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Module 04 · Stress and Trauma-Related Disorders

Module 5: Trauma- and Stressor-Related Disorders模块 5：创伤及应激相关障碍

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3rd edition as of July 2023
截至 2023 年 7 月的第 3 版

Module Overview 模块概述

In Module 5, we will discuss matters related to trauma- and stressor-related disorders to include their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. Our discussion will consist of PTSD, acute stress disorder, adjustment disorder, and prolonged grief disorder. Prior to discussing these clinical disorders, we will explain what stressors are, as well as identify common stressors that may lead to a trauma- or stressor-related disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of models to explain psychopathology (Module 2), and descriptions of various therapies (Module 3).
在模块 5 中，我们将讨论与创伤和应激相关障碍相关的问题，包括其临床表现、流行病学、共病、病因和治疗选择。我们的讨论将包括 PTSD、急性应激障碍、适应障碍和长期悲伤障碍。在讨论这些临床障碍之前，我们将解释什么是应激源，以及可能引发创伤或应激相关障碍的常见应激源。请确保您参考模块 1-3 来解释关键术语（模块 1）、心理病理学解释模型的概述（模块 2）以及各种疗法的描述（模块 3）。

Module Outline 模块大纲

Module Learning Outcomes 模块学习成果

  • Define and identify common stressors.
    定义和识别常见压力源。
  • Describe how trauma- and stressor-related disorders present.
    描述创伤和应激相关障碍的表现。
  • Describe the epidemiology of trauma- and stressor-related disorders.
    描述创伤和应激相关障碍的流行病学。
  • Describe comorbidity in relation to trauma- and stressor-related disorders.
    描述与创伤和应激相关障碍相关的共病情况。
  • Describe the etiology of trauma- and stressor-related disorders.
    描述创伤和应激相关障碍的病因。
  • Describe treatment options for trauma- and stressor-related disorders.
    描述创伤和应激相关障碍的治疗方案。

5.1. Stressors 5.1. 应激因素

Section Learning Objectives 章节学习目标

  • Define stressor.  定义应激源。
  • Identify and describe common stressors.
    识别和描述常见压力源。

Before we dive into clinical presentations of four of the trauma and stress-related disorders, let’s discuss common events that precipitate a stress-related diagnosis. A stress disorder occurs when an individual has difficulty coping with or adjusting to a recent stressor. Stressors can be any event—either witnessed firsthand, experienced personally, or experienced by a close family member—that increases physical or psychological demands on an individual. These events are significant enough that they pose a threat, whether real or imagined, to the individual. While many people experience similar stressors throughout their lives, only a small percentage of individuals experience significant maladjustment to the event that psychological intervention is warranted.
在深入探讨四种创伤和压力相关疾病的临床表现之前，让我们先讨论一下导致压力相关诊断的常见事件。当一个人难以应对或适应最近的压力源时，就会发生压力障碍。压力源可以是任何事件——无论是亲眼目睹、亲身经历，还是通过亲密家庭成员的经历——这会增加个人在身体或心理上的需求。这些事件足够重要，足以对个人构成威胁，无论是真实还是想象中的。虽然许多人一生中都会经历类似的压力源，但只有少数人会对事件产生重大不适应，需要心理干预。

Among the most studied triggers for trauma-related disorders are combat and physical/sexual assault. Symptoms of combat-related trauma date back to World War I when soldiers would return home with “shell shock” (Figley, 1978). Unfortunately, it was not until after the Vietnam War that significant progress was made in both identifying and treating war-related psychological difficulties (Roy-Byrne et al., 2004). With the more recent wars in Iraq and Afghanistan, attention was again focused on posttraumatic stress disorder  (PTSD) symptoms due to the large number of service members returning from deployments and reporting significant trauma symptoms.
在创伤相关障碍中最受研究的是战斗和身体/性侵犯。与战斗相关的创伤症状可追溯到第一次世界大战，当时士兵们回家时带着“战栗症”（Figley，1978）。遗憾的是，直到越南战争之后，在识别和治疗与战争相关的心理困难方面才取得了重大进展（Roy-Byrne 等，2004）。随着最近在伊拉克和阿富汗的战争，由于大量从部署中返回的士兵报告了显著的创伤症状，人们再次关注了创伤后应激障碍（PTSD）症状。

Physical assault, and more specifically sexual assault, is another commonly studied traumatic event. **Rape, **or forced sexual intercourse or other sexual act committed without an individual’s consent, occurs in one out of every five women and one in every 71 men (Black et al., 2011). Unfortunately, this statistic likely underestimates the actual number of cases that occur due to the reluctance of many individuals to report their sexual assault. Of the reported cases, it is estimated that nearly 81% of female and 35% of male rape victims report both acute stress disorder and posttraumatic stress disorder symptoms (Black et al., 2011).
身体攻击，尤其是性攻击，是另一种常见的创伤事件。强奸，或未经个人同意而进行的强制性行为或其他性行为，在每五名女性和每 71 名男性中发生一次（Black 等人，2011 年）。不幸的是，这个统计数据可能低估了实际发生案件的数量，因为许多个人不愿报告他们的性攻击。在报告的案件中，估计近 81%的女性和 35%的男性强奸受害者报告了急性应激障碍和创伤后应激障碍症状（Black 等人，2011 年）。

Now that we have discussed a little about some of the most commonly studied traumatic events, we will now examine the clinical presentation of posttraumatic stress disorder, acute stress disorder, adjustment disorder, and prolonged grief disorder.
现在我们已经讨论了一些最常见的创伤事件的概况，接下来我们将探讨创伤后应激障碍、急性应激障碍、适应障碍和长期悲伤障碍的临床表现。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到了以下内容：

  • A stressor is any event that increases physical or psychological demands on an individual.
    压力源是指任何增加个人生理或心理需求的任何事件。
  • It does not have to be personally experienced but can be witnessed or occur to a close family member or friend to have the same effect.
    它不一定要亲身经历，但可以是目睹或发生在亲密的家人或朋友身上，产生相同的效果。
  • Only a small percentage of people experience significant maladjustment due to these events.
    只有少数人因这些事件而经历显著的适应不良。
  • The most studied triggers for trauma-related disorders include physical/sexual assault and combat.
    创伤相关障碍最常研究的触发因素包括身体/性侵犯和战斗。

Section 5.1 Review Questions
第 5.1 节 复习问题

  1. Given an example of a stressor you have experienced in your own life.
    请给出你自己在生活中经历过的压力源示例。
  2. Why are the triggers of physical/sexual assault and combat more likely to lead to a trauma-related disorder?
    为什么身体/性侵犯和战斗的触发因素更可能导致创伤相关障碍？

5.2. Clinical Presentation 5.2. 临床表现

Section Learning Objectives 章节学习目标

  • Describe how PTSD presents.
    描述 PTSD 的表现。
  • Describe how acute stress disorder presents.
    描述急性应激障碍的表现。
  • Describe how adjustment disorder presents.
    描述调整障碍的表现。
  • Describe how prolonged grief disorder presents.
    描述长期悲伤障碍的表现。

5.2.1. Posttraumatic Stress Disorder 5.2.1. 创伤后应激障碍

Posttraumatic stress disorder, or more commonly known as PTSD, is identified by the development of physiological, psychological, and emotional symptoms following exposure to a traumatic event. Individuals must have been exposed to a situation where actual or threatened death, sexual violence, or serious injury occurred. Examples of these situations include but are not limited to witnessing a traumatic event as it occurred to someone else; learning about a traumatic event that occurred to a family member or close friend; directly experiencing a traumatic event; or being exposed to repeated events where one experiences an aversive event (e.g., victims of child abuse/neglect, ER physicians in trauma centers, etc.).
创伤后应激障碍，或更常见地称为 PTSD，是指在遭受创伤事件后出现的生理、心理和情绪症状。个体必须经历过实际或威胁到死亡、性暴力或严重伤害的情况。这些情况包括但不限于目睹他人遭受创伤事件；得知家庭成员或亲密朋友遭受的创伤事件；直接经历创伤事件；或暴露于反复发生的事件中，其中个体经历了厌恶事件（例如，儿童虐待/忽视的受害者、创伤中心的急诊科医生等）。

It is important to understand that while the presentation of these symptoms varies among individuals, to meet the criteria for a diagnosis of PTSD, individuals need to report symptoms among the four different categories of symptoms.
了解这些症状的表现因人而异很重要，但为了符合 PTSD 诊断标准，个人需要报告四个不同症状类别中的症状。

**     5.2.1.1. Category 1: Recurrent experiences. **The first category involves recurrent experiences of the traumatic event, which can occur via dissociative reactions such as flashbacks; recurrent, involuntary, and intrusive distressing memories; or even recurrent distressing dreams (APA, 2022, pgs. 301-2). These recurrent experiences must be specific to the traumatic event or the moments immediately following to meet the criteria for PTSD. Regardless of the method, the recurrent experiences can last several seconds or extend for several days. They are often initiated by physical sensations similar to those experienced during the traumatic events or environmental triggers such as a specific location. Because of these triggers, individuals with PTSD are known to avoid stimuli (i.e., activities, objects, people, etc.) associated with the traumatic event. One or more of the intrusion symptoms must be present.
5.2.1.1. 第一类：反复经历。第一类包括创伤事件的反复经历，可能通过解离反应（如闪回）；反复、不由自主、侵入性的痛苦记忆；甚至反复的痛苦梦境（APA，2022，第 301-2 页）。这些反复经历必须与创伤事件或其后的时刻相关，以满足 PTSD 的诊断标准。无论采用何种方法，反复经历可能持续几秒钟或长达几天。它们通常由与创伤事件期间经历相似的生理感觉或特定地点等环境触发因素引起。由于这些触发因素，患有 PTSD 的人会避免与创伤事件相关的刺激（即活动、物体、人等）。必须存在一种或多种侵入症状。

**     5.2.1.2. Category 2: Avoidance of stimuli. **The second category involves avoidance of stimuli related to the traumatic event and either one or both of the following must be present. First, individuals with PTSD may be observed trying to avoid the distressing thoughts, memories, and/or feelings related to the memories of the traumatic event. Second, they may prevent these memories from occurring by avoiding physical stimuli such as locations, individuals, activities, or even specific situations that trigger the memory of the traumatic event.
5.2.1.2. 第二类：避免刺激。此类涉及避免与创伤事件相关的刺激，以下一项或两项必须存在。首先，患有 PTSD 的人可能会被观察到试图避免与创伤事件的记忆相关的痛苦想法、记忆和/或感受。其次，他们可能会通过避免诸如地点、个人、活动或甚至特定情境等物理刺激来防止这些记忆的发生。

**     5.2.1.3. Category 3: Negative alterations in cognition or mood. **The third category experienced by individuals with PTSD is negative alterations in cognition or mood and at least two of the symptoms described below must be present. This is often reported as difficulty remembering an important aspect of the traumatic event. It should be noted that this amnesia is not due to a head injury, loss of consciousness, or substances, but rather, due to the traumatic nature of the event. The impaired memory may also lead individuals to have false beliefs about the causes of the traumatic event, often blaming themselves or others. An overall persistent negative state, including a generalized negative belief about oneself or others is also reported by those with PTSD. Similar to those with depression, individuals with PTSD may report a reduced interest in participating in previously enjoyable activities, as well as the desire to engage with others socially. They also report not being able to experience positive emotions.
5.2.1.3. 第三类：认知或情绪的负面改变。PTSD 患者经历的第一三是认知或情绪的负面改变，以下描述的症状至少有两个必须存在。这通常被报告为难以记住创伤事件的某个重要方面。应注意的是，这种健忘并非由于头部受伤、意识丧失或物质，而是由于事件的创伤性质。受损的记忆也可能导致个人对创伤事件的原因产生错误信念，通常责怪自己或他人。PTSD 患者还报告了一种持续的负面状态，包括对自己或他人的普遍负面信念。与抑郁症患者类似，PTSD 患者可能会报告对参与以前愉快的活动的兴趣减少，以及与他人社交的愿望。他们还报告无法体验积极的情绪。

**     5.2.1.4. Category 4: Alterations in arousal and reactivity. **The fourth and final category is *alterations in arousal and reactivity *and at least two of the symptoms described below must be present. Because of the negative mood and increased irritability, individuals with PTSD may be quick-tempered and act out aggressively, both verbally and physically. While these aggressive responses may be provoked, they are also sometimes unprovoked. It is believed these behaviors occur due to the heightened sensitivity to potential threats, especially if the threat is similar to their traumatic event. More specifically, individuals with PTSD have a heightened startle response and easily jump or respond to unexpected noises just as a telephone ringing or a car backfiring. They also experience significant sleep disturbances, with difficulty falling asleep, as well as staying asleep due to nightmares; engage in reckless or self-destructive behavior, and have problems concentrating.
5.2.1.4. 第四类：觉醒和反应性改变。第四和最后一类是觉醒和反应性改变，以下描述的症状中至少有两个必须存在。由于消极情绪和易怒性增加，患有 PTSD 的人可能会易怒并表现出攻击性行为，无论是言语上还是身体上。虽然这些攻击性反应可能是被激怒的，但有时也是无端的。人们认为这些行为是由于对潜在威胁的高度敏感性引起的，尤其是如果威胁与他们的创伤事件相似。更具体地说，患有 PTSD 的人有增强的惊跳反应，容易对突如其来的噪音做出反应，就像电话铃声或汽车回火声。他们还经历严重的睡眠障碍，入睡困难，以及由于噩梦而难以保持睡眠；进行鲁莽或自毁性行为，并难以集中注意力。

Although somewhat obvious, these symptoms likely cause significant distress in social, occupational, and other (i.e., romantic, personal) areas of functioning. Duration of symptoms is also important, as PTSD cannot be diagnosed unless symptoms have been present for at least one month. If symptoms have not been present for a month, the individual may meet criteria for acute stress disorder (see below).
尽管有些明显，但这些症状可能会在社交、职业和其他（即浪漫、个人）功能领域引起显著的不适。症状的持续时间也很重要，因为除非症状已经持续至少一个月，否则无法诊断创伤后应激障碍。如果症状未持续一个月，个体可能符合急性应激障碍的标准（见下文）。

5.2.2. Acute Stress Disorder 5.2.2. 急性应激障碍

Acute stress disorder is very similar to PTSD except for the fact that symptoms must be present from 3 days to 1 month following exposure to one or more traumatic events. If the symptoms are present after one month, the individual would then meet the criteria for PTSD. Additionally, if symptoms present immediately following the traumatic event but resolve by day 3, an individual would not meet the criteria for acute stress disorder.
急性应激障碍与 PTSD 非常相似，除了症状必须在暴露于一个或多个创伤事件后的 3 天至 1 个月内出现。如果症状在一个月后出现，个体则符合 PTSD 的标准。此外，如果症状在创伤事件发生后立即出现，但到第 3 天就消失了，那么个体不符合急性应激障碍的标准。

Symptoms of acute stress disorder follow that of PTSD with a few exceptions. PTSD requires symptoms within each of the four categories discussed above; however, acute stress disorder requires that the individual experience nine symptoms across five different categories (intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms; note that in total, there are 14 symptoms across these five categories). For example, an individual may experience several arousal and reactivity symptoms such as sleep issues, concentration issues, and hypervigilance, but does not experience issues regarding negative mood. Regardless of the category of the symptoms, so long as nine symptoms are present and the symptoms cause significant distress or impairment in social, occupational, and other functioning, an individual will meet the criteria for acute stress disorder.
急性应激障碍的症状与 PTSD 相似，但有几点例外。PTSD 需要在上述四个类别中都有症状；然而，急性应激障碍要求个体在五个不同类别（侵入症状、负面情绪、解离症状、回避症状和觉醒症状；注意，在这五个类别中总共有 14 个症状）。例如，一个人可能会经历几个觉醒和反应症状，如睡眠问题、注意力问题和高警觉性，但不会经历负面情绪问题。无论症状的类别如何，只要存在九个症状，并且这些症状导致显著的痛苦或在社会、职业和其他功能方面的损害，个体就会符合急性应激障碍的标准。

Making Sense of the Disorders 理解疾病

In relation to trauma- and stressor-related disorders, note the following:
关于创伤和应激相关障碍，请注意以下几点：

  • Diagnosis PTSD …… if symptoms have been experienced for at least one month
    诊断 PTSD……如果症状持续至少一个月
  • Diagnosis acute stress disorder … if symptoms have been experienced for 3 days to one month
    诊断急性应激障碍……如果症状持续 3 天至一个月

5.2.3. Adjustment Disorder 5.2.3. 调整障碍

Adjustment disorder is the least intense of the three disorders discussed so far in this module. An adjustment disorder occurs following an identifiable stressor that happened within the past 3 months. This stressor can be a single event (loss of job, death of a family member) or a series of multiple stressors (cancer treatment, divorce/child custody issues).
调整障碍是本模块中讨论的三种障碍中最轻微的一种。调整障碍发生在过去 3 个月内可以识别的压力源之后。这种压力源可以是一个单一事件（失业、家庭成员去世）或一系列多个压力源（癌症治疗、离婚/子女监护问题）。

Unlike PTSD and acute stress disorder, adjustment disorder does not have a set of specific symptoms an individual must meet for diagnosis. Rather, whatever symptoms the individual is experiencing must be related to the stressor and must be significant enough to impair social, occupational, or other important areas of functioning and causes marked distress “…that is out of proportion to the severity or intensity of the stressor” (APA, 2022, pg. 319).
与 PTSD 和急性应激障碍不同，适应障碍没有一套个体必须满足的诊断特定症状。相反，个体所经历的症状必须与应激源相关，并且必须足够严重，足以损害社会、职业或其他重要功能领域，并引起明显的痛苦“这种痛苦与应激源的严重程度或强度不成比例”（APA，2022，第 319 页）。

It should be noted that there are modifiers associated with adjustment disorder. Due to the variety of behavioral and emotional symptoms that can be present with an adjustment disorder, clinicians are expected to classify a patient’s adjustment disorder as one of the following: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, or unspecified if the behaviors do not meet criteria for one of the aforementioned categories. Based on the individual’s presenting symptoms, the clinician will determine which category best classifies the patient’s condition. These modifiers are also important when choosing treatment options for patients.
应注意的是，调整障碍与一些修饰符相关。由于调整障碍可能伴随各种行为和情绪症状，临床医生应将患者的调整障碍归类为以下之一：伴有抑郁情绪、伴有焦虑、伴有混合焦虑和抑郁情绪、伴有行为障碍、伴有情绪和行为混合障碍，或如行为不符合上述任何一种分类标准则不明确。根据个体的症状表现，临床医生将确定哪个类别最适合患者的状况。在选择治疗方案时，这些修饰符也很重要。

5.2.4. Prolonged Grief Disorder 5.2.4. 持续性悲伤障碍

The DSM-5 included a condition for further study called persistent complex bereavement disorder. In 2018, a proposal was submitted to include this category in the main text of the manual and after careful review of the literature and approval of the criteria, it was accepted in the second half of 2019 and added as a new diagnostic entity called prolonged grief disorder. Prolonged grief disorder is defined as an intense yearning/longing and/or preoccupation with thoughts or memories of the deceased who died at least 12 months ago. The individual will present with at least three symptoms to include feeling as though part of oneself has died, disbelief about the death, emotional numbness, feeling that life is meaningless, intense loneliness, problems engaging with friends or pursuing interests, intense emotional pain, and avoiding reminders that the person has died.
DSM-5 包括一个需要进一步研究的条件，称为持续复杂丧亲症。2018 年，提交了一项提案，将该类别纳入手册正文，并在仔细审查文献和批准标准后，于 2019 年下半年被接受，并新增为一个称为长期哀伤障碍的新诊断实体。长期哀伤障碍被定义为对至少 12 个月前去世的死者强烈的渴望/思念和/或对死者思想或记忆的专注。个体将表现出至少三种症状，包括感觉自身的一部分已经死去，对死亡的不信，情感麻木，感觉生活毫无意义，极度孤独，与朋友交往或追求兴趣的问题，强烈的情感痛苦，以及避免提醒这个人已经去世的提醒。

Individuals with prolonged grief disorder often hold maladaptive cognitions about the self, feel guilt about the death, and hold negative views about life goals and expectancy. Harmful health behaviors due to decreased self-care and concern are also reported. They may also experience hallucinations about the deceased, feel bitter an angry be restless, blame others for the death, and see a reduction in the quantity and quality of sleep (APA, 2022).
个体患有长期悲伤障碍时，常常持有关于自我的不适应认知，对死亡感到内疚，对生活目标和预期持有负面看法。由于自我护理和关注的减少，还报告了有害的健康行为。他们还可能经历关于已故者的幻觉，感到苦涩和愤怒，坐立不安，责怪他人对死亡负责，以及睡眠数量和质量下降（APA，2022）。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到了以下内容：

  • In terms of stress disorders, symptoms lasting over 3 days but not exceeding one month, would be classified as acute stress disorder while those lasting over a month are typical of PTSD.
    关于应激障碍，持续 3 天以上但不超过一个月的症状，可被归类为急性应激障碍，而持续超过一个月的症状则典型于 PTSD。
  • If symptoms begin after a traumatic event but resolve themselves within three days, the individual does not meet the criteria for a stress disorder.
    如果创伤事件后出现症状，但三天内自行缓解，则个人不符合压力障碍的诊断标准。
  • Symptoms of PTSD fall into four different categories for which an individual must have at least one symptom in each category to receive a diagnosis. These categories include recurrent experiences, avoidance of stimuli, negative alterations in cognition or mood, and alterations in arousal and reactivity.
    PTSD 的症状分为四个不同的类别，一个人必须在每个类别中至少有一个症状才能被诊断为患有 PTSD。这些类别包括反复的经历、回避刺激、认知或情绪的负面改变以及觉醒和反应性的改变。
  • To receive a diagnosis of acute stress disorder an individual must experience nine symptoms across five different categories (intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms).
    要被诊断为急性应激障碍，个体必须在五个不同类别（闯入症状、负面情绪、解离症状、回避症状和唤起症状）中体验到九种症状。
  • Adjustment disorder is the last intense of the three disorders and does not have a specific set of symptoms of which an individual has to have some number. Whatever symptoms the person presents with, they must cause significant impairment in areas of functioning such as social or occupational, and several modifiers are associated with the disorder.
    调整障碍是三种障碍中最轻微的，没有一套特定的症状，个体必须具备一定数量的症状。无论个体表现出何种症状，都必须在社交或职业等功能领域造成显著损害，并且与该障碍相关联的修饰符有几个。
  • Prolonged grief disorder is a new diagnostic entity in the DSM-5-TR and is defined as an intense yearning/longing and/or preoccupation with thoughts or memories of the deceased who died at least 12 months ago.
    长期悲伤障碍是 DSM-5-TR 中的一个新的诊断实体，定义为对已故亲人至少 12 个月前的强烈渴望/思念和/或对死者思想或记忆的专注。

Section 5.2 Review Questions
第 5.2 节 复习问题

  1. What is the difference in diagnostic criteria for PTSD, Acute Stress Disorder, and Adjustment Disorder?
    PTSD、急性应激障碍和适应障碍的诊断标准有何区别？
  2. What are the four categories of symptoms for PTSD? How do these symptoms present in Acute Stress Disorder and Adjustment Disorder?
    PTSD 的四种症状类别是什么？这些症状在急性应激障碍和适应障碍中如何表现？
  3. What is prolonged grief disorder?
    什么是长期悲伤障碍？

5.3. Epidemiology 5.3. 流行病学

Section Learning Objectives 章节学习目标

  • Describe the epidemiology of PTSD.
    描述 PTSD 的流行病学。
  • Describe the epidemiology of acute stress disorder.
    描述急性应激障碍的流行病学。
  • Describe the epidemiology of adjustment disorders.
    描述调整障碍的流行病学。
  • Describe the epidemiology of prolonged grief disorder.
    描述长期哀伤障碍的流行病学。

5.3.1. PTSD 5.3.1. 创伤后应激障碍

The national lifetime prevalence rate for PTSD using DSM-IV criteria is 6.8% for U.S. adults and 5.0% to 8.1% for U.S. adolescents. There are currently no definitive, comprehensive population-based data using DSM-5 though studies are beginning to emerge (APA, 2022). It should not come as a surprise that the rates of PTSD are higher among veterans and others who work in fields with high traumatic experiences (i.e., firefighters, police, EMTs, emergency room providers). In fact, PTSD rates for combat veterans are estimated to be as high as 30% (NcNally, 2012). Between one-third and one-half of all PTSD cases consist of rape survivors, military combat and captivity, and ethnically or politically motivated genocide (APA, 2022).
国家使用 DSM-IV 标准对 PTSD 的终身患病率进行统计，美国成年人为 6.8%，美国青少年为 5.0%至 8.1%。尽管研究开始出现（APA，2022 年），但目前尚无使用 DSM-5 的明确、全面的基于人群的数据。PTSD 的患病率在退伍军人和在其他高创伤经历领域工作的人（如消防员、警察、EMTs、急诊室医护人员）中较高，这并不令人惊讶。实际上，战斗退伍军人的 PTSD 患病率估计高达 30%（NcNally，2012 年）。所有 PTSD 病例中，三分之一到一半由强奸幸存者、军事战斗和被俘、种族或政治动机的种族灭绝组成（APA，2022 年）。

Concerning gender, PTSD is more prevalent among females (8% to 11%) than males (4.1% to 5.4%), likely due to their higher occurrence of exposure to traumatic experiences such as childhood sexual abuse, rape, domestic abuse, and other forms of interpersonal violence. Women also experience PTSD for a longer duration. (APA, 2022). Gender differences are not found in populations where both males and females are exposed to significant stressors suggesting that both genders are equally predisposed to developing PTSD. Prevalence rates vary slightly across cultural groups, which may reflect differences in exposure to traumatic events. More specifically, prevalence rates of PTSD are highest for African Americans, followed by Latinx Americans and European Americans, and lowest for Asian Americans (Hinton & Lewis-Fernandez, 2011). According to the DSM-5-TR, there are higher rates of PTSD among Latinx, African-Americans, and American Indians compared to whites, and likely due to exposure to past adversity and racism and discrimination (APA, 2022).
关于性别，PTSD 在女性（8%至 11%）中比男性（4.1%至 5.4%）更为普遍，这可能是由于她们更频繁地暴露于童年性虐待、强奸、家庭暴力和其他形式的人际暴力等创伤性经历。女性患 PTSD 的时间也较长。（APA，2022）。在男女双方都暴露于重大压力源的人群中，并未发现性别差异，这表明两种性别对发展 PTSD 的易感性相同。在不同文化群体中，患病率略有差异，这可能反映了创伤性事件暴露的差异。更具体地说，PTSD 的患病率在非裔美国人中最高，其次是拉丁裔美国人、欧洲裔美国人，最低的是亚裔美国人（Hinton & Lewis-Fernandez，2011）。根据 DSM-5-TR，与白人相比，拉丁裔、非裔美国人和美洲印第安人的 PTSD 患病率更高，这可能是由于过去的不幸经历以及种族主义和歧视（APA，2022）。

5.3.2. Acute Stress Disorder 5.3.2. 急性应激障碍

The prevalence rate for acute stress disorder varies across the country and by traumatic event. Accurate prevalence rates for acute stress disorder are difficult to determine as patients must seek treatment within 30 days of the traumatic event. Despite that, it is estimated that anywhere between 7-30% of individuals experiencing a traumatic event will develop acute stress disorder (National Center for PTSD). While acute stress disorder is not a good predictor of who will develop PTSD, approximately 50% of those with acute stress disorder do eventually develop PTSD (Bryant, 2010; Bryant, Friedman, Speigel, Ursano, & Strain, 2010).
急性应激障碍的患病率在全国范围内以及不同创伤事件中有所不同。由于患者必须在创伤事件发生后 30 天内寻求治疗，因此准确确定急性应激障碍的患病率很困难。尽管如此，据估计，在经历创伤事件的个人中，有 7-30%的人会发展为急性应激障碍（创伤后应激障碍国家中心）。虽然急性应激障碍不是预测谁会发展为创伤后应激障碍的好指标，但大约 50%的急性应激障碍患者最终会发展为创伤后应激障碍（Bryant，2010；Bryant，Friedman，Speigel，Ursano 和 Strain，2010）。

As with PTSD, acute stress disorder is more common in females than males; however, unlike PTSD, there may be some neurobiological differences in the stress response, gender differences in the emotional and cognitive processing of trauma, and sociocultural factors that contribute to females developing acute stress disorder more often than males (APA, 2022). With that said, the increased exposure to traumatic events among females may also be a strong reason why women are more likely to develop acute stress disorder.
与 PTSD 一样，急性应激障碍在女性中比在男性中更常见；然而，与 PTSD 不同，应激反应中可能存在一些神经生物学差异，创伤的情感和认知处理中的性别差异，以及导致女性比男性更频繁地发展急性应激障碍的社会文化因素（APA，2022）。换句话说，女性对创伤事件的增加暴露也可能是女性更可能发展急性应激障碍的强烈原因。

5.3.3. Adjustment Disorder 5.3.3. 调整障碍

Adjustment disorders are relatively common as they describe individuals who are having difficulty adjusting to life after a significant stressor. In psychiatric hospitals in the U.S., Australia, Canada, and Israel, adjustment disorders accounted for roughly 50% of the admissions in the 1990s. It is estimated that anywhere from 5-20% of individuals in outpatient mental health treatment facilities have an adjustment disorder as their principal diagnosis. Adjustment disorder has been found to be higher in women than men (APA, 2022).
调整障碍相对常见，因为它描述了在经历重大压力源后难以适应生活的人群。在美国、澳大利亚、加拿大和以色列的精神病院中，调整障碍在 20 世纪 90 年代占到了入院人数的大约 50%。据估计，在门诊心理健康治疗机构中，有 5-20%的人的主要诊断是调整障碍。研究发现，调整障碍在女性中比男性中更为常见（APA，2022）。

5.3.4. Prolonged Grief Disorder 5.3.4. 持续性悲伤障碍

As this is a new disorder, the prevalence of DSM-5 prolonged grief disorder is currently unknown. Using a different definition of the disorder a meta-analysis of studies across four continents suggests a pooled prevalence of 9.8%. It should be noted that these studies could only be loosely compared with one another making the reported prevalence rate questionable.
由于这是一种新病症，DSM-5 持续性悲伤障碍的患病率目前尚不清楚。使用不同的病症定义，对四大洲的研究进行荟萃分析表明，合并患病率为 9.8%。需要注意的是，这些研究只能大致进行比较，使得报告的患病率存在疑问。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到了以下内容：

  • Regarding PTSD, rates are highest among people who are likely to be exposed to high traumatic events, women, and minorities.
    关于 PTSD，发病率最高的是可能暴露于高创伤事件的人群、女性和少数族裔。
  • As for acute stress disorder, prevalence rates are hard to determine since patients must seek medical treatment within 30 days, but females are more likely to develop the disorder.
    关于急性应激障碍，由于患者必须在 30 天内寻求医疗治疗，因此患病率难以确定，但女性更容易患上这种障碍。
  • Adjustment disorders are relatively common since they occur in individuals having trouble adjusting to a significant stressor, though women tend to receive a diagnosis more than men.
    调整障碍相对常见，因为它们发生在难以适应重大压力源的个体中，尽管女性比男性更容易被诊断出。

Section 5.3 Review Questions
第 5.3 节 复习问题

  1. Compare and contrast the prevalence rates among the trauma and stress-related disorders.
    比较创伤和压力相关障碍的患病率。
  2. What do we know about the prevalence rate for prolonged grief disorder and why?
    我们了解关于长期悲伤障碍的患病率是多少以及为什么吗？

5.4. Comorbidity 5.4. 并发症

Section Learning Objectives 章节学习目标

  • Describe the comorbidity of PTSD.
    描述 PTSD 的共病情况。
  • Describe the comorbidity of acute stress disorder.
    描述急性应激障碍的共病情况。
  • Describe the comorbidity of adjustment disorder.
    描述调整障碍的共病情况。
  • Describe the comorbidity of prolonged grief disorder.
    描述长期悲伤障碍的共病情况。

5.4.1. PTSD 5.4.1. 创伤后应激障碍

Given the traumatic nature of the disorder, it should not be surprising that there is a high comorbidity rate between PTSD and other psychological disorders. Individuals with PTSD are more likely than those without PTSD to report clinically significant levels of depressive, bipolar, anxiety, or substance abuse-related symptoms (APA, 2022). There is also a strong relationship between PTSD and major neurocognitive disorders, which may be due to the overlapping symptoms between these disorders (Neurocognitive Disorders will be covered in Module 14).
鉴于该疾病的创伤性质，PTSD 与其他心理疾病之间的高共病率并不令人惊讶。患有 PTSD 的人比没有 PTSD 的人更有可能报告临床上有意义的抑郁、双相、焦虑或物质滥用相关症状（APA，2022）。PTSD 与主要神经认知障碍之间也存在强烈的关联，这可能是由于这些障碍之间症状的重叠（神经认知障碍将在第 14 模块中介绍）。

5.4.2. Acute Stress Disorder 5.4.2. 急性应激障碍

Because 30 days after the traumatic event, acute stress disorder becomes PTSD (or the symptoms remit), the comorbidity of acute stress disorder with other psychological disorders has not been studied. While acute stress disorder and PTSD cannot be comorbid disorders, several studies have explored the relationship between the disorders to identify individuals most at risk for developing PTSD. The literature indicates roughly 80% of motor vehicle accident survivors, as well as assault victims, who met the criteria for acute stress disorder went on to develop PTSD (Brewin, Andrews, Rose, & Kirk, 1999; Bryant & Harvey, 1998; Harvey & Bryant, 1998). While some researchers indicated acute stress disorder is a good predictor of PTSD, others argue further research between the two and confounding variables should be explored to establish more consistent findings.
因为创伤事件发生后 30 天内，急性应激障碍会发展成为 PTSD（或症状缓解），急性应激障碍与其他心理障碍的共病性尚未得到研究。虽然急性应激障碍和 PTSD 不能是共病，但有几项研究探讨了两种障碍之间的关系，以确定最易发展为 PTSD 的个人。文献表明，大约 80%符合急性应激障碍标准的机动车事故幸存者和袭击受害者最终发展为 PTSD（Brewin, Andrews, Rose, & Kirk, 1999；Bryant & Harvey, 1998；Harvey & Bryant, 1998）。虽然一些研究人员指出急性应激障碍是 PTSD 的良好预测指标，但其他人则认为应进一步研究两者之间的联系以及混杂变量，以建立更一致的结果。

5.4.3. Adjustment Disorder 5.4.3. 调整障碍

Unlike most of the disorders we have reviewed thus far, adjustment disorders have a high comorbidity rate with various other medical conditions (APA, 2022). Often following a critical or terminal medical diagnosis, an individual will meet the criteria for adjustment disorder as they process the news about their health and the impact their new medical diagnosis will have on their life. Other psychological disorders are also diagnosed with adjustment disorder; however, symptoms of adjustment disorder must be met independently of the other psychological condition. For example, an individual with adjustment disorder with depressive mood must not meet the criteria for a major depressive episode; otherwise, the diagnosis of MDD should be made over adjustment disorder. As the DSM-5-TR says, “adjustment disorders are common accompaniments of medical illness and may be the major psychological response to a medical condition” (APA, 2022).
与迄今为止我们审查的大多数疾病不同，调节障碍与其他各种医疗状况的共病率很高（APA，2022）。通常在严重的或终末期的医疗诊断之后，个人在处理有关他们健康状况和新的医疗诊断将如何影响他们生活的消息时，将符合调节障碍的标准。其他心理障碍也被诊断为调节障碍；然而，调节障碍的症状必须独立于其他心理状况。例如，患有抑郁情绪调节障碍的个人不得符合重度抑郁发作的标准；否则，应将 MDD 的诊断置于调节障碍之上。正如 DSM-5-TR 所说，“调节障碍是医疗疾病的常见伴随症状，可能是对医疗状况的主要心理反应”（APA，2022）。

5.4.4. Prolonged Grief Disorder 5.4.4. 持续性悲伤障碍

Prolonged grief disorder is commonly comorbid with MDD, PTSD if the death occurred in violent or accidental circumstances, substance use disorders, and separation anxiety disorder.
长期悲伤障碍通常与 MDD、PTSD（如果死亡发生在暴力或意外情况下）、物质使用障碍和分离焦虑障碍共病。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到了以下内容：

  • PTSD has a high comorbidity rate with psychological and neurocognitive disorders while this rate is hard to establish with acute stress disorder since it becomes PTSD after 30 days.
    创伤后应激障碍与心理和神经认知障碍的共病率较高，而急性应激障碍的此比率难以确定，因为 30 天后它转变为创伤后应激障碍。
  • Adjustment disorder has a high comorbidity rate with other medical conditions as people process news about their health and what the impact of a new medical diagnosis will be on their life.
    调整障碍与其他医疗状况的共病率较高，因为人们在处理有关自己健康状况的消息以及新的医疗诊断对他们生活的影响时。
  • Prolonged grief disorder has a high comorbidity with PTSD, MDD, separation anxiety disorder, and substance use disorders.
    长期悲伤障碍与 PTSD、MDD、分离焦虑障碍和物质使用障碍的共病率较高。

Section 5.4 Review Questions
第 5.4 节 复习题

  1. What are the most common comorbidities among trauma and stress-related disorders?
    最常见的创伤和压力相关疾病的共病有哪些？
  2. Why is it hard to establish comorbidities for acute stress disorder?
    为什么难以确定急性应激障碍的共病？

5.5. Etiology 5.5. 病因

Section Learning Objectives 章节学习目标

  • Describe the biological causes of trauma- and stressor-related disorders.
    描述创伤和应激相关障碍的生物原因。
  • Describe the cognitive causes of trauma- and stressor-related disorders.
    描述创伤和应激相关障碍的认知原因。
  • Describe the social causes of trauma- and stressor-related disorders.
    描述创伤和应激相关障碍的社会原因。
  • Describe the sociocultural causes of trauma- and stressor-related disorders.
    描述创伤和应激相关障碍的社会文化原因。

5.5.1. Biological 5.5.1. 生物

**HPA axis. **One theory for the development of trauma and stress-related disorders is the over-involvement of the **hypothalamic-pituitary-adrenal (HPA) axis. **The HPA axis is involved in the fear-producing response, and some speculate that dysfunction within this axis is to blame for the development of trauma symptoms. Within the brain, the **amygdala **serves as the integrative system that inherently elicits the physiological response to a traumatic/stressful environmental situation. The amygdala sends this response to the HPA axis to prepare the body for “fight or flight.” The HPA axis then releases hormones—**epinephrine **and cortisol—to help the body to prepare to respond to a dangerous situation (Stahl & Wise, 2008). While epinephrine is known to cause physiological symptoms such as increased blood pressure, increased heart rate, increased alertness, and increased muscle tension, to name a few, cortisol is responsible for returning the body to homeostasis once the dangerous situation is resolved.
HPA 轴。关于创伤和压力相关疾病发展的一个理论是下丘脑-垂体-肾上腺（HPA）轴过度参与。HPA 轴参与产生恐惧的反应，有些人推测，该轴的机能障碍是创伤症状发展的原因。在大脑中，杏仁核作为整合系统，天生会引发对创伤/压力环境情况的生理反应。杏仁核将这种反应发送到 HPA 轴，以准备身体进入“战斗或逃跑”状态。然后，HPA 轴释放激素——肾上腺素和皮质醇，以帮助身体为应对危险情况做准备（Stahl & Wise，2008）。肾上腺素已知会引起生理症状，如血压升高、心率加快、警觉性增加和肌肉紧张等，而皮质醇则负责在危险情况解决后使身体恢复稳态。

Researchers have studied the amygdala and HPA axis in individuals with PTSD, and have identified heightened amygdala reactivity in stressful situations, as well as excessive responsiveness to stimuli that is related to one’s specific traumatic event (Sherin & Nemeroff, 2011). Additionally, studies have indicated that individuals with PTSD also show a diminished fear extinction, suggesting an overall higher level of stress during non-stressful times. These findings may explain why individuals with PTSD experience an increased startle response and exaggerated sensitivity to stimuli associated with their trauma (Schmidt, Kaltwasser, & Wotjak, 2013).
研究人员研究了创伤后应激障碍（PTSD）患者的大脑杏仁核和 HPA 轴，发现他们在压力情境下杏仁核反应增强，以及对与个人特定创伤事件相关的刺激过度敏感（Sherin & Nemeroff，2011）。此外，研究还表明，PTSD 患者也表现出恐惧消退减少，这表明他们在非压力时期整体压力水平较高。这些发现可能解释了为什么 PTSD 患者对与他们的创伤相关的刺激表现出增加的惊跳反应和夸张的敏感性（Schmidt，Kaltwasser，& Wotjak，2013）。

5.5.2. Cognitive 5.5.2. 认知

Preexisting conditions of depression or anxiety may predispose an individual to develop PTSD or other stress disorders. One theory is that these individuals may ruminate or over-analyze the traumatic event, thus bringing more attention to the traumatic event and leading to the development of stress-related symptoms. Furthermore, negative cognitive styles or maladjusted thoughts about themselves and the environment may also contribute to PTSD symptoms. For example, individuals who identify life events as “out of their control” report more severe stress symptoms than those who feel as though they have some control over their lives (Catanesi et al., 2013).
既往存在抑郁或焦虑状况可能使个体易患 PTSD 或其他压力相关障碍。一种理论认为，这些个体可能会反复思考或过度分析创伤事件，从而将更多注意力集中在创伤事件上，导致压力相关症状的发展。此外，消极的认知风格或对自己和环境的失调思维也可能导致 PTSD 症状。例如，将生活事件标识为“无法控制”的个体比那些感觉自己能对生活有所控制的人报告了更严重的压力症状（Catanesi 等，2013）。

5.5.3. Social 5.5.3. 社会

While this may hold for many psychological disorders, social and family support have been identified as protective factors for individuals prone to develop PTSD. More specifically, rape victims who are loved and cared for by their friends and family members as opposed to being judged for their actions before the rape, report fewer trauma symptoms and faster psychological improvement (Street et al., 2011).
尽管这可能适用于许多心理障碍，但社会和家庭支持已被确定为易患创伤后应激障碍（PTSD）个体的保护因素。更具体地说，与在强奸前因自己的行为受到评判相比，那些得到朋友和家人爱护和照顾的强奸受害者报告的创伤症状更少，心理恢复也更快（Street 等，2011）。

5.5.4. Sociocultural 5.5.4. 社会文化

As was mentioned previously, different ethnicities report different prevalence rates of PTSD. While this may be due to increased exposure to traumatic events, there is some evidence to suggest that cultural groups also interpret traumatic events differently, and therefore, may be more vulnerable to the disorder. Hispanic Americans have routinely been identified as a cultural group that experiences a higher rate of PTSD. Studies ranging from combat-related PTSD to on-duty police officer stress, as well as stress from a natural disaster, all identify Hispanic Americans as the cultural group experiencing the most traumatic symptoms (Kaczkurkin et al., 2016; Perilla et al., 2002; Pole et al., 2001).
如前所述，不同民族报告的 PTSD 患病率不同。虽然这可能是由于对创伤事件的暴露增加，但也有一些证据表明，文化群体对创伤事件的解释也不同，因此可能更容易受到这种疾病的侵害。西班牙裔美国人一直被认定为经历 PTSD 比率较高的文化群体。从与战斗相关的 PTSD 到在职警察的压力，以及自然灾害带来的压力，所有这些研究都将西班牙裔美国人认定为经历最严重创伤症状的文化群体（Kaczkurkin 等，2016；Perilla 等，2002；Pole 等，2001）。

Women also report a higher incidence of PTSD symptoms than men. Some possible explanations for this discrepancy are stigmas related to seeking psychological treatment, as well as a greater risk of exposure to traumatic events that are associated with PTSD (Kubiak, 2006).  Studies exploring rates of PTSD symptoms for military and police veterans have failed to report a significant gender difference in the diagnosis rate of PTSD suggesting that there is not a difference in the rate of occurrence of PTSD in males and females in these settings (Maguen, Luxton, Skopp, & Madden, 2012).
女性报告的 PTSD 症状发生率也比男性高。这种差异的一些可能解释包括寻求心理治疗的耻辱感，以及与 PTSD 相关的创伤事件的暴露风险更高（Kubiak，2006）。研究军事和警察退伍军人 PTSD 症状发生率的调查未能报告出显著的性别差异在 PTSD 的诊断率上，这表明在这些环境中，男性和女性 PTSD 的发生率没有差异（Maguen，Luxton，Skopp，& Madden，2012）。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到了以下内容：

  • In terms of causes for trauma- and stressor-related disorders, an over-involvement of the hypothalamic-pituitary-adrenal (HPA) axis has been cited as a biological cause, with rumination and negative coping styles or maladjusted thoughts emerging as cognitive causes.
    在创伤和应激相关障碍的病因方面，下丘脑-垂体-肾上腺（HPA）轴过度参与被视为一种生物学原因，而沉思和消极应对方式或失调思维则被视为认知原因。
  • Culture may lead to different interpretations of traumatic events thus causing higher rates among Hispanic Americans.
    文化可能导致对创伤事件的解读不同，从而在西班牙裔美国人中导致更高的发生率。
  • Social and family support have been found to be protective factors for individuals most likely to develop PTSD.
    社会和家庭支持被发现是预防个体发展创伤后应激障碍（PTSD）的保护因素。

Section 5.5 Review Questions
第 5.5 节 复习题

  1. Discuss the four etiological models of the trauma- and stressor-related disorders. Which model best explains the maintenance of trauma/stress symptoms? Which identifies protective factors for the individual?
    讨论创伤和应激相关障碍的四种病因模型。哪种模型最能解释创伤/应激症状的维持？哪种模型确定了个体的保护因素？

5.6. Treatment 5.6. 治疗

Section Learning Objectives 章节学习目标

  • Describe the treatment approach of the psychological debriefing.
    描述心理疏导的治疗方法。
  • Describe the treatment approach of exposure therapy.
    描述暴露疗法的治疗方法。
  • Describe the treatment approach of CBT.
    描述认知行为治疗（CBT）的治疗方法。
  • Describe the treatment approach of Eye Movement Desensitization and Reprocessing (EMDR).
    描述眼动脱敏与再加工（EMDR）的治疗方法。
  • Describe the use of psychopharmacological treatment.
    描述心理药理治疗的使用。

5.6.1. Psychological Debriefing 5.6.1. 心理疏导

One way to negate the potential development of PTSD symptoms is thorough **psychological debriefing. **Psychological debriefing is considered a type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event (Kinchin, 2007). While there are a few different methods to a psychological debriefing, they all follow the same general format:
一种消除 PTSD 症状潜在发展的方法是通过彻底的心理疏导。心理疏导被认为是一种危机干预，要求近期经历过创伤事件的人讨论或处理与创伤事件相关的想法和感受，通常在事件发生后的 72 小时内进行（Kinchin，2007）。尽管心理疏导有几种不同的方法，但它们都遵循相同的一般格式：

  1. Identifying the facts (what happened?)
    识别事实（发生了什么？）
  2. Evaluating the individual’s thoughts and emotional reaction to the events leading up to the event, during the event, and then immediately following
    评估个体对导致事件发生的事件、事件期间以及随后立即的情绪反应和思考
  3. Normalizing the individual’s reaction to the event
    正常化个体对事件的反应
  4. Discussing how to cope with these thoughts and feelings, as well as creating a designated social support system (Kinchin, 2007).
    讨论如何应对这些想法和感受，以及建立指定的社会支持系统（金钦，2007）。

Throughout the last few decades, there has been a debate on the effectiveness of psychological debriefing. Those within the field argue that psychological debriefing is not a means to cure or prevent PTSD, but rather, psychological debriefing is a means to assist individuals with a faster recovery time posttraumatic event (Kinchin, 2007). Research across a variety of traumatic events (i.e., natural disasters, burns, war) routinely suggests that psychological debriefing is *not *helpful in either the reduction of posttraumatic symptoms nor the recovery time of those with PTSD (Tuckey & Scott, 2014).  One theory is these early interventions may encourage patients to ruminate on their symptoms or the event itself, thus maintaining PTSD symptoms (McNally, 2004). In efforts to combat these negative findings of psychological debriefing, there has been a large movement to provide more structure and training for professionals employing psychological debriefing, thus ensuring that those who are providing treatment are properly trained to do so.
过去几十年中，关于心理疏导有效性的争论一直存在。该领域的专家认为，心理疏导不是治愈或预防创伤后应激障碍（PTSD）的手段，而是一种帮助个体在创伤事件后更快恢复的方法（Kinchin，2007）。各种创伤事件（如自然灾害、烧伤、战争）的研究通常表明，心理疏导在减少创伤后症状或缩短 PTSD 患者的恢复时间方面并无帮助（Tuckey & Scott，2014）。一种理论认为，这些早期干预可能促使患者反复思考他们的症状或事件本身，从而维持 PTSD 症状（McNally，2004）。为了对抗心理疏导的负面发现，出现了大量运动，旨在为采用心理疏导的专业人士提供更多结构和培训，从而确保提供治疗的人已经接受了适当的培训。

5.6.2. Exposure Therapy 5.6.2. 暴露疗法

While exposure therapy is predominately used in anxiety disorders, it has also shown great success in treating PTSD-related symptoms as it helps individuals extinguish fears associated with the traumatic event. There are several different types of exposure techniques—**imaginal, in vivo, **and **flooding **are among the most common types (Cahill, Rothbaum, Resick, & Follette, 2009).
虽然暴露疗法主要用于焦虑障碍，但它也在治疗与 PTSD 相关的症状方面显示出巨大的成功，因为它有助于个体消除与创伤事件相关的恐惧。存在几种不同的暴露技术类型——想象、现实和泛滥是其中最常见的类型（Cahill, Rothbaum, Resick, & Follette, 2009）。

In imaginal exposure, the individual mentally re-creates specific details of the traumatic event. The patient is then asked to repeatedly discuss the event in increasing detail, providing more information regarding their thoughts and feelings at each step of the event. During in vivo exposure, the individual is reminded of the traumatic event through the use of videos, images, or other tangible objects related to the traumatic event that induces a heightened arousal response. While the patient is re-experiencing cognitions, emotions, and physiological symptoms related to the traumatic experience, they are encouraged to utilize positive coping strategies, such as relaxation techniques, to reduce their overall level of anxiety.
在想象性暴露中，个体在心理上重新构建创伤事件的特定细节。然后要求患者反复详细讨论事件，提供有关他们在事件每个步骤中的思想和感受的更多信息。在现实暴露中，个体通过使用与创伤事件相关的视频、图像或其他有形物体来提醒他们创伤事件，这些物体能引发增强的唤醒反应。当患者在重新体验与创伤经历相关的认知、情绪和生理症状时，他们被鼓励利用积极的应对策略，如放松技巧，以降低他们的整体焦虑水平。

Imaginal exposure and in vivo exposure are generally done in a gradual process, with imaginal exposure beginning with fewer details of the event, and slowly gaining information over time. In vivo starts with images or videos that elicit lower levels of anxiety, and then the patient slowly works their way up a fear hierarchy, until they are able to be exposed to the most distressing images. Another type of exposure therapy, flooding, involves disregard for the fear hierarchy, presenting the most distressing memories or images at the beginning of treatment. While some argue that this is a more effective method, it is also the most distressing and places patients at risk for dropping out of treatment (Resick, Monson, & Rizvi, 2008).
想象暴露和体内暴露通常是一个渐进的过程，想象暴露从事件的较少细节开始，随着时间的推移逐渐获取信息。体内暴露从引起较低焦虑水平的图像或视频开始，然后患者逐渐克服恐惧层次，直到能够接触到最令人痛苦的形象。另一种暴露疗法，即泛滥疗法，不考虑恐惧层次，在治疗开始时呈现最令人痛苦的记忆或图像。虽然有些人认为这是一种更有效的方法，但它也是最令人痛苦的，并使患者面临退出治疗的风险（Resick，Monson，& Rizvi，2008）。

5.6.3. Cognitive Behavioral Therapy (CBT) 5.6.3. 认知行为疗法（CBT）

Cognitive Behavioral Therapy, as discussed in the mood disorders chapter, has been proven to be an effective form of treatment for trauma/stress-related disorders. It is believed that this type of treatment is effective in reducing trauma-related symptoms due to its ability to identify and challenge the negative cognitions surrounding the traumatic event, and replace them with positive, more adaptive cognitions (Foa et al., 2005).
认知行为疗法，如情绪障碍章节所述，已被证明是治疗创伤/压力相关疾病的有效治疗方法。人们认为这种治疗方法在减少与创伤相关的症状方面是有效的，因为它能够识别和挑战围绕创伤事件的负面认知，并用积极的、更适应性的认知来替代它们（Foa 等，2005）。

**Trauma-focused cognitive-behavioral therapy (TF-CBT) **is an adaptation of CBT that utilizes both CBT techniques and trauma-sensitive principles to address the trauma-related symptoms. According to the Child Welfare Information Gateway (CWIG; 2012), TF-CBT can be summarized via the acronym PRACTICE:
创伤焦点认知行为疗法（TF-CBT）是 CBT 的一种改编，结合了 CBT 技术和创伤敏感原则来处理创伤相关症状。根据儿童福利信息网（CWIG；2012）的说法，TF-CBT 可以通过缩写 PRACTICE 来概括：

  • P: Psycho-education about the traumatic event. This includes discussion about the event itself, as well as typical emotional and/or behavioral responses to the event.
    P: 关于创伤事件的心理学教育。这包括对事件本身的讨论，以及对此事件典型情绪和/或行为反应的讨论。
  • R: Relaxation Training. Teaching the patient how to engage in various types of relaxation techniques such as deep breathing and progressive muscle relaxation.
    R: 放松训练。教授患者如何进行各种放松技巧，如深呼吸和渐进性肌肉放松。
  • A: Affect. Discussing ways for the patient to effectively express their emotions/fears related to the traumatic event.
    A: 影响。讨论患者有效表达与创伤事件相关的情绪/恐惧的方法。
  • C: Correcting negative or maladaptive thoughts.
    C: 改正负面或不良适应性的想法。
  • T: Trauma Narrative. This involves having the patient relive the traumatic event (verbally or written), including as many specific details as possible.
    T: 创伤叙述。这涉及到让患者重新经历创伤事件（口头或书面），尽可能包括尽可能多的具体细节。
  • I: In vivo exposure (see above).
    I: 体内暴露（见上文）。
  • C: Co-joint family session. This provides the patient with strong social support and a sense of security. It also allows family members to learn about the treatment so that they are able to assist the patient if necessary.
    C: 联合家庭会诊。这为患者提供了强大的社会支持和安全感。同时，也使家庭成员能够了解治疗情况，以便在必要时协助患者。
  • E: Enhancing Security. Patients are encouraged to practice the coping strategies they learn in TF-CBT to prepare for when they experience these triggers out in the real world, as well as any future challenges that may come their way.
    E: 加强安全。鼓励患者练习他们在 TF-CBT 中学习的应对策略，以备他们在现实世界中遇到这些触发因素时使用，以及未来可能遇到的任何挑战。

5.6.4. Eye Movement Desensitization and Reprocessing (EMDR) 5.6.4. 眼动脱敏与再加工（EMDR）

In the late 1980s, psychologist Francine Shapiro found that by focusing her eyes on the waving leaves during her daily walk, her troubling thoughts resolved on their own. From this observation, she concluded that lateral eye movements facilitate the cognitive processing of traumatic thoughts (Shapiro, 1989).
20 世纪 80 年代末，心理学家弗朗辛·夏皮罗发现，在每天散步时，她将目光聚焦于摇曳的树叶，她困扰的思绪便自行消解。从这个观察中，她得出结论，横向眼动有助于创伤性思绪的认知处理（夏皮罗，1989）。

While EMDR has evolved somewhat since Shapiro’s first claims, the basic components of EMDR consist of lateral eye movement induced by the therapist moving their index finger back and forth, approximately 35 cm from the client’s face, as well as components of cognitive-behavioral therapy and exposure therapy. The following 8-step approach is the standard treatment approach of EMDR (Shapiro & Maxfield, 2002):
自从 Shapiro 首次提出以来，EMDR 有所发展，但其基本成分包括由治疗师在距离客户脸部约 35 厘米处前后移动食指引起的侧向眼动，以及认知行为疗法和暴露疗法的一些成分。以下 8 步方法是 EMDR 的标准治疗方法（Shapiro & Maxfield，2002）：

  1. Patient History and Treatment Planning – Identify trauma symptoms and potential barriers to treatment.
    患者病史和治疗计划 - 识别创伤症状和治疗潜在障碍。
  2. Preparation – Psychoeducation of trauma and treatment.
    准备 - 创伤和心理治疗的心理教育。
  3. Assessment – Careful and detailed evaluation of the traumatic event. Patient identifies images, cognitions, and emotions related to the traumatic event, as well as trauma-related physiological symptoms.
    评估 - 对创伤事件的仔细和详细评估。患者识别与创伤事件相关的图像、认知和情绪，以及创伤相关的生理症状。
  4. **Desensitization and Reprocessing – **Holding the trauma image, cognition, and emotion in mind, while simultaneously assessing their physiological symptoms, the patient must track the clinician’s finger movement for approximately 20 seconds. At this time, the patient must “blank it out” and let go of the memory.
    脱敏与再加工 - 在心中保持创伤图像、认知和情感的同时，评估其生理症状，患者必须跟踪临床医生的手指移动大约 20 秒。此时，患者必须“将其置之脑后”并放下记忆。
  5. **Installation of Positive Cognitions – **Once the negative image, cognition, and emotions are reduced, the patient must hold onto a positive image or thought while again tracking the clinician’s finger movement for approximately 20 seconds.
    安装积极认知 - 当负面图像、认知和情绪减少后，患者必须保持一个积极的图像或想法，同时再次追踪临床医生的手指移动大约 20 秒。
  6. **Body Scan – **Patient must identify any lingering bodily sensations while again tracking the clinician’s fingers for a third time to discard any remaining trauma symptoms.
    身体扫描 – 患者必须识别任何残留的身体感觉，同时再次追踪临床医生的指尖，第三次以排除任何剩余的创伤症状。
  7. Closure – Patient is provided with positive coping strategies and relaxation techniques to assist with any recurrent cognitions or emotions related to the traumatic experience.
    闭合 - 为患者提供积极的应对策略和放松技巧，以协助处理与创伤经历相关的任何反复出现的认知或情绪。
  8. Reevaluation – Clinician assesses if treatment goals were met. If not, schedules another treatment session and identifies remaining symptoms.
    复评 - 医师评估治疗目标是否达成。如未达成，安排另一治疗疗程并识别剩余症状。

As you can see from above, only steps 4-6 are specific to EMDR; the remaining treatment is essentially a combination of exposure therapy and cognitive-behavioral techniques. Because of the high overlap between treatment techniques, there have been quite a few studies comparing the treatment efficacy of EMDR to TF-CBT and exposure therapy. While research initially failed to identify a superior treatment, often citing EMDR and TF-CBT as equally efficacious in treating PTSD symptoms (Seidler & Wagner, 2006), more recent studies have found that EMDR may be superior to that of TF-CBT, particularly in psycho-oncology patients (Capezzani et al., 2013; Chen, Zang, Hu & Liang, 2015). While meta-analytic studies continue to debate which treatment is the most effective in treating PTSD symptoms, the World Health Organization’s (2013) publication on the Guidelines for the Management of Conditions Specifically Related to Stress, identified TF-CBT and EMDR as the only recommended treatment for individuals with PTSD.
如您所见，只有步骤 4-6 是特定于 EMDR 的；其余治疗基本上是暴露疗法和认知行为技术的组合。由于治疗技术之间高度重叠，已有不少研究比较了 EMDR 与 TF-CBT 和暴露疗法的治疗效果。虽然最初的研究未能确定哪种治疗方法更优越，常常将 EMDR 和 TF-CBT 视为在治疗 PTSD 症状方面同样有效（Seidler & Wagner，2006），但最近的研究发现，EMDR 可能比 TF-CBT 更优越，尤其是在心理肿瘤学患者中（Capezzani 等，2013；Chen，Zang，Hu 和 Liang，2015）。尽管元分析研究仍在争论哪种治疗方法在治疗 PTSD 症状方面最有效，但世界卫生组织（2013）关于特定于压力状况的管理指南的出版物，将 TF-CBT 和 EMDR 确定为唯一推荐的针对 PTSD 患者的治疗方法。

The National Institute for Health and Care Excellence (NICE) says to consider EMDR for adults with a diagnosis of PTSD and who presented between 1 and 3 months after a non-combat related trauma if the person shows a preference for EMDR and to offer it to adults with a diagnosis of PTSD who have presented more than three months after a non-combat related trauma. They state that EMDR for adults should (cited directly from their website):
国家卫生与临床卓越研究所（NICE）表示，对于被诊断为 PTSD 且在非战斗相关创伤后 1 至 3 个月内出现症状的成年人，如果该人偏好 EMDR，则应考虑使用 EMDR；对于被诊断为 PTSD 且在非战斗相关创伤后超过 3 个月出现症状的成年人，应提供 EMDR。他们表示，对于成年人，EMDR 应（直接引用其网站内容）：

  • be based on a validated manual
    基于经过验证的手册
  • typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas
    通常在 8 至 12 次会话中提供，但如有临床指征，则可能更多，例如，如果他们经历了多次创伤
  • be delivered by trained practitioners with ongoing supervision
    由经过培训的从业者提供，并持续监督
  • be delivered in a phased manner and include psychoeducation about reactions to trauma; managing distressing memories and situations; identifying and treating target memories (often visual images); and promoting alternative positive beliefs about the self
    以分阶段的方式进行，包括关于创伤反应的心理教育；管理令人不安的回忆和情境；识别和治疗目标记忆（通常是视觉图像）；以及促进关于自我替代的积极信念
  • use repeated in-session bilateral stimulation (normally with eye movements but use other methods, including taps and tones, if preferred or more appropriate, such as for people who are visually impaired) for specific target memories until the memories are no longer distressing
    使用会话中重复的双侧刺激（通常使用眼球运动，但如果更合适或偏好，可以使用其他方法，包括轻敲和声音，例如对于视力受损的人）来针对特定的目标记忆，直到这些记忆不再令人痛苦
  • include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions.
    包括自我平静技巧和应对闪回技巧的教学，用于会话内和会话之间。

For more on NICE’s PTSD guidance (2018) as it relates to EMDR, please see Sections 1.6.18 to 1.6.20: https://www.nice.org.uk/guidance/ng116/chapter/Recommendations
关于 NICE 的 PTSD 指南（2018）与 EMDR 相关内容，请参阅第 1.6.18 至 1.6.20 节：https://www.nice.org.uk/guidance/ng116/chapter/Recommendations

5.6.5. Psychopharmacological Treatment 5.6.5. 精神药理学治疗

While psychopharmacological interventions have been shown to provide some relief, particularly to veterans with PTSD, most clinicians agree that resolution of symptoms cannot be accomplished without implementing exposure and/or cognitive techniques that target the physiological and maladjusted thoughts maintaining the trauma symptoms. With that said, clinicians agree that psychopharmacology interventions are an effective second line of treatment, particularly when psychotherapy alone does not produce relief from symptoms.
尽管心理药理学干预已被证明可以提供一些缓解，尤其是对患有 PTSD 的退伍军人，但大多数临床医生认为，没有实施针对维持创伤症状的生理和心理不适应的认知和/或暴露技术，就无法解决症状。话虽如此，临床医生一致认为，心理药理学干预是有效的二线治疗方法，尤其是在单独进行心理治疗不能缓解症状时。

Among the most common types of medications used to treat PTSD symptoms are selective serotonin reuptake inhibitors (SSRIs; Bernardy & Friedman, 2015). As previously discussed in the depression chapter, SSRIs work by increasing the amount of serotonin available to neurotransmitters. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are also recommended as second-line treatments. Their effectiveness is most often observed in individuals who report co-occurring major depressive disorder symptoms, as well as those who do not respond to SSRIs (Forbes et al., 2010). Unfortunately, due to the effective CBT and EMDR treatment options, research on psychopharmacological interventions has been limited. Future studies exploring other medication options are needed to determine if there are alternative medication options for stress/trauma disorder patients.
在治疗 PTSD 症状的常用药物中最常见的是选择性 5-羟色胺再摄取抑制剂（SSRIs；Bernardy & Friedman，2015）。如前所述，在抑郁章节中，SSRIs 通过增加神经递质可用的 5-羟色胺量而起作用。三环类抗抑郁药（TCAs）和单胺氧化酶抑制剂（MAOIs）也被推荐作为二线治疗方法。它们的有效性通常在报告共病重度抑郁症状的个体以及那些对 SSRIs 无反应的个体中观察到（Forbes 等，2010）。遗憾的是，由于有效的 CBT 和 EMDR 治疗方案，心理药理学干预的研究受到了限制。需要未来的研究探索其他药物选择，以确定是否存在针对压力/创伤障碍患者的替代药物选项。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到了以下内容：

  • Several treatment approaches are available to clinicians to alleviate the symptoms of trauma- and stressor-related disorders.
    多种治疗方法可供临床医生使用，以缓解创伤和应激相关疾病的症状。
  • The first approach, psychological debriefing, has individuals who have recently experienced a traumatic event discuss or process their thoughts related to the event and within 72 hours.
    第一次方法，心理疏导，让近期经历过创伤事件的人讨论或处理与事件相关的想法，并在 72 小时内进行。
  • Another approach is to expose the individual to a fear hierarchy and then have them use positive coping strategies such as relaxation techniques to reduce their anxiety or to toss the fear hierarchy out and have the person experience the most distressing memories or images at the beginning of treatment.
    另一种方法是让个体接触恐惧等级，然后让他们使用积极的应对策略，如放松技巧来减轻焦虑，或者一开始治疗就让个体经历最令人痛苦的记忆或图像，并摒弃恐惧等级。
  • The third approach is Cognitive Behavioral Therapy (CBT) and attempts to identify and challenge the negative cognitions surrounding the traumatic event and replace them with positive, more adaptive cognitions.
    第三种方法是认知行为疗法（CBT），旨在识别和挑战围绕创伤事件的负面认知，并用积极的、更适应性的认知来替代它们。
  • The fourth approach, called EMDR, involves an 8-step approach and the tracking of a clinician’s fingers which induces lateral eye movements and aids with the cognitive processing of traumatic thoughts.
    第四种方法，称为 EMDR，涉及 8 步方法，并跟踪治疗师的手指，这会引起横向眼动，有助于创伤性思维的认知处理。
  • Finally, when psychotherapy does not produce relief from symptoms, psychopharmacology interventions are an effective second line of treatment and may include SSRIs, TCAs, and MAOIs.
    最后，当心理治疗不能缓解症状时，精神药理学干预是一种有效的二线治疗方案，可能包括 SSRIs、TCAs 和 MAOIs。

Section 5.6 Review Questions
第 5.6 节 复习题

  1. Identify the different treatment options for trauma and stress-related disorders. Which treatment options are most effective? Which are least effective?
    确定创伤和压力相关障碍的不同治疗方案。哪些治疗方案最有效？哪些效果最差？

Module Recap 模块总结

In Module 5, we discussed trauma- and stressor-related disorders to include PTSD, acute stress disorder, adjustment disorder, and prolonged stress disorder. We defined what stressors were and then explained how these disorders present. In addition, we clarified the epidemiology, comorbidity, and etiology of each disorder. Finally, we discussed potential treatment options for trauma- and stressor-related disorders. Our discussion in Module 6 moves to dissociative disorders.
在模块 5 中，我们讨论了创伤和应激相关障碍，包括 PTSD、急性应激障碍、适应障碍和长期应激障碍。我们定义了应激源是什么，然后解释了这些障碍的表现。此外，我们阐明了每种障碍的流行病学、共病和病因。最后，我们讨论了创伤和应激相关障碍的潜在治疗方法。我们在模块 6 的讨论转向分离性障碍。

3rd edition  第 3 版

Source: https://opentext.wsu.edu/abnormal-psych/chapter/module-5-trauma-and-stressor-related-disorders/