Leon Piterman(著)，邱珊嬌(譯)，黃文靜(譯)，楊輝(譯)

·世界全科醫(yī)學(xué)工作瞭望·

《The Medical Republic》案例分享
——X 線正?？赡懿坏扔趶?fù)原: 從創(chuàng)傷后應(yīng)激障礙學(xué)到的

Leon Piterman(著)1，邱珊嬌(譯)2，黃文靜(譯)2，楊輝(譯)1

全科醫(yī)生；應(yīng)激障礙，創(chuàng)傷后；心理療法

PITERMAN L.X線正常可能不等于復(fù)原——從創(chuàng)傷后應(yīng)激障礙學(xué)到的[J].邱珊嬌，黃文靜，楊輝，譯.中國(guó)全科醫(yī)學(xué)，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.

當(dāng)我第一次見(jiàn)到鮑里斯，他是孤獨(dú)和絕望的樣子。

他今年45歲，可看起來(lái)卻像65歲。他像中年發(fā)福一樣的超重，面色紅潤(rùn)，邁著緩慢和有目的的步態(tài)，很高興能逮住機(jī)會(huì)，把自己陷在我對(duì)面的病人椅子上。是他的老板把他送到我診所的，是為了評(píng)估在他病休6個(gè)月后重新回去工作的可能性。我知道，給他看病要花很長(zhǎng)時(shí)間，但愿不要花的時(shí)間太長(zhǎng)；或者，可能要給他看好幾次病。

以前，鮑里斯在我們?cè)\所附近的印刷廠擔(dān)任下午班或晚班經(jīng)理。

他出生在保加利亞，20歲之后就一直住在澳大利亞。他跟一位小他12歲的女子結(jié)婚，生了兩個(gè)兒子，分別是8歲和6歲。他以往一直堅(jiān)持鍛煉身體，40歲之前一直在踢足球。他為自己健美的身材和陽(yáng)剛氣概感到驕傲。

所有這一切在6個(gè)月前的一個(gè)晚上被完全改變了。鮑里斯在工作時(shí)遇到了事故。當(dāng)時(shí)，他正在工廠里修理一個(gè)墻上的電燈開(kāi)關(guān)，一輛叉車沖著他倒車過(guò)來(lái)，并停車，把他擠壓在墻上，動(dòng)彈不得。他感到被壓扁了，心想自己死定了。

雖然重啟叉車只用了幾分鐘，但感覺(jué)像是用了幾個(gè)小時(shí)。這段時(shí)間，鮑里斯一直保持著警覺(jué)，雖然他的胸部、背部和骨盆疼痛難忍。有人叫了急救車，鮑里斯被緊急送到了當(dāng)?shù)氐慕虒W(xué)醫(yī)院。醫(yī)院給他做了體檢，照了X線，做了掃描檢查，并在留觀室留觀了24 h。醫(yī)生告訴他僅是擦傷，沒(méi)有骨折，這些問(wèn)題會(huì)在短時(shí)間內(nèi)得到恢復(fù)，然后把他送回家，并給他預(yù)約了2周后的骨科門診。去骨科門診復(fù)診的路上他感到很痛苦，然后又在候診室忍受了漫長(zhǎng)的等待，結(jié)果得到的是很短暫的專家接診。骨科醫(yī)生告訴他沒(méi)有嚴(yán)重的損傷，給他開(kāi)了2周的病假證明，讓他再看病的話去找全科醫(yī)生。

然而，鮑里斯并沒(méi)有如期恢復(fù)。他的疼痛一直持續(xù)著，而且噩夢(mèng)不斷。他夢(mèng)到自己被壓扁或淹死，并經(jīng)常在冷汗中驚醒。這些噩夢(mèng)和閃回變成了他生活常態(tài)。他的妻子經(jīng)常被他吵醒，所以把他打發(fā)到另一個(gè)空房間去。

醫(yī)生給他開(kāi)了安眠藥，并讓他繼續(xù)休息1個(gè)月，但他發(fā)現(xiàn)自己越來(lái)越抑郁和焦慮。他無(wú)法忍受汽車噪聲和喇叭聲。他有幾次回到自己工作的地方，但一看到叉車就感到無(wú)比害怕。他開(kāi)始每天喝烈酒，而且和妻子的關(guān)系也變得惡化。他甚至懷疑妻子可能有外遇。

在持續(xù)5個(gè)月無(wú)法工作后，他被精神病專家確診為創(chuàng)傷后應(yīng)激障礙(PTSD)，開(kāi)始使用選擇性血清素再吸收抑制劑(SSRI)類藥物(5-羥色胺再攝取抑制劑)治療，并轉(zhuǎn)診去做心理治療。

現(xiàn)在，PTSD已經(jīng)是我們的字典中廣泛使用的術(shù)語(yǔ)，因?yàn)樵谌粘Ｉ钪胁粩嗄慷酶鞣N各樣的創(chuàng)傷性事件。

對(duì)于PTSD最早的系統(tǒng)描述，稱為“炮彈休克”，是1917年第一次世界大戰(zhàn)期間發(fā)明的新詞。有1/7的部隊(duì)士兵受到PTSD的折磨，總共8萬(wàn)名英軍士兵接受治療，其中有很多人不是前線部隊(duì)的。

在伊拉克和阿富汗戰(zhàn)爭(zhēng)中，25萬(wàn)美國(guó)士兵受到PTSD影響。參加這些戰(zhàn)爭(zhēng)的3 000多名澳大利亞士兵也受到相似的折磨。

很多參加世界大戰(zhàn)和越南戰(zhàn)爭(zhēng)的退伍軍人在沉默中忍受痛苦，然后轉(zhuǎn)向酗酒、吸毒和暴力行為，或者直接變得長(zhǎng)期焦慮和抑郁。我們對(duì)PTSD的認(rèn)識(shí)，意味著通過(guò)早期干預(yù)，并采用一系列傳統(tǒng)和新的治療方法，能讓他們得到更好的健康結(jié)果。

當(dāng)然，PTSD不僅影響經(jīng)歷過(guò)戰(zhàn)爭(zhēng)的人。其可以影響直接地或間接地暴露于被認(rèn)為是威脅生命的創(chuàng)傷事件的任何人。包括交通事故、與工作相關(guān)的事故(如鮑里斯的案例)、自然災(zāi)害、犯罪或恐怖主義行為、兒童虐待和家庭暴力。

遭受PTSD的人可能不是創(chuàng)傷的直接受害者，但可能是目睹了其可怕結(jié)果的人。尤其影響急救服務(wù)人員和健康工作者，甚至影響僅是旁觀的人，正如最近發(fā)生的墨爾本市中心悲劇(注：2017年1月，一個(gè)人駕車沖進(jìn)墨爾本繁華的市中心，造成4人死亡，數(shù)十人受傷)。

據(jù)估計(jì)，澳大利亞PTSD終生流行率是7.2%，12個(gè)月流行率是4.4%。真不敢想象，在敘利亞PTSD會(huì)是什么情況！

PTSD有一系列的臨床表現(xiàn)，包括：反復(fù)重現(xiàn)創(chuàng)傷性體驗(yàn)、噩夢(mèng)、失眠、癥狀閃回、負(fù)面的想法和自我懊惱；在遇到與當(dāng)時(shí)場(chǎng)景有關(guān)的線索時(shí)，出現(xiàn)諸如出汗、心悸、胸痛等生理反應(yīng)；易激惹(如對(duì)噪聲的反應(yīng))、逃避行為、攻擊行為、興趣低下和注意力不集中。

其中有些癥狀也明顯表現(xiàn)為抑郁和焦慮。

PTSD的治療方法包含心理治療和藥物治療。一般來(lái)說(shuō)，早期干預(yù)會(huì)有較好的結(jié)果。

心理治療包含認(rèn)知行為療法、延長(zhǎng)暴露療法(談?wù)摵驮俣润w驗(yàn)痛苦的回憶)、眼動(dòng)脫敏與再加工療法(即當(dāng)想到痛苦回憶的時(shí)候，專注于其他活動(dòng)如眼球運(yùn)動(dòng)和用手敲擊)。

藥物治療包括SSRI的使用，這些藥物也用于治療抑郁和焦慮。

并不是每個(gè)暴露于創(chuàng)傷的人均會(huì)發(fā)展成PTSD。例如，在阿富汗和伊拉克服役的200萬(wàn)名美軍士兵中，約有10%的人有PTSD。這種現(xiàn)象促使研究者提出關(guān)于個(gè)人易感性的研究問(wèn)題。對(duì)PTSD的神經(jīng)生物學(xué)研究，是一個(gè)新的研究方向，可能有助于我們識(shí)別出哪些人有患PTSD高風(fēng)險(xiǎn)，并開(kāi)發(fā)出更有針對(duì)性的治療方法。

經(jīng)過(guò)治療后，鮑里斯在病休6個(gè)月后能夠回到崗位做兼職工作，9個(gè)月后能夠做全職工作。

我一直在推演某種情形，如果醫(yī)院急診和骨科門診對(duì)他的情況有更深刻的了解，并在此了解的基礎(chǔ)上給他治療，那么他的預(yù)后會(huì)不會(huì)大不相同呢。

如果有人告訴你：“你的X線檢查正常，所以你沒(méi)有大問(wèn)題”，這種說(shuō)法可能既不代表你軀體沒(méi)病，也不說(shuō)明你心理無(wú)恙。給患者做更具有同情心的評(píng)估，再加上意識(shí)到危及生命的事件可能帶來(lái)長(zhǎng)期的心理并發(fā)癥，那么就可能有助于幫到諸如鮑里斯這樣的患者，讓其免受PTSD帶來(lái)的損害。

我最近參加了一個(gè)PTSD的研討會(huì)，詳情參閱：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.

(本文編輯：賈萌萌)

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)

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現(xiàn)在其自行制定行業(yè)標(biāo)準(zhǔn)、自主進(jìn)行資質(zhì)考核及自主執(zhí)業(yè)等方面，也體現(xiàn)在《The Medical Republic》這一共享平臺(tái)上。Leon Piterman是Monash University的副校長(zhǎng)、全科醫(yī)學(xué)教授，從事全科醫(yī)學(xué)臨床服務(wù)近40年，其建議我國(guó)的全科醫(yī)生應(yīng)培養(yǎng)“共和”思想，以為全科醫(yī)學(xué)領(lǐng)域提供更多的平等交流機(jī)會(huì)。目前Piterman教授定期為《The Medical Republic》撰寫(xiě)文章，本刊深受“醫(yī)學(xué)共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對(duì)Piterman教授的文章進(jìn)行編譯，并將進(jìn)行連載刊登，希望對(duì)我國(guó)的全科醫(yī)生有所幫助和啟發(fā)！本文中，Piterman教授講述了自己管理的一例經(jīng)歷創(chuàng)傷后，X線檢查正常，未再進(jìn)行更細(xì)致檢查，從而確診為創(chuàng)傷后應(yīng)激障礙(PTSD)患者，建議醫(yī)生接診遭遇危及生命事件的患者時(shí)，給予更具同情心的評(píng)估，并意識(shí)到可能帶來(lái)的心理并發(fā)癥，從而減少PTSD的發(fā)生，敬請(qǐng)關(guān)注！

1.3168 Monash University,Melbourne,Australia

2.518003 廣東省深圳市，羅湖醫(yī)院集團(tuán)黃貝嶺社區(qū)健康服務(wù)中心

注：本文首次刊登于《The Medical Republic》