the intervention technology is not mature, and the intervention measures for different trauma options are not appropriate; the evaluation project of PTSD intervention effect is not comprehensive. There is comorbidity in PTSD, and the assessment should not be limited to the disappearance or reduction of characteristic symptoms of PTSD; psychotherapy is affected by the relationship between doctors and patients with different effects; new and more effective intervention techniques are needed to be studied.
Complication
Post-traumatic stress disorder complications Complications, psychosis, psychosis
It can be complicated by acute stress psychosis, a subtype of acute stress disorder, a psychotic disorder directly caused by a traumatic event that is intense and lasts for a certain period of time. Symptoms and serious affective disorders are the main symptoms. Content is closely related to stressors and is easier to understand. Acute or subacute onset has a good prognosis after appropriate treatment, and the spirit is normal after recovery, generally no defects.
Symptom
Symptoms of post-traumatic stress disorder Common symptoms Shortness of breath Shortness of sleep Difficult to fall asleep or easy to wake up Emotional numbness pale pale startling sleepless insomnia flustered heartbeat
PTSD is characterized by a series of characteristic symptoms following a major traumatic event.
1. Repeatedly reproduce the traumatic experience: patients re-experience traumatic events in various forms, intrusive memories, repeated repetitive traumatic dreams, painful dreams, vivid experiences of recurrence of stressful events Repeated traumatic dreams or nightmares, repeated recurrence of traumatic experience; sometimes patients have a state of separation of consciousness, duration can vary from a few seconds to a few days, called Flash back, at this time the patient seems to be completely The situation at the time of the traumatic event, re-expressing the various emotions associated with the event, the patient is faced with, and is exposed to traumatic events or similar events, situations or other clues, usually with strong psychological pain and Physiological reactions, such as the anniversary of an event, similar weather and various similar scenarios, may trigger a patient's psychological and physiological response (Davidson JRT, 1995; American Psychiatric Association, 1994).
2. Persistent avoidance: After traumatic events, patients have persistent avoidance of trauma-related stimuli. The objects of avoidance include specific scenes and situations, related thoughts, feelings and topics. Patients are reluctant to mention related events and avoid related Conversation, media interviews after traumatic events and the process of obtaining evidence involving legal procedures often bring great pain to the client. Losing memory for certain important aspects of traumatic events is also regarded as one of the performances of avoidance. At the same time, there is also the expression of mental numbness or emotional paralysis. The patient gives a feeling of being indifferent to the whole, consciously has no interest in anything, and is equally interested in activities that have been keen on the past, and feels alienated from the outside world, even Incompetent, not in contact with others; no reaction to the surrounding environment; lack of pleasure; avoiding memories of past traumatic activities, fear and avoiding the feeling of suffering from trauma, and seemingly indifferent to everything, difficult to express and feel various The emotions that are meticulously hopeful are disheartening to the future, and they are resigned to their fate. The occurrence of negative thoughts, suicide attempts.
3. Increased levels of persistent anxiety and alertness: manifested as a spontaneously high alert state, such as difficulty falling asleep, not restful, vulnerable to fright, do not concentrate on doing things, etc., and often have autonomic symptoms such as palpitation, shortness of breath and so on.
Examine
Examination of post-traumatic stress disorder
1. Laboratory examination: timely blood routine, urine routine, cerebrospinal fluid routine test (CSF), neurological examination, and provide effective laboratory test data. There is currently no specific laboratory test for this disease. When other conditions, such as infection, occur, laboratory tests show positive results from other conditions.
2, clinical examination: patients in a variety of forms to re-experience traumatic events, inevitable intrusive memories, repeated re-emergence of traumatic scenarios, painful dreams, that is, the vivid experience of recurrence of stressful events, repeated trauma Sexual dreams or nightmares, repeated repetitive traumatic experiences; sometimes patients have a state of separation of consciousness, durations ranging from a few seconds to a few days. And there is a constant avoidance of the patient's trauma-related stimuli after the traumatic event. The objects to be avoided include specific scenes and situations, related thoughts, feelings and topics. Patients are reluctant to mention related events and avoid abnormal performances such as related conversations.
Diagnosis
Diagnosis and differentiation of post-traumatic stress disorder
Diagnostic criteria
China's widely used CCMD, ICD and DSM diagnostic systems have diagnostic criteria for PTSD. The definition and diagnosis of this disorder are basically the same, but relatively speaking, DSM-IV defines PTSD more comprehensively and specifically. Therefore, the diagnostic criteria for DSM-IV are mainly introduced here (American Psychiatric Association, 1994; Stein MB, 1997).
DSM-IV diagnostic criteria for PTSD include 6 major items from A to F, A is the event standard, B, C, D are symptom criteria, E is the disease standard, and F is the severity standard.
According to the definition of PTSD, traumatic events are the main cause of its occurrence. There are no unusual traumatic events. The diagnosis of PTSD is ineffective. It has been assumed in the past that the symptoms of PTSD correspond to the intensity of traumatic events, but the increasing research The evidence does not support this view. Therefore, the current research not only focuses on the objective nature of the event, but also emphasizes the subjective meaning of the event to the individual, reflected in the diagnostic criteria, DSM-IV from the event itself and the emotional response triggered by the event. To define a source of traumatic stress, an individual experiences an event that jeopardizes his or her life or physical integrity, or witnesses the death of another person, is injured or threatened by life, or learns about family members and friends who are suffering from a terrible accident. Strong fear, isolation or panic.
In terms of symptoms, the satisfaction of diagnosis needs to exist: 1 continuous re-experience trauma (at least 1 of 5); 2 persistent avoidance and overall emotional response, Muran (at least 3 of 7), in addition to avoidance and numbness Symptoms should be at least 1 each; 3 persistent alertness increased, at least 2 of 5, need to pay attention to the symptoms, DSM-IV in the description of each group of symptoms emphasize that the symptoms are very painful and persistent Or recurring, the course of the disease requires that the above three types of symptoms last for at least one month, in severity, the symptoms bring significant subjective pain or impaired social function.
DSM-IV classifies PTSD into 3 types: acute (less than 3 months), chronic (3 months or longer), and delayed (symptoms appear after 6 months of traumatic events).
According to clinical observations, the following points are summarized:
1. Cause: The disease must be caused by an unusual traumatic event, and there is an experience of traumatic and unusual events or situations for almost everyone.
2. Repeatedly reproduce the traumatic experience: repeatedly reproduce the traumatic experience, mainly in the memory, during the daytime imagination or dream, or "touching the scene", and at least one of the following performance.
(1) I can't help but think back to the experience of being hit.
(2) The nightmare of repeated traumatic content.
(3) The vivid experience of recurring traumatic events in the form of illusions or fantasy.
(4) The mental pain of touching the scene is repeated.
3. The level of sustained alertness is increased and at least one of the following:
(1) It is difficult to fall asleep or wake up easily.
(2) Increased irritability.
(3) Focus on difficulties.
(4) Excessive startle response.
(5) Obvious physiological reactions, such as heartbeat, sweating, paleness, etc., when encountering an occasion or scene similar to a traumatic event.
4. Continuous avoidance, and at least one of the following performances:
(1) Try not to think about traumatic experience.
(2) Avoid participating in activities that may cause painful memories, or not in places that may cause painful memories.
(3) alienated from others, not friendly, and weakened with relatives.
(4) The range of interests and hobbies is narrowed, but activities that are not related to traumatic experience can still be of interest.
(5) Can not recall (forgotten) an important aspect of traumatic experience.
(6) Losing embarrassment for the future.
5. There are obvious emotional changes, feeling numbness and avoiding the stimulation that causes traumatic memories.
6. Symptoms appear within 6 months after the trauma, and the symptoms last for more than 1 month.
7. Can be associated with autonomic nervous system disorders, such as rapid heartbeat, sweating, pale and so on.
It should be emphasized that the diagnosis of stress-related disorders should not only be based on symptoms and course of disease, but also on the factors that influence the cause of the disease: unusual stressful life events, or obvious life changes that cause persistent unpleasant environments. Acute stress disorder, the latter can lead to adaptation disorders, although less severe psychological stress can induce this type of disorder, but it is generally believed that the occurrence of this type of disorder is a direct consequence of acute stress or persistent psychological trauma, that is, this type The factors are the basic and overwhelming reasons. Without the direct effect of these factors, the obstacle will not occur, and thus lead to successful coping mechanisms damage and social function damage.
It must be noted that the diagnosis of post-traumatic stress disorder should not be too broad, and there must be evidence that it occurs within 6 months after a very serious traumatic event, with typical clinical manifestations, or no other appropriate diagnosis (eg anxiety, forced Symptoms, or depression, etc.) are available, but the interval between the event and the onset is more than 6 months. Symptoms are typical and can be diagnosed.
Special emphasis is placed on the fact that children's PTSD is easily missed by doctors because the cause of PTSD in children (stressors) is different from that of adults. Symptoms of PTSD include repeated recurrence of traumatic experience, nightmares, insomnia, withdrawal and depression, etc. Jeffrey H. Newcorn, director of the Child and Adolescent Psychiatry Department at Mount Sinai Medical Center, told Reuters that "adult traumatic stress, death, domestic violence and other things we usually distinguish are A traumatic event, and the source of traumatic stress in children is related to the fear events encountered during their development, such as falling from a bicycle or being intimidated by another child. The survey found that there are 70% to 80% of children and adults encounter some stressors, and 60% of respondents think that some of their experiences can be counted as traumatic stress factors, because this experience makes them feel helpless and afraid, there are 45 Children and their parents or guardians went to the psychiatric clinic in the city to see the clinic. After encountering the experience consistent with PTSD, 20% to 30% of the respondents showed complete PTSD. Shape, including repeated traumatic experience, try to avoid the cause of traumatic recall, people, things, etc., 20% of people show some symptoms of PTSD, "whether completely or partially PTSD, children can show symptoms of anxiety or depression Newcome said, "Clinical doctors tend to diagnose emotional disorders, not PTSD, and doctors are largely unaware of PTSD," according to Claude Chemtob, the PTSD Center (located in Hawaii). Say: 42% of children will develop PTSD when they are in domestic violence. The domestic violence agency has conducted a survey on their mother. They can only report their symptoms. "You can't tell which children are sick by talking to your mother." With PTSD, Newcomb commented on this study, which shows that the intervention of domestic violence must be successful, focusing on both PTSD children and the family unit.
Differential diagnosis
PTSD is caused by unusual threats or catastrophic psychological trauma (almost severe pain for everyone), such as being tortured, victims of terrorist activities, being raped, witnessing the tragic death of others, etc., leading to delayed and long-lasting mental disorders, Some people have personality defects or have a history of neurosis, and thus reduce the ability to cope with stressors or aggravate the disease process, mainly as: recurrence of invasive traumatic experience recurrence (pathological recurrence) Or flashback), repeated reappearance of traumatic scenes in dreams, or painful and involuntary recollections due to situations similar or related to stimuli; sustained alertness; sustained intentional avoidance is reminiscent of trauma Activities and situations, occasionally visible acute panic attacks or aggression, which is triggered by a sudden recall of traumatic memories or stimuli, often triggered by trigger action, often accompanied by excessive autonomic nervous state, manifested as excessive alertness, shock response, Insomnia, anxiety and depression, suicidal ideation is also more common, selective forgetting of traumatic experience, loss of future , etc. These performance diagnosis is not difficult, but it is clinically necessary to pay attention to whether the patient has head trauma and disturbance of consciousness and substance abuse in the case of traumatic events, because it may induce or aggravate the symptoms of post-traumatic stress disorder. In addition, some patients often have excessive drinking and taking drugs after major trauma, which makes the situation more complicated. The acute poisoning state or withdrawal state of alcohol, medicine is sometimes difficult to distinguish from post-traumatic stress disorder. After the elimination of the effects of alcohol and medicine, the questions to be identified include:
1. Acute stress disorder and adaptation disorder
Some patients have obvious mental symptoms and strong mental pain after major traumatic events, but they do not fully meet the diagnostic criteria for post-traumatic stress disorder. Some patients also meet the post-traumatic symptoms in terms of symptoms, duration and severity. The corresponding criteria for stress disorder, but the induced events are general stress events such as loss of love, dismissal, etc., neither of the above should be diagnosed as post-traumatic stress disorder, but should be considered as adaptation disorders, acute stress disorder and trauma The main difference between post-stress disorder is the onset time and course of disease. The onset of acute stress disorder is within 4 weeks of the event, and the course of disease is shorter than 4 weeks. When the symptoms persist for more than 4 weeks, the diagnosis should be changed to post-traumatic stress disorder. .
2. Other mental disorders
(1) Depression: This disease is of interest to decline, alienation from others, feeling the future, and there are also sad experiences, similar memories of "touching the scene", emotional changes, etc., but there are still differences between the two, but Simple depression disorder does not have intrusive memories and dreams associated with traumatic events, and there is no avoidance for specific topics or scenarios. The depression mood of depression involves a wide range of interests, including daily interests, daily preferences, personal futures, etc. Aspects, negative, inferiority or suicide attempts are also common.
(2) Anxiety neurosis: When delayed autonomic response has persistent alertness and autonomic nervous system symptoms, it should be differentiated from chronic anxiety. Anxiety disorders often have excessive anxiety about their own health, and there are more complaints about the body. There is a tendency to be suspected, and there is no obvious cause of mental trauma.
(3) Obsessive-compulsive disorder: It can express recurrent obsessive-compulsive thinking, but it often shows inappropriateness and there is no unusual life event before the disease, so it is different from post-traumatic stress disorder.
(4) Severe mental disorders: schizophrenia and mental disorders associated with physical illness can have hallucinations and illusions, but these diseases do not have an unusual traumatic experience before the disease, and the symptoms are different, so It is not difficult to distinguish from the hallucinations and illusions of post-traumatic stress disorder.
3. In China's clinical work, the diagnosis of PTSD is not much. The delayed stress disorder in CCMD-2-R in China and the PTSD in DSM system generally correspond to the symptom standard. The time standard is not the same. Classification and disease duration criteria are often changed in each diagnostic system.
