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复合型创伤后应激障碍(Complex PTSD)诊断的意义及临床应用

Some of us still remember when PTSD (post-traumatic stress disorder) was introduced into mental disorders classification systems in the 1980s. This category was much needed to fill a gap in assessing and treating mental consequences of extreme stress caused by external conditions like war, sexual violence or severe accidents. Since then, our knowledge about PTSD has increased tremendously. By reviewing the existing literature and its clinical implications – particularly taking into account the meaning and clinical utility of the existing PTSD diagnosis – the ICD-11 Working Group on Disorders Specifically Associated with Stress proposed a new sibling diagnosis of PTSD called Complex Post-Traumatic Stress Disorder (CPTSD) for inclusion in the ICD-11. CPTSD is intended to replace the previous ICD-10 diagnosis “Enduring Personality Change after Catastrophic Experience” (EPCACE).

无论你对EPCACE的诊断是否了解,这一诊断只在少数国家的一些精神病学家以及心理学家中比较流行。在ICD-10分类标准中,EPCACE并没有和PTSD联系在一起。它的核心症状被描述为由创伤引起的对世界的不信任感、社交退缩症、感觉空虚或无助、疏离感以及长期感觉到的被人威胁。 

与EPCACE的情况相反,在过去的20余年中,复合型创伤 (Complex traumatization) 甚至复合型创伤后应激障碍(Complex PTSD)作为一种替代性的诊断名称已经在世界很多地区被广泛应用于临床实践中。作为最早开始研究创伤性应激后的精神疾病的著名学者之一,波士顿的精神病学家Judith Lewis Herman博士在她出版于1992年的里程碑式的著作“创伤与恢复”(Trauma and Recovery)中已经对这一复杂的创伤相关的诊断进行了详尽的描述。通过临床个案报告及令人印象深刻的案例研究,她为我们提供了一种区分PTSD和CPTSD的方法。其他临床医生和学者,如Bessel van der Kolk博士,也对这个复合型创伤概念的研究作出了很多贡献。他们的工作直接导致了在DSM-IV(精神疾病诊断与统计手册第四版,Diagnostic and Statistical Manual of Mental Disorders - IV)中引入了一个类似EPCACE的诊断 – 无法归类的极度精神紧张障碍 (Disorder of extreme stress, not otherwise specified, DESNOS),然而这一诊断并没有出现在DSM-5中。  

ICD-11应激相关精神障碍工作小组通过广泛咨询了全世界大量对复合型创伤后精神疾病的研究具有丰富经验的临床机构,只发现了很少的关于EPCACE的经验性研究。以往的有关复合型创伤的科学研究的结果并不完全一致。编写ICD-11精神及行为障碍诊断指南的重要目的之一就是要改善新标准的临床实用性,因此工作小组对那些既符合我们对疾病的临床认识,又那个满足基本的科学性要求的新观点进行了考察。 

目前已有大量针对ICD-11中提出的新的复合型PTSD诊断标准的临床研究。全球临床实践网络应激相关精神障碍现场研究是其中非常重要的概念验证试验。你可能已经参与了这个国际性的研究。研究结果显示,临床医生可以有效区分CPTSD,PTSD以及正常人,新的诊断标准在临床应用中优于ICD-10中的EPCACE诊断标准。根据上述试验的结果, 针对在试验中暴露出来的临床医生感觉不够明确部分内容,工作小组对复合型PTSD诊断标准进行了进一步完善。随后对收集到国际性数据进行的各种分析发现,复合型PTSD是经过科学地验证,具有临床应用价值的诊断标准,是对精神疾病诊断手册的有益补充。 Global Clinical Practice Network field study for Disorders Specifically Associated with Stress was a major proof of the concept, and you may have participated in this international study. The main result concerning Complex PTSD was that clinicians were able to differentiate from PTSD and normality and that the new disorder outperformed the ICD-10 category of EPCACE. Based on the study results, the Working Group modified the diagnostic guidelines of Complex PTSD to address issues that appeared to have been unclear for study participants. As findings from various analyses of international datasets further suggest, Complex PTSD is a clinically useful and scientifically warranted addition to the diagnostic manual of mental disorders.