儿童及青少年创伤后应激障碍的杏仁体磁共振波谱研究

目的:运用磁共振波谱成像(MRS)探讨儿童及青少年创伤后应激障碍(PTSD)患者双侧杏仁体的神经生化改变。方法:共纳入38例汶川地震幸存者,包括19例PTSD患者[年龄(13.33±1.91)岁]及19例健康人作为对照[年龄(13.11±1.45)岁)]。运用3.0T磁共振仪进行双侧杏仁体单体素MRS采集,采用LC Model测定各代谢物的绝对浓度,比较其组间差异及左右侧差异,并对各代谢物浓度与PCL-C量表评分进行相关性分析。结果:与对照组比较,PTSD患者左侧杏仁体NAA及Glx浓度增高[分别为(9.402±1.033)和(16.865±2.270)mmol/kg],Cr浓度[(7.243±0.945)mmol/kg]降低;右侧杏仁体NAA及Glx浓度亦显著性增高[分别为(9.270±1.555)和(16.081±0.607)mmol/kg]。此外,对照组左侧杏仁体Cr浓度显著高于右侧,而PTSD组左右侧杏仁体Cr浓度无明显差异。PTSD组右侧Glx浓度与PCL-C评分呈显著正相关(r=0.740,P=0.036)。结论:儿童及青少年PTSD患者双侧杏仁体的神经生化均有异常改变,但左侧更明显;其中Glx的改变可能在PTSD病理生理机制中起关键作用。     

创伤后应激障碍患者海马活体MR波谱研究

目的探讨创伤后应激障碍（PTSD）患者双侧海马活体MR波谱（MRS）的特点,为创伤后应激障碍的诊断和病因学机制提供线索.方法应用多体素活体MRS成像技术,对12例PTSD患者和12例正常对照者进行波谱分析,检测双侧海马的N-乙酰天门冬氨酸（NAA）,肌酸（Cr）和含胆碱化合物（Cho）峰值,并进行统计学比较.结果PTSD患者左侧海马的NAA/Cr比值明显低于正常对照组（F=9.99,P=0.006）,Cho/Cr比值差异无统计学意义（F=0.36,P=0.55）;右侧海马的NAA/Cr比值、Cho/Cr比值差异均无统计学意义（F=1.44,P=0.25）.性别之间的波谱差异比较无统计学意义（F=0.56,P=0.82）;年龄、受教育时间、PTSD症状严重程度与左侧海马NAA/Cr比值的相关系数分别为0.47、0.35和0.18,差异无统计学意义（P＞0.05）.结论PTSD患者左侧海马存在病理性变化,NAA/Cr比值低于正常人.     

创伤后应激障碍的MRS研究进展

创伤后应激障碍（PTSD）是个体面临或经历了超负荷创伤性事件后产生的一种精神应激障碍疾病。常规MRI在诊断PTSD等精神疾病方面提供的信息量很少,而氢质子磁共振波谱（1H-MRS）能够在大脑结构改变之前检测到其细微的生物化学方面改变,近年来为PTSD的研究提供了有效手段。综述MRS在PTSD研究中的重要发现和研究进展,重点介绍MRS在海马、杏仁核、前扣带回和岛叶等脑区的研究发现,并展望今后可能的研究方向。     

质子磁共振波谱对创伤后应激障碍患者海马神经元异常的诊断价值

目的 探讨质子磁共振波谱（1HMRS）在诊断创伤后应激障碍（post traumatic stress disorder，PTSD）患者海马神经元异常中的价值。方法 对19例PTSD患者及19例健康对照组行常规MRI和1HMRS检查。结果 PTSD患者MRI检查未出现信号的异常。19例患者两侧海马均显示NAA／Cr明显减低，与健康对照组相比，差异有统计学意义（P〈0．01）；而患者两侧海马的Cho／Cr与健康对照组相比，差异无统计学意义（P〉0．05）。结论 1HMRS揭示了PTSD时海马存在着神经元的丢失或功能紊乱，而这些改变是构成PTSD的神经生物学基础之一。     

创伤后应激障碍脑功能神经影像学研究和进展

创伤后应激障碍是个体经历严重的创伤性事件(如战争、受虐)后产生的严重的精神障碍。近年来,脑神经影像研究尤其是功能神经影像学研究在创伤后应激障碍中的应用日益增多,功能神经影像技术有利于观察创伤后应激障碍功能脑区以及神经环路的异常。本文综述功能神经影像技术(功能磁共振成像,正电子发射断层扫描,和单光子发射计算机体层扫描)在创伤后应激障碍研究中的重要发现,并提出今后可能的研究方向。     

Premature treatment termination by angry patients with combat-related post-traumatic stress disorder

Angry patients with conjoined post-traumatic stress disorder often direct their anger at health care providers during the course of treatment. Such misplaced anger can interfere with treatment. Emerging treatments for trauma-related anger are effective. However, even in the course of psychotherapy for trauma-related anger, these patients direct anger at their therapists, compromising the treatment alliance and increasing the likelihood of premature termination. A case example is presented to illustrate the effect of anger on the treatment alliance. A therapeutic strategy is proposed to reduce the likelihood of premature treatment termination in these high-risk patients. This strategy may also be helpful in primary care contexts.     

交通伤后创伤后应激障碍的预测研究

目的预测交通伤后引起创伤后应激障碍（post traumatic stress disorder，PTSD）发生的早期因素。方法对2004年3—9月人院的87例交通伤患者应用前瞻性随访方法，对早期因素致创伤后应激障碍发生进行预测研究。结果交通伤后患者症状自评量表（SCL-90）大部分因子得分高于常模（P〈0．05）。伤后3—4月PTSD发生率为31％，是否患PTSD两组间早期因素差异有统计学意义的是：人格、心理水平等（P〈0．05）。Logistic回归分析显示，早期预测因素为人格N因子和SCL-90中的精神病性因子（P〈0．05）。结论需对交通创伤患者尤其有神经质人格或精神病倾向患者及早给予心理救助。     

Aggressive behavior in combat veterans with post-traumatic stress disorder

The incidence of aggression and violent behavior in combat veterans varies and can be observed with regard to the presence or absence of post-traumatic stress disorder (PTSD). Significantly greater occurrence of aggression was observed in combat veterans with PTSD compared with those without PTSD. There are various types of aggressive behavior that frequently are combined. Autoaggressive (suicidal) and heteroaggressive (interpersonal violence) behaviors predominate, with dominating verbal aggression and impulsive somatic reactions. Impulsive reactions are more frequently directed toward unknown persons, whereas verbal aggression is mostly aimed at known people. In the occurrence of aggressive behavior in combat veterans with PTSD, important roles are played by education level, low socioeconomic status, maltreatment in childhood, and previous types of violent behavior (before participation in war events).     

Concurrent psychiatric illness in inpatients with post-traumatic stress disorder

The discharge diagnoses of 374 inpatients on a VA Medical Center general psychiatry ward were reviewed. Sixty-three (16.8%) were diagnosed as having posttraumatic stress disorder (PTSD). The mean number of diagnoses was 2.9 for the PTSD group, compared with 1.4 for the non-PTSD patients. The most common comorbid conditions in the PTSD patients were alcohol abuse, unipolar major depression, substance abuse, atypical psychosis, and intermittent explosive disorder. All of these disorders except substance abuse occurred significantly more frequently in the PTSD patients than in those free of PTSD. Schizophrenia and organic mental disorders occurred significantly more frequently in the non-PTSD group. These results suggest a need for thorough psychiatric evaluation in patients with PTSD and the need to evaluate for PTSD when combat veterans present with one of several psychiatric syndromes mentioned above.     

Assessment of post-traumatic stress disorder and comorbidity

The symptoms of lifetime post-traumatic stress disorder (PTSD) and comorbid diagnoses were compared among 502 combat-experienced soldiers under examination for compensation-related purposes to confirm or deny the diagnosis of PTSD and 196 soldiers with combat experience without any psychiatric disorder. The two groups were matched with regard to duration of combat experience, time between combat experience and the study, age, marital status, and education. PTSD was diagnosed by psychiatrists with a structured clinical interview according to the research version of the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders. The psychologists applied the Mississippi Scale for Combat-Related PTSD, Watson's criteria for PTSD, the Minnesota Multiphasic Personality Inventory version 201, and the Trauma Questionnaire. Also, a very detailed heteroanemnestic questionnaire was completed by social workers. Medical documentation and data from the combat services were provided during the examination for compensation-related purposes. After psychiatric and psychological assessment, 20% of the combat-experienced soldiers under examination for compensation-related purposes were diagnosed with lifetime PTSD, 47% were diagnosed with PTSD and comorbid disorders, 6% were diagnosed with PTSD and enduring personality change, and 5% were diagnosed with adjustment disorder. Twelve percent did not fulfill any diagnostic psychiatric criteria, and 10% fulfilled diagnostic criteria for other psychiatric disorders, although they had previous medical documentation confirming PTSD diagnoses. Correlation coefficients between psychiatric and psychological assessment were significant, indicating their complementarity in reaching the final diagnosis. It is necessary to include many different assessment methods in the examination for forensic or compensation-related purposes to obtain a more objective assessment.     

Psychotic symptoms in combat-related post-traumatic stress disorder

The presence of psychotic symptoms in post-traumatic stress disorder (PTSD) has already been recognized. Using the Structured Clinical Interview Diagnostic and Statistical Manual, we searched for and assessed psychotic symptoms in 91 males suffering from combat-related PTSD. Hallucinations and delusions were present in 20% of patients. We divided all patients into three groups: the group with hallucinations and delusions, the group without these symptoms, and the group with "subthreshold" psychotic symptoms. Using the Harvard Trauma Questionnaire, Clinician-Administered PTSD Scale, and Structured Clinical Interview Diagnostic and Statistical Manual, we investigated differences between groups in the intensity of traumatization, severity of PTSD symptoms, and the frequency of depression. There were no significant differences between groups; however, there was one exception: severity of hyperarousal symptoms was positively correlated with occurrence of psychotic symptoms.     

Coexisting physical conditions among inpatients with post-traumatic stress disorder

Discharge summaries over a four-year period for 543 veteran inpatients treated for post-traumatic stress disorder (PTSD) were reviewed for the frequency and nature of medical problems. Results demonstrated that a majority, 60% of the sample, had an identified medical problem. Of those patients, 42% had multiple medical problems. One patient in four showed some type of musculoskeletal or pain problem. Eight per cent had sequelae from combat-related trauma. The results illustrate a high base rate with a wide variety of physical conditions among PTSD inpatients. This suggests that closer attention should be given to the interaction of medical problems with PTSD expressed symptomatology in future research or clinical treatment.     

Cyproheptadine for combat nightmares in post-traumatic stress disorder and dream anxiety disorder

Pharmacologic treatment of patients with post-traumatic stress disorder often involves antidepressant drugs. Combat nightmares often persist. The addition of cyproheptadine, in a median dose of 16-24 mg orally at night, controls the nightmares.     

创伤后应激障碍诊治研究进展

创伤后应激障碍指个体在遭受强烈的身体和精神创伤后出现行为和精神异常的一种疾病.其三大核心症状为:创伤事件再体验、警觉性增高以及回避、麻木.本文对创伤后应激障碍(PTSD)的概况、流行病学、致病机制、生物标记物及其预警诊断、防治措施等方面的研究进行综述,并提出相关研究中存在的问题及未来的研究方向.     

Prevalence of psychotic comorbidity in combat-related post-traumatic stress disorder

OBJECTIVE: We explored the prevalence of comorbidity of psychotic symptoms among Croatian war veterans with combat-related post-traumatic stress disorder (PTSD) and the psychotic features among these patients, as well as the association between psychotic symptoms and personality disorders. METHODS: The study included 680 men who had experienced combat stress and had diagnoses of PTSD confirmed before examination. They were compared with a group of 289 soldiers with combat experience under regular medical examination, who were still in active military service. The groups were matched in duration of combat experience, time elapsed between combat experience and the study, age, marital status, and education. Statistical analyses were performed using the t test and chi2 test. RESULTS: The study showed that 15% of war veterans had current chronic PTSD and 45% had PTSD with one or more comorbid diagnoses. Psychotic disorders with PTSD were confirmed for 17% of those patients and major depressive disorder with psychotic features for 15%. Depression and psychotic symptoms were more often found among patients without personality disorders. Also, we found that 9% of the war veterans who were still in active military service had some psychiatric disorders. CONCLUSIONS: Many patients demonstrated psychotic symptoms different from flashbacks and dissociative symptoms. Those psychotic symptoms are an integral part of PTSD and have a symbolic relation to the trauma.     

创伤应激障碍综合征的发展历史与诊断标准的进展

创伤后应对各种实际与潜在损失的能力以及对机体功能障碍的适应性,不仅是决定躯体功能康复与再适应的关键,也将是决定创伤患者创伤后生存质量的关键。是否能够适应"创伤"这一应激性事件对人体整体包括躯体与精神的影响,决定创伤后的社会功能。创伤后引起生存质量降低的最常见疾病即为创伤后应激障碍综合征,本文从这一疾病的认识历史、诊断标准进展的角度进行综述,为创伤医护工作者认识并积极筛查该疾病、早期正确有效干预奠定基础。     

The prevalence of temporomandibular disorders in war veterans with post-traumatic stress disorder

The purposes of this study were to assess the prevalence of temporomandibular disorders in Croatian war veterans suffering from post-traumatic stress disorder (PTSD) and to analyze the impact of the disease on mandibular function. One hundred eighty-two male subjects participated in the study. The examined group consisted of 94 subjects who had taken part in the war in Croatia and for whom PTSD had previously been diagnosed. Patients were compared with an age- and gender-matched group of subjects who had not taken part in the war and for whom PTSD was excluded by means of a psychiatric examination. The study used a clinical examination and standard questionnaire. Statistically significant differences were found in almost all measured parameters. With regard to restricted movements, overbite, and overjet, the differences obtained did not have clinical significance. The most significant differences were found in the parameters of pain. Headache was experienced by 63.83% of the subjects with PTSD, facial pain by 12.77%, and pain in the region of the jaw by 10.64%. Headache was the most intense pain, with an average intensity of 4.92 on a scale of 0 to 10. Pain on loading, temporomandibular joint clicking, and intrameatal tenderness were more prevalent in the PTSD group than in the healthy control group. The study supports the concept that PTSD patients are at increased risk for the development of temporomandibular disorder symptoms.     

轻微肝性脑病的氢质子MR波谱研究

目的 应用氢质子MR波谱(~1H-MRS)检测肝硬化患者脑内代谢物改变,评价其异常变化是否能鉴别轻微肝性脑病(MHE),并与临床神经心理测试进行相关性分析.方法 选取54例肝硬化患者(肝硬化组)和13名健康志愿者(正常对照组)完成神经心理测试,包括数字连接试验A(NCT-A)和数码-符号试验(DST),54例肝硬化患者中包括肝性脑病(HE)9例(HE组)、MHE 23例(MHE组)、无HE和MHE者22例(无HE组).所有患者和志愿者均进行常规头颅MR扫描以及枕叶皮质、左侧顶叶白质的~1H-MRS扫描,分别计算各代谢物包括N-乙酰天冬氨酸(NAA)、胆碱化合物(Cho)、肌醇(mI)和谷氨酰胺复合物(Glx)与肌酸(Cr)的比值.正常对照组与肝硬化组的代谢物比值比较采用独立样本t检验,正常对照组和肝硬化各分组间代谢物比值的比较采用单因素方差分析,组间两两比较采用非参数Mann-Whitney U检验,并用Bonferroni法进行校正.~1H-MRS代谢物比值与HE分级、神经心理测试结果、静脉血氨的相关性分析采用Spearman等级相关分析.结果 肝硬化组枕叶皮质和左顶叶白质的代谢物比值NAA/Cr、Cho/Cr/、mI/Cr、Glx/Cr值分别为1.55±0.12、0.48±0.10、0.42±0.14、2.52±0.48和1.73±0.17、0.75±0.16、0.42±0.16、2.75±0.59,其中无HE组为1.53±0.10、0.48±0.09、0.51±0.11、2.20±0.39和1.69±0.15、0.82±0.14、0.53±0.12、2.40±0.40,MHE组为1.58±0.13、0.48±0.08、0.38±0.13、2.62±0.39和1.78±0.18、0.74±0.14、0.38±0.15、2.84±0.58,HE组分别为1.54±0.12、0.50±0.13、0.29±0.07、3.04±0.31和1.70±0.19、0.62±0.16、0.29±0.07、3.37±0.38.正常对照组相应部位代谢物比值分别为1.61±0.06、0.60±0.10、0.63±0.04、2.05±0.11和1.78±0.07、1.01±0.14、0.70±0.07、1.93±0.34.与正常对照组比较,肝硬化组及肝硬化各分组的Cho/Cr、mI/Cr值均降低,Glx/Cr值均升高,差异均有统计学意义(肝硬化组与对照组比较,枕叶皮质:t值分别为3.196、9.394、-6.527,肝硬化各分组与对照组比较,F值分别为5.097、25.896、20.204,P值均＜0.01.左顶叶白质:t值分别为5.592、9.717、-6.681,F值分别为16.435、28.660、21.283,P值均＜0.01＝.枕叶皮质和左顶叶白质的Glx/Cr值在无HE组、MHE组和HE组间的差异均有统计学意义(P值均＜0.0084＝,mI/Cr值在无HE组和MHE组间比较差异也有统计学意义(P＜0.0084＝.Cho/Cr、mI/Cr值与肝硬化患者HE的严重程度成负相关(枕叶皮质Cho/Cr和mI/Cr的r值分别为-0.316和-0.740,P值均＜0.01;左顶叶白质Cho/Cr和mI/Cr的r值分别为-0.620和-0.749,P值均＜0.01＝,Glx/Cr值与其呈正相关(枕叶皮质和左顶叶白质的r值分别为0.709、0.720,P值均＜0.01＝.正常对照组NCT-A值为(49±8)s,DST值为39 ±6,肝硬化组HE、MHE、无HE组患者NCT-A值分别为(134±37)、(83±26)、(64 ±22)s,DST值分别为15±2、25±9、35±8.正常对照组和肝硬化组67例的代谢物比值Cho/Cr、mI/Cr、Clx/Cr的改变与神经心理测试有很好相关性(P＜0.01＝,其中Glx/Cr值与NCT-A为正相关(枕叶皮质r=0.570,左顶叶白质r=0.541),与DST值为负相关(枕叶皮质r=-0.642,左顶叶白质r=-0.632).各代谢物比值与静脉血氨值之间无相关性.结论 ~1H-MRS研究能显示肝硬化患者大脑皮质与白质区代谢物异常改变,以mI/Cr值和Glx/Cr值明显,并且与神经心理测试之间存在相关性,可以作为HE分级的参考,对MHE有提示作用.