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重症精神疾患における心的外傷、子ども時代の逆境体験、心的外傷後ストレス障害の実態についての研究

冨本 和歩 東北大学

2021.03.25

概要

【背景】
統合失調症をはじめとする精神病性障害、双極性障害や大うつ病性障害を含む気分障害の病態、経過に対して、心的外傷（トラウマ）、子ども時代の逆境体験（ adverse childhood experiences: ACEs ）、 心的外傷後ストレス障害（posttraumatic stress disorder: PTSD）が影響することが知られている。精神症状の遷延、慢性化、治療への反応の悪さ、社会機能の低下を特徴とした疾患横断的な概念である重症精神疾患（severe mental illness: SMI）の者には、トラウマや ACEs の既往、PTSD の併存が多いと言われ、症状や機能に⻑期的な影響を及ぼすと考えられている。トラウマ体験の想起に基づくトラウマへの頻回の曝露は、回避、自己・他者・世界に対する認知と感情のネガティブな変化、過度の警戒といった PTSD 相当の症状につながり、SMI の精神症状の経過を複雑にすることが分かってきている。しかし、通常これらの体験は被害を受けた者から語られることは少なく、臨床現場でも話題に上ることが少ないため、その実態は把握されていないことが多い。このため、トラウマ、ACEs、PTSD の併存を正確に把握し、これらが SMI の症状や機能にどのように関連するかを調べ、実態を把握することで、SMI の者に対する適切な介入が可能となり、症状や機能の改善に寄与することが期待される。

【目的】
欧米の先行研究では、SMI の者のトラウマ、ACEs、PTSD の併存は一般人口よりも多いことが示されており、こうしたトラウマ性の体験は SMI の社会機能の低下に関連していると言われている。アジア、日本においても同様にこうしたトラウマ性の体験を経験している SMI の者は多く存在すると考えられ、社会機能の低下にも影響をしている可能性が考えられる。しかし、トラウマ、ACEs、 PTSD は、国や地域の文化、社会的要因に大きく影響するといわれているが、 SMI におけるトラウマ性の要因に関する研究の多くは欧米で行われており、その他の地域における研究は乏しい。アジアにおいてはその実態が十分に把握されておらず、トラウマ性の体験を持つ SMI の者が適切な診断や治療を受けられていない可能性があることを考慮すると、アジアにおける実態を把握することは重要である。本研究では、SMI におけるトラウマ、ACEs、PTSD に着目し、それぞれの体験の実態と、SMI の特徴のひとつである社会機能の低下との関連を明らかにすることを目的とする。

【本研究の構成】
本研究は 3 つの研究から構成されている。研究 1 では、SMI の者を対象として、トラウマ体験と、併存する PTSD の割合を検討する。研究 2 では、同一の対象者に対して、18 歳未満で経験された ACEs の割合を検討する。研究 3 では SMI の社会機能の低下に着目し、研究 1、研究 2 で調べた体験をもとに、トラウマ、ACEs、PTSD を含めた、どのような人口統計学的、臨床的要因が社会機能の低下を予測する要因であるかを検討する。

【方法】
研究 1、2 では、対象者は東北大学病院精神科の外来に現在通院中で、過去 10年以内に精神科の入院歴のある、精神病性障害の患者 51 名、気分障害の患者 31名の計 82 名を対象とした。精神疾患の診断・統計マニュアル第 5 版（Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5）による臨床診断に加えて、精神疾患簡易構造化面接法（Mini-International Neuropsychiatric Interview: MINI）を用いて診断を確認した。

研究 1 で対象とするトラウマ体験は、1）DSM-5 による PTSD 診断基準のうち、出来事基準（A 基準）に基づく体験、2）精神科における入院治療に基づいた体験、3）東日本大震災の被災に基づいた体験とした。A 基準を満たすトラウマについては、ライフイベンツチェックリスト DSM-5 版（Life Events Check List for DSM-5: LEC-5）を用いて把握し、体験の詳細を面接法で聴取した後、それが A 基準に該当するか評価者が判断し、割合を求めた。精神科の入院治療に基づくトラウマ体験、東日本大震災の被災によるトラウマ体験は対象者全員に聴取し、現在もトラウマとして想起されると報告された場合に、トラウマと評価した。対象者は体験の中から、現在最もトラウマである体験ひとつに対して、 PTSD 相当の症状の有無の評価に用いる自記入式尺度である PTSD チェックリスト DSM-5 版（PTSD Check List for DSM-5: PCL-5）を記入した。次に、半構造化面接による PTSD の診断を PTSD 臨床診断面接尺度 DSM-5 版（Clinician-Administered PTSD Scale for DSM-5: CAPS-5）を用いて行い、割合を求めた。また、診療録を後方視的に調査し、臨床的に PTSD の診断であった者の割合を求めた。

研究 2 では、研究 1 と同様の対象者に対して、18 歳未満で経験した虐待・ネグレクト、いじめられた体験、親との死別・離別と定義した ACEs の割合を求めた。虐待・ネグレクトについては、子ども時代のトラウマ質問紙（Childhood Trauma Questionnaire Short Form: CTQ-SF）を用いて評価し、心理的虐待、身体的虐待、性的虐待、心理的ネグレクト、身体的ネグレクトの体験の有無とその重症度を調べた。いじめられた体験、親との死別、親との離別の体験は、対象者全員に対して面接法によって、これらの体験が現在もトラウマとして想起されるかどうかを聴取してその割合を求めた。

研究 3 では、研究 1、2 で CAPS-5 を完了した者 78 名を対象とした。対象者の評価には、陽性・陰性症状評価尺度（Positive and Negative Syndrome Scale: PANSS）と機能の全体的評定（Global Assessment of Functioning: GAF）を実施して、精神症状と機能を評価した。次に GAF 得点とトラウマ体験の有無、虐待・ネグレクト、PTSD の有無を含めた臨床的変数の相関を求めた。最後に、GAF得点を従属変数として、トラウマの有無、CTQ-SF 得点による虐待・ネグレクトの重症度、CAPS-5 による PTSD 診断の有無、精神病性障害か気分障害かをみた診断カテゴリーを含めた臨床指標との関連を、重回帰分析を用いて調査した。

【結果】
［研究 1］
少なくともひとつ以上のトラウマを経験した割合は 68.3％だった。身体的暴力と性的体験に基づくトラウマが多かった。CAPS-5 による PTSD 診断の者は 12.8％、PCL-5 による PTSD 相当の症状を有する者は 36.7％だった。一方、診療録に PTSD の診断が記載されていた者は 1 名（1.2％）だった。精神科の入院治療に基づくトラウマは 25.6％、東日本大震災の被災に基づくトラウマは 29.3％だった。

［研究 2］
少なくともひとつ以上の ACEs を経験した割合は 90.2％だった。CTQ-SF による虐待・ネグレクトを少なくともひとつ以上経験していた割合は 86.5％だった。虐待・ネグレクトの平均累積数は 2.3 だった。いじめられた体験は 70.7％が報告し、親との死別は 4.9％、離別は 17.1％が経験していた。

［研究 3］
GAF 得点で評価された社会機能は、CAPS-5 による PTSD 診断があること（r=-0.278, p=0.014）、子ども時代の虐待・ネグレクトを経験している場合（r=- 0.253, p=0.025）、そして PTSD 症状（r=-0.255, p=0.024）が強いほど低かった。一方、トラウマ体験の有無は社会機能とは関連しなかった（r=-0.178, p=0.120）。また、社会機能は精神症状が悪いほど低く（r=-0.549, p<0.001）、診断が精神病性障害である方が、気分障害であることよりも低かった。人口統計学的要因としては、教育年数が低いほど（r=-0.228, p=0.045）、就労をしていないほど（r=0.553, p<0.001）社会機能は低かった。重回帰分析では SMI の社会機能の低下には、精神病性障害か気分障害かをみた診断カテゴリー、および PTSD 診断の併存があることが予測する要因として関連した。

【考察】
本研究では、SMI の病態や経過に影響を与えうるトラウマ、ACEs、PTSD の併存に着目し、これらの割合を調べ、さらに SMI の社会機能の低下にどの人口統計学的、臨床的要因が関連するかを調査した。

研究 1、研究 2、研究 3 の結果を総合すると、本研究のサンプルでは、トラウマ、ACEs、PTSD を経験している者の割合が多かった。また、SMI の社会機能の低下に影響する要因として、精神病性障害の診断があることに加え、PTSD 診断が併存していることが関連した。このように日本においても SMI の人々はトラウマ性の体験を経験する割合が高いと考えられ、臨床場面では SMI の社会機能の低下に影響する PTSD 診断の併存の有無を適切に把握する必要があると考えられた。

それぞれの研究について考察すると、研究 1 の結果は、SMI のトラウマ、PTSDが一般人口に比べて多く経験されているという先行研究を支持するものであった。特に身体的暴力、および性的暴力を含む性的体験に基づくトラウマの割合が多かったことは、SMI の者が PTSD のリスクの高い出来事による被害に遭遇しやすい可能性があることを示している。欧米とは社会や文化の異なるアジアでも、SMI の者でトラウマ性の体験を高い割合で経験している可能性があることが示された。診療録では 1 名のみが PTSD の併存診断であり、欧米と同様に本邦でも SMI のトラウマや PTSD が過小診断されている可能性が明らかになった。また、精神科入院治療による体験はトラウマとなりうる可能性があり、先行研究における割合よりは低かったものの、本研究での対象者の 4 人に 1 人がこの体験がトラウマであると報告したことは、隔離拘束を含めた強制的な治療が増えている日本において看過できない結果であった。

研究 2 の結果は、SMI の ACEs が一般人口よりも多く経験されているという先行研究の報告と一致し、虐待やネグレクトの経験の割合も、欧米と同等の割合であった。また、本研究で心理的虐待、心理的ネグレクト、身体的ネグレクトの割合が高かったことは先行研究と類似していた。いじめられた体験は、日本の一般人口での割合よりも高かったが、SMI を対象とした研究は欧米の報告を含めて他になく、今後、さらなる研究が必要である。親との死別は欧米の精神疾患を対象とした研究、および日本の一般人口における研究よりも低く、少なくとも本研究の結果からは SMI において死別を経験した者の割合が高いとは言えなかった。親との離別は、欧米の精神疾患を対象とした研究より低く、日本の一般人口での割合の範囲内であり、日本の離婚率の低さが結果に反映された可能性が考えられた。SMI の研究で対象となる ACEs の多くは身体的虐待と性的虐待であり、心理的虐待、心理的ネグレクト、身体的ネグレクト、いじめられた体験、親との死別・離別は研究が乏しい。本研究は SMI で経験されうる ACEs を幅広く調査した初めての研究だったが、これらが SMI の症状や機能にどのような影響を与え、関連するかについては、今後の研究が重要である。

研究 3 において、SMI の社会機能の低下に対して、相関分析では PTSD 診断の併存、自覚的な PTSD 症状、虐待やネグレクトが関連している可能性が示された。重回帰分析の結果を見ると、精神病性障害の診断であること、PTSD 診断が併存することが社会機能の低下を有意に予測した。統合失調症をはじめとした精神病性障害は SMI を構成する主要な疾患群であり、過去の研究でも精神病性障害では社会機能の低下が著しいことが示されているが、本研究の結果はこのことに一致した。また、PTSD 診断の併存が SMI の社会機能の低下に関連したという結果からは、SMI の人々に対してもトラウマを適切に評価し、PTSD の併存の有無を把握することが重要であることが示唆された。一方、過去の出来事であるトラウマ体験の有無や虐待・ネグレクトの既往の影響は限定的であった。トラウマ性の要因が SMI の症状や機能に与える影響を解明していくために、サンプル数を増やしたさらなる研究が必要であると考える。

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