Posttraumatische Belastungsstörung (PTSD)
Entsprechend der Vorstellung, dass bei der Ausbildung einer PTSD viele Faktoren zusammenwirken, gibt es auch eine Vielfalt von Erklärungsversuchen, die die Perspektiven und Denkgewohnheiten der verschiedenen Therapieschulen wiederspiegeln. Unter anderem folgende „Modelle“ können voneinander unterschieden werden:
- ein psychodynamisches Modell
- ein entwicklungspsychologisches Modell
- ein verhaltenstherapeutisches resp. kognitives Modell
- ein genetisches Modell
- ein neurobiologisches Modell
Diese Modelle zur Entstehung einer PTSD sollen im Fogenden kurz mit ihren Kernaussagen vorgestellt werden.
Das psychodynamische Modell
Das sogenannte „psychodynamische Modell“ geht auf die Erkenntnisse der Psychoanalyse und ihres Begründers S. Freud zurück. Freud definierte das „Trauma“ (Jenseits des Lustprinzips, 1920) im Sinne eines überwältigenden Reizgeschehens, welches eine normale psychische Abwehr verunmöglicht. Das Gefühl völliger Hilflosigkeit dem traumatisierenden Ereignis gegenüber stellt für Freud den Kristallisationspunkt zur Ausbildung der weiteren Traumafolgen dar. Hilflosigkeit ist ein sehr schlecht aushaltbares Gefühl. Dies ist vermutlich der Grund, warum die Psyche nach einem überwältigenden Ereignis nicht einfach so zur Ruhe kommen kann. Stattdessen versucht sie einerseits die Wiederkehr der Erinnerung an das Trauma zu verhindern, um sich vor erneuten Traumatisierungen durch das Erinnern selbst zu schützen. Gleichzeitig gibt es aber auch wie eine Art Zwang, sich immer wieder mit dem Vorgefallenen zu beschäftigen, sich dem bedrohlichen Ereignis immer wieder zumindest gedanklich auszusetzen, um vielleicht doch im Nachhinein eine Verarbeitung zu erreichen und damit das Erlebnis der existentiellen Hilflosigkeit durch eine neue Sicherheit oder Gewissheit zu überwinden. Der traumatisierte Mensch pendelt daher zwischen zwei gegensätzlichen Zuständen: zwischen der „Leugnung“ (Vermeidung, Dissoziation) des Geschehenen und einem „Zwang, sich immer wieder erinnern zu müssen („Intrusionen“).Nach psychoanalytischer Ansicht handelt es sich bei diesen gegensätzlichen Motivationen klassischerweise um einen „innerseelischen (=intrapsychischen) Konflikt“.
Von diesem Traumamodell abgeleitete, modernere psychodynamische Theorien, die neuere Erkenntnisse der Informationsverarbeitung berücksichtigen, gehen auf Horowitz (1986) zurück.
Das entwicklungspsychologische Modell
Dieses Modell fokussiert v.a. die Auswirkungen von frühen körperlichen und sexuellen Traumata bei gleichzeitiger relativer Schutzlosigkeit des Kindes auf die weitere psychische Entwicklung. Die bisherigen Forschungsergebnisse zeigen, dass früh traumatisierte Heranwachsende oft schwerwiegende Defizite in der Fähigkeit zur Steuerung intensiver Affekte und sexueller, bindender oder aggressiver Impulse aufweisen und auch in ihrer Bindungsfähigkeit erheblich gestört sind. Stattdessen herrschen sehr extreme Bindungsmodi vor, z.B. extrem abhängige Beziehungsmuster oder völlige soziale Isolierung oder auch nur desorganisierte Bindungsstile. Folgen früher Traumatisierungen sind häufig auch Aufmerksamkeits- und Konzentrationsstörungen, dissoziales Verhalten, Entstehung körperlicher Symptome als Alsdruck seelischer Probleme (Somatisierung) sowie eine tiefgreifende Hoffnungslosigkeit und Mangel an Urvertrauen.
Je früher die Traumatisierungen stattfinden, umso tiefgreifender sind in der Regel die Folgen, weil zur Bewältigung von Traumaerlebnissen die Stabilität und Differenziertheit der Persönlichkeitsstruktur und der Affekte, Selbstvertrauens und Vertrauen in eine konstante Umwelt notwendig sind, die erst im Laufe des Heranwachsens als Folge einer stabilen und positiv erlebten Bindung an die Eltern erworben werden können.
Das verhaltenstherapeutische resp. kognitive Modell
Dieses auf den Erkenntnissen der Lerntheorie basierende Modell eignet sich besonders gut, um die Entstehung einer Reihe von typischen Symptomen der PTSD zu erklären. So lässt sich die Triggerbarkeit der Symptomatik bei traumatisierten Menschen durch Schlüsselsituationen oder -erlebnisse sehr gut im Sinne der Konditionierungstheorie erklären. Die Annahme eines Konditionierungsgeschehens als Grundmechanismus für die Entstehung einer PTSD eignet sich auch sehr gut, um zu erklären, warum Desensibilisierungsmethoden eine gute therapeutische Wirksamkeit haben.
Offenbar können solche pathologischen Lernprozesse auch auf neuronalem Niveau, also an der Nervenzelle selber festgeschrieben werden. So entdeckte Kolb (1987), dass die Wucht eines Traumas bleibende Veränderungen an den Nervenzellen hervorrufen kann mit der Folge, dass Traumatisierte bereits auf unterschwellige Reize sehr empfindlich reagieren und v.a. die Fähigkeit zur Unterscheidung verschiedener Stimuli einbüssen. Die Unfähigkeit traumatisierter Patienten, zwischen wichtigen und unwichtigen Reizen unterscheiden zu können, sondern stattdessen „ereigniskorreliert“ zu reagieren (Paradigma der ereigniskorrelierten Potentiale), kann zu einer sehr verzerrten Weltsicht führen, die das Erkennen wirklicher Gefahren und bedrohlicher Ereignisse erschwert, wenn diese in affektiv neutraler Weise auftauchen. Weitere Konzepte aus dieser Denkrichtung sind das der „erlernten Hilflosigkeit“ (Seligman, 1975)
Das genetische Modell
Wenn innerhalb der Familie eines Menschen mehrere Personen an einer psychischen Störung leiden, dann ist nachweislich die Anfälligkeit dieses Menschen für die Ausbildung einer PTSD nach einem Trauma im Vergleich zur Restbevölkerung unspezifisch erhöht. Es gibt auch Hinweise auf Transgenerationseffekte in Familien mit KZ-Opfern im Dritten Reich.
Das neurobiologische Modell
Es gibt eine Fülle von psychophysiologischen, neurohormonellen, neuroanatomischen und immunologischen Reaktionen, mit denen der Organismus versucht, einer Traumatisierung zu begegngen. Im Rahmen von sogenannten „Stressreaktionen“ werden z.B. Katecholamine, Serotonin und endogene Opioide freigesetzt, und es kommt zu einer Aktivierung der Hypothalamus-Hypophysen-Nebennierenrinden-Achse. Diese „normalen“ Reaktionen, die der Stressbewältigung dienen, können aber erheblich gestört und in der Folge „dysfunktional“ werden, wenn das Trauma zu heftig ist oder zu lange andauert. So führt eine „adrenerge Dysfunktion“ zu dem bei PTSD typischem „Hyperarousal“. Eine „serotonerge Dysfunktion“ zeigt sich symptomatisch in einer erhöhten Schreckhaftigkeit und Hypersensibilität auf banale Reize. Die körpereigene Opioid-Ausschüttung im Rahmen der Stressreaktion führt anfänglich dazu, dass das Trauma weniger Panik auslöst, sondern eher eine Erstarrung und ein Betäubungsgefühl. Sind körperliche Verletzungen aufgetreten, werden die Schmerzen unter der Opioidwirkung weniger oder gar nicht verspürt. Im Falle eines posttraumatischen Syndroms kann aber auch diese ursprünglich „sinnvolle“ Stressreaktion in eine „Dysfunktion“ übergehen, wenn nämlich die Betäubung und Erstarrung anhalten, zu einer dauerhaften „Dissoziation“, also einer Trennung zwischen Gefühlen und Bewusstsein führen und die Verarbeitung des Traumas erschweren. In der Stressreaktion kommt es auch zu einer Aktivierung der Hypothalamus-Hypophysen-NNR-Achse und einem damit verbundenen Kortisolausstoss, der offenbar dazu dient, der Stressreaktion selber und ihren negativen Folgen neutralisierend entgegenzuwirken. Kortisol besitzt, indem es zeitgleich mit den Stresshormonen ausgeschüttet wird, eine protektive Wirkung auf den Organismus! Wenn sich aus dem Trauma eine PTSD entwickelt, dann geht das offensichtlich mit der Ausbildung einer Vermehrung und einer Hypersensitivität (Überempfindlichkeit) der hypophysären Glukokortikoidrezeptoren auf Kortisol einher (Man spricht von einer „progressiven Sensitivierung“ der Hypothalamus-Hypophysen-NNR-Achse). Einen wichtigen Beitrag zum Verständnis der Chronifizierung von Traumatisierungen im Sinne der Ausbildung einer PTSD stellen die Konzepte zum „Kindling“-Prozess und zur „Sensitivierung“ dar. Es gibt Erkenntnisse, dass das dopaminerge mesokortikolimbische System entscheidend bei der „Sensitivierung“ neuronaler Strukturen nach Einwirkung geeigneter Stressoren beteiligt ist und eine Art Lern- und Erinnerungsprozess auf neuronaler Ebene initiiert. Noradrenerge und serotonierge Systeme modulieren offenbar den Ausprägungsgrad dieser Sensitivierung.
Unter „Kindling“, dem entscheidenden Prozess beim Übergang eines Traumas in eine PTSD, versteht man die „Festschreibung“ einer allgemeinen Hyperreagibilität auf Reize im Sinne des genannten neuronalen Lernprozesses. Dabei handelt es sich möglicherweise um eine völlige permanente Umstrukturierung in den Amygdala und in der Hippocamous-Region im Gehirn.
Einen weiteren Beitrag zum neurobiologischen Verständnis der PTSD leisten Techniken wie dasNeuroimaging oder PETStudien, auf die an dieser Stelle aber nicht weiter eingegangen werden kann. Aufgrund dieser Untersuchungen gibt es derzeit bereits recht anschauliche Modellvorstellungen über die Informationsverarbeitung im Gehirn. Besonders beteiligt sind dabei der Thalamus (erste Integration von Afferenzen), die Amygdala (weitere emotionale Bewertung) und der Hippocampus (Integration auf hohem Niveau, insbesondere auch Abgleich der Afferenzen mit bereits bekannten Informationen).
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