Zu den psychischen Störungen, die sich „reaktiv“ im Zusammenhang mit einer vorhergehenden Belastung oder einer Traumatisierung entwickeln können gehören nach ICD-10 folgende Krankheitsbilder:
- akute Belastungsreaktion (F43.0)
- Posttraumatische Belastungsstörung (F43.1)
- Anpassungsstörung (F43.2)
Akute Belastungsreaktion
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Posttraumatische Belastungsstörung
Vorbemerkung:
Die „Posttraumatische Belastungsstörung„, kurz: PTSD, ist ein Störungsbild, welches aktuell (wieder) zunehmend diagnostiziert wird und auch in den Medien grössere Beachtung findet. Es gab andere Zeiten, in denen der Bedeutung von Traumata für die Entstehung ernstzunehmender psychischer Belastungen und Erkrankungen jegliche Bedeutung abgesprochen wurde. In grösseren Zeitverläufen betrachtet befindet sich das Interesse für diese Erkrankung in einer wellenförmigen Bewegung zwischen völliger Missachtung und Verleugnung von Kausalzusammenhängen einerseits und aufwändiger Erforschung und Hypothesenbildung andererseits.
Interessanterweise gibt es eine Analogie zwischen dieser Wellenbewegung der Bewertung von Traumata im gesellschaftlichen Umfeld und der Verarbeitung dieser Störung beim betroffenen Patienten. Denn auch im therapeutischen Prozess wechseln sich Phasen der Verleugnung mit solchen ab, in denen der Patient vor der Überflutung mit traumatischem Material geschützt werden muss. Im Wechselspiel dieser Phasen über einen längeren (mehrmonatigen oder mehrjährigen) Prozess zwischen Annäherung an das und Auseinandersetzung mit dem Trauma einerseits und Verleugnung des und innerer Distanzierung vom Trauma andererseits gelingt im positiven Fall (mit oder ohne therapeutische Hilfe) in einer Art dialektischem Prozess eine schrittweise Verarbeitung mit möglichst weitgehender Neutralisierung oder Integration der traumatisierenden Erlebnisinhalte in den Lebenszusammenhang.
Es scheint die unerträgliche Wucht des traumatischen Erlebnisinhaltes zu sein, die diese dialektische Wellenbewegung mit ständiger Verleugnung und Wiederannäherung wie notgedrungen auslöst und die Verarbeitung nur in Raten zulässt. Diese Wellenbewegung bleibt nicht auf den Patienten beschränkt, sondern erfasst auch das therapeutische und soziale Umfeld, in welchem er lebt. Auch diese bewegen sich zwischen Faszination und Abgestossensein.
Was ist ein „Trauma“?
Grundlage für eine sichere Diagnosestellung einer PTSD ist eine klare Definition, was man eigentlich unter einem Trauma verstehen will.
Dazu H.-P. Kapfhammer (2000):
„Als Trauma wird ein Ereignis definiert, das für eine Person entweder in direkter persönlicher Betroffenheit oder indirekter Beobachtung eine intensive Bedrohung des eigenen Lebens, der Gesundheit und körperlichen Integrität darstellt und Gefühle von Horror, Schrecken und Hilflosigkeit auslöst. Ein posttraumatischer Stress umfasst sowohl psychische als auch somatische Symptome, die auf die Konfrontation mit einem Trauma folgen.“ (in: Möller, Laux, Kapfhammer; 2000)
Was ist eine Posttraumatische Belastungsstörung?
Eine posttraumatische Belastungsstörung („posttraumatic stress disorder“/PTSD) kann sich nach der Belastung mit einem „Trauma“ (s.o.) entwickeln, das heisst, wenn ein Mensch mit Ereignissen oder mit Situationen konfontiert wird, die sein Verarbeitungsvermögen übersteigen. Dabei hängt die Frage, ob ein Ereignis „traumatisierend“ wirkt von Beidem ab, von der Art und Stärke des Ereignisses/der Situation und von der Person, die dem Ereignis/der Situation ausgesetzt ist. Auf Seiten der Person spielt oft eine entscheidende Rolle, in welcher Gesamtverfassung sie sich befindet, ob ein Ereignis/eine Situation „traumatisch“ wirkt oder verarbeitet werden kann.
Trotz dieser Wechselseitigkeit muss man aber offenbar unterstellen, dass es keine Person gibt, die nicht durch ein ausreichend intensives Ereignis traumatisierbar wäre. Es gibt vermutlich auch Ereignisse und Situationen, die schon aufgrund ihrer Schwere oder Unvereinbarkeit mit menschlichem Leben für alle Menschen „traumatisierende“ Wirkung haben. Umgelehrt gibt es Menschen, deren Abwehrmechanismen und Bewältigungsfähigkeit besonders stark ausgeprägt oder flexibel sind bzw. deren Empfindlichkeit (Vulnerabilität) für ein bestimmtes „traumatisierendes“ Ereignis überdurchschnittlich gering ist. Diese Menschen sind dann gegenüber solchen Ereignissen im Durchschnitt resistenter als andere.
Ob ein Ereignis oder eine Situation „traumatisierend“ (im Sinne einer PTSD) wirkt, hängt also nicht nur von der Schwere oder Art des Ereignisses, sondern auch von der momentanen konstitutionellen Empfänglichkeit des Betreffenden bzw. seiner Abwehrstärke zu diesem Zeitpunkt ab und von der Fähigkeit oder Unfähigkeit, das Erlebte über die Zeit hinweg integrieren zu können.
Ob einer „Traumatisierung“ und der damit verbundenen Symptomatik ein Krankheitswert zugesprochen wird, ist in Einzelfällen sehr davon abhängig, wie glaubhaft der Traumatisierte sein Leiden darstellen kann, wie gross die gesellschaftliche Akzeptanz für derartige „Probleme“ ist. Es gibt halt den, dem man „es abnimmt“ und den, dem man „Simulation“ zutraut. (Es gibt, so glaube ich zu beobachten, eine Tendenz, Randgruppen (z.B: auch Ausländern, aber auch Vermögenden) eher ein Simulieren bzw. hysterisches Agieren zu unterstellen und Mittelständlern (dem Durchschnittsbürger) eher zu glauben.)
In der deutschsprachigen Psychiatrie sind Traumatisierungen v.a. im Zusammenhang mit den Weltkriegen Gegenstand emotionsgeladener Konzeptualisierungen gewesen. Bereits 1889 prägteOppenheim den Begriff der „traumatischen Neurose„, wobei er von einer Schädigung des Nervensystems ausging, der die psychischen Symptome dann erst folgen.
Anpassungsstörung
Unterschieden werden bei der Anpassungsstörung nach ICD-10 folgende Varianten:
- kurze depressive Reaktion (F43.20)
- verlängerte depressive Reaktion (F43.21)
- Angst und depressive Reaktion, gemischt (F43.22)
- mit vorwiegender Störung anderer Gefühle (43.23)
- mit vorwiegender Störung des Sozialverhaltens (43.24)
- mit gemischter Störung von Gefühlen und Sozialverhalten (F43.25)
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