创伤后应激障碍的睡眠障碍

尽管睡眠障碍在精神疾病中非常常见，但他常常被当作精神疾病的二级症状，认为对其主要精神疾病的治疗才是缓解睡眠苦恼的最可行办法。事实上，比如创伤后应激障碍(PTSD)的噩梦并不随总症状评分的下降而减少，有时可持续很长时间，而采用针对睡眠紊乱的治疗方案后，超过50％患者的创伤后应激症状可得到有效缓解。现论述PTSD对睡眠的影响，并讨论睡眠紊乱的治疗问题。     

创伤后应激障碍的心理治疗

心理治疗被认为是创伤后应激障碍(PTSD)的首选治疗方案.根据目前的理论解释和文献研究,认知行为治疗技术如暴露治疗、焦虑管理训练、认知治疗等对PTSD比较有效.眼动脱敏和再加工 治疗方法可能对PTSD有效,但需要进一步的研究支持.本综述从理论解释、具体方法、效果研究和治疗原则等方面介绍PTSD的心理治疗技术.     

创伤后应激障碍

本文介绍创伤后应激障碍及其有关的几个问题。     

创伤后应激障碍的神经生物学机制

美国精神障碍诊断与统计手册第4版(DSM-Ⅳ)关于创伤后应激障碍(PTSD)的定义中所述及的症状是因为中枢神经系统对应激信息的记忆过程出现了障碍，使条件化的恐惧反应难于抑制或过分抑制所致。目前关于其产生机制包括以下方面：     

创伤后应激障碍的遗传病因研究

创伤后应激障碍(Posttraumatic stress disorder,PISD)是指突发性、威胁性或灾难性生活事件导致个体延迟出现和长期持续存在的精神障碍,其临床表现包括闯入性症状、回避症状和激惹性增高三大核心症状群,终生患病率达7%～12%[1].     

癌症与创伤后应激障碍

严重威胁生命的恶性疾病如癌症所导致的创伤后应激障碍（ＰＴＳＤ）越来越引起临床医生的重视,国外不少精神科医生致力于与癌症相关ＰＴＳＤ的临床研究,积累了一些经验,本文就此做一综述。     

创伤后应激障碍

本综述了创伤后应激障碍的病因学、临床特征及治疗方面的新进展。     

创伤后应激障碍的临床亚型

从临床及神经影像学的角度对创伤后应激障碍可能的临床亚型进行介绍.     

早年创伤对女性创伤后应激障碍患者焦虑症状及人格改变的远期影响

目的探讨早年创伤对女性创伤后应激障碍（PTSD）患者焦虑症状及人格改变的远期影响。方法早年创伤定义：躯体虐待、性虐待、躯体忽视≥8分;情感虐待≥10分和／或情感忽视≥15分。共收集15例符合DSM—IV诊断标准的曾经遭受过早年创伤的PTSD患者（研究组）,17例经历早年创伤无PTSD者（时照1组）,20名健康人（对照2组）。所有受试者均为女性。采用儿童期创伤问卷（CTQ）评估是否存在儿童期精神创伤,状态特质焦虑问卷（STAI）评估焦虑症状;明尼苏迭多相人格测验（MMPI）评估人格特征。结果状态焦虑和特质焦虑的情绪体验严重程度依次是研究组、对照1组、对照2组（P〈0．01）。MMPI测验显示癔症、精神病态、男一女性化、精神衰弱、精神分裂、轻躁狂3组间比较差异无统计学意义（P〉0．05）。3组对象抑郁、社会内向严重程度依次为研究组、对照1组、对照2组（P〈0．01）。研究组、对照1组疑病和偏执因子得分均高于对照2组（P〈0．01）。结论早年创伤从某种程度上可能影响PTSD的焦虑情绪及人格改变,且与创伤的严重程度有关。     

创伤后应激障碍发生自杀的研究进展

随着近年来对创伤后应激障碍（PTSD）的关注越来越多,目前认为PTSD患者自杀率远远高于普通人群,因此,早期识别自杀并干预将具有重大的医学和社会意义。现从PTSD发生自杀的流行病学、影响因素、生物学机制及干预几个方面进行综述。     

Trauma exposure and post-traumatic stress disorder in the general population

OBJECTIVE: To examine the lifetime prevalence of trauma experiences and post-traumatic stress disorder (PTSD). METHOD: Questionnaire-assessed PTSD, the type of traumatic event experienced, perceived trauma impact, and trauma frequency in 1824 randomly selected men and women. RESULTS: PTSD lifetime prevalence was estimated at 5.6% with a 1 : 2 male-to-female ratio, in spite of men reporting greater trauma exposure. The highest PTSD risk was associated with sexual and physical assault, robbery and multiple trauma experiences. Controlling for trauma type did not account for gender differences, while controlling for experienced distress did. CONCLUSION: The conditional probability for PTSD varied as a function of trauma type, frequency and impact of the event, with increased rates associated with prevalent trauma exposure and higher perceived distress. The latter accounted for the gender effect, suggesting that gender differences in PTSD in part represent a generally greater vulnerability to stress in women.     

Fluvoxamine treatment in veterans with combat-related post-traumatic stress disorder

This study was designed to investigate the efficacy of the antidepressant fluvoxamine in the treatment of combat-related post-traumatic stress disorder (PTSD). Fifteen veterans with combat-related PTSD and no other psychiatric diagnosis except depression were recruited to participate in a 14-week open-label study of fluvoxamine. Patients underwent a 30-day washout period and were rated with the Clinician Administered PTSD Scale (CAPS), Mississippi Scale, Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HAM-D) and Hamilton Rating Scale for Anxiety (HAM-A) at baseline, and every 2 weeks until week 14. Three patients stopped fluvoxamine prematurely due to side effects and 7 withdrew consent before completing the 14-week trial. Eight patients completed at least 8 weeks of treatment. The total daily dose of fluvoxamine ranged from 100 to 300 mg with a mean daily dose of 150 mg at week 14. Intent-to-treat analysis revealed a significant improvement in total CAPS scores, and in the intrusion and the avoidance/numbing subscales. The CAPS hyper-arousal scores did not change significantly. HAM-A score also improved significantly. No significant changes were seen on the Mississippi scale, HAM-D, or Beck Depression Inventory in the intent-to-treat analysis. In summary, our study shows that fluvoxamine appears to improve combat-related PTSD symptoms but not depressive symptoms. The high attrition rate and lack of a placebo group limits the conclusions of our study. Controlled studies of fluvoxamine in the treatment of PTSD are warranted.     

Early intervention for post-traumatic stress disorder

Aims: The potentially debilitating effect of posttraumatic stress disorder (PTSD) has created much interest in early intervention strategies that can reduce PTSD. This review critiques the evidence for psychological debriefing approaches and alternate early intervention strategies. Methods: The review critiques the randomized controlled trials of psychological debriefing, and early provision of cognitive behavior therapy. The latter approach involves therapy attention on acutely traumatized individuals who are high risk for PTSD development, and particularly in people with acute stress disorder (ASD). Results: Psychological debriefing does not prevent PTSD. Cognitive behaviour therapy strategies have proven efficacy in reducing subsequent PTSD in ASD populations. Conclusions: Despite the promising evidence for early provision of CBT, many people do not benefit from CBT. This review concludes with consideration of major challenges facing early intervention approaches in the context of terrorist attacks and mass disasters.     

Clinical correlates of DHEA associated with post-traumatic stress disorder

OBJECTIVE: Increased plasma dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) have been demonstrated in post-traumatic stress disorder (PTSD), but the documented beneficial effects of these steroids in enhancing mood and cognition, as well as neuroprotection, suggest their presence in PTSD may be associated with defensive rather than maladaptive effects. METHOD: We, therefore, examined plasma DHEA, DHEAS, cortisol, and the DHEA/cortisol ratio in 40 male veterans with or without PTSD, and determined their relationships to PTSD symptom severity and symptom improvement. RESULTS: The PTSD group showed significantly higher plasma DHEA and non-significantly higher DHEAS levels as well as a significantly lower cortisol/DHEA ratio, controlling for age. Regression analyses demonstrated that DHEA and DHEAS levels could be predicted by symptom improvement and coping, whereas the cortisol/DHEA ratio was predicted by severity of childhood trauma and current symptom severity. CONCLUSION: That greater symptom improvement was related to DHEA levels may suggest for a role for these hormones in modulating recovery from PTSD.     

Hemispheric asymmetry in non-linear interdependence of EEG in post-traumatic stress disorder

Aim: While volumetric and metabolic imaging on post‐traumatic stress disorder (PTSD) patients has been intensively performed, few studies using electroencephalograms (EEG) have been done as yet. The aim of the present study was to investigate abnormalities in functional connectivity of cortical networks in PTSD. Methods: Non‐linear interdependence (NI), a measure of bidirectional, non‐linear information transmission between two time series, was used. Resting EEG were recorded for 18 PTSD patients and 18 sex‐matched healthy subjects on 16 channels with their eyes closed. Results: The NI patterns in PTSD patients were hemisphere asymmetric: an increase in NI in the fronto‐parieto‐temporal regions of the left hemisphere (F7, F3, T3, C3, T5 and P3) and a decrease in the fronto‐parieto‐occipital regions of the right hemisphere (F4, C4, P4 and O2). The non‐linearity of NI in EEG, estimated from the surrogate data method, exhibited an increase in the PTSD patients as compared with that of healthy subjects, particularly in the left hemispheric cortex. Conclusion: Abnormal functional connectivity in PTSD can be assessed using NI, a measure of multi‐channel EEG.     

Neural correlates of self-reflection in post-traumatic stress disorder

Bluhm RL, Frewen PA, Coupland NC, Densmore M, Schore AN, Lanius RA. Neural correlates of self‐reflection in post‐traumatic stress disorder. Objective: Disturbances in self‐referential processing (SRP) are increasingly recognized in post‐traumatic stress disorder (PTSD). In healthy adults, SRP tasks engage the medial prefrontal cortex (MPFC) and posterior cingulate cortex (PCC) brain regions that have shown altered function in PTSD. We hypothesized that individuals with PTSD would differ from controls in functional activation of the MPFC and PCC during SRP. Method: We compared neural activation in healthy controls (n = 15) and participants with PTSD (n = 20) during a SRP task, using fMRI at 4.0T. Results: Controls made faster responses to the self‐relevance of personal characteristics than to the accuracy of general facts, whereas response times did not differ between these conditions in PTSD. Controls also demonstrated greater MPFC (dorsal and ventral) and PCC response when considering the self‐relevance of personal characteristics in comparison with the accuracy of general facts. Individuals with PTSD demonstrated less MPFC response than did healthy controls for the contrast of self‐relevance of personal characteristics relative to general facts. Conclusions: These results implicate MPFC in SRP disturbances associated with PTSD. These findings are relevant to current proposals for including symptoms of negative self‐referential cognition and identity‐existential disturbance as diagnostically relevant to PTSD.     

Predictors of post-traumatic stress disorder following severe injury.

The chronicity and morbidity of established post-traumatic stress disorder (PTSD) has stimulated interest in recognizing and understanding the early development of the disorder. Acute stress disorder, a new diagnosis intended to facilitate early case detection, rests on the occurrence of dissociative reactions. It remains uncertain whether dissociation is a universal or unique early predictor of subsequent PTSD. Traumatic injury is an important and relatively understudied antecedent of PTSD. The objective of this study was to preliminarily identify which previously implicated early reactions and risk factors would apply to the prediction of PTSD following severe traumatic injury. Patients admitted to a regional Level I trauma center following life threatening events who had recall of the incident and did not have signs of traumatic brain injury or recent psychopathology were enrolled. Comprehensive assessments were conducted during hospitalization and after discharge approximately 2 months after the traumatic event. At follow-up, 24% of the available 50 subjects met full criteria for PTSD and an additional 22% met criteria for two of three symptom clusters. Early symptoms of heightened arousal and coping with disengagement were independent predictors of PTSD severity at follow-up. Relationships to initial dissociative reactions and a diagnosis of ASD were not significant. These early predictors found in a setting of severe injury only partially overlap findings from previous PTSD studies.