道路交通事故所致精神损害的法医学评价研究
|
摘要
前言
在人身损害赔偿案件中，精神损害赔偿是人身损害赔偿的一项重要内容。创伤后应激障碍(Posttraumatic Stress Disorder，PTSD)是精神损害的主要表现形式。道路交通事故(Road Traffic Accidents，RTA)作为现代社会常见的创伤性事件之一，又是导致PTSD的最常见因素之一。由于PTSD不如躯体损伤易于鉴别和评定，常不为人们所重视。因此，开展PTSD相关法医学问题的研究具有十分重要的意义。本研究的主要内容：1．研究起诉至法院请求赔偿的RTA受害人这一特殊群体中PTSD的发生情况；2．与PTSD发生有密切关系的因素，特别是伤残等级与PTSD的关系；3．PTSD对心理状态(包括抑郁和焦虑两类常见的心理反映)及生活质量的影响；4．PTSD的发生与转归与是否获得赔偿的关系。本研究主要目的：为司法实践中精神损害赔偿提供科学依据和司法建议。
对象与方法
2001年9月至2003年3月因RTA申请伤残程度鉴定的被鉴定人156例(排除颅脑损伤、拒绝合作者、身体情况不适宜临床精神病学检查者)，年龄在18岁～60岁之间。通过临床精神病学检查确定PTSD的诊断，临床法医学检查评定躯体损伤的伤残等级，并通过问卷调查进一步确定受害人的心理社会状态。应用t检验、卡方检验、等级资料秩和检验(Mann-Whitney检验)等统计学方法进行分析。
结果
因RTA申请伤残等级鉴定的156例被调查对象，经临床精神病学检查，符合ICD-10诊断标准者81例，PTSD发生率为51.92％，其中男性41例(44.57％)，女性40例(62.5％)。经卡方分析(x~2=7.126，P＜0.01)，男女PTSD的发生率具有统计学的显著性差异；PTSD与非PTSD两组在年
龄、文化程度上经过统计学检验，无显著性差异;PISD的发生率距离交通事
故发生的时间，在统计学上有显著性差异(t二5 .600，P<0.001);损伤部位
与PlsD的发生率经卡方检验(扩=4.755，P>0.05)，无统计学上的关系;
PISD组与非川SD组的伤残等级构成经过Mann一Whi仇ey检验(等级资料
秩和检验)(U二2382.5，P<0.05)，两组有显著性差异，表明随着伤残程度
的严重性增加，发生PISD的可能性也随着增加;PISD组与非P路D组在生
活质量总均分和生理、心理、社会关系、环境四个维度以及焦虑、抑郁的各项
得分中都有显著性差异(Boffermni Correeted t tests，p蕊0.001);对获得赔
偿与未获得赔偿的两组对象，分别进行P玲D发生率的比较，其发生率分别
为:23/156 x 100%=14.74%、12辫8 x 100%=25%，经xZ检验(xZ=4.
117，P<0.05)，表明获得赔偿将明显降低PlsD的发生率。
结论
1.RTA作为创伤性事件，申请赔偿的RTA受害人存在较高的班SD发
生率，获得良好的赔偿可以明显地降低申请赔偿的RTA受害人班SD的发
生率。申请赔偿的RTA受害人中，女性PrSD的发生率明显高于男性，但与
损伤部位无明显关系。
2.随着伤残等级的增高，申请赔偿的RTA受害人发生PTSD的可能性
也随之增加。1下TSD的发生严重地影响RTA受害人的心理状态和生活质
量。
3.PISD作为精神损害的后果具有生物学基础，通过医学检查可以判定
精神损害的后果。
4.精神损害是人身损害的一项重要内容，精神损害与躯体损害一样可
以导致收益的减少和财产损失。在立法上，精神损害赔偿作为独立的诉讼
标的，应该允许单独进行诉讼;在司法裁判过程中，精神损害的赔偿数额应
与精神损害的后果一致。RTA发生后，在明确赔偿范围、赔偿责任等的前
提下，尽快对受害人进行合理的赔偿完全有可能防止PTSD的发生，避免损
失的扩大。
5.为精神损害后果的评价提供了科学的依据，有助于防止精神损害赔
偿的司法滥用。
Preface
Psychiatric injury is an important composer of the injury compensations. The fact that PTSD ( Posttraumatic Stress Disorder) may occur after accidents is well known. Road traffic accidents ( RTA) are probably the most common sources of traumatic stress in modern world, and are becoming the leading causes of PTSD. As PTSD is more difficult to be differentiated and evaluated than the physical injuries, the role of PTSD is usually ignored. In present study, the following are involved: 1. The common information on the victims of RTA who applied to the court for a costs order; 2. The relationship between PTSD and severities of injury; 3. The effect of PTSD on quality of life and its association of anxiety and depression; 4. A particular type of connection existing between the development and progression on PTSD and the acquirement of awarded costs. This study is aimed at supplying accumulating evidence for psychiatric compensation in court.
Subjects and Methods
One hundred and fifty six victims of RTA were recruited who applied to court for a costs order from Sep. 2001 to Mar. 2003. The ages of subjects are 18 ~ 60. The victims were examined for psychiatric diagnosis by psychiatrists and for severities of injury by experts in clinical forensic medicine. The self - report psychopathological status and quality of life were also measured. The statistic analyses included t - test, x2 test and Mann - Whitney test.
Results
Eighty one victims of 156 (51. 92% ) fulfilled the criteria for PTSD (ICD - 10) , including males 41 (44. 57% ) and females 40 (62. 5% ). x2 test revealed that morbidity difference in male and female were significant (x2 =7. 126, P<0.01); There were few differences of ages and education durations in PTSD and non - PTSD groups; The intervals from traumatic accidents to injury identification were significantly different between PTSD and non - PTSD groups using t test (t = 5. 600, P < 0.001) ; There were no relationships between injury parts and incidence of PTSD (x2 =4. 755, P >0. 05 ) ; The injuries were more severe in PTSD than non - PTSD by Mann - Whitney test, U = 2382. 5, P < 0. 05; The scores in World Health Organization Quality of Life were lower and in SAS and SDS were higher in PTSD group than in non - PTSD group (t tests, after Bofferroni Corrected, P 0.001) ; The significant different morbidities existed in two groups, one of which obtained the social support (14. 74% ) and the other did not obtain the support (25% ). The x2 test result was x2 =4. 117, P < 0.05.
Conclusions
1. The higher PTSD incidence existed in the RTA victims who applied to court for a costs order, and social support could prevent PTSD; After the RAT, it will avoid the PTSD development that the victims are awarded reasonable costs as soon as quickly. The morbidities were associated with sex, but not with injury parts;
2. It is more possible to develop PTSD with more severe injuries. Victims of PTSD showed more symptoms of depression and anxiety, and their qualities of life were damaged.
3. The psychiatric injury could be assessed by medical examination;
4. The psychiatric injury is the same importance as the physical injury, therefore, this injury could be individually litigated.
5. This study supplied cumulating evidence for the psychopathological sequel of PTSD, which could protect the abuse in the compensation of psychiatric injury.
在人身损害赔偿案件中，精神损害赔偿是人身损害赔偿的一项重要内容。创伤后应激障碍(Posttraumatic Stress Disorder，PTSD)是精神损害的主要表现形式。道路交通事故(Road Traffic Accidents，RTA)作为现代社会常见的创伤性事件之一，又是导致PTSD的最常见因素之一。由于PTSD不如躯体损伤易于鉴别和评定，常不为人们所重视。因此，开展PTSD相关法医学问题的研究具有十分重要的意义。本研究的主要内容：1．研究起诉至法院请求赔偿的RTA受害人这一特殊群体中PTSD的发生情况；2．与PTSD发生有密切关系的因素，特别是伤残等级与PTSD的关系；3．PTSD对心理状态(包括抑郁和焦虑两类常见的心理反映)及生活质量的影响；4．PTSD的发生与转归与是否获得赔偿的关系。本研究主要目的：为司法实践中精神损害赔偿提供科学依据和司法建议。
对象与方法
2001年9月至2003年3月因RTA申请伤残程度鉴定的被鉴定人156例(排除颅脑损伤、拒绝合作者、身体情况不适宜临床精神病学检查者)，年龄在18岁～60岁之间。通过临床精神病学检查确定PTSD的诊断，临床法医学检查评定躯体损伤的伤残等级，并通过问卷调查进一步确定受害人的心理社会状态。应用t检验、卡方检验、等级资料秩和检验(Mann-Whitney检验)等统计学方法进行分析。
结果
因RTA申请伤残等级鉴定的156例被调查对象，经临床精神病学检查，符合ICD-10诊断标准者81例，PTSD发生率为51.92％，其中男性41例(44.57％)，女性40例(62.5％)。经卡方分析(x~2=7.126，P＜0.01)，男女PTSD的发生率具有统计学的显著性差异；PTSD与非PTSD两组在年
龄、文化程度上经过统计学检验，无显著性差异;PISD的发生率距离交通事
故发生的时间，在统计学上有显著性差异(t二5 .600，P<0.001);损伤部位
与PlsD的发生率经卡方检验(扩=4.755，P>0.05)，无统计学上的关系;
PISD组与非川SD组的伤残等级构成经过Mann一Whi仇ey检验(等级资料
秩和检验)(U二2382.5，P<0.05)，两组有显著性差异，表明随着伤残程度
的严重性增加，发生PISD的可能性也随着增加;PISD组与非P路D组在生
活质量总均分和生理、心理、社会关系、环境四个维度以及焦虑、抑郁的各项
得分中都有显著性差异(Boffermni Correeted t tests，p蕊0.001);对获得赔
偿与未获得赔偿的两组对象，分别进行P玲D发生率的比较，其发生率分别
为:23/156 x 100%=14.74%、12辫8 x 100%=25%，经xZ检验(xZ=4.
117，P<0.05)，表明获得赔偿将明显降低PlsD的发生率。
结论
1.RTA作为创伤性事件，申请赔偿的RTA受害人存在较高的班SD发
生率，获得良好的赔偿可以明显地降低申请赔偿的RTA受害人班SD的发
生率。申请赔偿的RTA受害人中，女性PrSD的发生率明显高于男性，但与
损伤部位无明显关系。
2.随着伤残等级的增高，申请赔偿的RTA受害人发生PTSD的可能性
也随之增加。1下TSD的发生严重地影响RTA受害人的心理状态和生活质
量。
3.PISD作为精神损害的后果具有生物学基础，通过医学检查可以判定
精神损害的后果。
4.精神损害是人身损害的一项重要内容，精神损害与躯体损害一样可
以导致收益的减少和财产损失。在立法上，精神损害赔偿作为独立的诉讼
标的，应该允许单独进行诉讼;在司法裁判过程中，精神损害的赔偿数额应
与精神损害的后果一致。RTA发生后，在明确赔偿范围、赔偿责任等的前
提下，尽快对受害人进行合理的赔偿完全有可能防止PTSD的发生，避免损
失的扩大。
5.为精神损害后果的评价提供了科学的依据，有助于防止精神损害赔
偿的司法滥用。
Preface
Psychiatric injury is an important composer of the injury compensations. The fact that PTSD ( Posttraumatic Stress Disorder) may occur after accidents is well known. Road traffic accidents ( RTA) are probably the most common sources of traumatic stress in modern world, and are becoming the leading causes of PTSD. As PTSD is more difficult to be differentiated and evaluated than the physical injuries, the role of PTSD is usually ignored. In present study, the following are involved: 1. The common information on the victims of RTA who applied to the court for a costs order; 2. The relationship between PTSD and severities of injury; 3. The effect of PTSD on quality of life and its association of anxiety and depression; 4. A particular type of connection existing between the development and progression on PTSD and the acquirement of awarded costs. This study is aimed at supplying accumulating evidence for psychiatric compensation in court.
Subjects and Methods
One hundred and fifty six victims of RTA were recruited who applied to court for a costs order from Sep. 2001 to Mar. 2003. The ages of subjects are 18 ~ 60. The victims were examined for psychiatric diagnosis by psychiatrists and for severities of injury by experts in clinical forensic medicine. The self - report psychopathological status and quality of life were also measured. The statistic analyses included t - test, x2 test and Mann - Whitney test.
Results
Eighty one victims of 156 (51. 92% ) fulfilled the criteria for PTSD (ICD - 10) , including males 41 (44. 57% ) and females 40 (62. 5% ). x2 test revealed that morbidity difference in male and female were significant (x2 =7. 126, P<0.01); There were few differences of ages and education durations in PTSD and non - PTSD groups; The intervals from traumatic accidents to injury identification were significantly different between PTSD and non - PTSD groups using t test (t = 5. 600, P < 0.001) ; There were no relationships between injury parts and incidence of PTSD (x2 =4. 755, P >0. 05 ) ; The injuries were more severe in PTSD than non - PTSD by Mann - Whitney test, U = 2382. 5, P < 0. 05; The scores in World Health Organization Quality of Life were lower and in SAS and SDS were higher in PTSD group than in non - PTSD group (t tests, after Bofferroni Corrected, P 0.001) ; The significant different morbidities existed in two groups, one of which obtained the social support (14. 74% ) and the other did not obtain the support (25% ). The x2 test result was x2 =4. 117, P < 0.05.
Conclusions
1. The higher PTSD incidence existed in the RTA victims who applied to court for a costs order, and social support could prevent PTSD; After the RAT, it will avoid the PTSD development that the victims are awarded reasonable costs as soon as quickly. The morbidities were associated with sex, but not with injury parts;
2. It is more possible to develop PTSD with more severe injuries. Victims of PTSD showed more symptoms of depression and anxiety, and their qualities of life were damaged.
3. The psychiatric injury could be assessed by medical examination;
4. The psychiatric injury is the same importance as the physical injury, therefore, this injury could be individually litigated.
5. This study supplied cumulating evidence for the psychopathological sequel of PTSD, which could protect the abuse in the compensation of psychiatric injury.
引文
1．传田健三，马沂译．外伤后的应激障碍性损害．日本医学介绍，2002，23(5)：225
2. Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents. BMJ, 1993,307 (6905) : 647～651
3. Gold PB, Frueh BC. Compensation- seeking and extreme exaggeration of psychopathology among combat veterans evaluated for posttraumatic stress disorder. J Nerv Merit Dis, 1999, 187 (11) : 680～684
4. Mayou R, Bryant B. Outcome 3 years after a road traffic accident. Psychol Med, 2002, 32 (4): 671～675
5. Frommberger U, Stieglitz RD, Straub S, et al. The concept of "sense of coherence" and the development of posttraumatic stress disorder in traffic accident victims. J Psychosom Res, 1999, 46 (4): 343～348
6. Turner S. Patients who experience traumatic stress. Med Prog SEA, 2000, 27:5～7
7. Hales RE, Zatzick DF. What is PTSD? Am J Psychiatry, 1997, 154 : 141～144
8. Frommberger UH, Stieglitz RD, Nyberg E, et al. Prediction of posttraumatic stress disorder by immediate reactions to trauma: A prospective study in road traffic accident victims. European Archives of Psychiatry and Clinical Neuroscience, 1998, 248 (6): 316～321
9．陈显余．谈道路交通事故预防新机制．浙江公安高等专科学校学报《公安学刊》，2003，10(5)：66～68
10. Shalev AY, Peri T, Canetti L, et al. Predictors of PTSD in injured trauma survivors: a prospective study. Am J Psychiatry, 1996, 153 (2): 219～225
11．韩建波，刘兰芬．105例车祸伤后病人应激障碍的随访研究．中国全科医学，2003，6(10)：840～842
12. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic Stress Disorder in the national comorbidity survey. Archives of General Psychiatry, 1995, 52
(12): 1048～1060
13. Palinkas LA, Petterson JS, Russell J, et al. Community patterns of psychiatric disorders after the Exxon Valdez oil spill. Am J Psychiatry, 1993, 150 (10) : 1517～1523
14. Feinstein A, Dolan R. Predictors of post - traumatic stress disorder following physical trauma: an examination of the stressor criterion. Psychol Med, 1991, 21 (1): 85～91
15. Green MM, McFarlane AC, Hunter CE, et al. Undiagnosed post - traumatic stress disorder following motor vehicle accidents. Med J Aust, 1993, 159 (8) : 529～534
16. Conlon L, Fahy TJ, Conroy R. PTSD in ambulant RTA victims:a randomized controlled trial of debriefing. J Psychosom Res, 1999, 46 (1): 37～44
17. The Lowa Persian Gulf Study Group. Self-reported illness and health status among Gulf War veterans: A populationbased study. JAMA, 1997, 277 (3) : 238～245
18. Roger G, Leigh AN. Post-traumatic stress disorder following military combat of peace keeping. BMJ, 2002, 324 (7337): 340～342
19. Davidson JR. Recognition and treatment of posttraumatic stress disorder. JAMA, 2001, 286 (5): 584～588
20. Taylor S, Koch WJ, Woody S, et al. Anxiety sensitivity and depression: how are they related? J Abnorm Psychol, 1996, 105 (3): 474～490
21. Pavlovic S, Sinanovic M. PTSD of Somatization in soldiers during the war in Bosnia. J Med Arch, 2001, 55 (3) : 145～149
22．刘爱忠，谭红专，周价，等．洪灾后创伤性应激障碍及其影响因素的研究．中国医师杂志，2003，5(12)：1630～1632
23．汪向东，赵丞智，新福尚隆，等．地震后创伤性应激障碍的发生率及影响因素．中国心理卫生杂志，1999，13(1)：28～30
24．黄松有主编，最高人民法院民事审判第一庭编著．最高人民法院人身损害赔偿司法解释的理解与适用．北京：人民法院出版社，2004：262～276
2. Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents. BMJ, 1993,307 (6905) : 647～651
3. Gold PB, Frueh BC. Compensation- seeking and extreme exaggeration of psychopathology among combat veterans evaluated for posttraumatic stress disorder. J Nerv Merit Dis, 1999, 187 (11) : 680～684
4. Mayou R, Bryant B. Outcome 3 years after a road traffic accident. Psychol Med, 2002, 32 (4): 671～675
5. Frommberger U, Stieglitz RD, Straub S, et al. The concept of "sense of coherence" and the development of posttraumatic stress disorder in traffic accident victims. J Psychosom Res, 1999, 46 (4): 343～348
6. Turner S. Patients who experience traumatic stress. Med Prog SEA, 2000, 27:5～7
7. Hales RE, Zatzick DF. What is PTSD? Am J Psychiatry, 1997, 154 : 141～144
8. Frommberger UH, Stieglitz RD, Nyberg E, et al. Prediction of posttraumatic stress disorder by immediate reactions to trauma: A prospective study in road traffic accident victims. European Archives of Psychiatry and Clinical Neuroscience, 1998, 248 (6): 316～321
9．陈显余．谈道路交通事故预防新机制．浙江公安高等专科学校学报《公安学刊》，2003，10(5)：66～68
10. Shalev AY, Peri T, Canetti L, et al. Predictors of PTSD in injured trauma survivors: a prospective study. Am J Psychiatry, 1996, 153 (2): 219～225
11．韩建波，刘兰芬．105例车祸伤后病人应激障碍的随访研究．中国全科医学，2003，6(10)：840～842
12. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic Stress Disorder in the national comorbidity survey. Archives of General Psychiatry, 1995, 52
(12): 1048～1060
13. Palinkas LA, Petterson JS, Russell J, et al. Community patterns of psychiatric disorders after the Exxon Valdez oil spill. Am J Psychiatry, 1993, 150 (10) : 1517～1523
14. Feinstein A, Dolan R. Predictors of post - traumatic stress disorder following physical trauma: an examination of the stressor criterion. Psychol Med, 1991, 21 (1): 85～91
15. Green MM, McFarlane AC, Hunter CE, et al. Undiagnosed post - traumatic stress disorder following motor vehicle accidents. Med J Aust, 1993, 159 (8) : 529～534
16. Conlon L, Fahy TJ, Conroy R. PTSD in ambulant RTA victims:a randomized controlled trial of debriefing. J Psychosom Res, 1999, 46 (1): 37～44
17. The Lowa Persian Gulf Study Group. Self-reported illness and health status among Gulf War veterans: A populationbased study. JAMA, 1997, 277 (3) : 238～245
18. Roger G, Leigh AN. Post-traumatic stress disorder following military combat of peace keeping. BMJ, 2002, 324 (7337): 340～342
19. Davidson JR. Recognition and treatment of posttraumatic stress disorder. JAMA, 2001, 286 (5): 584～588
20. Taylor S, Koch WJ, Woody S, et al. Anxiety sensitivity and depression: how are they related? J Abnorm Psychol, 1996, 105 (3): 474～490
21. Pavlovic S, Sinanovic M. PTSD of Somatization in soldiers during the war in Bosnia. J Med Arch, 2001, 55 (3) : 145～149
22．刘爱忠，谭红专，周价，等．洪灾后创伤性应激障碍及其影响因素的研究．中国医师杂志，2003，5(12)：1630～1632
23．汪向东，赵丞智，新福尚隆，等．地震后创伤性应激障碍的发生率及影响因素．中国心理卫生杂志，1999，13(1)：28～30
24．黄松有主编，最高人民法院民事审判第一庭编著．最高人民法院人身损害赔偿司法解释的理解与适用．北京：人民法院出版社，2004：262～276