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心的外傷後ストレス反応(PTSD) (2)

 前回は、PTSDの医学的な診断基準について紹介しました。できるだけ、分かりやすくと思いながら書いたのですが、ちょっと難しい話になってしまいました。しかし大切な事なので、今回ももう少し医学的な話を続けます。

 PTSDについては、これに関連して

「複雑性PTSD」
または、
"Disorders of Extreme Stress Not Otherwise Specified (DESNOS)"
と呼ばれる別の診断名があります。

 複雑性PTSDは、「心的外傷と回復」"Trauma And Recovery"の著者である、Hermanらが提唱したのが始まりで、DSM-IV-TRにはDESNOSの名で載せられています。PTSDはあくまでも、外傷体験(Traumatic events:トラウマ)を受けた人の主症状(Core Symptoms)のみを基準としていて、外傷体験が長期に与える影響については触れられていません。そこでHermanらは、膨大な調査を元に、幼少期(少なくとも13歳未満)の外傷体験が長期的に人にどのような影響を与えるのかを分析し、共通の問題点や症状をリストアップしこれを「複雑性PTSD」と名付けました。

 さて、Hermanらの説にはいろいろと賛否両論はあるのですが、少なくとも子供時代のトラウマが(適切な援助や介入がなければ)心身の発達や成人後も様々な分野に影響を及ぼすという点では、大方の同意は得られるのではないかと思います。

 私が病院で、あるいは研究所でお会いする方の半分以上が、子供時代に長期にわたる身体的・性的虐待(ここには当然心理的虐待も含まれます)を受け、しかもほとんど何の介入も受けずに今に至っており、この「複雑性PTSD」のカテゴリーに入る方々です。そして、私自身も、このカテゴリーにすっぽり入っていると思います。

 

 
 「複雑性PTSD」の診断基準には次のようなものが含まれます。


A.感情のコントロール機能の変化
 (1) 慢性的に感情のコントロールができなくなる(つまり気分の変化が激しい)
 (2) 怒りの制御が困難
 (3) 自殺を図るなど自己破壊的な行動を起こす
 (4) 性的関係の制御が困難
 (5) 衝動的で自らを危険にさらすような行動を起こす
B.注意や意識の維持に対する変化
 (1) 物忘れがひどくなる
 (2) 解離症状 (これはPTSDと重なっています)
C.多様で頻繁に変化する身体化症状
D.慢性的な人格の変化
 (1) 自己認識の変化:
    慢性的な罪悪感や恥辱感、自責の念や自分は役に立たないという気持ち、
    あるいは永久にダメージを受けている感じ
 (2) 加害者についての認識の変化:加害者に対するゆがんだ信念の形成や理想化
 (3) 他人との関係の変化
    (a) 他人への信頼感が持てず、安定した人間関係を維持できない
    (b) 再被害を受ける傾向がある(これは同一人物からとは限らない)
    (c) 他者に被害を及ぼす傾向がある(自分が加害者になる可能性がある)
E.意味体系における変化
 (1) 絶望感や希望の喪失(自分自身の存在価値に関して)
 (2) 以前に自分を支えていた信念を失う

 (引用は "Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society"より。少し分かりやすくしてあります)

 この「複雑性PTSD」は、通常PTSDの基準Aを満たし、PTSDの症状を部分的にでも表しており、なおかつ上記のいくつかを満たす時に診断されます。

個人的な意見なのですが、複雑性PTSDに当てはまる人でも問題の出し方にはかなり個人差があるように思います。あまり衝動的で自己破壊的な行動に出ない代わりに厳格な道徳観や、白か黒かの極端な価値観を持つ人が、私のお会いする患者さんには多いような気がします。どちらかというと私もこのタイプですね。

 いずれにしても、トラウマがその人の人間観や人間関係に及ぼす打撃はかなりのものです。


 (まだ続きます)

 

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