Посттравматическое стрессовое расстройство (ПТСР). Литература по теме: «Современные тенденции в терапии тревожных расстройств: от научных данных к клиническим рекомендациям»


ПТСР развивается после тяжелого дистресса, который был сопряжен с физическим повреждением или угрозой физического вреда. Состояние характеризуется повторяющимися (навязчивыми) тягостными воспоминаниями о событии, кошмарами, чувством повторного переживания опыта с иллюзиями, галлюцинациями, интенсивными стрессами при каком-либо напоминании о травме. Часто присутствуют избегание мест, событий или общения, связанных с травмой, неспособность вспомнить важные аспекты травмы. Сложность диагностики и терапии ПТСР связаны с его промежуточным положением между ТР („неврозами») и острыми реакциями на стресс (расстройство адаптации, реактивная депрессия). Однако, несмотря на реактивный характер заболевания, ПТСР имеет сходные с основными ТР нейрохимические механизмы развития. Поэтому принципы его терапии довольно близки к принципам лечения ТР.

Для терапии ПТСР СИОЗС являются препаратами первого выбора. Эффективность этой группы антидепрессантов была показана в большом количестве РКИ. Эффективность при лечении ПТСР доказана для пароксетина (Tucker Р. et al., 2001), сертралина (Stein М. et al., 2007), флувоксамина (Marmar С., 1996). Есть данные об успешном применении венлафаксина (Hammer М. et al., 1998) и миртазапина (Kim W. et al., 2005). Для лечения ПТСР использовались ТЦА — имипрамин (Frank J. et al., 1988) и амитриптилин (Davidson J. et al., 1993). Однако эффективность ТЦА при ПТСР нуждается в дополнительном изучении в соответствии с современными критериями доказательной медицины.

БД не обнаружили достаточной эффективности при терапии ПТСР. Однако, на этапе острого периода (первые сутки) успешно используются БД с коротким периодом полувыведения (алпразолам, лоразепам) или инъекционные формы (диазепам, феназепам). Так, есть данные об эффективности алпразолама при редукции тревожного компонента ПТСР (Braun Р. et al., 1990), однако применение БД связано с высоким риском развития зависимости или синдрома отмены (Jacobsen L et al., 2001). Важную роль, начиная с первых часов после психотравмы, играет психотерапия. На более поздних этапах ПТСР значение психотерапии возрастает, хотя до настоящего времени доказательных данных об эффективности психотерапии в лечении ПТСР недостаточно.

За последние 10 лет в арсенале противотревожных средств появился ряд новых препаратов. В связи с тем, что они относятся к разным группам психотропных препаратов (антидепрессанты, антиконвульсанты, атипичные антипсихотики), а исследования их эффективности проводились по принципу монотерапии, их появление поставило ряд клинических проблем. Актуальными являются вопросы взаимодействия новых и традиционных групп препаратов, рекомендации поэтапной терапии ТР, а также подбор наиболее эффективных комбинаций препаратов различных групп при борьбе с резистентными или коморбидными ТР. Также очевидно, что в ближайшее время прогресс в терапии расстройств тревожного спектра будет связан с мультидисциплинарным подходом и поиском новых эффективных комбинаций психофармакотерапии и психотерапии.

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