，周海鈴(譯)，邱珊嬌(譯)，黃文靜(譯)，楊 輝(譯)

·世界全科醫(yī)學(xué)工作瞭望·

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現(xiàn)在其自行制定行業(yè)標(biāo)準(zhǔn)、自主進(jìn)行資質(zhì)考核及自主執(zhí)業(yè)等方面，也體現(xiàn)在《The Medical Republic》這一共享平臺上。Leon Piterman是醫(yī)學(xué)學(xué)士，醫(yī)學(xué)博士，教育學(xué)碩士，英國醫(yī)生學(xué)會會員，澳大利亞全科醫(yī)生學(xué)會會員，Monash University副校長、全科醫(yī)學(xué)教授，從事全科醫(yī)學(xué)臨床服務(wù)近40年；研究興趣為慢性病管理、心理健康、醫(yī)學(xué)教育；曾獲澳大利亞勛章，醫(yī)學(xué)部醫(yī)學(xué)教育獎(jiǎng)，澳大利亞全科醫(yī)生學(xué)會研究獎(jiǎng)，香港全科醫(yī)生學(xué)會研究獎(jiǎng)等；獲多項(xiàng)澳大利亞衛(wèi)生和醫(yī)學(xué)研究理事會等大型研究項(xiàng)目，發(fā)表科學(xué)文章和著作章節(jié)120余篇，是《全科醫(yī)學(xué)中的精神病學(xué)》合作著者。Piterman教授建議我國的全科醫(yī)生應(yīng)培養(yǎng)“共和”思想，以為全科醫(yī)學(xué)領(lǐng)域提供更多的平等交流機(jī)會。目前Piterman教授定期為《The Medical Republic》撰寫文章，本刊深受“醫(yī)學(xué)共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對Piterman教授的文章進(jìn)行編譯，并進(jìn)行連載刊登！本期Piterman教授為我們講述了一例為遭受創(chuàng)傷性事件家庭提供醫(yī)療服務(wù)的案例，指出全科醫(yī)生應(yīng)該為居民提供“以家庭為單位”的照顧，不僅要關(guān)心家庭成員的軀體疾病，也要重視家庭成員的身-心關(guān)聯(lián)，重視代際間情感和關(guān)系互動(dòng)的家庭社會史和家庭心理史。敬請關(guān)注！

《The Medical Republic》案例分享
——跨越幾代人的創(chuàng)傷：孩子的過錯(cuò)？

LeonPiterman1，周海鈴(譯)2，邱珊嬌(譯)2，黃文靜(譯)2，楊 輝(譯)1

注：本文首次刊登于《TheMedicalRepublic》

全科醫(yī)生；應(yīng)激障礙，創(chuàng)傷性

PITERMAN L.跨越幾代人的創(chuàng)傷：孩子的過錯(cuò)？[J].周海鈴，邱珊嬌，黃文靜，等，譯.中國全科醫(yī)學(xué)，2017，20(31)：3847-3849.[www.chinagp.net]

PITERMAN L.Transgenerational trauma:the sins of the child?[J].ZHOU H L,QIU S J,HUANG W J,et al,translators.Chinese General Practice，2017，20(31)：3847-3849.

全科醫(yī)生需要面對的，可能是由于創(chuàng)傷性事件觸發(fā)的大范圍內(nèi)家庭成員在健康方面的級聯(lián)影響。

全科醫(yī)生需要提供“以家庭為單位”的照顧，這種照顧常常會跨越家庭中的兩代、三代甚至是四代人。影響某一代人的事件，如疾病，通常也會影響其他幾代人。核心家庭內(nèi)的結(jié)構(gòu)與關(guān)系，使得各家庭成員不可避免地要共同受到創(chuàng)傷性事件的影響?；蛟S我們應(yīng)該感激這些事件的發(fā)生，因?yàn)檫@也意味著家庭成員間可以相互支持和幫助，只有必要的時(shí)候會需要醫(yī)務(wù)人員的幫助，當(dāng)然最重要的還是全科醫(yī)生。

作為全科醫(yī)生，我們經(jīng)常會遇到一些家庭被不明原因的創(chuàng)傷性事件極度困擾。我們經(jīng)常會覺得困惑，為什么這個(gè)家庭會遭受如此不幸的折磨？什么地方出了錯(cuò)？他們做了什么才會遭受如此懲罰？怎么去預(yù)防？全科醫(yī)生應(yīng)該以一種什么樣的定位來為家庭提供干預(yù)和支持，以盡量減少創(chuàng)傷性事件帶來的危害？一次意外事故、一場嚴(yán)重疾病、一段關(guān)系破裂，都可能是一連串事件的創(chuàng)傷觸發(fā)點(diǎn)，接下來要講述的故事中的“孩子迷失”也是一個(gè)觸發(fā)點(diǎn)。創(chuàng)傷性事件對其他家庭成員的影響，可能不僅在于心理上的(抑郁、焦慮、失眠、創(chuàng)傷后應(yīng)激障礙)，也可能是軀體上的，這一現(xiàn)象強(qiáng)調(diào)了心身聯(lián)系的重要意義。

我第一次見到亞歷克薩是在她3歲的時(shí)候，當(dāng)時(shí)她的外公喬治65歲、外婆索菲亞63歲，我已經(jīng)照顧了他們10年。喬治有肥胖癥、高血壓、2型糖尿病病史，索菲亞有高血壓、腎病史，考慮為IgA腎病。喬治和索菲亞直到最近還在郊區(qū)經(jīng)營著一家水果店，但現(xiàn)在他們已經(jīng)賣掉水果店，高興地開始退休生活了。

二十世紀(jì)六十年代初，喬治和索菲亞同許多希臘家庭一起移民到澳大利亞，他們?yōu)橥ㄟ^自己努力所得到的成就感到自豪。喬治和索菲亞有一個(gè)女兒，叫安娜，現(xiàn)在是化工專家，安娜的丈夫是會計(jì)師邁克爾。兩位老年人非常寵愛他們唯一的外孫女亞歷克薩，現(xiàn)在他們退休了，可以有更多的時(shí)間在安娜和邁克爾工作的時(shí)候照顧亞歷克薩。

安娜帶亞歷克薩來我這里就診。亞歷克薩有過敏史，表現(xiàn)為濕疹和哮喘。同時(shí)，亞歷克薩有嚴(yán)重的過敏家族史，特別是邁克爾那側(cè)的家庭。此次的就診原因?yàn)樯虾粑兰膊≌T發(fā)的哮喘加重。安娜和邁克爾均為35歲左右，身體健康。

在接下來的十年里，我頻繁地為這個(gè)家庭的三代人提供服務(wù)。喬治的健康狀況逐漸變差，70來歲的時(shí)候患了缺血性心臟病。不幸的是，索菲亞的身體也逐漸變差，需要接受透析治療。安娜和邁克爾的健康狀態(tài)保持良好。亞歷克薩十幾歲時(shí)，僅伴有偶爾的哮喘發(fā)作，她成績優(yōu)異，看起來適應(yīng)得很好。但在15歲那年，事情似乎變得非常糟糕，亞歷克薩拒絕使用預(yù)防哮喘的藥物，花很長時(shí)間在網(wǎng)絡(luò)群里聊天，拒絕參加家庭活動(dòng)。學(xué)習(xí)成績也下滑，而且有明顯的逃課現(xiàn)象，教師懷疑她吸毒，遭到了她的堅(jiān)決否認(rèn)。有時(shí)候晚上和周末，亞歷克薩會謊稱自己在同學(xué)家，之后被發(fā)現(xiàn)在和一名22歲的輟學(xué)大學(xué)生交往。而這名輟學(xué)大學(xué)生和一些有奇怪宗教信仰的吸毒者住在一個(gè)房子里。16歲時(shí)，亞歷克薩離家出走，幾個(gè)星期沒有與父母聯(lián)系。

以上的大部分信息都是亞歷克薩的家人轉(zhuǎn)達(dá)給我的。在這1年中他們出現(xiàn)了嚴(yán)重的健康問題。邁克爾出現(xiàn)了便血和腹瀉，檢查結(jié)果提示為潰瘍性結(jié)腸炎；喬治出現(xiàn)了多次短暫性腦缺血發(fā)作，最終發(fā)生卒中，遺留輕度左側(cè)肢體偏癱；索菲亞錯(cuò)過了幾次透析，需要在重癥監(jiān)護(hù)室治療腎衰竭和心臟并發(fā)癥；安娜疲于工作，盡最大努力保持著家庭的完整。

我們都很清楚心理壓力與軀體疾病之間的關(guān)聯(lián)。然而，我很少看到僅在幾個(gè)月內(nèi)就有這么多不幸同時(shí)發(fā)生在一個(gè)家庭里。我需要照顧三名家庭成員的身體，同時(shí)也試著給第四名家庭成員提供情感支持，希望這一切可以讓亞歷克薩回歸家庭，保持家庭的完整。家人，尤其是父母，會非常包容孩子的過錯(cuò)。他們最關(guān)心的是孩子的幸福，并且愿意做任何事情確保孩子的茁壯成長。這個(gè)案例的最終結(jié)局是寬容、理解以及和睦共處，但這耗費(fèi)了兩年的時(shí)間，并且在這期間留下了不可彌補(bǔ)的創(chuàng)傷。

譯者注：跨代創(chuàng)傷(transgenerational trauma)：原意是指遭受創(chuàng)傷的第一代幸存者，將創(chuàng)傷傳遞到第二代甚至更后輩，使他們也遭受創(chuàng)傷的折磨，其機(jī)制是創(chuàng)傷后應(yīng)激障礙在代際上的延伸，即第一代的創(chuàng)傷后應(yīng)激障礙直接或間接地傳遞給了下一代或幾代，造成“繼發(fā)創(chuàng)傷”。既往研究發(fā)現(xiàn)，二戰(zhàn)大屠殺幸存者的孩子會更多地尋求醫(yī)療服務(wù)，幸存者的孫輩接受兒童心理治療的比例是其他兒童的3倍。澳大利亞的殖民者將土著人的孩子從家中強(qiáng)行帶走去接受教育感化，給土著人家庭及其數(shù)代人造成了嚴(yán)重的跨代創(chuàng)傷，澳大利亞總理也因此鄭重地向土著人道歉。在普通家庭中，也存在跨代創(chuàng)傷問題，如家境貧困、家庭暴力、性侵犯、被奴役、關(guān)系破裂等?？绱鷦?chuàng)傷不僅是從上至下的代際傳遞，正如Piterman教授在上述案例中講述的故事，其也可以逆向地從晚輩傳遞到上輩，或者說是代際互動(dòng)。雖然上輩的軀體問題可能具有“偶然性”或是在亞歷克薩出現(xiàn)青春期叛逆的時(shí)間段中加重，但家庭各成員的身-心關(guān)聯(lián)(body-mind link)是“為什么這個(gè)家庭會遭受如此不幸的折磨”的部分原因。Piterman教授隱藏在故事里的另一個(gè)線索，是這個(gè)家庭屬于上世紀(jì)60年代的希臘移民。二戰(zhàn)后，希臘爆發(fā)了內(nèi)戰(zhàn)，16萬希臘人為逃避戰(zhàn)火而來到澳大利亞(主要是維多利亞州)，這些第一代移民(如故事中的喬治和索菲亞)在澳大利亞的工廠和農(nóng)場做勞工，生活非常艱難，直到他們的第二代(如故事中的安娜)生活才有起色。在我國，重大的歷史事件(大歷史)、社區(qū)的過往和文化事件(小歷史)、大家庭和核心家庭內(nèi)的重要事件，均有可能會影響到幾代人的身心健康，這也是全科醫(yī)生可以發(fā)現(xiàn)健康問題的“觸發(fā)點(diǎn)”。全科醫(yī)學(xué)關(guān)注家庭的真正意義，不僅包括狹義的疾病遺傳家族史，還包括反映出代際間情感和關(guān)系互動(dòng)的家庭社會史和家庭心理史。

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國全科醫(yī)學(xué)》。

GPs can be faced with the cascading impact on the health of a wide range of family members triggered by a traumatic event.

GPs care for families.That care often occurs across two,three or sometimes four generations.Events including illnesses affecting one generation may often have an impact on other generations.The composition and relations within nuclear families is such that sharing the impact of traumatic events is inescapable.Perhaps we should be grateful that this still takes place as it also means that support can be offered within families by family members helping one another,assisted only where necessary by health professionals,including,most importantly,GPs.

As GPs,we often witness traumatic events plaguing certain families which,for apparently unexplained reasons,appear excessive and out of the norm.We are left wondering why should so much misfortune afflict this family? What went wrong? What did they do to deserve this? What could have been done to prevent it? And now that it has happened,what interventions and support can we as GPs put in place to minimise the harm caused by these traumatic events?

The traumatic trigger for the cascade of events that follow may be an accident,a serious illness,relationship breakdown or,as in the case described here,a child "gone missing".

The impact on other family members may not only be psychological(depression,anxiety,insomnia,post-traumatic stress disorder) but we also witness the sudden emergence of physical illnesses which serves to emphasise the significance of the mind-body nexus.

I first met Alexa when she was three years old.At that stage,I had looked after her grandparents George and Sofia for 10 years.George was aged 65 and Sofia was aged 63.

George had a history of obesity,hypertension and type 2 diabetes.Sofia had a history of hypertension,set against a background of renal disease thought to be IgA nephropathy.George and Sofia had until recently run a suburban fruit shop which they sold and were now happy to be retired.

Along with many other Greek families,they had migrated to Australia in the early 1960s and were proud of their achievements,having raised a daughter,Anna,who was now an industrial chemist and married to Michael,an accountant.Naturally they doted over their only granddaughter Alexa,and now that they were retired,they spent more time looking after her while Anna and Michael were at work.

Anna brought Alexa to see me.She had a history of atopy,which included eczema and asthma.There was a strong family history of atopy,especially on Michael′s side of the family.The reason for the visit was an upper respiratory illness which had triggered an exacerbation of the asthma.Both Anna and Michael were in good health and in their mid-30s.

Over the next decade I saw the three generations of this family on a multitude of occasions.

George′s health deteriorated and he developed ischaemic heart disease in his early 70s.Sadly Sofia′s health took a similar course and she needed dialysis.Anna and Michael remained well and as Alexa reached her teens she would have only the occasional asthma attack.She was a high-achieving student and seemed well adjusted.

Things seemed to go very wrong when she turned 15.Over the ensuing 12 months she refused to take her asthma preventers,spent long hours on internet chat groups,refused to attend family functions,and school reports showed deteriorating performance as well as notable absences from class.Parent-teacher interviews raised suspicions about drug use which Alexa vehemently denied.

In the months that followed there were nights and weekends that Alexa said she was spending at her school friend′s house,but this was not confirmed.It then emerged she was in a relationship with a 22-year-old university dropout who lived in a share-house with a number of drug addicts who belonged to a strange religious cult.Eventually,at the age of 16,she left home and made no contact with her parents for weeks on end.

Much of this information was relayed to me by family members as they began to suffer serious health problems over this 12-month period.

Alexa′s father,Michael,presented with rectal bleeding and diarrhoea.Investigations revealed ulcerative colitis.Alexa′s grandfather had a series of transient ischaemic attacks culminating in a stroke which left him with a mild left hemiplegia.Alexa′s grandmother missed some of her dialysis sessions and required treatment in intensive care for renal failure with cardiac complications.Anna struggled to keep working and to keep the family together.

We are well aware of the link between stress and physical illness.However,rarely had I seen such devastation occurring in one family in the course of several months.

I was left to coordinate care for three family members,while trying to provide emotional support to the fourth and hoping throughout all of this that Alexa would make an effort to restore family unity.

Family,and particularly parents,can be very forgiving of their children′s misdemeanours.Ultimately they are concerned for the wellbeing of their children and will do anything to ensure their children thrive.

Tolerance,understanding and rapprochement prevailed in this case,but it took two years and left much irreparable damage along the way.

TransgenerationalTrauma:TheSinsofTheChild?

General practitioners;Stress disorders,traumatic

1.3168MonashUniversity,Melbourne,Australia

2.518003 廣東省深圳市，羅湖醫(yī)院集團(tuán)黃貝嶺社區(qū)健康服務(wù)中心

R 749.72

A

10.3969/j.issn.1007-9572.2017.31.003

2017-09-11)

(本文編輯：王鳳微)