认知暴露疗法治疗创伤后应激障碍

Cognitive-exposure therapy for post-traumatic stress disorder

目的:探讨认知暴露疗法结合药物治疗创伤后应激障碍(post-traumaticstressdisorder,PTSD)的效果。方法:于2003-06/2004-06选择第四军医大学西京医院心身科、西安交通大学第一医院和西安市精神卫生中心的门诊和住院PTSD患者20例。均符合美国精神疾病诊断与统计手册第四版PTSD诊断标准。将20例患者按随机数字表法分为结合治疗组和药物治疗组,每组10例。一组采用认知暴露疗法结合药物干预,另一组采取单纯药物干预。认知暴露疗法方案:向患者讲解创伤应激的有关知识、呼吸再训练、放松训练、创伤记忆暴露、自我重复、认知治疗。治疗次数固定,共7次心理治疗会谈。药物治疗方案:①苯二氮革类药物:罗拉,0.5～1.0mg,3次/d,口服。②抗抑郁药物,盐酸氟西汀,20mg,1次/d。于治疗前24h内、临床治愈后24h内、治疗结束后第91天进行PTSD症状清单量表(主要包括3个分量表:再体验、回避和高激惹)、症状自评量表(包括9个因子,分别是躯体化、强迫症状、人际关系敏感、抑郁、焦虑、敌对、恐怖、偏执和精神病性,还有一个其他项目,共计为10个因子)、贝克抑郁问卷、状态-特质焦虑问卷、汉密顿抑郁量表、汉密顿焦虑量表评定。各量表评定分数越高症状越严重。结果:随访期间无一例失访。①PTSD症状清单量表总分及其回避、高激惹两个分量表评分变化在两组之间无差异,而两组间创伤性再体验分量表评分差异有显著性意义(F=5.502,P<0.05);量表总分及回避、高激惹两个分量表评分组内比较差异有显著性意义(F=8.912,9.399,6.007,P<0.01),创伤性再体验分量表评分则无显著差异;两两比较结果发现,量表总分在3个测量点间差异均有显著性意义(t=2.342,3.547,3.124,P<0.05),表明治疗后比治疗前症状显著改善,随访时有显著回升,但仍显著好于治疗前;创伤性再体验分量表评分治疗后显著低于治疗前(t=2.804,P<0.05),其余时间点比较差异不显著;回避和高激惹分量表评分治疗后及随访时均显著低于治疗前(t=3.542,3.124,5.246,4.138,P<0.05),治疗后与随访时差异不显著。②症状自评量表总分两组间比较差异不显著,组内比较差异有显著性意义(F=41.21,P<0.01),量表总分的时间变化与分组之间无交互作用。两两比较结果发现,症状自评量表总分治疗后及随访时均显著低于治疗前(t=10.526,6.354,P<0.01),治疗后与随访时差异不显著。③贝克卓艹抑郁问卷、状态-特质焦虑问卷、汉密顿抑郁量表、汉密顿焦虑量表评分两组间均无差异;各量表组内比较差异有显著性意义(F=56.701,33.165,33.222,33.491,P<0.01),量表评分与分组之间有交互作用(F=9.615,7.110,4.380,3.953,P<0.05)。④结合治疗组有2名不再符合PTSD诊断,药物治疗组仍全部符合PTSD诊断,两组比较无显著差异(χ2=2.004,P>0.05)。结论:认知暴露疗法能够弥补药物治疗的效果短和无法进行认知重建的不足,减少创伤性应激障碍患者的复发,有助于PTSD患者的心理康复。

AIM： To study the effect of cognitive-exposure therapy combined medication on post-traumatic stress disorder. METHODS： Twenty inpatients and outpatients with post-traumatic stress disorder were selected from the Psychology Department of Xijing Hospital, Fourth Military Medical University, First Hospital of Xi＇an Jiaotong University and Xi＇an Mental Health Center between June 2003 and June 2004, who were diagnosed according to the Post-traumatic Stress Disorder Standards in Diagnostic and Statistical Manual-IV. The patients were randomly divided into combined group, which was treated with medication and cognitive-exposure therapy; medication group, which was only given medication with 10 cases in each group. The cognitive-exposure therapy included explanation of knowledge about stress, re-training of breath, relaxation training, exposure of trauma memory, repeat of trauma events and reconstruct of cognitive. The whole treating procedure included 7 psychological treatment talking. Medication project was as follows： ①Benzodiazepine drugs： 0.5-1.0 mg Iorazepam by orally taken three times daily; ②Antidepressant drugs： 20 mg fluoxertine hydrochloride, once daily. The evaluation of effect was performed in 24 hours before and after treatment and at day 91 after treatment with Post-traumatic Stress Disorder Checklist Scale （PCLS, including three subscales： re-experience, avoidance and hyper-vigilance）, Symptoms Checklist （SCL-90, including 9 factors： somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism besides another item）, Beck＇s Depression Inventory （BDI）, State-Trait Anxiety Inventory （STAI）, Hamilton Depression Scale （HAMD） and Hamilton Anxiety Scale （HAMA）. High marks represented serious symptoms. RESULTS： There was no case loss during follow up. ①There was no significant differences between two groups in the total score and the score of avoidance, hyper-vigilance of PCLS, but in score of re-experience, the differences were obvious （F =5.502, P 〈 0.05）. There were significant differences intra-group in total score, the score of avoidance and hyper-vigilance of PCLS （F =8.912, 9.399, 6.007, P 〈 0.01）, but in score of re-experience. Comparison among the 3 points had significant differences （t =2.342, 3.547, 3.124, P 〈 0.05）, indicating that the symptoms after treatment were improved significantly than those before treatment, which were aggravated during follow up, but still better than before treatment. Symptoms of re-experience after treatment were better than those before treatment （t =2.804, P 〈 0.05）, and the difference was no obvious at other time points; Symptoms of avoidance and hyper-vigilance after treatment and during follow up were both better than those before treatment （t =3.542, 3.124, 5.246, 4.138, P 〈 0.05）, and the difference was not significant between the two stages. ②No significant difference was found between two groups in the scores of SCL-90, while significant differences in any one group （F=41.21, P〈 0.01）, and there was no interaction in the time changes and groups. Cohnparison between two groups showed that the total score of SCL-90 after treatment and during follow up were lower significantly than that before treatment （t =10.526, 6.354, P 〈 0.01）, and the difference was not significant between the two stages. ③There was no significant difference in the trend of BDI, STAI, HAMD and HAMA between two groups, while there was difference intra groups （F=56.701, 33.165, 33.222, 33.491, P 〈 0.01）, and there was interaction between scores and groups （F=9.615, 7.110, 4.380, 3.953, P〈 0.05）. ④Two patients in the combined group did not accord with the diagnosis of post-traumatic stress disorder, and there was no significant difference between groups （Х^2=2.004, P 〉 0.05）. CONCLUSION： Cognitive-exposure therapy could make up the disadvantages of medication such as short effect and difficult for cognition re-construction; it could reduce the recurrence of post-traumatic stress disorder and help to return to mental health of patients.