亚临床型血友病A合并颅脑外伤的围手术期处理2例分析

为了探讨亚临床型血友病A患者合并颅脑外伤行手术治疗时的围手术期处理方法,2例亚临床型血友病A合并颅脑外伤患者术后确诊,在围手术期通过动态的监测血Ⅷ因子活性（FⅧ：C）水平,调整FⅧ输入并维持FⅧ：C在止血水平（30％～50％）,至伤口愈合。结果显示,2例亚临床型血友病A合并颅脑外伤手术患者,术后都得到了及时的恢复。提示亚临床型血友病A合并颅脑外伤患者关键是准确诊断,围手术期要求保持血中凝血因子FⅧ的促凝活性维持在止血水平,直到伤口愈合为止。     

浅谈自发性脑出血诊断的辩证思维

自发性脑出血作为临床常见疾病,其背景复杂,对其予以准确诊断较为困难。除最常见于高血压性脑出血外,其既可作为某些疾病的首发表现,也可作为其他疾病的并发症或某些药物治疗的副作用而出现。其准确诊断除需具备完整临床知识结构外,亦要求我们具有辩证思维。本文旨在从辩证思维和临床角度探讨自发性脑出血的准确诊断。     

Acute stress disorder: a synthesis and critique

The diagnosis of acute stress disorder (ASD) was introduced to describe initial trauma reactions that predict chronic posttraumatic stress disorder (PTSD). This review outlines and critiques the rationales underpinning the ASD diagnosis and highlights conceptual and empirical problems inherent in this diagnosis. The authors conclude that there is little justification for the ASD diagnosis in its present form. The evidence for and against the current emphasis on peritraumatic dissociation is discussed, and the range of biological and cognitive mechanisms that potentially mediate acute trauma response are reviewed. The available evidence indicates that alternative means of conceptualizing acute trauma reactions and identifying acutely traumatized people who are at risk of developing PTSD need to be considered.     

An Integrative Approach to Conceptualizing and Treating Complex Trauma

Complex trauma (CT) often presents with polymorphous symptoms (i.e., emotional dysregulation, dissociation, somatic distress) resulting from repeated and chronic exposure to traumatic stressors. While the public is increasingly aware of posttraumatic stress disorder (PTSD) and its accompanying symptoms, the phenomena of complex trauma is less recognized and understood. Since the trauma reactions with CT typically occur during childhood, and the symptoms go well beyond PTSD, the authors of this article assert that an integrative approach is needed that synthesizes the most effective elements of cognitive-behavioral therapy (CBT) while blending a self-psychological approach. A review of the literature addresses the definition of complex trauma, cognitive-behavioral conceptualizations and treatment approaches, self-psychological models, current theories of attachment, and advances in neuropsychoanalysis. An integrative model is then proposed, supported by clinicians in the trauma field, identifying three intertwined phases of treatment.     

A Comparison of Two References for Using Knowledge of Performance in a Motor Task

In the present study, the learning of a task in which the goal of the movement was not isomorphic with a specific movement pattern was examined. The subjects' (N = 48) goal in the task was to be both spatially and temporally accurate in reaching 4 targets with a right arm lever movement. After each acquisition trial, the displacement profile of the movement just produced was provided to all subjects as knowledge of performance (KP). The relative effectiveness of 2 possible references, with which subjects could compare the KP, was examined. One of the references examined was knowledge of results (KR), which was provided by reporting the total absolute timing and amplitude errors from the 4 targets. The other reference examined was a criterion template (CT), which was defined as the most efficient movement pattern for reaching the 4 targets. In the feedback display, CT was superimposed on the displacement profile of the movement just produced. A factorial design, in which 2 levels of KR (KR, no KR) were crossed with 2 levels of CT (CT, no CT), produced 4 feedback conditions. After 120 acquisition trials with feedback, immediate and delayed retention tests without feedback and a reacquisition test with KR (20 trials per test) were conducted. Acquisition results indicated that KR was a better reference than CT for per-forming the timing aspect of the movement and for producing the generalized motor program (GMP) associated with the most efficient movement pattern. Delayed retention results showed that KR was also a better reference than CT for learning the most efficient GMP. The calibration strategy undertaken by subjects who were provided with KR during acquisition explains the superiority of the KR reference. The calibration strategy is compared with the pattern-matching activity that was probably undertaken by subjects who had received CT as a reference.     

Correlates of autobiographical memory specificity: the role of depression, anxiety and childhood trauma

The present study examined the role of childhood trauma, major depressive disorder (MDD), and anxiety disorder (AD) in overgeneral autobiographical memory. Ninety-three outpatients and 24 healthy controls completed a childhood trauma questionnaire and an autobiographical memory test (AMT). Results showed that MDD diagnosis rather than trauma history predicted AMT-performance. Memory specificity was not related to AD diagnosis, recovered MDD, or self-rated depression severity. The present findings cast doubts on theories that emphasize the role of childhood trauma in overgeneral autobiographical memory.     

A Randomized Trial of Cognitive Behaviour Therapy and Cognitive Therapy for Children with Posttraumatic Stress Disorder Following Single-Incident Trauma

The present study compared the efficacy of trauma-focused cognitive behavior therapy (CBT) with trauma-focused cognitive therapy (without exposure; CT) for children and youth with posttraumatic stress disorder (PTSD). Children and youth who had experienced single-incident trauma (N = 33; 7–17 years old) were randomly assigned to receive 9 weeks of either CBT or CT which was administered individually to children and their parents. Intent-to-treat analyses demonstrated that both interventions significantly reduced severity of PTSD, depression, and general anxiety. At posttreatment 65% of CBT and 56% of the CT group no longer met criteria for PTSD. Treatment completers showed a better response (CBT: 91%; CT: 90%), and gains were maintained at 6-month follow-up. Maternal depressive symptoms and unhelpful trauma beliefs moderated children’s outcome. It is concluded that PTSD secondary to single-incident trauma can be successfully treated with trauma-focused cognitive behavioural methods and the use of exposure is not a prerequisite for good outcome.     

Clinical Perspectives on Neurobiological Effects of Psychological Trauma

Physical trauma to the brain has always been known to affect brain functions and subsequent neurobiological development. Research primarily since the early 1990s has shown that psychological trauma can have detrimental effects on brain function that are not only lasting but that may alter patterns of subsequent neurodevelopment, particularly in children although developmental effects may be seen in adults as well. Childhood trauma produces a diverse range of symptoms and defining the brain's response to trauma and the factors that mediate the body's stress response systems is at the forefront of scientific investigation. This paper reviews the current evidence relating psychological trauma to anatomical and functional changes in the brain and discusses the need for accurate diagnosis and treatment to minimize such effects and to recognize their existence in developing treatment programs.     

Composite Trauma and Mental Health Diagnosis as Predictors of Lifetime Nonsuicidal Self-Injury History in an Adult Online Sample

Some research indicates that trauma history might be related to nonsuicidal self-injury (NSSI), but the exact nature of this relationship is unknown. Therefore, we created and tested a structural equation model for the relationships between composite trauma, NSSI, mental health diagnosis, and gender in a community sample of 296 U.S. adults recruited through Amazon Mechanical Turk. Composite trauma and mental health diagnosis were significantly predictive of an NSSI history. The pathway between NSSI and gender was not significant. It is important to consider multiple domains of trauma, in the form of composite lifetime trauma, as risk factors for NSSI.     

Cognitive therapy for post-traumatic stress disorder: development and evaluation

The paper describes the development of a cognitive therapy (CT) program for post-traumatic stress disorder (PTSD) that is based on a recent cognitive model (Behav. Res. Therapy 38 (2000) 319). In a consecutive case series, 20 PTSD patients treated with CT showed highly significant improvement in symptoms of PTSD, depression and anxiety. A subsequent randomized controlled trial compared CT (N = 14) and a 3-month waitlist condition (WL, N = 14). CT led to large reductions in PTSD symptoms, disability, depression and anxiety, whereas the waitlist group did not improve. In both studies, treatment gains were well maintained at 6-month follow-up. CT was highly acceptable, with an overall dropout rate of only 3%. The intent-to-treat effect sizes for the degree of change in PTSD symptoms from pre to post-treatment were 2.70-2.82 (self-report), and 2.07 (assessor-rated). The controlled effect sizes for CT versus WL post-treatment scores were 2.25 (self-report) and 2.18 (assessor-rated). As predicted by the cognitive model, good treatment outcome was related to greater changes in dysfunctional post-traumatic cognitions. Patient characteristics such as comorbidity, type of trauma, history of previous trauma, or time since the traumatic event did not predict treatment response, however, low educational attainment and low socioeconomic status were related to better outcome.     

原发性醛固酮增多症的临床实践与分析

探讨原发性醛固酮增多症(原醛)临床特点及诊治方面的经验,以早期诊断、根治,改善预后。对确诊的原醛53例临床资料(临床特征、实验室检查、影像学检查、病理类型、治疗情况)进行回顾性研究。男女比为1：1.65,30～49岁年龄段最多。50.9%高血压首发,15.1%低钾血症首发,并发高心痛9.4%,尿毒症1.9%,脑卒中13.2%。肾素-血管紧张素-醛固酮(RAA)系统激素检查,血浆醛固酮/血浆肾素活性比值(ARR)＞200者80.7%,ARR＞400者占半数,血浆醛固酮(PAC)＞140pg/ml者占84.6%。CT及MRI阳性率高。术后病理肾上腺皮质腺瘤占85%,结节性增生占15%(其中原发性肾上腺增生占12.5%)。手术后血压及血钾均较前改善,非手术者口服安体舒通有效。原醛是可治性内分泌性高血压之一,建议高血压和/或低血钾者应常规检查RAA系统激素,并争取行影像学检查,以使原醛得到早期诊治,改善预后。     

Cognitive Behavioral Therapy for PTSD: The Role of Complex PTSD on Treatment Outcome

Posttraumatic stress disorder (PTSD) represents an often chronic and debilitating mental illness resulting from exposure to trauma. Although the most compelling evidence for the treatment of PTSD is cognitive behavioral therapy (CBT), many patients experience residual functional impairment, or relapse, suggesting that this approach does not work for all cases of PTSD. Repeated severe trauma, particularly during development, might increase the risk for a more intricate clinical profile, called complex PTSD (CPTSD), which might contribute to poorer treatment response. The following provides a comprehensive summary of the evidence examining whether CPTSD symptomatology is related to poorer treatment outcome of CBT, reviews the literature on the treatment of CPTSD, and offers insights into current issues and future directions of the construct.     

Trauma theory in Sándor Ferenczi’s writings of 1931 and 19321

The author states that it is Ferenczi ’s writings of 1931 and 1932 that exhibit the most conspicuous departures from Freud ’s ideas and at the same time contain Ferenczi ’s most original contributions. The texts concerned – Confusion of tongues between adults and the child ( Ferenczi, 1932a ), the Clinical Diary ( Dupont, 1985 ), and some of the Notes and fragments ( Ferenczi, 1930–32 ), all of which were published posthumously – present valuable and original theories on trauma which are significant not only in historical terms but also because the ideas concerned are relevant to our conception of clinical psychoanalysis today. The aim of this paper is to give an account of Ferenczi ’s trauma theory as it emerges from his writings of 1931–32 and to specify the points on which he differs from Freud.     

Effects of experience and training on diagnostic accuracy

In this reexamination of a previously published report (R. Brammer, 1997), psychologists and psychology students (N = 138) were provided an artificial intelligence program that simulated a clinical interview, The "client" provided paragraph-length answers to the questions participants chose to ask. At the end of their interview, the participants provided a brief diagnosis for the client. A path analysis revealed that clinical experience is a strong predictor of the ability of form an accurate diagnosis and that an individual's level of training, mediated by the number of diagnostic questions asked, also helps to derive accurate diagnoses.     

Childhood trauma and psychosis: Review of the evidence and directions for psychological interventions

There is controversy over whether childhood trauma (CT) is a causal risk factor for psychosis. The aim of this study was to provide psychologists with a brief overview of the research into relationship between childhood trauma and psychosis and directions for psychological interventions. It details six of the highest quality studies in the area and tentatively concludes from these that there is evidence for a relationship between CT and psychosis. Hallucinations and delusions have been implicated as important factors in the relationship between CT and psychotic disorder and these are discussed, along with post‐traumatic intrusions and schemas, which have been conceptualised as part of the psychological mechanisms whereby CT confers a risk for psychosis. The development of psychological interventions for people with psychosis who have experienced CT is in its infancy but has been based on evidence‐based cognitive behavioural interventions in psychosis and post‐traumatic stress disorder. A formulation‐based approach is described in this paper, along with a case study.     

Recovering the context in posttraumatic stress disorder: The psychosocial trauma in victims of political violence and terrorism

Abstract

Throughout history, humans have frequently carried out harmful actions against one another. Often, these actions result in intensive and long lasting pain and suffering. Posttraumatic stress disorder (PTSD) diagnosis has been the theoretical tool used mostly by psychologists to understand the physical, emotional and behavioural symptoms following a traumatic experience. Due to its clinical and medical roots, PTSD diagnosis represents man in a social vacuum, a man without context, and a model of health closely tied to illness. The aim of the paper is to reintroduce the social context of human beings into trauma diagnosis, and to develop a health model that is more focused on well-being than on illness. Both points of view help us to seek a theoretical way for better understanding the psychosocial trauma that result from political violence and terrorism. Psychosocial trauma has definite roots, and destroys our inner world—the world of our most valuable meanings—infects our minds with hate against others, and breaks the social fabric we belong to.     

Adverse Childhood Experiences,Trauma Symptoms,Mindfulness, and Intimate Partner Violence: Therapeutic Implications for Marginalized Men

Adverse childhood experiences (ACEs) and trauma symptoms have been linked with intimate partner violence (IPV) perpetration and victimization among men, yet the field lacks depth in several key areas hampering progress toward violence intervention. Specifically, posttraumatic stress disorder (PTSD) dominates the field’s scope of trauma symptoms under study, limiting understanding of other manifestations of trauma especially among men. Furthermore, most research focuses exclusively on men’s physical IPV perpetration and rarely focuses on other types of IPV, severity of violence, or men’s victimization. Also, few studies examine potential protective factors grounded in the ACE framework, such as mindfulness, among clinical populations. Finally, most research has not focused on men of color, despite some racial/ethnic minority groups disproportionate rates of IPV exposure. Therefore, the relationships between IPV frequency and severity (psychological, physical, injury) and ACEs, PTSD, trauma symptomology (separate from PTSD), and mindfulness self-efficacy were examined in a sample of 67 predominantly low-income men of color in a batterer intervention program. More than half of the sample (51.5%) reported exposure to four or more ACEs, and 31.1% met the clinical cutoff for a probable PTSD diagnosis. Higher ACE scores predicted increased rates for nearly all types of self-reported IPV perpetration and victimization. PTSD symptoms and complex trauma symptom severity together explained between 13% and 40% of IPV outcomes, and each was uniquely associated with certain types of self-reported IPV victimization and perpetration frequency and severity. Mindfulness self-efficacy was associated with decreased self-report psychological IPV perpetration and victimization frequency and severity. Clinical implications relevant to marginalized men are reviewed, including screening, training, and potential therapeutic interventions.     

Traumatic memories and pseudomemories in posttraumatic stress disorder

Intrusive imagery was investigated in survivors of motor vehicle accidents with (a) posttraumatic stress disorder (PTSD) and accurate recall of the trauma, (b) PTSD and amnesia of the trauma, (c) no PTSD, or (d) control participants who simulated PTSD. Imagery was precipitated by presentation of an audiotape of a motor vehicle accident. Whereas the traumatic imagery of participants who had accurate recall of their trauma was consistent with third party accounts of the trauma, the imagery of amnesic participants was inconsistent with these accounts. Participants were then interviewed about cognitive and emotional aspects of their responses. All participants with PTSD and simulators reported similar levels of imagery detail, involuntariness, re-experiencing, and emotional response, and reported higher levels than participants with no PTSD. Findings are discussed in terms of cognitive and contextual factors that can mediate accurate and inaccurate traumatic imagery. © 1998 John Wiley & Sons, Ltd.     

Who is who in dissociation?: A plea for psychodynamics in a time of trauma1

Contemporary theories of dissociation and trauma for the most part have evolved outside of psychoanalysis. Psychoanalytic writings have also been regarded as being in opposition to trauma‐based notions of human psychopathology. The specific psychoanalytic contribution—the emphasis on unconscious conflict and meaning—is for the most part excluded from the discourse on dissociation, often resulting in a mechanic conceptualisation of trauma. In this paper, based on clinical material, the author argues in favour of including conflict, unconscious intention and personal meaning in understanding the kind of dissociation we see in cases of multiple personality pathology. Textual analysis of letters written to the analyst illustrates how events of abuse are defensively elaborated. The author demonstrates that patterns of affect regulation and dominant object–relational strategies can be captured through analysis of the discourse structure. She focuses on how an organised character pattern, revealed mainly through narrative style and the analyst's countertransference, serves protective purposes as well as wishfulfillment. She argues that dissociation in the form of multiple personalities may imply an active, strategic agent.     

Problematic,absent and stigmatizing diagnoses in current mental disorders classifications: Results from the WHO-WPA and WHO-IUPsyS Global Surveys

This study examined English- and Spanish-speaking psychologists’ and psychiatrists’ opinions regarding problematic, absent and stigmatizing diagnoses in current mental disorders classifications (ICD-10 and DSM-IV), and their perceived need for a national classification of mental disorders. Answers to open-ended questions included in WHO-WPA and WHO-IUPsyS surveys were examined using an inductive content-analysis method. A total of 3,222 participants from 35 countries were included. The most problematic diagnostic group was personality disorders, especially among psychiatrists, because of poor validity and lack of specificity. Complex posttraumatic stress disorder was the most frequent diagnosis suggested for inclusion, mainly by psychologists, to better account for the distinct processes and consequences of complex trauma. Schizophrenia was the diagnosis most frequently identified as stigmatizing, particularly by psychiatrists, due to lack of public understanding or knowledge about the diagnosis. Of the 14.4% of participants who perceived a need for a national classification system, two-thirds were from Africa or Latin America. The rationales provided were that mental disorders classifications should consider cultural and socio-historical diversity in the expression of psychopathology, differences in the perception of what is and is not pathological in different nations, and the existence of culture-bound syndromes. Implications for ICD-11 development and dissemination are discussed.