1、百度文庫(kù)-讓每個(gè)人平等地提升自我一例社交焦慮障礙患者的循證治療姓名錢(qián)潔學(xué)號(hào)00病例患者，女性，26歲.在一家外資企業(yè)工作，雖然業(yè)務(wù)工作表現(xiàn)尚可，但幾乎從不參加聚會(huì)，吃飯和集體外出，每次皆找借口而回避.患者自中學(xué)時(shí)代便有不和群，不善交際，過(guò)度內(nèi)向，怕見(jiàn)陌生人和害怕被注目.經(jīng)常會(huì)臉紅，曾被同學(xué)戲稱(chēng)為“害羞女生”.近三個(gè)月來(lái)癥狀明顯加重，因?yàn)楸惶嵘秊榻?jīng)理秘書(shū)經(jīng)常要參加會(huì)議，文字準(zhǔn)備工作較多，但患者發(fā)現(xiàn)在做記錄寫(xiě)字或電腦打字時(shí)都會(huì)手抖，怕被人注意，經(jīng)常要找借口請(qǐng)假不參加會(huì)議.為此，患者痛苦不堪.評(píng)估患者情況并提出問(wèn)題該患者在社交場(chǎng)合顯著才e久的怕被人審視，在該情景中會(huì)焦慮，有明確的回避行為，這種癥狀自

2、中學(xué)時(shí)代就有，近三個(gè)月來(lái)加重，符合CCMD-3的診斷標(biāo)準(zhǔn)，為典型的社交焦慮障礙患者.目前社交焦慮障礙的治療主要分為心理治療和藥物治療.心理治療有認(rèn)知行為療法，森田療法等藥物治療有抗焦慮藥，單氨氧化酶抑制劑，SSRI.以及兩個(gè)相結(jié)合治療.針對(duì)該患者的情況，提出以下問(wèn)題：1).該種患者應(yīng)該首選何種治療方式？哪種效果更優(yōu)？2)藥物治療與心理治療相比較在長(zhǎng)期有效性與復(fù)發(fā)的問(wèn)題上，何者更優(yōu).文獻(xiàn)證據(jù)檢索文獻(xiàn)檢索資源：數(shù)據(jù)庫(kù)：Pubmed;TheCochranelibrary檢索主題詞：PhobicDisorders,socialphobia,socialanxietydisorder檢索Z果Pubmed

3、中豐題詞檢索PhobicDisorders,選中副主題詞therapy和drugtherapy.檢索式為：(socialphobiaanddrugtherapy)ANDsystematicsb共檢出31篇，以下4篇緊密相關(guān).1. Psychologicalandpharmacologicaltreatmentsofsocialphobia:ameta-analysis.JClinPsychopharmacol.2001Jun;21(3):311-24.,.PMID:PubMed-indexedforMEDLINE2. Pharmacotherapyforsocialphobia.Cochran

4、eDatabaseSystRev.2004Oct18;(4):CD001206.Review.PMID:PubMed-indexedforMEDLINE,.3. Theevidence-basedpharmacologicaltreatmentofsocialanxietydisorder.IntJNeuropsychopharmacol.2003Dec;6(4):427-42.Review.,.PMID:PubMed-indexedforMEDLINE4. Pharmacologicaltreatmentofsocialanxietydisorder:ameta-analysis.Depre

5、ssAnxiety.2003;18(1):29-40.,.PMID:PubMed-indexedforMEDLINECochraneCbrary簡(jiǎn)單檢索:socialphobia5篇淇中一篇相關(guān).1. Psychologicalandpharmacologicaltreatmentsofsocialphobia:ameta-analysis.JClinPsychopharmacol.2001Jun;21(3):311-24./PMID:PubMed-indexedforMEDLINE為Pubmed中的第一篇.評(píng)價(jià)證據(jù)/1. 2001年，.的”社交焦慮障礙的心理治療和藥物治療”的Meta分析中，

6、對(duì)十一種治療方法做了比較：完全對(duì)照組，藥物安慰劑對(duì)照組，苯二氮卓治療組，SSRI治療組，單氨氧化酶抑制劑，注意力安慰劑組，暴露療法組，認(rèn)知治療組，暴露加認(rèn)知治療組，社交技巧訓(xùn)練組，放松治療組.得出的結(jié)論是：治療社交恐怖癥始終有效的是藥物治療，SSRI與苯二氮卓同樣有效，且受試者退出率與其他組無(wú)顯著差別，耐藥性由于沒(méi)有足夠的隨訪數(shù)據(jù)的藥物研究而無(wú)法評(píng)彳t，而心理治療組雖然效果中等，但是隨訪長(zhǎng)期效果好，療效在治療結(jié)束后仍然起作用.相比較之下，SSRI與苯二氮卓對(duì)與治療社會(huì)恐怖癥是有效的，至少在短期療效顯著.2. 2004年等的一篇題為“社會(huì)恐怖癥的藥物治療”的綜述，主要以評(píng)估社會(huì)恐怖癥藥物治療是否

7、比其他治療方法更加有效為目的做了分析.得出結(jié)論：分析后證據(jù)指出，與其他治療方法相比較，藥物治療的短期療效是肯定的，尤其是SSRI的療效非常顯著.并且，數(shù)據(jù)肯定了對(duì)藥物治療有效的受試者的長(zhǎng)期效果.3. 2003年，等的一篇綜述題為：社交焦慮障礙的詢(xún)證基礎(chǔ)上的藥物治療對(duì)發(fā)表的安慰劑對(duì)照研究和Meta分析做了研究.提出了三個(gè)問(wèn)題：社交焦慮障礙的第一線藥物是什么？治療療程應(yīng)為多久？當(dāng)有抗藥性的情況出現(xiàn)應(yīng)當(dāng)如何處理？分析指出：SSRIs對(duì)大多數(shù)患者來(lái)說(shuō)應(yīng)為第一線藥物，而對(duì)于治療的最適療程沒(méi)有足夠的可用信息.然而數(shù)據(jù)彳向于12-20周后停藥的病人比繼續(xù)接受治療的更加容易復(fù)發(fā).無(wú)足夠?qū)嶒?yàn)室證據(jù)指出抗藥性的病

8、例的處理辦法.臨床經(jīng)驗(yàn)顯示SSRI無(wú)效的患者可能對(duì)大劑量的地西泮或者加巴噴丁有效，或者轉(zhuǎn)用MAOIs,RIMAs,地西泮或者加巴噴丁.另外，認(rèn)知行為治療可能是有幫助的4. 2003年，,等的一項(xiàng)題為：社交焦慮障礙的藥物治療的Meta分析中，重點(diǎn)研究了藥物治療中各個(gè)藥物間的療效差異，得出結(jié)論，藥物治療有效依次為苯乙腫,氯硝安定，加巴噴丁，澳法羅明，SSRI.這些藥物間的療效差別無(wú)統(tǒng)計(jì)學(xué)意義.但是，正規(guī)的方法分析有明顯的證據(jù)支持SSRI和澳法羅明有明顯的優(yōu)勢(shì)療效.另外，在穩(wěn)定性，安全性療效和耐藥性等多方面都顯示支持SSRI作為第一線藥物.回答問(wèn)題問(wèn)題1)該患者應(yīng)首選藥物治療還是心理治療？第一篇文章

9、中明確指出：治療社交恐怖癥始終有效的是藥物治療，并且與心理治療做了對(duì)照研究.綜合以上四篇文獻(xiàn)分析，各項(xiàng)證據(jù)都指向于首選SSRI類(lèi)藥物作為第一線藥物，對(duì)這類(lèi)藥物的療效耐藥性安全性都有一定的肯定.并且有對(duì)照研究表明，藥物的療效要優(yōu)于心理治療療效.故對(duì)該病人而言，可以首選SSRI類(lèi)藥物.問(wèn)題2)藥物治療與心理治療相比較在長(zhǎng)期有效性與復(fù)發(fā)的問(wèn)題上，何者更優(yōu).?第一篇文章中指出：心理治療組雖然效果中等，但是隨訪長(zhǎng)期效果好，療效在治療結(jié)束后仍然起作用.但縱觀以上文獻(xiàn)摘要，藥物治療的長(zhǎng)期有效性及復(fù)發(fā)的問(wèn)題沒(méi)有明確的結(jié)論，與心理治療相比較沒(méi)有數(shù)據(jù)明確支持何者更優(yōu).但是心理治療的效果與安慰劑組相比也是有效的.制

10、定用于患者的方案/首選SSRI類(lèi)藥物治療，可以以心理治療作為輔助治療./效果評(píng)價(jià)/摘要/摘要1.Ameta-analysisofpsychologicalandpharmacologicaltreatmentsforsocialphobiawasconductedtoevaluatewhetherthevarioustreatmentsdifferintheirefficacyfortreatingsocialphobia,whethertheyaremoreeffectivethanwait-listandplacebocontrols,whetherratesofattritiondiff

11、er,andwhethertreatmentgainsaremaintainedatfollow-up.Atotalof108treatment-outcometrialsforsocialphobiametinclusion/exclusioncriteriaforthemeta-analysis.Eleventreatmentconditionswerecompared:wait-listcontrol,pillplacebo,benzodiazepines(BDZs),selectiveserotoninreuptakeinhibitors(SSRIs),monoamineoxidase

12、inhibitors,attentionplacebo,exposure(EXP),cognitiverestructuring(CR),EXPplusCR,socialskillstraining,andappliedrelaxation.Themostconsistentlyeffectivetreatmentsforsocialphobiawerepharmacotherapies.BDZsandSSRIswereequallyeffectiveandmoreeffectivethancontrolconditions.Dropoutratesweresimilaramongallthe

13、activetreatmentconditions.Assessmentofthedurabilityoftreatmentgainsforpharmacotherapieswasnotpossiblebecauseaninsufficientnumberofdrugstudiesincludedfollow-updata.Thetreatmentgainsofpsychologicaltherapies,althoughmoderate,continuedduringthefollow-upperiod.BDZsandSSRIsseemtobeeffectivetreatmentsforso

14、cialphobia,atleastintheshortterm.Recommendationsforfutureresearchincludeassessingthelong-termoutcomeforpharmacotherapiesandevaluatingtheinclusionofacognitive-behavioraltreatmentduringthedrugtaperingperiod.摘要:Socialphobia(SP),orsocialanxietydisorder,isaprevalentanddisablingdisorder.Thereisgrowingevid

15、encethatSPismediatedbyspecificneurobiologicalfactors,andincreasedinterestintheuseofmedicationinitstreatment.OBJECTIVES:ToassesstheeffectsofpharmacotherapyforSocialPhobia,andtodeterminewhetherparticularclassesofmedicationaremoreeffectiveand/oracceptablethanothersinitstreatment.SEARCHSTRATEGY:Studieso

16、fthepharmacotherapyofSPwereidentifiedusingliteraturesearchesoftheCochraneDepression,Anxiety&NeurosisGroup(CCDAN)specialisedregister,theCochraneCentralRegisterofControlledTrials(TheCochraneLibraryissue1,2004),MEDLINE(1966to2003)andPsycLit(1966to2003).Inaddition,publishedandunpublishedRCTswererequeste

17、dfromSPresearchersandpharmaceuticalcompaniesandadditionalstudiesofanylanguageweresoughtinreferencelistsofretrievedarticles.SELECTIONCRITERIA:AllRCTsofthepharmacotherapyofSPwereconsideredforthereview.DATACOLLECTIONANDANALYSIS:ThequalityofselectedRCTswasindependentlyassessedby2ratersontheCCDANQualityR

18、atingScale,withthesameraterscollatingdataontreatmentresponseandSPsymptomratings.Investigatorswerecontactedtoobtainmissingdata.Summarystatisticswerestratifiedbymedicationclass(SSRIs-selectiveserotoninreuptakeinhibitors;MAOIs-Monoamineoxidaseinhibitors;RIMAs-reversibleinhibitorsofmonoamineoxidaseA),fr

19、omwhichdichotomousandcontinuousmeasureswerecalculated,heterogeneitywasassessed,andsubgroup/sensitivityanalysesundertaken.MAINRESULTS:36RCTsofarangeofmedicationswereincludedintheanalysis(4268participants),ofwhich26wereshort-term(14weeksorless).Afunnelplotprovidedevidenceofpublicationstatisticsforresp

20、onderstatus(assessedusingtheClinicalGlobalImpressionsscalechangeitem(CGI-C)from25short-termcomparisonsdemonstratedsuperiorityofvariousmedicationagentsoverplacebo(relativeriskofnon-response(RR)=;95%CI=,;randomeffectsmodel).Responsetotreatmentbyserotoninreuptakeinhibitors(N=11;RR=;95%CI=,MAOIs(N=3;RR=

21、;95%CI=,andRIMAs(N=6;RR=;95%CI=,supportedthevalueoftheseagents.However,theSSRIsweresignificantlymoreeffectivethantheRIMAs(Deeksstratifiedtestofheterogeneity(Deeks2001):Qb=;p.SummarystatisticsforSPsymptomsfrom16comparisonsusingtheLiebowitzSocialAnxietyScale(LSAS)showedastatisticallysignificantdiffere

22、ncebetweenmedicationandplacebo(weighedmeandifference=,95%CI=,withthiseffectonceagainmostevidentfortheSSRIs.MedicationwasalsosignificantlysuperiortoplaceboinreducingSPsymptomclusters,comorbiddepressivesymptoms,andassociateddisability.Thevalueoflong-termmedicationtreatmentintreatmentresponderswassuppo

23、rtedby3comparisonsfrommaintenancestudies(relativeriskofnon-response=;95%CI=,and5comparisonsfromrelapsepreventionstudies(relativeriskofrelapse=;95%CI=,.REVIEWERSCONCLUSIONS:ThisreviewprovidesevidencethatmedicationcanbeeffectiveintreatingSPovertheshortterm,withthestrongestevidenceoftreatmentefficacyob

24、servedamongsttheSSRIs.Furthermore,thedatasupportcontinuedpharmacotherapyinmedicationrespondersoverthelonger-term.Nevertheless,thepossibilityofpublicationhastobeacknowledged.AdditionalissuesforfutureresearchincludetheuseofmedicationinchildrenandadolescentswithSP,andinSPwithcomorbidpsychiatricdisorder

25、s.摘要3.Socialanxietydisorder(SAD)isahighlyprevalentandoftendisablingdisorder.ThispaperreviewsthepharmacologicaltreatmentofSADbasedonpublishedplacebo-controlledstudiesandpublishedmeta-analyses.Itaddressesthreespecificquestions:Whatisthefirst-linetreatmentofSAD?Howlongshouldtreatmentlast?Whatshouldbeth

26、emanagementoftreatment-resistantcases?BasedontheirefficacyforSADandcommoncomorbiddisorders,tolerability,andsafety,SSRIsshouldbeconsideredasthefirst-linetreatmentformostpatients.Lessinformationisavailableregardingtheoptimallengthoftreatment,althoughindividualswhodiscontinuetreatmentafter12-20wkappear

27、morelikelytorelapsethanthosewhocontinueonmedication.Evenlessempiricalevidenceisavailabletosupportstrategiesfortreatment-resistantcases.ClinicalexperiencesuggeststhatSSRInon-respondersmaybenefitfromaugmentationwithbenzodiazepinesorgabapentin,orfromswitchingtoMAOIs,RIMAs,benzodiazepinesorgabapentin.Co

28、gnitive-behaviouraltherapymayalsobeahelpfuladjunctoralternative.摘要4.Placebo-controlledtrialshaveevaluatedtheefficacyofseveralmedicationsinthetreatmentofsocialanxietydisorderbutinformationregardingtheirrelativeefficacyislacking.Wecomparedtheefficacyofmedicationssystematicallystudiedforthetreatmentofs

29、ocialanxietydisorderusingmeta-analytictechniques.ThemethodologyincludedadatabasesearchofarticlespublishedbetweenJanuary1980andJune2001andmanualsearchesofbibliographiesinpublishedmanuscripts.TrialswereincludediftheyreportedoutcomedataontheLiebowitzSocialAnxietyScale(LSAS)oracategoricalmeasureofresponderstatus.Datawereextractedind