Psychiatry (Abingdon, England)最新文献

Our understanding of what might constitute appropriate and effective early intervention for those exposed to trauma and mass disaster has developed significantly over the past decade. This article describes potential methods of early intervention and summarizes the available evidence of their effectiveness. It is argued that there is currently little evidence to support the routine use of preventative interventions, such as psychological debriefing, prophylactic medication or multiple-session preventative psychological interventions. However, there is evidence to support the use of brief trauma-focused cognitive behavioural Intervention for individuals whose traumatic stress symptoms are not improving. There is consensus that interventions that aim to promote safety and connectedness, and address immediate physical and social needs should take priority in the acute phase after disaster. Early psycho-social intervention programmes should ideally be part of coordinated disaster-management plans, which also address these broader needs. Stepped or stratified care models provide one solution to managing limited post-trauma resources by aiming to provide education and information to all exposed individuals and identifying and prioritizing those who are most likely to benefit from further intervention.

This is not an article about a psychiatric condition, but rather one about a particular population of people, some of whom may present with special needs whereas others may have no psychiatric problems at all. This article begins with the legal definition of a refugee, an account of the scale of the problem worldwide and in the UK, and proceeds to consider mental health and cultural implications. Assessment and diagnosis should be undertaken in the usual way, but there may be a need to learn more about diverse cultural backgrounds and to work with interpreters in assessment and treatment. In the intervention, a phased approach is often appropriate, engaging different professionals at different stages of treatment.

The history of trauma research is a relatively short one, dating back to the introduction of post-traumatic stress disorder (PTSD) into the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Whilst the introduction of PTSD has provided a major impetus for the scientific investigations of post-traumatic conditions in a variety of samples, fewer epidemiological studies have been conducted in the general population for both adults and children. Large differences in the lifetime prevalence rates reported for adult exposure to traumatic events (3.9–89.6%) as well as for PTSD (1.0–11.2%) have been observed owing to variations in the design, sampling strategies, and method of diagnostic assessments used. Despite these differences, however, several consistent findings have emerged, although it remains unclear to what extent the outcome of population-based surveys conducted predominantly in the USA can be generalized to other countries. Similarly, disasters occur in a wide variety of settings and circumstances, thereby introducing a number of methodological challenges that may deviate substantially from those commonly used in traditional epidemiological studies. Systematic reviews of the disaster literature based on meta-analyses have sought to address these limitations. A similar approach has been applied to the identification of vulnerability factors for PTSD in trauma-exposed adults to establish why considerable individual differences exist. Such knowledge is imperative to inform the selective use of interventions. We still await a better understanding of why some individuals display positive changes after trauma, given evidence of resilience in the face of even the most severe stressor.

The Diagnostic and Statistical Manual and the International Statistical Classification of Diseases do not distinguish clearly between the clinical presentations resulting from exposure to single as opposed to multiple trauma. The developmental age of the victim is similarly not emphasized in symptom development and clinical presentation. Developmental trauma disorder and complex post-traumatic stress disorder (PTSD) are emerging as useful diagnostic frameworks in children and adults. This article reviews the literature and highlights conceptual evolution and differences from simple PTSD, as well as discussing differential diagnoses and clinical management.

This article argues that, while emergencies and disasters are distressing for most people and may result in mental disorders for a substantial minority of affected persons at some time in the following months and years, there are personal and collective sources of psychosocial resilience. The concepts, bases, and practical potential of resilience have been explored for more than 40 years. However, studies of pathology, which emphasizes people’s vulnerability over their adaptive capacities, have predominated. The nature and basis of personal psychosocial resilience are outlined, and a new approach to collective resilience that has been developed through recent research on crowd psychology is described. The article concludes with some implications for managing disasters and practice, including the suggestion that crowds be treated as part of the solution rather than part of the problem in mass emergencies and disasters.

Trauma is a relatively common experience in childhood. It can have lasting detrimental effects on development and on physical and mental health in adulthood. Recovery from a single trauma can be rapid, but multiple traumatic experiences can cause lasting impairment in many domains of functioning. This article describes some key issues related to good practice in therapeutic work with children with both simple and complex trauma-related disorders.

Various theories have been proposed to explain the development and maintenance of post-traumatic stress disorder (PTSD). This article reviews psychological and social theories that have been influential. The most prominent current theories – emotional processing, dual representation, and the cognitive model of PTSD – draw on earlier work, in particular conditioning, information processing, and classical cognitive theory. Psychodynamic and attachment theory have also influenced thinking in this area. The latest theories combine stimulus and response elements with meaning, interpretation, and appraisal; they argue that successful processing depends on being able to access and assimilate new information within pre-existing schemas. Social factors are also recognized as playing a significant role in the development and maintenance of PTSD. These are considered along with the contention that PTSD is a socio-political construct as opposed to a true disease.

In recent years a number of authors have proposed that traumatic events, particularly childhood sexual abuse, can lead to psychotic symptoms or psychotic illness, including schizophrenia. There does appear to be an association, but the research to date has not clearly demonstrated a causal relationship. Traumatic events, like other genetic and environmental influences, can make individuals vulnerable to the development of all types of psychiatric illness, including psychosis. Trauma may well cause psychosis-like symptoms, perhaps through dissociation, but any presumed causal relationship between trauma and psychotic illness may be due to poor understanding of phenomenology, inadequate history-taking and clinical examination, and lack of diagnostic clarity.

Since the last edition of this review, there has been an impressive body of new evidence adding to our knowledge of psychological treatments. There have also been two new major reviews covering the complete range of available treatments: the second edition of the guidelines from the International Society for Traumatic Stress Studies (ISTSS) and the US Institute of Medicine's review. The National Institute for Clinical Excellence (NICE) guidelines were published before the last edition of this article, and there are currently no plans to revise them. However, the Australian guidelines build on the NICE guidelines, and provide the most comprehensive and user-friendly clinical guidance currently available. It is fascinating that such major and thorough reviews have arrived at different conclusions. The Institute of Medicine endorses trauma-focused cognitive behavioural therapy (TF-CBT) and prolonged exposure but not eye movement desensitization and reprocessing (EMDR) or drug treatment; NICE endorses TF-CBT and EMDR but not drugs; and the ISTSS guidelines, second edition, endorses drugs, EMDR, and TF-CBT. What is the bewildered therapist to do? Hopefully this review will clarify some of these issues. In truth, the discrepancy arises not because these learned and expert bodies have been perverse, negligent, or biased in their reviewing, but largely because they differ in what they have regarded as a clinically significant difference between two interventions as opposed to a statistical difference.

Self-injury is now recognized as a form of behaviour in its own right, distinct from self-harm and attempted suicide. It can be defined as a behaviour that involves deliberately injuring one’s own body, without suicidal intent and with or without pain. Self-injury takes many different forms, with cutting the most common. Although its prevalence is impossible to determine accurately, self-injury is common, widespread, and probably on the increase. Self-injury is in general more common in younger women, but men and older women also self-injure. The causes are multifactorial, with biological, psychological, and social explanatory theories. Self-injury does serve many different functions for the individual, acting as a way of coping with stress, regulating unpleasant emotions, calming and comforting, relieving a sense of guilt, restoring a sense of reality, and providing a means of communicating distress to others. Hospital studies suggest that those who self-injure or cut themselves receive worse services than those who poison, and yet may be at greater risk of repeat self-harm and even eventual suicide. Treatment must always be based on positive attitudes to the self-injurer and proceed via a detailed individual formulation. Choice of therapy is determined by the underlying causes of the behaviour.