【作者】 侯彩兰；

【导师】 李凌江；

【作者基本信息】 中南大学 ， 精神病与精神卫生学， 2007， 博士

【摘要】 第一部分矿难后2个月及10个月创伤后应激障碍的发生率及相关因素研究目的调查矿难后2个月及10个月创伤后应激障碍(posttraumatic stress disorder，PTSD)的发生率及相关因素。方法矿难后2个月，首先采用创伤后应激障碍清单(PTSD Checklist-Civilian Version，PCL-C)调查矿难幸存者PTSD的发生率。随后按照PCL-C评分，选取48名幸存者(包括24名重性PTSD患者及24名非PTSD对照)进行包括矿难前后一般情况、PTSD症状、焦虑抑郁状况、艾森克人格问卷(EPQ)及韦氏记忆等详细评估。矿难后10个月进行随访。结果矿难后2个月，所有112名生还矿工中有104名(92.9％)接受了调查，矿难后2个月PTSD的发生率为50％；分别选取的24名重性PTSD患者和非PTSD(Non-PTSD)对照在PTSD症状分析、焦虑抑郁、个性及记忆功能方面都有显著的差别；逐步回归分析显示状态焦虑、矿难后恢复上班情况、Beck抑郁问卷(BDI)总分、神经质、矿难发生时所在位置、井下工龄进入回归方程。矿难后10个月，随访到了112名幸存者中的85名，符合PTSD诊断标准的占30.6％；上述48名幸存者中有18名PTSD患者、23名Non-PTSD对照接受随访，与矿难后2个月相比，PTSD患者在PTSD症状、焦虑症状、及韦氏记忆方面有明显改善，抑郁症状无显著差别；逐步回归分析显示，状态焦虑改善、矿难后恢复上班情况、积极应对、情感平衡、井下工龄是PTSD症状减轻的因素。结论矿难后PTSD的发病率高、症状严重，对幸存矿工的心理及职业影响很大，需要及时干预与治疗。状态焦虑、矿难后恢复上班晚、BDI、神经质、矿难发生时所在位置最危险、井下工龄短是PTSD发生的危险因素。积极应对是PTSD恢复的积极因素之一。第二部分矿难后2个月及10个月创伤后应激障碍的脑功能及脑结构研究目的以前大多数创伤后应激障碍的脑功能、脑结构影像研究是针对长期的慢性病人。本研究探索急性重性PTSD(矿难后2个月)的脑功能和脑结构特点，研究在PTSD神经环路发挥重要作用的脑机制。矿难后10个月进行随访，探讨PTSD脑结构及脑功能的变化并进行纵向比较。方法第一部分中选取的24名急性重性PTSD患者和24名对照者作为研究对象。接受3项脑功能检查，包括情绪识数stroop、症状激发任务及症状激发的短期记忆提取任务，3项功能任务为区间设计，每一任务是5分12秒。随后为三维成像(3D)及弥散张量成像(DTI)检查。所有受试检查完成后，研究小组为其提供心理及药物干预。矿难后10个月，所有PTSD患者接受第二次脑功能及脑结构检查。以上结构及功能影像数据都通过统计参数图(statistical parametric mapping，SPM2)软件来处理。结果(1)情绪识数stroop：矿难后2个月，PTSD患者相比对照者，双侧前扣带回、右侧额下回、左侧颞上回等脑区激活下降；矿难后10个月，PTSD患者相比对照者，左侧额叶内侧回、右侧额中回、右侧扣带回及左侧海马旁回激活增强；PTSD患者矿难后10个月与矿难后2个月前后配对比较，矿难后10个月PTSD患者双侧额上回、双侧额中回、右侧扣带回及左侧海马旁回激活增强。(2)症状激发任务：矿难后2个月，PTSD患者相比对照者，右侧前扣带回、左侧额下回及双侧额中回等部位激活下降，左侧海马旁回激活增强；矿难后10个月，PTSD患者相比对照者，右侧颞上回(BA38)激活增强，右侧颞上回(BA22)、右侧岛叶等脑区激活下降；PTSD患者矿难后10个月与矿难后2个月前后配对比较，矿难后10个月PTSD患者右侧扣带回激活下降。(3)症状激发的短时提取任务：矿难后2个月，PTSD患者相比对照者，右侧额下回、右侧额中回、左侧枕中回等脑区激活下降；矿难后10个月，PTSD患者相比对照者，右侧额下回及右侧额中回等脑区激活下降；PTSD患者矿难后10个月与矿难后2个月进行配对比较，右侧海马旁回及双侧颞上回激活下降。(4)矿难后2个月，短时记忆提取任务相比症状激发任务，右侧海马旁回激活下降；矿难后10个月，短时记忆提取任务相比症状激发任务，左侧海马旁回激活下降。(5)矿难后2个月，脑形态学显示PTSD患者左侧额中回灰质密度低于对照组；矿难后10个月，PTSD患者双侧海马旁回及右侧额中回灰质密度低于对照组；PTSD患者矿难后10个月与矿难后2个月进行配对比较，右侧海马旁回、左侧扣带回、左侧额下回、左侧额叶内侧回、左侧岛叶等脑区灰质密度增高。(6)矿难后2个月，DTI结果显示，PTSD患者左侧前扣带回、右侧扣带回、左侧胼胝体下回、右侧额中回及左侧海马旁回等脑区FA值高于对照组。结论研究结果表明，PTSD急性期已存在脑功能、脑结构改变及记忆功能损害。主要的脑区在前额叶及海马部位。通过纵向比较可以看出PTSD患者脑功能及脑结构也发生了变化，一些脑区功能恢复，而有些脑区功能未恢复甚至功能进一步下降。创伤对于PTSD患者的影响是长期的。更多还原

【Abstract】 PartⅠPrevalence and risk factors for posttraumatic stressdisorder among survivors from a Hunan coal miningaccident after two and ten monthsObjective The study ascertained the prevalence of posttraumaticstress disorder (PTSD) among survivors from a Hunan coal miningaccident after two and ten months. Factors related to PTSD were alsoconsidered.Methods To estimate the prevalence of PTSD, the miners weresurveyed through use of the PTSD Checklist-Civilian Version (PCL-C)after two months of the coal mining accident. According the rating ofPCL-C, 24 acute severe PTSD patients and 24 Non-PTSD subjects wereevaluated through the use of Clinician Associated PTSD scale (CAPS),Impact of Event Scale-Revised (IES-R), State-Trait Anxiety Inventory(STAI), Beck Depression Inventory(BDI), Eysenck PersonalityQuestionnaire (EPQ), Wechsler memory Scale -Revised (WMS-R) anddetailed instances before and after the accident. After ten months of theaccident, the surviors were surveyed again.Results one hundred and four (92.9%) of the 112 survivors weresurveyed. The current prevalence rate among survivors from the coalmining accident was 50%. There were significant difference of PTSD symptoms, anxiety and depression, personality, and memory performancebetween the chosen 24 severe PTSD patients and 24 Non-PTSD controls.State anxiety, when to renew the work, BDI, EPQ-Neurorticism, wherewere they when accident happening, and length services are predictors ofPTSD. After ten months of the accident, 85 survivors were evaluated, inwhich 30.6 percent surviors still met the criterion of PTSD. In theabove-mentioned 48 miners, 18 PTSD patients and 23 Non-PTSDcontrols received the second evaluation. Compared with 2 months afterthe accident, PTSD symptoms, anxiety, as well as memory performanceimproved clearly, while the depressive symptoms had no significantdifference. We found that state anxiety, when to renew the work, positivecoping, emotional balance and length services were the factors of PTSDsymptoms healing.Conclusion The current prevalence rate of PTSD among survivorsfrom coal mining accident is high. The mining accident had made greatinfluence on victims, and psychological or medication interventions werenecessary. There were lots of risk factors of the prevalence of PTSD, andpositive coping may be a benefit factor of PTSD recovery.PartⅡThe brain functional and structural mechanism incoal mining survivors with PTSD after two and ten monthsObjective Functional and structural neuroimaging studies havelargely been performed in patients with longstanding chronicposttraumatic stress disorder (PTSD). We sought to characterize the brain responses and structure of patients with acute severe PTSD, andinvestigate the neurocircuit of PTSD. All subjects would be reevaluatedat ten months after the coal mining accident for the longitudinalobservations.Methods 24 individuals with acute severe PTSD resulting from themining accident and 24 subjects exposed to the mining accident withoutPTSD underwent functional magnetic resonance imaging (fMRI) whileperforming the emotional counting stroop, the symptom provocation andtrauma related short-term memory recall paradigms. All three functionaltasks were block designs. The duration of every series was 5 minutes and12 seconds. 3 dimension imaging (3D) and diffusion tensor magneticresonance imaging (DTI) examinations were followed. After fMRI andMRI tests were finished, we offered to them free psychological andmedication therapy. All the subjects were reassessed and diagnosed forPTSD symptoms at the ten months from the mining accident, and thePTSD patients who were diagnosed for the first time received fMRI andMRI tests for the second time. The data of structural and functional MRIwere dealt with statistical parametric mapping (SPM2) software.Results (1) During the emotional counting stroop, PTSD subjectsshowed diminished responses in bilateral anterior cingulate gyrus, rightinferior frontal gyrus, left superior temporal gyrus and etc, compared withNon-PTSD controls at the two months after the accident. PTSD subjectsshowed enhanced responses in left medial frontal gyrus, right middlefrontal gyrus, right cingulate gyrus, left parahippocampal gyrus comparedwith Non-PTSD controls at ten months after the accident. When PTSDsubjects at ten months were compared with at two months by paired t-test,bilateral superior frontal gyrus, bilateral middle frontal gyrus, rightcingulate gyrus, left parahippocampal gyrus had enhanced responses. (2) During symptom provocation paradigm, PTSD subjects showeddiminished responses in right anterior cingulate gyrus, left inferior frontalgyrus and bilateral middle frontal gyrus, and enhanced leftparahippocampal gyrus response compared with Non-PTSD controls attwo months after the accident. PTSD subjects showed enhanced rightsuperior temporal (BA 38) response and diminished responses in rightsuperior temporal gyrus (BA 22), right insula compared with Non-PTSDsubjects at ten months after the accident. By paried t-test, PTSD patientsat ten months showed diminished right cingulate gyrus responsecompared with PTSD patients at two months. (3) During the short-termmemory recall paradigm, PTSD group showed diminished responses inright inferior frontal gyrus, right middle frontal and left middle occipitalgyrus in comparison with controls at two months. PTSD group showeddiminished responses in right inferior frontal gyrus and right middlefrontal gyrus compared with Non-PTSD subjects at ten months. By pariedt-test, PTSD subjects at ten months showed diminished rightparahippocampus gyrus and bilateral superior temporal gyrus comparedwith PTSD patients at two months. (4) PTSD group exhibited diminishedright parahippocampal gyrus response during the memory recall task ascompared to the symptom provocation task at two months. PTSD groupexhibited diminished left parahippocampal gyrus response during thememory recall task as compared to the symptom provocation task at tenmonths. (5) The brain morphologic showed that the Gray Matter Density(GMD) of left middle frontal gyrus was significantly lower than thecontrols at two months. The brain morphologic showed that the GrayMatter Density (GMD) of bilateral parahippocampal and right middlefrontal gyrus were significantly lower than the controls at ten months.The brain morphologic showed that the Gray Matter Density (GMD) ofright parahippocampal, left cingulate gyrus, left inferior frontal gyrus, left medial frontal gyrus, left middle temporal gyrus, left inferior temporal,left insula and left inferior parietal lobule were significantly higher than attwo months. (6) The DTI results showed PTSD patients at two monthshad significantly higher fractional anisotropy values in the left anteriorcingulate gyrus, right posterior cingulate gyrus, left subcorpus callosum,right middle frontal gyrus, and left parahippocampal gyrus.Conclusions Our findings suggest that neurophysiologicalalterations, memory performance deficit have developed in acute severePTSD. By longitudinal research, we found the brain function andstructure made changes. Some brain regions recovered, but some didn’t.In all, the brain areas such as frontal lobe and hippocampus mayimportantly contribute to the PTSD neurocircurity. Additionally, therewere some ambivalent results in the present study and need futureresearch and interpretation. Tranma influenced PTSD patientschronically.更多还原