中島 聡美

Grief reactions to the bereavement of a close individual could involve empathy for pain, which is fundamental to social interaction. To explore whether grief symptoms interact with social relatedness to a person to whom one directs empathy to modulate the expression of empathy, we administered an empathy task to 28 bereaved adults during functional magnetic resonance imaging, in which participants were subliminally primed with facial stimuli (e.g., faces of their deceased or living relative, or a stranger), each immediately followed by a visual pain stimulus. Individuals' grief severity promoted empathy for the pain stimulus primed with the deceased's face, while it diminished the neural response to the pain stimulus primed with the face of either their living relative or a stranger in the medial frontal cortex (e.g., the right dorsal anterior cingulate cortex). Moreover, preliminary analyses showed that while the behavioral empathic response was promoted by the component of "longing" in the deceased priming condition, the neural empathic response was diminished by the component of "avoidance" in the stranger priming condition. Our results suggest an association between grief reactions to bereavement and empathy, in which grief symptoms interact with interpersonal factors to promote or diminish empathic responses to others' pain.

Abstract Grief reactions to the bereavement of a close individual could involve empathy for pain, which is fundamental to social interaction. To explore whether grief symptoms interact with social relatedness to a person to whom one directs empathy to modulate the expression of empathy, we administered an empathy task to 28 bereaved adults during functional magnetic resonance imaging, in which participants were subliminally primed with facial stimuli (e.g., faces of their deceased or living relative, or a stranger), each immediately followed by a visual pain stimulus. Individuals’ grief severity promoted empathy for the pain stimulus primed with the deceased’s face, while it diminished the neural response to the pain stimulus primed with the face of either their living relative or a stranger in the medial frontal cortex (e.g., the right dorsal anterior cingulate cortex). Moreover, preliminary analyses showed that while the behavioral empathic response was promoted by the component of “longing” in the deceased priming condition, the neural empathic response was diminished by the component of “avoidance” in the stranger priming condition. Our results suggest an association between grief reactions to bereavement and empathy, in which grief symptoms interact with interpersonal factors to promote or diminish empathic responses to others’ pain.

During the Great East Japan Earthquake, many people experienced the loss of family and friends, among other traumatic events. This study sought to clarify the impact of the loss of significant close others on posttraumatic stress symptoms (PTSS), as well as the factors associated with PTSS, among individuals who experienced the loss of significant close others (i.e., bereaved group). Self-administered questionnaires were mailed to men and women (N = 180,604) aged 16 years and older living in municipalities that included evacuated areas surrounding the Tokyo Electric Power Company's Fukushima Daiichi Nuclear Power Station, which was significantly damaged following an earthquake and tsunami in March 2011, causing subsequent radiation leakage; this mailing yielded a 40.7% response rate, with 57,388 valid responses, in 2012. We used the Posttraumatic Stress Disorder Checklist–Specific (PCL-S) to measure PTSS as the outcome variable. Loss of significant close others in the disaster and respondents’ relationship with the deceased constituted the explanatory variables. Basic characteristics and disaster-related factors were the confounding variables. Data were analyzed using chi-square tests and logistic regression analyses. The bereaved group showed more severe PTSS than the nonbereaved group, aOR = 1.58, 95% CI [1.50, 1.67]. The risk of developing PTSS increased if the deceased was a respondent's spouse, aOR = 1.67, 95% CI [1.22, 2.29]; child, 1.51 [1.01, 2.25]; or friend, 1.33 [1.16, 1.53]. Individuals who lose significant close others, including both family and friends, in disasters require close mental health care and, if necessary, should be referred for psychiatric treatment.

Cognitive processing therapy (CPT) is one of the most widely tested evidence-based treatments for posttraumatic stress disorder (PTSD). However, most studies on CPT have been conducted in Western cultural settings. This open-label, single-arm trial investigated the feasibility, acceptability, and preliminary efficacy of CPT for treating Japanese patients with PTSD. A total of 25 outpatients underwent 12 CPT sessions. The primary outcome was the assessment of PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV); secondary outcomes included the assessment of subjective PTSD severity, depressive and anxiety symptoms, trauma-related cognitions, and subjective quality of life. All outcomes were evaluated at pretreatment (i.e., baseline), posttreatment, and 6- and 12-month follow-ups. On average, participants attended 13 sessions of CPT (SD = 1.38), with a completion rate of 96.0%. One serious adverse event (hospitalization) occurred. Significant within-subjects standardized mean differences in CAPS-IV scores were found from baseline to treatment completion, g = -2.28, 95% CI [-3.00, -1.56]; 6-month follow-up, g = -2.95, 95% CI [-3.79, -2.12]; and 12-month follow-up, g = -2.15, 95% CI [-2.89, -1.41]. Moderate-to-large effects, gs = -0.77 to -2.45, were found on secondary outcomes. These findings support the feasibility, acceptability, and preliminary efficacy of CPT in a Japanese clinical setting.

性暴力被害者は、PTSD等の精神疾患の有病率が高いことが報告されているが、被害に遭ったことを知られたくない等の理由から、受診できない事例が多い。本研究は、厚生労働省令和元年度障害者総合福祉推進事業「犯罪被害等によるストレス性障害に対する対応状況及び多職種・地域連携に関する実態調査」(武蔵野大学、2020)のうち、29の「性犯罪・性暴力被害者のためのワンストップ支援センター」(以下:センター)を対象に、被害者の精神科医療機関等への紹介を中心に連携の実態と、連携促進に資する取り組みについて、χ2検定を用いて分析した。紹介件数が多い機関(年間10件以上)では、少ない機関(9件以下)に比べ、スーパーヴァイズの依頼(p=.003)、紹介事例のカンファレンス(p=.002)の取り組みが有意に多かった。精神科医療機関等の利用促進にはセンターと医療機関等が事例を通した協力関係を構築することが重要である。(著者抄録)

OBJECTIVE: No prior studies have used a single sample of bereaved families of cancer patients to compare multiple scales for assessing Complicated Grief. Here, we compare the two measures. METHODS: We sent a questionnaire to the bereaved families of cancer patients who had died at 71 palliative care units nationwide. RESULTS: The analysis included 3173 returned questionnaires. Prevalence of Complicated Grief was 7.8% by Brief Grief Questionnaire (with a cutoff score of 8) and 15.5% for Inventory of Complicated Grief (with a cutoff score of 26). The Spearman's correlation coefficient between the Brief Grief Questionnaire and the Inventory of Complicated Grief was 0.79, and a ceiling effect was seen for the distribution of the Brief Grief Questionnaire scores. Although 6.4% of respondents scored both 8 or higher on the Brief Grief Questionnaire and 26 or higher on the Inventory of Complicated Grief, only 1.4% scored both 8 or higher on the Brief Grief Questionnaire and <26 on the Inventory of Complicated Grief. In contrast, 9.1% scored <8 on the Brief Grief Questionnaire but 26 or higher on the Inventory of Complicated Grief. CONCLUSION: The prevalence of Complicated Grief was estimated to be higher by the Inventory of Complicated Grief than by the Brief Grief Questionnaire in this sample. Patients with severe Complicated Grief might be difficult to discriminate their intensity of grief by the Brief Grief Questionnaire. Once the diagnostic criteria of Complicated Grief are established, further research, such as optimization of cutoff points and calculations of sensitivity and specificity, will be necessary.

性暴力被害者は心的外傷後ストレス障害(Posttraumatic Stress Disorder:PTSD)の有病率が高いことが報告されている(Kessler et al.、2017)。認知療法ではPTSDの回復を妨げる機序として、外傷体験を自分の信念と過去の経験に関連づけて解釈する点があげられる(Resick et al.、2017)。認知処理療法(cognitive processing therapy:CPT)では、頭の中で蟠った考えを認知再構成する過程で、自分の思考パターンに気づき、自責や極端な考えから、新たなほどよい考えを見つけ出すことを目的としている。本稿では、性暴力被害後にPTSDとパニック発作が顕著となり、CPT導入に至った一事例について報告する。性暴力被害者に特有な認知様式の再構成により、クライエントは現実的な思考と適応的対処が可能となり、症状回復に繋がったものと考えられる。本事例のCPTによるPTSD症状改善の機序について、認知の変化を通し、効果について考察する。(著者抄録)

Background: This self-administered mail survey examined whether post-disaster residential location after the Fukushima nuclear power plant accident affected psychological distress, with related factors. Methods: We targeted 180,604 individuals, including 24,177 residents within evacuation order areas, in FY2011 and FY2015. Psychological distress trajectory was examined using a growth mixture model (GMM) on a total K6 score per year. Relationships between post-disaster residential location and psychological distress trajectory were examined. Results: GMM analysis showed five distress trajectories: Group 1, continuously low (less distressed) K6 scores from FY2011; Group 2, higher than Group 1 but lower than other groups; Group 3, similar to Group 2 in FY2011 but increasing afterwards; Group 4, gradual decline (improvement) from high scores in FY2011; Group 5, continuously high throughout. Post-disaster residential location in FY2011 and trajectory type was significantly associated after adjusting for covariates. Within-prefecture residents outnumbered out-of-prefecture residents in Group 1 and vice versa in Group 5. Significant associations between residential location and distress trajectory disappeared when additional covariates (job loss, FY2012 social network, and FY2012 problem drinking) were entered into multinomial logistic regression models. Similar tendencies were observed with FY2015 residential location as the exposure variable: those who continued living out-of-prefecture had higher psychological distress than those living within (or returned to) the prefecture, owing to covariates. Conclusions: To prepare for future disasters, networks and systems must be established to support problem drinkers and assist with re-employment. A seamless social network will allow evacuees access to appropriate support wherever they evacuate to.

This commentary discussed the psychological issues related to bereavement in the wake of the COVID-19 pandemic. Specifically, we addressed two aspects in the context of Japanese culture. The first relates to the psychological distress of members of the bereaved family who could not visit their loved ones who had COVID-19 before or after their death. The second relates to the bereavement experience of those who were unable to be with their loved ones when the end came, even though they did not have COVID-19, because of restrictions on visiting hospitals. We seek to focus on the need for a support system for bereaved families to help them through the grieving process, and discuss end-of-life care in such circumstances, and in the post-COVID-19 era, as in current day Japan.

死別ケアにおいて悲嘆の軽減を目的とした認知行動療法が世界各国で進められている。遺族へのウェブベースの介入も進められているが、構造化された筆記課題、事実への直面、認知再構成、行動活性化等の要素が取り入れられている。その一つであるWagnerらの開発した認知行動療法プログラムの筆記課題と進行について概説した。本稿では、青年期の自死遺族の筆記表現と治療者のフィードバックの両方を詳述した。筆記療法は悲嘆ケアとして利便性の高さ、低コストが期待できるとともに、対面による緊張感の軽減にも役立つかもしれない。ただ、非対面の状況での一人での心理的直面のハードルの高さや、筆記後の疲労感やネガティブな感情へのフォローについては、治療者からの個人に応じたフィードバックや心理教育の提供が、治療を継続することに貢献するだろう。遺族の望む時に多様なスタイルでの介入がある環境が望まれる。(著者抄録)

本論文では、心的外傷後ストレス障害をはじめとしたトラウマの治療やケアにおいて、悲嘆の症状で苦しむ人を臨床家がどのように理解し、対応できるかを、複雑性悲嘆治療(complicated grief treatment)の観点から考察した。まず複雑性悲嘆および遷延性悲嘆障害の概念の変遷を述べた後、コロンビア大学のKatherine M.Shear博士によって開発された複雑性悲嘆治療の理論や内容を紹介した。複雑性悲嘆治療の特徴である、ともに歩む関係性、回復志向の治療内容、エクスポージャー手続きの実施法から、トラウマ治療における悲嘆の理解と対応の工夫を考察した。最後に、複雑性悲嘆治療が重視するポジティブ感情についても紹介した。(著者抄録)

2000年以降、複雑性悲嘆に焦点を当てた認知行動療法の有効性が報告され、国内でも臨床が進められている。しかし、精神科治療や心理療法への来談が困難な遺族も少なくない。遺族にとって、インターネットを含む遠隔での介入が支援の選択肢の一つにあることは有益と思われる。Wagnerらは遺族を対象とした認知行動療法プログラムを開発したが、筆者らは現在日本での実践を蓄積している。治療者と対象者は5週間にわたって電子メールの送受信および数回の短時間の電話によって交流する。対象者は自宅等PCにて筆記10回の筆記課題を行い治療者へ送信し、相談者に応じた返信を受け取る。本法は、筆記による開示と認知行動療法の2要素から構成され、(1)死別のきっかけへの曝露、(2)統合と修復、(3)認知的再評価の3段階へと進行する。本稿では、セッション内容と特徴、自死遺族の自験例を概説した。日本での臨床における課題と今後の展望について言及した。(著者抄録)

【背景・目的】性暴力被害者が被害後の急性期に被害による心身への影響や司法手続きおよび支援に関する情報を得ることは，被害後のストレスを軽減し，被害者を適切な治療や支援に繋げやすくすると考えられる．しかし，被害後急性期の被害者に総合的な支援情報を提供する媒体は少なく，その有用性について評価されたものはない．そこで，急性期性暴力被害者のための情報提供用ハンドブック（以下，冊子）を作成し，性暴力被害者の支援者または治療者（以下，支援・治療者）を対象に本冊子の有用性について評価を行った． 【方法】先行研究や性暴力被害者への聞き取りを基に冊子原案を作成し，多職種の専門家，被害当事者（29名）に意見を求めて原案を修正し冊子を作成した．本冊子の有用性を評価するため，産婦人科医療機関や支援機関に所属する性暴力被害者の支援・治療者（186名）を対象に自記式アンケート調査を行った．本調査では，調査協力者へ先に本冊子を配布し冊子を使用してもらい，3カ月後に本冊子の有用性についての自記式調査票を配布し回答を得た．本研究の実施にあたり，国立精神・神経医療研究センター倫理委員会の承認を得た． 【結果】対象者のうち104名（回収率55.9%）から回答を得た．回答者は，女性が95.2%であり，平均年齢は54.1±13.1歳であった．調査期間に被害者に本冊子を使用した者は18.3%であった．冊子全体の評価では，支援者および被害者・家族にとって「役に立った」という回答は80%以上あり，「理解しやすかった」という回答は70%以上であった．調査期間中に支援・治療を経験した者では，そうでない者と比べ「治療・支援が円滑に行えた」という評価が高い一方，「時間の負担」が増したとする意見が多かった． 【考察】本冊子は，支援者の視点から被害者に情報提供をする上で有用であるという評価を得た．今後は性暴力被害者から評価を得て本冊子の内容を検討することが課題である．

Background: The conditions under which memory generalization occurs are not well understood. Although it is believed that fear memory generalization is gradually established after learning, it is not clear whether experiences soon after learning affect generalization. Results: Using a contextual fear conditioning paradigm in mice, we found that fear memory generalization occurred when mice were exposed to a familiar, unconditioned context soon after fear learning. Conclusions: Our results suggest that the familiarity of contexts and the timing of their exposure influences memory generalization, which increases our understanding of the mechanisms of generalization.

Objective: We intended to build consensus on appropriate disaster mental health services among professionals working in the area affected by the Great East Japan Earthquake. Methods: We focused on the first 3 months after the disaster, divided into 3 phases: immediate aftermath, acute phase, and midphase. We adopted the Delphi process and asked our survey participants (n = 115) to rate the appropriateness of specific mental health services in each phase and comment on them. We repeated this process 3 times, giving participants feedback on the results of the previous round. Through this process, we determined the criterion for positive consensus for each item as having the agreement of more than 80% of the participants. Results: We found that the importance of acute psychiatric care and prescribing regular medication for psychiatric patients gained positive consensus in the immediate aftermath and acute phase. Counseling and psychoeducation after traumatic events or provision of information gained consensus in the acute phase and midphase, and screening of mental distress gained consensus in the midphase. Conclusions: Higher priority was given to continuous psychiatric services in the immediate aftermath and mental health activities in later phases.

Objectives: In this survey, we aimed to build consensus and gather opinions on ‘Kokoro-no care’ or mental health services and psychosocial support (MHSPSS) after a disaster, among mental health professionals who engaged in care after the Great East Japan Earthquake. Methods: We recruited mental health professionals who engaged in support activities after the Great East Japan Earthquake, which included local health professionals in the affected areas and members of mental health care teams dispatched from outside (n = 131). Adopting the Delphi process, we proposed a definition of ‘Kokoro-no care’, and asked the participants to rate the appropriateness on a 5-point Likert scale. We also solicited free comments based on the participants’ experiences during the disaster. After Round 1, we presented the summary statistics and comments, and asked the participants to re-rate the definition that had been modified based on their comments. This process was repeated twice, until the consensus criterion of ≥ 80% of the participants scoring ≥ 4 on the statement was fulfilled. Results: In Round 1, 68.7% of the respondents rated the proposed definition ≥ 4 for its appropriateness, and 88.4% did so in Round 2. The comments were grouped into categories (and subcategories) based on those related to the definition in general (Appropriate, Continuum of MHSPSS, Cautions in operation, Alternative categorisation of care components, Whether the care component should be categorised according to the professional involved, Ambiguous use of psychology, and Others), to mental health services (Appropriate, More specification within mental health services, More explicit remarks on mental health services, and Others), and to psychosocial support (Whether the care component should be categorised according to the professional involved, Raising concerns about the terms, and Others), and others. Conclusion: We achieved a consensus on the definition of ‘Kokoro-no care’, and systematically obtained suggestions on the concept, and practical advice on operation, based on the participants’ experiences from the Great East Japan Earthquake. This collective knowledge will serve as reference to prepare and respond to future disasters.

Background: Little is known about the association between quality of end-of-life care of a patient and complicated grief among bereaved family members. Objective: This study aims to examine the impact of quality of end-of-life care on complicated grief among bereaved family members in a Japanese general population sample. Methods: A mail-based cross-sectional questionnaire survey was used. A total of 641 individuals aged 40 to 79 years in the general population who lost their loved one within the period between 6 months and 10 years were enrolled. Complicated grief was assessed using the Brief Grief Questionnaire, and the bereaved family members' perceptions on quality of end-of-life care were assessed using the Care Evaluation Scale and the Good Death Inventory. Logistic regression analysis was used to identify the variables that associated with possible complicated grief. Results: Possible complicated grief was observed in 24.5% of the participants. Three components of quality of end-of-life care, namely, dissatisfaction with the explanation to the family about the patient's expected outcome, unreasonable cost of care, and family's perception that the deceased person had not achieved a sense of completion about his or her life, were significantly associated with possible complicated grief. Spousal relationship, primary caregiver, and high psychological distress also had significant association. Conclusions: Perceptions on quality of end-of-life care were significantly associated with complicated grief. Providing sufficient information to patients' family about expected outcome and enhancing patients' sense of completion about their life may prevent bereaved family members from developing complicated grief.

40～79歳の一般市民への質問紙調査から，救急外来とICUで過去10年以内に死別を体験した家族の複雑性悲嘆の有病率を「簡易版悲嘆質問票（brief grief questionnaire, BGQ）」で評価し，一般病棟と比較した。救急外来49名，ICU 156名，一般病棟432名を分析した結果，複雑性悲嘆は，救急外来3名（6％），ICU 5名（3％），一般病棟10名（2％），閾値下レベルの複雑性悲嘆は，救急外来11名（22％），ICU 37名（24％），一般病棟99名（23％）で，統計的な有意差はなかった。死別者の主要疾患，死の予測の有無において，救急外来，ICUともに，有意差があったが，これらは有病率に影響を与えていなかったことが推察された。

Introduction: The current study investigated whether the influence of alexithymia on psychological distress (PD) differed according to the seriousness of complicated grief (CG) and the time since bereavement in the Japanese general population. Methods: 1162 participants between 40 and 79 years of age (effective response rate: 58.8%) completed a cross-sectional anonymous questionnaire regarding the following factors: alexithymia (DD: Difficulty describing feeling, DI: Difficulty identifying feeling, EO: Externally oriented thinking), PD, and CG. To compare the non-bereaved (group 1) with four other groups, which were organized by CG score (high/low) and the time since bereavement (within half/two years postloss); the half year_low/high CG (group 2 and 3) and the two years_low/high CG (group 4 and 5), a simultaneous analysis of the five groups with standard maximum likelihood estimations was performed and hypothesized models were verified. Results: The model (RMSEA=0.000, AIC=57.686) showed that the models' constructions for group 1 and 4 were significantly similar. In the other groups, the degree of correlation between alexithymia (especially EO) and psychological distress was significantly different. Limitations: The study is a cross-sectional design and not with a clinical population. Conclusions: Our findings showed that the relationship between alexithymia and psychological distress was significantly same for group 1 and 4. In group 2, EO was less correlated with the other subscales of alexithymia, which suggests that EO is utilized as a coping style for bereavement that, in turn, influences convalescence during the half year following bereavement. (C) 2013 Elsevier BY. All rights reserved.

Background: Incidence proportion of post-traumatic stress disorder (PTSD) after motor vehicle accidents (MVA) vary considerably across countries, and whether heart rate (HR) and respiratory rate (RR) immediately after MVA predict subsequent PTSD remains controversial. This study examined the incidence proportion of PTSD at 6 months after MVA in Japan, and the predictors of PTSD in MVA survivors. Method: Patients with MVA-related injuries consecutively admitted to the intensive care unit of a teaching hospital in Tokyo were recruited. Six months after MVA, PTSD was diagnosed using the Clinician Administered Post-traumatic Stress Disorder Scale (CAPS). Results: Of the 300 participants, 106 completed the assessments at 6 months after MVA and PTSD was diagnosed in 7.5% of the patients. Eight of the 300 participants (2.7%) were regarded as having PTSD after imputing their CAPS score at follow-up assessment for participants who dropped out. In multivariate regression analysis, no variables were shown to be independent predictors for PTSD. HR and RR did not predict PTSD in the analysis. Discussion: The results suggested that the incidence proportion of PTSD following MVA in Japan was lower than that in most developed countries, and HR and RR might not be accurate screening tools despite their importance in a fear-conditioning model of the genesis of PTSD.

We recently developed new disaster mental health guidelines in Japan through the Delphi process, a method for building consensus among experts, using as a reference the guidelines developed by The European Network for Traumatic Stress (TENTS) in Europe. We included in our survey 30 items used in the TENTS survey, 20 of which achieved positive consensus in that survey. Here we report on the extent of agreement of 95 Japanese experts on each of these 30 items and examine the reasons for disagreements with the TENTS survey results based on the comments obtained from the participants of our survey. Of the 20 items, 12 also gained consensus in our survey and 1 additional item achieved consensus that did not achieve it in the TENTS survey. Items that did not gain consensus in our survey, but did in the TENTS survey, were recommendations for close collaboration with the media, screening volunteers for their suitability, and withholding formal screening of the affected population. The need for specialist care for specific populations was endorsed in our survey, but not in the TENTS survey. Overall, the opinion of Japanese experts was congruent with that of Western experts, but some guideline amendments would be beneficial. © 2013 International Society for Traumatic Stress Studies.