obsesiur-kompulsiuri aSliloba (oka)

obsesiur-kompulsiuriaSliloba (oka)klinikuri praqtikis erovnuli rekomendacia(gaidlaini)1

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)`obsesiur-kompulsiuri aSliloba (oka)~ miRebulia klinikuripraqtikis erovnuli rekomendaciebis (gaidlainebi) dadaavadebaTa marTvis saxelmwifo standartebis (protokolebi)SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2008wlis 5 noembris #1 sxdomaze da damtkicebulia saqarTvelosSromis, janmrTelobisa da socialuri dacvis ministris 2008wlis 18 dekembris # 275/o brZanebiT.2

obsesiur-kompulsiuri aSliloba (oka)gaidlaini gankuTvnilia⇒ fsiqiatrebisaTvis, pirveladi jandacvis da stacionarulisamedicino dawesebulebebis personalisaTvis, romelTac uSualoSexeba aqvT obsesiur-kompulsiuri aSlilobebis mqone sxvadasxvaasakis pacientebTan;⇒ SeiZleba gamoyenebul iqnas okupaciuri Terapevtebis,fsiqoTerapevtebisaTvis da socialuri muSakebis mier;⇒ SeiZleba gamoyenebuli iyos umaRlesi da saSualo samedicinodawesebulebebis pedagogebis mier uwyveti samedicinoganaTlebisaTvis.1. daavadebis definicia, sinonimebi, terminologia daklasifikaciaobsesiur-kompulsiuri aSliloba (oka) aris fsiqikuri aSliloba,romelsac axasiaTebs ganmeorebiTi, recidiuli, akviatebuli azrebi _obsesiebi da akviatebuli moqmedebebi _ kompulsiebi.terminologia• obsesia (laT. Obsessio _ blokada, alya, garSemortyma). igulisxmebaindividis nebis gareSe mis cnobierebaSi aRmocenebuliakviatebuli azrebi, grZnobebi, warmodgenebi, romlebicstereotipuli formiT meordeba gonebaSi. Tan axlavs kritikulidamokidebuleba da maTi avadmyofuri warmoSobis gancda;• kompulsia (laT. Compello _ vaiZuleb). igulisxmeba dauZleveliakviatebuli ltolva raime moqmedebisaken, romelic aRmocendebagonebis, nebis, grZnobis sawinaaRmdegod da individis mierSeicnoba, rogorc araswori, miuRebeli, ris gamoc misi realizebaar xdeba. igi xSirad winaaRmdegobaSia individis moralur-eTikurdayenebebTan. ufro farTo gagebiT - moZraobiTi sferosnebismieri akviateba, maT Soris _ akviatebuli ritualebi;• rituali _ igulisxmeba akviatebuli Cveva, romlis daniSnulebaaTiTqosda momavali safrTxis Tavidan acileba, SiSis daZleva.xSirad mowyvetilia SiSis realur suraTs da atarebs simbolurxasiaTs.sinonimebi: akviatebul mdgomareobaTa nevrozi, anankasturi nevrozi.istoriuli mimoxilvaklinikur fsiqiatriaSi obsesiur-kompulsiuri aSlilobebis msgavsfsiqopaTologiur fenomenTa aRwera saTaves XVII saukuneSi iRebs. maTipirveli aRwera ekuTvnis 1617 wels platers. SemdgomSi 1621 welsbartonis mier aRwerili iyo “sikvdilis akviatebuli SiSi”. eskirolma3

1827 wels aRwera msgavsi fenomenebi da uwoda maT “azrTa meryeobisnevrozi”. SemdgomSi am movlenis Seswavla ganviTarda balinskis (1858)mier “akviatebuli warmodgenebis” aRwerisas da morelisa da manianisSromebSi. 1866 wels morelma akviatebul azrebs uwoda “emociuribodvebi”; maniani Tvlida, rom am paTologiis safuZvels warmoadgenstvinis anomaluri ganviTareba, rac iwvevs “degeneraciis epizodurgamovlineba”-s. 1877 wels vestfalma xazi gausva akviatebuliaSlilobebis Taviseburebas, rodesac pirovnebis nebis gareSe,cnobierebaSi amotivtivdeba akviatebuli azrebi da miuxedavad imisa,rom am azrTa ucnauroba kritikulad fasdeba pirovnebis mier, mas arZaluZs maTi Tavidan mocileba. SemgomSi akviatebuli mdgomareobebiaRwera frangma mecnierma pier Janem, gamoyo ra isini yvela sxvanevrozuli aSlilobebisagan da uwoda “fsiqasTenia”. akviatebulaSlilobaTa gaerTianeba erTi daavadebis _ fsiqasTeniis qveS, Janesdidi avtoritetis gamo, didi xniT gabatonda safrangeTsa da msofliofsiqiatriaSic. momdevno periodSi germanul fsiqiatriaSi kvlav moxdaam fenomenTa Seswavla da simptomokompleqsma miiRo “akviatebulmdgomareobaTa nevrozis” saxeli. inglisur enaze akviatebaiTargmneboda “obsesiad”, amitom inglisurenovan fsiqiatriaSi amfenomenebs uwodes “obsesiuri nevrozi”. amerikelma fsiqiatrebmaupiratesoba mianiWes akviatebis aRmniSvnel sinonims “kompulsias” da amsimptomokompleqss daarqves “kompulsiuri nevrozi”. mravali wlisganmavlobaSi ingliseli fsiqiatrebi Tvlidnen, rom am aSlilobebisZiriTadi maxasiaTebeli iyo akviatebuli azrebi _ ideatorulikomponenti, maSin rodesac amerikuli fsiqiatria wamyvan paTologiadmiiCnevda akviatebul moqmedebebs _ qceviT aSlilobas. SemdgomSi esori komponenti gaerTianda da sabolood Camoyalibda, rogorcobsesiur-kompulsiuri aSliloba. Tanamedrove fsiqiatriaSi damkvidrdaazri, rom “obsesiebi”, iseve rogorc “kompulsiebi” warmoadgenen erTida igive paTogenezis da struqturis mqone simptomokompleqss, romelicgamovlindeba erT SemTxvevaSi ideatorul, xolo meore SemTxvevaSi -nebiT sferoSi.2. epidemiologia (I – A) (1, 56)• obsesiur-kompulsiuri aSliloba dReisaTvis ganixileba rogorcsakmaod gavrcelebuli daavadeba. zogierTi monacemebiT pirveladiSemTxvevebis maCvenebeli saerTo populaciaSi ganisazRvreba 1,5%-iT.mosaxleobs masStaburi kvlevebiT dadgenilia, rom fsiqikuraSlilobebs Soris oka sixSiriT meoTxe adgilzea depresiis,alkoholizmi/wamaldamokidebulebis da socialuri fobiis Semdeg dadaaxloebiT 2-3%-s Seadgens, rodesac iTvaliswineben gamwvavebaTaepizodebs, romelic mTeli cxovrebis manZilze aRiniSneba (anuqronikuli, recidiuli SemTxvevebi). (C-III) (2);• obsesiur-kompulsiuri aSlilobis mqone pacientebi Seadgenen imkontingentis 1%-s, romelic mkurnalobs fsiqiatriuldawesebulebebSi. qalebSi daavadeba gvxvdeba ramdenadme ufroxSirad (genderuli Tanafardoba qalebsa da mamakacebSi 1.5:1);4

• daavadebis dawyebis saSualo asakia 20 w., ori asakobrivi pikiT _ 12-14 da 20-22 weli. sakmarisad xSiria bavSvebSi. (III-C) (3);• aRsaniSnavia am aSlilobis maRali komorbidoba sxvadasxvaaSlilobebTan, gansakuTrebiT depresiasTan (4,5,6), SfoTvasTan (7,8,9),alkoholizmsa da narkomaniasTan (10) an kvebiT aSlilobebTan (11);• sxvadasxva kvlevebiT dadgenilia, rom obsesiur-kompulsiuriaSlilobis mqone pacientTa inteleqti, Cveulebriv, saSualozemaRalia. 60-70% SemTxvevebSi aSliloba viTardeba garkveuli stresisSemdeg, mag.: orsuloba, seqsualuri problemebi, axlobeli adamianissikvdili. SemTxvevaTa naxevarSi aRiniSneba mwvave dasawyisi;• vinaidan bevri pacienti xSirad malavs Tavis mdgomareobas da eqimsdaxmarebisaTvis mimarTavs daavadebis dawyebidan 5-10 wlis Semdeg,hospitalizebul avadmyofTa saSualo asaki Seadgens 30 wels;• jandacvis msoflio organizaciis mier oka Sedis im 10 daavadebisricxvSi, romelic iwvevs funqcionirebis mkveTr SezRudvas damniSvnelovan gavlenas axdens adamianis cxovrebis xarisxzedaswavlis da Sromis unaris daqveiTebis, samuSao adgilisSenarCunebis, umuSevrobis da, aqedan gamomdinare dabaliSemosavlebis gamo (12, 13).• oka-is mqone pirebs mniSvnelovani problemebi eqmnebaT socialursferoSi. igi xSirad xdeba socialuri kavSirebis rRvevis mizezi,magaliTad, partniorTan an meuRlesTan daSoreba/ganqorwineba.• oka-s dros yvelaze xSirad gamovlenili obsesiebis dakompulsiebis CamonaTvali warmodgenilia cxrilis saxiT: (III- C) (14)obsesiis saxevirusiT (mag. HIV-iT), baqteriebiT dasnebovnebisan WuWyiT, webovani an qimiuri nivTierebebiT,fekaluri masebiT dabinZurebis SiSimaterialuri zianis miyenebis SiSi (mag.: karissaketi saimedo ar aris)wesrigis, simetriulobis dacvaze gadaWarbebulizrunvaakviatebuli azrebi sxeulis formis an sxvaraime fizikuri simptomis Sesaxebreligiuri, eretikuli da mkrexeluri Sinaarsisazrebiseqsualuri Sinaarsis azrebi (mag.: TiTqos arispedofili an homoseqsuali)azrebi (an dauZleveli survili) usargeblonivTebis koleqcionerobis an sakuTri qonebisganadgurebis Sesaxebprocenti35.8%23.6%10.0%7.2%5.9%5.5%4.8%5

Zaladobrivi an agresiuli azrebi (mag.: bavSvisdaWris akviatebuli azri)4.3%kompulsiis saxeprocentigadamowmebebi (mag.: karebis saketis, gazquris) 28.8%recxva, dasufTaveba 26.5%ganmeorebiTi moqmedebebi 11.1%mentaluri kompulsiebi (mag.: specialuri10.9%sityvebis an locvebis garkveuli TanmimdevrobiTgameoreba)simetriulobis dacva nivTebis dalagebisas 5.9%koleqcioneroba/dagroveba 3.5%akviatebuli Tvla 2.1%3. etiopaTogenezimonacemebi oka-s etiologiasa da paTogenezze dReisTvis metadmravalmxrivi da xSirad urTierTsawinaaRmdegoa (15). oka-sneirobiologiuri Teoriebi emyareba mraval faqts pacientebSisxvadasxva tipis nevrologiuri disfunqciis arsebobis Sesaxeb (mag.:qala-tvinis travma, samSobiaro travma da sxva). aRwerilia oka-sgansakuTrebuli varianti bavSvebSi beta-stafilokokuri infeqciisgadatanis Semdeg (III-C) (16). am SemTxvevaSi akviatebebisa da ritualuriqcevebis garda klinikur suraTSi saxezea emociuri labiloba, SfoTvada tikebi.pozitronul-emisiuri tomografiiT (pet) kvlevisas, rig SemTxvevaSigamovlenilia Tavis tvinis qerqis orbitaluri zonis Sublis wilebis,limburi sistemis da kudiani birTvis aqtivoba (glukozis Warbimoxmareba), anu im zonebis daintereseba, sadac Warbad arisganTavsebuli serotoninerguli receptorebi.ukanasknel wlebSi dagrovda informacia oka-s paTogenezSi dofaminurisistemis monawileobis Sesaxeb. klinikuri faqtebi avlenen oka-s maRalkomorbidulobas turetis sindromTan (40-60%) (17). cns-is mxriv saqmegvaqvs procesis lokalizaciasTan bazaluri gangliebis doneze, sadacxdeba Sua tvinis nakeris zonidan aRmavali serotoninerguli da SavibirTvidan momavali dofaminuri gzebis gadakveTa. (III-C) (18)serotoninerguli sistemis normaluri funqcionirebis dros xdebadofaminerguli sistemis aqtivobis SezRudva. serotoninis gamoyofisSesusteba ki iwvevs am ori neirotransmiteruli sistemis disbalanssda bazalur gangliebSi dofaminis aqtivobis momatebas. amiT SeiZleba6

aixsnas oka-s bevri klinikuri simptomi, dakavSirebuli stereotipulqcevasTan da motorul darRvevebTan. bazaluri gangliebidaneferentuli gzebiT ki xdeba qerqis Sublis wilebis agzneba, racSeiZleba iyos ideatoruli akviatebebis mizezi.oka-s ganviTarebaSi gansakuTrebuli roli ekuTvnis agreTvememkvidreobiT-genetikur faqtorebs. daavadebis sixSire sarwmunodmaRalia monozigotur tyupebSi, dizigoturTan SedarebiT. oka-ssixSire 2-jer metia axlo naTesavebSi (pirveli xazi naTesavebSi oka-ssimptomebi 20-30%-Si gvxvdeba). aseve xSiria am populaciaSi SfoTviTida afeqturi aSlilobebi da turetis sindromi.fsiqodinamikuri fsiqiatriis mimdevrebi oka-s mizezad miiCnevenpirovnebis fiqsacias genitaluri ganviTarebis stadiaze da regressadreul analur stadiaze. amiT aixsneba midrekileba “magiuriazrovnebis~ elementebisadmi da ambivalentoba. amas, fsiqoanalitikosTaazriT, mivyavarT “super ego”-s meqanizmebis CarTvamde. sayuradReboa,rom mkurnalobis fsiqodinamikuri meTodi ar aris efeqturi oka-sTerapiisas.bihevioruli fsiqoTerapiis warmomadgenlebi oka-s warmoSobispirvelad mizezad miiCneven konkretul viTarebaSi aRmocenebulSfoTvas (mag.: dabinZurebis, dasnebovnebis realuri viTareba), romelicSemdegSi myardeba pirobiTi refleqsis saxiT. SfoTvis donisdaqveiTebis mizniT avadmyofi mimarTavs ritualur (TavdacviT) qcevebs,romlebic aseve myardeba pirobiTi refleqsis saxiT. miuxedavad imisa,rom eqsperimentuli kvlevebi ar adastureben am mosazrebebs, qceviTiTerapia rCeba oka-s mkurnalobis erT-erT yvelaze gavrcelebulmeTodad.erT-erTi ukanaskneli aris rasmusenis Teoria (19), romlis mixedviToka-s ganviTarebas safuZvlad udevs 3 ZiriTadi fenomeni:1. riskis Sefasebis unaris paTologiuri Secvla;2. paTologiuri eWvianoba;3. utyuarobis, srulyofilebis, sisworis damtkicebis ZlierimoTxovnileba.4. klinikuri simptomatikaa. simptomebis CamonaTvalidaavadebis ZiriTad gamovlinebas warmoadgens sxvadasxva saxisakviatebebi _ obsesiebi da kompulsiebi, romelTac gaaCniaT zogierTisaerTo Tvisebebi:1. subieqtis cnobierebaSi azris an impulsis Canergva xdebadaJinebiT da intensiurad;2. ZiriTadi gamovlinebebis Tanmxlebi SfoTva da SiSi iwvevssubieqtis mier sapirispiro RonisZiebebis SemuSavebas, racmimarTulia aRmocenebuli azris an impulsis winaaRmdeg;7

3. obsesia da kompulsia ucxoa ego-sTvis, ese igi aRiqmebasubieqtis mier rogorc misi pirovnebisaTvis miuRebeli;4. ramdenadac mZafri da gamomwvevi ar unda iyos obsesiebi dakompulsiebi, subieqti mainc acnobierebs maT absurdulobas dairacionalizms;5. subieqti itanjeba obsesiebis da kompulsiebisagan, aqvs Zlierisurvili ganTavisufldes da winaaRmdegobas uwevs maT(winaaRmdegobis xarisxi gansxvavebulia).obsesiur-kompulsiuri aSlilobebi vlindeba Semdegisimptomokompleqsebis saxiT:• obsesiuri azrebi – avadmyofis nebisagan damoukidebladaRmocenebuli azrebi, msjelobebi, warmodgenebi, romlebicnaZaladevad iWreba avadmyofis cnobierebaSi. Tumca avadmyofismier aRiqmeba rogorc sakuTari, igi cdilobs raime gziT winaRudges maT. obsesiurma azrebma SesaZlebelia miiRos calkeulisityvebis, frazebis an gariTmuli strofebis forma; Cveulebrivisini avadmyofisaTvis arasasiamovnoa da SesaZlebelia iyosuwmawuri, uxamsi da Sokis momgvrelic ki;• obsesiuri warmodgenebi – es aris naTlad warmosaxuli scenebi,xSirad gaaCnia Zaladobis an zizRismomgvreli xasiaTi da moicavsmagaliTad, seqsualuri gaukuRmarTebis Sinaarss;• obsesiuri impulsebi – es aris moqmedebisadmi swrafva Cveulebrivdamangreveli, saxifaTi an Semarcxveneli. magaliTad, moZraviavtotransportis win gzaze gadarbena, bavSvis dasaxiCreba,sazogadoebaSi ucenzuro sityvebis wamoZaxeba (koprolalia);• obsesiuri ritualebi _ isini moicavs rogorc fsiqikurmoqmedebas (mag., ganmeorebadi Tvla gansakuTrebuli sistemismixedviT, an calkeuli sityvebis gameoreba), aseve ganmeorebad,Tumca uazro saqciels (mag., xelebis dabana dReSi 20-jer dametjer). zogierTi maTgani dakavSirebulia winamorbed akviatebulazrebTan, mag., xelebis ganmeorebiTi dabana dakavSirebuliadabinZurebis azrebTan. sxva ritualebs (mag., regularulad Cacmiswin tansacmlis rTuli TanmimdevrobiT dalageba) aseTi kavSiriar gaaCnia. zogierTi avadmyofi ganicdis gadaulaxav miswrafebasaseTi moqmedeba gaimeoros gansazRvruli raodenobiT; Tu es argamodis, igi iZulebulia yvelaferi daiwyos xelaxla. avadmyofebiacnobiereben, rom es ritualebi moklebulia logikas daCveulebriv cdiloben damalon isini. zogierTs aqvs SiSi, rom amsimptomebs gaaCnia “SeSlilobis” dawyebis niSnebi. rogorcobsesiuri azrebi, aseve ritualebi qmnis problemebs yoveldRiurcxovrebaSi;• akviatebuli msjeloba (“azrebis ReWva/coxna”) – es aris Sinaganidebatebi, yoymani, romlis drosac dausruleblad xdebaargumentebis awon-dawonva, rac yoveldRiur umartivesmoqmedebebzec ki vrceldeba. akviatebuli yoymani imaSimdgomareobs, rom pacientis mier Sesrulebuli moqmedeba (mag.:8

Rumelis gamorTva an karebis daketva) aRiqmeba, rogorc arasworian dausrulebeli; SesaZlebelia es sxva moqmedebebi exeba sxvaadamianebisadmi zianis miyenebis SiSs (magaliTad, avtomobilisgverdiT mimavali velosipedistis dazianeba). zogjer yoymanidakavSirebulia religiuri kanonebis da ritualebis SesaZlodarRvevasTan – “sindisis qenjna”;• kompulsiuri moqmedebebi – ganmeorebadi stereotipuli qmedebebi,romlebic zogjer dacviTi ritualis xasiaTs iRebs. amukanasknelis mizania avadmyofs an mis axloblebs Tavidanaacilos raime saxifaTo, magram obieqturad naklebad savaraudo,movlena;• gansakuTrebuli adgili miekuTvneba akviatebul moqmedebebsizolirebuli, monosimptomuri moZraobiTi darRvevebis saxiT. maTSoris, gansakuTrebiT bavSvTa asakSi, xSiria tikebi. gansxvavebiTorganulad ganpirobebuli uneblie moZraobebisagan, am drossruldeba gacilebiT ufro rTuli motoruli aqtebi, romlebsacdakarguli aqvT Tavisi pirvandeli azri. tikebi xSirad tovebsutrirebul Cveuli fiziologiuri moZraobebis STabeWdilebas. esaris Taviseburi karikatura garkveul moZraobebze, bunebrivJestebze. gansxvavdeba sxva akviatebuli moqmedebebisagan imiT, romar arsebobs moucileblobis subieqturi gancda, ar aRiqmebarogorc ucxo da avadmyofuri. nevrozuli aSlilobebi, romelTadrosac gvxvdeba mxolod akviatebuli tikebi xasiaTdeba kargiprognoziT. zogjer aseTi aSliloba SeiZleba iyos myaric,SenarCundes wlebis ganmavlobaSi da gamovlinebebis mxrivmxolod nawilobriv icvalos saxe.akviatebebi (obsesiebi) iyofa xatovan anu grZnobad obsesiebad,romlebsac Tan axlavs afeqturi komponenti (xSirad mZime), daafeqturad neitraluri Sinaarsis akviatebebad.grZnobad akviatebebs miekuTvneba akviatebuli iWvneuloba, mogonebebi,warmosaxvebi, ltolva, moqmedebebi, SiSebi, antipaTiis akviatebuligrZnoba, akviatebuli SiSebi Cveuli qcevebis mimarT.• akviatebuli iWvneuloba – logikis sawinaaRmdegod, naZaladevadaRmocenebuli daurwmunebloba ukve Sesrulebuli an mimdinareqmedebis sisworeSi. iWvneulobis Sinaarsi gansxvavebulia:akviatebuli yofa-cxovrebiTi SiSebi (daketilia Tu ara karebi,kargadaa Tu ara daxuruli fanjara an onkani, gamorTulia Tuara Rumeli, eleqtroxelsawyoebi), iWvneuloba dakavSirebulisamsaxurebriv saqmianobasTan (sworadaa Tu ara dawerilidokumenti, xom ar aris SecdomiT miTiTebuli saqmian qaRaldebzemisamarTi, xom ar aris miTiTebuli araswori cifrebi, sworadaaTu ara Camoyalibebuli da Sesrulebuli gankarguleba) da sxv.miuxedavad Sesrulebuli qmedebis mravaljeradi gadamowmebisa,eWvneuloba, rogorc wesi, ar qreba da fsiqologiur diskomfortsiwvevs;9

• akviatebuli mogonebebi _ maT miekuTvneba daJinebuli,gadaulaxavi mZime mogonebebi raime, samwuxaro, usiamovno anavadmyofisTvis samarcxvino movlenaze, romelsac Tan axlavssircxvilis grZnoba, monanieba da romelic pacientiscnobierebaSi dominirebs miuxedavad imisa, rom igi cdilobsmaTze ar ifiqros;• akviatebuli ltolvebi – ama Tu im sastiki an ukiduresad saSiSiqmedebisHCadenis ganzraxva,Hrasac Tan moyveba saSinelebis, SiSis,SfoTvis gancda, romlisgan ver xerxdeba ganTavisufleba.avadmyofs ipyrobs survili matarebels Cauvardes an ubiZgosCasavardnad axlobel adamians. pacients am dros ipyrobsmtanjveli SiSi, rom esa Tu is gadawyvetileba sisruleSi iqnebamoyvanili;• kontrastuli akviatebebi (“agresiuli obsesiebi”) – salanZRavi,mkrexeluri azrebi, sakuTari Tavisa da garSemomyofebisadmimimarTuli zianis miyenebis SiSi. am jgufis fsiqopaTologiuriwarmonaqmnebi miekuTvneba upiratesad xatovan akviatebebs mkafiodgamoxatuli afeqturi foniT, romelic mTlianad moicavsavadmyofis cnobierebas. maTi ganmasxvavebeli sxva akviatebebisaganaris sruli gaucxoebis gancda, absoluturad aramotivirebuliSinaarsi, agreTve mWidro kavSiri akviatebul ltolvebTan damoqmedebebTan. avadmyofebi kontrastuli akviatebebiT uCiviandauZlevel miswrafebas, mosmenils daumaton replikebi, romelicnaTqvams miscems usiamovno an muqaris Sinaarss, gaimeorongarSemomyofebis mier warmoTqmuli religiuri Sinaarsis frazebiukve ironiuli an sarkastuli elferiT. sakuTari Sexedulebebisada sazogadod miRebuli moralis sawinaaRmdegod cinikuriSinaarsis sityvebi an frazebi wamoiZaxon. isini SiSoben, dakargonkontroli sakuTari Tavze da Seasrulon saxifaTo an uazromoqmedebebi, miayenon ziani sakuTar Tavs an garSemomyofebs.zemoTqmuls xSirad Tan axlavs mWreli sagnebis (mWreli sagnebis– dana, Cangali, najaxi da a.S.) fobiebi. kontrastuli akviatebebisjgufs nawilobriv miekuTvneba seqsualuri Sinaarsis akviatebebi(gaukuRmarTebul seqsualur aqtebze tabudadebuli warmodgenebistipis akviatebebi, romelTa obieqtebi SesaZlebelia iyvnenbavSvebi, imave sqesis wamomadgenlebi, cxovelebi);• dabinZurebis akviatebuli ideebi (mizofobia). obsesiebis am jgufsmiekuTvneba rogorc dabinZurebis (miwiT, mtvriT, SardiT,ganavliT da sxva sibinZureebiT) SiSi. aseve organizmSi mavne damomwamlavi nivTierebebis (cementi, sasuqi, toqsikuri narCenebi),mcire zomis sagnebis (minis namtvrevebi, nemsi, specifikurimtveri), mikroorganizmebis moxvedris SiSi. rig SemTxvevebSidabinZurebis SiSi SesaZlebelia atarebdes SezRudul xasiaTs,SenarCunebuli iyos mravali wlis ganmavlobaSi preklinikurdoneze da gamovlindes mxolod piradi higienis zogierTTaviseburebaSi (TeTreulis xSiri cvla, xelebis mravaljeradidabana) an saojaxo saqmianobaSi (sakvebi produqtebissaguldagulo damuSaveba, iatakis yoveldRiuri wmenda, Sinauricxovelebis zizRi, maTi akrZalva). aseTi saxis monofobiebi10

arsebiT gavlenas ar axdens cxovrebis xarisxze dagarSemomyofebisagan Sefasebulia rogorc ucnauri Cvevebi(utrirebuli sisufTave, gadaWarbebuli zizRianoba). mizofobiisklinikurad gamovlinebuli variantebi miekuTvneba mZimeakviatebebis jgufs. am SemTxvevebSi wina planze gamodis TandaTangarTulebuli dacviTi ritualebi: dabinZurebis wyaroebis da“binZuri” sagnebis Sexebis Tavidan acileba, nivTebis higienuridamuSaveba, sarecxi saSualebebisa da pirsaxocebis gamoyenebisgarkveuli Tanmimdevrobis dacva da sxva. dacviTi RonisZiebebitardeba sacxovrebeli binis gareTac: quCaSi gasvla specialuri,damcavi samosiT, saxlSi mitanili sagnebis gansakuTrebulidasufTaveba. daavadebis mogvianebiT stadiebze avadmyofebisakuTar oTaxsac ar toveben. mizofobias miekuTvneba agreTveraime daavadebiT dasnebovnebis SiSic, romelic ar miekuTvnebaipoqondriuli fobiebis kategorias. wina planzea garedansafrTxis SiSi: organizmSi daavadebis gamomwvevi baqteriebismoxvedris SiSi;• akviatebuli antipaTiis grZnoba _ antipaTia, romelic vlindebaakviatebul azrebsa da warmosaxvebSi, xSirad garkveuliaxlobeli an sapativcemulo adamianebis, agreTve religiuripirebis _ wmindanebis, eklesiis msaxurebis mimarT;• akviatebuli SiSebs (fobiebs) miekuTvneba samaRlis, Ria andaxuruli sivrcis, xalxmravlobis, ucabedi sikvdilis, ama Tu imganukurnebeli daavadebis mimarT SiSi. erTsa da imave pirovnebasSeiZleba ganuviTardes sruliad gansxvavebuli fobiebi, romlebiczogjer iReben yovlismomcvel xasiaTs (panfobia) da bolos,SesaZlebelia gaCndes SiSis aRmocenebis SiSic (fobofobia),agreTve mania fobia anu „gagiJebis“ SiSi;• specifikuri (izolirebuli) fobiebi – akviatebuli SiSebi,Semofargluli gansazRvruli situaciiT – simaRlis, Weqaquxilis,Sinauri cxovelebis, stomatologTan mkurnalobis daa.S. vinaidan am situaciasTan Sexebas Tan axlavs intensiuriSfoTva, avadmyofi cdilobs gaeqces am situacias.• ipoqondriuli fobiebi (nozofobia) _ raime mZime daavadebisakviatebuli SiSi. yvelaze xSiria kancero-, insulto-, kardio-,sifilo-, Sidsofobia da sxva. aseTi avadmyofebi SfoTvis pikzemimarTaven Sesabamisi profilis eqimebs, iTxoven gamokvlevebis damkurnalobis Catarebas. rogorc wesi amis Sedegad yalibdebaipoqondriuli nevrozi, rasac Tan axlavs xSiri vizitebieqimebTan da samkurnalo saSualebaTa gaumarTlebeli arasaWiromiReba.akviatebuli SiSebis Sedegad xSirad yalibdeba ritualebi _moqmedebebi, romlebic iZenen „magiuri“ Selocvis mniSvnelobas.miuxedavad pacientis kritikuli damokidebulebisa obsesiebis mimarT,isini xorcieldeba ama Tu im SesaZlebeli ubedurebisagan dacvismizniT. raime mniSvnelovani saqmis dawyebamde avadmyofma aucilebladunda ganaxorcielos garkveuli moqmedeba, raTa gamoricxos11

warumatebloba am saqmeSi. ritualebi SeiZleba gamovlindes magaliTad:TiTebis dakakunebiT, raime melodiis wamRerebiT, garkveuli sityvebiswarmoTqmiT, an sxeulis garkveuli moZraobiT. ritualebi,kombinirebuli sxva akviatebebTan warmoadgens sakmaod stabilursistemas, romelic aRiniSneba xolme wlebis ganmavlobaSi.afeqturad neitraluri Sinaarsis akviatebebi _ akviatebuli brZnoba,akviatebuli Tvla (ariTmomania), terminTa, formulirebebis da sxvaTaakviatebuli gaxseneba. isini naklebad Semawuxebelia, magram xelsuSlis avadmyofis inteleqtualur saqmianobas.b. oka-s mimdinareoba, garTulebebi, prognozioka-s axasiaTebs qronikuli mimdinareoba. daavadebis epizodurigamovlinebis da sruli gamojanmrTelebis SemTxvevebi SedarebiTiSviaTia. aRsaniSnavia, rom pacientTa erT nawilSi, gansakuTrebiTromelime tipis akviatebis aRmocenebis da xangrZlivad SenarCunebisas(xelebis akviatebuli bana, akviatebuli angariSi da sxv.), SesaZlebeliamdgomareobis stabilizacia. am SemTxvevebSi SesamCneviafsiqopaTologiuri simptomatikis TandaTanobiT (Cveulebriv, cxovrebismeore naxevarSi) Serbileba da socialuri readaptacia. magaliTad,pacientebi, romlebsac aReniSnebodaT transportis zogierT saxeebSimgzavrobis an sajaro gamosvlis SiSi, Tavs aRar grZnoben naklovanpirovnebad da cxovroben ise, rogorc janmrTelebi. oka-s msubuqiformebis dros daavadeba umetesad keTilsaimedod mimdinareobs(ambulatorul doneze). am SemTxvevaSi simptomatikis ukuganviTarebaxdeba manifestaciidan 1-5 wlis manZilze.ufro mZime da rTuli formebi (mizofobia, kontrastuli warmodgenebi,mravalricxovani ritualebi) piriqiT - iCenen simyares, rezistentobasmkurnalobisadmi, an am dros aRiniSneba tendencia recidiulimimdinareobisaken, rac klinikuri suraTisa da, zogadad, daavadebisTandaTanobiT garTulebaze miuTiTebs.SemTxvevaTa 80%-Si pacientebs obsesiebi da kompulsiebi aReniSnebaTerTdroulad. ufro iSviaTia oka mxolod obsesiuri simptomebiT dakidev ufro iSviaTi _ mxolod kompulsiuri gamovlinebebiT.obsesiuri azrebi da kompulsiuri ritualebi garkveul situaciebSiZlierdeba; magaliTad, garSemomyofebisadmi zianis miyenebis obsesiuriazrebi Zlierdeba samzareuloSi an sxva adgilas, sadac inaxeba danebi.vinaidan avadmyofebi xSirad gaurbian aseT situaciebs, SesaZlebeliaaRiniSnos erTgvari msgavseba SfoTviT-fobikuri aSlilobis drosgamovlenil ganridebis qcevasTan. SfoTva warmoadgens obsesiurkompulsiuriaSlilobis mniSvnelovan komponents. zogierTi ritualiamcirebs SfoTvas, zogierTi piriqiT, aZlierebs. obsesiebi xSiradviTardeba depresiis farglebSi. zogierTi avadmyofisTvis esganixileba rogorc fsiqologiurad gasagebi reaqcia obsesiurkompulsiursimptomebze, Tumca sxva SemTxvevebSi viTardeba, rogorcdamoukidebeli depresiis ganmeorebadi epizodebi.sxvadasxva avtorebis monacemebiT obsesiur-kompulsiuri aSlilobismqone pacientebis 1/3-s uviTardeba depresiuli mdgomareoba (xSiradmZime depresia) da Sesabamisad maRalia suiciduri riski.12

4. subieqti acnobierebs faqts, rom obsesiebi misi fsiqikis nayofiada ara garedan Tavs moxveuli (gansxvavebiT naZaladevi, „garedanCadebuli“ azrebi).kompulsiebi ganisazRvreba rogorc (1), (2):1. myari, ganmeorebadi qceva (xelebis bana, xSiri gadamowmeba) anmentaluri aqtivoba (mag: locva, Tvla, sityvebis mravaljeradiganmeoreba), rasac pirovneba aRiqvams, rogorc obsesiis sapasuxoqmedebas, anda raime gansazRvruli wesis mimarT daqvemdebarebas,romelic aucileblad unda Sesruldes;2. qmedebis an mentaluri aqtiurobis mizani, SeaCeros an Seamcirosdiskomforti, an Tavidan aicilos raime saxifaTo movlena,situacia, Tumca aRniSnuli aqtiuroba an ver wyvitavs problemas,anda aSkarad gadaWarbebulia.B. aSlilobis mimdinareobis garkveul etapze pirovneba acnobierebs,rom obsesiebi da kompulsiebi gadaWarbebuli an miuRebelia.(SeniSvna: aRniSnuli ar exeba bavSvebs);C. obsesiebi da kompulsiebi iwvevs Zlier sulier tanjvas dadidxans grZeldeba (dReSi aranakleb erTi saaTisa) damniSvnelovnad uSlis xels pacients yoveldRiur cxovrebaSi,profesiul saqmianobasa da socialur funqcionirebaSi;D. Tu sxva fsiqikuri aSlilobis pirveli RerZis simptomebigamoixateba obsesiur-kompulsiuri aSlilobebis saxiT, es araaoka-s diagnozis dasmis safuZveli (mag.: saWmelze mudmivi fiqrikvebiTi aSlilobis dros, Tmebis amogleja triqotilomaniisdros, garegnobaze wuxili dismorfofobiuli aSlilobebis dros,wamlebze ganuwyveteli fiqri wamalTdamokidebulebis dros, mZimedaavadebis SiSi ipoqondriis dros, seqsualuri fantaziebi dawarmosaxvebi parafiliis dros, braleulobis gancda depresiuliaSlilobis dros);E. aRniSnuli aSliloba uSualod ar ukavSirdebawamaldamokidebulebiT gamowveul fsiqologiur efeqtebs anzogad samedicino mdgomareobebs.diferencialuri diagnozioka-s dros diferencialuri diagnozi tardeba Semdeg aSlilobebTan:1. didi depresia;2. generalizebuli SfoTviTi aSliloba;3. panikuri aSliloba;4. hipoqondria;5. turetis sindromi;6. Sizofrenia.14

6. gamokvlevis sqemaa. klinikuri interviu;b. simptomebis simwvave fasdeba ieli-braunis obsesiur-kompulsiuriskaliT (22).msubuqi oka (ieli-braunis obsesiur-kompulsiuri skaliT 8-15) iwvevsdistress, magram ara disfunqcias da pacientebi dRis ganmavlobaSisxvaTa daxmarebas ar saWiroeben. saSualo simZimis oka (skaliT 16-31)iwvevs rogorc distress, ise funqciur SezRudulobas. ukiduresad mZimeda mwvave oka (skaliT 32 an meti) iwvevs seriozul funqciur darRvevas,rac saWiroebs sxvaTa mxridan mudmiv daxmarebas.iel-braunis skala obsesiur-kompulsiuri aSlilobisaTvissaxeli, gvari: TariRi: eqimi:SeniSvna: qulebi unda asaxavdes pacientze obsesiur-kompulsiuri simptomebiserTobliv zemoqmedebas. yoveli punqtisaTvis SeafaseT saSualo SemTxveva winakviris ganmavlobaSi, maT Soris intervius periodSi. SemoxazeT yvelazemisaRebi pasuxi.simptomisimwvavis xarisxi1. obsesiebze 0 sT/dR 0-1 sT/dR 1-3 sT/dR 3-8 sT/dR >8 sT/dRdaxarjuli droqula 0 1 2 3 42. obsesiebiTgamowveulidabrkolebebiara msubuqi garkveuli,magramdaZlevadimZime mwyobridangamomyvani3. distresiobsesiebis gamo4. obsesiebisadmimdgradoba5. obsesiebiskontroliqula 0 1 2 3 4ara mcireodeni saSualo, mZimemagramdaZlevadiTiTqmismudmivad,Sromisunarisdakargvamdequla 0 1 2 3 4sruli mcireodeni zomierad xSiradwin veraRudgebasruladnebdebaqula 0 1 2 3 4sruli upiratesad zomierad mciredi verakontrolebaakontrolebsqula 0 1 2 3 4qulaTa jami (obsesiebi)15

simptomisimwvavis xarisxi6. kompulsiebze0 0-1 sT/dR 1-3 sT/dR 3-8 sT/dR >8 sT/dRdaxarjuli dro sT/dRqula 0 1 2 3 47. kompulsiebiTgamowveulidabrkolebebiara msubuqi garkveuli,magramdaZlevadimZime mwyobridangamomyvani8. distresikompulsiebisgamo9. kompulsiebisadmimdgradobaqula 0 1 2 3 4ara mcireodeni saSualo, mZimemagramdaZlevadiTiTqmismudmivad,Sromisunarisdakargvamdequla 0 1 2 3 4sruli mcireodeni zomierad xSiradwin veraRudgebasruladnebdebaqula 0 1 2 3 410. kompulsiebiskontrolisruli upiratesadakontrolebszomierad mciredi verakontrolebsqula 0 1 2 3 4qulaTa jami (kompulsiebi)saerTo jamiobsesiur-kompulsiuri aSlilobebis simwvavis xarisxi:0-7 klinikurad gamoxatuli ar aris;8-15 msubuqi;16-23 zomierad gamoxatuli;24-31 mZime;32-40 ukiduresad mZime.7. oka-s mkurnalobis sqema (23, 24)mkurnaloba naCvenebia pacientTa umravlesobisaTvis, romlismdgomareoba kvalificirebulia ICD-10-is an DSM-IV-is kriteriumebisSesabamisad – obsesiur-kompulsiuri aSliloba (oka).akviatebul mdgomareobaTa Tanamedrove Terapia aucilebladgulisxmobs kompleqsur midgomas (fsiqoTerapia da farmakoTerapia).amasTan, mTavar amocanas warmoadgens SfoTvis reduqcia, Sinaganikonfliqtis gadaWra da stresidan gamosvlis efeqturi gzebis moZebna.mkurnalobis gegmis Sedgenisas gaTvaliswinebuli unda iyos:1. pacientis ufleba Tanxmoba ganacxados mkurnalobaze;2. daavadebis simwvave,3. Tanmxlebi daavadebebi, garTulebebi, narkomania, an suicidis (I-A)(25) riski;4. adre Catarebuli mkurnalobis efeqturoba;5. zog qveyanaSi, SeiZleba gaTvaliswinebuli iqnes mkurnalobisxarjebic.16

medikamenturi mkurnalobis dawyebisas gaTvaliswinebuli unda iqnasSemdegi faqtorebi:• pacientis survili iTanamSromlos eqimTan (gverdiTi movlenebissimcire, dRiuri dozis miRebis reJimi);• pacientis asaki (tricikluri antodepresantebis (tca) miRebisasasakovan pirebSi maRalia sedacia, orTostatiuli hipotonia,Sardis Sekavebis albaToba, an cnobierebis abneva da mxedvelobisgaoreba);• pacientis cxovrebis stili - ramdenad mobiluria da aqtiuri igidRis ganmavlobaSi;• Tanmxlebi somaturi daavadeba - mag., tca-s maRali dozebi iwvevsariTmias an orTostatikul hipertenzias gulis daavadebisSemTxvevaSi;• Tamxlebi fsiqikuri aSliloba (mag.: oka + depresia);• adre miRebuli medikamentebis efeqturoba.a. oka-s mkurnalobaSi gamoyenebuli preparatebis dafsiqoTerapiuli teqnikis zogadi daxasiaTeba• fsiqotropul saSualebebs Soris yvelaze efeqturi aRmoCndaantidepresantebis jgufi. mkvlevarTa umravlesoba Tvlis, romoka-s dros gansakuTrebiT efeqturia klomipramini (I-A) (26, 27, 28).kvlevebismonacemebiklomipraminis efeqturobis damadasturebeli monacemebi damiRebis formebi warmodgenilia cxrilis saxiT• placebo-kontroliT Catarebuli kvlevebismonacemebiT, klomipraminis peroralurad daparenteralurad gamoyenebis zogadi efeqturobameryeobs 40-80%-is farglebSi (29);• placebo efeqti, depresiisagan gansxvavebiT, oka-sdros mxolod 5%-s Seadgens (30);• yuradsaRebia klomipraminis sxva triciklurantidepresantebTan SedarebiTi kvlevebi: mag.:amitriptilinTan, imipraminTanTan, doqsepinTan,romelSic sakmao mtkicebebia ideatoruliakviatebebis (obsesiebis), ritualebis (kompulsiebis)da fobikuri simptomatikis reducirebisTvalsazrisiT klomipraminis sasargeblod (28) (I –A).• pirdapiri ormagi brma meTodiT CatarebuliSedarebiTi kvlevebi, klomipraminisa da sumsi-isjgufis preparatebs Soris, aseve sxva kvlevebismetaanalizi avlens mniSvnelovan gansxvavebas ampreparatebis klinikur efeqturobas Sorisklomipraminis sasargeblod.simptomzemoqmedeba• izolirebuli akviatebis sindromis nozologiurikuTvnileba gavlenas ar axdens klomipraminisefeturobaze;17

preparatismiRebapreparatismoxsnagverdiTimovlenebi• igi erTnairad axdens akviatebaTa reduqcias (maTSoris, ritualurisac) rogorc depresiis, iseSizofreniis dros;• ukeTesi Sedegi miiRweva izolirebul akviatebis anmonoritualebisas (mag.: xelebis xSiri dabana);• (52) klomipraminis efeqturoba sagrZnoblad dabaliageneralizebuli oka-s dros (mag.: mravlobiTidacviTi ritualebis Sesrulebisas) iseTiideatoruli akviatebebis dominirebiT, romlebiczeRirebulovan warmodgenebs uaxlovdeba, xoloSizofreniiT daavadebulebebSi - interpretaciulbodviTi azrebis arsebobisas.• oka-s mkurnalobis dros klomipraminis sawyisi dozaa25-50 mg/dR, romlis mateba xdeba dRiurad 25-50 mg-iT.Terapiuli efeqti dgeba 225-300 mg/dR dozaze;• xangrZlivad mimdinare klinikurad kargadgamoxatuli obsesiur-kompulsiuri sindromismkurnaloba SeiZleba daviwyoT intravenuri wveTovanigadasxmebiT 25-50 mg/dR, TandaTan (5-10 dReSi) dozismatebiT dRiur 200-250 mg-mde (57). Terapiis kursi 2kviraa;• xSirad klomipraminis intravenuri infuzia (100 – 125mg) kombinirebulia preparatis peroralur miRebasTan(100-200 mg/dR);• infuziis pirvel dReebSi gansakuTrebul yuradRebasvaqcevT arteriul wnevas;• orTostatiuli kolafsis Tavidan asacilebladpacienti unda iwves infuziis damTavrebidan 1 saaTisganmavlobaSi;• efeqtis miRwevis Semdeg (romelic Cveulebrivad dgebaTerapiis pirvel or kviraSi) gadavdivarT preparatisperoralur miRebaze, romelic unda gagrZeldes 4-6kvira, xolo mZime, socialuri dezadaptaciisgamomwvevi akviatebebisas – preparatis miReba xdebaufro meti xnis ganmavlobaSi.• Terapiis Sewyvetis SemTxvevaSi, doza TandaTan undaSevamciroT;• klomipraminis uecari Sewyveta, rogorc wesi,amwvavebs obsesiur-kompulsiur simptomebs daSesaZloa ganviTardes ”aRkveTis” sindromi.• klomipramins avadmyofebi kargad itanen;• ZiriTad gverdiT movlenebs miekuTvnebaantiqolinerguli efeqti (akomodaciis darRvevebi,yabzoba, Sardis Sekaveba, piris simSrale, abneva).orTostatiuri hipoTenzia, iSviaTad –kardiotoqsikuri movlenebi (saWiroa ekg-monitoringi)da krunCxviTi aqtivobis zRurblis daqveiTeba.18

• serotoninis ukumitacebis seleqtiuri inhibitorebi (SSRI - sumsi)pirveli arCevis preparatebia ekonomiurad ganviTarebul qveynebSiobsesiur-kompulsiuli aSlilobis mkurnalobis dros an imSemTxvevaSi, roca depresia da oka Tanaarsebobs. (24)• serotoninis ukumitacebis seleqtiuri inhibitorebis (SSRI - sumsi)efeqturobis damadasturebeli monacemebi da miRebis formebiwarmodgenilia cxrilis saxiT:sumsi-sprofilisimptomzemoqmedebapreparatismiReba• serotoninis ukumitacebis seleqtiuri inhibitorebi(SSRI) Tavisi efeqturobiT utoldeba tca-is moqmedebas• maT ar axasiaTebT sedacia, amitom Zilis darRvevebisada gamoxatuli SfoTvisas, mainc upiratesoba tca-ebseniWebaT;• susti antiqolinerguli moqmedebis gamo, farTodgamoiyeneba geriatriul praqtikasa da kardiologiuriprofilis pacientebSi.• preparatebis miReba erTjeradadaa SesaZlebeli ;• sumsi-is efeqti sakmaod male vlindeba (Terapiis II-IVkvira) da TandaTan Zlierdeba me-8 – me-12 kvirisaTvis.(III-C) (31);• pirveladi gaumjobeseba mWidro korelaciaSiaantidepresantebis zogadad damaxasiaTebelefeqturobasTan;• preparatis Terapiuli dozebi axlosaa maqsimalurTanda saSualoze maRalia, rac depresiismkurnalobisaTvis da Seadgens: fluvoqsamini – 150-300mg/dR; fluoqsetini – 40-80 mg/dR; sertralini – 150-250mg/dR; paroqsetini – 40-60 mg/dR; citaloprami – 40-60mg/dR ( III-C) (32, 33);• zogierTi am preparatis SemTxvevaSi aRiniSnapirdapiri korelacia dozasa da efeqturobas Soris(Wheadon D.A. da sxv. 1995, - (III-C) (34);• dasaSvebia SSRI-is kombinireba msubuq anqsiolizursaSualebebTan (53; II-B);• miRebis pirvel kviraSi matulobs suicidis daTviTdazianebis riski, rac saWiroebs yuradRebisgamaxvilebas maRali riskis jgufebze – 30 wlamdeasakis pacientebi, Tnamxlebi depresiis SemTxvevebi,anamnezSi suiciduri qmedebis mqone pirebi (24, 31) (III-C);• serotoninerguli antidepresantebis TerapiisxangrZlivoba saSualod Seadgens daaxlebiT 3 Tves,zog kvlevebSi – 2 welze met xans. SemTxvevaTaumravlesobaSi wamlis moxsnis Semdeg erTi wlismanZilze obsesiur-kompulsiuri simptomatika kvlavgamovlinda, Tumca rig pacientebSi aRiniSna SedarebiTmyari remisia (35), gansakuTrebiT myaria remisiaadekvaturi, ganmamtkicebeli fsiqoTerapiis fonze.19

preparatismoxsnagverdiTimovlenebi(eqspertTa mosazreba)• zogadad, sumsis jgufis preparatebi bevrad sjobsklomipramins ganmamtkicebeli TerapiisaTvis, radganmas pacientebi gacilebiT ukeT itanen. dReisaTvissayovelTaod miRebulia serotoninerguliantidepresantebis minimum erTwliani gamoyeneba. (24, 31;III-C)• efeqturi profilaqtikuri Terapiis SewyvetisSemTxvevaSi dozas nela vamcirebT – dozis 20-30%-iTyovel 2-3 TveSi.• mkurnalobis pirvel kviraSi sumsi-is miRebas SeiZlebaTan axldes mcire gverdiTi movlenebi, rogoricaa:gulisrevis SegrZneba, Tavistkivili, nevrotuloba,insomnia da diarea - rac gardamavalia da Zalzemsubuqi. (24, 31, 46; III-C);• mousvenroba, gamRizianebloba, SfoTviTi simptomebisgaZliereba da uZiloba mkurnalobis pirvel dReebSian kvirebSi SeiZleba gaxdes mkurnalobaze uaris Tqmismizezi. sawyisi dozis daklebam SeiZleba SeamciroszemoaRniSnuli simptomebi (24, 31, 53; II-B), (46, eqspertTamosazreba);• xangrZlivi mkurnalobisas SeiZleba gamovlindessqesobrivi sferos disfunqcia an aRkveTis sindromi,anqsiolizuri efeqti SeiZleba dadges 2-4 kvirisperiodSi an ufro gvian;• uZiloba da gverdiTi movlenebi Semcirdeba, Tupreparats davniSnavT diliT da SuadRes.• zogierT pacientisaTvis efeqturi SeiZleba aRmoCndes preparatitrazodoni, (58; III-C). dRiuri doziT 300-600 mg. romelic avlensgamoxatul anqsiolizur efeqts;• arsebobs winaswari monacemebi oka-s dros axali antidepresantisvenlafaqsinis efeqturobis Taobaze, romelic mcire doziT (150mg/dR) avlens serotoninpozitiur efeqts, xolo did dozebSi(225mg/dR) ormag – serotoninergul da noradrenergul moqmedebas(54);• qceviTi Terapia medikamenturi Terapiis eqvivalentur xangrZlivefeqts iZleva (I-A) (36, 37, 38);• medikamenturi Terapiisagan gansxvavebiT, romlis moxsnacsimptomebs amwvavebs, fsiqoTerapiis Sedegi saxezea mravali Tvisda wlis ganmavlobaSi. fsiqoTerapias ukeT emorCilebakompulsiebi, obsesiebTan SedarebiT. qceviTi fsiqoTerapiiszogadi efeqturoba 50-60%-s aRwevs. SfoTvis gaZlierebis SiSiTzogjer pacienti uars acxadebs Caitaros Terapia. (24, 31; II-B);• mkurnalobaSi upiratesoba eniWeba kognitiur-biheviorul (qceviT)Terapias (I-A) (39,40), agreTve fsiqoganaTlebas (5, 15). aucilebeliasxvadasxva socioreabilitaciuri RonisZiebebis gatarebac;• mZime, arakupirebadi akviatebebisas iyeneben aramedikamenturmeTodebs – ekT-s (eleqtrokrunCxviTi Terapia), transkranialuri20

magnitur stimulacias (tms), stereotaqsiuri wina kafsulotomiasan cingulotomias (41, 42).amrigad, oka-s TerapiaSi paTogenezuri midgoma dReisaTvis, gulisxmobsserotoninis ukumitacebis inhibitorebis (klomipramini, sumsi)gamoyenebis gziT serotoninerguli neirogadacemis gaZlierebas.zogjer efeqturia dofamin-blokeris gamoyeneba – aseTiaantifsiqozuri preparatebi: pimozidi, haloperidoli, risperidoli daa.S.mZime, rezistentul SemTxvevaTa 30-50%-Si efeqturi aRmoCndaqirurgiuli Careva – stereotaqsiuri cingulotomia, Tumca seriozuligarTulebebis, maT Soris, krunCxviTi sindromis ganviTarebis gamo, misigamoyeneba mniSvnelovnad SezRudulia.rekomendacia 1. inicialuri mkurnalobis strategiis SerCeva• oka-s dros rekomendebulia mkurnalobis dawyeba an mxolodkognitiur-bihevioruli TerapiiT (kbT) (III-C) (43, 43) ankombinaciiT - kbT da medikamenti (kbT +SRI).o miTiTeba: SRI - serotoninis ukumitacebis inhibitorebi. maTSorisaa 5 preparati: klomipramini, fluoqsetini, fluvoqsamini,paroqsetini, sertralini. SSRI (serotoninis ukumitacebisseleqtiuri inhibitori) aris yvela maTgani, garda klomipraminisa.• medikamentis arCeva dakavSirebulia oka-s simwvavesa da pacientis asakze.msubuqi oka-s dros, mxolod kbT aris pirveli rigis arCevani. simwvavismomatebasTan erTad, ukve dawyebul kbT-s emateba preparati an pacientseZleva mxolod medikamenti. axalgazrda pacientebSi, eqspertebirekomendacias aZleven mxolod kbT-s.rekomendacia 2. specifikuri kognitiur-qceviTi teqnikis SerCeva• specifikuri kognitiur-bihevioruli Terapiis efeqturobadadasturebulia oka-s mkurnalobisaTvis. kognitiur-bihevioruliTerapia aerTianebs qceviT Terapias da kognitiur Terapias.• kognitiur-qceviTi Terapiis Sedegi, medikamenturi TerapiisagangansxvavebiT, mogvianebiT dgeba.• qceviTi anu bihevioruli Terapia oka-s dros aerTianebs, erTimxriv, pacientisaTvis saSiS situaciasTan Sexebas (eqspozicias),xolo meore mxriv - pasuxis an ritualis prevencias (55).o magaliTad, eqspoziciisas pacienti, romelsac baqteriebiTdasnebovnebis SiSi aqvs, imden xans rCeba kontaqtSi”baqteriebTan”, sanam misi SfoTva ar Semcirdeba. ganmeorebiTeqspozicias, rogorc wesi, Tan sdevs SfoTvis ufro dabali done,xolo mravaljeradi ganmeorebisas - pacients aRar eSiniaspecifikur gamRizianeblebTan Sexeba.• am teqnikis saSualebiT pacienti aseve axerxebs gaTavisufldesritualebis an ganridebis qcevisagan, rasac pasuxis an ritualisprevencia hqvia.21

omagaliTad, dabinZurebis SiSis mqone pacienti aramarto undaSeexos WuWyian sagans, aramed Tavi unda Seikavos xelis dabanisritualidan SfoTvis Semcirebamde.• kognitiuri Terapia, romelic erTvis qceviT anueqspoziciur/prevenciul Terapias, mimarTulia iseTi problemebisgadasaWrelad, rogoricaa safrTxis araadekvaturi Sefaseba anpirovnuli pasuxismgeblobis gaZlierebuli gancda.• kognitiuri Terapia gacilebiT efeqturi aRmoCnda paTologiuriiWvneulobis, agresiuli obsesiebis da sxva akviatebuli azrebisSemTxvevaSi, vidre ltolvismagvari simptomebisas, rogoricaa,magaliTad, SexebiTi ritualebis ganxorcieleba. Cvevis Secvla,romelic upiratesad xorcieldeba urTierTsawinaaRmdego azrebisseriuli dapirispirebiT da gansakuTrebiT mizanSewoniliatikismagvari kompulsiebis dros.kbT-sSerCevapirvelirigisarCevaniobsesiebieqspozicia da pasuxisprevenciaeqspozicia da pasuxisprevencia kognitiurTerapiasTan kombinaciaSikompulsiebieqspozicia da pasuxisprevenciaeqspozicia da pasuxisprevencia kognitiurTerapiasTankombinaciaSirekomendacia 2a. kbT-is Catarebis intensivoba da xangrZlivoba (24,61)• mkurnalobis dasawyisSi individualuri kbT tardeba kviraSierTxel;• mizanSewonilia pacientisaTvis saSinao davalebis micema;• jgufuri kbT meore rigis arCevania;• pacientisaTvis sakmarisia 13-20 sesia;• mwvave SemTxvevebSi intensiuri kbT SesaZlebelia CatardesyoveldRiurad 3 kviris ganmavlobaSi.pirveli rigis arCevanimeore rigis arCevaniintensivoba • kviraSi erTxel + saSinaodavaleba;• or kviraSierTxel;• intensiuri kbT• dRis stacionari;(yoveldRiurad 3 kviris • stacionari.ganmavlobaSi).forma • individualuri • jgufuri;• individualuri +ojaxuri Terapia.sesiebisraodenoba• 13-20 sesia;• 7-12 sesia.• 20-50 sesia;• 3-6 sesia.22

ekomendacia 3. specifikuri medikamentis SerCevis strategia• medikamentebis sxvadasxva klasebs Soris, serotoninisukumitacebis inhibitorebi (SRI) yvelaze efeqturad aris miCneulioka-s samkurnalod. rekomendebulia xuTive dasaxelebis SRI:klomipramini, fluoqsetini, fluvoqsamini, paroqsetini,sertralini. sxva wamlebi, maT Soris venlafaqsini, mao-sinhibitorebi da klonazepami, miCneulia mesame rigis preparatebadda SeiZleba gamarTlebuli iyos, roca SRI TavisTavad efeqturiar aris (33, 45, 46, 47) (III-C);• SRI jgufis preparatebi ufro efeqturia paTologiuriiWvneuloba da agresiuli obsesiebisas, fsiqikuri (gonebrivi)ritualebisas, vidre gardamavali da tikismagvari simptomebisas;• Tu pacienti ar reagirebs SRI–is jgufis preparatebis saSualodozaze, rekomendebulia dozis TandaTanobiT mateba mkurnalobisdawyebidan 4-8 kviris ganmavlobaSi maqsimalur Terapiul dozamde;• rekomendebulia sxva SRI-ze gadasvla, Tu pasuxi ar aris,maqsimaluri dozis miRebidan 4-6 kviris Semdeg;• Tu pacienti nawilobriv pasuxobs saSualo doziT mkurnalobas,rekomendebulia dozis mateba maqsimumamde – mkurnalobisdawyebidan 5-9 kviris ganmavlobaSi. roca doza maqsimumamdeizrdeba, mizanSewonilia dozis matebis periodi pacientisaTvisiyos 2-4 kvira, raTa sakmarisi dro gvqondes preparatis dozazeadekvaturi pasuxis misaRebad;• im pacientebSi, romlebic nawilobriv reagireben preparatze damcire gverdiTi movlenebi aReniSnebaT, preparatis dozebi arunda avwioT maRal donemde, sanam mkurnalobis dawyebidan sulcota 12 kvira ar gaivlis;• eqspertebi Tvlian, rom 8-13 kvira sakmarisia adekvaturimedikamentis SesarCevad, sanam SecvliT an CaanacvlebT sxvapreparatiT.23

pirveli rigimedikamenti**fluvoqsaminifluoqsetiniklomipraminisertraliniparoqsetinidozissazRvrebi (mg)100–30020–80100–30075–22520–60saSualodRiuridoza(mg)2005020015050pasuxi araris SRI–issaSualodozazedozisgradualurimatebamaqsimumamdemkurnalobisdawyebidan4-8 kvirisganmavlobaSinawilobrivipasuxia saSualoSRI-is dozazemoumateT dozamaqsimumamde –mkurnalobisdawyebidan 5-9kvirisganmavlobaSi** doza damrgvalebulia standartul ”tabletis dozamde”. dozireba individualuriada SeiZleba iyos meti an naklebi, rac damokidebulia individualur, dozasTandakavSirebul pasuxis mrudze. medikamentebi CamoTvlilia eqspertebis mier miniWebuliqulebis ranJirebis Tanaxmad.rekomendacia 4. mkurnalobis efeqturobis gazrda• roca pirvelad daniSnuli mkurnaloba efeqturi ar arisaucilebelia daniSnulebis gadasinjva;• roca pacientis mdgomareoba, romelsac mxolod kbT utardeba,ucvlelia, mizanSewonilia (SRI) jgufis medikamentis damateba dapiriqiT, roca mxolod medikamenturi mkurnaloba uSedegoa,rekomendebulia kbT-s damateba an axal medikamentze gadasvla;• Tu pacienti ar pasuxobs kombinirebul Terapias, aucilebeliasxva SRI-jgufis preparatze gadasvla da kbT-s gagrZeleba;• Tu pacienti nawilobriv pasuxobs kombinirebul Terapias,rekomendebulia axal SRI-ze gadasvla, kbT-is intensifikacia(damatebiTi sesiebis xarjze) an axali formati (akviatebuliazrebis SeCerebis teqnikis CarTva an ojaxuri Terapiis damateba)da mkurnalobis sqemaSi damatebiTi preparatis CarTva.rekomendacia 5: strategia, gamoyenebuli mkurnalobisadmirezistentul pacientebSi• mkurnalobis efeqturobis Sesafaseblad rekomendirebulia oka-sSefasebis skalis gamoyeneba;• sanam pacienti mkurnalobisadmi rezistentulad CaiTvleba, undadarwmundeT, rom diagnozi sworadaa dasmuli, pacientiemorCileba mkurnalobas, preparatis doza sworadaa SerCeuli dasakmarisi droa gasuli mkurnalobis dawyebidan;• mkurnalobis efeqturobaze gavlena SeiZleba moaxdinos iseTmapreparatebmac, rogoricaa nivTierebaTa cvlis mastimulirebelian inhibitori;24

• mkurnalobis Sedegze SeiZleba gavlena iqonios fsiqosocialurmafaqtorebma;• roca pirvelad arCeuli Terapia uSedegoa, eqimma undagadawyvitos, rodis Secvalos medikamenti;• mraval pacientTan, romelTac mkurnalobisadmi rezistentobaaReniSnebaT, dadebiTi Sedegi moaqvs antidepresantis klasisSecvlas (mag: gadarTva sumsi-dan tca-ze an piriqiT).pirvelirigimeore rigipasuxi ar aris kbT + 3 SRIgamoyenebisas*Caanacvle** sxva medikamentiTSearCieT kbT –is axali formatian teqnika an gazardeTSexvedraTa intensivobagadarTeT sxva preparatze, mag.:(SRI) gadarTeT sxva preparatzemag.: (IMAO)nawilobrivi pasuxiakbT + 3 SRIgamoyenebisas*Caanacvle** sxvamedikamentiTSearCieT kbT –isaxali formati anteqnika an gazardeTSexvedraTaintensivobagadarTeT sxvapreparatze, mag.: (SRI)gadarTeT sxvapreparatzemag.: (IMAO)iSviaTadsaWiroa,magramzogjeraucilebeliaklomipramini (intravenurad)ekT – Tu depresiulianeiroqirurgia (internalurikafsulotomia)klomipramini(intravenurad)* erT-erT preparatad gamoyenebulia klomipramini** CanacvlebiT strategiaSi SeiZleba gamoyenebuli iqnas: klomipramini,klonazepami, konvenciuli neiroleptikebi, buspironis hidroqloridi,risperidoni, olanzapini. meore SSRI SeiZleba daematos pirvels.25

ekomendacia 6: mkurnaloba SemanarCunebel fazaSivizitisganrigipirvel 3-6TveSi mwvavefazis SemdegrodisSevamciroTdozebi?rogorSevamciroTdoza?gaxangrZlivebuliprofilaqtikurimkurnalobarekomendebuliayovelTviuriviziti1,5 - 2 wlisSemdgomgradualuri*,yovelTviuriSefasebiT2-4 mwvaverelafsis Semdeg3-4- saSualodanmsubuqrelafsamdeaseve misaRebiayovelkvireulivizitebigradualuri*,yovelTviurikbT-sinokulaciuri(imunizaciuri)sesiebiTvizitimedikamentissakiTxze* gradualurSi igulisxmeba medikamentis dozis Semcireba 25%-iT da 2 TvianiSualedebiT (gasaTvaliwinebelia pacientis mdgomareoba). Terapiis Sewyvetazegadawyvetilebis miRwevis SemTxvevaSi, doza TandaTan unda davakloT, radganpreparatis uecari Sewyveta, rogorc wesi amwvavebs obsesiur-kompulsiur gancdebs daSesaZloa ganviTardes ”aRkveTis” sindromi.26

ekomendacia 7: wamlis gverdiTi movlenebis SemcirebaproblemurigverdiTimovlenebigulsisxlZarRvTasistemispaTologiawamlebi, romlebicnaklebad iwvevenSSRIswamlebi, romlebic ufrometad iwvevenklomipraminisedacia SSRI klomipraminiinsomnia klomipramini SSRIantiqolinerguliefeqtiSSRIklomipraminiwonis mateba SSRI klomipraminiseqsualuriaSlilobaSSRIklomipraminiakaTizia klomipramini SSRIRebineba/diarea klomipramini SSRIrekomendacia 8: oka-s mkurnaloba Tanmxlebi fsiqikuridaavadebebisas• oka-s axasiaTebs maRali komorbidoba Semdeg aSlilobebTan:depresia, SfoTva, alkoholizmi/wamaldamokidebuleba, kvebiTiaSlilobebi, dismorfuli aSliloba (24, 31);• Tu akviateba aRmocenebulia Sizofreniis CarCoebSi ankomorbidulia turetis sindromTan da sxva motoruldarRvevebTan, SesaZlebelia neirolefsiuri preparatebis(risperidoni, pimozidi an haloperidoli) daniSvnaindividualurad SerCeuli dozebiT, individualuri amtanobisgaTvaliswinebiT (59). saWiroa sifrTxile, vinaidaneqstrapiramidulma gverdiTma movlenebma SesaZloa gaaZlierosakviatebebi. amitom, bolo dros upiratesoba eniWeba atipurnerolefsiur preparatebs, magaliTad, risperidons doziT 2-6mg/dR;• anqsiolizuri preparatebis (trankvilizatorebi) moqmedebisspeqtrSi antiobsesiuri efeqti ar aris, magram maTi daniSvnaantidepresantebTan erTad rezistentuli pacientebis kuraciisasmizanSewonilia, vinaidan amcirebs akviatebaTa SfoTviT27

komponents da gansakuTrebiT efeqturia sxva SfoTviTiaSlilobis Tanaarsebobisas. am mizniT rekomendebuliaalprazolamis gamoyeneba doziT 2-4 mg/dR an klonazepami doziT1-4 mg/dR. es is preparatebia, romelTa gamoyeneba efeqturiapanikuri Setevebisas da amave dros aqvT garkveuliTimoanalefsiuri moqmedeba (60);• SesaZlebelia buspironis hidroqloridis gamoyenebac doziT 20-40mg/dR. is 5HT 1A -serotoninuri receptoris agonistia da avlensTvisebas, gaaZlieros fluoqsetinis moqmedeba rezistentulpacientebSi (63). pacientebi preparats kargad itanen, magram arSeiZleba misi dainiSvna mao-is inhibitorebTan (arteriuli wnevismatebis gamo) an haloperidolTan kombinaciaSi – sisxlisplazmaSi misi koncentraciis matebis gamo;• efeqturi SeiZleba aRmoCndes trazodoni (62). preparati, doziT300-600 mg/dR, damoukidebladac avlens gamoxatul anqsiolizurefeqts.TanmxlebidaaavadebapanikuriaSliloba,socialuri fobiapirveli rigikbT + SSRIkbT mxolodmeore rigikbT + klomipraminikbT + SRI + romelimebenzodiazepinikbT + MAOI +/- romelimebenzodiazepinidepresia kbT + SRI kbT mxolodkbT + MAOIkbT + SRI + romelimebenzodiazepinibipolaruliaSliloba(remisia, stabilizatorebisfonze)kbT + guneb-ganwyobisstabilizatori kbT +guneb-ganwyobisstabilizatori + SRISRI + guneb-ganwyobisstabilizatoriSizofrenia SRI + neiroleptiki kbT + SRI + neirolefsiurituretissindromiyuradRebisdeficitis dahiperaqtiurobissindromiqceviTidarRvevebikbT + SRI + konvenciurineiroleptikikbT + SSRI + romelimefsiqostimulatoriSRI + kbT + ojaxuriTerapiakbT + SRI +risperidoni ana-2 agonistikbT + SRIkbT mxolodkbT + klomipramini +romelimefsiqostimulatorikbT + SRIkbT mxolodkbT + ojaxuri Terapiaklomipramini + kbT28

SSRI + kbTSSRIklomipraminikbT mxolodrekomendacia 9: oka-s mkurnaloba orsulobisas an Tanxlebidaavadebisasorsuloba gulis daavadeba TirkmlispaTologiapirvelirigikbT mxolodkbT mxolodkbT + SSRIkbT mxolodkbT + SSRImeorerigikbT + SRI SSRI SSRI8. gaidlainis gadasinjvisa da ganaxlebis vada – 2 weli9. gaidlainis miRebis xerxi/wyarogzamkvlevis SemuSavebis meTodologia (49)• oka-s Sesaxeb arsebobs samecniero mtkicebulebis safuZvelzeSeqmnil rekomendaciaTa sakmarisi raodenoba. mocemuligzamkvlevis Semqmnis procesSi samuSao jgufis gadawyvetilebiTmoZiebuli da Sefasebuli iqna ukve arsebuli praqtikuligzamkvlevebi, ramdenime fundameturi naSromi da eqspertTajgufis konsensusis Sedegad mowodebuli rekomendaciebi.bazisurad gamoyenebuli iqna Semdegi naSromebi:o WFSBP - World Federation of Societies of Biological Psychiatry (2002) Guidelines forthe Pharmacological Treatment of Anxiety, Obsessive-Compulsive and PosttraumaticStress Disorders - Bandelow B., Zohar J., Hollander E., Kasper Z, Möller HJ - World JBiol Psychiatry (2002) 3, 171 - 199o March, J.S., Frances, A., Carpenter, D., et al. (1997) The expert consensus guidelineseries: treatment of obsessive-compulsive disorder. Journal of Clinical Psychiatry, 58(Suppl 4), 13–72.o NICE - National Institute for Health and Clinical Excellence (2006) Obsessivecompulsivedisorder: core interventions in the treatment of obsessive-compulsivedisorder and body dysmorphic disorder. www.nice.org.uk/CG031• moxda arsebuli rekomendaciebis Targmna, masalis Sejereba daadaptirebuli variantis SemuSaveba, romelic, erTi mxriv,pasuxobs saerTaSoriso moTxovnebs, xolo, meore mxriv,iTvaliswinebs saqarTvelos samedicino dawesebulebaTa rogorcadamianur, ise teqnikur resursebs;29

• rekomendaciaTa moZieba xorcieldeboda klinikurirekomendaciebis saerTaSoriso reestrebSi, eleqtronulimonacemebis bazebSi internetis gamoyenebiT.qveyana da resursisdasaxelebaaSSAgency for Healthcare Researchand Quality (AHRQ)American Medical AssociationCenters for Disease Control andPrevention (CDC)Health Services TechnologyAssessment Text (HSTAT) andNational Library of Medicine(NLM)Evidence-Based Medicine [EBM]toolbox, Centre for Evidence-Based MedicineUS National GuidelineClearinghouse (NGC)didi britaneTiNational Institute for ClinicalExcellence (NICE)Health evidence bulletins WalesNational electronic Library forHealth (NeLH)German Guideline InformationService (GERGIS)mtkicebiTispecialistTaregionTaSorisisazogadoebamedicinisinternet-misamarTihttp://www.ahrq.gov/clinic/cpgsix.htmhttp://www.ama-assn.orghttp://www.phppo.cdc.govhttp://hstat.nlm.nih.govhttp://www.cebm.nethttp://www.guideline.govhttp://www.nice.org.ukhttp://hebw.cf.ac.uk/archive/archivemental/index.htmlhttp://www.nelh.nhs.uk/guidelinesfinderhttp://www.leitlinien.de/english/english/view;http://www.osdm.orgklinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTiwyaroebi da meTodebi• koxreinis biblioTeka - The Cochrane Library 2006, Issue 4• amerikis samedicino biblioTekis mier Seqmnili eleqtronulbibliografiul monacemTa baza - MEDLINE30

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