精神医学49巻9号

2007年09月発行

展望

縦断的疫学研究からみたPTSDの転帰―慢性化をめぐって

著者： 尾鷲登志美¹² 上島国利¹³

所属機関： ¹昭和大学医学部精神医学教室 ²マックス・プランク精神医学研究所 ³国際医療福祉大学

ページ範囲：P.890 - P.896

文献概要

はじめに

　外傷体験の後に外傷後ストレス障害（posttraumatic stress disorder；PTSD）を発症し得ることはよく知られている。PTSD発症にあたり，死に至るような重篤な出来事を体験（もしくは目撃）することが診断基準に必須であるものの，それに相当する体験をした全ての人がPTSDを発症するわけではないのは周知の通りである。国や地域によって，外傷体験の割合^9,10,24,31)やPTSDの有病率には格差が大きく，DSM-IV診断によるPTSDの生涯有病率は海外で1.3～14％と報告されている^{1,9,15,25,38)}。川上らによると本邦におけるPTSDの生涯有病率は1.1％（男性0.4％，女性1.6％）であり，諸外国よりも低い数値を示している²³⁾（表1）。本邦でも震災などの自然災害や，人為犯罪，事故などに遭遇することは無縁ではなく，司法との関与など，PTSDに対する関心は高いにもかかわらず，縦断的予後についての検討はまだ少ないようである。

　PTSDの回復率は，うつ病よりもさらに低かったという報告^33,34)や，PTSDにおける機能的な障害はうつ病や他の不安障害よりも深刻であったという報告があり⁴³⁾，その転帰は楽観視できるものではない。すでに複数のPTSD治療ガイドラインがあるが，選択的セロトニン再取り込み阻害薬による寛解率は30～40％と報告されている。今後PTSDに対する関心とともに，治療法の進展が期待されるが，まず自然経過の現状を十分に把握することが必要と思われる。本稿ではPTSDの自然経過における縦断的疫学研究から，まずPTSDの転帰について概観し，次いでPTSD経過の慢性化と関連する因子について文献的に検討した。また，これらの縦断的研究から，治療介入の可能性を検討した。

参考文献

1) Alonso J, Angermeyer MC, Bernert S, et al：European Study of the Epidemiology of Mental Disorders(ESEMeD)Project. Prevalence of mental disorders in Europe：results from the European Study of the Epidemiology of Mental Disorders(ESEMeD) project. Acta Psychiatr Scand(Suppl) 420：21-27, 2004

2) American Psychiatric Association：Diagnostic and Statistical Manual of Mental Disorders. Third Edition. American Psychiatric Association, Washington, DC, 1980

3) American Psychiatric Association：Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Reviced. American Psychiatric Association, Washington, DC, 1987

4) American Psychiatric Association：Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, Washington, DC, 1994

5) Anderson JP, Bush JW, Berry CC：Classfying function for health outcome and quality of life evaluation：Self versus interviewer modes. Med Care 24：454-469, 1986

6) Blanchard EB, Hickling EJ, Barton KA, et al：One-year prospective follow-up of motor vehicle accident victims. Behav Res Ther 34：775-786, 1996

7) Bremner JD, Southwick SM, Darnell A, et al：Chronic PTSD in Vietnam combat veterans：Course of illness and substance abuse. Am J Psychiatry 153：369-375, 1996

8) Breslau N, Davis GC, Andreski P, et al：Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 48：216-222, 1991

9) Breslau N, Davis GC：Posttraumatic stress disorder in an urban population of young adults：Risk factors for chronicity. Am J Psychiatry 149：671-675, 1992

10) Breslau N, Kessler RC, Chilcoat HD, et al：Trauma and posttraumatic stress disorder in the community：the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 55：626-632, 1998

11) Breslau N, Wilcox HC, Storr CL, et al：Trauma exposure and posttraumatic stress disorder：A study of youths in urban America. J Urban Health 81：530-544, 2004

12) Carlier IV, Lamberts RD, Gersons BP：Risk factors for posttraumatic stress symptomatology in police officers：A prospective analysis. J Nerv Ment Dis 185：498-506, 1997

13) Cohen S, Hoberman HM：Positive events and social support as buffers of life change stress. J Appl Soc Psychol 13：99-125, 1983

14) Davidson JR, Hughes D, Blazer DG, et al：Post-traumatic stress disorder in the community：An epidemiological study. Psychol Med 21：713-721, 1991

15) Delahanty DL, Herberman HB, Craig KJ, et al：Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents. J Consult Clin Psychol 65：560-567, 1997

16) Ehlers A, Mayou RA, Bryant B：Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. J Abnorm Psychol 107：508-519, 1998

17) Frans O, Rimmo PA, Aberg L, et al：Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatr Scand 111：291-299, 2005

18) Frisch MB：QOLI or Quality of Life Inventory. Minneapolis, MN：Pearson Assessments.〔文献47)より孫引き〕

19) Goenjian AK, Steinberg AM, Najarian LM, et al：Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence. Am J Psychiatry 157：911-916, 2000

20) Goenjian AK, Walling D, Steinberg AM, et al：A prospective study of posttraumatic stress and depressive reactions among treated and untreated adolescents 5 years after a catastrophic disaster. Am J Psychiatry 162：2302-2308, 2005

21) Grieger TA, Cozza SJ, Ursano RJ, et al：Posttraumatic stress disorder and depression in battle-injured soldiers. Am J Psychiatry 163：1777-1783, 2006

22) Harvey AG, Bryant RA：Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. Am J Psychiatry 157：626-628, 2000

23) Helzer JE, Robins LN, McEvoy L：Post-traumatic stress disorder in the general population. Findings of the epidemiologic catchment area survey. N Engl J Med 317：1630-1634, 1987

24) 辺見弘，松岡豊，中島聡美，他：交通外傷患者における精神的ストレスに関する研究．平成17年度厚生労働科学研究費補助金(こころの健康科学分野研究事業)分担研究報告書(www.ncnp.go.jp/nimh/seijin/Henmi-H17Kokoro-text.pdf-)

25) Holbrook TL, Hoyt DB, Coimbra R, et al：Long-term posttraumatic stress disorder persists after major trauma in adolescents：new data on risk factors and functional outcome. J Trauma 58：764-769, 2005

26) Kaplan RM, Buch JW：Health-related quality of life measurement for evaluation research and policy analysis. Health Psychol 1：61-80, 1982

27) 川上憲人，大野裕，宇田英典，他：地域住民における心の健康問題と対策基盤の実態に関する研究：3地区の総合解析結果．平成14年度厚生労働科学研究費補助金(厚生労働科学特別研究事業)心の健康問題と対策基盤の実態に関する研究 分担研究報告書(mental.m.u-tokyo.ac.jp/h14tokubetsu/分担研究報告書1-1.pdf-)

28) Kessler RC, Sonnega A, Bromet E, et al：Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52：1048-1060, 1995

29) Kessler RC, Berglund P, Demler O, et al：Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62：593-602, 2005

30) Koren D, Arnon I, Klein E：Long term course of chronic posttraumatic stress disorder in traffic accident victims：A three-year prospective follow-up study. Behav Res Ther 39：1449-1458, 2001

31) Koenen KC, Stellman JM, Stellman SD, et al：Risk factors for course of posttraumatic stress disorder among Vietnam veterans：A 14-year follow-up of American Legionnaires. J Consult Clin Psychol 71：980-986, 2003

32) Kulca RA, Schlenger WE, Fairbank JA, et al：Trauma and the Vietnam War Generation：Report of Findings From the National Vietnam Veterans Readjustment Study. New York, Brunner/Mazel, 1990

33) Landau R, Litwin H：The effects of extreme early stress in very old age. J Trauma Stress 13：473-487, 2000

34) Marshall GN, Schell TL, Glynn SM, et al：The role of hyperarousal in the manifestation of posttraumatic psychological distress following injury. J Abnorm Psychol 115：624-628, 2006

35) Mizuta I, Ikuno T, Shimai S, et al：The prevalence of traumatic events in young Japanese women. J Trauma Stress 18：33-37, 2005

36) Nandi A, Galea S, Tracy M, et al：Job loss, unemployment, work stress, job satisfaction, and the persistence of posttraumatic stress disorder one year after the September 11 attacks. J Occup Environ Med 46：1057-1064, 2004

37) North CS：The course of post-traumatic stress disorder after the Oklahoma City bombing. Mil Med 166(12 Suppl)：51-52, 2001

38) North CS, Kawasaki A, Spitznagel EL, et al：The course of PTSD, major depression, substance abuse, and somatization after a natural disaster. J Nerv Ment Dis 192：823-829, 2004

39) North CS, Pfefferbaum B, Tivis L, et al：The course of posttraumatic stress disorder in a follow-up study of survivors of the Oklahoma City bombing. Ann Clin Psychiatry 16：209-215, 2004

40) O'Donnell ML, Creamer M, Pattison P：Posttraumatic stress disorder and depression following trauma：Understanding comorbidity. Am J Psychiatry 161：1390-1396, 2004

41) Orcutt HK, Erickson DJ, Wolfe J：The course of PTSD symptoms among Gulf War veterans：A growth mixture modeling approach. J Trauma Stress 17：195-202, 2004

42) Perkonigg A, Kessler RC, Storz S, et al：Traumatic events and post-traumatic stress disorder in the community：Prevalence, risk factors and comorbidity. Acta Psychiatr Scand 101：46-59, 2000

43) Perkonigg A, Pfister H, Stein MB, et al：Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. Am J Psychiatry 162：1320-1327, 2005

44) Price RK, Risk NK, Haden AH, et al：Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use. Drug Alcohol Depend 76(Suppl)：S31-43, 2004

45) Resnick HS, Kilpatrick DG, Dansky BS, et al：Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol 61：984-991, 1993

46) Schell TL, Marshall GN, Jaycox LH：All symptoms are not created equal：The prominent role of hyperarousal in the natural course of posttraumatic psychological distress. J Abnorm Psychol 113：189-197, 2004

47) Schnurr PP, Hayes AF, Lunney CA, et al：Longitudinal analysis of the relationship between symptoms and quality of life in veterans treated for posttraumatic stress disorder. J Consult Clin Psychol 74：707-713, 2006

48) Shipherd JC, Stafford J, Tanner LR：Predicting alcohol and drug abuse in Persian Gulf War veterans：What role do PTSD symptoms play?　Addict Behav 30：595-599, 2005

49) Solomon Z, Dekel R：Posttraumatic stress disorder among Israeli ex-prisoners of war 18 and 30 years after release. J Clin Psychiatry 66：1031-1037, 2005

50) Solomon Z, Mikulincer M：Trajectories of PTSD：A 20-year longitudinal study. J Psychiatry 163：659-666, 2006

51) Spertus IL, Yehuda R, Wong CM, et al：Childhood emotional abuse and neglect as predictors of psychological and physical symptoms in women presenting to a primary care practice. Child Abuse Negl 27：1247-1258, 2003

52) Wang X, Gao L, Shinfuku N, et al：Longitudinal study of earthquake-related PTSD in a randomly selected community sample in north China. Am J Psychiatry 157：1260-1266, 2000

53) Ware JE, Sherbourne CD：The MOS 36-Item Short-Form Health Survey(SF-36)：I. Conceptual framework and item selection. Medical Care 30：473-483, 1992

54) Yehuda R, Kahana B, Southwick SM, et al：Depressive features in Holocaust survivors with post-traumatic stress disorder. J Trauma Stress 7：699-704, 1994

55) Zatzick DF, Marmar CR, Weiss DS, et al：Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. Am J Psychiatry 154：1690-1695, 1997

56) Zlotnick C, Warshaw M, Shea MT, et al：Chronicity in posttraumatic stress disorder(PTSD)and predictors of course of comorbid PTSD in patients with anxiety disorders. J Trauma Stress 12：89-100, 1999