国内の PTSD 患者に対する認知処理療法の事例研究 Cognitive Processing Therapy for Japanese PTSD Patients: A Study of Case Series MASAKI, Tomoko HORIKOSHI, Masaru KONISHI, T
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2 国内の PTSD 患者に対する認知処理療法の事例研究 Cognitive Processing Therapy for Japanese PTSD Patients: A Study of Case Series MASAKI, Tomoko HORIKOSHI, Masaru KONISHI, Takako はじめに Post Traumatic Stress Disorder PTSD APA, 2000 PTSD PTSD WHO, 2012 PTSD Foa et al., 2009 National Institute for Health and Clinical Excellence, 2005 Bisson, 2007 Prolonged Exposure Therapy PE Foa et al., 2005 Cognitive Processing Therapy CPT Resick & Schinicke, 1992 PTSD PE 2002 CPT Benedek et al., 2009 PE CPT PTSD Resick et al., 2002 DV CPT 95
3 Iverson et al., 2011 Chard et al., 1999 PTSD CPT PTSD CPT CPT CPT CPT プログラム概要 CPT Patricia Resick PTSD Resick & Schinicke, CPT 表 1.CPT プログラム内容 セッション 内容 宿題 1 導入と教育 出来事の意味 2 出来事の意味 ABC シート 3 考えや感情を捉える ABC シート トラウマ記録 4 トラウマティックな出来事を思い出す ABC シート トラウマ記録 5 スタックポイントを探る 考え直しのための質問シート 6 考え直しのための質問 よくない思考パターンシート 7 よくない思考パターン 考え直しシート ( 総合版 ) 8 安全に関する問題 考え直しシート ( 総合版 ) 9 信頼に関する問題 考え直しシート ( 総合版 ) 10 力 / コントロールに関する問題 考え直しシート ( 総合版 ) 11 価値に関する問題 考え直しシート ( 総合版 ) 出来事の意味 12 親密さに関する問題と出来事の意味 1 1 PTSD CPT 2 Impact Statement 96
4 PTSD Stuck Point CPT 3 ABC ABC worksheet Challenging Questions Worksheet Patterns of Problematic Thinking Worksheet PTSD CPT 12 PTSD 症例提示 PTSD CPT CPT CPT 方法 CPT CPT 2± CPT PTSD Clinical Administered Scale for PTSD CAPS Post Traumatic Cognitive Inventory JPTCI CPT PTSD Impact of Event Scale-Revised IES-R Dissociative Experiences Scale DES Beck Depression Inventory- BDI-II Overall Anxiety Severity and Impairment Scale OASIS CPT CPT 97
5 症例 1:A 子 A CPT A PTSD CPT 事前評価 A 2 CAPS PTSD JPTCI 3 PTSD A 表 2. 症例 1 の治療介入前後得点 評価尺度 事前評価 (pre) 事後評価 (post1) 6 か月後 (post2) CAPS 合計 74( 頻度 39/ 強度 35) 77( 頻度 41/ 強度 36) 20( 頻度 11/ 強度 10) CAPS 再体験 20( 頻度 8/ 強度 12) 23( 頻度 12/ 強度 11) 12( 頻度 7/ 強度 5) CAPS 回避 36( 頻度 22/ 強度 14) 31( 頻度 17/ 強度 14) 8( 頻度 3/ 強度 5) CAP 過覚醒 18( 頻度 9/ 強度 9) 23( 頻度 12/ 強度 11) 0( 頻度 0/ 強度 0) JPTCI 合計 Ⅰ 自己への否定的認知 Ⅱトラウマに関する自責の念 Ⅲ 社会への否定的認知 IES-R BDI-II DES OASIS
6 PTSD 治療介入 1 2 Impact Statement A CPT A ABC 3 A A ABC 4 PTSD A 5 A 99
7 A ABC 6 7 A % 20% A A % 30 80% 0 60% 0 100
8 PTSD A 結果 A CPT 1 IES-R BDI-II OASIS DES A IES-R DES BDI-II OASIS 線形 (DES) 10 0 PRE POST POST2 図 1. 症例 1 の CPT 各セッションの心理尺度推移 PTSD PTSD Non Trauma 101
9 PTSD PTSD PTSD Non Trauma Pre 6.00 Mid Post Post2 Non trauma Trauma with no PTSD PTSD 図 2. 症例 1 の JPTCI( 外傷後認知 ) 下位尺度毎の得点推移 CAPS PTSD PTSD 得点 Pre Post1 Post2 CAPS 総得点 再体験 回避 感情麻痺 覚醒亢進 図 3. 症例 1 の CAPS 総得点及び下位尺度の得点推移 102
10 PTSD 症例 2:B 子 B B B ASD PTSD PTSD CPT B 事前評価 CAPS B CAPS 3 JPTCI 3 PTSD 表 3. 症例 2 の治療介入前後得点 評価尺度 事前評価 (pre) 事後評価 (post1) CAPS 合計 73( 頻度 40/ 強度 33) 13( 頻度 8/ 強度 5) CAPS 再体験 25( 頻度 10/ 強度 15) 5( 頻度 3/ 強度 2) CAPS 回避 29( 頻度 18/ 強度 11) 2( 頻度 1/ 強度 1) CAP 過覚醒 19( 頻度 12/ 強度 7) 6( 頻度 4/ 強度 2) JPTCI 合計 Ⅰ 自己への否定的認知 Ⅱトラウマに関する自責の念 Ⅲ 社会への否定的認知 IES-R BDI-II 17 5 DES OASIS 8 0 B B 103
11 治療介入 B ABC B 4 A4 B B B B 5 A4 1 B
12 PTSD 8 5 B 5 CPT B 結果 B 1 3 B CPT 4 IES-R BDI-II 4 9 OASIS 得点 IES-R DES BDI-II OASIS P R E P O S T 図 4. 症例 2 の IES-R DES BDI-II OASIS 得点推移 105
13 10 12 PTSD Non Trauma PTSD PTSD Non Trauma 5 PTSD PTSD CAPS PTSD Pre Mid Post1 Non trauma Trauma with no PTSD PTSD 図 5. 症例 2 の JPTCI( 外傷後認知 ) 下位尺度毎の得点推移 得点 Pre Post CAPS 総得点 再体験 25 5 回避 感情麻痺 28 2 覚醒亢進 19 6 図 6. 症例 2 の CAPS 総得点及び下位尺度の得点推移 106
14 PTSD 考察 CPT A A B 2 A B 3 A B A B CPT A CAPS PTSD PTSD A CPT PTSD CPT 12 A 6 CPT PTSD PTSD B A CPT PTSD CPT 107
15 CPT CPT CPT PTSD PTSD CPT CPT PTSD 2 2 CPT 2 CPT 付記 B 文献 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text rev.). Washington, DC: Author. Asukai, N., Kato, H., Kawamura, N., Kim, Y., Yamamoto, K., Kishimoto, J., et al. (2002). Reliability and validity of the Japanese-language version of the impact of event scale-revised (IES-R-J): four studies of different traumatic events. J Nerv Ment Dis, 190(3), Benedek, D. M., Friedman, M.J., Zatzick, D., Ursano, R.J. (2009). Guideline watch(march 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder: America Psychiatric Association. Bisson J.A.M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews. Chard, K.M., Resick, P.A.,& Wertz, J.J. (1999). Group treatment of sexual assault survivors. In B.H. Young & D.D. Blake (Eds.), Grop treatments for post-traumatic stress disorders: conceptualization, themes, and process (pp.35-50). Philadelphia: Brunner/Mazel. Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A. M., Riggs, D. S., Feeny, N. C., et al. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), Foa, E. B., Keane, T. M., Friedman, M. J. Cohen, J.A. (Ed.). (2009). Effective treatments for PTSD; Practice guideline from the International Society for Traumatic Stress Studies, Second Edition: Guilford Press. Iverson, K.M., Gradus, J.L., Resick, P.A., Suvak, M.K., Smith, K.F., & Monson, C.M. (2011). Cognitivebehavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors. Journal of Consulting and Clinical Psychology, vol 79(2), Apr 2011,
16 PTSD National Institute for Health and Clinical Excellence (2005). Post traumatic stress disorder. The management of PTSD in adults and children in primary and secondary care. London/Leicester: Gaslell and British Psychological society. Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60(5), Wrold Health Organization. (2012). Sexual violence-understanding and addressing violence against women. World Health Organization. 109
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