외상후 스트레스 장애(PTSD)의 이해와 치료 민병배 (마음사랑인지행동치료센터)

외상적 경험이란 무엇인가? 외상(trauma): (1) 자신(혹은 타인)에 대한 죽음(혹은 손상)의 실제적(혹은 지각된) 위협을 포함하는 사건을 경험(혹은 목격)함. (2) 또한 그 사건 동안 극심한 공포 혹은 무력감을 느낌. 따라서 모든 스트레스 경험이 다 외상적 경험은 아니다.

잠재적으로 외상적인 사건들 자연재해(화재, 홍수, 지진 등) 전쟁 생명을 위협하는 사고(자동차 사고 등) 자신 혹은 타인의 심각한 상해 신체적 폭력 무기에 의한 위협 사랑하는 사람의 갑작스런 죽음 강간 전쟁 지역 거주

외상의 유형(1) Single-blow vs. repeated trauma (Terr, 1991) (1) Short-term or type I traumatic events that are abrupt, often lasting a few minutes and as long as a few hours (2) Sustained and repeated traumatic events (or Type II traumatic events) typically involve chronic, repeated, and ongoing exposure.

외상의 유형(2) Natural vs. Technological disaster (1) not completely clear-cut (2) They may differ with regard to whether there is someone to “blame” for the event and whether it could have been prevented. (3) The community pulls together around natural disaster; people help and support each other. Technological disasters, on the other hand, tend to be more socially divisive, because much attention is diverted to finding fault and fixing blame.

외상의 유형(3) Varieties of Man-made trauma: War and political violence; Criminal violence; Rape; Domestic violence; Child abuse; and others The effects are likely to be most severe if the trauma is man-made, repeated, unpredictable, multifaceted, inflicted with sadistic or malevolent intent, undergone in childhood, and perpetrated by a caregiver.

외상 동안의 보편적 반응 끔찍스러운 공포 깊은 슬픔과 비통함 불신, 충격과 무력감

외상 후의 보편적 반응 외상 후 스트레스 증상 외상적 비통 증상 우울 알코올 혹은 물질 남용 기능 손상

외상 후 스트레스 증상 (Post Traumatic Stress Symptoms) A. Reexperiencing: Distressing thoughts and feelings about the trauma, nightmares, and flashbacks B. Avoidance and numbing: avoiding trauma-related situations, thoughts and activities, diminished interest in activities, detachment from others, and restricted range of affect C. Increased arousal: Sleep disturbances, outburst of anger, difficulty concentrating, hypervigilance When these symptoms become chronic, they are diagnosed as a psychological disorder (PTSD)

외상적 비통 증상 (Traumatic Grief Symptoms) Symptoms that overlap with PTSD Recurrent intrusive thoughts and images of the death Avoidance of situations, activities, or people Symptoms unique to traumatic grief Intense yearning and longing for the dead person Extreme sadness rather than arousal and anxiety

Common Traumatic Stress Reactions(1) Emotional reactions shock, terror, irritability, blame, anger, guilt, grief or sadness, emotional numbing, helplessness, loss of pleasure derived from familiar activities, difficulty feeling happy, difficulty experiencing loving feelings Cognitive reactions impaired concentration, impaired decision making ability, memory impairment, disbelief, confusion, nightmares, decreased self-esteem, decreased self-efficacy, self-blame, intrusive thoughts/memories, worry, dissociation

Common Traumatic Stress Reactions(2) Physical reactions fatigue, exhaustion, insomnia, cardiovascular strain, startle response, hyper-arousal, increased physical pain, reduced immune response, headaches, gastrointestinal upset, decreased appetite, decreased libido, vulnerability to illness Interpersonal reactions increased relational conflict, social withdrawal, reduced relational intimacy, alienation, impaired work (or school) performance, decreased satisfaction, distrust, externalization of blame, externalization of vulnerability, feeling abandoned/rejected, over-protectiveness

Common Traumatic Stress Reactions(3) Although stress reactions may seem 'extreme', and cause distress, they generally do not become chronic problems. Most people recover fully from even moderate stress reactions within 6 to 16 months (Baum & Fleming, 1993; Green et al., 1994; La Greca et al., 1996; Steinglass & Gerrity, 1990).

Common Traumatic Stress Reactions(4) “Posttraumatic Growth” (Tedeschi & Calhoun, 1995) Interpersonal relationships are improved through valuing friends and family more, greater openness and self-disclosure, and increased compassion and altruism. Self-perception is changed through increased resiliency together with the acceptance of their vulnerabilities and limitations. Life philosophy is altered through shifts in existential perspective, with survivors finding a fresh appreciation for each new day, and re-negotiating what really matters to them in the full realization that their life is finite.

자료: 9/11 사건 후 PTSD의 회복 1~2달: 7.5% 6~9달: 1.45%

외상에 대한 반응: 요약 외상 희생자의 대다수는 시간이 지나면 회복된다. PTSD는 자연적인 회복 과정의 실패를 반영한다.

Problematic Stress Responses Severe dissociation Severe intrusive re-experiencing Extreme avoidance Severe hyper-arousal Debilitating anxiety Severe depression Problematic substance use Psychotic symptoms  trauma-related psychiatric disorders

Trauma-related Psychiatric Disorders Posttraumatic Stress Disorder (including ASD) Dissociative Disorders Depressive Disorders Substance Abuse Anxiety Disorders: Panic, OCD, etc Somatization Disorder Sexual dysfunction Eating Disorders Borderline Personality Disorder

Acute Stress Disorder(ASD)의 진단기준 Exposed to a traumatic event & Response (intense fear, helplessness, or horror) Dissociative Sx (≥3) A subjective sense of numbing, detachment, or absence of emotional responsiveness A reduction in awareness of his or her surroundings Depersonalization Derealization Dissociative amnesia Re-experiencing trauma Avoidance of reminders of trauma Anxiety/arousal Significant impairment in functioning & quality of life Duration of the disturbance: 2 days ~ 4 weeks ; Occurrence within 4 weeks of the traumatic event

Posttraumatic Stress Disorder(PTSD)의 진단기준 Exposed to a traumatic event & Response (intense fear, helplessness, or horror) Symptom clusters Re-experiencing (≥1) Avoidance & emotional numbing (≥3) Increased arousal (≥2) Duration of the disturbance > 1 month Significant impairment in functioning & quality of life Immediate vs. Delayed Onset if onset of symptoms is at least 6 months after the stressor  delayed Acute vs. Chronic course duration of symptoms < 3 months  acute ≥3 months  chronic

PTSD: Re-experiencing recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. recurrent distressing dreams of the event. acting or feeling as if the traumatic event were recurring intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

PTSD: Avoidance and Numbing efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others restricted range of affect sense of a foreshortened future

PTSD: Increased Arousal difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response

유병률(prevalence) DSM-IV(1994) 평생 유병률 : 1 ~ 14 % 고위험 집단에서는 3 ~ 58 % The National Comorbidity Survey (1990-1992, 미국인을 대상으로 한 자료) 외상에 대한 노출 경험: 남자 61%, 여자 51% 평생 유병률: 7.8% (남자 5%, 여자 10.4 %)

왜 ? 자연적 회복의 실패에 영향을 주는 요인 외상을 당한 모든 개인이 만성적인 PTSD로 발전하는 것은 아니다. 외상의 성질 외상의 강도 개인차

외상의 성질에 따른 PTSD의 비율 Kessler, 1995

외상의 강도에 기여하는 요인 통제 불가능성, 예측 불가능성 및 지각된 위협의 정도 실제적인 상실 혹은 손상 지속적 혹은 반복적 외상 외상 예방 실패에 대한 지각된 느낌(예: 죄책감, 수치심)

개인적인 취약성 요인 Childhood trauma or abuse Psychiatric illness (depression, anxiety, personality disorder) Substance abuse Poor social support Low educational and socioeconomic status Family history of PTSD Biological vulnerability Rachel Yehuda, M.D. Identifying Posttraumatic Stress Disorder (Talk 1) GlaxoSmithKline 2001

Holocaust 생존자 자녀들의 PTSD 유병률 PTSD 3 times more likely in children of Holocaust survivors in response to trauma vs controls Risk factor appears to be parental PTSD, not parental trauma Shalev, 1997

자연적 회복의 과정: 이 과정은 어느 때 성공하며 어느 때 실패하는가? 자연적 회복의 과정: 이 과정은 어느 때 성공하며 어느 때 실패하는가?

공포 구조(Fear Structure) A fear structure is a program for escaping danger It includes information about: The feared stimuli The fear responses The meaning of stimuli and responses

외상 기억(Trauma Memory) Trauma memory is a specific fear structure that includes representations of: Stimuli present during the trauma Physiological and behavioral responses that occurred during the trauma Meanings associated with these stimuli and responses Associations among stimulus, response, and meaning representations may be realistic or unrealistic

강간 직후의 기억에 대한 도식적 모델 Afraid Uncontrollable I - Me Rape Man Confused Say “I love you” Shoot Alone Suburbs Tall Gun Home Bald Scream PTSD Symptoms Freeze Confused Incompetent Dangerous

외상 경험 직후의 공통적인 인지 안전한 상황이 위험한 것으로 지각된다. 외상 동안의 정상적인 반응(울음, 얼어붙음 등)이 무능함의 증거로 지각된다. 외상기억이 빈약하게 조직화되고 파편화된다. 따라서 외상은 일시적으로 “세상은 극히 위험하다”, “나는 매우 무능하다”는 지각을 촉진한다.

회복 과정: 외상을 생각나게 하는 것들에 대한 직면 회복 과정: 외상을 생각나게 하는 것들에 대한 직면 정상적인 활동을 지속하는 것은 외상적인 사건이 좀처럼 일어나지 않고 독특한 것이었음을 깨닫게 한다. 따라서 세상은 위험하고 자신은 무능하다는 믿음이 반증된다. 외상적인 기억의 처리(그 사건에 대해 생각하고 말하기)는 그 사건에 대한 일관적이고 조직화된 서술을 가능하게 하며, 이를 통해 그 사건을 “과거 속의 한 사건”으로 받아들일 수 있게 된다.

회복된 강간 기억에 대한 도식적 모델 Afraid Uncontrollable I - Me Rape Man Confused Say “I love you” Shoot Alone Suburbs Tall Gun Home Bald Scream Freeze Confused Incompetent Dangerous

만성적인 PTSD로 이끄는 요인 지속적인 인지적 회피와 행동적 회피가 회복을 방해한다. (1) 부정적 인지를 반증할 경험에 대한 노출을 제한함. (2) 기억의 조직화를 방해하여 외상을 과거의 한 사건으로 위치시키지 못함. 회피는 ‘세상은 위험하며 자신은 스트레스에 효과적으로 대처할 수 없을 것’이라는 믿음을 유지시킨다.

만성적인PTSD의 강간기억에 대한 도식적 모델 Afraid Uncontrollable I - Me Rape Man Say “I love you” Shoot Alone Suburbs Tall Gun Home Bald Scream PTSD Symptoms Freeze Confused Incompetent Dangerous

고통을 겪어내는 데 있어서의 개인차가 회피로 이끈다 고통을 겪어내는 데 있어서의 개인차가 회피로 이끈다 Most people resume normal activities and face trauma reminders despite the associated distress Individual factors render some people especially unable to tolerate distress These people avoid trauma reminders at all cost in order to minimize distress

PTSD 이면의 역기능적, 부정적 인지 The world is extremely dangerous People are untrustworthy No place is safe I (the victim) am extremely incompetent PTSD symptoms are a sign of weakness Other People would have prevented the trauma

집단별 PTCI 척도 점수 Median Scaled Scores

외상으로부터의 회복에 실패한 사람들을 어떻게 도울 수 있을까?

PTSD에 대한 개입 Individual counseling Support groups Psychodynamic psychotherapy (e.g., psychoanalysis) Short-term cognitive behavioral Therapy(CBT) CBT is the only type of psychotherapy for PTSD that has received strong empirical support for its efficacy

Cognitive-Behavioral Treatment Exposure therapy Anxiety management or stress inoculation training Cognitive therapy

Exposure Therapy A set of techniques designed to help patients confront their feared objects, situations, memories, and images.

Anxiety Management A set of techniques that helps patients manage their anxiety Relaxation Training Controlled Breathing Positive Self-talk and Imagery Social Skills Training Distraction Techniques (e.g., thought stopping)

Cognitive Therapy A set of techniques that help patients changes their negative, unrealistic cognitions by: Challenging these cognitions Replacing these cognitions with functional, realistic cognitions Identifying dysfunctional, unrealistic cognitions (thoughts and beliefs)

심리학적 결과들의 함의 Treatment should repeatedly activate the traumatic memory via safe confrontations with trauma reminders (exposure therapy) These confrontation will helps patients modify the dysfunctional, negative cognitions underlying their PTSD 1

Treatments: 여성 강간 피해자에 대한 연구 Prolonged Exposure (PE) Stress Inoculation Training (SIT) SIT + PE Wait List Controls Treatments included 9 sessions conducted over 5 weeks Foa et al.,1999

Prolonged Exposure Therapy(PE) for PTSD Education about common reactions to trauma (25 minutes) Breathing retraining (10 minutes at session 1) Imaginal exposure (reliving) to the trauma memory (30~45 minutes during sessions 3~12) In vivo exposure to trauma reminders in real life between sessions 9~12 weekly or twice weekly 90-minute sessions

Prolonged Exposure (PE) Therapy for PTSD Imaginal exposure: Patients recount the traumatic memories during sessions and listen to the tape- recorded recounting between sessions In vivo exposure: Patients confront safe trauma-related situations and objects between sessions, beginning with less fearful situations and moving on to more fearful ones

치료 후 효과 크기 비교: PE vs. SIT vs. PE/SIT Foa et al., 1999

치료 전후 PDSD 증상 비교 PTSD Severity PE WL

치료 전후 우울 증상 비교 Depression Severity PE WL

결론 Several CBT programs are effective for PTSD: Prolonged exposure therapy (PE) Stress inoculation training (SIT) Cognitive therapy (CT) Prolonged exposure has received the most empirical evidence with a wide range of traumas including traumatic grief Treatment programs that include exposure to trauma reminders seem more effective than programs who do not include exposure Clinicians who are not experts in CBT can successfully learn PE in a short period of time

많은 PTSD 희생자들은 치료에 참여하지 않으려 한다. 왜? 혹자는 자신이 스스로 증상을 극복할 수 있을 것이라고 믿는다. 혹자는 사건에 대한 죄책감을 느껴서 자신이 고통을 받아 마땅하다고 생각한다. 혹자는 자신의 증상과 외상적 사건을 연관시키지 못한다. 혹자는 치료를 받게 되면 그 사건에 대해 생각해야 하기 때문에 치료를 피한다. 대다수의 사람들은 자신의 문제에 대한 효과적인 치료가 있다는 것을 모른다.

외상 피해자에게 주는 메시지 당신이 회피하고 있는 외상적 기억과 외상관련 상황에 직면할 수 있도록 돕는 치료를 찾으라. 이러한 치료들은 당신이 외상 이후에 잃어버린 삶을 재생할 수 있도록 도와줄 것이다.