Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut.
Department of Psychiatry, Columbia University Medical Center, New York, New York3New York State Psychiatric Institute, New York.
JAMA Psychiatry. 2017 Apr 1;74(4):407-415. doi: 10.1001/jamapsychiatry.2016.3325.
Posttraumatic stress disorder (PTSD) is a common psychiatric illness, increasingly in the public spotlight in the United States due its prevalence in the soldiers returning from combat in Iraq and Afghanistan. This educational review presents a contemporary approach for how to incorporate a modern neuroscience perspective into an integrative case formulation. The article is organized around key neuroscience "themes" most relevant for PTSD. Within each theme, the article highlights how seemingly diverse biological, psychological, and social perspectives all intersect with our current understanding of neuroscience.
Any contemporary neuroscience formulation of PTSD should include an understanding of fear conditioning, dysregulated circuits, memory reconsolidation, epigenetics, and genetic factors. Fear conditioning and other elements of basic learning theory offer a framework for understanding how traumatic events can lead to a range of behaviors associated with PTSD. A circuit dysregulation framework focuses more broadly on aberrant network connectivity, including between the prefrontal cortex and limbic structures. In the process of memory reconsolidation, it is now clear that every time a memory is reactivated it becomes momentarily labile-with implications for the genesis, maintenance, and treatment of PTSD. Epigenetic changes secondary to various experiences, especially early in life, can have long-term effects, including on the regulation of the hypothalamic-pituitary-adrenal axis, thereby affecting an individual's ability to regulate the stress response. Genetic factors are surprisingly relevant: PTSD has been shown to be highly heritable despite being definitionally linked to specific experiences. The relevance of each of these themes to current clinical practice and its potential to transform future care are discussed.
Together, these perspectives contribute to an integrative, neuroscience-informed approach to case formulation and treatment planning. This may help to bridge the gap between the traditionally distinct viewpoints of clinicians and researchers.
创伤后应激障碍（PTSD）是一种常见的精神疾病，由于从伊拉克和阿富汗返回的士兵中普遍存在这种疾病，因此在美国越来越受到公众关注。本教育评论介绍了一种将现代神经科学观点纳入综合病例形成的当代方法。本文围绕与 PTSD 最相关的关键神经科学“主题”组织。在每个主题中，本文都强调了看似不同的生物、心理和社会观点如何都与我们当前对神经科学的理解相交。
任何当代 PTSD 的神经科学形成都应该包括对恐惧条件作用、失调电路、记忆再巩固、表观遗传学和遗传因素的理解。恐惧条件作用和其他基本学习理论的元素为理解创伤事件如何导致一系列与 PTSD 相关的行为提供了框架。电路失调框架更广泛地侧重于异常网络连接，包括前额叶皮层和边缘结构之间的连接。在记忆再巩固的过程中，现在很清楚，每次记忆被重新激活，它都会暂时变得不稳定——这对 PTSD 的产生、维持和治疗都有影响。各种经历（尤其是早期经历）引起的表观遗传变化会产生长期影响，包括对下丘脑-垂体-肾上腺轴的调节，从而影响个体调节应激反应的能力。遗传因素非常相关：尽管 PTSD 与特定经历有明确的联系，但它被证明具有高度遗传性。讨论了这些主题中的每一个对当前临床实践的相关性及其改变未来护理的潜力。
这些观点共同为病例形成和治疗计划提供了一种综合的、受神经科学启发的方法。这可能有助于弥合临床医生和研究人员之间传统上截然不同的观点之间的差距。
