Definition der Traumatisierungen und der reaktiven psychischen Störungen
Nach ICD-10 werden die Reaktionen auf Belastungen unterteilt in die
- akute Belastungsreaktion (ICD-10 F43.0)
- Posttraumatische Belastungsstörung (ICD-10 F43.1)
- Anpassungsstörung (ICD-10 F43.2)
Eine weitere psychische Störung, die auf schwere Belastungen zurückgeführt wird und die im ICD-10 bei den Persönlichkeitsstörungen kodiert wird, ist die
- andauernde Persönlichkeitsänderung nach Extrembelastungen („Persönlichkeitswandel/Verfolgtensyndrom“)
Die Definition der Posttraumatischen Belastungsstörung zeigt fliessende Übergänge zu den anderen genannten reaktiven Störungen, weshalb wir hier dem Lehrbuch Tölles folgen und alle vier Störungsbilder definitorisch gegenüberstellen:
Akute Belastungsreaktion:
„Es sind Belastungen gemeint wie Naturkatastrophen, schwere Unfälle, Kriegshandlungen, Vergewaltigung, um nur einige zu nennen. Die unmittelbare Reaktion besteht insbesondere in vorübergehender Benommenheit (Betäubung oder Schock im alltagssprachlichen Sinne), sodann Unruhe, Angst, Fluchttendenz, vegetativen Symptome wie Herzjagen und Schwitzen. Die Symptomatik ist sehr heterogen. Die Störungen gehen alsbald zurück, oft schon nach Minuten, und klingen im allgemeinen in einigen Stunden oder Tagen ab.“ (Tölle, Psychiatrie (1999), S. 69)
Posttraumatische Belastungsstörung:
„Hiervon unterschieden (allerdings ohne scharfe Grenze) wird die Posttraumatische Belastungsstörung (F43.1 nach ICD 10). Gemeint sind langanhaltende Reaktionen auf sehr schwere Belastungen und Bedrohungen. Auch hier werden insbesondere Naturereignisse, Krieg und andere Katastrophensituationen, Mißhandlung und Vergewaltigung genannt, des weiteren ausgeprägte frühkindlicheDeprivation. Die Belastungen sind hier von „katastrophalem“ Ausmaß, womit die Krankheitsdauer erklärt wird. Relativ wenig belastbare, auch neurotisch strukturierte Menschen sind besonders betroffen.
Die Symptome sind den eben beschriebenen ähnlich, hinzu kommen Angst, emotionale Einengung, Teilnahmslosigkeit, bedrückte Stimmung, Schlafstörung.Die angstbesetzte Situation kann lange in der Erinnerung bleiben (Wiederinszenierung, flashback) und in Träumen auftauchen. Alkohol- oder Tablettenmissbrauch im Sinne eines Selbstbehandlungsversuches kann die folge sein. Die psychische Symptomatik, die zuweilen mit einer gewissen Latenzzeit von einigen Tagen bis zu Wochen eintritt bzw. stärker hervortritt, nimmt einen wechselhaften Verlauf. Im Extremfall bleibt sie sehr lange oder auch zeitlebens bestehen, wie die Schicksale vieler rassisch Verfolgter zeigen. Ein anderes Beispiel sind anhaltende Störungen nach sexuellem Mißbrauch.“ (S. 69f)
Anpassungsstörung:
„Im Zusammenhang mit den Belastungsreaktionen spricht man auch von Anpassungsstörungen. Die Wortwahl Anpassung (adjustment) läßt allerdings leicht Mißverständnisse aufkommen (nur Anpassungsstörung, keine Krankheit). Gemeint sind die Folgen stärkerer Belastungen (Traumen) in einem bestimmten Sinne: der Betroffenen kommt aus dem Gestörtsein nicht heraus, es gelingt ihm nicht die Bewältigung und die Anpassung an die neue Situation.
Anpassungsstörungen (F 43.2 nach ICD 10) reichen von der Reaktion auf den Verlust eines nahen Menschen (Trauerreaktion) bis zu den Anpassungsstörungen von Migranten. Die Störungen bestehen hauptsächlich in Depressivität und Angst, Gefühl der eigenen Unzulänglichkeit, Unsicherheit und Unfähigkeit, eingeschränkter Lebenstüchtigkeit im Alltag. Bei Kindern kann Regression eintreten, erkennbar an Enuresis und anderem kleinkindlichem Verhalten. Bei Jugendlichen kann es auch zu dissozialen Störungen kommen.
Es handelt sich im wesentlichen um das Krankheitsbild, das herkömmlich als reaktive Depression bezeichnet wurde. Sie tritt nach einschneidenden Veränderungen der Lebensverhältnisse auf wie Verlust des gewohnten Lebensraumes und der vertrauten Atmosphäre, auch nach Wechsel des beruflichen Tätigkeitsfeldes, nach einem Umzug oder einer Pensionierung. Jeweisl ist weniger das äussere Ereignis als das Erleben der Veränderung ausschlaggebend. Häufig liegen depressiven Reaktionen tiefgreifende Kränkungen und Selbstwertkrisen zugrunde. Prototyp ist die Trauerreaktion…“ (S. 70)
Andauernde Persönlichkeitsänderung nach Extrembelastungen (am Beispiel der KZ-Opfer im Dritten Reich):
„Die Belastungen, die mit langer Haft im Konzentrationslager verbunden waren, haben bei einem Teil der Betroffenen anhaltende psychische Folgen hinterlassen…
Wenn es zu einer anhaltenden psychopathologischen Symptomatik kommt, besteht diese vor allem in chronischer Angst, verbunden mit depressiver Verstimmung, Leistungsinsuffizienz und psychosomatischen Beschwerden (Somatisierungsstörungen). Es handelt sich um eine Umstrukturierung der Persönlichkeit, die erlebnisbedingter Persönlichkeitswandel genannt wird. Die Betroffenen leiden unter angsterfüllten Erinnerungen an die KZ-Situationen, die ständig im Bewusstsein bleiben und als Angstträume wieder durchbrechen. Das Verfolgungserleben kann weder vergessen noch verdrängt werden. Hinzu kommt bei Vielen das Schuldgefühl des „unverdient Überlebenden“. Die Treue gegenüber den während des Holocaust umgekommenen Angehörigen kann einen inneren Protest verlangen, der eine Aussöhnung mit dem Schicksal nicht zuläßt (Lauter). Verbitterung und Resignation prägen das Leben dieser Menschen.
Diese chronisch gewordene Angstsymptomatik ist für den psychischen Dauerschaden nach Verfolgung so charakteristisch, daß man sie als das Kernsyndrom oder dasVerfolgungssyndrom bezeichnet hat. Sie ist die häufigste Störung bei Verfolgten im mittleren Lebensalter; für ältere Patienten ist dagegen mehr eine chronische depressive Verstimmung kennzeichnend, häufig verbunden mit hartnäckigen psychosomatischen Störungen. Demgegenüber sind andere psychopathologische Syndrome bei Verfolgten seltener. Zuweilen wurde der Ausbruch einer Psychose (hauptsächlich mit paranoid-halluzinatorischer und depressiver oder andere Symptomatik) während der Verfolgung, kurz nach oder auch nach einer Latenzzeit von einigen Jahren beobachtet.Bei Kindern, soweit sie die Verfolgung überhaupt überlebt haben, richtet sich die Spätsymptomatik auch nach dem Alter, in dem sie der Verfolgungszeit ausgesetzt waren. Die Verfolgung während der frühesten Kindheit bewirkte vor allem Störungen der Kontaktfähigkeit und der Fähigkeit zu sozialer Selbständigkeit. Fiel die Verfolgung in die Vorpubertät und Pubertät, gleicht die Symptomatik der Folgezustände mehr dem charakteristischen Verfolgtensyndrom der Erwachsenen (Lempp)…“(S. 73)
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