Verlauf-Definition über Zeitkriterien
In der ICD-10 sind die Verläufe der reaktiven Störungen zunächst über Zeitkriterien definiert:
- akute Belastungsstörung (die Störung bildet sich innerhalb eines Monats zurück)
- Posttraumatische Belastungsstörung (PTSD) (Dauer mindestens ein Monat)
- Anpassungsstörung (weniger heftiges, dafür oft chronifizierendes Zustandsbild, als Reaktion auf eine belastende Lebenssituation, mit weniger spezifischen Symptomen im Sinne von Gefühlsstörungen und/oder Auffälligkeiten im Sozialverhalten)
- Persönlichkeitsstörung (mögliche Langzeitfolge von Traumatisierungen; Beispiel: Entwicklung einer Borderline-Persönlichkeitsstörung nach Gewalterfahrungen in der frühen Kindheit)
Wesentliche prognostische Faktoren
- das Fehlen oder die Ausbildung von Folgestörungen
- Selbstverletzendes Verhalten
- Suizidversuche
- Essstörungen
- Substanzmissbrauch ohne/mit Abhängigkeitsentwicklung
- die Art des erlittenen Traumas (Davidson et al 1991):
- Remission nach Gewalteinwirkung, schwerer Verletzung oder Schock im Mittel 36 Monate
- Remission nach Tod einer nahestehenden Person im Mittel nur 13 Monate
- das Fehlen oder Vorhandensein von protektiven Faktoren, z.B.:
- Grad der sozialen Unterstützung nach dem Trauma
- positive oder negative Bewältigungsstil
Verlauf
Die Verlaufsdynamik der PTSD ist aufgrund ihrer komplexen Psychopathologie sehr variantenreich. Es gibt vielfach spontane Remissionen (Rückbildungen), aber auch prolongierte, chronifizierende und invalidisierende Verläufe. Die möglichen Folgen einer Traumatisierung sind also recht vielgestaltig.
Bei c a einem Drittel der PTSD-Patienten findet sich ein chronischer Verlauf mit einer mittleren Remissionszeit von 3 Jahren (behandelt) bis 5 Jahren (unbehandelt). 15-25% der Patienten bleibt dauerhaft krank.
Langzeiteffekte der PTSD sind neben den erwähnten Folgestörungen (s.o.) eine Alexithymie, Dissoziationen, Somatisierungen, ausgeprägtes Misstrauen, Mangel an Verantwortungsgefühl, Identitätsdiffusion, eine tiefgreifende Beziehungsstörung bzw. Neigung zu extremen Bindungsformen (z.B. Hörigkeitsverhältnisse, sadomasochistische Beziehungsmuster mit Täter-Opfer-Konstellationen etc.) oder Kontaktscheu.
Psychotherapieforschung
Die vorliegenden Studien zur Psychotherapieforschung lassen die Aussage zu, dass sowohl verhaltenstherapeutisch-kognitive als auch psychodynamische Therapien zu einer Reduktion der spezifischen Symptome der PTSD führen.
Am besten beeinflussbar sind:
- Intrusionen
- Alpträume
- Hyperarousal, Schreckreaktionen
- Impulsivität
- Ärger
Weniger beeinflussbar sind häufig
- Symptome der emotionalen Betäubung
- das Entfremdungsgefühl
- der eingeschränkte Affektspielraum
Weitere Erkenntnisse der Psychotherapieforschung
- Eine differenzierte Studie von Ehlers et al (1997) zeigte, dass von der Konfrontationstherapie v.a. die Patienten profitieren, die sich während der Traumatisierung nicht aufgegeben haben. Diejenigen, die nichts unternommen haben, sich evt. schuldig fühlen und sich ungeliebt (ausgeprägt negative Selbstbildveränderung!) fühlen, profitieren viel weniger von diesem Verfahren.
- Man kann wohl vorsichtig sagen, dass die kognitive Therapie mit der Zielsetzung einer veränderten Einstellung zu sich und den Anderen bei der Therapie der PTSD eine besondere Bedeutung beanspruchen kann.
- Traumata sind nicht selten auch Kristallisationspunkt für Einstellungsveränderungen auf höheren Ebenen (Sinnfragen, existentielle Dimension des Traumas). Ausgangspunkt ist dann die Feststellung: „Nichts ist mehr so, wie es vor dem Trauma war.“ Es folgt günstigenfalls ein Reifungsprozess
Coping-Strategien (Bewältigungs- und Verarbeitungsversuche) der Betroffenen
- Traumata führen oft zu dem Bedürfnis, sich in besonderer Weise zu engagieren im sozialen Bereich („Finding a mission“). „Zeugenschaft für Andere“ kann zur eigenen Therapietechnik werden
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