Klinische Typen
Klinisch kann man die Patienten mit einer PTSD je nach zusätzlicher Symptomatik in verschiedene Typen einteilen, die hier kurz aufgelistet werden sollen (Alarcon 1997, Davidson u. Foa 1993):
- Depressiver Typ (PTSD-Symptome + Selbstwertverlust, psychomotorische Hemmung, sozialer Rückzug, Antriebsverlust, Interesselosigkeit, Schuldgefühle („Überlebensschuld“)
- Dissozialer Typ (Flashbacks, Pseudohalluzinationen, Fuguezustände, Depersonalisation/Derealisation, dissoziative Identitätsstörung)
- Somatoformer Typ (Chronischer Schmerz, z.B. Kopfschmerzen, Rückenschmerzen, Bauchschmerzen, Fibromyalgie ohne somatische Erklärung, evt. zusätzlich vegetative Beschwerden und chronische Müdigkeit)
- Psychoseähnlicher Typ (meist kurze, in der Intensität stark wechselnde psychosenahe Verhaltens- und Verarbeitungsweisen, paranoide Reaktionen, Abulie, Ratlosigkeit, Regression)
- Organomorpher Typ (Erhebliche kognitive Defizite mit Verminderung von Konzentrationsfähigkeit und Aufmerksamkeit, mnestische Störungen, Verwirrtheit)
- Neuroseähnlicher Typ (PTSD-Kernsymptomatik + Ängste, Panikattacken, Phobien oder Zwangssyndrome)
Diagnostische Leitlinien
Die PTSD belegt innerhalb der psychischen Störungen in den Klassifikationessystemen (ICD-10 und DSM-IV) eine Sonderstellung, da sie nicht rein deskriptiv, sondern äthiopathogenetisch konzipiert ist. Das heisst, anders als bei anderen psychischen Störungen, wird unterstellt, dass es eine spezifische Ursache der PTSD gibt, nämlich ein vorhergegangenes Trauma.
Die beiden Klassifikationssysteme (ICD-10 und DSM-IV) unterscheiden sich in ihren Forderungen an die Diagnostik z.T. deutlich. Während die ICD-10 z.B. einen grossen Spielraum lässt hinsichtlich der Einschätzung, was als „Trauma“ verstanden wird, gibt das DSM-IV wesentlich klarere Leitlinien vor.
Obwohl die ICD-10 für die praktische Diagnostik in deutschsprachigen Ländern eine grössere Bedeutung hat, werden wir uns im Folgenden an das DSM-IV halten, da dieses Manual in einigen Punkten als fortschrittlicher anzusehen und besser geeignet ist, die PTSD scharf zu erfassen.
Zur Diagnosestellung müssen sich Symptome aus drei „Clustern“ zu finden sein:
- Intrusionen: z.B.
- Albträume
- Immer wieder sich aufdrängende, traumabezogene Vorstellungen
- Intensive, immer wiederkehrende, traumabezogene Emotione
- Eine allgemeine physiologische Reagibilität bei Erinnerungen an das Trauma
- Vermeidungsverhalten: z.B.
- Vermeidung trauma-bezogener Gefühle
- Vermeidung bewusster Erinnerungen an das Trauma
- „Vergessen“ (psychogene Amnesie)
- „emotionale Betäubung“
- Absonderung, Entfremdung, sozialer Rückzug
- Hyperarousal, z.B.
- Übermässige Erregtheit
- Konzentrationsstörungen
- Allgemeine Reizbarkeit, Wutausbrüche
- Vermehrte Wachsamkeit (Vigilanz)
- Schreckreaktionen
Als diagnostische Hilfsmittel kommen neben den Algorithmen der ICD-10 oder des DSM-IV z.B. auchSelbstbeurteilungsskalen oder psychologische Tests zum Einsatz, z.B.:
- Impact of Events Scale (IES) von Horozitz et al (1979)
- PTSD Symptom Scale-Self Report (PSS-SR) von Foa et al 1993
- Posttraumatic Stress Syndrome-10 Questions Inventury (PTSS-10) von Weisaeth 1993
- Strukturiertes Klinisches Interview nach DSM IV (SCID); dt. Version: Wittchen et al. 1997
Differentialdiagnose
Die differentialdiagnostischen Abgrenzungen der PTSD gegenüber anderen psychischen Störungen ist nicht immer leicht. Zum einen gibt es viele Überlappungen der Symptome mit denen andere Störungsbilder. Darüberhinaus kann der jeweilige klinische Prägnanztyp die dahinterliegende PTSD-Kernsymptomatik verdecken. Oder aber die sichtbare Symptomatik zum Zeitpunkt der Diagnosestellung ist bereits eine der zahlreichen Folgestörungen der PTSD, imponieren aber wie eigene Störungen. Es geht also, wie so oft, um das Problem der Koexistenz oder der Komorbidität.
Komorbidität besteht häufig (Kapfhammer 2000) mit
- Substanz- und Alkoholmissbrauch
- Depressionen
- Angststörungen
- Somatoformen Störungen
- psychotischen Störungen
- Persönlichkeitsstörungen
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