付記する学位プログラム名: グローバル生存学大学院連携プログラム / 京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22151号 / 社医博第99号 / 新制||社医||10(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 古川 壽亮, 教授 森田 智視, 教授 村井 俊哉 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

This paper presents results from cost-analysis research for treating Post-Traumatic Stress Disorder in adults. Data for this research was provided by Cigna, a nation-wide healthcare manager in the United States of America. The sample size was 12,845 adults who were diagnosed with PTSD and received outpatient individual and family psychotherapy from one of the following mental health care providers: Marriage and Family Therapists (MFTs), Master’s Nurses (RNs), Medical Doctors (MDs), Professional Counselors (LPCs), Psychologists (PSYs), and Social Workers (MSWs). Results were compared across treatment modality, across practitioner license type and between practitioner educational levels. The results demonstrated that family therapy was most cost effective and used the fewest sessions, while mixed therapy was least cost effective. Among practitioner licensure types MDs were found to be the most cost effective, while the group of RNs, MSWs and MFTs were least cost effective compared to one another. Also, no significant differences in cost effective treatment outcomes were found between Masters Level and Doctoral Level practitioners.

The material in current emergency medical services (EMS) curricula is insufficient to prepare prehospital emergency medical care personnel recognize the signs and symptoms of post-traumatic stress disorder (PTSD) within their workforce. Prehospital emergency textbooks focus on treating patients affected with PTSD, but there is very little included about how EMS professionals may also be affected. Moreover, supervisors and managers of EMS agencies receive very little education on workforce PTSD in their personnel. The purpose of this study was to understand the educational preparation of EMS supervisors in order to develop a PTSD-awareness course. The research question investigated the educational preparation that EMS supervisors receive. The conceptual framework of the study was Conti-O’Hare’s wounded healer theory. EMS professionals are wounded healers from frequent critical incident exposure. A qualitative approach featuring a case study design was used. The study included 9 participants. A focus group was used that consisted of three paramedics and three emergency medical technicians (EMTs). Separate interviews were conducted with three EMS supervisors. Data gained from the focus group and individual interviews were analyzed through coding with the goal of investigating the education received by EMS supervisors on PTSD. The themes that emerged were EMS supervisors do not receive enough education on workforce PTSD and a course specifically targeted on this subject is needed. Positive social change may be achieved through this study by enabling EMS managers to help paramedics and EMTs cope with a critical incident (CI) improving prehospital healthcare.

Cette recherche a étudié l’évolution psychique de neuf victimes directes des attentats qui ont touché Paris durant l’année 2015 et dont les symptômes étaient atypiques, voire, inexistants, a priori. Si les symptomatologies d’états de stress post traumatiques caractéristiques sont communément admises, tant par les soignants, que par les acteurs juridiques de la réparation en dommage corporel, les états de dissociation péri et post traumatiques, lorsqu’ils sont identifiés, ne sont, en revanche, jamais envisagés autrement que comme des temps de latences augurant de futurs états de stress post traumatiques sévères. A l’aide des contenus d’entretiens cliniques réalisés à trois mois puis dix-huit mois des attentats, accompagnés de deux passations d’une échelle d’évaluation des états de stress post traumatiques (PCL/S), l’évolution psychologique de neuf victimes directes, sans symptômes caractéristiques apparents, a ainsi été effectuée. Cette étude a permis de démontrer que chez certains sujets, la confrontation au Réel de la mort se fait dans une telle violence qu’elle engendre la mise en marche de mécanismes de défense archaïques tel le déni de l’effroi décrit par Lebigot (2005) puis le clivage, et non des tableaux caractéristiques d’état de stress post traumatiques. Chez deux tiers des sujets, il a été démontré que la réassociation par le langage et le retour aux processus de symbolisation étaient néanmoins possibles, sans effondrement pathologique, mais en respectant une progression lente vers l’élaboration du traumatisme, dans le cadre d’alliances thérapeutiques étayantes et ininterrompues. Chez un tiers des sujets, en revanche, la permanence de tels tableaux cliniques, c’est-à-dire asymptomatiques pour deux d’entre eux, ou caractérisé par une amnésie dissociative pour l’un d’entre eux, n’a pas permis de déterminer le caractère adaptatif et non pathologique de tels mécanismes dissociatifs. L’ensemble des résultats démontre néanmoins la nécessité d’accroître les connaissances sur le sens, le repérage et la fonction de tels mécanismes, qui ne sont pas toujours identifiés, du fait même de leur origine qui exclue toute capacité de verbalisation de la part des victimes, mais qui nécessitent cependant des proposition soins appropriées. / This research studied the psychological evolution of nine direct victims of the terrorist attacks that struck Paris in 2015 and whose symptoms were, at first glance, atypical, or even non-existent. While the symptomatologies of post-traumatic stress disorder are commonly recognised, both by carers and legal bodies involved in physical injury compensation, peri and post-traumatic dissociative disorders, when they are identified, are never perceived as anything other than periods of latency, predicting future severe post-traumatic stress disorder.The psychological evolution of the nine direct victims lacking apparent typical symptoms was thus studied based on the content of clinical interviews carried out three months and eighteen months after the attacks, backed by two assessments using the PCLS rating scale for post-traumatic stress disorder. This study has enabled us to show that with some subjects the confrontation with the real of death occurred in such violence that it triggered archaic defence mechanisms, such as denial of the dread as described by Lebigot (2005) then splitting, and not the typical presentations of post-traumatic stress disorder. With two-thirds of the subjects, it was shown that reassociation through language and a return to the process of symbolisation were still possible, without a pathologic breakdown, by respecting a slow progression towards the formulation of the trauma as part of continuous and substantiated therapeutic relationships. However, with one third of subjects the permanence of such clinical presentations, i.e. asymptomatic for two of them or characterised by dissociative amnesia for one of them, made it impossible to determine the adaptive and non-pathological character of such dissociative mechanisms. Nevertheless, the combined results show there is a need to learn more about the meaning, identification and function of these mechanisms which are not always identified, precisely because of their cause which excludes all ability on the part of victims to express themselves, but which nonetheless require that appropriate treatment be offered.

In March 2012, the Durban High Court found three accused guilty of murder on two of the accused’s parents. The Lotter case was covered extensively by the media, because of its unusual story: The two Lotter siblings claimed that they were brainwashed by the sister’s boyfriend as he had made them believe that he was the third son of God. As the siblings’ defences they decided to use the controversial defence of non-pathological criminal incapacity. This dissertation gives an extensive outline of case law that has covered this defence. While attempting to define this defence, the courts have limited its uses to such an extent, that it appears to be abolished. Viewpoints of academic authors have been considered to assist the reader in defining new borders for this defence. Redefinition is necessary in light of the Constitution of the Republic of South Africa. Concepts such as ‘coercive persuasion’ are explained in terms of psychological, psychiatric and legal backgrounds. Other countries have taken measures to restrict the use of coercive persuasion, specifically religious coercive persuasion. We therefore compare South Africa’s lack of legislation to those countries that have adopted anti-coercive persuasion legislation as the Constitution permits that foreign law may be taken into account when interpreting and developing the law. There is also a discussion on the role of expert evidence in a South African court, specifically the psychologist, as well as discussion on Post-Traumatic Stress Disorder and the Battered Partner/Spouse/ Wife syndrome in context of coercive persuasion. Coercive persuasion is viewed in terms of the defence of non-pathological criminal incapacity – as a prevailing factor that discredits the second (conative) leg of the capacity test: The ability to act in accordance with right and wrong. Defences such as automatism and private defence are also considered in context of coercive persuasion. By analysing the case of Cézanne Visser along with the other cases that considered the defence of non-pathological criminal incapacity, one is able to view that the Lotter case is not the first case that mentions a person coercively persuaded by her partner to commit crimes. After the discussion of the Lotter case (the facts and judgment are covered in detail), similarities are drawn between the two women that were coercively persuaded by their partners. An alternative judgment and sentence reveals that the Lotter case had an opportunity to develop the defence, in context of coercive persuasion, and in light of the Constitution, but failed to do so. The recommendations that follow are based on the defective dialogue that occurs between psychologists and psychiatrists, the unnecessary absence of expert evidence in court, the transformation of the defence of non-pathological criminal incapacity, a development of the term ‘coercive persuasion’ for purposes of the court when considering cases that deals with religious practices and the lack of legislative protection for women who murder their abusive husbands. / Dissertation (LLM)--University of Pretoria, 2012. / Public Law / unrestricted

Childhood and adolescent bullying victimization procures mental health issues and dysfunction. Using a longitudinal design from the McMaster Teen study dataset, a semi-parametric group- based trajectory analysis was used to identify distinct patterns of peer victimization across ages 10 to 18. A three-class solution of peer victimization was selected. Most individuals followed a low decreasing trajectory of peer victimization (71.3%). The next largest group followed a moderate decreasing peer victimization trajectory (25.2%), and the smallest group followed a high stable peer victimization trajectory (3.5%). These trajectory groups were used to predict Borderline Personality Disorder (BPD) symptoms and Post-Traumatic Stress Disorder (PTSD) in emerging adulthood (ages 19 to 22). Results indicated that the high stable and moderate decreasing groups differed from the low decreasing group on BPD symptoms; individuals who were bullied by their peers in childhood and adolescence were more likely to have elevated symptoms of BPD in adulthood. However, when controlling for gender and childhood maltreatment, this differentiation only held true for the high stable group. Results also indicated that children and adolescents who followed a high stable trajectory of bullying victimization were more likely to meet PTSD diagnostic criteria in emerging adulthood than those who followed a low decreasing or moderate decreasing trajectory. The implications of the positive associations of childhood and adolescent bullying victimization on BPD symptoms and PTSD are considered via a group socialization theory lens. High levels of bullying victimization are explained as a form of relational trauma. Results suggest that peer relations are powerful enough to lead to subsequent personality pathology, and implications of these associations are examined through a developmental trauma framework. Understanding the developmental impact of childhood and adolescent bullying on BPD symptoms and PTSD provides insight and supports prevention and intervention initiatives at the school level and in clinical practice.

Posttraumatic stress disorder (PTSD) symptoms and substance use have been associated with increased suicide ideation, but have rarely been examined within a larger theoretical context of suicide risk. The interpersonal theory of suicide posits that feeling disconnected from others (i.e., thwarted belongingness) and feeling like a burden on others (i.e., perceived burdensomeness) are associated with increased suicide ideation. We hypothesized that perceived burdensomeness and thwarted belongingness would mediate the relation between PTSD symptoms and suicide ideation, and that using substances to cope would moderate these relations. Participants were 254 college students reporting exposure to potentially traumatic experiences. Findings from a moderated mediation analysis indicated that perceived burdensomeness, but not thwarted belongingness, mediated the relation between PTSD symptoms and suicide ideation, and using substances to cope moderated this relation. Therapeutic interventions aimed at reducing suicide ideation might benefit from decreasing perceived burdensomeness and the use of substances to cope.

An Unbearable Illumination of Truth is a series of sculptures created to explore the connection between trauma and healing. The sculptural exhibition addresses economic, occupational, childhood, sexual, and gender-based trauma. These sculptures incorporate familiar motifs and visual metaphors to express narratives of varying types of traumas. A broad range of sculptural materials (such as wood, fabric, and found objects) and methods are used to create these symbolic, objective forms. The juxtaposition of shelters with other forms and materials visually enacts the themes of vulnerability and intrigue that characterizes traumatic incidents. Shelters are referenced throughout this entire body of work as an allegory for identity. Ultimately, this work is intended to induce empathy and raise awareness of important, underlying social issues that revolve around trauma. This message is especially important today due to a dramatic increase of trauma related issues as a result of the COVID-19 pandemic.

The present investigation evaluated whether dispositional use of emotional approach coping partially accounts for the association between parental response to emotional expression and posttraumatic stress symptoms (PTSS) in a sample of 252 trauma-exposed individuals drawn from a pool of college students and college-age members of the community at-large. An online survey assessed parental reactions to participants' negative emotions during childhood (i.e., offspring retrospective report), as well as participant trauma history, PTSS, and use of emotional approach coping. Findings complement literature illustrating the long-lasting implications of the parent-child relationship, such that both supportive and unsupportive parenting were related to PTSS. Supportive parental reactions also were related to emotional expression, but not emotional processing, and unsupportive reactions did not significantly relate to either aspect of emotional approach coping. Notably, emotional approach coping strategies were unrelated to PTSS in the full sample, and thus the indirect effects models were not supported. Post hoc analyses indicated preliminary support for the indirect effect of emotional expression on the relation between supportive parenting and PTSS in the local college student sample (n = 117). Limitations and implications for future research are discussed.

An increasing number of women are serving in the military. We initiated a retrospective study to evaluate vitamin D status and monitoring in female veterans, and to examine the potential link between vitamin D status, age, race, post-traumatic stress disorder (PTSD), health care costs, and utilization. Approximately 44 percent of the 3,608 female veterans evaluated between 2001 and 2010 were vitamin D deficient (25(OH)D < 20 ng/ml), a rate substantially higher than that of the general population. While younger (<55 years) and older (55+ years) women did not differ significantly in initial vitamin D status, older women had significantly more vitamin D monitoring and follow-up testing than younger women. Approximately 44 percent of vitamin D deficient women did not receive follow-up vitamin D testing. Minority female veterans were most likely to be vitamin D deficient. Female veterans with PTSD did not differ from others regarding their initial vitamin D status; those that were initially deficient were significantly more likely to receive follow-up testing and were more likely to achieve a replete state. Vitamin D deficiency in female veterans was also associated with increased health-care costs. Appropriate monitoring and replacement of vitamin D should be offered to all female veterans.