tpnbupgpsnvmj!btmjmpcfcj!ofwspmphjvs! lmjojlbtj! · 2 1. masala da gamokvlevis metodebi kvlevis...

akademikos petre sarajiSvilis saxelobis nevrologiisa

da neiroqirurgiis instituti

d a v iT g i g i n e i S v ili

tpnbupgpsnvmj!bTmjmpcfcj!ofwspmphjvs!

lmjojlbTj!

!

!

medicinis mecnierebaTa

doqtoris samecniero xarisxis

mosapoveblad warmodgenili

d i s e r t a c i a

/14.00.13/

`nervuli sneulebani~

samecniero konsultanti:

med.mecn.doqtori, prof. roman SaqariSvili

2006 w.

2

1. masala da gamokvlevis meTodebi

kvlevis klinikuri nawili warmoebda 1992 wlidan 2003 wlamde

p.sarajiSvilis sax. nevrologiisa da neiroqirurgiis institutSi.

kvlevis mTavar kohortebs Seadgenda institutTan arsebuli epilefsiur

centrSi 1997-1998 wlebSi moTavsebuli pacientebi romelTa Setevebi ar

iyo gamowveuli epilefsiiT (n=35) da institutis klinikuri

nevrologiis ganyofilebaSi 2001-2002 wlebSi hospitalizirebuli

pacientebi romlebsac daudgindaT fsiqikuri darRvevebi (n=37/623).

kvlevis Teoriuli nawilis (klasifikaciuri da meTodologiuri

sakiTxebis garCeva) etapebi Sesrulda sxvadasxva wlebSi jons

hopkinsis universitetis jandacvis skolis epidemiologiur

kaTedraze (baltimori, aSS), aiCi samedicino universitetis

neirofsiqiatriis kaTedraze (nagakute, iaponia) da nevrologiuri

daavadebebis samedicino institutis nacionalur epilefsiur centrSi

(Sizuoka, iaponia) avtoris mivlinebebis dros.

kvlevis miznebidan gamomdinare iyo gamoyenebuli meTodTa mTeli

paketi, romelic warmoadgenda orsafexurian process. pirveli etapi

moicavda fsiqogenuri nevrologiuri simptomebis negatiur

diagnostikas – rac gulisxmobs nevrologiuri daavadebis (da maT

Soris epilefsiis) gamosavlenad saWiro sruli diagnostikuri

algoriTmis gamoyenebas, romlis Sedegad miviRebT mxolod negatiur

pasuxs. masSi igulisxmeba nevrologiuri gamokvleva, daavadebisa da

cxovrebis anamnezis Sekreba, daavadebis msvlelobis dinamiuri

dakvirveba da instrumentaluri gamokvlevebi. maT Soris

eleqtroencefalografiuli (eeg), eleqtromiografiuli, 24 saaTiani

ambulatoriuli kaseturi eeg monitoringi, kompiuteruli

tomografia, birTvuli magnitur-rezonansuli gamosaxva da sxva.

Ppirveli etapis Sedegad klinikuri niSnebis Sesabamisi organuli

daavadebis (dazianebis) gamouvlenobis SemTxvevaSi fsiqologiuri

darTvevis gamovlenis etapi iwyeboda. mentaluri aSlilobis

3

dasadgenad iyeneboda neirofsiqiatriuli gamokvleva, romelic

Seicavda Cvens mier SemuSavebuli mentaluri statusis Semfasebeli

skalas (msSs). ukanaskneli Seiqmna im mizniT, rom nevrologiuri

pacientebSi fsiqiatriuli darRvevebis (rogorc Tanaarsebul, aseve

nevrologiuri daavadebis Sedegad ganviTarebul) natifi diagnostika

yofiliyo SesaZlebeli. mas safuZvlad daedo dasavleTSi farTod

gavrcelebuli mentaluri statusis gamokvlevis sqema, romelic

mniSvnelovnad gamdidrda (samecniero periodikis, amerikis

fsiqiatrTa asociaciis mier gamoqveynebul DSM-IIIR (1987) da DSM-IV

(1994), PRIME-MD kiTxvaris (1995) da CID-s (1993) da piradi klinikuri

masalis damuSavebis Sedegad miRebuli) diagnostikuri niSnis

matarebeli simptomebiTa da qveviTi maxasiaTeblebiT. aq mTavari

yuradreba daeTmo nevrologiur daavadebebTan asocirebul

personologiur niSnebsa da qceviT darRvevebs. es skala da misi

meSveobiT pacientis mentaluri statusis dinamikaSi Sefaseba,

zemoaRniSnuli algoriTmTan erTobliobaSi, safuZvlad daedo

fsiqogenuri nevrologiuri simptomis pozitiuri diagnostikis

meTods (Gigineishvili, 1998; Гигинейшвили Д.А., Шакаришвили Р.Р. 2006).

fsiqologiuri darRvevis diagnozis gamotana xorcieldeboda

jandacvis msoflio organizaciis mier daavadebaTa saerTaSoriso

klasifikaciis me-10 reviziis mentaluri da qceviTi aSlilobebis

klinikuri aRwerilobas da diagnostikuri kriteriumebis Sesabamisad

(WHO, ICD-10, 1992-1993). zemoaRniSnul kohortebidan gamovlenili

fsiqologiuri darRvevebis mqone pacientTa daxasiaTeba mocemulia

tabula #1 da tabula #2-Si danarTis saxiT.

aRniSnuli miznis misaRwevad saWiro gaxda pirveladi wyaroebis

mopoveba uSualod sazRvargareTuli organizaciebidan (amerikis

fsiaiatrta asociacia, jandacvis msoflio organizacia),

zemoaRniSnuli diagnostikuri kriteriumebis srulyofili

qarTulenovani versiis Sesaqmnelad (gigineiSvili, 2001; 2005). qceviTi

4

da mentaluri darRvevebis amsaxveli klinikuri simptomebis

monacemTa bankis Sesaqmnelad iqna damuSavebuli yvela misawvdomi

inglisurenovani, rogorc samedicino wignebi (gamocemuli 1995

wlidan), aseve samedicino JurnalebSi gamoqveynebuli statiebi (1980

wlidan 2005 wlis CaTvliT). am procesSi CarTuli iqna standartuli

sainterneto saZiebo sistemebi (PubMed etc.) jons hopkinsisa da aiCis

universitetebis da jmo-s HINARI samedicino biblioTekebis qselebis

gamoyenebiT, maT gankargulebaSi myof fizikur sabiblioTeko da

biblioTekTaSoriso fondebTan erTad.

moRebuli Sedegebis statistukuri damuSaveba ganxorcielda

avtoris mier kompiuteruli samedicino statistikis programis

meSveobiT STATA 7.0 (College Station, TX, USA).

kvlevis mizani

‘auxsneli’ somaturi (isteriuli) simptomis mimarT nevrologiis interesi

ganpirobebulia am simptomebis msgavsebiT mravali nevrologiuri

daavadebebis gamovlinebebisadmi da maSasadame nervuli sistemis

dazianebis eWviT. sxvadasxva monacemebis Tanaxmad, nevrologiur qselSi,

fsiqogenuri xasiaTis simptomebis sixSire maRalia sxva samedicino

specialobebTan SedarebiT (Carson et al., 2000; Reid et al., 2001). nevrologiur

klinikaSi igi warmoadgens gamotanili diagnozebis 1%-s (Marsden, 1986),

epilefsiur centrebSi ki - Semosuli pacientebis 12.8-20%-s (Gates et al., 1985;

Smith et al., 1999) da eleqtroencefalografiuli monitoringCatarebul

pacientTa 15-34%-s (Benbadis et al., 2001, 2004; Martin et al., 2003). maTi msgavseba

organul nevrologiur simptomebTan imdenad maRalia, rom fsiqogenuri

araepilefsiuri Setevebis SemTxvevaSi saboloo diagnozis gamotana xdeba

xolme paroqsizmebis gamovlenidan ara uaxloes 5 wlisa (De Timary et al.,

2002; Reuber et al., 2002). diagnozis gadavadeba ki safuZvelia rogorc janmrTe-

lobis gauaresebisa, aseve socio-ekonomiuri mdgomareobis damZimebisa.

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‘auxsneli’ (anu funqciuri) somaturi simptomebi (ass) gvxvdeba ara

mxolod nevrologiur, aramed sxva arafsiqiatriul qselSic da

upiratesad jandacvis pirvelad rgolSi. aseTi Civilebis mqone

pacientTa raodenoba aRwevs meoTxedidan naxevramde im pacientTa

ricxvidan, romelic mimarTavs zogadi profilis eqims (Kroenke, 2003;

Khan et al., 2003; Rosendal et al., 2005; Toft et al., 2005). problemas gaaCnia ara

mxolod diagnostikuri mniSvneloba. mZimea socialuri da ekonomiuri

tvirTi, romelic Tan axlavs fsiqogenuri xasiaTis aSlilobebs.

pacientebi gamoirCevian myari SromisuunarobiT (Akagi & House, 2001) da

samedicino xarjebi 2.2 jer aWarbebs samedicino qselSi erT

pacientze gamoangariSebul xarjebis saSualo maCvenebels (Hiller et al.,

2003). aqedan naTelia, ramdenad aqtualuria drouli diagnostikasTan

erTad swori menejmentis warmarTva im pacientebis mimarT, romlebic

avlenen funqciuri xasiaTis nevrologiur simptomebs.

winamdebare disertacia isaxavs miznad somatoformuli aSlilobebis

sistemuri analizis Catarebas da pozitiuri kliniko-diagnostikuri

maCveneblebis dadgenas, romlebic ganasxvaveben am aSlilobebs

nevrologiuri simptomebis mqone organuli xasiaTis mravalferovani

darRvevebisagan. dasaxul amocanebs Sorisaa: nevrologiur qselSi

gavrcelebul somatoformuli aSlilobebis epidemiologiuri

maCveneblebis, klinikuri suraTis Taviseburebebis, diagnostikuri

algoriTmebisa da menejmentis optimaluri sqemebis gamovlena.

somatoformuli aSlilobebi warmoadgenen unikalur magaliTs,

rodesac am darRvevebis terminologiur da klasifikaciur sakiTxebs

ganixilaven fsiqiatrebi (kerZod, mentaluri darRvevebis uaxles

taqsonomiebSi), xolo klinikuri da Terapiuli TavalsazrisiT, isini

ukeTaa Seswavlili zogadTerapiul disciplinebSi.

fsiqogenuri warmoSobis darRvevebs Soris yuradrebas ibyrobs

araepilefsiuri gulyrebi rogorc, erTis mxriv somatizaciis (an/da

disociaciis) gamovlenis yvelaze dramatul da xSir formas (Reuber et al.,

6

2003) da, meores mxriv, rogorc klinikurad, aseve paraklinikurad

(metwilad video-monitoringis damkvidrebis gamo) yvelaze Seswavlil

funqciuri xasiaTis simptoms. (Gram et al., 1993; Rowan & Gates 1993; 2000).

Cven varaudobT, rom am sakiTxis irgvlis dagrovili gamocdileba (da

maT Soris SemoTavazebuli axali diagnostikuri algoriTmi) SeiZleba

iyos gamoyenebuli modelad danarCeni funqciuri (fsiqogenuri)

simptomebis, rogorc zogadi samedicino problemis, kliniko-

diagnostikuri sakiTxebis gadaWraSi. am amocanasTan paralelurad

dasaxulia uaxlesi informaciis srulyofilad miwodeba da

somatoformuli dajgufebis rogorc terminologiur, aseve

etiologiur sakiTxebis (funqciuri somaturi simptomis warmoSobis

hipoTezuri modelis) irgvliv diskusiis gamarTva, rac Cvenis azriT

xels Seuwyobs saqarTveloSo fsiqosomaturi medicinis am aspeqtebSi

samedicino ganaTlebis vakuumis Sevsebas.

7

2. auxsneli somaturi simptomebi – somatoformuli

aSlilobebis mTavari klinikuri gamovlena

somatur simptomebs (maT Soris nevrologiurs), romelsac imdenad

ganicdis pacienti, rom mimarTavs eqims, magram romlis mimarT

samedicino Sefaseba ver avlens mimdinare somatur daavadebas an misi

ganviTarebis paTofiziologiur meqanizms, ewodeba auxsneli

somaturi simptomebi (ass; dasavlur publikaciebSi ‘samedicino

TvalsazrisiT auxsneli simptomebi – medically unexplained symptoms).

auxsneli Civilebis klasteri miemsgavseba praqtikulad medicinis

nebismieri dargis aSlilobas (nevrologiurs, kardiologiurs,

endokrinuls da a.S.). maTi udidesi nawili, romlebSic moiazreba

fsiqologiuri motivacia, amJamad miekuTvneba fsiqiatriul

darRvevebs (tab #1), sxvebi ki funqciuri sindromebis saxiT

ganixileba Sesabamis dargebSi (tab #2 [Manu, 1998; Barsky & Borus, 1999;

Mayou & Farmer, 2002; Escobar et al., 2002]).

Tumca ass-ebi SeiZleba iyos warmodgenili mravali fsiqiatriuli

darRvevis klinikur suraTSi (afeqturi, fobiuri, disociaciuri da

somatoformuli aSlilobebis, Sizofreniisa da mZime stresze

reaqciis), mxolod somatoformuli aSlilobebis (sa) dros ass-ebi

warmoadgens klinikuri gamovlenis mTavar birTvs. amitomac yvelaze

xSirad ass vlindeba somatoformuli aSlilobebis mqone pirebSi.

tabula #1. fsiqiatriuli aSlilobani, romlebic SeiZleba

wardgnen somaturi simptomebiT

ICD-10 DSM-IV

xasiaTis (afeqturi)

aSlilobani (F30-F39)

xasiaTis aSlilobani (Mood

Disorders)

fobiuri SfoTviTi SfoTviTi aSlilobani

8

aSlilobani (F40)

sxva fobiuri aSlilobani

(F41)

(Anxiety Disorders)

disociaciuri (konversiuli)

aSlilobani (F44)

somatoformuli aSlilobani

(F45)

somatoformuli aSlilobani

(Somatoform Disorders)

mozrdilebis

personologiisa da qcevis

sxva aSlilobani (F68)

xelovnurad

demonstrirebuli

aSlilobani (Factitious

Disorders)

Sizofrenia, Sizotipaluri

da bodviTi aSlilobani

(F20-F29)

Sizofrenia da sxva

fsiqoturi aSlilobani

(Schizophrenia and Other Psychotic

Disorders) reaqcia mZime stresze da

adaptaciis aSlilobani (F43)

adaptaciis aSlilobani

(Adjustment Disorders)

tabula #2. zogierTi funqciuri somaturi sindromebis CamonaTvali

funqciuri somaturi sindromi specialoba

gaRizianebuli nawlavis sindromi gastroenterologia

qronikuli menjis tkivili ginekologia

fibromialgia revmatologia

atipuri tkivili mkerdis areSi kardiologia

qronikuli daRlilobis sindromi infeqciuri daavadebebi

daZabulobis tipis Tavis tkivili nevrologia

temporomandibularuli

disfunqcia

stomatologia

yelSi gaCxirvis sindromi yel-yur-cxviris daavadebebi

mravlobiTi qimiuri senzitioba alergologia

9

jandacvis msoflio organizaciis mier gamoqveynebuli mentaluri

da qceviTi aSlilobebis saerTaSoriso klasifikaciis ICD-10-is (1992)

klinikur aRwerolobis Tanaxmad: “somatoformuli aSlilobebis

mTavari niSani aris fizikuri simptomebis ganmeorebiTi warmodgena

samedicino gamokvlevebis daJinebiT moTxovnebTan erTad, miuxedavad

ganmeorebiT miRebuli negatiuri pasuxebisa da eqimTa darwmunebisa

(axsna-ganmartebisa), rom simptomebs ar gaaCnia raime somaturi

safuZveli”. termini ‘somatoformuli’ xmarebaSi Semovida 1980 wlidan,

amerikis fsiqiatrTa asociaciis (afa) mier gamoqveynebul

diagnostikur da statistikur saxelmZRvanelos mesame gamocemis

(DSM-III-s) publikaciis Semdeg. igi Tavs uyris gansxvavebul

diagnostikur erTeulebs, romelTac aerTianebT erTi mTavari

principi – fizikuri simptomis arseboba, romelic ver aixsneba

organuli faqtorebiT. sityva ‘somatoformuli’Aatarebs wminda

aRwerilobiT xasiaTs: sufiqsi ‘form’, romelic tradiciulad

gamoiyeneboda fsiqiatriaSi, miuTiTebs mdgomareobas, romelic

emsgavseba sxva sindroms an darRvevas. anu, martivad rom vTqvaT,

Civilebi iseT fizikur (somatur) daavadebas gamoxatavs, romliTac

pacienti ar aris realurad Sepyrobili.

somatoformuli aSlilobis kategoria, kerZod afa-s mentaluri da

statistikuri sexelmZRvaneloebis Tanaxmad (DSM-III da DSM-IV),

warmoadgens sxeulisa da sulis (body and mind) dayofis, rogorc

dasavluri filosofiuri dualizmis anarekls, romlis Tanaxmad,

samedicino problemis fizikuri da fsiqologiuri axsna-ganmarteba

ganixileba, rogorc alternativebi. amitomac, rodesac pacientis

Civilebi ver aixsneba organuli mizeziT da imavdroulad

gamovlenilia winamorbedi stresuli faqtorebi, igi martivad

miekuTvneba fsiqologiur (fsiqiatriul) darRvevebs. imaTTvis, vinc

ar aris aRzrdili dasavluri filosofiisa da medicinis

10

tradiciebiT, aseTi dixotomia gaugebaria da Seqmnis garkveul

problemebs.

afa-s klasifikaciis Sesabamisad somatoformul aSlilobebs aqvT

Semdegi saziaro niSnebi: simptomebi, romliTac pacienti aris

Sepyrobili, iwvevs distress an darRvevas moRvaweobis mniSvnelovan

sferoebSi; simptomebi ar aris ganzrax an xelovnurad gamowveuli

(intentionally produced) da ar miekuTvneba sxva mentalur darRvevebs.

aSlilobebis es jgufi moicavs warsulSi konversiuli tipis

isteriul nevrozad cnobil darRvevebs. meore jgufis Civilebi –

cnobierebis darRvevis (gaxleCvis) mTeli gama, romelic inicirebulia

fsiqologiuri travmiT, Sevida disociaciur aSlilobaTa jgufSi.

amrigad, isteriuli nevrozi gadanawilda or centralur

klasifikaciur erTeulSi. qvemiT moyvanilia tabula, romelic

uCvenebs Zvels (eqimebisaTvis metad nacnob) klasifikaciaSi asaxul

kategoriebis Sesatyvisobas Tanamedrove klasifikaciebTan.

tabula #3. somatoformuli aSlilobebis kategoriebi ICD-10, ICD-9

da DSM-IV klasifikaciebSi

DSM-IV ICD-10 ICD-9

disociaciuri

aSlilobani

disociaciuri

(konversiuli

aSlilobani) F44

300.1 isteriuli

nevrozi

(disociaciuri tipi)

300.12 disoc. amnezia F44.0 disoc. amnezia

300.13 disoc. fuga F44.1 disoc. fuga

F44.2 disoc.stupori

F44.3 transi

somatoformuli

aSlilobani

300.11 konversiuli

aSliloba

F44.4 disociaciuri

motoruli

300.1 isteriuli

nevrozi

11

motoruli

simptomiT an

deficitiT

aSlilobebi

gulyrebiT an

krunCxvebiT

F44.5 disociaciuri

konvulsiebi

sensoruli

simptomebiT an

deficitiT

F44.6 disociaciuri

anesTezia da

mgrZnobelobis

dakargva

Sereuli

simptomebiT

F44.7 Sereuli

disociaciuri

aSliloba

(konversiuli tipi)

somatoformuli

aSilobani F45

.0 somatizirebuli

aSliloba

300.81 somatizire-

buli aSliloba

aradiferenciuli

somatoformuli

aSliloba

.1 aradiferenciuli

somatoformuli

aSliloba

300.8 sxva nevrozuli

aSlilobebi

300.7 ipoqondria .2 ipoqondriuli

aSliloba

300.7 ipoqondriuli

nevrozi

307.xx tkivilis

aSliloba

.4 gamudmebuli

somatoformuli

tkivilis aSliloba

307.8 fsixalgia

saukuneebis manZilze isteriis qveS igulisxmeboda mdgomareoba,

romelic xasiTdeba mravloboTi, ganmeorebadi somaturi CivilebiT

gadmocemuli dramatuli emociuri gancdiT da auxsneli im droisaTvis

gamovlenili daavadebebiT. miuxedavad Tavisi ZvelberZnuli

warmoSobisa (hystera niSnavs saSvilosnos), isteriis magvari

mdgomareobis aRweriloba moxseniebulia Zvel egviptur wyaroebSi

12

(Cvens welTaRricxvamde 1900 weli) (Gates et al., 1991; Guggenheim 2000). maSin

eqimebs sjerodaT, rom am daavadebis mizezia saSvilosnos gadaadgi-

leba Tavisi Cveuli poziciidan da sxva organoebze zemoqmedeba. es

Tvalsazrisi Camoyalibda im dakvirvebebis safuZvelze, romliTac

mravlobiTi auxsneli simptomebi axasiaTebdaT marto qalebs repro-

duqciulad aqtiur asakSi. Sua saukuneebis epoqaSi dominirebda

‘demonuri’ Sepyrobis Tvalsazrisi, ris gamoc isterias aramunebriv

sawyisebs ukavSirebnen da daavadebiT Sepyrobil pirebs zogjer kidevas

sdevniden.

pirveli eWvi, rom isterias individis fsiqologiur mdgomareobasTan

aqvs kavSiri gamoiTqva XVII saukuneSi Tomas sidenheimis mier (Thomas

Sydenham 1666). man aRniSna isteriisaTvis damaxasiaTebeli Tvisebebi,

rogoricaa sxva daavadebebis imitaciis maRali unari da daakavSira

igi darRveul vnebebTan, rac im droisaTvis iyo cnobili, rogorc

‘warsuli sevdebi’ (antecendent sorrows) (Guggenheim 2000). imavdroulad man

pirvelma aRmoaCina es darRveva kacebSic (Martin and Yutzy 1996).

XIX saukuneSi cnobili frangi eqimebis, pol brikes (Paul Briquet) da

Jan-marten Sarkos (Jean-Martin Charcot) mier gamoiTqva azri, rom isteria

aris centraluri nervuli sistemis dazianebis Sedegi. Sarko

varaudobda, rom simptomebi viTardeba konstituciurad midrekil

pirebSi, rodelac tvinis receptuli nawili imyofeba garegani

stresoris gavleniS qveS. orive mkvlevari amaod cdilobda

gamoevlina isteriis biologiuri substrati, ramac ubiZga maT

CamoeyalibebinaT nervuli sistemis dinamiuri dazianebis hipoTeza,

rac safuZvlad udevs funqciur darRvevebs isteriul pacientebSi.

Sarkos brwyinvale Sedegebma hipnozis gamoyenebisa, rogorc

isteriuli simptomebis gamowvevasa, aseve misi gankurnebis mizniT

dasabami mica SemdgomSi isteriis fsiqodinamiuri modelis

Camoyalibebas. zemoaRniSnulis gaTvaliswinebiT, XIX saukunis

miwuruls zigmund froidi (Sigmund Freud) da iozef broieri (Josef

13

Breuer) uaryofen isteriis organul safuZvels da miakuTvnian

isteriul simptomebs aracnobier fsiqologiur meqanizmebs. froidma

ixmara sityva konversia, romliTac ganmarta miuRebeli ideis

ganiaraReba misi energiis somaturi arxebSi gadayvaniT. procesis

Sedegad Camoyalibebuli simptomebs ki konversiuli simptomebi

uwoda. froidis fsiqodinamiuri koncefciis Tanaxmad isteriuli

(konversiuli) darRvevebis CamoyalibebaSi ori dacviTi meqanizmi devs

safuZvlad – represia da konversia. pirvelis meSveobiT emociurad

datvirTuli idea, romelsac ar SeuZlia iyos gamovlenili

pirovnebis eTikuri an moraluri SezRudvebis gamo, ganidevneba

cnobierebidan da Seinaxeba (excluded & lodged) aracnobierSi. Semdgom

igi ukve gardaiqmneba somatur simptomSi, rasac konversiis meqanizmi

warmoadgens. Sedegad, pirovneba aracnobierad xdeba daculi muqaris

momtani fsiqologiuri travmisagan, Tumca isteriuli (konversiuli)

simptomis gamovlenis xarjze. SemdgomSi pier Janem (Pierre Janet)

erTianobaSi ganixila isteriuli fsiqologiuri da somatoformuli

funqciebi da ivarauda, rom isteriis dros xdeba personis

integrirebuli mentaluri procesebis gaxleCva da maTi

damoukideblad arsebioba. anu disociaciis gamovlena aris ara

mxolod fsiqologiuri (rac tradiciulad ganixileba disociaciis

konteqstSi), aramed somaturi simptomebic. mdgradi xasiaTis Civilebs

man uwoda ‘mentaluri stigmata’ (Nijenhuis 2000). maT miekuTvneba

nawilobrivi an sruli mexsierebis dakargva (amnezia), sensoruli

darRvevebi – anestezia, smenis, mxedvelobis, ynosvisa da gemovnebis

moSla da motoruli funqciis dakargva (Janet 1925). darCenili

aramudmivi simptomebi moicaven pirovnebis cnobierebaSi SeRwevad

disociaciur emociebs, fiqrebs da a.S., somnambulizms, isteriul

Setevebs da disociaciur deliriums. maSasadame, istoriulad

konversiul simptomebs miekuTvneba is ass-ebi, romlebic eWvs badeben

14

nevrologiuri dazianebis arsebobaze, anu fsevdonevrologiuri

simptomebi.

Semdgom periodSi sityva isteria ixmareboda Zalze farTo

konteqstSi, Teatraluri pirovnebis, qalebSi gaRizianebuli qcevis,

SfoTvis an calkeuli simptomis aRsaniSnavad. misi, rogorc

sindromis validobis dasadgenad q.senluisis vaSingtonis

universitetis (misuri, aSS) specialistebma Caatares srulyofili

samecniero gamokvlevebi, ris Sedegad daadgines isteriis

multisimptomuri sindromad gamoyofis siswore da mas ‘brikes

sindromi’ daarqves (Perley & Guze 1962; Woodruff 1968; Merskay 1995).

mentaluri aSlilobebis moqmedi klasifikaciebis Tanaxmad

konversiuli simptomi rogorc obligaturi klinikuri niSani

warmodgenilia or diagnostikur sindromSi. rodesac Civilebi

Semofarglulia sensoruli da/an motoruli funqciis moSliT (rac

nervuli sistemis dazianebas varaudobs), darRvevas konversiuls

uwodeben. aseT SemTxvevaSi sindromi Seicavs mxolod konversiul

simptomebs. rodesac ass-ebi polisimptomaturi xasiaTis arian (anu

moicaven Civilebs organizmis sxvadasvxa sistemebis mxridan da ara

mxolod nervuli) _ aseT mdgomareobas somatizirebuli aSliloba

ewodeba (uaxloes warsulSi ‘brikes sindromi’). am konteqstSi sityva

somatizacia gamoiyeneba somatoformuli aSlilobebis erT-erTi

diagnostikuri erTeulis aRsaniSnavad da aireklavs iseT somatur

distress, rodesac sxvadasxva fiziologiur sistemebSi vlindeba ass-

ebis maRali sixSire. magram istoriulad somatizacia ixmareba aseve

procesis aRsaniSnavad, romelic gulisxmobs ramdenime komponents.

kerZod, somaturi distresis gancdasa da gadmocemas, rodesac

somaturi simptomebi ver aixsneba gamovlenili organuli

cvlilebebiT, pacientis mier simptomebis mikuTvneba seriozul

somatur daavadebas, ris gamoc igi ganuwyvetliv mimarTavs saeqimo

daxmarebas (Lipowski 1987).

15

Tuki Civilebis raodenoba zRvrulze naklebia da mdgomareoba

somatizirebuli aSlilobis kriteriumebs srulad ver akmayofilebs,

igi didi albaTobiT miekuTvneba aradiferenciul somatoformul

aSlilobas. somatizirebuli aSlilobis DSM-IV-sa da ICD-10-s

diagnostikuri kriteriumebi gansxvavdeba erTmaneTisagan. pirvelis

Tanaxmad unda iyos gamoxatuli aranakleb rva ass dakavSirebul 4

sxvadasxva jgufTan: tkivilis, kuW-nawlavis, seqsualuri da

fsevdonevrologiuri (tabula #4). ICD-10 iTxovs yvelaze mcire 6

simptoms CamonaTvalSi mocemuli nebismieri ori jgufidan (an kuW-

nawlavis, an gul-sisxlZarRvTa, an Sardsasqeso da an kanis da

tkivilis sistemidan; ixile tabula #5). orive klasifikaciuri

sistemaSi warmodgenili somatizaciis mTavari moTxovnebi asaxulia

tabula #6-Si.

tabula #4. afa-s mier gamoqveynebuli DSM-IV klasifikaciis

somatizirebuli aSlilobis (300.81) diagnostikuri kriteriumebi

A. 30 wlamde dawyebuli mravali fizikuri Civilebis istoria,

romelsac adgili aqvs ramdenime wlis ganmavlobaSi da mTavrdeba

moTxovnili mkurnalobiT an sagrZnobi darRveviT socialur,

samsaxurebriv an moRvaweobis sxva mniSvnelovan sferoSi.

B. darRvevis mimdinareobis nebismier dros TiToeuli Semdgomi

kriteriumi warmodgenili unda iyos calkeuli simptomebiT:

oTxi tkivilis simptomi (Tavis, muclis, zurgis, saxsrebis,

kidurebis, mkerdis, menstruaciis dros, Sardvisas an seqsualuri

aqtivobis dros)

ori kuW-nawlavis simptomi (gulisreva, Seberiloba, Rebineba

gansxvavebuli vidre fexmZimobis dros, diarea an autanloba

ramdenime sxvadasxva sakvebis mimarT)

16

erTi seqsualuri simptomi (seqsualuri gulcivoba, ereqciis an

eakulaciis disfunqcia, araregularuli menzesi, gadaWarbebuli

menstrualuri sisxldena, gulisreva mTeli fexmZimobis dros)

erTi fsevdonevrologiuri simptomi (iseTi konversiuli simptomebi,

rogoricaa darRveuli koordinacia da wonasworoba, parezi an

adgilobrivi sisuste, ylapvis gaZneleba an yelSi gaCxirvis

SegrZneba, afonia, Sardis Sekaveba, halucinacia, sensoruli

SegrZnebis dakargva, mxedvelobis gaoreba an sibrmave, siyrue,

gulyra; disociaciuri simptomebi, rogoricaa amnezia an gonebis

dakargva sxva tipis vidre gulis wasvla).

C. an (1) an (2):

(1) saTanado gamokvlevebis Semdeg yoveli simptomi B kriteriumidan

ver aixseba srulad zogadTerapiuli mdgomareobiT, an nivTierebis

pirdapiri gavlenebiT (magaliTad, samedicino preparatis an

narkotikis gamoyeneba)

(2) Tuki imavdroulad saxezea simptomebTan dakavSirebuli

zogadTerapiuli sneuleba, somaturi Civilebi an misgan gamomdinare

socialuri da samsaxurebrivi siZneleebi aris gadametebuli imasTan,

Tu ra unda yofiliyo mosalodneli daavadebis mimdinareobis,

fizikuri gamokvlevis da laboratoriuli Sedegebis mixedviT

D. simptomebi ar aris ganzrax gamowveuli an simulirebuli (rogorc

amas adgili aqvs xelovnurad demonstrirebul aSlilobisa [Factitious

Disorder] an simulaciis [Malingering] dros).

17

tabula #5. jmo-s mier gamoqveynebuli mentaluri da qceviTi

aSlilobebis klasifikaciis ICD-10 somatizirebuli aSlilobis

(F45.0) diagnostikuri kriteriumebi

A. unda iyos mravlobiT da variabelur somatur simptomebze

Civilebis Tundac 2 wlis istoria. simptomebi ver aixsneba romelime

gamovlenili somaturi daavadebiT (nebismieri ukve cnobili somaturi

darRvevebi ar xsnis somaturi Civilebis simZimes, masStabs,

nairsaxeobas da Seupovroba an masTan dakavSirebul socialur

unarSezRudulobas).

B. simptomebiT Sepyroba iwvevs mudmiv distress, ris gamoc pacienti

iRvwis ganmeorebiTi (sami an meti) konsultaciebisa an mTeli rigi

gamokvlevebisaTvis jandacvis pirveladi rgolis an viwro profilis

eqimebTan. samedicino daxmarebis miuwvdomlobis pirobebSi (finansuri

an sxva mizeziT) unda iyos warmodgenili gamudmebuli TviT-

mkurnaloba medikamentebiT an mravaljeradi konsultaciebi

adgilobriv mkurnalebTan.

C. mudmivi uaris Tqma samedicino rwmunebis miRebaze, rom ar aris

somaturi simptomebis adekvaturi fizikuri mizezi (diagnozis

gamotanas ar uSlis xels am mtkicebebis mokle xniT miReba,

magaliTad, ramdenime kviris manZilze gamokvlevebis dros an maT

Semdeg).

D. unda iyos aranakleb eqvsi an meti simptomisa Semdegi

CamonaTvalidan, da warmoadgendes Tundac or sxvadasva jgufs:

kuW-nawlavis simptomebi

(1) muclis tkivili;

(2) gulisreva;

(3) gazebis dagrovebisa an Seberilobis SegrZneba;

(4) cudi gemo pirSi, an nadebiani ena;

(5) Civilebi Rebinebaze an sakvebis regurgitaciaze;

18

(6) Civilebi kuW-nawlavis xSir moqmedebaze an siTxis dakargvaze

ukanalidan;

gul-sisxlZarRvTa simptomebi

(7) qoSini yvelanairi daZabvis gareSe;

(8) tkivilebi gulmkerdis areSi;

Sardsasqeso simptomebi

(9) dizuria an Civilebi xSir Sardvaze;

(10) arasasiamovno SegrZnebebi genitaliebSi an maT irgvliv;

(11) Civilebi saSvilosnodan ucnaur an Warb gamonadenze;

kanis da tkivilis simptomebi

(12) dalaquli an uferuli kani;

(13) tkivilebi kidurebSi an saxsrebSi;

(14) arasasiamovno dabuJebis an Cxvletis SegrZneba;

E. umeteswilad gamosaricxi mizezebi. simptomebi ar vlindeba mxolod

nebismieri Sizofrenuli an masTan dakavSirebuli aSlilobebis dros

(F20-F29), nebismieri afeqturi aSlilobebis (F30-F39) an panikuri

aSlilobis dros (F41.0).

tabula #6. somatizirebuli aSlilobis gansxvavebuli koncefciebis

maxasiaTeblebi

koncefcia DSM-IV ICD-10

simptomTa minimaluri

raodenoba

8 6

xangrZlivoba dawyeba 30 wlamde 2 weli

gavlena cxovrebaze + +

samedicino daxmarebis

gamoyeneba

+ +

simptomTa jgufebi 4 2

19

maSin, rodesac klinikur suraTSi algiuri simptomebia

warmodgenili, rac pacientis cxovrebis seriozul distress iwvevs

da sadac savaraudoa uSualo kavSiri fsiqologiur faqtorebTan –

msgavs kategorias tkivilis aSliloba ewoda. ipoqondria ki

tradiciulad is mdgomareobaa, rodesac pirovneba Sepyrobilia SiSiT

an rwmeniT, rom mas sWirs seriozuli daavadeba an garkveuli

defeqti garegnobaSi. am kategoriis moTavsebam somatoformulis

jgufSi miuxedavad misi msgavsebisa obsesiur-kompulsiuri speqtris

aSlilobebTan, ganapiroba im momentma, roca mis dasadgenad unda

gamoiricxos somaturi daavadeba, romlis arseboba ase sjera

pacients.

miuxedavad Tavisi msgavsebisa, somatoformuli aSlilobebSi

Semaval sindromebs gaaCniaT maTTvis damaxasiaTebeli niSnebi,

riTiTac SeiZleba maTi gansxvavba erTmaneTisagan (tabula #7).

tabula #7. somatoformuli aSlilobebis diferenciacia

pacientis yuradreba mipyrobilia:

ipoqondria fizikuri simptomebis

mniSvnelobaze (darRveuli

Semecneba)

somatizirebuli

aSliloba

mravlobiT auxsnel fizikur

simptomebze (darRveuli

SegrZneba)

sxeulis dismorfuli

aSliloba

garegnobis avadmyofur

warmosaxvaze

konversiuli aSliloba motoruli an sensoruli

funqciis darRvevaze, romelic

male aRmocendeba cxovrebiseuli

stresis an konfliqtis Semdeg

tkivilis aSliloba mkveTr tkivilze, sadac

20

fsiqologiur faqtorebs wvlili

Seaqvs tkivilis dawyebaSi,

siZliereSi da mis

xangrZlivobaSi

somatoformuli aSlilobani ar aris erTaderTi magaliTi, rodesac

fizikuri simptomebi da niSnebi dakavSirebulia fsiqiatriul

mdgomareobebTan (gigineiSvili, 2005). amis mkafio magaliTebia:

JrJolva, gaxSirebuli guliscema, zerele da gaZnelebuli sunTqva da

mravali sxva somaturi simptomebi panikuri aSlilobisas, Sekruloba,

pirSi simSrale da wonis dakleba ki _ depresiisas. magram, Tu am

ukanasknel SemTxvevebSi, es urTierTkavSiri somaturi simptomebisa

da fsiqiatriuli diagnozisa advilad misaRebia pacientisTvis da

jandacvis pirveladi rgolis eqimisTvis, ris Sedegadac dgeba mTeli

sqema RonisZiebebisa am mdgomareobis dasaZlevad, pirvel SemTxvevaSi

viTareba sawinaaRmdegoa. jer erTi pirveladi jandacvis eqimebs,

Tveebisa da wlebis manZilzec ki daudgeneli rCebaT somatoformuli

aSlilobis diagnozi. pacienti darwmunebuli aris gamouvleneli

darRvevis fizikur warmoSobaze da aseve darwmunebulia, rom fsiqika

ar TamaSobs aranair rols daavadebis ganviTarebaSi (Crimlisk et al. 2000;

Rief et al. 2004). rodesac, sabolood, pacienti xdeba informirebuli

diagnozis Sesaxeb, rogorc wesi, is ar aris ganwyobili miiRos igi.

aqedan gamomdinare, zemoT moyvanili SemTxvevebisagan gansxvavebiT,

erTgvari gaugebroba yalibdeba pacientsa da eqims Soris

diagnostikuri procesis dros. amitomac pacienti cdilobs mimarTos

sxva eqimebs, Caitaros damatebiTi gamokvlevebi da aseve gaiaros

mkurnalobis kursebi (qirurgiuli Carevebis CaTvliT), romelic ar

aris am dros gamarTlebuli. msgavsi qcevis paterni miCneulia,

rogorc avadmyofis araadekvaturi qceva (inadequate illness behaviour),

radgan pacienti iTvisebs avadmyofis rols, miuxedavad somaturi

21

daavadebis damamtkicebeli monacemebis ararsebobisa (Scicchitano et al.

1996).

magram garda fsiqokuri aSlilobebisa aris ramdenime somaturi

paTologia, romelic SeiZleba gamovlindes imdenad mravalferovani

da imavdroulad aramkafio simptomebiT, rom klinicists eWvi

gauCndes somatoformuli, kerZod somatizirebuli aSlilobis

arsebobaze. maT Soris aris gafantuli sklerozi, sxva neiropaTiebi,

sistemuri wiTeli mglura, mwvave xangamoSvebiTi porfiria, sxva

hepaturi da hematopoeturi porfiriebi, zogierTi qronikuli

infeqcia, miopaTiebi da vaskulitebi (Betts 1997). aRniSnuli

mdgomareobebi iwyeba disiminirebuli, araspecifiuri subieqturi

simptomebiT da tranzituli (xanmokle) an orazrovani fizikuri

niSnebiT an laboratoriuli cvlilebebiT. nevrologis

gansakuTrebul interess ibyrobs somatizirebuli aSlilobis

diferenciacia miasTeniasa da gafantul sklerozTan (gigineiSvili d.

2005).

miasTenias safuZvlad udevs imunodamokidebuli, nervkunTovani

gadacemis moSla, romlis dros vlindeba garkveuli kunTebis

sisuste. aRniSnuli sisuste, rogorc wesi, matulibs datvirTvis

Semdeg da klebulobs mosvenebul mdgomareobaSi.

aRniSnuli paTologia saWiroebs diferenciul diagnostikas,

rogorc garkveul nevrologiur paTologiebTan, aseve fsiqiatriul

aSlilobebTan. sayuradReboa, rom hiperdiagnostika ormxriv

saxifaToa: depresiuli an nevrozuli mdgomareobebi SesaZloa iyos

SecdomiT Sefasebuli, rogorc miasTenia da piriqiT. literaturaSi

aRwerilia SemTxvevebi (Lishman 1998), rodesac pacientebSi CivilebiT

sisusteze da daRlilobaze antiqolinerguli testi iZleva placebo

efeqts, miT ufro, Tu igi ar aris gadamowmebuli kunTis Zalis

obieqturi SefasebiT. testis cru pozitiuri Sedegebi safuZvlad

22

udevs miasTeniis diagnozs da pacientis mxridan antiqolinerguli

preparatebis uzomo da araswor miRebas.

meore mxriv, miasTenia sawyis stadiaze SeiZleba miCneul iqnas

konversiul (an sxva nevrozul) aSlilobad. emociis garkveuli

gavlena sisusteze, klinikuri niSnebis mravalferovneba da

fsuqtuacia, anamnezSi fsiqologiuri darRvevebis faqtebi safuZvels

uyris mentaluri aSlilobis arsebobis varauds (Nicholson et al. 1986).

Tuki miasTeniis sawyis etapze kunTTaAjgufi, romelSic vlindeba

sisuste, profesiuli saqmianobasTan aris uSualo kavSirSi, Civilebi

aRiqmeba rogorc samsaxurebrivi viTarebiT simulirebuli ‘krampi’,

moulodnelad ganviTarebuli qveda kidurebis sisuste varjiSis

Semdeg ki - konversiul (isteriul) krunCxvad. klinikuri simptomebis

gamovlenidan miasTeniis diagnostireba pacientTa mexuTedSi 2 wlis

Semdeg xdeba (Oosterhuis & Wilde 1964; Sneddon 1980). magram, amJamad

eleqtrofiziologiuri da imunologiuri (antiqolinesTerazuli

receptorebis antisxeulebis gansazRvra SratSi) testebis arsebobis

pirobebSi msgavsi Secdomebis ricxvi sagrZnoblad Semcirebulia.

isteriisa da gafantuli sklerozis gansakuTrebuli

urTierTdamokidebuleba warsulSi yuradRebas imsaxurebda.

daavadebis sawyis stadiaze did siZneles hqmnis mkafio diferenciacia

am or darRvevas Soris. gamoTqmuli iyo mosazreba, rom gafantul

sklerozs mogvianebiT stadiaSi axasiaTebs isteriuli simptomebis

gamovlena da es miewereboda SesaZlo erTian paTofiziologiur

meqanizmebsac ki (Brain 1930; Lishman 1998). Tumca, pratis (Pratt 1951)

kvlevam ar daamtkica es mosazreba. gasaTvaliswinebelia

‘gaSterebuli gulgrilobis’ (eiforiis gamomxatveli gafantuli

sklerozis mqone pacientebSi) msgavseba ‘mSvenier gulgrilobasTan’ (la

belle indifference). pacientebi ‘mSvenieri gulgrilobiT’ ver axerxeben

Seafason TavianTi darRvevebis mniSvneloba. fsiqodinamiuri

TvalsazrisiT, es fenomeni asaxavs pacientis mxridan daavadebis

23

uaryofas an represias (ixileT TavSi ‘konversiuli aSliloba’). Tavis

tvinis qsovilis dazianebis dros, upriania msgavs simptoms ewodos

anosodiaforia (anosodiaphoria) anu mdgomareoba, rodesac pacienti

cerebruli dazianebiT ver aRiqvams Tavis nevrologiur deficits.

gafantuli sklerozis diagnostika efuZneba klinikur gamokvlevas,

romelic avlens sivrceSi da droSi disiminirebul niSnebs.

birTvuli magnitur-rezonansuli gamosaxva Zalze informaciulia da

amJRavnebs qerqqveSa TeTri nivTierebis ovalur dazianebebs,

orientirebuls gverdiTi parkuWebis perpendikularulad. axali kera

irTavs rentgenokontrastul gadoliniums saSualod oTxi kviris

ganmavlobaSi. miuxedavad imisa, rom ar arsebobs gafantuli

sklerozis specifiuri paTognomuri diagnostikuri meTodi, Tav-

zurgtvinis siTxis gamokvleva, sadac vlindeba IgG-s momatebuli

koncentracia, klinikur gamovlinebebTan erTad xels uwyobs

diagnozis gamotanas.

gasaTvaliswinebelia is garemoeba, rom somatoformuli

aSlilobani ar aris sakmarisad Seswavlili, arc meta-analizma da

arc faqtebze dayrdnobilma medicinam (evidence-based medicine)

mniSvnelovani araferi Semata am sferos (Silber and Pao 2003). es

ganpirobebulia Tavad am jgufis aSlilobebis diagnostikuri da

klinikuri TaviseburebiT da maTi Semswavleli kvlevebis empiriuli

xasiaTiT. amitomac, nebismieri dakvirveba, Tundac mcirericxovan

pacientTa jgufze, warmoadgens interess da SeiZleba mniSvnelovnad

gaafarTovos Cveni warmodgena am darRvevebze.

24

epidemiologia

ass-s gavrceleba jandacvis pirvelad qselSi maRalia (20-33%;

Kroenke 2003; Rosendal et al. 2005). Catarebuli kvlevebis safuZvelze

gamovlinda (Hamilton et al. 1996; Reid et al. 2001; Maiden et al, 2003), rom

auxsneli samedicino simptomebis mqone pacientTa ricxvi meryeobs 29-

dan 35%-de sxvadasxva profilis klinikebTan arsebul

specializirebul ambulatoriebSi (kardiologia, revmatologia,

gastroenterologia da nevrologia). iqedan garkveuli wili eWiraT

depresiul da SfoTvis aSlilobebs. ass-ebis erT-erTi yvelaze

maRali maCvenebeli (33%) aReniSna pirvelad pacientebs Soris,

romlebic mimarTaven nevrologiur klinikis ambulatorias (Carson et

al. 2000).

rac Seexeba saerTo populaciur maCveneblebs, aq kvlevebi mcirea

da monacemebi sxvadasxvanairi. kanadaSi Catarebuli qalaqis

mosaxleobis gamokiTxvis Tanaxmad bolo 12 Tvis ganmavlobaSi

respondentTa 10.5%-Si gamovlinda Tundac erTi ass-i. maT Soris

yvelaze xSiri Civilebi moicavda ZvalkunTovan (30.3%-Si) da

gastroenteralur (17.7%-Si) tkivilebs (Kirmayer et al. 2004). tkivilis

simptomebi iyo mosaxleobis yvelaze xSiri Civili bolo ori wlis

ganmavlobaSi sxva farTomasStabian kvlevaSi, sadac

specializirebuli somatoformuli simptomebis kiTxvari

(SemuSavebuli, rogorc DSM-IV aseve ICD-10 kriteriumebis mixedviT)

iyo simptomTa gamovlenis mTavari iaraRi (Rief et al. 2001). welis da

saxsrebis tkivili – 30 da 25%-Si Sesabamisad, gastrointestinaluri

da kardialuri simptomebidan ki tkivili muclis areSi da guliscema

Tanabrad gamovlinda 11%-Si.

saerTod, unda iTqvas, rom funqciuri xasiaTis Civilebi xSiria

saerTo populaciaSi, magram marto mcire nawili aris dakavSirebuli

fsiqiatriul darRvevebTan. umetesoba ki aris tranzitoruli

25

xasiaTis, ara aqvs kavSiri fsiqikur aSlilobebTan da advilad

ganikurnebian gadarwmunebis Sedegad.

somatoformuli aSlilobebis epidemiologiur maCveneblebze

dayrdnobiT, yvelaze didi wili modis aradiferenciul

somatoformul aSlilobaze (Fink et al., 1999, Kirmayer & Robbins 1991; Smith

et al., 2005) da ara somatizirebul aSlilobaze, radgan ukanaskneli

warmoadgens yvelaze dramatul da qronikul gamovlenas

somatizaciis klinikur speqtrSi.

aradiferenciuli somatoformuli aSlilobis gavrceleba

mosaxleobaSi sxvadasxva monacemebiT meryeobs 13.8%-19.7% (Faravelli et al.

1997; Grabe et al. 2003). germaneli kvlevarebis mier SeTavazebuli

alternatiuli variantiP- polisimptomaturi somatoformuli

aSliloba, romelic garkveulad warmoadgens somatizirebuli da

aradifereciuli aSlilobis sinTezs (Rief et al. 1999) gamovlinda

mosaxleobis 12.5%-Si (Rief et al. 2001).

jandacvis pirvelad rgolSi ki somatoformuli aSlilobebi

gamovlenilia 22.3% da 30.3%-Si (ICD-10 da DSM-IV kriteriumebis

Sesabamisad). jmo-s klasifikaciis Tanaxmad yvelaze xSiri

somatoformuli aSlilobebidan iyo avtonomiuri disfunqcia (12.5%),

xolo danarCeni diagnostikuri erTeulebidan maRali gavrceleba

axasiaTebda tkivilis aSlilobas – 7.3% da somatizirebul

aSlilobas – 5.7%. afa-s kriteriumebis mixedviT ki yvelaze xSiri iyo

aradiferenciuli somatoformuli aSliloba (27%), radgan igi jmo-s

kriteriumebisagan gansxvavebiT moiTxovs mxolod erTi

somatizirebuli simptomis arsebobas (Fink et al. 1999). zogadi profilis

eqimebis unari, gamoavlinon somatoformuli aSliloba, iyo maRali

da meryeobda 50-71% jmo-s kriteriumebiT da 36-48% afa-s

kriteriumebiT, rac miuTiTebs am problemis gavrcelebas gacilebiT

Sors fsiqiatriuli sivrcidan.

26

bolo wlebSi gamoqveynebuli monacemebis Tanaxmad sa-s sixSire arc

ise dabalia zogadTerapiuli profilis stacionarSi (anu jandacvis

meorad rgolSi) moxvedril pacientebs Soris (18.2-20.2% [Fink et al., 2004;

Meng et al, 1999]) da igi kidevac metia nevrologiuri klinikis

pacientebs Soris (20.5-25% [Ekstrand et al., 2004; Fink et al., 2005]).

Cveni kvlevis masalas warmoadgenda akad. p.sarajiSvilis sax.

nevrologiisa da neiroqirurgiis institutis klinikuri nevrologiis

ganyofilebaSi 2000-2001 wlebSi moTavsebuli pacientebi. aRniSnul

kohortaSi (n=623) somatoformuli aSlilobebis sixSire (ICD-10

kriteriumebis Tanaxmad) iyo 3.69%. sxva mentaluri darRvevebidan

aRsaniSnavia depresia (0.64%) da SfoTviTi aSlilobebi (0.64%).

klinikuri gamokiTxva warmoebda neirofsiqiatris mier institutSi

SemuSavuli mentaluri statusis Semfasebeli skalis safuZvelze.

diagnozi ismeboda ICD-10 mentaluri da qveviTi darRvevebis

klasifikaciis kvleviTi diagnostikuri kriteriumebis Tanaxmad (WHO,

1993). aRniSnuli interviu utardeboda mxolod im pacientebs,

romlebSic diagnostikuri procesis Sedegad nevrologiuri

simptomatikis organuli xasiaTi eWvis qveS dadga. somatoformuli

aSlilobebis jgufSi Semavali diagnostikuli erTeulebis

gavrceleba mocemulia tabula #8 (Гигинейшвили Д.А., Шакаришвили Р.Р.

2006b).

konversiuli aSlilobis diagnozi gawerisas sWarbobda sxva sa

diagnozebs Soris (69.6%). sxva diagnozebis sixSire iyo Semdegnairi:

somatizirebuli aSliloba – 13%; somatoformuli vegetatiuri

disfunqcia – 8.7%; ipoqondriuli da aradiferenciuli – 4.3%

TiToeuli. sruli kohortis (23 pacienti) saSualo asaki iyo 27.8(±10.1)

weli, qalebi (61%) dominirebdnen mamakacebze (39%).

27

tabula #8. somatoformuli aSlilobebis gavrceleba nevrologiur

klinikaSi hospitalizirebul pacientebs Soris

sruli kohorta (n=623) somatoformuli

aSlilobebi

2000w

(n=298)

2001w

(n=325) N (%) genderuli

Sefardeba

(md/mamr)

saSualo

asaki

(diapazoni)

somatizirebuli

aSliloba

2 (0.67%) 1 (0.31%) 3 (0.48%) 2/1 30 (20-41)

konversiuli/

disociaciuri

aSliloba:

krunCxvebiT

sxva motoruli

stuporiT

Sereuli

9 (3.02%)

7

1

2

7 (2.15%)

5

1

1

16

(2.57%)

9/7 27.6 (16-47)

ipoqondriuli - 1 1 (0.16%) 0/1 32

aradiferenciuli

somatoformuli

- 1 1 1/0 15

somatoformuli

vegetatiuri

disfunqcia

1 (0.34%) 1 2 (0.32%) 2/0 31 (22-40)

jami 12 11 23

(3.69%)

14/9 27.8 (15-47)

Sedegebma aCvena, rom sa-s Soris konversiulis diagnozi iqna

gamotanili yvelaze xSirad (16/23). es iyo mosalodneli, radgan

umTavresi moTxovna am diagnstikuri erTeulis gamosatanad aris

nevrologiuri daavadebebis simptomTa msgavseba. analogiuri Sedegi

iqna gamovlenili holandiur naSromSi, sadac konversiuli diagnozis

wili sxva fsiqiatriul diagnozebis Soris iyo 66.7% nevrologiur

klinikaSi da 26.1% - zogadTerapiul klinikaSi (Thomassen et al., 2003).

28

magram somatoformuli aSlilobebis gavrceleba hospitalizirebul

pacientebs Soris Cveni SedegebiT Tanaxmad ar aRemateba 4%-s, rac

sagrZnoblad dabalia, vidre 20.5-25%, rac moyvanilia bolo wlebis

naSromebSi. daniur kvlevaSi (Fink et al., 2005) fsiqologiuri sindromis

gamosavleni mTavari iaraRi iyo SCAN (neirofsiqiatriaSi klinikuri

Sefasebis megzuri), rac warmoadgens sakmaod farTo da

detalizirebul diagnostikur instruments mentaluri darRvevebis

gamosavlenad (Hiller & Janca, 2003). miRebuli monacemebis safuZvelze ICD-10

fsiqiatriuli diagnozebi ismeboda konpiuteruli programis

daxmarebiT. avtorebi aRniSnaven, rom SCAN pozitiuri pacientebis

mxolod 55.3% iqna gamocnobili nevrologebis mxridan klinikuri

Sefasebis safuZvelze, rac SesaZlebelia xsnides Cvens mier miRebul

dabal monacemebs. aseve gamotanili klinikuri diagnozebis Soris

Tavad nevrologiur daavadebebs ekava ara umetesi erTi mesamedisa

(29.3%). aseve maRali iyo somatoformuli diagnozebis Tanaarseboba sxva

mentalur darRvevebTan (60%-de), aRniSnuli metyvelebs daniur kvlevis

masalisa da Cveni kohortebis arahomogenurobaze., vinaidan Cven

kvlevaSi yuradreba davuTmeT im SemTxvevebs, sadac nevrologiuri

somatizacia iyo klinikurad wamyvani an erTaderTi mentaluri

darRveva. amerikul kvlevaSi (Ekstrand et al., 2004) skriningis instruments

warmoadgenda PRIME-MD kiTxvari, romelsac avsebda pacienti. am

gamokvlevis Sedegebi ar iZleva calkeuli diagnozis gamotanis

saSualebas, Tumca miakuTvnebs darRvevas somatoformuls an

depresiuls. somatoformuli iqna miCneuli is mdgomareoba, sadac sami

an meti qronikuli da mainvalidizirebeli ass iyo warmodgenili.

amavdroulad sa diagnozebidan 59.3% (35/59) iyo Tanaarsebuli

nevrologiur daavadebasTan. am ricxvis gamoklebis Semdeg gamodis,

rom sa safuZvlad edo pacientis mimarTvianobas nevrologiur

klinikaSi 10.2%-Si. es garkveulad uaxlovdeba Cvens monacemebs. magram

mTavari gansxvaveba devs meTodologiaSi – winamdebare kvlevaSi Cven ar

29

CavutareT mTel kohortas neirofsiqiatriuli gamokvleva, aramed

mxolod imaT, romelTac gamoericxa nevrologiuri daavadeba. Tavisi

wvlili SeiZleba Seitanos aseve momarTvianobis suraTma, romelzec

qveynis socio-ekonomiuri faqtorebi axdenen gavlenas. aradamakmayo-

filebelma socialurma pirobebma da mosaxleobis mcire nawilis Cabmam

srulfasovani samedicino dazRvevis sistemaSi SeiZleba ganapirobos

qronikulad mimdinare, sicocxlisaTvis arasaxifaTo daavadebebis mqone

pacientebis mxridan samedicino momsaxureobis iSviaTi moTxovna.

Cveni Sedegebi miuTiTebs, rom nevrologiuri Civilebis gamomwvevi

organuli dazianebis argamovlenis pirobebSi, maRalia am simptomebis

gamomwvevi fsiqologiuri darRvevis arsebobis Sansi, rac srulad

exmaureba zemomoyvanil gamokvlevas (Ekstrand et al., 2004). meore mxriv,

rodesac aris raime nevrologiuri daavadebis arsebobis monacemebi,

nevrologi SesaZlebelia ar cdilobs Tanaarsebuli fsiqologiuri

darRvevis gamovlenas, radgan es aris misi amocanisa da

profesionalizmis miRma.

boloSi aRsaniSnavia, rom fns-is da mis safuZvlad arsebul sa-s

arcTu umniSvnelo sixSire nevrologiur samsaxurSi miuTiTebs

detaluri neirofsiqiatriuli gamokvlevis saWiroebaze pacientebSi

ass-ebiT rogorc jandacvis pirvelad rgolSi, aseve stacionarSi

moxvedrisas. es nabijebi Seamcireben diagnostikuri procesisaTvis

gankuTvnil dros da xarjebs da daaCqareben pacientis CarTvas

misTvis Sesabamis Terapiul procesSi.

somatizaciis tvirTi

pacientebi mravlobiTi somaturi CivilebiT ara marto wardgebian

mniSvnelovani problemebiT marTvaSi, aramed gaaCniaT funqcionirebis

imdenad mZime darRvevebi, rom isini gadawonian analogiur

cvlilebebs pacientebSi sxva, egreT wodebuli mZime mentaluri

30

daavadebiT, rogoricaa Sizofrenia (Hiller et al. 1997). somatoformuli

aSlilobebidan erT-erTi yvelaze dramatuli – somatizirebuli

aSliloba aris dakavSirebuli funqcionirebis did darRvevasTan

(Escobar et al. 1989). aSS-Si Catarebulma gamokiTxvam aCvena, rom amgvari

pacientebis mier TviTSefasebuli fizikuri funqcionireba iyo ufro

dabali vidre imaTi, vinc Sepyrobili iyo qronikuli organuli

daavadebiT: ass-ebis mqone pirebi TveSi saSualod Svid dRes

atarebdnen sawolSi (Smith et al. 1986). pacientebi somatizaciiT avlenen

sagrZnoblad darRveul maCveneblebs cxovrebis xarisxis

gansxvavebul aspeqtebSi da sakmaod maRal Sromisuunarobis da

samedicino daxmarebis gamoyenebis dones (Ladwig et al. 2001; Jyväsjärvi et al.

2001). naCvenebia, rom funqcionirebis darRvevebi mkafiod matulobs,

roca pacients gaaCnia Tanaarsebuli depresia an/da SfoTviTi

aSliloba (Gara et al. 1998; De Waal et al. 2004). pacientebi somatizaciiT

xSirad mimarTaven pirveladi jandacvis qselis samsaxurs. fineTSi

Catarebuli kvlevis Tanaxmad, somatizirebulTa ricxvi im pacien-

tebSi, romlebic xSirad (rva an metjer) mimarTaven zogadi profilis

eqims, sagrZnoblad metia, imaTTan SedarebiT, vinc ar gamoirCeva

xSiri vizitebiT eqimebTan (28.6% 16-is winaaRmdeg) (Jyväsjärvi et al. 2001).

msgavsi ram SeiZleba iTqvas konversiuli aSlilobis mqone

pacientebzec, kerZod, qronikulad mimdinare simptomebis arsebobisas.

bolodroindelma gamokvlevebma cxadyo, rom qronikul isteriasTan

dakavSirebuli Sromisuunarobis tvirTi gacilebiT metia, vidre es

Cveulebrivi praqtikis mqone fsiqiatrs SeeZlo evarauda (Akagi and

House 2001).

naCvenebia, rom somatoformuli aSlilobebis mqone pacientebis,

rogorc poliklinikuri, aseve stacionarSi hospitalizaciasTan

dakavSirebuli xarjebi 2.2 jer aRemateba imas, rac saSualod

ixarjeba pacientze samedicino qselSi. mkurnalobis 2 wlis Tavze ki

es xarjebi Semcirda, rac miuTiTebs fsiqologiuri mkurnalobis

31

sargeblianobaze ara mxolod samkurnalo TvalsazrisiT, aramed

samedicino daxmarebis xarjebis optimizaciis mizniT (Hiller et al. 2003).

es mosalodnelia, vinaidan avadmyofis qcevasa, romelic vlindeba,

magaliTad, eqimebTan xSir konsultaciebSi, medikamentebis

araadekvatur gamoyenebaSi (somatizaciis mqone pacientis centraluri

gamovlena), da ekonomiur danaxarjebs Soris aris udavod mWidro

kavSiri.

magram xarjianobis maRali maCvenebeli (kerZod, poliklinikuri da

stacionaruli jamuri xarji ori wlis ganmavlobaSi 2500€ da zeviT)

ar aris somatoformuli aSlilobis mqone pacientebis aucilebeli

niSani. igi gansakuTrebiT axasiaTebT imaT, vinc avlens avadmyofis

qcevis paternis, Sromisuunarobis (samsaxurSi), organizmis

TviTSefasebuli sisustis (CABAH) da ipoqondriuli elferis

simptomebis maRal maCveneblebs (Hiller & Fichter 2004). aseve maRalia

maTSi somatizirebuli simptomebiT gamowveuli subieqturi distresis

(wuxilis) gancda, rac SemecnebiTi da kognitiuri procesebis CarTvas

gulisxmobs.

basi da misi kolegebi (Bass et al. 2001) Tavis vrcel naSromSi ixilaven

mizezebs, Tu ratom aris es darRvevebi ase ignorirebuli

fsiqiatrebis mier. upirvelesad, avtorebi aRniSnaven fsiqiatriuli

diagnostikis praqtikis bunebas. somatoformuli aSlilobebi

fsiqiatriuli klasifikaciebis Tanaxmad daiyo dabali gavrcelebis

(prevalence) mqone erTgvar (SedarebiT) homogenur dajgufebad. xolo

somaturi distresis yvelaze xSiri gamovlenebi, rogoricaa

xangrZlivi daRliloba, ZvalkunTovani tkivili da kuW-nawlavis

simptomebi, mkafiod ar arian gadanawilebuli validur (sarwmuno)

kategoriaSi _ ‘aradiferenciuli somatoformuli aSlilobebi’.

rogorc Sedegi, isini ara mxolod Sors arian Semdgomi klinikuri

da kvleviTi ganxilvebisagan, aramed maTi WeSmariti gavrceleba aris

Seufasebeli. sxva mizezad avtorebi asaxeleben fsiqiatrebis met

32

interess ‘seriozul mentalur darRvevebisadmi’, magaliTad,

rogoricaa Sizofrenia da bipolaruli aSliloba. mesame mizezi aris

is, rom fsiqiatrebis umetesoba naklebad urTierTobs zogadi

profilis hospitalTan da amitomac maT gaaCniaT sakmaod SezRuduli

gamocdileba im avadmyofebisagan, romlebic wardgebian ass-ebiT. da

bolo argumenti is gaxlavT, rom msgavsi pacientebi ar mimarTaven

sakonsultaciod fsiqiatrs garkveuli daRis SiSiT. maT aqvT

somaturi Civilebi, romlis asaxsnelad iZebneba fizikuri mizezi, ris

gamoc mimarTva fsiqologiuri SemowmebisaTvis namdvilad ar aris

pacientTa gamokvlevis prioritetul siaSi.

saqarTvelos sinamdvileSic, pacientebi somatoformuli aSlilobiT

zurgs aqceven fsiqiatriul samsaxurs. amis umTavresi mizezi,

rogorc zemoT iyo naxsenebi, mdgomareobs imaSi, rom mravlobiTi

somaturi Civilebi iniRbeba Terapiuli an nevrologiuri darRvevebis

saxiT, amitomac pacienti mimarTavs saTanado samsaxurebis

specialistebs. sxva mizezia pacientis mcdeloba Tavi aaridos

socialur stigmas, rac SeiZleba Sedegad mohyves fsiqiatriuli

samsaxuris mimarTvas. gasaTvaliswinebelia aseve, rom TviT

fsiqiatrebic metad gatacebuli da gaTvicnobierebuli arian ‘sufTa’

fsiqoturi darRvevebiT. amas, aseve, xels uwyobs saqarTveloSi

fsiqologiuri samedicino samsaxuris Canasaxur mdgomareobaSi yofna

(fsiqoTerapiuli SesaZleblobis mimarT warsulSi politikurad

dakveTili siyruis gamoCenis gamo), rac ar aZlevs raime upiratesobas

fsiqiatriul menejments sxva Terapiuli modalobebisagan

gansxvavebiT.

naTelia, rom radgan somatoformuli aSlilobebi yvelaze xSiri

fsiqiatriuli darRvevaa arafsiqiatriul samedicino qselSi (zogadi

profilis saavadmyofoebSi da pirveladi jandacvis qselSi),

gansakuTrebul mniSvnelobas iZens swori saganmanaTleblo politika

profesiuli kadris momzadebaSi. dasavluri mkvlevarebi xazs usvamen

33

saerTo praqtikis eqimebis aradamakmayofilebel Teoriul momzadebas

ass-ebis mimarT, rac maTi azriT susti sauniversiteto da diplomis

Semdgomi swavlebis Sedegia (Rosendal et al. 2005). ingliseli eqimebis

mier (Sharpe et al. 1996) SemoTavazebulia ‘fsiqologiuri medicinis’

kursis aucilebeli swavleba samedicino institutis

studentebisaTvis, rac, avtorTa mosazrebiT, moamzadebs maT momavali

samedicino karierisaTvis. samwuxarod, CvenSi es problema

gadauwyvetelia, radgan samedicino universitetdamTavrebulebs

sakmaod bundovani warmodgena aqvT daavadebebis biofsiqosocialur

modelze, rac saganmanaTleblo programis udavo sisustea.

meore mxriv, zogadi profilis eqimis informaciuloba aseve unda

iyos adekvaturi dRevandelobisadmi. radgan auxsneli somaturi

Civilebis mqone pacientebisaTvis samedicino daxmarebis samsaxurTan

pirveli Sexeba iwyeba poliklinikuri rgolis eqimTan urTierTobiT,

am ukanasknelis momzadeba da ganswavluloba am problemis

gamovlenaSi da Semdgomi menejmentSi, bevrad ganapirobebs pacientis

momaval beds da misi mdgomareobis gamosavals. Tumca, es cxadia, ar

gulisxmobs mxolod zogadi praqtikis eqimis mxrebze amgvari

pacientebis movla-patronobis dakisrebas. dargis cnobil

mkvlevarebs: hilers, rifs, Sarps da sxvebs metad damajereblad

miaCniaT, rom rekomendaciebisa da literaturis miuxedavad,

qronikulad da mZimed mimdinare somatoformuli aSlilobebis

pacientebis srulyofili fsiqologiuri mkurnaloba efeqturia

mxolod da mxolod fsiqosomatur saavadmyofoSi, romelic, sxvaTa

Soris, erTaderTia germaniaSi (Hiller et al. 2003; Rief & Sharp 2004).

am kuTxiT, jandacvis pirveladi rgolis da zogadi profilis

eqimebisTvis garkveul aucileblobas warmoadgens saswavlo kursebi,

sadac isini gaecnobian jandacvis pirveladi rgolis pacientis

movlis fsiqologiur da fsiqiatriul Tanamedrove warmodgenebs da

aspeqtebs.

34

2. fsiqogenuri nevrologiuri simptomebi

sityva konversia gulisxmobs meqanizms, romliTac garkveuli

somaturi simptomebi warmoiSveba aracnobieri gancdebis

transformaciiT. es ukanaskneli warmoadgens ganutvirTav emociebs

(afeqts), dakavSirebul fsiqologiur travmasTan, romlisgan Tavis

daRweva an emociuri gantvirTviT saSualebiT an kidev normaluri

gadasroliT cnobierebaSi ver moxerxda. amgvari froidiseuli axsna

daedo safuZvad konversiis koncefcias da im droidan igi iyeneba

iseTi simptomebis aRsaniSnavad, romlebic nervuli sistemis

funqcionirebis moSlas asaxaven. ’konversiuli simptomebi’ ewodeba

simptomTa limitirebul jgufs da amJamad, miuxedavad Tavisi

fsiqoanalitikuri warmoSobisa, atarebs mxolod aRwerilobiT

Sinaars da ar asaxavs etiologiur paTogenur meqanizms. Tuki

simptomi fsiqologiuri xasiTisaa (mexsierebis dakargva an fuga,

gaucnobierebeli erTi SexedviT mizandasaxuli saqcielebi, romlic

dros pirovnebis TviTaRqma darRveulia), mas dicociaciurs uwodeben.

arsiT konversias da disociacias erTiani safuZveli gaaCnia.

amitomac jmo-s klasifikaciaSi isini Tavmoyrilia erTian seqciaSi

F44 ’disociaciuri (konversiuli) aSlilobebis’ saxeliT. Tumca DSM-

is bolodroindel versiebSi konversiuli da disociaciuri

aSlilobebi arian gansxvavebul jgufebSi. aRsaniSnavia is garemoeba,

rom konversiuli (disociaciuri) simptomebi esadageba pacientis

ideebs (warmodgenebs), Tu rogor unda moiSalos sxeulis nawilis an

azrovnebis funqcia. maSasadame simptomebi atareben ideogenur

xasiaTs.

amJamindel klasifikaciur sistemebSi aracnobieri fsiqologiuri

konfliqti, rogorc simptomis warmoSobis Teoriuli safuZveli ar

aris warmodgenili diagnostikuri kriteriumebis nawilSi. magram

kriteriumebSi aRniSnulia, rom simtomebi warmoiSoba emociuri

35

konfliqtis Sedegad (tabula #8). magaliTad, ICD-10-is Tanaxmad ’unda

vlindebodes fsiqologiuri mizezobrioba droSi naTeli asociaciis

saxiT, stresis momtani movlenebTan da problemebTan an darRveul

urTierTobebTan (Tundac uaryofili iyos pirovnebis mier)’ (WHO,

1992). sxva mniSvnelovan diagnostikis aspeqts warmoadgens

cnobierebis monawileoba somptomebis CamoyalibebaSi. ass-ebi arian

mTavari klinikuri gamovlena ara mxolod sa-ebis dros, aramed

xelovnurad demonstrirebul aSlilobebisa da simulaciis dros.

orive SemTxvevaSi aris daavadebis ganzrax fabrikacia, romlis dros

xdeba raime somaturi an kidevac fsiqologiuri darRvevis imitireba.

da aqac monawileobs ideogenuri komponenti, msgavsad konversiuli

aSlilobisa, rodesac sensoruli an motoruli deficitis klinikuri

gamovlena Seesabameba aramc organuli dazianebisTvis damaxasiaTebel

suraTs, aramed pacientis warmodgenas anatomiaze da fiziologiaze.

simulaciis (Malingering) dros pacienti nebiT da gacnobierebulad

iRebs gadawyvetilebas, rom warmoadginos daavadebis imitacia. es

xorcieldeba garegani sargeblis mizniT, kerZod aaridos Tavi,

rogorc mtkivneul garTulebebs, aseve moipovos Cveulebriv

pirobebSi miuRweveli emociuri mxardaWera an privilegiebi. miznis

miRwevisas an rodesac avadmyofobas ukve ar moaqvT sasurveli

sargebeli, simptomebi TavisTavad alagdeba. xelovnurad

demonstrirebuli aSlilobebis (Factitious disorders) dros aSlilobis

gayalbeba an xelovnurad provocireba aseve xerxdeba nebiT, Tumca

pacienti ver acnobierebs am kompulsiuri saqcielis motivacias da

iTvleba, rom igi gamowveulia aracnobieri fsiqologiuri

saWiroebiT, kerZod ‘pacientis rolis’ miTvisebiT. mouxedavad

amisa,AaseTi pacienti naTlad aRiqvams, rom mas mxolod pretenzia

gaaCnia daavadebis arsebobaze, Tumca ver ayalibebs (rogorc Tavis

Tavis, asve sxvebis winaSe) sxva mizezs, garda samedicino daxmarebis

miRebisa (gigineiSvili d. 2001). avadmyofebi ar eridebian Tavis

36

mowamvlas, dainficirebasa da fizikuri travmis miyenebas rasac

Sedegad moyveba hispitalizacia da mravlobiTi diagnostikuri da/an

qirurgiuli Carevebi. yvela aRniSnul SemTxvevaSi klinikuri

simptomebi ar aris gamowveuli raime somaturi daavadebiT. magram sa-

ebis dros simptomebi ar aris ganzrax an simulaciis Sedegad

warmoCenili da ar imyofebian nebiTi kontrolis qveS. am

mdgomereobebis ganmasxvavebeli ganmsazRvreli kriteriumebi

moyvanilia tabula #10-Si. magram klinikur praqtikaSi, rodesac

pacienti wardgeba wminda subiqtrui simpotomebiT, romlis asranairi

kavsiri ar gaacnia raime organuli dazianebastan an travmas ass-s

mikuTvneba aSlilobebis romelime am sam jgufs warmoadgens

usazrvrod znel amocanas, Tuki miviRebT mxedvelobaSi im faqts, rom

avadmyofobas avtomaturad moaqvs garkveuli SeRavaTebi da

gantavisufleba socialuri valdebulebebisagan (skola an samsaxuri).

tabula #9. afa-s mier gamoqveynebuli DSM-IV klasifikaciis

konversiuli aSlilobis (300.11) diagnostikuri kriteriumebi

A. erTi an meti simptomi an deficiti, romelic moicavs nebiT

motorul an sensorul funqcias, rac varaudobs nevrologiur an

sxva zogadTerapiul mdgomareobas.

B. miCneulia, rom fsiqologiuri faqtorebi dakavSirebulia

simptomTan an deficitTan, vinaidan simptomis an deficitis dawyebas

an xelmeored gamwvavebas win uswrebs konfliqtebi an sxva

stresorebi.

C. simptomebi ar aris ganzrax gamowveuli an simulirebuli (rogorc

amas adgili aqvs xelovnurad demonstrirebul aSlilobisa [Factitious

Disorder] an simulaciis dros [Malingering]).

D. saTanado gamokvlevebis Semdeg simptomi an deficiti ver aixsneba

srulad zogadTerapiuli mdgomareobiT an nivTierebis pirdapiri

37

gavleniT, an rogorc ama Tu im kulturis mier sanqcionirebuli

qceva an gamocdileba.

E. simptomi an deficiti iwvevs klinikurad TvalsaCino (sagrZnob)

distress, an cvlilebas (darRvevas) socialur, samsaxurebriv an

moRvaweobis sxva mniSvnelovan sferoebSi, an iZleva samedicino

gamokvlevis safuZvels.

F. simptomi an deficiti ar aris SezRuduli tkiviliT an seqsualuri

disfunqciiT, ar vlindeba gansakuTrebulad somatizirebuli

aSlilobis dros da ukeT ver aixsneba sxva mentaluri aSlilobiT.

gamoavlineT simptomis an deficitis saxe:

motoruli simptomiT an deficitiT (darRveuli koordinacia an

wonasworoba, dambla an lokaluri sisuste, ylapvis gaZneleba an

‘yelSi gaCxirvis’ SegrZneba, afonia da Sardis Sekaveba)

sensoruli simptomebiT an deficitiT (Sexebisa da tkivilis

SegrZnebis dakargva, mxedvelobis gaoreba, sibrmave, siyrue da

halucinaciebi)

gulyrebiT an krunCxvebiT (Seicavs gulyrebs an krunCxvebs nebiTi

motoruli an sensoruli komponentebiT)

warmodgenili Sereuli simptomebiT (maSin, rodesac saxezea

simptomebi erTze meti kategoriidan)

tabula #10. fsiqogenuri simptomebisa da niSnebis diferenciuli

diagnozi

somatoformuli

aSlilobebi

xelovnurad

demonstrirebuli

aSlilobebi

simulacia

motivaciis

gacnobiereba

ar vlindeba ar vlindeba vlindeba

gayalbebis

gacnobiereba

ar vlindeba vlindeba vlindeba

38

Tanamedrove koncefciebis Tanaxmad, somatizirebuli da konversiuli

aSlilobebi gansxvavdebian erTnmaneTisagan mxolod ass-ebis

raodenobiT da maTi klinikuri xasiaTiT. konversiuli aSlilobas

miakuTvnian simptomebs, romlebic asaxaven sensoruli da motoruli

funqciebis (anu nevrologiuri) moSlas gamokveTili tkivilis

komponentis gareSe. yvela sxva SemTxvevebi, romelic gamoirCeva

Civilebis simravliT da maTi mikuTvnebiT organizmis sxvadasxva

sistemebidan Sedian somatizirebuli aSlilobis kategoriaSi.

somatizirebuli aSliloba arc ise iSviaTad vlindeba im pirebSi,

romlebic manmade iyvnen diagnostirebuli konversiuli aSlilobiT.

aseve xelovnurad demonstrirebuli aSlilobis mqone pirebs

SeiZleba aRmoaCndes somatizirebuli aSliloba (Bass & Gill, 2000).

maSasadame konversiuli simptomebi (anu fsiqologiuri konfliqtebisa

da problemebis simboluri gadawyveta) SeiZleba gvxvdebodes mxolod

sa-ebis dros (kerZod, konversiulisa da somatizirebulis), maSin

rodesac fsevdonevrologiuri simptomi ki gvxvdeba rogorc sa-ebis

(maSin mas ukve konversiul uwodeben), aseve simulaciisa da

xelovnurad demonstrirebuli aSlilobebis dros.

simptomebis generaciis meqanizmi

gamovlenilia mTeli rigi faqtorebisa, romelsac wvlili Seaqvs

somatizirebuli simptomis ganviTarebaSi. naCvenebia, rom es

sxvadasxvanairi faqtori ar aris urTierTgamomricxavi da xSirad

ramdenime maTgani moqmedebs erTdroulad. Cven SevecdebiT

CamovTvaloT zogierTi maTgani:

1. gaZliereba (Amplification)

gaZlierebis koncefcia iyo gacxadebuli barskis mier (Barsky 1979).

is eyrdnoba im dakvirvebas, rom yvela adamiani erTnairad ar

pasuxobs (reagirebs) sxeulis SegrZnebebze, zogierTTaTvis simptomi

39

ufro mtkivneuli, problemuri da mainvalidebelia. faqtorebs Soris,

romelic ganapirobebs gaZlierebas moixsenieba konstituciuri

niSnebi, xasiaTobrivi mdgomareoba, kulturaTa faqtorebi da

fsiqosocialuri stresorebi.

2. sargeblebi (Gains)

avadmyofis rolSi yofnas mohyveba bevri upiratesoba (privilegiebi

– Primdore et al. 2004). zogierTi maTgani aris aSkara – rogoricaa

invalidobis pensia an ganTavisufleba samxedro valdebulebisagan.

sxva SemTxvevaSi sargebeli naklebad naTelia, magaliTad, mSoblis an

meuRlis pasuxismgeblobidan Tavis arideba. avadmyofoba aZlevs

subieqts imis racionalur axsnas, Tu ratom ver funqcionirebs igi

ise warmatebulad, rogorc surda. sargebeli, rogorc avadmyofis

roli xels uwyobs somatizaciis mudmivobas (Barsky 1999).

3. komunikaciis saSualeba

Tu pirovnebas gaaCnia siZneleebi azrebisa an grZnobebis pirdapiri

gamoxatvisas, an isini socialurad miuRebelni arian, man SeiZleba

komunikaciisaTvis gamoiyenos somaturi simptomebi.

4. aleqsiTimia (Alexithymia)

aleqsiTimiur adamians ar Seswevs unari gamoiyenos sityvebi

emociebis gamosaxatavad. axlaxans, prospeqtiuli kvlevis Sedegad

iqna naCvenebi, rom aleqsiTimia (obieqturad verificirebuli

toronto aleqsitimia skalis meSveobiT) axasiaTebs araepilefsiuri

gulyrebis mqone pacientebis 90.5% da epilefsiis mqone pacientTa

76.2%, rac sagrZnoblad metia kontrolTan SedarebiT, Tumca igi ar

warmoadgens sasurvel instruments pacientTa am ori jgufis

diferencirebisaTvis (Bewley et al., 2005). aleqsiTimiis mxolod erTi

ganzomileba (SegrZnebebis identifikaciis siZneleebi) aris

statistikurad sarwmuno prediqtori didi raodenobis

somatizirebuli simptomebis mdgradobisa (De Gucht et al. 2004).

5. sistemis problemebis gadawyveta (Solution to Systems Problems)

40

zogjer simptomebs SeuZlia iTamaSos socialuri sistemis

mastabilizebeli roli. es xSirad vlindeba maSin, rodesac ojaxis

(sistemis) ufrosi ganicdis emociur problemas, romlis

gamomJRavneba daarRvevs mis statuss am sistemaSi. amitomac, bavSvs

somaturi CivilebiT efeqturad gadaaqvs ojaxuri yuradReba sxva

mimarTulebiT.

6. fsiqikuri diagnozis stigmatizacia

stigma socialur konteqstSi warmoadgens individis niSnebs an

Tvisebebs, romliTac igi gamoiyofa sazogadoebisagan da Sedegad

gaufasurdeba masSi. dasavlur sazogadoebaSi fsiqikuri aSlilobani

jer kidev warmoadgens stigmas, vinaidan rogorc sazogadoeba

negatiurad aris ganwyobili pacientebisadmi (Crisp et al. 2000), aseve

Tavad avadmyofebic, diskriminaciis ararsebobis pirobebSic ki,

subieqturad aRiqvamen stigmas (Dinos et al. 2004). aseTi damokidebuleba

gamoxatulia nevrozebs (an isterias) mikuTvnebul diagnozebis mqone

pacientebis mimarTac. pacientebi qronikuli daRlilobis sindromiT

aseve aRiqvaven mas, radgan sxvebi eWvis TvaliT uyureben pacientis

mier gadmocemuli simptomebis WeSmaritebas da akuratulobas,

cdiloben klinikuri niSnebis gamovlena daukavSiron moralsa da

xasiaTs da aqedan gamomdinare, ganixilaven, rogorc fsiqologiurad

gamowveul emociur darRvevas (Looper and Kirmayer 2004). amitomac

pacientebs urCevniaT yuradReba gadaitanon somatur simptomebze,

rogorc avadmyofis rolis mopovebis socialurad misaReb gzaze,

vidre es roli daukavSiron raime mainvalidebel da fsiqiatriul

daavadebas.

7. ekonomiuri sakiTxebi

kerZo da saxelmwifoebrivi sadazRvevo programebi xSirad

anazRaureben fsiqiatriul da somatur daavadebebs sxvadasxva

ganfasebiT. am ekonomiuri Tvalsazrisidan gamomdinare pacientisTvis

41

sarfiania (benefit) gansxvavebulad ganixilos avadmyofoba da mas

uwodos somaturi, da ara fsiqikuri.

mravali fsiqologiuri faqtori iqna SemoTavazebuli, rogorc

etiologiuri procesis nawili, magram, cotaa monacemebi, romelic

erTmniSvnelovnad miuTiTebdes maT WeSmarit CarTvaze. Teoriulad,

konversiuli reaqciis Camoyalibeba xels uwyobs SfoTvis Semcirebas

(a), vinaidan aracnobieri intrafsiqikuri konfliqti (ganutvirTavi

fsiqikuri energia) gardaiqmneba somatur simptomSi (b), rac am

konfliqtis simbolur niSans atarebs (c). magaliTad, daTrgunuli

risxva gardaiqmneba im kiduris damblad, romelic gamoiyeneba

dartymis gansaxorcieleblad. es sami debuleba safuZvlad udevs

konversiuli aSlilobis fsiqodinamiur models. fsiqologiuri

stresis moqceva cnobierebis miRma konversiuli simptomis

CamoyalibebiT da SfoTvis Semcireba warmoadgens moSlilobis

pirvelad sargebels (primary gain). es intrafsiqikuri dacviTi

meqanizmia, riTac aRdgeba fsiqologiuri wonasworoba, Tumca

garkveuli safasuris xarjze. radgan es procesi warmoiSoba

aracnobierad, pacienti aRiqvams Camoyalibebul somatur Civilebs,

rogorc usiamovno da moulodnel darRvevebs. pacients sjera da

aRiqvams Tavis Tavs, rogorc daavadebiT Sepyrobils. somatizaciis

mqone pacienti ver acnobierebs im fsiqologiur distress, romelmac

dasabami misca simptomebis gamovlenas.

magram pirebi aqtualuri konversiuli simptomiT fsiqologiuri

testirebisas mainc xSirad avlenen SfoTvas (Lader & Sartorius 1968; Meares

and Horvath 1972; Gigineishvili et al. 1997). simbolizmic, romelic iSviaTi

movlenaa, arcTu ise martivi dasadgenia, radgan igi zedmetad

subieqturad fasdeba.

sxva aracnobieri mizani, romelsac emsaxureba konversiuli simptomi,

aris avadmyofis rolis miTviseba (assuming the sick role), rac gamoixateba

42

gansakuTrebuli damokidebulebis moTxovniT da garSemo myofebze

pasuxismgeblobis gadataniT.

kendelma (Kendell, ixileT Ron 1996) ivarauda, rom pacientma SeiZleba

moirgos avadmyofis roli, rodesac cxovrebis moTxovnileba misTvis

Zalian damamZimebelia. zogierTisTvis avadmyofis roli mxolod

gansakuTrebul viTarebaSi aris momxibvleli (jarSi samsaxuri

omianobis dros), Tumca umravlesi maTganisTvis, vinc klinikaSi

gvxvdeba, Znelia gaumklavdes (daZlios) cxovrebis normalur

moTxovnilebas, SezRuduli emociuri sferos maragis gamo, an

garSemo myofTagan im yuradRebisa da mzrunvelobis naklebobis gamo,

rasac iRebs avadmyofobis dros. es meorad sargebels warmoadgens

(secondary gain). am SemTxvevaSi individs aSliloba aZlevs saSualebas

Tavi aaridos misTvis arasasiamovno da muqaris momtan viTarebas, an

moipovos sxva SemTxvevaSi miuwvdomeli daxmareba. bavSvebSi

konversiulma simptomma SeiZleba gamoiwvios momatebuli yuradReba

mSoblebis an sxva momvlelebisagan, riTac, Tavis mxriv, SenarCundeba

bavSvis qceva. magram es Tviseba axasiaTebT agreTve im pirebs,

romlebic somaturi daavadebebiT arian Sepyrobili (Martin and Yutzy

1996). raskinis (Raskin et al. 1966) kvlevis Tanaxmad, meoradi sargebeli

iqna gamovlenili konversiuli aSlilobis mqone pacientebis 86%-Si

da organuli daavadebis mqone pacientebis 22%-Si. es miuTiTebs am

kriteriumis arauniversalobaze konversiuli aSlilobis

diagnostikaSi.

meoradi sargebeli konversiuli aSlilobis dros unda ganvasxvaoT

avadmyofis rolis miTvisebis pirveladi miznisagan, rac axasiaTebs

xelovnurad demonstrirebul aSlilobas, da meoradi sargeblisagan

simulaciisas. konversiuli aSlilobis simptomebi aris meoradi

mexsierebis da afeqtis represiis an disociaciis mimarT. garkveul

afeqtTan dakavSirebuli tkivilis SegrZnebis nacvlad,

fsevdonevrologiuri simptomebi mxars uWers afeqtis gancalkevebas

43

(disociacias) mexsierebisagan. meqanizmi, romliTac warmoiSoba

simptomebi, romelsac ganicdis pacienti, aris misi cnobieri

kontrolis miRma, ris gamoc igi Tavad aris sakuTari simptomebis

msxverpli.

xelovnurad demonstrirebuli aSlilobis dros simptomebi

Segnebulad aris warmoSobili im mizniT, rom individma Caiyenos Tavi

avadmyofis rolSi. simulaciisas simptomebi aseve Segnebulad aris

warmoSobili mxolod pirdapiri ganZraxviT raime garegani miznis

mosapoveblad, magaliTad samuSaos, samxedro valdebulebisa an

sasjelis gadaxdis acilebis an finansuri kompensaciis xelSi

Cagdebis mizniT.

sxva faqtorebic, Tumca SesaZloa arapirdapir, ganawyobs

konversiuli aSlilobisadmi. pacientebs konversiuli simptomebiT

axasiaTebT qaoturi ojaxuri da samsaxurebrivi situaciebi.

gadatanili an amJamindeli nevrologiuri darRvevebi xels uwyoben

‘modelirebas’, rodesac konversiuli simptomi emsgavseba im

nevrologiur simptoms, romelic iyo nanaxi axlobelSi an

gadatanili hqonda Tavad pacients. nevrologiuri daavadebis

damsgavsebis siRrmes ganapirobebs avadmyofis samedicino codnis

done.

konversiuli aSlilobisa da personologiuri darRvevebis

urTierTobaze ar aris erTiani Tvalsazrisi. rigi avtorebisa (Martin

& Yutzy 1996; Betts 1997) aRniSnaven, rom xSirad saxezea winaT arsebuli

personologiuri darRvevebi, kerZod, isteriuli personologiuri

darRveva (histrionic personality disorder), rasac avtorebis azriT, Tavisi

wvlili Seaqvs konversiuli aSlilobis CamoyalibebaSi.

literaturuli analizis Catarebis safuZvelze marsdeni (Marsden 1986)

askvnis, rom “isini, vinc avlenen isteriul simptomebs an konversiul

aSlilobas, Cveulebriv ar arian isteriuli (Teatraluri)

pirovnebebi”, radgan marto 20% avlens aRniSnul personologiur

44

darRvevas, sxvebi ki an arian obsesiuri (anankasturi), an pasiuri

(damoukidebelni), an darCenil did procents ar gaaCnia

personologiuri darRvevebi. lempertisa da Smidtis (Lempert and

Schmidt 1990) gamokvlevis Tanaxmad isteriuli personologiuri

darRvevis niSnebis gavrceleba konversiuli aSlilobis mqone

pacientebSi aris marto 8%. konversiuli aSlilobiT Sebyrobili

pacientTa didi nawili aRniSnavs seqsualuri da fizikuri Zaladobis

istorias (Martin and Yutzy 1996; Roelofs et al. 2002).

klinikuri gamovlena

fsiqogenuri nevrologiuri simptomebis klinikuri gamovlena

mravalferovania, igi SeiZleba iyos nervuli sistemis praqtikulad

nebismieri organuli dazianebis imitatori. literaluruli

monacemebze dayrdnobiT nevrologiur klinikaSi moTavsebul

pacientebs Soris konversiuli simptomebis sixSire iyo Semdegnairi

(absolutur maCveneblebSi):

tabula #11. fsiqogenuri simptomebi pacientebSi nervuli sistemis

disfunqciiT (absoluturi maCveneblebi)

simptomi Marsden (1986) Lempert et al. (1990)

parezi

mono-

hemi-

12 79

31

20

ataqsia

astazia/abazia

6 66

52

anesTezia 5 81

paresTezia 83

gulyra 11 81

45

amnezia 4 2

sibrmave 5 6

tkivili/cefalgia 5/? 89/61

Tavbrusxveva 85

disfagia 4

gulisreva 4

dizarTria 9

fsevdonevrologiuri simptomebi warmoadgenen ass-ebis sagrZnob da

mniSvnelovan wils, radgan isini warmoadgenen isteriisa da Semdgom

‘brikes sindromis’ klinikuri gamovlenis mtavar birTvs (kerZod,

Sarkos mier wodebuli isteroepilefsia [Gates et al., 1991; Martin & Yutzy,

1999]). DSM-IV-is (1994) somatizirebuli aSlilobis sadiagnostiko

kriteriumebSi moyvanili 33 simptomTa saerTo nusxidan isini

warmoadgenen 13 simptoms (39.4%, ixile tabula #4 da 11) da

dasavleTis qveynebSi jandacvis pirvelad rgolSi metad

gavrcelebuli diagnostikuri intervius (CIDI; Robins et al., 1998; Interian et

al., 2004) 41 somatizirebul simptomTa Soris - Txutmets (tab #12). am

simptomta mniSvnelobas adasturebs axlaxans Catarebuli kvleva,

sadac pirveladi jandacvis qselSi ass-ebis mqone pacientebs Soris

oTxi an meti fsevdonevrologiur somtomi gamovlinda praqtikulad

SemTxvevebis naxevarSi (46.22%, Interian et al., 2004).

tabula #12. fsevdonevrologiuri simptomTa nusxa CIDI-s

somatizirebul modulSi da somatizirebuli aSlilobis

diagnostikur kriteriumebSi (DSM-IV-is Tanaxmad)

somatizirebuli aSlilobis

DSM-IV diagnostikuri

kroteriumebi

pirvelad jandacvis

gamokiTxvis

saerTaSoriso sqema

CIDI

46

1 koordinaciisa da

wonasworobis darRveva

wonasworobis darRveva

2 dambla an lokaluri sisuste dambla

3 ylapvis gaZneleba an yelSi

gaCxirva

yelSi gaCxirva da

ylapvis gaZneleba

4 afonia xmis dakargva

5 Sardis Sekaveba -

6 halucinaciebi -

7 tkivili an Sexebis SegrZnebis

dakargva

fexSi an xelSi

SegrZnebis dakargva

8 gaoreba gaoreba

9 sibrmave sibrmave

10 siyrue siyrue

11 gulyra gulyra/konvulsiebi

12 amnezia amnezia

13 gulis wasvlisgan

gansxvavevbuli gonebis

dakargva

gonebis dakargvis sxva

formebi

14 - mxedvelobis dabindva

15 - gulis wasvla

16 - sisuste

17 - dabuJebisa da

Cxvletis SegrZneba

im 16 pacients Soris, romlebsac 2000 wels ssnni-s klinikuri

nevrologiis ganyofilebaSi moTavsebul saerTo ricxvidan (298)

daudgindaT fsiqologiuri aSlilobis diagnozi, fsiqogenuri

simptomebis sixSire iyo Semdegnairi:

47

tabula #13. fsiqogenuri simptomebi (sakuTari gamokvlevis Sedegebi)

simptomi sixSire simptomi sixSire

Tavis tkivili/sxva tkivili 9/2 oflianoba 5

guliscema 9 dabuJeba 4

gulis wasvla/gonebis

dakargva

3/7 Rebineba 3

paroqsizmebi/konvulsiuri 10/7 sibrmave 2

sunTqvis gaZneleba 7 anesTezia 2

JrJolva/kankali 6 sisuste

kidurebSi

2

diskomforti gulmkerdis

areSi

6 amnezia 1

gulisreva 6 daRliloba 1

savaraudoa, rom zemomoyvanili kvlevebis Sedegebis sxvadasxvaoba

Cven monacemebTan ganpirobebulia ara imiT, rom gansxvavebuli

fsiqologiuri darRvevebi iyo ganxiluli aRniSnul SromebSi,

aramed, savaraudod, eTnikuri da kulturaluri Sexedulebebis

TaviseburebobiT avadmyofobaze da mis sasignalo rolze

sazogadoebaSi. kulturalur faqtoris zemoqmedebis Sedegad

yalibdeba rogorc daavadebis klinikuri warmoCena, aseve

fsiqologiuri daZlevis meqanizmebi da menejmentis (movlisa da

mkurnalobis) misaRebi saxeoba.

Tuki gaviTvaliswinebT mosazrebas, rom konversiuli simptomi

personis gare samyarosTan komunikaciis saSualebas warmoadgens,

maSasadame, igi usaTuod Seicavs im eTnikuri jgufis warmodgenebs da

msoflmxedvelobas garkveul sistemaze, rasac Cvens konkretul

SemTxvevaSi ‘janmrTeloba da daavadeba’ hqvia. saqarTveloSi

mcxovrebi populaciisaTvis (rogorc tradiciuli qristianuli

dualisturi filosofiis mimdevrebisaTvis) Tavi da guli miCneulia

48

kargad yofnis (sulieri da fizikuri stabilurobis) umTavres

garantad, amitomac fsiqologiuri stresis faqtorebiT

ganpirobebuli darRveuli somatika uxSiresad warmodgeba am

organoTa sistemebis CivilebiT. magram igive unda vlindebodes

dasavluri samyaros sxva eTnikur kulturebSic. am SemTxvevaSi,

mxedvelobaSi misaRebia personologiuri Tvisebebi: moTxovnaTa

maqsimalizms da samxreTul temperaments win gamoaqvs yvelaze ‘mZime’

Civilebi, romlebic sxva, metad konservatiul garemoSi konversiuli

Civilebis qronikuli mimdinareobisas mogvianebiT gamoaSkaravdeba.

amiT unda aixsnes daZabulobis tipis Tavis tkivilis maRali sixSire

somatizaciuri Civilebis Soris Cveni populaciis gansakuTrebiT

dasavlur nawilis warmomadgenlebSi maSinac ki, rodesac

somatizaciis speqtrSi ar dominirebs somatoformuli tkivilis

aSliloba (F45.4).

konversiuli aSlilobis diagnozs (ICD-10-s kriteriumebis Tanaxmad)

akmayofilebda 9 pacienti (3.1%; 4 qali da 5 mamakaci), rac garkveulad

ufro maRali maCvenebelia, vidre es britanel specialistebs

londonis nevrologiis da fsiqiatriis institutebidan mohyavT

Sesabamisad (0.85%-1.55%; 1%, Marsden, 1986). magram es SeiZleba aixsnas

konversiuli Setevebis (rogorc krunCxviTi aseve arakrunCxviTi)

erTobliobaSi ganxilva sxva konversiuli niSnebis mqone

pacientebTan. aRniSvnis Rirsia, rom paroqsizmebis mqone pacientebis

naxevari (5) iqna moTavsebuli Cvens klinikaSi saswrafo daxmarebis

brigadis mier.

konversiuli xasiaTis mgrZnobelobisa (sensoruli) da moZraobis

(motoruli) moSlas bevri ram ganasxvavebs nervuli sistemis

organuli dazianebisagan. pirvel rigSi es gansxvaveba efuZneba im

garemoebas, rom funqciuri darRvevisas simptomebi Seesabameba

pacientis warmodgenas sxeulis nawilis funqciis moSlaze da ara

anatomiurad ganpirobebul organuli dazianebis paterns.

49

konversiuli motoruli deficitis mqone pacients aReniSneba

normaluri refleqsebi, uxSiresad normaluri kunTTa tonusi da

negatiuri babinskis niSani. pacientis qcevaze xangrZlivi

dakvirvebisas an sxva Temaze misi yuradRebis gadatanisas aRiniSneba

‘paretuli’ kunTis Zalis cvalebadoba an droebiTi aRdgena. am

pozitiur niSnebTan erTad ganixileba sxvadasxva testebi, romelic

organuli daavadebis ararsebobis paralelurad exmareba mkvlevars

gamoavlinos nevrologiuri simptomis funqciuri xasiaTi

(gigineiSvili, 2005). qvemoT moyvanilia testebis is nawili, romelic

Cveni dakvirvebiT metad gamosadegia klinikur viTarebaSi.

92% senzitiuroba gamoavlina mkerd-laviw-dvriliseburi kunTis

testma, sxva testebis senzitiuroba meryeobda 85-90%-is farglebSi.

magram yoveli testi dakavSirebulia sxeulis kerZo nawilis

(kiduris an kunTis) nevrologiur funqcionirebasTan, rac

konversiuli darRvevebis mravalferovnebis pirobebSi SeiZleba arc

ki iyos warmodgenili konkretul SemTxvevaSi. es miuTiTebs imaze,

rom konversiis dros testebi ar aris universaluri, isini mxolod

konversiis konkretul gamovlinebisaTvis aris gamosadegi.

zemoaRniSnuli testebis garkveuli sisuste mdgomareobs aseve imaSi,

rom maT ar gaaCniaT maRali validoba, anu msgavsi pozitiuri Sedegi

mosalodnelia aseve sxva viTarebebSi (SezRudva tkiviliT, organuli

da funqciuri sisustis kombinireba, simulacia an pacientis

gadametebuli mzadyofna daexmaros eqims da a.S.), rodesac pacients

namdvilad ara aqvs konversiuli motoruli deficiti. amitomac

funqciuri deficitis arsebobis yovelgvari eWvi unda ganixilos

erTobliobaSi anamnezur monacemebTan, daavadebis istoriasTan da

sxva garemo faqtorebTan (kerZod, daavadebis modelis arseboba mis

garemocvaSi da a.S.).

50

tabula #14. funqciuri nevrologiuri deficitis gamosavleni

testebis aRweriloba

testi funqciuri dazianeba organuli dazianeba

mkerd-laviw-

dvriliseburi

kunTis

sisuste Tavis

motrialebisas

hemiparetul mxares

sisuste Tavis

motrialebisas

hemiparezis

sapirispiro mxares

‘huveris’ qveda

kiduris

paretuli fexis quslis

zewolis gansxvaveba

mkvlevaris xelze

nebiTi (barZayis

gamarTva) da uneblie

(meore fexis aweva masze

gaweuli winaaRmdegobis

fonze) gaSlis dros

paretuli fexis

quslis zewolis

gansxvavebis

ararseboba

mkvlevaris xelze

nebiTi da uneblie

gaSlis dros

monoplegiuri

fexis Treva

pacienti fexs erTianad

iTrevs ukan, barZayis

rotacia an koWis

Setrialeba/

amotrialeba. sawolze

dawolisas

dasaxmareblad iyenebs

orive xels

spastikuri siaruli:

barZayisa da muxlis

gaSla, kiduris

cirkumduqcia da

terfis plantaruli

moxra da Setrialeba

TiTebis TreviT

iatakze

sensoruli

hemiparezi

mgrZnobelobis moSla

zustad Sua xazze,

irTavs xolme yvela

modalobas

genitaliebze da

mkerdze naklebad

mosalodnelia Sua

xazze, aramed

paramedialurad 1-2

sm SigniT

51

konversiuli simptomebi SeiZleba iyos rogorc sensoruli, aseve

motoruli. maT miekuTvneba umTavresi simptomebi, rogoricaa – damla

da lokaluri sisuste (romelic SeiZleba gadaizardos

kontraqturaSi), afonia, astazia-abazia, krunCxvebi, sibrmave da

sxeulis an kiduris anestezia (an kidev hipesTezia an paresTezia).

arc ise didi xnis win moZraobebis moSlaTa mTeli gama (tremori,

tortikolizi, saxis diskinezia, blefarospazmi da tikebi) iTvleboda

isteriul gamovlenad. Tumca dResdReobiT umetesoba maTgans

gamokveTili organuli mizezi gaaCnia (Merskey 1995). Crdiloamerikeli

kvlevarebi (Guggenheim 2000, Merskey 1995, DSM-IV) agreTve gamoyofen

visceralur formas da halucinaciebs. pirvelSi Sedis fsiqogenuri

gulisreva, Sardvis Sekaveba, faRaraTi, crufexmZimoba da yelSi

gaCxirvis SegrZneba.

Tavisi sixSiridan da klinikuri simZimidan gamomdinare

fsiqogenuri Setevebi aris Cveni kvlevis gansakuTrebuli yuradRebis

fokusSi.

52

3. fsiqogenuri araepilefsiuri gulyrebi

‘araepilefsiuri Setevebi’ (aS) gulisxmobs iseT qcevas, romelic

epilefsiuri gulyris msgavsia, magram, romelsac safuZvlad ar udevs

Tavis tvinis ruxi nivTierebis gadametebuli gantvirTva, ris gamoc

eeg-ze ar vlindeba epilefsiuri gulyrisTvis damaxasiaTebeli

cvlilebebi. aS-ebis diagnostika warmoadgens erT-erT urTules

amocanas nevrologiaSi, razedac Tundac is faqti miuTiTebs, rom

rezistentuli epilefsiis mqone pacientebSi aS-ebis wili meryeobs

12.8-dan 20%-de (Gates et al., 1985; Guberman & Bruni, 1999; Smith et al., 1999).

epilefsiuri gulyrebis mravalferovnebis gamo maTi imitatorebad

daavadebebis Zalze farTo speqtri wardgeba. aS-s mizezi SeiZleba

iyos organuli daavadeba an emociuri darRveva. fiziologiur

(organul) mizezda jgufs miekuTvneba sxvadasxva somaturi

daavadebebi, magaliTad nevrologiuri: tranzitoruli iSemiuri

Seteva, moZraobebis mravalgvari paroqsizmaluri darRvevebi;

kardiologiuri: sinkope, mitraluri klapanis prolafsi;

endokrinuli, Zilis darRvevebi da sxva. magram Tuki aS-s safuZvlad

udevs fsiqologiuri xasiaTis darRvevebi, maT fsiqogenur jgufs

miakuTvnian.

araepilefsiur qceviT paroqsizmebs literaturaSi sxvadasxvanairad

moixsenieben. magaliTad, rogorc fsevdogulyrebs (pseudoseizures),

fsevdepilefsiur gulyrebs (pseudoepileptic), istero-epilefsias (hystero-

epilepsy), isteriul Setevebs (hysterical seizures), araepilefsiur gulyrebs

(non-epileptic seizures) da fsiqogenur Setevebs (psychogenic seizures). maT

Soris yvelaze popularuli ‘fsevdogulyrebi’ da ‘fsiqogenuri

gulyrebi’ ver asaxaven problemis arss. fsevdo ar gamodgeba,

vinaidan Seicavs xelovnurobis (falsifikaciis) elements da Tan

ayenebs epilefsiis cnebas erTgvar diagnostikur kvarcxlbekze. arc

fsiqogenuri gulyra aris koreqtuli termini, radgan igi ufro

53

miesadageba im epilefsiur gulyrebs, romelic gamowveulia emociuri

gancdiT (Fenwick 1991). paroqsizmebis mTeli speqtris aRsaniSnavad

termini araepilefsiuri Setevebi migvaCnia yvelaze marTebulad, da

fsiqologiuri meqanizmebiT ganpirobebulebisTvis ki – fsiqogenuri

araepilefsiuri Setevebi (faS).

diagnostika

tradiciulad aS-s diagnostika efuZneba epilefsiis gamoricxvis

meTods, anu Seicavs gamokvlevis yvela im etapebs, rac aucilebelia

epilefsiis gamosavlenad (Porter 1993; Bortz 1998; Francis & Baker 1999; Kuyk et

al. 1999). isini Semdegia: nevrologiuri gamokvleva da daavadebis

srulyofili anamnezis Sekreba, daavadebis ojaxuri istoriisa da

bavSvobaSi gadatanili daavadebebis gamovlena, Setevis semiologia,

prolaqtinis gansazRvra SratSi, eleqtrofiziologiuri meTodebi

(rutinuli da ambulatoriuli 24 saaTiani eleqtroencefalografia,

video-monitoringi, Setevis xelovnurad gamowveva), fsiqologiuri

testireba da neiroradiologiuri gamokvleva (struqturuli da

funqciuri bmr gamosaxva), antiepilefsiuri Terapiis efeqturoba.

yuradReba eniWeba klinikuri niSnebis erTobas da ara calkeul

niSans. imavdroulad unda gvaxsovdes, rom pacientis Setevaze

dakvirveba (an gawrTvnili samedicino personalis mier an

specializirebuli video aparaturiT Sesrulebuli Canaweris

meSveobiT) misi fenomenologiis (klinikuri niSnebis) gamosavlenad

warmoadgens aucilebel da meTodologiurad gamarTlebul nabijs

epilefsiuri gulyrebisa da sxva paroqsizmuli qceviTi darRvevebis

diferenciaSi. aseT SemTxvevaSi unda viyoT darwmunebuli, rom

dakvirvebis qveS moqceuli calkeuli qceviTi paroqsizmi aris

damaxasiaTebeli avadmyofisaTvis, anu ‘tipuri’ misTvis. radgan

epilefsiis mqone pacients SeiZleba Semdgom ganuviTardes faS,

54

amitomac mxolod am ukanasknelis gamovlena jer kidev ar

gamoricxavs epilefsiis arsebobas.

mravali maCveneblebidan, romelic Seicaven informacias pacientze,

garkveul interess aS-sa da epilefsiis diferenciaSi warmoadgens

Semdegi:

a) paroqsizmebis dawyebis asaki, b) garemoebani, romlebSic viTardeba

paroqsizmi, g) Setevis semiologia, d) daqvemdebareba medikamentozur

Terapiaze, e) daavadebis istoria, v) diagnostikuri testebi.

a) paroqsizmebis dawyebis asaki

epilefsiur gulyrebTan SedarebiT aS-ebi klinikurad

manifestirdeba gvian asakSi. am dakvirvebas adasturebs bolo 15 wlis

manZilze Sesrulebuli yvela is kvleva, romelic mieZRvna aS-ebs

(Kuyk et al. 1997; Cragar et al. 2002). es gansxvaveba Setevebis dawyebis

saSualo asakSi TvalsaCino iyo maSinac, rodesac Sereuli jgufi

(epilefsiuri da faS erTdroulad) Seadares mxolod aS-is mqone

pacientebis jgufTan. Tuki pirvel SemTxvevaSi Setevebi iwyeboda 15

wlamde, meoreSi – gamovlenis asaki aRemateboda 20 wels (Özkara &

Dreifus 1995; De Timary et al. 2002; Galimberti et al. 2003).

b) garemoebani, romlebSic viTardeba paroqsizmi

emociuri da fizikuri travma warmoadgenen rogorc epilefsiuri,

aseve fsiqogenuri araepilefsiuri Setevebis precifitatorebs (Lesser

& Krauss 1993). miuxedavad am sakiTxisadmi garkveuli sawinaaRmdego

mosazrebebis arsebobisa, axlaxan Catarebulma kvlevebma faS-is mqone

pacientebSi rezistentuli epilefsiiT daavadebulebTan SedarebiT

gamokiTxvis Sedegad gamoavlina stresis gamomwvevi movlenebis da

maTi gavlenis sagrZnoblad maRali done (Tojek et al. 2000; Fleisher et al.

2002). isic gasaTvaliswinebelia, rom mkafio aqtualuri konfliqtisa

an stresoris ararseboba ar uaryofs faS-is arsebobas, radgan

ukanaskneli SeiZleba iyos precipitirebuli droSi daSorebuli (anu

55

bavSvobaSi gadatanili) stresis gamomwvevi movleniT (Bowman &

Markand 1996).

g) Setevis semiologia

araepilefsiuri (isteriuli) Setevebis klinikuri gamovlinebebi

didi xania aris klinicistebis yuradRebis sagani. mniSvnelovani

wvlili am sakiTxis SeswavlaSi da detaluri aRwerilobis

warmodgenaSi Seitanes rogorc frangma medikosebma – brike (1859) da

Sarkom (1879), aseve ingliselma nevrologma gouersma (William R. Gowers,

1881) (Sackellares & Kalogjera-Sackellares, 2002). wina saukunis 70-ani wlebidan

uamravi naSromi mieZRvna araepolefsiuri Setevebis klinikuri

niSnebis aRwerilobas da maTi diagnostikuri mniSvnelobis Sefasebas

(Gates et al. 1985; Kloster 1993; Lesser 1996; Francis & Baker 1999; Kanner & Parra 2000;

Browne & Holmes 2000; Huffman & Stern 2003).

miuxedavad literaturaSi yuradRebis gamaxvilebisa ama Tu im

klinikuri niSnis faseulobaze, ar aris arc erTi calkeuli niSani,

romelic sarwmunod ganasxvavebdes araepilefsiur da epilefsiur

Setevebs. tabula #15-Si mocemulia pirobiTi ganmasxvavebeli

klinikuri maxasiaTeblebi. magram, unda gvaxsovdes, rom iseTi

mkafiod ‘epilefsiuri’ Tvisebebi, rogoricaa Seukavloba,

postiqtaluri konfuzia, aura (Setevis dawyebis winaTgrZnoba) da

paroqsizmis maprovocirebeli faqtoris arseboba (fsiqologiuri an

fizikuri travma), aseve axasiaTebT aS-ebs, amitomac, isini ver

gamodgebian ganmasxvavebel (sadiferencio) markerad (Özkara and Dreifuss

1995; Gates et al. 1985).

56

tabula #15. krunCxviTi tipis epilefsiuri da araepilefsiuri

Setevebis damaxasiaTebeli niSnebi

niSani krunCxviTi

epilefsiuri

gulyra

krunCxviTi aS

dawyeba swrafi TandaTanobiTi an

swrafi

damTavreba* TandaTanobiTi

(SetevisSemdgomi

konfuzia an

Zilianoba)

swrafi

xangrZlivoba* xanmokle (2 wuTze

naklebi)

SedarebiT

xangrZlivi

TviT dazianebebi xSiri iSviaTi

enis mokvneta,

Seukavebloba

xSiri SeiZleba iyos

Tvalebi* Ria aziduli zeviT,

daketili (zogjer

naZaladevad)

kidurebis

moZraoba

sinqronuli

tonur-klonuri (in-

phase)

arasinqronuli (out

of phase)

mcire menjis

moZraoba*

ukan (retrothsusting) win (forward thrusting)

rigidoba mTeli sxeulis vlindeba iSviaTad

Tavis moZraoba unilateraluri erTi mxridan

meore mxares an

fleqsia

pacientis

kontroli

ar reagirebs

stimulze

SeiZleba miviRoT

pasuxi an

57

SevwyvitoT Seteva

cnobiereba daTrgunvili xSirad Senaxuli

Setevis gaxseneba nawilobriv

SesaZlebeli an

SeuZlebeli

gulgrili

damokidebuleba,

gamoxatuli

amnezia

tremori iSviaTi xSiri

gamomwvevi mizezi iSviaTad vlindeba vlindeba umetes

SemTxvevaSi

(stresi)

motivacia meoradi sargebeli

rogorc wesi ar

vlindeba

meoradi sargebeli

xSirad

gamovlindeba

*ganasxvavebs meti sarwmunoebiT

de timarisa da misi Tanaavtorebis mier (De Timary et al. 2002)

Catarebulma kvlevam gamoavlina, rom enis mokvneta, vardna da

Seukavebloba, rogorc epilefsiuri gulyrebis savaraudo specifiuri

niSnebi ar ganasxvavebdnen pacientTa jgufs mxolod aS-iT imaTgan,

visac Sereuli (epilefsiuri da araepilefsiuri) gulyrebi hqondaT.

aRniSnuli niSnebi iyo gamovlenili mxolod aS-is mqone pacientTa

66%-Si. metic, am niSnebis arseboba sarwmunod ayovnebda (aranakleb 5

wliT) swor diagnostikas am pacientebSi, anu axangrZlivebda dros

pirveli Setevidan koreqtuli diagnozis gamotanamde. miuxedavad

imisa, rom es klinikuri niSnebi miCneulia damatebiT argumentad

epilefsiis sasargeblod, isini arcTu ise iSviaTad vlindeba aS-is

dros (Chabolla et al. 1996).

klinikuri suraTidan (semiologia) gamomdinare aS SeiZleba daiyos

epilefsiuris msgavsad: krunCxviTi (konvulsiuri) da arakrunCxviTi.

58

ukanaskneli kidev SeiZleba daiyos 3 saxeobad: rTuli parcialuris,

atonuris da absansis msgavsi (Kanner & Parra, 2000). sxvagvari dayofa

SeiZleba motoruli aqtivobis gamovlenis safuZvelze: kolafsis

msgavsi (Zalagamoclili) Setevebi da pozitiuri motoruli niSnebis

mqone Setevebi (Meierkord et al. 1991; Kotagal et al. 2002; Reuber et al. 2003d). Betts

& Boden-ma (1991) warmoadgines emociuri Setevebis Tavisi originaluri

klasifikacia: atonuri (swoon), bavSvur-afeqturi (tantrum) da didi

krunCxviTi (abreactive). samive saxeobis saxelwodeba gamomdinareobs

garkveuli qceviTi paternebis msgavsebisagan, riTac avtorebma xazi

gausves faS-is Tundac klinikuri gamovlenis gansxvavebas

epilefsiisagan da metad TvalsaCinod daakavSires igi emociur

mdgomareobas. epilefsiuri gulyrebis klasifikaciisagan

gansxvavebuli maneriT dayofas gvTavazoben sxva mkvlevarebic,

romelic gamodian mkacrad klinikuri dakvirvebis monacemebidan (Leis

et al., 1992; Jedrzejczak et al., 1999; Abubakr et al., 2003) an faS-is klinikuri

niSnebis klasteruli analizidan (Gröppel et al., 2000).

arsebobs Tvalsazrisi, rom araepilefsiur SetevaTa Soris

dominirebs krunCxviTi tipi (Gulick et al. 1982; King et al. 1993; Bowman and

Markand 1996; Abubakr et al. 2003). ruberma da misma kolegebma (Reuber et al.

2003) 329 pacientis fsiqogenuri Setevebis analizis Sedegad

gamoavlines paroqsizmebis Semdegi sixSire: konvulsiebi dominirebda

61.1%-Si, tonuri Setevebi aRiniSna 23%-Si da Zalagamoclili da

sensoruli ki Sesabamisad 10% da 5.6%-Si.

faS-is klasificirebis mizniT, Cven gavaanalizeT masala, romelic

moicavda 2000-2001 wlebSi Cvens institutSi faS-is sarwmuno

diagnoziT gaweril yvela pacients. diagnozis gamotana xdeboda

orsafexurad (Gigineishvili 2005b). pirveli moicavda standartul

kliniko-laboratoriul kvleviT pakets, romelic gamoiyeneba

pacientSi epilefsiuri sindromis gamosavlenad. meore etapi

gulisxmobs epilefsiis sasargeblod uaryofiTi monacemebis

59

dagrovebisTanave da Setevebis araepilefsiuri bunebaze eWvis

gaCenisTanave neirofsiqiatris CarTvas, raTa pozitiuri niSnebis

safuZvelze gamovlindes fsiqogenuri paTologia, romelmac SeuZlia

axsnas paroqsizmebis (aseT SemTxvevaSi faS-is) arseboba. mentaluri

aSlilobebis diagnozi ismeboda ICD-10-is kriteriumebis Tanaxmad

(WHO, 1993). kvlevaSi moxvda mxolod is pacientebi, romlebis tipuri

paroqsizmebi iyo dokumentirebuli maTi uSualo naxviT an

epileftologis, an neirofsiqiatris an gamowrTvnili samedicino

personalis mier pacientis hospitalizaciis periodSi. Setevebis

semiologiuri suraTi dgeboda samedicino istoriaSi asaxuli

aRwerilobis, samedicino personalis garda sxva mowmeebis Cvenebis,

anamnezis detalurad Sekrebis Sejerebis safuZvelze. kvlevis mizani

iyo dagvedgina, iZleva Tu ara faS-is semiologiuri suraTi maTi

klasificirebis saSualebis sxva saxiT, vidre epilefsiuri

gulyrebia klasificirebuli (Commission on Classification and Terminology,

1981; Panayiotopoulos, 2002).

saboloo analizis qveS moeqca 17 pacienti, radgan kvlevaSi ar

moxvda is pacientebi, romelTa Setevbi ar iqna nanaxi (n=5), gaaCndaT

Tanaarsebuli epilefsia (n=2) an kidev dadasturebuli epilefsia

warsulSi (n=2).

Seswavlili jgufis udides nawils daudginda disociaciuri

(konversiuli) aSlilobis diagnozi (n=13), orSi gamovlinda

somatizirebuli aSliloba da amdenSive – posttravmuli stresuli

aSliloba. saSualo asaki iyo 27.1 (sd±10.35), da meryeobda 17-dan 47-de.

qalebi umniSvnelod dominirebdnen (aTi Svidis winaaRmdeg) da

saSualo asaki sqesis mixedviT erTmaneTisagan mniSvnelovnad ar

gansxvavdeboda (qalebSi 26.8 da mamakacebSi 27.4).

miRebuli monacemebis safuZvelze moxerxda faS-is klasificireba

oTx qvejgufSi klinikuri semiologiis niSniT. isini moyvanilia

tabula #16-Si.

60

tabula #16. Cvens mier gamoyofili faS-is klinikuri formebi

gulis wasvla

(fainting-like)

iwyeba vegetatiuri saxis CivilebiT: guliscema,

gulisreva, diskomforti gulmkerdis areSi, Semdeg

viTardeba tonusis moduneba, Cakecva, vardna

travmis gareSe, gare samyarosTan reagirebis

daTrgunva, minimaluri da iSviaTi motoruli

komponentebiT.

demonstraciuli

(demonstrative)

sunTqvis gaZneleba, guliscema, gulis areSi

arasasiamovno SegrZneba, JrJolva, kankali, kiduris

tonuri daWimuloba, cnobierebis variabeluri

daTrgunva (zedapirulidan Rrma stuporamde).

Tavisi motoruli gamovleniT igi ar aris

dramatuli

aforiaqebuli

(disruptive)

fsiqomotoruli agznebis msgavsi vegetatiuri

simptomatikiT (guliscema, oflianoba, sunTqvis

moSla), romelic gadaizrdeba aJitaciaSi da

agresiul motorul qcevaSi – kedelze muStebis

braxuniT, Tavis TavisTvis zianis miyenebiT,

rogorc wesi viTardeba woliT mdgomareobaSi

epilefsiuri

didi gulyris

magvari (Grand

mal-like)

sawyisi SeiZleba iyos guliscema, gulisreva,

Tavbrusxveva, sunTqvis moSla, Semdeg tonur-

klonuri, tonuri an klonuri krunCxvebi,

opistotonusiT (rkali), meanis xeliT, mcire menjis

biZgiTi moZraobebiT, reagirebis mkafio

daTrgunviT; viTardeba umeteswilad woliT

mdgomareobaSi

faS-is gamoyofili saxeobebi Semdegnairad iyvnen warmodgenili

gamokvleulTa srul kohortaSi:

61

tabula #17. faS-is saxeobebis gavrceleba

faS-is saxeobebi

yvela pacienti

(n=17)

mamakacebi

(n=7)

qalebi (n=10)

gulis wasvlis

magvari

29.4% 14.3% (1) 40% (4)

demonstraciuli 35.3% 57.1% (4) 20% (2)

aforiaqebuli 11.7% 14.3% (1) 10% (1)

didi gulyris

magvari

29.4% 14.3% (1) 40% (4)

zemomoyvanili klasifikacia didad esadageba sxva avtorebis mier

mowodebul faS-is dayofas (Betts & Boden 1991; Jedrzejczak et al., 1999;

Gröppel et al., 2000; Abubakr et al., 2003). absoluturi msgavseba ganovlinda

aramotoruli tipis (atonuri, Zalagamoclili, kolapsis an gulis

wasvlis magvari) Setevebis erT calkeul jgufad gamoyofaSi. Cvens

mier klasificirebuli aforiaqebuli Setevis saxeoba daemTxva

betsisa da bodenis mixedviT bavSvur-afeqturs (tantrum),

demonstratiuli ki – fsiqogenur mcire motoruls (cluster 2) gropelis

Tanaxmad da parcialuri gulyris magvars (group B) edrJerCakisa da

Tanaavtorebis mier SemoTavazebuls. yvela klasifikacia, Cvenis

CaTvliT erTiania didi gulyris (Grand mal-like) magvaris gamoyofaSi,

rac motoruli tipis faS-is yvelaze dramatul formas warmoadgens.

motoruli komponentebis mqone faS-is samive jgufi Cveni

klasificiis Tanaxmad asaxavs motoruli aqtivobis gamovlenis

dramatizms. SeiZleba iTqvas, rom demostraciuli tipis Seteva

warmoadgens aforiaqebuli saxeobis arasrulyofil (Sekvecil)

62

formas. saocaria, magram Cvens mier ganxorcielebulma faS-is

motoruli formebis dayofam (demonstraciuli, aforiaqebuli da

didi Setevebi) moicva sxva avtorebis mier aqamde gamoyofili yvela

saxeobis Setevebi.

SeiZleba iTqvas, rom qalebisaTvis metad damaxasiaTebelia ‘gulis

wasvlis’ da ‘didi gulyris’ msgavsi Setevebi, maSin rodesac

mamakacebisaTvis ki – ‘demonstraciuli’ tipis.

d) daqvemdebareba medikamentozur Terapiaze

Setevebis maRali sixSire antiepilefsiuri Terapiis miuxedavad

erT-erTi faqtoria, romelmac unda gamoiwvios eqimis safuZvliani

eWvi imaSi, rom xom ar aris arsebuli Setevebi araepilefsiuri

bunebis, magram unda gvaxsovdes, rom epilefsiis mqone populaciis

SedarebiT mcire raodenobaSi, Setevebis sruli kontroli aseve ver

xerxdeba da isini ganagrZoben xSiri Setevebis gancdas. 1997-1998

wlebSi epilefsiur centrSi diagnostirebuli aS-ebis kohortidan

momarTvianobis mizezi 20%-Si (n=7) iyo antiepilefsiuri Terapiis

uSedegoba pacientebSi rezistentuli epilefsiiT. es faqti mkafiod

miuTiTebs aS-is arsebobis ganxilvis aucileblobaze pacientebSi,

romelTa klinikur suraTSi rCeba gulyrebi mravalgvari

farmakologiuri Terapiis miuxedavad.

e) daavadebis istoria

mravali kvleva avlens aS-is mqone pacientebSi hospitalizaciis an

saswrafo daxmarebis gamoZaxebis xSir SemTxvevebs. metic, aRwerilia

aseve, fsiqogenuri araepilefsiuri Setevebis statusi (fsevdostatusi

– pseudostatus), romlis dros pacienti iyo intubirebuli (Levitan and

Bruni 1986; Howell et al. 1989; Pakalnis et al. 1991; Özkara & Dreifuss 1993). rogorc

wesi, maT ukan mJRavndeba konversiuli an sxva SfoTviTi aSliloba,

romelic precipitirebulia aqtualuri stresogenuli viTarebiT an

TviTdazianebis impulsuri mcdelobiT (Drake et al. 1992; Leis et al. 1992;

Rechlin et al. 1997; Gigineishvili 1999; Pakalnis et al. 2000). ruberisa da misi

63

kolegebis (Reuber et al. 2003b) mier gamokvleul faS-is mqone pacientTa

jgufis 27%-Si gamovlinda saswrafo daxmarebis mier intensiur

blokSi moTavseba fsiqogenuri statusis gamo da 38%-Si ki

ganmeorebiTi stacionirebis SemTxvevebi fsevdostatusis gamo. Cvens

mier Seswavlili 2000-2001 wlis faS-is kohortidan saswrafo

daxmarebis meSveobiT pacienti iqna hospitalizirebuli 8 SemTxvevaSi

(47%), iqedan erT SemTxvevaSi pacienti iqna intubirebuli, radgan

raionul saavadmyofoSi epilefsiur statusad miCneuli mdgomareoba

ver iqna daZleuli. 1997-1998 wlebis kohortaSi ki sam SemTxvevaSi

(8.6%) pacienti iqna gamogzavnili institutis epilefsiur centrSi

eWviT epilefsiur statusze.

Tumca Tvalsazrisi seqsualuri Zaladobis (sexual abuse) faqtis

mniSvnelobaze faS-is manifestaciaSi jer kidev saukuneebis win iyo

gamoTqmuli (Goodwin 1993), sistematuri kontrolirebadi kvlevebi

daiwyo wina saukunis 90-an wlebidan. betsma da bodenma (Betts & Boden

1992b) gamoavlines seqsualuri Zaladobis istoriis sagrZnoblad

meti maCveneblebi (70%-de) aS-is mqone qalebSi, kerZod, im pacientebSi,

visac Zalagamoclili (swoon) da simboluri (abreactive) Setevebi

axasiaTebdaT, vidre qalebSi epilefsiiT da sxva fsiqiatriuli

aSlilobebiT. magram betsi gvaxsenebs, rom epilefsiac, arcTu ise

iSviaTad, iwyeba stresuli precipitatoris gavleniT, da maT Soris

seqsualuri ZaladobiT (Betts & Duffy 1993), ris gamoc Zaladobis

faqtis arseboba ar niSnavs avtomaturad, rom pacients gaaCnia aS.

sxva avtorebi aRniSnaven rogorc seqsualuri, aseve fizikuri

Zaladobis (physical abuse) maRal sixSires (32.4-67%) fsiqogenuri

gulyrebis mqone pacientTa jgufSi, sadac Setevebi warmoadgendnen

fsiqiatriuli aSlilobebis (somatoformuli, disociaciuri da

SfoTviTi) klinikur suraTs (Alper et al. 1993; Bowman & Markand 1996;

Ettinger et al. 1999; Litwin & Cardeña 2000; Abubakr et al. 2003). miuxedavad xSiri

miTiTebisa, bavSvobaSi gadatanil seqsualuri da fizikuri

64

Zaladobis faqtebze pacientebSi aS-iT, ris gamoc isini moiazreba

rogorc aS-s risk faqtorebi, am stresul faqtorebsa da aS-s Soris

ar aris sworxazovani damokidebuleba, radgan zrdasrul asakSi

pacientebi avlenen fsiqopaTologiis mTel gamas, romelic moicavs

aseve depresias, posttravmul stresul aSlilobas da sxva SfoTviT

aSlilobebs (Francis & Baker 1999; Fiszman et al. 2004; LaFrance & Barry 2005). an

kidev isini urTierToben Suamavali faqtoris meSveobiT, rogorc

magaliTad SeiZleba iyos ojaxuri disfunqcia (Salmon et al. 2003).

Tavis farTo ganxilvaSi kregeri da misi kolegebi (Cragar et al. 2002)

askvnian, rom bavSvobaSi da axalgazrdobaSi gadatanili Zaladobis

istoriis saerTo maCvenebeli aris maRali faS-is dros (~75%), vidre

epilefsiis dros (~42%). aseve seqsualuri Zaladobis sabaziso done

aris ufro maRali faS-is mqone populaciaSi (~42%), vidre

epilefsiis mqone populaciaSi (~19%). magram arsebuli monacemebi ar

iTvaliswineben Sejerebas sqesze, arada, araepilefsiur populaciaSi

mdedrobiTi sqesi mkveTrad dominirebs da imavdroulad cnobilia,

rom seqsualuri Zaladobis ricxvi metia qalebSi, vidre mamakacebSi

(Oto et al., 2005), ris gamoc mdedrobiTi sqesi SeiZleba iyos ganxiluli

faS-is risk faqtoradac. gamoTqmulia mosazreba, rom faS-is siWarbe

qalebSi damokidebulia grZnobebis gamoxatvis genderul

gansxvavebaze (mamakacebSi metad SezRuduli) da bavSvobaSi

gadatanili seqsualuri da masTan dakavSirebuli fizikuri

Zaladobis sarZnoblad maRal maCvenebelze, romelsac aRniSnaven

pacientebi (Bowman and Markand 1999). amis gaTvaliswinebiT axlaxan

Catarda gamokvleva, sadac Sedarebuli iyo mxolod mdedrobiTi

sqesis pacientebis jgufebi. saerTo travmis, Zaladobis da

posttravmuli stresis maCveneblebi qalebSi faS-iT isev maRali iyo

kontrolTan, Tumca statistikurad arasarwmunod (Dikel et al. 2003).

araepilefsiuri Setevebi pacientebSi Zaladobis faqtebiT warsulSi

ganisazRvreba rogorc qronikuli posttravmuli stresuli

65

aSlilobis forma, romelic SeiZleba asaxavdes individis Tavis

daRwevas Zaladobis arasasiamovno gancdebidan (‘cutting off’ mechanism –

gaTiSvis meSveobiT) an warsulis gancdebis gadaTamaSeba (‘acting out’of a

flashback) dakavSirebuli travmatul movlenebTan (Betts & Duffy 1993; Betts,

1997). erTma kvlevam uCvena fizikuri da seqsualuri Zaladobis

kavSiri Semdgom ganviTarebul mxolod motoruli tipis faS-ebTan

(Abubakr et al., 2003), Tumca sxvebma gamoavlines rogorc kolaftoiduri

aseve did krunCxviTi araepilefsiuri Setevebi pacientebSi Zaladobis

warsuli istoriiT (Betts & Boden 1991).

kulturaluri Taviseburebisagan gamomdinare qarTul

sazogadoebaSi mosalodneli iyo arasrulwlovanebze seqsualuri da

fizikuri Zaladobis SedarebiT dabali done. es ukanaskneli iyo

ganpirobebulia sazogadoebis (da aseve kanonis) mxridan Zaladobis

aqtis mkacri dagmobiT da miuReblobiT da moZaladis gakicxviT.

amitomac ar aris gasakviri, rom zemomoyvanili kohortis yvela

gamokiTxulTa Soris ar gamovlinda arc erTi seqsualuri Zaladobis

faqti. sazogadoebaSi, sadac Zaladoba bavSvobis asakSi iolad

SeiZleba gamoaSkaravdes da aqedan gamomdinare mosalodnelia

Zaladobis Camdenis dasja an/da sazogadoebidan izolacia,

yvelanairi pirobebia SezRuduli am saSineli aqtis

ganxorcielebisaTvis.

Cven migvaCnia, rom faS-is CamoyalibebaSi sxva faqtorebi aris

wamyvani. maT Soris, vfiqrobT saWiroa ganvixiloT qalTa aqtivobis

SezRudva socialur da ojaxur garemoSi. tradiciul

sazogadoebebSi emociebisa da qmedebebis gamoxatva qalebis mxridan

istoriulad da kulturalurad aris sxvadasxva doziT

Semofargluli. diasaxlisis funqciebis (tvirTis) Sesrulebis

miuxedavad, qalis monawileoba ojaxis strategiuli xazis

gansazRvraSi arc ise didia, rom araferi vTqvaT ojaxis gareT

socialuri cxovrebaSi monawileobaze. faS SeiZleba iyos ganxiluli

66

rogorc komunikaciisa da yuradRebis miqcevis simboluri forma

risxvisa da protestis erTgvar nazavTan erTad maSin, rodesac

Tvalsazrisisa da reaqciebis pirdapiri gamoxatva ar aris miRebuli.

msgavsi daTrgunvis umwvavesi forma SeiZleba gamovlindes

saqarTveloSi mcxovreb zogierT eTnikur jgufebSi, kerZod,

kompaqturad dasaxlebul TaTrebSi. Cveni dakvirvebis Tanaxmad

faSFaris sagrZnoblad warmodgenili am populaciis qalebs Soris da

Zalze iSviaTia mamakacebSi (Gigineishvili 2005b). mzgavsi Tvalsazrisi

iyo gamoTqmuli rozenbaumis mier (Rosenbaum, 2000), romelmac aRniSna,

rom faS qalebSi aris metadre ganrisxebis, SiSis da umweobis

gamovlena da ara seqsualuri konfliqtis.

analogiuri intrafsiqiuri gancdebi SeiZleba gamovlindes

mamakacebSi, kerZod abxazeTis regionSi separatistebTan omis

veteranebSi. saxlis, ojaxis wevrebisa da qonebis dakargva aris

mZlavri stresis momtani faqtorebi, romlebic iwveven travmatul

mogonebebs iZulebiT gadaadgilebul pirebSi. aRniSnul SemTxvevebSi

SeiZleba ganviTardes faS, rogorc mZime posttravmuli stresuli

aSlilobis gamovlena, rac dafiqsirda or SemTxvevaSi Cveni

jgufidan.

fsiqogenuri aS SeiZleba ganvixiloT, rogorc ganswavluli qcevis

garkveuli forma, romelic Zlierdeba yuradRebisa da mxardaWeris

Semcveli reaqciebiT garesamyarosagan (ojaxi da megobrebi), ramac

SeiZleba kidevac moutanos avadmyofs garkveuli SeRavaTi

(magaliTad, valdebulebisagan Tavis arideba). Cven vvaraudobT, rom

SetevebiT mimdinare aSliloba icavs pacients misi valdebulebebis

Sesrulebisagan (profesionaluri, mSoblis, moqalaqeobrivi da a.S.),

romelic normalur viTarebaSi, rogorc Cans, aRemateba pacientis

fsiqologiur SesaZleblobebs, magram am mdgomareobaSi SeiZleba

iyos gadatanili sxvaze sakuTari saxis SenarCunebasTan erTad. es

aracnobieri meqanizmi (avadmyofis rolis miTviseba) ganvixileT,

67

rogorc sabaziso etiolgoiuri modeli Cvens mier seswavlili faS

pacientTa did nawilSi.

anamnezuri monacemebidan yuradRebas iqcevs aseve fizikuri travmis

arseboba. video-eeg monitoringiT dadasturebuli aS-is mqone

pacientTa vrcel seriaSi (n=157) qalatvinis travma, rogorc

Setevebis aRmocenebis wina piroba, figurirebda pacientTa istoriis

24%-Si (Barry et al. 1998). aqedan umetes SemTxvevaSi (89.2%) aS gamovlinda

travmis miRebidan erTi wlis ganmavlobaSi da anamnezSi sWarbobda

msubuqi simZimis qalatravma (78%), gansxvavebiT epilefsiuri

gulyrebisagan, romelTa sixSiris maRali maCveneblebi sarwmunod

ukavSirdeba mZime xarisxis qalatvinis travmas (Annegers et al. 1998). sxva

kvlevebis Tanaxmad, qalatvinis travma aRiniSna ufro met SemTxvevaSi

(31-32%) da utoldeboda Zaladobis istoriis sixSires (35%) (Westbrook

et al. 1998; Lobello et al. 2006). gamokvleulTa sagrZnobma umetesobam

finansuri sargebeli naxa travmisagan, da miuxedavad travmis dabali

simZimisa, erTi wlis Tavze sasurveli Sedegi ar gamovlinda

(Westbrook et al. 1998). sainteresoa mosazreba, rom travmis Semdgomi aS-

ebs Soris sWarbobs rTuli parcialuri gulyris msgavsi da ara

krunCxviTi tipis epizodebi (Novelly 1993; Barry et al. 1998). miCiganis

universitetis mkvlevarebma faS-is mqone pacientTa askacian seriaSi

gamoavlines msubuqi simZimis qalatvinis travma sinjis 52%-Si

(Kalogjera-Sackellares & Sackellares 1999). avtorebma isic dasZines, rom

Sarkos leqciebSi miuxedavad isteriuli gulyrebis mqone pacientebSi

fsiqologiur travmaze miniSnebisa, naxevarze met SemTxvevaSi naTlad

gamovlinda daxuruli qalatvinis travmis istoria (Sackellares &

Kalogjera-Sackellares 2002). avtorebis azriT es faqtori faS-is mqone

pacientebSi Tavis tvinis darRveul funqciaze miuTiTebs. axlaxan

Catarebuli kvlevis mixedviT, romelic moicavda dadasturebuli

qalatvinis travmis Semdeg aRmocenebuli da Terapiisadmi

rezistentuli gulyrebis mqone pacientebs, romlebmac gaiares

68

intensiuri video monitoringi, sabolood gamotanili diagnozebis

erT mesameds (33%) Seadgenda faS (Hudak et al. 2004). Cveni masalis

analizma gamoavlina faS-is mqone pacientebis anamnezSi gadatanili

msubuqi xarisxis Tavis qalas travma, Tumca arc iseTi maRali sixSiriT

– mxolod 5 pacientSi (29.4%).

zemoaRwerilidan gamomdinare cxadia, rom Setevebis mqone pacientis

istoria unda iyos detalurad gamoZiebuli da yuradReba daeTmos

rogorc yvela prodromalur simptomebs da faqtorebs, romlebic

asruleben precipitatorebis rols, aseve drosa da garemos, romelSic

viTardeba Seteva, mis xangrZlivobas, sixSires da stereotipulobas.

imavdroulad, yuradsaRebia iyo Tu ara pacienti warsulSi Zaladobis

msxverpli, hqonda Tu ara mas fsiqiatriuli darRveva da aris Tu ara

misi megobari an naTesavi Sepyrobili epilefsiiT.

v) diagnostikuri testebi

diagnostikur meTodebSi, romlebsac iyeneben paroqsizmebis

araepilefsiuri bunebus dasadgenad, Sedis eleqtroenecefalografiuli

gamokvlevebis mTeli nairsaxeoba, prolaqtinis gansazRvra SratSi,

fsiqologiuri da neirofsiqologiuri testireba.

eleqtroencefalografia warmoadgens Setevis da SetevaTaSoriso

periodSi fiziologiuri aqtivobis registraciis mniSvnelovan

instruments. radgan epilefsiuri gulyrebi Tanxlebulia neironTa

populaciis riTmuli gantvirTviT, rac iwvevs neironTa funqciis

rRvevas, rogorc adgilobrivad (lokalurad) aseve im midamoSi,

sadac vrceldeba gantvirTva, am aqtivobis dafiqsireba aucilebeli

pirobaa Setevebis epilefsiuri bunebis dasadgenad. da piriqiT

aRniSnuli paTologiuri aqtivobis ar arseboba Setevis periodSi

Caweril eeg-ze – is obieqturi kriteriumia, romelic miuTiTebs

Setevis araepilefsiur bunebaze.

Tavis tvinis eleqtrofiziologiuri aqtivoba SeiZleba iyos

aRricxuli skalpuri eleqtrodebiT pacientSi relaqsirebul

69

mdgomareobaSi, rasac rutinul eeg-Canawers uwodeben. misi

xangrZlioba ar aRemateba 20 wuTs da SeiZleba Seicavdes

fitostimulaciasa da hiperventilacias, rogorc damatebiT

maprovocirebel faqtors. rogorc wesi es meTodi emsaxureba

SetevaTaSoriso aqtivobis registracias da rutinuli Canaweris

dros epilefsiis mqone pacientTa did nawilSi vlindeba

sxvadasxvagvari, maT Soris epileftiformuli cvlilebebli. magram

variabeluri, normidan gansxvavebuli aqtivoba interiqtalur

periodSi iyo gamovlenili aseve pirebSi aS-iT (20-dan 25%-mde King et

al. 1982; Luther et al. 1982). aRmoCnda, rom cvlilebebi (zogjer

araspecifiuric) interiqtalur eeg-ze warmoadgenda faqtors,

romelic sagrZnoblad aferxebda aS-is swori diagnozis gamotanas.

amis safuZvelze, avtorebma (De Timary et al. 2002) daaskvnes,

romE’rutinul eeg-s SeuZlia mkurnali eqimis dabneuloba gazardos’.

Cveni masalis (1998-1999) rva Tanimdevrulad diagnostirebuli faS-iT

avadmyofis rutinuli eeg-ebi ganvixiled retrospeqtulad.

tabula #18. aS-s mqone pacientebis demografiuli, klinikuri da eeg

maCveneblebi

sqesi Fmd md md md md md md md

asaki 45 18 20 14 27 21 31 26

epilefsiis warsuli istoria √_ √+ √+ √_ √_

norma √ √ √ √

darRveva √ √ √

inter-

iqtaluri

eeg epileftiformuli √

Seteva Cawerili kaseturi

monitoringiT

√ √ √ √ √

provokaciuli testi √

qalatvinis travma anamnezSi √ √

70

SemTxvevebis naxevarSi SetevaTaSoris eeg-ze aReniSna cvlilebebi,

romelic upiratesad warmoadgenda nel (Teta) da maxvil-talRovan

kompleqsebs: or SemTxvevaSi fokusiT marcxena safeTqelSi da erT

SemTxvevaSi - marcxena TxemSi. mxolod or pacients aRmoaCnda

epilefsiis dadasturebuli istoria anamnezSi. 24 saaTiani kaseturi

monitoringiT dafiqsirebuli Setevebi (5 SemTxveva) ar iyo

TandarTuli aranairi paroqsizmuli aqtivobiT. danarCen SemTxvevebSi

diagnozi daisva ‘tipuri’ Setevis uSualo klinikuri dakvirvebis,

nevrologiuri da paraklinikuri gamokvlevebisa da pacientis

istoriis analizis safuZvelze. yvela paroqsizmis safuZveli iyo

fsiqologiuri darRvevebi. Cvenma Sedegebma naTlad miuTiTes

auCqarebeli analizis aucileblobaze, rodesac rutinul

interiqtalur eeg-ze vlindeba darRvevebi an mkafio

epileftiformuli aqtivoba im pacientebSi, romlebic wardgebian

qceviTi paroqsizmuli darRvevebiT (Gigineishvili 1999b).

matsonis dakvirvebiT interiqtaluri Canaweris mimdinareobisas

iSviaTad (ara umetes 5%-sa, Mattson 1993) SeiZleba iyos gamoWerili

spontanuri Seteva. sxva saSualebebs Soris, romelic xels uwyobs

epileftiformuli cvlilebebis gamomnJRavnebas, miekuTvneba Zilis

Canaweri da Zilis deprivacia. metad informaciuli meTodebia 24

saaTiani kaseturi monitoringi, sadac mxolod eeg Canaweri

fiqsirdeba da xangrZlivi video-eeg monitoringi, sadac qceviTi

paterni iwereba firze an kompiuteris mexsierebaSi, romlis gadaxedva

SeiZleba mogvianebiT sinqronulad eeg-CanawerTan erTad. ukanaskneli

xorcieldeba epilefsiur centrTan arsebul specializirebul

eleqtrofiziologiur laboratoriebSi da epilefsiuri da

araepilefsiuri Setevebis diferencialuri diagnostikis meTodebidan

warmoadgens yvelaze zust meTods.

pacientis tipuri Setevis eeg-ze dafiqsireba warmoadgens yvelaze

ufro sarwmuno xerxs paroqsizmebis gaurkveveli bunebis dasadgenad.

71

am meTodis faseuloba mkveTrad gaizarda video-telemetriis

danergvis Semdeg, ramac xeli Seuwyo araepilefsiuri bunebis

paroqsizmebis zust diagnostikas, rac diagnostikis oqros

standartad (gold standard) aris moxseniebuli zogierTi avtoris mier

(Bortz 1998; Glosser & Litt 2002; Cragar et al. 2002; Reuber & Elger 2003). am

ZviradRirebuli meTodis jerovnad gamoyenebis mizniT xSirad

mimarTaven Setevis gamowvevas provokaciuli meTodebiT, kerZod im

pacientebSi, romelTac xSiri paroqsizmebi ar axasiaTebT.

Setevebis sixSiris momateba ki SesaZlebelia, rogorc

antiepilefsiuri medikamentis SemcirebiT an moxsniT (Trimble 1982),

aseve mravali provokaciuli meTodebiT. maTi arsia pacientis

dajereba, rom qmedeba gamoiwvevs Setevas, Tumca Setevis gamowvevis

aranairi samedicino safuZveli ar arsebobs. Tu CavTvliT, rom

rTuli parcialuri Seteva ar gamoiwveva cnobierad, aqtivaciis

meTodiT gamowveuli Seteva, Tu igi pacientis tipuri Setevis

maggvaria, didi albaTobiT miuTiTebs paroqsizmebis araepilefsiur

bunebaze. aqtivaciis mizniT, video monitoringis dros, SeiZleba iyos

gamoyenebuli fotostimulacia da hiperventilaciac saTanado

sityvieri, an hipnozuri STagonebiT (Bortz 1998), rac bolo

namuSevrebis tanaxmad zrdis aS-is registraciis Sanss (McGonigal et al.

2002). moyvanili xerxis warumateblobis Semdeg dgeba placebos

gamoyenebis sakiTxi (French 1993). testi iTvleba pozitiuri im

SemTxvevaSi, rodesac fiziologiuri xsnari saTanado ganmartebebis

Semdeg iwvevs da aCerebs Setevas da eeg-ze ar vlindeba paTologiuri

gantvirTvebi.

mxolod Setevis dros pozitiur eeg-s (anu epileftiformuli

cvlilebebiT) SeuZlia erTmniSvnelovnad miuTiTos Setevis

epilefsiur bunebaze. magram, arc es meTodia utyuari: mkafio

cvlilebebis ararseboba yvela SemTxvevaSi rodi miuTiTebs

paroqsizmebis araepilefsiur bunebaze. erT-erT adreul kvlevaSi

72

iqna nanaxi, rom Setevis skalpuri Canaweri aris informaciuli

mxolod SemTxvevaTa 44%-Si (Wyler et al. 1989).

epilefsiis diagnostikuri testebis analizma uCvena, rom arc erTi

meTodi ar aris srulad saimedo. TviT ‘oqros standartad

aRiarebuli’ video-telemetriis analizic ki zogjer Sublisa da

safeTqlis Rrma mediobazaluri struqturebidan generirebuli

parcialuri Setevebis dros ar asaxavs eleqtrografiul korelatebs

skalpur CanawerSi (Mattson, 1993; Wyler et al., 1993; Williamson, 1993; Lesser,

1996; Luciano, 2002). specialurad intrakranialurad Canergili

eleqtrodebiT Catarebulma kvlevam SemTxvevaTa naxevarSi (6/12)

gamoavlina rTuli parcialuri Setevebi pacientebSi, romlebsac

manmade aS-s diagnozi gamoutanes (Wyler et al. 1993). pacientebs Cautarda

mravalmxrivi gamokvlevebi epilefsiur centrSi da maTi moxvedra

kvleviT jgufSi ganapiroba an antiepilefsiuri Terapiis uSedegobam,

an Setevebis negatiurma gavlenam pacientis yoveldRiur cxovrebaze,

an gaurkvevelobam diagnostikur procesSi. am Sedegebma kidev erTxel

aCvenes ramxela dilemas warmoadgens swori diagnozi rTuli

parcialuri gulyrebis msgavsi epizodebis mqone pacientebSi.

saWiroa gaviTvaliswinoT, rom epileftiformuli cvlilebebis

ararseboba generalizebuli tonur-klonuri gulyris msgavsi

epizodis win, paroqsizmis dros da Semdeg aris argumenti aS-is

diagnozis gamotanisaTvis. magram rTuli parcialuri gulyrebis

maggvari klinikuri fenomenologiis dros es argumenti, rogorc Cans,

naklebad sagulisxmoa.

amitomac epilefsiis diagnozi rCeba klinikuri, anu igi eWvgareSe

moiTxovs kompleqsur ganxilvas yvela danarCen meTodebTan erTad.

literaturaSi farTod cnobilia, rom eeg-s interpretacia ar aris

dazRveuli Secdomebisagan - eleqtrografiuli fenomenebis rogorc

gadametebuli, aseve fiziologiuri normis sazRvrebSi usafuZvlo

SefasebiT (Benbadis & Tatum, 2003). am naSromSi ganxilulia is mizezebi,

73

romelmac gamomgzavn nevrologs afiqrebina epilefsiaze, Tumca es

diagnozi faS-is sasargebloT iyo Secvlili epilefsiur centrSi,

rac sabolood faS-is diagnozebis saerTo ricxvidan 32%-s miaRwia.

mopovebuli eeg-CanawerebSi, rasac epilefsiis diagnozi eyrdnoboda,

xelaxla Semowmebis Sedegad gamovlinda mxolod keTilTvisebiani

pikebi (wicket spikes), hipnagogiuri hipersinqronuloba (hypnagogic

hypersynchrony), hiperventilaciiT gamowveuli Seneleba, wamaxvilebuli

alfa ritmis variantebi (‘namless’ fluctuations) an fonuri ritmis

fluqtuacia. avtorebi ver naxuloben amis axsnas, magram isini

yuradRebas amaxvileben aseTi Secdomis Sedegebze, radganac eeg-s

Tavdapirveli mcdari interpretaciis Semdgomi gadasinjva ufro

Znelia, Tanac araswori diagnozi fsiqologiuri da socio-

ekonomiuri TvalsazrisiT pirdapir axdens gavlenas arasasurvel

prognozze. aseve saWiroa nevrologiaSi treiningis dros meti

yuradReba gamaxvildes rogorc epileftiformuli cvlilebebis

‘normalur’ variantebze, aseve normaluri fonis ‘usaxelo’

variantebzec.

fsiqogenuri araepilefsiuri Setevebis fsiqologiuri axsna

faS-is etiologia mravalferovania. paroqsizmebi SeiZleba iyos

fsiqologiuri aSlilobis, fsiqosocialuri stresoris, viTarebis

daZlevis uunarobis da centraluri nervuli sistemis winaganwyobis

rTuli urTierTobis Sedegi. arc ise iSviaTad pacientebSi faS-iT

diagnostirdeba erTze meti mentaluri darRveva. Tanaarsebuli

fsiqologiuri aSlilobebidan aRsaniSnavia depresia, SfoTviTi

(kerZod, panikuri da posttravmuli stresuli aSlilobebi) da perso-

nologiuri aSlilobebi (Bowman 1999; Mökleby et al. 2002; LaFrance & Barry 2005).

radgan fizikuri da seqsualuri travma aris faS-is dadgenili risk

faqtorebi, rogorc qalebSi ise mamakacebSi, gamoTqmulia mosazreba,

74

rom am travmuli movlenis Sedegad pirovneba xdeba uunaro

gamoxatos da aseve moerios risxvas, SiSs, dakargvis SegrZnebas, ris

gamoc masSi yalibdeba disociaciuri mdgomareoba iseTi niSnebiT,

rogoricaa cnobierebis TvalsaCino dakargva, martooba, tirilianoba,

panikis gancda, rac savsebiT klinikurad esadageba aS-s. nawilSi

yalibdeba panika da SfoTva, rac SeiZleba iyos faS-is mizezi.

sxvebSi cxovrebiseuli winaaRmdegobebi xelmeored iwveven

gadatanili travmis gancdas da maT, ubralod, ar SeuZliaT daZlion

umweobis SegrZneba.

Zaladobis travmuli zemoqmedebis miRma ganixileba agresiisa da

risxvis mniSvneloba faS-is CamoyalibebaSi. rozenbaumi (Rosenbaum

2000) miiCnevs, rom mdedrobiTi sqesis dominireba faS-ian pacientebSi

aseve ganpirobebulia supresirebuli grZnobebiT, radgan, kulturuli

da religiuri tradiciebis Tanaxmad, qalebs ar eZlevaT imdeni

gamoxatvis saSualebebi, rac mamakacTa sazogadoebas.

disociacia, Janes ganmartebiT, warmoadgens meqanizms, romliTac

travmis zemoqmedebis Sedegad pirovnebis aqamde integrirebuli (ego-

kontrolis qveS myofi) cnobiereba ixliCeba da garkveuli mentaluri

procesebi agrZeleben arsebobas qvecnobierad. Jane Tvlida, rom

pirovneba genetikurad aris midrekili disociaciisadmi (Janet 1907).

disociacia aS-is fundamentaluri aspeqtia. magram cneba disociacia

imdenad farToa da krebiTi, rom brauni gamoyofs (Cardeña 1994; Brown

2002) disociaciuri konstruqciis sam waxnags. maT Soris, disociacia,

rogorc araintegraluri mentaluri erTeulebis sistema - yvelaze

xSirad gamoyeneba. DSM-IV-Si igi asaxulia disociaciuri

aSlilobaTa kategoriiT, romlis Tanaxmad ‘disociaciauri

aSlilobebis ganuyofeli Tviseba aris cnobierebis, mexsierebis,

identifikaciis an garemos Semecnebis Cveulebrivi integrirebuli

funqciis darRveva’. es ganmarteba metwilad efuZneba Janes klasikur

TvalTaxedvas, romlis mixedviT manamde integrirebuli mogonebebi

75

SeiZleba gaxdes miuwvdomeli cnobierebisTvis da akontrolon qceva

im mimarTulebiT, romelSic subieqti ver acnobierebs mas. Janeseuli

warmodgeniT, es procesi udevs safuZvlad, egreT wodebul, isteriul

simptomebs, romlebic moicaven rogorc fsiqologiur (amnezia,

somnabulizmi) aseve somatur (sensoruli da motoruli funqciebis

dakargva) fenomenebs. amJamad ICD-10 da DSM-IV-Si isini arian

dayofili somatoformul da disociaciur aSlilobebad. magram am

ori klasifikaciis Tanxvedra ar aris sruli. ICD-10 warmoadgens

disociaciis metad farTo ganmartebas, vinaidan igi aerTianebs

rogorc ‘fsiqologiur’ aseve ‘somatoformul’ disociacias (Nijenhuis

2000; tabula #3).

tabula #19. disociaciuri aSlilobaTa klasifikacia ICD-10 da

DSM-IV-Si

ICD-10: disociaciuri

(konversiuli) aSlilobani

DSM-IV: disociaciuri

aSlilobani

disociaciuri amnezia

disociaciuri fuga

disociaciuri motoruli

aSlilobebi

disociaciuri krunCxvebi

disociaciuri anesTezia da

mgrZnobelobis dakargva

disociaciuri stupori

transi

Sereuli disociaciuri

aSlilobebi

sxva da araspecifiuri

disociaciuri aSlilobebi

disociaciuri amnezia

disociaciuri fuga

disociaciuri identurobis

aSliloba

depersonalizaciuri

aSliloba

disociaciuri aSliloba,

araspecifiuri

76

disociaciuri da somatoformuli aSlilobebis jgufebs, ICD-is

Tanaxmad, aerTianebT is niSani, rom isini asaxaven simptomebs,

romlebic hgvanan zogadTerapiul daavadebebis dros arsebul

simptomebs, Tumca gaaCniaT fsiqologiuri safuZveli, da ganasxvavebT

is garemoeba, rom pirvelni emsgavsebian nevrologiur darRvevebs da

meoreni ki imaT, romlebic Sinagan sneulebebSi gvxvdebian (Brown and

Trimble 2000).

disociaciisa da aS-is kavSiri gamomdinareobs Semdegi

dakvirvebidan. upirvelesad, aS-is mqone pacientebis umetesobaSi, DSM-

IV kriteriumebis Tanaxmad, aRiniSneboda disociaciuri

fsiqopaTologiis sxvadasxva formebi (Bowman 1993; Bowman and Markand

1996). momdevno kvlevam faS-is avadmyofebSi naTlad gamoavlina

disociaciuri simptomebis sagrZnobi siWarbe epilefsianebTan

SedarebiT (Prueter et al. 2002). meore mxriv, aS-is mqone pirebSi aRmoCnda

hipnozis momatebuli amTvisebloba (Kuyk et al. 1999). maRali

hipnotiuroba aseve xSiri movlenaa disociaciuri fsiqopaTologiis

mqone subieqtebSi.

miiCneven, rom travmuli gancdebi xels uwyobs disociaciis

simptomebis Camoyalibebas, romelic Tavis mxriv icavs individs

gadametebuli SfoTvisa da fsiqologiuri dezintegraciisagan.

fizikuri, seqsualuri da emociuri Zaladobis Seusabamod maRali

sixSire gamovlenilia rogorc pacientebSi disociaciuri aSlilobiT

(Irwin 1994), aseve aS-iT (Bowman 1993), rac, zemomoyvanil faqtebTan

erTad, arapirdapir miuTiTebs aS-is disociaciuri interpretaciis

sasargeblod.

froididan moyolebuli warsuli fsiqoanalitikuri literatura

cdilobda isteriuli personologia pirdapir daekavSirebina aS-Tan.

isteriuli SetevebiT gamovlenili nevrozebis safuZveli iyo travma,

metwilad seqsualuri. Teoriis mimdevrebis TvalsazrisiT,

seqsualuri Zaladobis msxverplSi SeiZleba Seicvalos cnobierebis

77

done (disociaciuri tipis aSliloba) an/da ganviTardes krunCxviTi

motoruli aqtivoba (konversiuli aSliloba) didi xifaTis momtani

emociuri viTarebidan gaqcevis mizniT (Gross 1986).

fsiqodinamiuri modeli

nevrozuli simptomebis Camoyalibebis fsiqodinamiuri modeli

SeiZleba warmodgenili iyos Semdegnairad: nevrozebis RerZi,

intrafsiqikuri konfliqti, warmoiSoba im mTavar Zalebs Soris,

romlebiTac yalibdeba personologia: idi (the id), ego da superego.

idi moicavs primitiul, qvecnobier fsiqologiur instinqtur

ganzraxvebs (drives), romlebic urTierToben organizmis

moTxovnilebebTan da ase Tu ise ibrZvis misi dakmayofilebisaTvis.

ego warmoadgens pirovnebis cnobier nawils, romelic urTierTobs

gare samyarosTan, akontrolebs moZraobebis sistemas da SegrZnebebs.

igi cdilobs optimalurad daakmayofilos instinqtebi ise, rom amave

dros TanxmobaSi iyos gare samyarosTan da superegosTan. superego

aris personaSi akumulirebuli moraluri normebi da faseulobebi,

romlebic Camoyalibdnen mSoblebisa da sxva gareSe avtoritetuli

pirebis gavlenis Sedegad (Gabbard 2000). isteriul pacientSi azrebi,

afeqti da mogonebani, romlebic arian Seuracxmyofeli pirovnebis

superegosaTvis, ver gamovlindebian misi SfoTvis aRmocenebis gareSe,

amitomac isini ganidevnebian (ganicdian represias) cnobierebidan. am

konteqstSi represia aris iseTi mentaluri procesi, romelic xels

uwyobs pirovnebas daiviwyos an ar icodes akrZaluli an

arasasiamovno azrebi. magram akrZalulma mentalurma azrma SeiZleba

gamonaxos garkveuli gamosavali, rac pacientisTvis wardgeba

pirvelad sargeblad, Tuki mentalur procesebs Soris balansia

darRveuli. aseTi ‘gaJonva’akrZaluli azrebisa, romlebic SeniRbuli

arian, raTa egom isini ver amoicnos, egos aracnobieri nawilis

mcdelobasTan erTad ar dauSvas msgavsi ‘gaparva’, warmoSoben

nevrozul simptoms. ase rom, aracnobieri konfliqti gamoisaxeba

78

garkveuli simboluri formiT. am gziT pirovnebas eZleva saSualeba

gamoxatos romelime represirebuli azri SfoTvis an danaSaulobis

SegrZnebebis gareSe. simptomis saxiT ’id’ energiis gadineba inaxavs

mentalur procesebs garkveuli meTvalyureobis farglebSi da iZleva

saSualebas pacientisaTvis SemdgomSic Seinaxos konfliqti da

akrZaluli azrebi represirebuli saxiT. am Teoriis farglebSi

drois Sualedi travmis miRebidan pirovnebis srulyofili

ganviTarebis stadiamde agreTve iZens garkveul mniSvnelobas: rac

ufro didia igi, miT ufro mniSvnelovania travmis wili.

ganswavlis Teoriis modelebi

klasikuri pirobiTi refleqsis gamomuSaveba (classical conditioning)

am modelis mixedviT stimuli, romelic TavisTavad neitraluria,

pasuxis uciloblad gamomwvev stimulTan (unconditioned stimulus)

garkveuli droisa da viTarebis erTobis gamo, Tanimdevrulad

mogvitans msgavs pasuxs.

epilefsiasTan mimarTebiT, karg magaliTad gamodgeba refleqsuri

epilefsia, sadac romelime neitralur obieqts SeuZlia mogvianebiT

Setevebis provocireba, magram savaraudod, axali Setevebi unda iyos

araepilefsiuri bunebis. Tumca literaturaSi moyvanilia SemTxveva,

sadac neitralurma stimulma, refleqsuri epilefsiis mqone

pacientSi, SemdgomSi tipuri epilefsiuri Setevebic gamoiwvia (Bjørnæs

1993).

instrumentuli pirobiTi refleqsis gamomuSaveba (operant conditioning)

es meqanizmi varaudobs, rom garkveuli Semdgomi movlenebi

aZliereben pasuxis ganmeorebis tendencias, xolo axali pasuxebi

ukve ar saWiroebs nebismier cnobil stimuls da mas ewodeba

‘instrumentuli’. amitomac gulyris Sedegad miRebuli nebismieri

saxis ‘meorad sargebels’ SeuZlia gaaZlieros am Setevebis

ganmeorebis tendencia. gaZlierebuli pasuxi imavdroulad aris

79

Semdgomi xSiri pasuxebis sasurveli niadagi. es Tviseba xsnis imas,

Tu Semdgom, Tavdapirveli gulyris msgavsi susti pasuxi,

TandaTanobiT ratom gadaizrdeba dramatul formaSi, romelic aris

pacientis kontrolis miRma.

meoradi sargebeli, romelsac pacienti SeiZleba imkides

konversiuli simptomis formirebisas, vlindeba yuradRebisa da

mzrunvelobis mopovebaSi da pasuxismgeblobis aridebaSi. aseTi

Sedegi xels uwyobs pacientSi ganswavluli qcevis paternis

Camoyalibebas. radgan pacienti SetevebiT aicilebs SfoTvis

gamowvevas da gaeqceva stresis momtan viTarebas. faS, romelic

Tavdapirvelad garkveuli stresoriT iyo modulirebuli, amJamad

xdeba qceviTi paternis nawili. am Tvalsazrisis (ganswavlis

Teoriis) sasargeblod metyvelebs is faqti, rom faS-is mqone

pacientTa did nawilSi gamovlinda an epilefsiuri gulyrebis

warsuli istoria, an epilefsiis Tanaarseboba (Bowman 1993; Francis &

Baker 1997). aseve samedicino sferos muSakebis moulodnelad didi

raodenoba (eqTnebi, socialuri muSakebi, damxmare personali) arian

Sepyrobili aS-iT, rac SeiZleba iyos aseve ganpirobebuli Setevebis

dakvirvebis maRali SesaZleblobiT (Glosser & Litt 2002).

stresis modeli

stresi SeiZleba iyos aRqmuli, rogorc arasasiamovno emociuri

pasuxi zogierT xifaTis momtani movlenebis mimarT. xifaTi personis

an personis Rirebulebebis mimarT Tavdapirvelad modis gare

samyarodan, magram SemdgomSi warmoiSoba pacientis Sida samyarodan

mexsierebebis saxiT. rodesac pirovneba moxvdeba xifaTis momtani

viTarebis gavlenis qveS, igi afasebs SesaZleblobebs Tu rogor

daZlios viTareba. es Sefaseba xorcieldeba, rogorc realisturi

aseve nawilobriv ararealisturi poziciebidan da zogjer irTavs

aracnobier mentalur procesebs. garkveuli codnisa da

gamocdilebis resursebis erTi mxridan da xifaTismomtani viTarebis

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aspeqtebis meore mxridan SefasebiT individi askvnis – SeuZlia man

gadalaxos situacia, an piriqiT. viTarebis dauZlevlobis SemTxvevaSi

SiSi da SfoTva eufleba pacients da igi eZebs Tavis daRwevis

saSualebas. Tuki an winaaRmdegobis gawevis an ganridebis

saSualebebi ver iqna moZiebuli pacientis mier, sxva intrafsiqikuri

dacviTi meqanizmebi amoqmeddeba, rogoricaa magaliTad uaryofa,

represia da a.S. am modelis Tanaxmad, faS warmoadgens arasasiamovno

stresuli viTarebis daZlevis araadekvatur gzas. stresuli

zemoqmedeba SeiZleba gagrZeldes da pirovnebam gamoimuSavos

daZlevis individualuri stili, romelsac stereotipulad

gamoiyenebs sxvadasxva viTarebaSi. maSin, roca pacienti SiSobs, rom

aRmoCnda yuradRebis miRma, an CarTuli konfliqtSi, valdebulebebSi

da a.S. (Ramani and Gumnit 1982).

Tanamedrove mosazreba mdgomareobs imaSi, rom Seteva aris iseTi

qceviTi paterni, romelic viTardeba, raTa pirovnebas mieces

saSualeba gaumklavdes gadametebul stresors. es warmogvidgeba

rogorc SfoTvis Semcirebis meqanizmi (Francis & Baker 1999). msgavsi

qceviTi paterni xels aZlevs pacients Tavi aaridos

pasuxismgeblobas da gaeqces stresis momtan viTarebas. stresis,

aridebiT daZlevasa da Setevebs Soris urTierTobis arsebobaze

mianiSnebs kvlevis Sedegebi, sadac gamovlinda, rom pacientebi faS-

iT, jansaR kontrolTan SedarebiT yoveldRiur cxovrebaSi

ganicdian gacilebiT nakleb stress, imavdroulad isini, savaraudod,

metad iyeneben aridebiT daZlevis strategias.

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fsiqogenuri araepilefsiuri Setevebi mentaluri darRvevebis

Tanamedrove taqsonomiebSi

mentaluri da qceviTi darRvevebis moqmedi klasifikaciebis analizma

uCvena, rom warmodgenili semiologiuri klasifikaciis Sesabamisad

faS-is calkeuli formebi ar aris srulad asaxuli aRniSnul

taqsonomiebSi (ixile tabula #3). kerZod, motoruli formebi,

rogoricaa didi gulyris msgavsi da aforiaqebuli, iolad eteva

krunCxviTi gulyrebis konversiuli-disociaciuri aSlilobis

qveseqciaSi (F44.5 – ICD-10; 300.11–DSM-IV). demonstraciuli metwilad

esadageba apa-s mier SemoTavazebul konversiuli aSlilobis

gulyrebian formas (300.11 konversiuli aSliloba gulyrebiT an

krunCxvebiT). magram aramotoruli faS-is guliswasvlis forma,

diagnostikuri ganmartebebis Sesabamisad, ar Seesatyviseba

konversiuli krunCxvebis kategorias. nawili dasavluri avtorebisa

mas ganixilavs rogorc disociaciuri aSlilobis araspecifiur

formas (300.15 - Bowman & Markand, 1996), zogi ki rogorc posttravmuli

stresuli aSlilobis gamovlenas (Betts, 1997). aseTi Tavisufali

interpretaciis saSualeba imitomac rCeba, rom klasifikaciebSi faS-

is absansis msgavsi formebi ar aris ganxiluli. Cven migvaCnia, rom

Semdgomi DSM-V versiis mzadebaSi mizanSewonilia epileftologebis

CarTva, raTa gamoinaxos faS-is am formebis adekvaturi diagnosikuri

kategoria.

82

fsiqogenuri araepilefsiuri Setevbis ganaxlebuli diagnostikuri

algoriTmi

Tavad epilefsiis diagnostikuri procesi ar aris martivi da

sworxazovani. garkveul SemTxvevebSi epilefsiis arsebobis an

ararsebobis sakiTxi mZime da dauZlevel amocanad gvevlineba, Tumca

zogjer misi gamovlena ar warmoadgens gadaulaxav problemas

gamocdili eqimisaTvis.

Tuki Seteva araprovocirebulia, zemoaRniSnuli gamokvlevebis

safuZvelze miRebuli pozitiuri Sedegebi miuTiTeben Setevis

epilefsiur bunebaze. Semdeg klinicisti avlens gulyris saxeobas,

epilefsiur sindroms da epilefsiis etiologias. es diagnostikuri

algoriTmi (suraTi #1), romelic Tavad moiTxovs sagrZnob

gamocdilebas da unars, ar pasuxobs im kiTxvaze, ra bunebisaa Seteva,

Tuki misi epilefsiisadmi mikuTvneba ar mtkicdeba. diagnostikuri

procesis Sedegad yalibdeba daskvniTi diagnozi – epilefsiuri

sindromis an aS-s saxiT. ukanaskneli rogorc wesi xdeba avadmyofis

gaweris mizezi. Tumca igi TavisTavad ar gulisxmobs mkurnalobis

swor taqtikas da rac mTavaria, ver uzrunvelyofs mas. erTaderTi,

rac amas Sedegad mohyveba, Tumca arc ise umniSvnelo, aris zianis

momtani antiepilefsiuri Terapiis da ‘epilefsiis’ daRTan

dakavSirebuli stigmatizaciis arideba. magram dagrovili

gamocdilebisa da diagnozis xarisxis amaRlebis mouxedavad, am

kategoriis avadmyofebSi cxovrebis xarisxi mainc rCeba dabali.

meore mxriv, unda gvaxsovdes, rom aS-is diagnozi ar warmoadgens

advil amocanas, razec miuTiTebs im pirTa mniSvnelovani nawili,

romelic Tavdapirvelad iyo gamovlenili, rogorc qronikuli

epilefsiiT daavadebuli da Semdgomi mravalwliani dakvirvebis

Sedegad Sefasda, rogorc aS-iT Sepyrobili. amgvar Secdomebs

moyveba arasasiamovno Sedegebis mTeli kaskadi, kerZod

83

antiepilefsiuri medikamentis xangrZlivi miReba da sxva socialuri

SezRudvebi, rogorc pacientisTvis, aseve misi ojaxisTvis, rac

mosdevs xolme epilefsiis diagnozs (Гигинейшвили Д.А.и др. 1998).

magaliTad, naCvenebia, rom aS-is mqone pacientTa 80%-mde itarebs

antiepilefsiur Terapias swori diagnozis gamotanamde (Benbadis 1999;

Oto et al., 2005; Lobello et al. 2006). drois es monakveTi, anu saboloo

hvmzsjt!jefoujgjlbdjb!

qspwpdjsfcvmj!!Uv!fqjmfgtjvsj!

hvmzsjt!lmbtjgjdjsfcb!

fqjmfgtjjt!lmbtjgjdjsfcb!

fXwjt!Tfubob!hvmzsjt!bsbfqjmfgtjvs!cvofcb{f!

suraTi #1. araepilefsiuri Setevebis

standartuli diagnostikuri algoriTmi

hvmzsjt!bSxfsj.mpcb-!ffh!

lmjojlvsj-!qbsblmjojlvsjnpobdfnfcj-!pkbyvsj!eb!ebbwbefcjt!!jtupsjb-!fujpmphjb! fujpmphjjt!

ebehfob!

bT.jt!ejbhoptujlb!hbnpsjdywjt!nfUpej!

bwbenzpgjt!hbnplwmfwb!

fqjmfgtjvs!dfousTj!njnbsUwb!

84

diagnozis gamotanis gadavadebis periodi Seadgens xolme 7-8 wels

(Reuber et al. 2002c; De Timary et al. 2002). marTebulia vTqvaT, rom arsebuli

aS-is diagnostirebis meTodologia ar aris srulyofili, metic, igi

iZleva Secdomebis sagrZnob raodenobas, rac miuTiTebs misi

gadaxedvis aucileblobaze.

sityva ‘gulyra’ (seizure) farTo SinaarsiT moicavs yvelanair

paroqsizmul (anu droSi Semofarglul) Setevebs, romelic vlindeba

reagirebis mkafio darRveviT, motoruli, sensoruli an avtonomiuri

disfunqciiT (Porter 1993). terminis TavsarTi ki miuTiTebs etiologiur

warmomavlobaze – magaliTad: organuli (anu gamowveuli cnobili

paTofiziologiuri meqanizmebiT) da fsiqogenuri (romlis mizezia

fsiqologiuri darRveva). ‘epilefsiuri Seteva’ miuTiTebs Tavis

tvinis qronikul daavadebaze da ‘araepilefsiuri’ ki moicavs im

darRvevebis farTo speqtrs, romelic klinikurad vlindeba qceviTi

paroqsizmebiT, magram romlis safuZveli ar aris Tavis tvinis

neironebis gadametebuli eleqtruli gantvirTva. konceftualurad,

epilefsia unda wardges, rogorc mxolod erT-erTi etiologiuri

toti (suraTi #2). magram tradiciulad mkurnalis (nevrologis da

zogjer epileftologis) warmodgenaSi sityva Seteva ganuyrelad

asocirdeba epilefsiur gulyrasTan. piriqiT, eqimma, rodesac igi

dgas Setevis gamomwvevi darRvevis gamocnobis winaSe, unda

warmoidginos es sqematuri dajgufeba da Tanabari mniSvnelobiT

ganixilos Setevebis yvela mizezi. msjeloba aseTi diagnostikuri

algoriTmis safuZvelze udavod minimumamde daiyvans diagnostikur

Secdomebs. es niSnavs, rom Seteva ar unda iyos gaigivebuli mxolod

da upirvelesad epilefsiasTan.

85

magram Semofargvla organizmis garkveuli sistemis gamovleniT,

romlis disfunqciam savaraudod gamoiwvia qceviTi paroqsizmuli

darRveva, ar SeiZleba iyos sakmarisi problemis sruli

mogvarebisaTvis. konkretuli aSlilobis dadgena unda warmoadgendes

samedicino menejmentis aucilebel mizans. Cevni Semdgomi ganxilvis

sagani iqneba yvela is fsiqologiuri darRvevebi, romlebsac

SeuZliaT epilefsiis imitireba.

fsiqikuri aSlilobebis mravali simptomi atarebs paroqsizmul

xasiaTs da SeiZleba iyos SecdomiT Sefasebuli, rogorc

epilefsiuri auris niSani, an kidev iqtaluri an SetevisSemdgomi

periodis gamovlena. sapirispirod, pacientebSi epilefsiiT, iqtaluri

simptomebi SeiZleba iyos interpretirebuli, rogorc fsiqiatriuli

gamovlena. amas xels uwyobs is faqtic, rom epilefsiis mqone

populaciaSi fsiqopaTologiis done ufro maRalia, vidre saerTo

populaciaSi (Krishnamoorthy 2002).

sxvadasxva wyaroebi miuTiTeben, rom faS-s lomis wili ukavia

araepilefsiur Setevebs Soris (Kanner & Iriarte, 1999; Guberman & Bruni,

1999; Smith et al., 1999). bolowlebis publikaciebis Tanaxmad (Gates, 2000;

!Tfufwb!

ofwsp.

mphjvsj!

lbsejp.mphjvsj!

nfub.cpmvsj!

gtjrj.

busjvmj!

fqjmfgtjb!

tywb!

suraTi #2. Setevebis etiologiuri klasifikacia

86

Devinsky & Paradiso, 2000; Luciano, 2002) faS SeiZleba gamovlindes mravali

mentaluri darRvevis klinikur suraTSi (tabula #20). epilefsiis

fsiqiatriuli imitatorebi SeiZleba daiyos sam did jgufad –

nevrozuli jgufi, romelic moicavs somatoformul da disociaciur

aSlilobebs, sadac disociaciuri da/an konversiuli meqanizmi aris

wamyvani simptomis formirebaSi; simulantebis jgufi, romelic

Sedgeba ganzrax gamowveuli an simulirebuli SetevebiT, sadac

moCvenebiTi (feigned) qcevis sargebeli SeiZleba iyos naTeli

(simulacia) an gaurkveveli (xelovnurad demonstrirebuli

aSlilobani) da fsiqoturi jgufi, sadac qceviTi paroqsizmi aris

erT-erTi gamovlena didi fsiqiatriuli darRvevis, rogoricaa mwvave

fsiqozi an depresia.

tabula #20. mentaluri darRvevebi, romlebic iwveven fsiqogenur

araepilefsiur Setevebs.

I. somatoformuli aSlilobani

A. somatizirebuli aSliloba

B. konversiuli aSliloba

C. aradiferenciuli somatoformuli aSliloba

II. disociaciuri aSlilobani

A. disociaciuri fuga

B. depersonalizirebuli aSliloba

III. SfoTviTi aSlilobani

A. panikuri aSliloba

B. panikuri aSliloba agorafobiiT

C. posttravmuli stresuli aSliloba

D. mwvave stresuli aSliloba

IV. fsiqoturi aSlilobebi

V. xelovnurad demonstrirebuli aSliloba

VI. simulacia

87

gulyrismagvari paroqsizmebi yvelaze xSirad warmoadgens

konversiul an/da disociaciur simptoms, romelic dakavSirebulia

qvecnobier fsiqologiur konfliqtTan. rogorc cnobilia aS aris

sixSiriT meore simptomi konversiuli aSlilobebs Soris da gvxvdeba

pacientTa 15-20%-Si (Ljundberg 1957; Toone 1990; Cope & Ron 1997).

konversiuli aSlilobis diagnostikuri kriteriumebi mocemulia

zemoT (ixile tabula #8). faS SemTxvevaTa or mesamedSi SeiZleba

iyos motoruli gamovlinebebiT (konversiuli tipi), rasac Cveni

monacemebi adastureben. danarCeni SemTxvevebi modis Setevebze

aramotoruli komponentebiT: absansebisa an parcialuri gulyrebis

msgavsi ‘patara’ Setevebi (disociaciuri tipi). umniSvnelo nawils

warmoadgens Sereuli SemTxvevebi, rodesac motoruli da

Zalagamoclili Setevebi aReniSneba erT pacients. Setevebis aseTi

dayofa disociaciurze da konversiulze asaxavs mxolod DSM-IV

klasifikaciis Taviseburebas, ICD-10-is mixedviT isini moqceulni

arian disociaciuri darRvevebis erTian kategoriaSi.

sxva diagnostikuri erTeuli somatoformuli aSlilobaTa jgufSi,

sadac aS SeiZleba gamovlindes aris somatizirebuli aSliloba. misi

diagnozi maSin daismeba, roca daavadebis klinikuri istoria moicavs

ara mxolod fsevdonevrologiur simptomebs (rogorc konversiuls,

aseve disociaciurs), aramed sxva modalobis somatizirebul

simptomebsac.

rogorc Cvens mier ukve iyo zemoaRniSnuli Tanamedrove

diagnostikur algoriTms gamoricxvis meTodiT mivyavarT faS-mde.

misi saSualebiT, ukeTes SemTxvevaSi, pacients eZleva gezi romelime

samedicino dargis specialistisaken, magram ‘araepilefsiuri’-s niSniT

gaweril pacientTa umetesobis Semdgomi menejmenti da bedi

bundovania. am siZnelis dasaZlevad ar kmara mxolod gamoricxvis

meTodebi, saWiroa pozitiuri diagnostika. kerZod, faS-is SemTxvevaSi

es gulisxmobs mentaluri statusis gansazRvras, romelic xels

88

Seuwyobs epileftologs (neirofsiqiatrs), raTa gamoavlinos

konkretuli fsiqikuri aSliloba, romelic vlindeba paroqsizmuli

qceviTi darRvevebiT. Cvens mier iqna SemuSavebuli mentaluri

statusis Semafasebeli skala, romelic dagvexmareboda, rogorc im

somatoformuli aSlilobebis gamovlenaSi, romlebic

manifestirdebian gulyrismagvari epizodebiT (SeiniRbebian

epilefsiuri gulyrebiT), aseve im fsiqopaTologiaSi, romelic

SeiZleba axlavdes epilefsias. msgavsi natifi gamoyofa jer

fsiqologiuri simptomTa jgufebisa da Semdgom maTi klinikuri

gaazreba diagnostikur WrilSi, arsebuli paraklinikuri Sedegebisa

da daavadebis istoriis paralelurad, warmoadgens pozitiuri

diagnostikis mTavar iaraRs. Cvens skalas safuZvlad daedo

mentaluri statusis standartuli gamokvlevis sqemis erT-erTi

varianti (Barber & Jenkins 1990). igi iqna kritikulad gaazrebuli da

Sevsebuli im momentebiT, romlebic metad aqtualuria epilefsiis da

somatoformuli aSlilobebis mqone pacientebSi. analogiurad, Tuki

epilefsiis gamovlenis procesSi daibada eWvi kardiologiur an

endokrinul paTologiaze, procesSi srulyofilad erTvebian

kardiologi an/da endokronologi. damatebiTi instumentaluri

gamokvlevebis daxmarebiT (eleqtrokardiograma mosvenebul da

datvirTyl mdgomareobaSi, SratSi hormonebisa da mineralebis

gansazRvra da a.S.)

bolo wlebSi gamoCnda naSromebi, romlebic eZRvneba

araepilefsiuri SetevebiT warmodgenili mentaluri darRvevbis

speqtris gamovlenas, rac garkveul wilad ganpirobebulia faS-is

maRali sixSiriT. Tumca Zalze iSviaTia publikacia, sadac

Seiswavleba araepilefsiuri Setevebis gamomwvevi daavadebebis farTo

speqtri da ara mxolod fsiqiatriuli. amitom Cven ganvixileT 1997-

1998 wlebSi epilefsiur centrSi moTavsebuli pacientebs Soris

gamovlenili aS-is yvela SemTxveva. Cveni mTavari amocana iyo

89

gamogveaSkaravebina is organuli da mentaluri darRvevebi, romlebic

xasiaTdebodnen gulyrismagvari klinikuri gamovlinebebiT.

paroqsizmebis araepilefsiuri bunebis dadgena da maTi gamomwvevi

avadmyofobis diagnostika xdeboda zemoaRniSnuli pozitiuri

meTodis gamoyenebiT, fsiqologiuri aSlilobaTa diagnozebi

gamotanili iyo ICD-10 kvleviTi diagnostikuri kriteriumebiT

Sesabamisad.

1997-1998 wlebis kohortaSi dadgenil araepilefsiur Setevebs mqone

pacientebs Soris (35) fsiqogenuri genezis aRmoCnda 26 pacientSi

(74.3%), xolo organuli – rvaSi (22.8%) da erTi pacientis aS iyo

simulaciis gamovlena. fsiqogenur jgufSi somatoformuli

darRvevebis diagnozebs ekava udidesi nawili (57.7%), panikur

aSlilobas – 19.2%, posttravmul stresul aSlilobas – 7.7%,

depresias – 7.7%. mxolod faS-is jgufidan 5 SemTxvevaSi gamovlinda

araepilefsiuri Setevebis Tanaarseboba epilefsiurTan (an

amJamindeli, an anamnezSi dadasturebuli epilefsiuri Setevebis).

motoruli komponentebis mqone faS-ebi iyo klasificirebuli rogorc

disociaciuri aSlilobis konversiuli gamovlena (konversiuli

krunCxvebi) da sapirispirod, aramotoruli saxis (guliswasvlis

maggvari) faS-ebi ki iyo diagnostirebuli rogorc disociaciuri

aSlilobis disociaciuri saxeoba. konversiul qvejgufSi sam

pacients aReniSna polimorfuli Setevebi da or SemTxvevaSi ki

damatebiTi konversiuli sensoruli simptomebi (amavrozi, akuzia an

hipestezia). Setevebis semiologiis analizma gamoavlina motoruli

paroqsizmebis siWarbe guliswasvlis saxeobebTan SedarebiT

fsiqogenur jgufSi (17 SemTxveva 12-is winaaRmdeg). sawinaaRmdegod

organul jgufSi Setevis kolaptoiduri simptomatika aRemateboda

motoruls (6/2), rac sagrZnoblad ganasxvavebda mas fsiqogenuri

jgufidan (χ2=4.04; p=0.054, Fisher’s exact).

90

organuli mizezebidan neirogenuli sinkope iyo yvelaze xSiri

diagnozi (n=5, 62.5%). erT SemTxvevaSi aRiniSna hipoglikemiuri koma

da erTi pacienti iyo hipokalciemiiT ganpirobebuli spazmofiliiT.

parasomnia (Ramis koSmari) aseve erT pacientSi iyo verificirebuli.

neirogenuli sinkopeebs Soris dominirebda vazovagaluri

guliswasvlebi (60%), darCenil SemTxvevebSi aReniSna ortostatiuli

hipotenzia (20%) da emociurad ganpirobebuli guliswasvla (20%).

gamokvleul kohortaSi qalebi sWarbobdnen mamakacebs (25/10). saSualo

asaki jgufSi iyo 26.9 (sd±11.37). qalebSi igi udrida 28.1 (sd±12.61) da

mamakacebSi ki – 24.1 (sd±7.1). yvelaze xandazmulebi iyvnen pacientebi

somatizirebuli aSlilobis diagnoziT (47.5 weli) da simulaciiT (52

weli). qalebis raodenoba aRemateboda mamakacebis raodenobas rogorc

fsiqogenuri aS-is (19/8), aseve organuli aS-is jgufSi (6/2).

epilefsiur centrSi moTavsebis mTavari mizezi SemTxvevaTa umetes

nawilSi (71.4%, n=25) iyo gamomgzavni eqimis eWvi epilefsiaze.

antiepilefsiuri Terapiis araefeqturoba da rezistentuli epilefsiis

Semdgomi menejmenti iyo Semosvlis mizezi danarCen 20%-Si (n=7).

darCenil sam SemTxvevaSi pacienti moTavsda statusis maggvari

mdgomareobis gamo, romelic Tavdapirvelad aRqmuli iyo rogorc

epilefsiuri. iqedan erTi kidevac iyo intubirebuli moTavsebamde.

SemTxvevaTa erT mesamedSi moxsnili iyo winaT gamotanili

rezistentuli epilefsiis diagnozi. epilefsiis SecdomiT

gamotanili diagnozis analizma gamoavlina, rom yvelaze xSiri

faqtori, romelmac epilefsiis hiperdiagnostikaSi iTamaSa roli, iyo

eqimebis mier daskvnis gamotana Setevis vizualuri dakvirvebis

gareSe, rasac Cveni aqamde arsebuli dakvirvebac adasturebs

(Gigineishvili, 1999). paroqsizmis klinikur gamovlinebaTa vizualuri

analizi zog SemTxvevaSi sakmarisi aRmoCndeboda sxva diagnostikuri

testebis SedegebTan erTad, raTa gamocdil eqims gamoetana

araepilefsiuri Setevebis diagnozi. Cven daskvnebs srulad exmaureba

91

kaneris da iriartes dakvirveba, rom semiologiaze dafuZnebuli faS-

is swori diagnozi SesaZlebelia 50-dan 81%-de (Kanner & Iriarte 1999).

tabula #21. mTavari klinikuri diagmnozebi araepilefsiuri

Setevebis mqone pacientTa jgufSi

wamyvani diagnozi qalebi mamakacebi SeniSvnebi

konversiuli

Setevebi

6 2 SemTxvevaTa naxevarSi

polimorfuli aS

(motoruli da

guliswasvlismagvari) an

sxva sensoruli

konversiuli simptomebi

sxva disociaciuri

aSlilobebi

4 1

somatizirebuli

aSliloba

2 - Tanaarsebuli epilefsiis

erTi SemTxveva

posttravmuli

stresuli aSliloba

1 1

panikuri aSliloba 3 2

depresia 1 1

personologiuri

darRvevebi

1 1 isteriuli da mosazRvre

sinkopaluri

mdgomareoba

4 1

parasomnia - 1

hipoglikemia 1 -

hipokalciemia 1 - spazmofiliis Setevebi

qveda kidurSi

simulacia 1 -

jami 25 10

92

zemomoyvanilidan gamomdinare migvaCnia, rom msSS warmoadgens qceviTi

paroqsizmaluri darRvevebiT warmodgenili individis fsiqologiuri

da qceviTi maxasiaTeblis gamovlenis adekvatur iaraRs.

fenomenologiuri da neirofsiqiatriuli monacemebis Semdgomi analizi

nevrologiuri gasinjvis da paraklinikuri gamokvlevebis SedegebTan

erTad qmnis im niadags, romelic daexmareba klinicists ara mxolod

meti sizustiT miakuTvnos SetevebiT mimdinare avadmyofoba

fsiqologiuri bunebis aSlilobebs, aramed gamoavlinos konkretuli

fsiqopaTologia diagnostikuri erTeulis farglebSi. Cvens mier

SeTavazebuli qceviTi paroqsizmuli darRvevebis diagnostikuri

algoriTmi gamoiyureba Semdegnairad (suraTi #3).

faS-is etiologiuri faqtorebis gaanalizebam aCvena, rom umetes

SemTxvevaSi faS asaxavda ojaxur distress. sainteresoa, rom aq

gamovlinda ori tendencia: Seteva, rogorc interpersonaluri

urTierTobis iaraRi da gaukuRmarTebuli kulturuli tradiciebis

mimarT aracnobieri protestis forma. pirveli metad

damaxasiaTebelia qalaqis macxovrebel da mosamsaxure pirebisTvis,

meore _ soflis da eTnikur umciresobis warmomadgenlebisTvis.

ukanaskneli aRsaniSnavia, rogorc risxvisa da agresiis gamovlenis

SeniRbuli forma, rodesac kulturuli tradiciebis gadametebuli

mimdevroba iTxovs mkacr ojaxur morCilebas da socialur

pasiurobas qalebisagan, imavdroulad ar utoveben ojaxSi sakuTari

Tvalsazrisis gatanis aranair saSualebas. personologiuri

Taviseburebebs, kerzod ki primitiul personologias, didi wvlili

SeaqvT am paternebis gamovlenaSi, radgan FfaS iqceva komunikaciis

erTaderT saSualebad. disociaciuri stuporis SemTxveva iyo

ganswavluli qcevis paternis mkafio magaliTi, rodesac Seteva

warmoCnda rogorc samsaxurebrivi siZneleebidan daRwevis forma.

simulaciis SemTxveva arcTu ise Zneli iyo gamosavlenad, radgan

pacientma da misma garemom, eqimebis mxridan Setevebis

93

araepilefsiuri bunebis dadgenis informaciis miwodebis Semdeg,

naTlad gamoamJRavna meoradi sargeblis (pensiis) mopovebis mkafio

motivacia.

qp{jujvsj!

ejbh

optujlb!

hbnpsjd

ywjt!nfU

pej!

hvmzsjt!tfnjpmphjb!eb!

ebbwbefcjt!jtupsjb!lpsfmjsfct!

svujovm!ffh.{f!fqjmfgujgpsnvmj!

dwmjmfcfcj!

lj!

lj!

fqjmfgtjb!

bsb

wjefp. bo!bncvmbupsjvmj!lbtfuvsj!npojupsjohjU!qbsprtj{nvmj!brujwpcb!ujqvsj!Tfufwjt!espt!

bsb

lsvoDywjUj!hfofsbmj{fcvmj!

bsblj!

Dbofshjmj!fmfruspefcjU!

bo!SPECT hbnplwmfwb{f!dwmjmfcfcj!

bsb

efqsftjb!bo!TgpUwb!

lj!

lj!

tywb!!lpowfstjvmj!tjnqupnfcj!

gtjrpmphjvsj!!ejtusftjt!bo![bmbepcjt!jtupsjb!

bsb

pshbovmj!

bT!

gtjrphfovsj!

bT!

Tfufwb!bsbqspwpdjsf.

cvmj!eb!hbonfpsfcjUj!

lj!

qspmbrujojt!npnbufcb!tjtymTj!qptujjrubmvsbe!

suraTi #3. araepilefsiuri Setevebis Tanamedrove

diagnostikuri algoriTmi

94

4. funqciuri somaturi simptomebis etiologiuri modeli

auxsneli somaturi simptomebiT warmodgenili sindromebis

nozologiuri mikuTvneba asaxavs dasavluri medicinis tradiciul

dayofas: zogadTerapiul disciplinebSi isini moixsenieba rogorc

funqciuri somaturi sindromebi (ixile tabula #2) da fsiqiatriaSi

ki upiratesad arian warmodgenili sa-s kategoriaSi. funqciuri

somaturi sindromebis saxeli warmoiqmneba an aRwerilobiTi

(qronikuli daRliloba an menjis tkivili), an savaraudo

etiologiuri (laimis qronikuli daavadeba, gaRizianebuli nawlavi)

principiT, an, Tundac sxeulis romelime nawilze mikuTvnebiT

(temporomandibularuli moSliloba). es ukanaskneli arc aris

gasakviri, radgan specialistebi met yuradRebas aqceven Tavisi

dargisaTvis Sesabamis organospecifiur Civilebs, ris gamoc,

miuxedavad Tavisi bundovnebisa da araspecifiurobisa, sindromebi

naxuloben asaxvas medicinis praqtikulad yvela disciplinaSi.

Sesabamisad sityva funqciuri fsiqogenezs ki ar gulisxmobs, aramed

organizmis darRveul funqcionirebas. fsiqiatriuli sindromis

gamovlenisas wamyvani aris fsiqologiuri procesis safuZvlebis

dadgena, romlis Sedegad simptomebi mulsistemur xasiaTs atarebs.

amitomac ass aRwerisaTvis gamoiyeneba sxvadasxva ganmartebebi:

somatizacia, somatoformuli, funqciuri, samedicino TvalsazrisiT

auxsneli simptomebi da sxva. aseTi ormagi klasifikaciis arseboba

garkveul dabneulobas da problemebs qmnis.

miuxedavad Tavisi simravlisa da warmomadgenlobisa yvela

samedicino specialobebSi, funqciuri sindromebis Sedarebam uCvena

maTi msgavseba fundamentalur aspeqtebSi (Wessely et al. 1999; Barsky &

Borus 1999). kerZod, literaturaSi moyvanili sxvadasxva funqciuri

sindromebis SemTxvevebis diagnostikuri niSnebi zogjer emTxveva

erTmaneTs. magaliTad, meteorizmi, tkivili muclis areSi, Tavis

95

tkivili da sisuste aRniSnulia umetesoba maTganSi. meore mxriv,

pacientebi erTi sindromiT akmayofileben meore sindromis

diagnostikur moTxovnebs, Tuki isini mizandasaxulad iqnebian

gamokiTxuli. da bolos, araklinikuri maCveneblebiT (asaki, sqesi,

prognozi, Sedegianoba Terapiis garkveuli saxeobis mimarT da sxva)

pacientebi gansxvavebuli sindromebiT amJRavneben msgavsebas. kerZod

naCvenebia, rom qalebi aWarbeben mamakacebs fss-s sixSiriT (Barsky et al.,

2001; Kroenke & Spitzer 1998); meta-analizma gamoavlina oTxi funqciuri

sindromis mWidro kavSiri depresiasTan da SfoTvasTan rogorc

jansaR pirebTan SedarebiT, aseve pacientebTan organuli

daavadebebiT, visac msgavsi simptomologia gaaCnda (Henningsen et al.

2003). im fss mqone pacientebs Soris, romlebic xSirad mimarTaven

pirvelad jandacvas, SfoTva da depresia gamovlenilia 60.2%-Si (Smith

et al. 2005). am sindromebis dros specifiuri organos funqciis

darRvevaze varaudis miuxedavad, funqciuri neirovizualuri

kvlevebis Sedegebi uCveneben centraluri nervuli sistemis CarTvas

fss-s CamoyalibebaSi.

somatizirebuli simptomebi Zalze xSiria depresiisa da/an SfoTvis

mqone pacientebSi: maSin, rodesac DSM-IV-is mixedviT gamotanil

somatoformuli aSlilobis mqone pacientTa jgufSi depresiis an/da

SfoTvis gavrceleba udrida 26%, afeqturi an/da SfoTvis mqone

pacientebSi somatoformuli aSliloba gamovlinda 54%-Si (De Waal et

al. 2004). am fsiqologiuri darRvevebis mWidro Tanaarsebobaze adrec

iqna gamaxvilebuli yuradReba, rodesac kirmaierma da robinsma

(Kirmayer and Robbins 1991) gamoTqves mosazreba somatizaciis sami

variantis arsebobaze, romelTagan erT-erTi gulisxmobda depresiis

somatur gamovlenas. sauniversiteto hospitalSi axlaxan

Catarebulma kvlevebma gamoavlina somatoformuli aSlilobebis

mqone pacientTa jgufSi depresiisa da SfoTvis arseboba (32-59.3%

[Fink et al. 2004; Henningsen et al. 2005]). savsebiT marTebulad, am dargis

96

cnobilma mkvlevarebma Sarpma da maiom (Sharp & Mayou 2004) gamoTqves

azri, rom somatizaciis simptomebis somatoformuli aSlilobaTa

jgufiT warmoCena gamouvlenels xdis depresiasa da SfoTvas.

avtorebis azriT, es erT-erTi im argumentTagania, romelic

miuTiTebs somatoformuli aSlilobaTa kategoriis gamoudegarobaze,

rac mis momaval klasifikaciaSi Secvlas saWiroebs.

pacientebi fss-iT, msgavsad somatizirebulebisa, aseve warmoadgenen

siZneleebs eqimisaTvis, amitomac maT Soris yalibdeba daZabuli da

zogjer konfliqturi urTierToba (Hahn 2001; Jackson & Kroenke 1999).

aRsaniSnavia pacientTa am orive jgufSi Sromisuunarobis da

samedicino daxmarebis gamoyenebis sagrZnoblad maRali done (Hiller et

al. 2003). rac exeba samedicino menejments, aq ikveTeba rogorc

antidepresantebis (O’Malley et al. 1999) aseve kognitiur-qceviTi

fsiqoTerapiis Sedegianoba (Kroenke & Swindle 2000) yvela saxeobis

funqciuri somaturi sindromebisas.

somatizirebuli aSlilobis klinikuri suraTi aseve garkveulad

Seicavs funqciuri xasiaTis samedicino sindromebis simptomebs,

rogoricaa magaliTad, fibromialgia, qronikuli daRliloba da

gaRizianebuli nawlavis sindromi. imdenad gadaifareba isini

fenomenologiurad, rom zogierTma avtorma kiTxvis niSnis qveSac

daayena maTi gancalkevebulad aresobobis mizanSewoniloba (Sharpe and

Wesseley 2000; Burton 2003). auxsneli somaturi Civilebis qveS

gaerTianebuli, yvelaze xSirad gavrcelebuli da dResdReobiT

moqmedi klasifikaciebis diagnostikuri erTeulebis urTierTkavSiri

SeiZleba aisaxos Semdegnairad (suraTi #4).

97

suraTi #4. ass-ebiT warmodgenili diagnostikuri erteulebis

urTierTkavSiri

bolo wlebSi Camoyalibebuli zogierTi funqciuri sindromis

diagnostikuri kriteriumebis miuxedavad (Manu 1998), isini

gamoirCevian etiologiuri mizezebis simravliTa da samedicino

gaurkvevlobis arc Tu mcire doniT. ufro swori iqneba yvela saxis

sindromebi, romelTa birTvs warmoadgenen ass, iqnen ganxiluli

erTian sivrceSi, sadac klinikuri gamovlenis simZimis TvalsazrisiT

erT mxares iqneba somatizirebuli aSliloba da sapirispiros ki -

funqciuri sindromebi. maT Soris sivrces iolad daikavebs yvela is

samedicino mdgomareobebi, rodesac pacientis mravlobiTi somaturi

Civilebi srulad ver akmayofileben somatoformuli aSlilobebis

amJamindeli klasifikaciebis diagnostikur kriteriumebs. es

sagulisxmo samedicino kategoriaa, radgan igi sagrZnoblad xSirad

aris warmodgenili mosaxleobaSi da jandacvis pirvelad qselSi.

maTi rubri-fikaciis mizniT SeTavazebul iqna kriteriumebis

raodenobis Semcirebis sxvadasxva midgomebi (Escobar et al. 1989; Escobar et

al. 1998). SeiZleba vivaraudoT, rom fsiqologiuri premorbidis,

mravalgvari stresoris da kognitiuri mzaobis urTierT-qmedeba qmnis

98

fsiqosocialuri distresis klinikuri gamovlenis imdenad mrval

variantebs, rom warmoSobs mTel am zemoaRniSnul kontinuums.

bunebrivia, rom sakiTxis aqtualoba jandacvis nebismieri

rgolisaTvis da imavdroulad misi bundovani ganTavseba sadRac

fsiqiatriisa da medicinis zogadTerapiul dargebs Soris (ormagi

klasifikaciis erTdrouli arsebobis gamo) warmoadgens mZlavr

motivs kvlevebis SesrulebisaTvis. maTi nawili ver adasturebs

funqciuri somaturi sindromebis, rogorc calkeuli diagnostikuri

erTeulebis arsebobas (Nimnuan et al 2001; Olde Hartman et al. 2004). ukve

gamoiTqva axali mravalRerZiani klasifikaciuri sistemis danergvis

da sa-s arsebuli klasifikaciis Secvlis Tavlsazrisi (kerZod,

Semdgomi DSM-V klasifikaciis farglebSi (Mayou et al. 2005).

bolo dekadebis manZilze gamoCnda interesi funqciuri

simptomebis neironaluri meqanizmebis gamovlenisadmi. kanadeli

mkvlevarebis jgufma flo-henris xelmZRvanelobiT 80-an da 90-an

wlebSi mravali neirofsiqologiuri da neirofiziologiuri

kvlevebis safuZvelze gamoTqva azri, rom lateralizebuli

konversiuli simptomi aris hemisferoTaSorisi urTierTobis moSlis

Sedegi marjvena hemisferos upiratesi aqtivaciiT (Flor-Henry et al., 1981;

Flor-Henry et al., 1990). Tavis tvinis marjvenamxrivi struqturuli da

fiziologiuri cvlilebebi iqna gamovlenili pacientebSi

konversiuli krunCxvebiT epilefsiis mqone pacientebTan SedarebiT

(Devisnky et al., 2001). magram kvlevebma funqciuri neirovizualuri

meTodebis gamoyenebiT (pozitronul-emisiuri (pet) da funqciuri

birTvul magnitur-rezonansuli gamosaxva) pacientis motoruli an

sensoruli funqciuri defeqtis dros gamoavlina aqtivacia ara

pirvelad motorul an sensorul ubnebSi, rac jansaR pirebSi

gamoiwveva saTanado motoruli an sensoruli datvirTvis pirobebSi,

aramed sxva ubnebSi, magaliTad, marjvena orbitofrontalur da wina

sartyelSi (Marshall et al., 1997; Halligan et al., 2000; Mailis-Gagnon et al., 2003;

99

Werring et al., 2004; Гигинейшвили Д.А., Шакаришвили Р.Р. 2006b). aRniSnulma

kvlevebma win wamowies cnobieri aqtiuri daTrgunvis (conscious active

inhibition) roli fsiqogenuri simptomis CamoyalibebaSi (Hurwitz, 2003).

mkvlevarebis sxva jgufma konversiuli damblis mqone pacientebSi

ivarauda nebiTi aqtis daTrgunva misi generaciis doneze (volition). pet-

is meSveobiT Catarebul kvlevaSi pacientebSi marcxena xelis

isteriuli dambliT normaluri da xelovnurad gamowveuli damblis

mqone subieqtebTan SedarebiT iqna nanaxi marcxena

dorsolateraluri prefrontaluri qerqis hipofunqcia, romelic

monawileobs moqmedebis aqtis momzadebaSi (Spence et al., 2000). Semdgomma

kvlevebma aseve daadastures, rom konversiuli damblisa da

xelovnurad gamowveuli (simulirebuli) damblis Camoyalibebis

neironaluri meqanizmebi gansxvavebulia (Ward et al., 2003). am

SemTxvevaSi simulirebuli parezis dros gamovlinda marcxena

ventrolateraluri prefrontaluri qerqis aqtivacia konversiul

damblasTan SedarebiT, rac erTgvarad exmianeba wina kvlevis

Sedegebs.

savaraudoa, rom aqtiuri daTrgunvis (an tvinis ubnebis SedarebiTi

aqtivaciis cvalebadobis) intensioba gansazRvravs monosimptomatur

an polisimptomatur somatoformuli sindromis Camoyalibebas

(Gigineishvili 2005). udavoa, rom am procesSi garkveuli roli unda

iTamaSon neirotrasmiterulma sistemebma. serotonerguli

aminomJavebis koncentraciis Semcireba sisxlSi pacientebSi

somatizirebuli aSlilobiT depresiasTan da kontrolTan SedarebiT

miuTiTebs am sistemis deficitze (Rief et al., 2004b). radgan cnobilia,

rom serotonerguli sistemis (5-HT) aqtivoba aris genetikuri

kontrolis qveS, riTac ganapirobebs misi receftorebis, sinTezuri

enzimebisa da mitacebis adgilmdebareobebis aqtivobas, SesaZlebelia

vivaraudoT rom genetikuri faqtori (neiroqimiaze zemoqmedebis

meSveobiT) monawileobs funqciuri somaturi simptomis generaciis

100

meqanizmSi (imis msgavsad, rogorc es gamovlenilia mosazRvre

personologiuri darRvevis dros - New et al., 2001). Tumca genetikuri

faqtoris gavlena SesaZlebelia xorcieldebodes ara mxolod

neiroqimiis doneze, aramed igi uSualod axdendes gavlenas

anatomiaze. stresi, rogorc gamSvebi meqanizmi zemoqmedebs

genetikazec, uSualod organizmis fiziologiur funqciebzec da

individis kognitiur sferozec. rogorc somaturi SegrZnebebis da

organizmis fiziologiuri procesebis, aseve ‘avadmyofis rolis’

aRqma xorcieldeba pacientis kognitiuri sferos meSveobiT (Mechanic,

1962; Mai, 2004). igi, imav dros, CarTulia ‘ganswavlis procesSi’,

rodesac individs saSualeba aqvs garSemomyofebisagan Seiswavlos

daavadebis modeli, an gaaCnia qronikuli daavadebis piradi

gamocdileba. kognitiur aRqmaze aseve did gavlenas axdens individis

personologiuri Tvisebebi da emociuri ganwyoba. erTianobaSi, Cvens

mier warmodgenili funqciuri simptomis warmoqmnis modeli

gamoiyureba Semdegnairad (suraTi #5 [Gigineishvili 2005]).

101

gj{jpmphjvsj!gvordjfcjt!ebsSwfwfcj;!bwupopnjvsj!foeplsjovmj!

jnvovsj!

ofjsprjnjb!

bo/eb!bobupnjb!

lphojujvsj!tgfsp!

bwbenzpgpcjt!hbnpdejmfcb!

tusftj!

hfofujlb!!

gvordjvsj!tpnbuvsj!tjnqupnj

suraTi #5. funqciuri somaturi simptomis

etiologiis hipoTezuri axsna

102

5. somatoformuli aSlilobebis menejmenti

somatoformuli aSlilobebis Tanamedrove Terapiis arsebuli

xerxebis umetesoba testirebulia mxolod empiriulad da

mimarTulia: avadmyofis distresisa da mravlobiT somatur

CivilebTan dakavSirebuli funqcionirebis SezRudvis Semcirebisaken;

arafris momtani diagnostikuri da Terapiuli procedurebis da

medikamentebis aridebisaken; da iseTi potenciuri garTulebebisagan

dacvisaken, rogoricaa qronikuli invalidizacia da medikamentozuri

damokidebuleba (Martin and Yutzy, 1996).

nevrologis poziciidan met yuradrebas ibyrobs konversiuli

aSliloba. misi mkurnaloba iwyeba im momentidan, rodesac srulad

varT darwmunebuli nevrologiuri daavadebis ar arsebobaSi, rac

gulisxmobs, rom yvela saWiro neirodiagnosikuri gamokvlevebi

(paroqsizmebis arsebobisas ki video an kaseturi eeg-monitoringi)

ukve Catarebulia. Semdegi nabiji unda iyos daskvnebis miwodeba

pacientisadmi da Semdgomi gamokvlevebis acileba. es Zneli da drois

momcveli etapia, radgan igi gulisxmobs yvelanairi konfrontaciis

aridebas. ukanaskneli mosalodnelia, pirvel rigSi imitom, rom

pacienti gamokvlevebis Sedegad miRebuli negatiuri pasuxebis

miuxedavad, Civilebis mdgradobis safuZvelze, SeiZleba moiTxovdes

xelmeore gamokvlevebs. meore mxriv, misi Civilebis gamomwvev mizezad

stresiT ganpirobebuli somatizaciis arsebobis gamxela

moumzadebel pacientSi iwvevs undoblobas, eWvs eqimis kompetenciaSi

da SeiZleba dasruldes klinikis TviTneburi mitovebiTac. amitomac

menejmentis procesSi unda iyos CarTuli gamocdil eqimTa gundi,

romelic Tavdapirvelad yuradRebas gadaitans avadmyofobis

socialur da fsiqologiur Sedegebze, rac gaaadvilebs pacientTan

mWidro da ndobiT aRWurvil urTierTobis damyarebas. mxolod amis

Semdeg rekomendirebulia konservatiuli meTodi, rogoricaa

103

gadarwmuneba (reassurance). procesis arsi gulisxmobs pacientisaTvis

informaciis miwodebas, rom simptomebis Camoyalibeba aris ara

organuli paTologiis, aramed fsiqologiuri konfliqtis Sedegi. mas

win unda uswrebdes an axldes garkveuli samedicino ganaTleba.

magram gadarwmunebisas yuradReba eqceva daavadebis orive, rogorc

fizikur, aseve fsiqologiur aspeqts da xazi esmeva im garemoebas,

rom es WeSmaritad samedicino problemaa, riTac kidevac moxdeba misi

legalizacia. pacienti unda iyos CarTuli am reabilitaciis

procesSi ise, rom misi Tavmoyvareoba ar Seilaxos. xeli unda

SevuwyoT pacientis bolodroindeli cxovrebiseuli movlenebis

ganxilvas (verbalizacias) yvelanairi mizezSedegobrivi

urTierTobaze yuradRebis gamaxvilebis gareSe.

mwvaved ganviTarebuli konversiuli sindromis dros stacionarSi

myof pacientisaTvis procesis dasaCqareblad marTebulia

relaqsaciisa da STagonebis gamoyeneba. Cveni gamocdilebiT

STagonebiTi Terapia metad efeqturia fizioTerapiis procedurebTad

erTobliobaSi. motoruli an/da sensoruli deficitis pirobebSi

eleqtrostimulaciuri fizioTerapiuli seansi sugestiur

TerapiasTan erTad, warmoebuli eqimis mxridan, aRwevs deficitis

metad swraf da Sedegian aRdgenas. Cveni Sedegebidan gamomdinare, am

jgufis pacientTa 85%-Si iyo saWiro mxolod ramdenime seansi

konversiuli deficitis mosaxsnelad an sagrZnobi SemcirebisaTvis.

paralelurad unda mimdinareobdes konversiuli simptomis gamomwvevi

mentaluri darRvevis gamovlena. amisaTvis dasadgenia an aqtualuri

konfliqti an travma, am ukanasknelis ararsebobis pirobebSi ki -

bavSvobaSi da axalgazrdobaSi gadatanili travma an Zaladobis

faqti, rac metad aqtualuria faS-is pirobebSi. es procesi saWiroebs

erTobliv Zalisxmevas, rogorc nevrologisa, aseve fsiqiatris da

fsiqologis.

104

literaturuli monacemebis Tanaxmad raime Tanaarsebuli an

konversiuli simptomis uSualo gamomwvevi arasomatoformuli

aSlilobis gamovlenisas mizanSewonilia medikamenturi Terapiis

gamoyeneba (Hurwitz, 2003; LaFrance & Devinsky 2004). magram Cveni

gamocdilebidan gamomdinare igi efeqturia rogorc mwvaved

ganviTarebuli konversiuli aSlilobisas, aseve mis klinikur

suraTSi disociaciuri elementebis arsebobisas (transi, stupori,

absansis magvari Setevebi). aseT SemTxvevaSi Cvens mier

rekomendirebulia medikamentebis Seyvanis parenteraluri forma:

ampulirebuli klomipramini an melipramini (25mg dReSi) da

sulpiridi (100mg dReSi) intramuskularulad. msgavsi RonisZieba

exmareba mkurnals Terapiuli aliansis damyarebaSi pacientis

axloblebTan, primitiuli fsiqologiis mqone individebTan an maTTan

visTanac pirdapiri kontaqti gaZnelebulia (enis ucodinrobis gamo).

qronikulad mimdinare konversiuli aSlilobis dros

gamarTlebulia yvela zemoaRniSnuli nabiji. mxedvelobaSi unda

viqonioT, rom mizanSewonilia faqtorTa sami jgufis gamovlena:

isini, romlebic ganawyoben (predisposing), iwveven (precipitants) da

axangrZliveben (perpetuating) darRvevas. stresoris an konfliqtis

gamovlenas SesaZlebelia dasWirdes xangrZlivi dro. aseve garkveuli

Zalisxmeva esaWiroeba maskirebuli depresiisa an SfoTvis

gamoaSkaravebas. am miznisaTvis pacients SeiZleba dasWirdes

xangrZlivi stacionireba. Setevebis xangrZlivi istoriis pirobebSi,

mosalodnelia winaT gamotanili epilefsiis diagnozis uaryofa da

antiepilefsiuri Terapiis (aeT) Sewyveta. sagulisxmoa, rom pacientTa

sakmao nawili (35-47%), romelsac ar gaaCnia Tanaarsebuli epilefsiis

monacemebi, faS-is diagnozis gamotanis Semdegac iRebs

antiepilefsiur preparatebs (Krumholz and Niedermeyer, 1983; Walczak et al.,

1995; Ettinger et al., 1999; Reuber et al., 2003c). amitomac aeT-is moxsna faqizi

da xangrZlivi procesia. igi ar unda moxdes erTbaSad, aramed faS-is

105

uSualo mizezis fsiqofarmakologiuri da/an fsiqoTerapiuli

mkurnalobasTan paralelurad.

amJamad farTod ganixileba fsiqoTerapiis gamoyeneba pacientebSi

somatoformuli aSlilobebiT. dasavlur samecniero publikaciebSi

ar arsebobs erTiani azri imaze, Tu romeli meTodi aris upiratesi,

rac faS-Tan mimarTebaSi garkveul wilad gamowveulia

kontrolirebadi randomizirebuli kvlevebis ararsebobiT (Bowman,

1999; La France & Devinsky, 2002; 2004; Lesser, 2003). sagulisxmoa erTi, rom

Terapia mimarTulia, raTa gamoaSkaravdes stresori da

fsiqologiuri travma, gamovlindes is xelSemSleli winaaRmdegobebi

da faqtorebi, romlebic Trgunaven emociebis gamovlenas da

Sesabamisad gaadvildes pacientis emociebis gamoxatva verbalurad

da ara fizikurad. qceviTi Terapiis mizania Semcirdes garemosagan

mowyalebis gaReba paroqsizmuli qcevisadmi. imavdroulad xeli unda

Seewyos jansaR qcevas, rac gulisxmobs fsiqosocialuri stresuli

viTarebis aridebis an misi arasomatur arxebSi gadayvanis

stimulirebas. msgavsi Terapia efeqturia saavadmyofos an

reabilitaciuri klinikebis pirobebSi an kidev, iSviaT SemTxvevaSi,

ojaxur garemoSi, romelic mWidrod TanamSromlobs pacientis

samedicino menejmentis jgufTan. erTaderTma randomizirebulma

kontrolirebulma kvlevam uCvena qceviTi Terapiis upiratesoba

standartul TerapiasTan pacientebSi konversiuli motoruli da

sensoruli simptomebiT (Dickes, 1974). Cvenma gamocdilebam gviCvena, rom

es mizani standartul garemoSi praqtikulad miuRwevadia. ojaxuri

Terapia efeqturia viTarebaSi, sadac ojaxuri disharmonia da

uTanxmoeba aris mozardis (an ufrosis) konversiuli paroqsizmis

mizezi. gansxvavebuli qceviTi paternis Seswavla ojaxisaTvis

safuZvels gamouclis meoradi sargeblis mopovebas da ‘avadmyofis

rolis’ SenarCunebas pacientis mxridan (Betts, 1997; Reuber & House, 2002).

ojaxuri wyvilis Terapia (marital therapy) mizanSewonilia, Tuki

106

partniorebs Soris urTierToba an Sewyvilebis Sedegad miRebuli

gancdebi aris faS-is mizezi. aseT viTarebaSi sasurvelia

individualuri fsiqoTerapiis kombinaciac. hipnoTerapias

konversiuli aSlilobis dros xangrZlivi istoria gaaCnia. misi

gamoyeneba saTaves iRebs pier Janes autohipnozis, rogorc

pirovnebisaTvis mtkivneuli da dauZleveli informaciisagan dacviTi

meqanizmis Teoriidan, romelic disociaciuri fenomenis asaxsnelad

iqna wamoyenebuli. radgan konversiuli aSlilobis mqone pirebSi

hipnozisadmi ganwyobis done aris sarwmunod maRali, vidre jansaR

populaciaSi (Bliss, 1984; Kuyk et al., 1999; Roelofs et al., 2002) mowodebulia

misi farTo gamoyeneba konversiuli simptomebis da faS-is mqone

pirebSi. erTaderTma randomizirebulma kontrolirebadma kvlevam

aCvena hipnozis Terapiuli efeqtis mdgradoba 6 Tvis Tavze

pacientebSi konversiuli motoruli simptomebiT (Moene et al., 2003).

individualuri fsiqoTerapia ar aris farTod rekomendirebuli

(pirvel rigSi misi uSedegobis gamo dabali da primitiuli

inteleqtis mqone pirebSi), Tumca misi mxardaWeriTi forma (supportive)

SeiZleba gamodges efeqtur pirebSi, romlebic arian gadametebuli da

dauZleveli mravlobiTi stresoris an emociebis daTrgunvis

msxverplni (Betts, 1997; Bowman, 1999).

rogorc wesi, arc erTi meTodi ar iyeneba srulad izolirebulad,

avtorebis umravlesoba gvTavazobs kompleqsur fsiqoTerapiul

midgomebs, sadac ramdenime zemoaRniSnuli meTodi gamoiyeneba

kombinaciaSi (Ramani, 1993; Devinsky, 1998; Reuber & Elger, 2003).

somatoformuli aSlilobebis mqone pacientTa mkurnalobisas Cven

mivzdevdiT sqemas, romelic moyvanilia tabula #22-Si. es mraval-

safexuriani procesi ar sruldeboda standartulad, fsiqoTerapiul

seqciaSi gamoiyeneboda is elementebi, romelic konkretuli

viTarebiT iyo nakarnaxebi da Seesabameboda Cvens praqtikul

SesaZleblobebs.

107

tabula #22. somatoformuli aSlilobebis bazisuri Terapiis

elementebi

1. nevrologiuri gamokvleva – diagnostikis metwilad negatiuri

meTodi

2. mentaluri statusis Sefaseba – diagnosikis pozitiuri meTodi

3. pacientTan da mis garemosTan ndobiT aRWurvili urTierTobis

damyareba

4. pacientisadmi diagnozis miwodeba swor maneraSi, raTa man

naklebad mtkivneulad aiTvisos igi

5.1 fsiqoTerapia

a. etiologiis da Setevebis generaciis SesaZlo fsiqologiuri

meqanizmebis ganxilva da diskusia (ganaTleba)

b. yuradrebis gadatana fizikuri problemebidan fsiqologiuri

konfliqtisa da distresis arsebobaze satanado axsna-ganmartebis

safuZvelze (gadarwmuneba)

g. kompleqsuri fsiqoTerapia (konkretuli viTarebidan gamomdinare

5.2 farmakoTerapia

a. aeT-is TandaTanobiTi moxsna (Tuki monacenebi ar metyveleben

Tanaarsebul epilefsiaze)

b. antidepresnatebisa da atipuri neiroleftikebis kombinaciis

titracia (parenteraluri formebis gamoyeneba mwvave SemTxvevaSi

da enteraluri - qronikuli mimdinareobis dros)

unda gvaxsovdes, rom konversiul simptomebs axasiaTebT epizoduri

mimdinareoba. Sesabamisad, erTi epizodis drouli gankurneba kidev

ar niSnavs aSlilobis srul gankurvnas. amitomac, miTumetes Tuki

pacienti aris faS-iT, saWiroa Terapiuli da ganmanaTlebeli

saubrebis dros iqnes yvelanairi aqcentis gareSe miniSnebuli, rom

mosalodnelia Setevis an sxva nevrologiuri deficitis xelmeored

gameoreba.

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Ffsiqogenuri araepilefsiuri Setevebis mkurnaloba

swori da efeqturi mkurnalobis sawindaria swori diagnozi. anu

diagnozi, romelic Seicavs ara mxolod im warmodgenas, rom Setevebi

ar aris epilefsiuri bunebis, aramed akuratulad asaxavs im

konkretul fsiqopaTologias, romlis qveS imaleba faS.

zemoaRniSnuli pirobis Sesrulebis moTxovna ar unda iyos gasakviri,

radgan ramdenad mravalferovania epilefsiuri gulyrebis

Semadgeneli epilefsiuri sindromebi, imdenadve darRvevebis farTo

speqtri SeiZleba asaxavdes faS-s. amitomacaa ar arsebobs

universaluri Terapiuli midgoma aS-is mimarT. Tuki ar iqneba

gaTvaliswinebuli es mosazreba, ar iqneba Semcirebuli is ekonomiuri

tvirTi, romelic samedicino qselisTvis moaqvT amgvari tipis

avadmyofebs (tabula #23). magaliTisaTvis, aS-is araswori

diagnostika da mkurnaloba epilefsiis niSniT aSS-Si jdeba 110-920

milioni dolari, swori rediagnostika ki amcirebs xarjebs 6 Tvis

manZilze saSualod 84%-iT (Martin et al. 1998).

sawyisi sabaziso Terapiis elementebi igive rCeba, rac

somatoformuli aSlilobebisaTvis aris rekomendirebuli da Seicavs

diagnozis miwodebas, saTanado axsna-ganmartebis Catarebas imisaTvis,

rom diagnozi uaryofisa da samedicino personalTan dapirispirebis

gareSe iyos aRqmuli, rogorc pacientis, aseve misi axloblebis mier

(LaFrance et al., 2006 in press).

tabula #23. faS-is menejmentis mTavari principebi

1. SetevebiT mimdinare daavadebis bunebis gamovlena

2. specifiuri fsiqopaTologiis dadgena, romelic iniRbeba

fsiqogenuri araepilefsiuri SetevebiT

3. gamovlenili fsiqopaTologiis uSualo mkurnaloba

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momdevno Terapiuli nabijebi nakarnaxebia imiT, iyo Tu ara

warsulSi pacientis Setevebi Sefasebuli, rogorc epilefsiuri da

Rebulobda Tu ara igi antiepilefsiur medikamentebs. im SemTxvevaSi,

Tu pacients manamde epilefsiis diagnozi hqonda gamotanili da

Sesabamisad igi iRebda antiepilefsiur Terapias, rekomendirebulia

Tanmimdevrulad gacnoba im mosazrebisa, rom amJamindeli Setevebi

(romelic registrirebulia eeg-ze an videoTi) ar warmoadgens

epilefsiur variants. dapirispirebis acileba am SemTxvevaSi

aucilebelia. magram nevrologiuri menejmenti unda gagrZeldes da

antiepilefsiuri Terapiis reJimi darCes am etapze Seucvleli. Tuki

avadmyofis mdgomareobis Semdgomi (gaweridan 6 Tvis manZilze)

monitoringi ar iZleva aranair pozitiur monacemebs epilefsiuri

Setevebis Tanaarsebobaze, mizanSewonilia antiepilefsiuri

medikamentebis TandaTanobiTi moxsna. es SesaZlebelia mkacri

semiologiuri kontroliT: anu klinikaSi dafiqsirebuli Seteva unda

iyos msgavsi imisa, rogoric iyo aqamde saxlSi. amitomac semiologiis

detaluri ganxilva Setevebis yvela arsebul mowmeebTan warmoadgens

mkacr aucileblobas.

antiepilefsiuri Terapiis moxsna-armoxsnis saxiTxis mimarT ar aris

erTgvarovani damokidebuleba. zogi dasavluri specialisti miiCnevs,

rom aeT-s SeiZleba iyos gamoyenebuli Tavisi efeqtis gamo pacientis

xasiaTze da impulsur qvevaze, iseve rogorc tkivilis kupirebaze.

imavdroulad, imaTTvis, vinc xangrzlivad iRebda aeT-s, misi moxsna

warmoadgens garkveul Terapiul Carevas (LaFrance et al., 2006 in press).

am jgufis avadmyofebi yvelaze Tavsatex problemas qmnian

klinicistebisaTvis, radgan arc ise iSviaTia, rodesac pacienti

antikonvulsantebiT Terapiis moxsnis Semdeg ganicdis axali tipis

Setevas, rac Znelia erTgvarovnad iyos interpretirebuli: Setevebi

SeiZleba warmoadgendes aqamde kargad kontrolirebuli epilefsiuri

gulyrebis xelaxla aRmocenebas an faS-s, romelic pacientis axali,

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misTvis ‘diskomfortuli’ viTarebisadmi protestiT aris gamowveuli.

amgvari protesti mimarTulia ‘stabiluri gulyrebiani pacientis’

iarliyis dasabruneblad, rac warmoadgens cxovrebis iseT

komfortul niSas, sadac imaleba avadmyofi dramatuli, qaoturi da

socialuri stresebiT savse garemosagan. am tipis pacientebis

menejmenti, rogorc wesi, warmoadgens dauZlevel problemas

samedicino qselis specialistebisaTvis.

im pacientTa mkurnaloba, romlebsac epilefsiis diagnozi ar

qondaT aqamde gamotanili (pirveli mimarTva stacionarSi an

ganmeorebiTi ukve aqamde gamoTqmuli varaudiT Setevebis fsiqogenur

xasiaTze), damokidebulia daavadebis klinikur mimdinareobaze. mwvave

suraTis dros, rodesac pacients Setevebis seriuli an statusuri

mimdinareoba axasiaTebs da, rodesac klinikuri suraTi da eeg

monacemebi mkafiod miuTiTeben araepilefsiur bunebaze,

medikamentozuri Terapia mizanSewonilia. igi axdens mwvaved

ganviTarebuli Setevis safuZvlad myofi fsiqopaTologiis

Semcirebas, rac SeiZleba iyos warmodgenili depresiiT an

posttravmuli stresuli aSlilobiT. aseT SemTxvevebSi Cveni

gamocdileba Semdegnairia: imipraminis an klomipraminis da

sulpiridis erTdrouli ineqciebi kunTSi. dozireba Semdegnairia:

tricikluri antidepresantis ori ineqcia (erT ampulaSi Sedis

imipraminis an klomipraminis 25mg) da atipuri neiroleftikis

erTjeradi ineqcia (1 ampula Seicavs sulpiridis 100mg). es

ukanaskneli, mkurnalobis mesame dRidan SeiZleba iyos

gadanawilebuli dReSi or jerze (TiToOineqcia 50mg). paralelurad

unda vawarmooT pacientis axloblebTan intensiuri saubrebi, raTa

ara mxolod davadginoT fsiqogenuri gulyris aRmocenebis

SesaZlebeli meqanizmi, aramed gavacnoT maT Cveni warmodgena

daavadebis arsze da misi warmoSobis mizezebze. saubrebi unda

tardebodes gulaxdilad, Tumca informaciis sruli gamolageba

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arasasurvelia, radgan SesaZlebelia pacientis socialuri da/an

intimuri cxovrebis stresorebi iyos mamoZravebeli Zala misi

samedicino mdgomareobis warmoCenaSi. es sfero saWiroebs garkveul

sifaqizes da ukve Sesabamisad ojaxuri an mxardaWeriTi Terapiis

warmarTvas avadmyofTan erTad. Setevebis dramatuli mimdinareobis

SeCerebasTan erTad mizanSewonilia ineqciuri formebi Seicvalos

peroralurebiT.

qvemwvave klinikuri suraTisas upriania aseve medikamentebis

peroraluri formebis gamoyeneba. paralelurad yuradRebis

gamaxvileba, raTa Semcirdes ZviradRirebuli gamokvlevebis da

specialistebis konsultaciebis usafuZvlo nusxa (miuxedavad

pacientis meurveebis aqtiuri moTxovnebisa), rac sagrZnoblad

Seamcirebs xarjebis saerTo jams. medikamentebidan rekomendirebulia,

rogorc tricikluri - imipramini, klomipramini (50 milgramamde

dReSi), aseve atipuri antidepresantebi Tianeptini (Tianeptine)

(samjeradi miRebiT 37,5mg) an alprazolami (Alprazolam) (0.25 mg samjer

dReSi). paralelurad SegviZlia davuniSnoT zemoaRniSnuli

neiroleftiki sulpiridi (orjeradi miReba 100mg dReSi).

mxardaWeriTi fsiqoTerapiasTan erTad saWiroa informaciuli da

saganmanaTlebo saubrebi, rogorc pacientTan, aseve ojaxis

wevrebTan.

miuxedavad imisa, rom dasavluri wyaroebis umetesoba (Ramani 1993;

Roy & Barris 1993; Betts 1997; Reuber & House 2002) mizanSewonilad miiCnevs

farmakoTerapiis dawyebas mxolod maSin, rodesac depresia an

posttravmuli stresuli aSliloba aris mkafiod gamovlenili

Tanaarsebuli an mTavari fsiqopaTologiis saxiT, romelic

safuZvlad udevs faS-s, Cven migvaCnia, rom igi dasaSvebia gacilebiT

farTo SemTxvevebSi. es Tvalsazrisi gamomdinareobs Cveni

mosaxleobis farmakoTerapiisadmi tradiciuli mzadyofnidan da

ndobidan maSin, rodesac alternatiuli fsiqologiuri daxmarebis

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saSualebebi ar aris saTanadod ganviTarebuli. magaliTad maSinac ki,

rodesac Setevebi wminda konversiul xasiaTs atarebs da

intrafsiqikuri konfliqtis gamovlenaa, romelsac garkveuli

meoradi sargebloba moaqvs pacientisTvis, medikamentozuri Terapia

SesaZloa asrulebdes ara uSualo zemoqmedebas paTogenezur

rgolze, aramed asrulebdes ‘fsiqologiuri xidis’ rols.

pacientis garemocvis ndobis mopovebis garda, medikamenti

garkveulwilad amagrebs medicinis Zalas. amiT xdeba pacientis

daavadebis erTgvari legalizacia (anu gadayvana samedicino da ara

fsiqiatriul relsebze) da exmareba pacients ar dakargos Tavisi

saxe sazogadoebis da axloblebis winaSe mxolod imitom, rom misi

mougvarebeli fsiqologiuri problemebi iwveven garkveul

invalidizacias. farmakologiuri mkurnalobis TandarTva diagnozze

orientirebul fsiqoTerapiaze warmoadgens bolodroindeli

publikaciebis daskvniT rekomendaciebs (LaFrance & Devinsky 2002; 2004).

iqve naxsenebia, rom nevrologiuri daavadebebisa da insultis

nacionalurma institutma (The National Institute of Neurological Disorders and

Stroke) wamoiwyo mcire kvleva, sadac Sefasdeba serotoninis

ukumitacebis inhibitorebis da kognitiuri Terapiis efeqturoba

pacientebSi faS-iT, rogorc calke, aseve kombinirebulad.

yuradsaRebia is garemoebac, rom amgvari pacientebis Setevebi ar aris

simulirebuli an ganzrax gamovlenili, aramed es realuri Setevebia,

romlebic asaxaven pacientis daavadebas. amisaTvis dasavluri

avtorebi gvTavazoben pacientTan erTad misi Setevebis videomasalis

ganxilvas (Betts 1999; Reuber & Elger 2003).

faS-is Terapia xangrZlivi da Zneli procesia. ar unda velodoT

swraf da myar efeqts, Tundac maSin, rodesac movaxerxebT

fsiqogenuri Setevebis seriis an statusis droul kupirebas.

mizanSewonilia, rom saubarSi pacientis wresTan davadasturoT, rom

Seteva savaraudod ganmeordeba, mxolod am viTarebaSi igi ar

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warmoadgens saSiSroebas, mkurnaloba Seamcirebs mis sixSires da

SesaZlebels gaxdis pacientis integracias gare samyarosTan.

aS-is mkurnalobis sakiTxze aqamde gamoqveynebuli naSromebidan arc

erTi ar warmoadgens randomizirebul kontrolirebad kvlevas.

arsebuli publikaciebi ki atareben retrospeqtiuli dakvirvebis

xasiaTs (Ramani 1993; LaFrance & Devinsky 2002). miuxedavad miRebuli

monacemebisa da mkurnalobis gamosavlis gansxvavebisa, dasavluri

avtorebi Tanxmdebian faS-is fsiqoTerapiis aucileblobaze da

efeqturobaze.

qceviTi Terapia (Ramani 1993; Betts 1999) miznad isaxavs aaridos

pacienti Setevis gamovlenis gaZlierebas da xeli Seuwyos iseT

viTarebas, rodesac igi ar ganicdis Setevebs. amisaTvis saWiroa

pacients Setevis dros mieqces naklebi yuradReba garemomcvelTagan,

romelSic igulisxmebian rogorc pacientis axloblebi da ojaxi,

aseve samedicino personali. amitomac es meTodi, erTi Tvalis

gadavlebiT TiTqos martivia da moxerxebuli, cxovrebaSi ki arcTu

ise ioli dasanergi. meTodis gamoyenebis pirvel etapze Setevebis

raodenoba matulobs, rac prognozulad karg niSnad aris miCneuli,

Semdgom etapze ki yvela pirobebis dacvis SemTxvevaSi, Setevebis

ricxvi Seuqcevadad klebulobs.Pmagram Tuki garemo da zogjer

gauwafavi samedicino personali ver asrulebs saWiro moTxovnebs da

Sesabamisad iqmneba garkveuli konfrontacia, es Terapiuli xerxi

srulad gamoudegaria, rasac xSirad vawydebodiT Cven misi

danergvisas qarTul garemoSi. Tuki pacienti warmoadgens

disfunqciur ojaxs, sadac wevrebs Soris damkvidrebulia

aramdgradi, darRveuli urTierTobebi, aseT viTarebaSi qceviTi

fsiqoTerapia ganwirulia marcxisTvis.

radgan faS garkveulad warmoadgens garegani da Sinagani

stresorebisadmi pirovnebis adaptaciis xerxs, saWiroa am

stresorebis gamoaSkaraveba. kognitiuri Terapia gamiznulia

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gamoavlinos is azrebi da emociebi, romlebic an uswreben, an

gadaizrdebian SetevebSi. maTze kontrolis unaris daufleba

TavisTavad miiyvans pacients Setevebis kontrolis SesaZleblobamde,

rac prodromaluri niSnebis gamovlenis dros iols gaxdis Setevebis

Tavidan aridebas.

faS-Tan mimarTebaSi aseve rekomendirebulia kompleqsuri

Terapiuli midgomebi, sadac ramdenime mkurnalobis meTodi

gamoiyeneba kombinaciaSi (Ramani, 1993; Devinsky, 1998; Reuber & House, 2002;

Reuber & Elger, 2003). mis ganxorcielebaSi usaTuod CarTuli unda iyos

multidisciplinaruli gundi eqimi nevrologis, fsiqiatris (romelic

flobs fsiqoTerapiul meTodebs), fsiqologis, socialuri muSakis

da saTanadod momzadebuli eqTanis SemadgenlobiT. es midgoma

Seicavs avadmyofis premorbidul personologiis srulyofil

analizs, imis gamovlenas, Tu ra gzebiT umklavdeba igi stresul

viTarebas, mimdinare cxovrebiseuli stresorebis gamovlenas da

socialuri daxmarebis xarisxs da moculobas. mkurnaloba SeiZleba

Seicavdes fsiqodinamiur da qceviT fsiqoTerapiul meTodebs.

yvelaze mZime da qronikul SemTxvevebSi, sadac somatizirebuli

aSliloba saxezea mravlobiTi CivilebiT, rekomendirebulia erTi

eqimis arCeva, romelTanac iqneba mimagrebuli pacienti da xSiri

axsna-ganmartebiTi saubrebi simptomebis kavSirze pacientis emociur

statusTan da aqtualur stresorebTan. upirvelesi mizani aseT

SemTxvevaSi aris saswrafo daxmarebis brigadis gamoZaxebebis, yovlad

usafuZvlo da usargeblo gamokvlevebisa da mkurnalobis Semcireba.

faS-is mkurnalobisas fsiqologiuri Terapiis nairsaxeobebi

warmoadgens alternativas, Tumca dRemde ar moipoveba dabejiTebiTi

monacemebi romelimes upiratesobisa, radgan pirvel rigSi faS ar

aris monoetiologiuri problema. etiologiis swori gamovlena da

Terapiuli modalobebis adekvaturi SerCeva, rac am tipis pacientebis

115

swori menejmentis sawindaria, aseve damokidebulia imaze, Tu

ramdenad gamocdilia am sakiTxSi praqtikosi eqimi, romelsac

mimarTavs pacienti.

116

daskvnebi:

1. somatoformuli diagnozebis sixSire (ICD-10-s kriteriumebiT) ar

aRemateba 3.69% yvela im diagnozis ricxvidan, romelic iyo

gamotanili 2 wlis manZilze klinikuri nevrologiis

ganyofilebaSi hospitalizirebul pacientebSi. es maCvenebeli

sagrZnoblad naklebia bolodroindel gamoqveynebul Sedegebze

(20.5-25% – Ekstrand et al., 2004; Fink et al., 2005), rac ganpirobebulia

mravali mizeziT. Tuki zemoaRniSnul kvlevebze gavavrcelebT

CarTvis mkacr kriteriumebs, romelic Cvens kvlevaSi aris

gamoyenebuli, prevalensis maCvenebeli daiklebs 10%-de. ukve am

maCveneblis gansxvaveba Cvens mier miRebul sixSireze aixsneba

kvlevebis meTodologiuri gansxvavebiT (klinikuri Sefaseba

naxevradstruqturirebuli intervius CaTvliT Cvens SemTxvevaSi

da skriningi specializirebuli diagnostikuri interviuTi

dasavlur kvlevebSi) da SesaZloa populaciis socio-ekonomikuri

mdgomareobiT, rac ganapirobebs specializirebuli klinikaSi

mimarTvianobis suraTs. konversiuli aSliloba, rogorc

mosalodneli iyo, sWarbobda am kontingentSi (69.6%), rac srulad

esadageba dasavlur monacemebs (66.7% - Thomassen et al., 2003).

2. nevrologiur klinikaSi moTavsebul pacientebs Soris auxsneli

somaturi simptomebi umetes wilad wardgeba Tavis tkivilis,

guliscemisa da Setevebis (paroqsizmebis) saxiT. funqciuri

simptomebis aseTi speqtri da maT Soris paroqsizmuli

mdgomareobebis maRali sixSire savaraudod ganpirobebulia

populaciis eTno-kulturuli TaviseburebebiT, kerZod, sxeulisa

da janmrTelobis aRqmis fsiqobiologiuri faqtorebiT.

diagnostikur WrilSi ki disociaciuri (konversiuli) aSliloba

sagrZnoblad aRemateba somatizirebul aSlilobas (80-85% vs. 15-

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20%). moyvanili monacemebi korelirebs dasavlur publikaciebSi

gamoqveynebul maCveneblebTan.

3. rodesac nevrologiuri Civilebis Sesatyvisi organuli

dazianebia ar gamovlindeba (anu somatizaciis pirobebSi),

maRalia am Civilebis gamomwvevi mentaluri darRvevis arsebobis

Sansi (77%). amitom, mizanSewonilad migvaCnia amgvari pacientis

mimarT gamokvlevebis ganmeorebisa da gaxangrZlivebis, an Tundac,

Sewyvetisa da gaweris nacvlad Catardes detaluri

neirofsiqiatriuli gamokvleva mentaluri darRvevis gamovlenis

mizniT. aRniSnuli nabijebi xels Seuwyobs diagnostikuri

procesisaTvis gankuTvnil drois da xarjebis Semcirebas da

daaCqarebs pacientis CarTvas misTvis Sesabamis Terapiul

procesSi.

4. konversiuli (funqciuri) nevrologiuri simptomebis diagnozi ar

unda eyrdnobodes mxolod nevrologiuri gamokvlevebis negatiur

pasuxebs. igi aseve unda Seicavdes pozitiuri diagnostikis

elementebs, kerZod, garkveuli testebis gamoyenebas motoruli da

sensoruli deficitis dros da mentaluri statusisa da

fsiqosocialuri premorbidis detalur Seswavlas, gansakuTrebiT

Setevebis araepilefsiur bunebaze eWvis dros. es miiRweva mxolod

nevrologiuri, fsiqologiuri da fsiqiatriuli samedicino

rgolebis erToblivi (multidisciplinuri) muSaobiT.

5. paroqsizmuli darRvevis bunebis dasadgenad da mosalodneli

diagnostikuri Secdomebis asacileblad ganmeorebiTi

paroqsizmebis genezi ar unda CaiTvalos apriori epilefsiurad.

etiologiur faqtorebs Soris Tanabrad unda ganixilebodes aseve

endokrinuli, kardiologiuri da fsiqologiuri paTologia.

ukanasknelis gamovlenis SemTxvevaSi diagnostikuri procesi ar

unda dasruldes, aramed gagrZeldes konkretuli mentaluri

darRvevis gamovleniT, romelic vlindeba faS-iT. am amocanis

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dasaZlevad Cvens mier aris warmodgenili srulyofili

diagnostikuri algoriTmi, romlis pozitiuri diagnostikis

qvakuTxeds warmoadgens mentaluri statusis Sefaseba.

6. fsiqogenuri araepilefsiuri Setevebi Tavisi klinikuri

gamovlinebebiT SeiZleba daiyos oTx jgufad: demonstraciuli,

aforiaqebuli, didi gulyrisa da gulswasvlis msgavsi. Cven

vvaraudobT, rom sqesi SeiZleba iyos dakavSirebuli faS-is

semiologiasTan. kerZod, didi gulyrisa da guliswasvlis msgavsi

Seteva ufro xSiria qalebSi, maSin rodesac demonstraciuli

Setevebi ki - mamakacebSi.

7. fsiqogenuri araepilefsiuri Setevebis etiologiur mizezebs

Soris aRsaniSnavia qalis socialuri da ojaxuri diskriminacia,

rac rig SemTxvevebSi warmoadgens kulturalur faqtorebsa

(tradiciebs) da personis aracnobier moTxovnilebebs Soris

konfliqtis ukidures gamovlenas. sxva modelebs Soris

niSandoblivia ganswavluli qcevis paterni, rasac individi

sabolood miyavs avadmyofis rolis miTvisebamde. Cvens

sazogadoebaSi iSviaTi (da aqedan gamomdinare naklebad

mniSvnelovani rogorc etiolgoiuri faqtori) aRmoCnda fizikuri

da seqsualuri Zaladobis istoria, rac kidevac mosalodneli

iyo. magram cxovrebis esTetiuri da socialuri standartebis

swrafi cvlisa da arevis pirobebSi savaraudoa ukanaskneli

faqtoris rolis wamoweva.

8. faS-is gamovlenili klinikuri formebi ar aris srulyofilad

asaxuli mentaluri da qceviTi darRvevebis Tanamedrove

taqsonomiebSi. maSin, rodesac motoruli formebi iolad etevian

konversiuli(disociaciuri) krunCxvebis diagnsotikur erTeulSi

(F44.5 – ICD-10; 300.11–DSM-IV), aramotoruli formebisaTvis ar

moiZebneba maTTvis Sesatyvisi diagnostikuri kategoria, ris

gamoc isini moiazrebian an araspecifiur disociaciur an kidevac

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posttravmul stresul aSlilobis qveS. aRniSnuli situacia

savaraudod ganpirobebulia imiT, rom nevrologebi

(epileftologebi) ar iyvnen CarTuli klasifikatorTa jgufSi,

rac gasaTvaliswinebelia momavalSi, kerZod DSM-V mzadebis

procesSi.

9. somatoformuli aSlilobebis (mravalferovani nevrologiuri

gamovlinebebiTa da maT Soris faS-iT) menejmenti

mravalwaxnagovani da rTulia. arc Tu ise martiv diagnostikur

procesTan erTad igi moicavs fsiqotropul medikamentebTan

erTad mkurnalobis fsiqologiur da fsiqiatriul midgomebs.

menejmentis Sedegianoba miiRweva rogorc pacientTan momuSave

samedicino gundis mudmivobiT, aseve masSi fsiqologebisa,

fsiqiatrebis (neirofsiqiatrebis) da fizioTerapevtebis

aucilebeli CarTviT. aRniSnuli metyvelebs funqciuri

nevrologiuri sindromebis polietiologiuri hipoTezis

sasargeblod.

120

praqtikuli rekomendaciebi

bolodroindeli literaturuli monacemebis safuZvelze

somatoformuli aSlilobebis globaluri tvirTi aRemateba sxva

qronikuli daavadebebis an zogadTerapiuli pacientis tvirTs.

saqarTvelos saerTo ekonomiur-politikuri viTarebidan gamomdinare

somatizaciis mqone pacientTa sicocxlis xarisxi ar unda

aRematebodes imas, rac ganviTarebul qveynebSia dadgenili. am saerTo

suraTis Sesacvlelad mizanSewonilia kompleqsuri saxelmwifoebrivi

midgoma, rac gulisxmobs :

• pirvel rigSi swori da Tanamedrove ganaTlebis uzrunvelyofas

saunoversiteto swavlebis programis farglebSi. fsiqologiuri

kursis aucilebeli Setana gavlenas moaxdens momavali mkurnalis

swori warmodgenis CamoyalibebaSi.

• radgan auxsneli somaturi simptomebi gvxvdeba samedicino qselis

nebismier rgolSi da specialobaSi, saWiroa eqimebis farTo CarTva

treiningebsa da leqcia-seminarebSi, sadac iqneba miwodebuli

funqciuri somaturi sindromebis irgvliv uaxlesi informacia da

diagnostikuri sqemebi. miRebuli codna iqneba sawindari

somatizaciis drouli da swori gamovlenisa, rogorc jandacvis

pirvelad rgolSi aseve specializirebul klinikebSi.

• erTiani sakoordinacio centris Seqmnas, romelsac daevaleba

rogorc adekvaturi codnis gavrvelebis kompaniis warmoeba, aseve

kliniko-epidemiologiuri sakiTxebis monitoringi, romelic

fokusirebuli unda iyos diagnostikuri vadebis optimizaciaze da

diagnostikuri saSualebebis Tadarigian gamoyenebaze, rac

somatizaciiT gamowveuli globaluri tvirTis Semcirebis winapiroba

gaxdeba.

121

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sarCevi

Tavi 1. masala da gamokvlevis meTodebi 2

Tavi 2. auxsneli somaturi simptomebi – somatoformuli

aSlilobebis mTavari klinikuri gamovlena 7

epidemiologia 24

somatizaciis tvirTi 29

Tavi 3. fsiqogenuri nevrologiuri simptomebi 34

simptomebis generaciis meqanizmi 38

klinikuri gamovlena 44

Tavi 4. fsiqogenuri araepilefsiuri gulyrebi 52

diagnostika 53

fsiqogenuri araepilefsiuri Setevebis fsiqologiuri axsna 73

fsiqogenuri araepilefsiuri Setevebi mentaluri darRvevebis

Tanamedrove taqsonomiebSi 81

fsiqogenuri araepilefsiuri Setevbis ganaxlebuli

diagnostikuri algoriTmi 82

Tavi 5. funqciuri somaturi simptomebis etiologiuri modeli 94

Tavi 6. somatoformuli aSlilobebis menejmenti 102

Ffsiqogenuri araepilefsiuri Setevebis mkurnaloba 108

daskvnebi 116

praqtikuli rekomendaciebi 120

literatura 121

sarCevi 140

danarTi 141

141

danarTi tabula #1. 1997-1998 wlebSi hospitalizirebuli pacientTa kohorta,

romlebSic paroqsizmaluri darRvevis mizezad ar gamovlinda epilefsia

(araepilefsiuri Setevebis gamomwvevi darRvevebisa da interiqtaluri eeg-

cvlilebebis kvlevis jgufebi)

1997-1998 asaki sqesi Setevis

saxeoba

diagnozi

(ICD-10)

damatebiTi

informacia

1 24 md stupori,

krunCxvebi

dak

2 45* md stupori,

krunCxvebi,

sensoruli

dak eeg kvlevis

jgufi;

Tqt

3 20* md krunCxvebi,

sensoruli

dak eeg kvlevis

jgufi

4 14* md krunCxvebi dak,

epilefsia

eeg kvlevis

jgufi

5 27* md krunCxvebi dak,

epilefsia

eeg kvlevis

jgufi

6 14 md krunCxvebi dak,

epilefsia

7 22 mamr krunCxvebi,

sensoruli

dak

8 25 mamr krunCxvebi dak,

epilefsia

9 21* md gulis

wasvla

dad eeg kvlevis

jgufi

10 23 md gulis

wasvla

dad

11 25 md gulis

wasvla

dad

12 18 md gulis dad

142

wasvla

13 19 mamr gulis

wasvla

dad

14 25 md pa

15 31 md pa

16 40 md pa

17 31 mamr pa

18 28 mamr pa

19 16 md sinkope

20 25 md sinkope

21 13 md sinkope

22 53 md sinkope

23 16 mamr sinkope

24 35 md depresia

25 38 mamr depresia

26 18* md sad eeg kvlevis

jgufi

27 21 md sad

28 22 mamr sad

29 26 mamr sad

30 45 md sa

31 50 md sa,

epilefsia

32 52 md simulacia

33 16 md spazmofilia

34 14 mamr parasomnia

35 32 md hipoglikemia

143

tabula #2. 2000-2001 wlebSi hospitalizirebuli pacientTa kohorta,

romlebsac daudgindaT fsiqikuri darRvevebi (somatoformuli

aSlilobebisa/auxsneli somaturi simptomTa da faS-is semiologiuri

klasifikaciis kvlevis jgufebi)

2000

weli

asaki sqesi Setevis saxeoba diagnozi

1 21 md gulis wasvla dad/dak Sereuli

2 24 md gulis wasvla dad

3 20 md gulis wasvla sa

4 31 mamr demonstraciuli dak Tqt

5 43 md demonstraciuli dak fizikuri

Zaladoba,

Tqt

6 17 mamr demonstraciuli dak

7 28 mamr demonstraciuli dak stupori,

Tqt

8 17 mamr aforiaqebuli dak

9 18 md didi gulyris

msgavsi

dak fizikuri

Zaladoba

10 27 mamr didi gulyris

msgavsi

dak/ptsa

11 29 mamr - sa

12 22 md sad

13 29 mamr pa

14 45 md pa

15 27 mamr pa alkoholis

miRebis

Sewyveta

16 30 md nevrasTenia

2001 weli

17 16 md gulis wasvla dad

18 44 mamr gulis wasvla dad (dak?) Tqt

144

19 24 mamr demonstraciuli dak Tqt

20 23 md demonstraciuli ptsa

21 21 md aforiaqebuli,

didi gulyris

msgavsi

dak


msgavsi

sa


msgavsi

dak

24 15 md asa

25 40 md sad

26 32 mamr ip

27 22 md - dad stupori

28 41 md - dak

29 46 mamr depresia

30 33 md gSa

31 20 mamr ptsa

32 41 md sinkope

33 18 mamr disTimia

34 42 mamr disTimia

35 33 mamr SfoTva?

36 49 md depresia

37 18 md vazovagaluri

sinkope

diagnozebi mocemulia ICD-10 klasifikaciis Tanaxmad: dak – disociaciuri

aSliloba (konversiuli tipi); dad – disociaciuri aSliloba

(disociaciuri tipi), pa – panikuri aSliloba, sad-somatoformuli

avtonomiuri disfunqcia; sa-somatizirebuli aSliloba, Tqt-Tavisqala

travma. ptsa-posttravmuli stresuli aSliloba, ip-ipoqondria, gSa-

generalizebuli SfoTviTi aSliloba, asa-aradiferenculi somatoformuli

aSliloba.

tpnbupgpsnvmj!btmjmpcfcj!ofwspmphjvs! lmjojlbtj! · 2 1. masala da gamokvlevis metodebi kvlevis...

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