ეს პროექტი დაფინანსებულია ევროკავშირის მიერ. wameba. Sedegebi, diagnostika, eqspertiza da reabilitacia. (saxelmzrvanelo klinicistebisatvis)

Transkript

1 ეს პროექტი დაფინანსებულია ევროკავშირის მიერ wameba!! Sedegebi, diagnostika, eqspertiza da reabilitacia (saxelmzrvanelo klinicistebisatvis) თბილისი

2 This Project is Funded by the European Union Torture Qonsequenses, Diagnostics, Expertise and Rehabilitation (Manual for Clinicians) Tbilisi

3 ს ა რ ჩ ე ვ ი ნაწილი I წამება, ზოგადი საკითხები, ფსიქიკური / ფსიქოლოგიური საკითხები თავი 1- წამება....5 თავი 2 - წამების მეთოდები... 7 თავი 3 - წამების შედეგები თავი 4 - დიაგნოსტიკა და ექსპერტიზა...77 თავი 5 - მკურნალობა და რეაბილიტაცია...92 დანართი 1 - პოსტტრავცმული სტრესული აშლილობის მკურნალბის ექსპერტთა შეთანხმებული გაიდლაინების ზოგიერთი სქემა 100 დანართი 2 - წამების მსხვერპლთა მონიტორინგისა და რეაბილიტაციის სამედიცინო და ფსიქო - სოციალური პროგრამა..113 გამოყენებული ლიტერატურა ნაწილი II ფიზიკური საკითხები თავი 1 - სასამართლო სამედიცინო ექსპერტიზა საქართველოში 130 თავი 2 - სხეულის დაზიანების სასამართლო სამედიცინო ექსპერტიზის საკითხები თავი 3 - წამების ფიზიკური მტკიცებულებები თავი 4 - წამება და მისი პრევენცია სტამბოლის პროტოკოლის მიხედვით 145 თავი 5 - საკანონმდებლო საკითხები წამების, მისი პრევენციის და სასამართლო ექსპერტიზის საკითხებთან დაკავშირებით თავი 6 - სტამბოლის პროტოკოლის გამოყენება სამედიცინო-ფიზიკური გამოკვლევისათვის

4 nawili I ზოგადი და fsiqikuri/fsiqologiuri sakitxebi mariam jiskariani, msoflio fsiqiatrta asociaciis seqciis wamebis fsiqologiuri Sedegebi da arkveta sabwos wevri wamebis msxverplta reabilitaciis centri empatia, (RCT/EMPATHY, Georgia) Address: 23 Kandelaki Str. Tbilisi, 0160, Georgia. Phone/Fax: + ( ) E mail : centre@empathy.ge URL: Tbilisi

5 Tavi I. wameba wamebis ganmarteba (gaeros wamebis sawinaarmdego konvencia muxli1). arnisnuli konvenciis Tanaxmad wamebis definicia Semdegia: nawili I muxli 1. am konvenciis miznebisatvis gansazrvreba wameba nisnavs nebismier moqmedebas, romlitac romelime pirs ganzrax ayeneben tkivils an tanjvas, fizikurs an zneobrivs, rata misgan an mesame pirisgan miiron cnobebi an ariareba, dasajon qmedebisatvis, romelic man an mesame pirma Caidina an romlis CadenaSic igi ewvmitanilia, agretve daasinon an aizulon igi an mesame piri an nebismieri mizezit, romelsac safuzvlad udevs nebismieri xasiatis diskriminacia, roca aset tkivilsa da tanjvas ayenebs, saxelmwifos Tanamdebobis piri an sxva oficialuri piri, an mati waqezebit, nebartvit da mdumare TanxmobiT. wameba warmoadgens arahumanuri, adamianuri Rirsebis Semlaxavi mopyrobisa da dasjis ukidures formas. wamebis mizani jalatebis mier mowodebuli axsna ganmartebebis Tanaxmad, xsir SemTxvevaSi, isini Tavs imartleben, rom wameba emsaxureba informaciis mopovebas, gansakutrebit ki isini amartleben wamebis gamoyenebas im SemTxvevebSi, roca saqme exeba teroristebis dakavebas da sazogadoebisatvis sasis damnasaveebs, sazogadoebis usafrtxoebisatvis sawiro informaciis mopovebas; Tumca unda arinisnos, rom aseti formulireba ar asaxavs wamebis WeSmarit mizans da mxolod Tavis martlebis formaluri xasiatis matarebelia. rogorc acvena msofliosi Catarebulma kvlevebma da aseve Cvens mier wlebis manzilze Seswavlili wamebis SemTxvevebis statistikurma Tu fsiqo socialurma analizma, wamebis umtavres mizans Seadgens: pirovnebis saboloo gatexva ganadgureba, misi momavlis sruli ganadgureba; misi fsiqo socialuri funqcionirebis sruli mosla. zogadad sazogadoebis dasineba terorizireba, xsir SemTxvevaSi, iseti danasaulis ariareba, romelic arnisnul pirovnebas ar Caudenia; izuleba, gaxdes informatori, an miawodos informacia sxva adamianebze, xsirad ki imgvar faqtebze, romelic am sxva adamianebs ar CaudeniaT; xsir SemTxvevaSi wameba da sastiki mopyroba emsaxureba EeTnikuri nisnit Seuracxyofisa da datrgunvis motxovnilebas; aseve armsareblobisa da ideologiis gamo pirovnebis damcirebasa da ganadgurebas; 5

6 xsir SemTxvevaSi, wameba rogorc Tavis Tavad arasamartlebrivi qmedeba, xdeba sasualeba kriminaluri samartlis damkvidrebisa, rogoric aris fulis gamozalvis miznit adamianta dapatimreba, xsir SemTxvevaSi ukanono, Zalovani struqturebis mxridan reketireba da terorizireba; Zalze xsirad amgvari qmedeba dakavsirebulia jalatta sadistur tendenciebtan. da bolos, wamebis praqtika uryevi safuzveli xdeba avtoritaruli saxelmwifos urtiertobebisa da globalurad emsaxureba sazogadoebis ukidures dasinebasa da datrgunvas, rata mat ar mimarton raime saxis protests da ver gabedon arsebuli rejimis winaarmdeg galasqreba. amgvarad, wameba ara marto pirovnebis fizikur da fsiqologiur ganadgurebas emsaxureba, aramed mas ufro farto da zogadi danisnuleba gaacnia, iseti rogoric aris socialuri da politikuri Sedegebi, rogorc calkeuli qveynebisatvis, aseve mteli kacobriobisatvis. igi mtels kacobriobasi Tesavs SemaZrwunebeli SiSis, umweobisa da morcilebis gancdebs, romelic gadaecema mtel rig Taobebs da xsir SemTxvevaSi, aracnobierad ayalibebs qcevis stereotipebs, rogorc potenciur jalatta Soris (saxelmwifo manqanis warmomadgenelni), aseve potenciur msxverplta Sorisac da xdeba safuzveli mtel rig saxelmwifoebsi stabiluri da Znelad transformirebadi, myari avtokratuli mmartvelobis stereotipis Camoyalibebisa. socialur-politikuri TvalsazrisiT, mteli rigi avtorebi wamebas ganixilaven Semdegnairad: Lira (1995): ufro fartod rom ganvixilot, wamebis mizania daasinos mesame mxareebi da sazogadoebasi gamowvios SiSi, datrgunva, paralizeba, uunaroba da morcileba. adamianis uflebebis darrveva ar unda ganvixilot gancalkevebulad mxolod erti pirovnebis uflebebis darrvevis gadmosaxedidan. mati Sedegebi mravlismomcvelia, radgan isini asaxaven ara marto konfliqtis mimart sistemis reagirebas, aramed zogadad politikuri dasinebis garemos. es qmnis qronikuli SiSis atmosferos. aqedan gamomdinare, wameba warmoadgens sazogadoebisatvis ara marto politikuri, aramed socialuri, zneobrivi, fsiqo-socialuri da fsiqikuri jamrtelobis problemas. wamebis faqtis gamozieba nisnavs wamebis, rogorc movlenis ganxilvas, romelic gavlenas axdens mosaxleobaze da adamianebze, rogorc sazogadoebis socialur arsebebze. Summerfield (1995): sisastike xsirad miznad isaxavs msxveplis ekonomiuri, socialuri da kulturuli samyaros gamiznulad ganadgurebas. am TvalsazrisiT, wamebam SeiZleba gamoiwvios Temis travmireba, romelmac Tavis mxriv SesaZloa gamoiwvios sxvadasxva formis sazogadoebrivi disfunqciis Camoyalibeba. wamebas SeuZlia terorsi amyofos mosaxleoba da Seqmnas iseti wesrigi, romelic efuzneba 6

7 moaxloebul, masstabur SiSs, muqaras, terors da datrgunvas da ara damoukideblobasa da Tavisuflebas. mas SeuZlia Seqmnas represiuli garemo. es aris daucveli, teroris, undoblobis da socialuri cxovrebis gaxlecvis garemo. wamebis mimart koleqtiuri SiSi xangrzlivi droit axdens gavlenas koleqtiur qcevaze. ufro metic, kvlevam gvacvena, rom wamebis Sedegebi SeiZleba gadaeces Taobebs, warmoqmnas istoriuli travma. (Lira, 2002). Tavi II. wamebis metodebi wameba aris dinamiuri procesi, romelic iwyeba dakavebit an Tavisuflebis SezRudviT da romelic moicavs arnisnulis Sedegad miyenebul ert an ramdenime travmas, romelic SeiZleba moxdes sxvadasxva drosa da sxvadasxva adgilas da dasruldes msxveplis gatavisuflebit an gardacvalebit (Somnier, 1992). movlenebis es kaskadi SeiZleba isev daiwyos mokle drosi ise, rom ar dautovos pirovnebas gamojanmrtelobis dro. xsir SemTxvevaSi gamoiyeneba rogorc wamebis fizikuri metodebi, aseve fsiqologiuri; Tumca unda arinisnos, rom amgvari dayofa pirobitia: nebismier SemTxvevaSi wameba moicavs orive komponents: rogorc fizikurs, aseve fsiqikursac. wamebis metodebi, romlebic ganimarteba rogorc fizikuri wameba _ moicavs metodebs, romlebic gulisxmobs msxverplis mimart jalatebis mier ganxorcielebul fizikur Zaladobas da tkivils an sxva piris mier ganxorcielebul nebismier sxva fizikur (sxeulis) travmirebas, da aqve gvinda SevitanoT fizikuri wamebis metodebi, romlebic ar tovebs raime fizikur kvals (magalitad gazit mogudva-senirbva); ra Tqma unda, isev gavimeorebt, rom wamebis dayofa fizikur da fsiqologiur metodebad Zalian Znelia da pirobitia, radgan yvela fsiqologiur metods aqvs fizikuri-somaturi Sedegebic (magalitad, sicive, SimSiloba da sxva) da, rara Tqma unda, fizikur metodebs aqvt Semdgomi fsiqologiuri Sedegebic. zemot arnisnulidan gamomdinare, fsiqologiur metodebad ganixileba pirobitad iseti metodebi, romlebic upirveles yovlisa zians ayeneben msxverplis moralur da fsiqologiur mdgomareobas da ar moicavs sxva piris mxridan raime saxis fizikur Zaladobas. ariarebulia, rom wamebis metodebi, romelnic seriozul safrtxes uqmnian adamianis sicocxles an mis fizikur Tu fsiqikur funqcionirebas, iwveven SemaZrwunebeli SiSis gancdas, rac pirovnebisatvis Rrma da xangrzlivi travmatizaciis mizezi xdeba. unda arinisnos, rom mexsiereba, Tavdacva, arsebuli sazogadoebis arqma da biologiuri metodebi mwidro urtiertkavsirsia. fsiqologiur (`TeTri ) da fizikur (`witeli ) wamebas Soris adre arsebuli gansxvaveba DdRes xelovnurad gamoiyureba, magram orive aspeqti unda ganvixilot Semowmebis dros, rogorc aucilebeli nawili (Thomas Wenzel, WPA, 2004). 7

8 wameba SeiZleba daigegmos eqspertebis an `Cveulebrivi jalatebis mier, is SeiZleba gamoyenebuli iyos sistematurad an drodadro. Sedegebi xsirad `asaxavs am ganzraxvebs. wamebis miznebi SeiZleba gansxvavdebodes, magram xsirad mati mizania: xanmokle SedegisaTvis: msxverplis an sxva pirebis `gatexva informaciis mirebis an sxva miznit. xolo xangrzlivi SedegisaTvis: sakutari Tavisadmis rwmenisa da socialuri funqcionirebis daqveiteba, qronikuli tanjva, ndobis dakargva (wameba aris `demokratiis winaaarmdeg mimartuli yvelaze efeqturi iarari (Inge Genefke). rogorc ukve iqna arnisnuli, sakutriv wamebas win uswrebs dapatimrebisa da egret wodebuli «lomkis» (gatexvis) periodi, romelic xasiatdeba Semdegi zogadi Tu konkretuli fizikuri Tu fsiqologiuri sisastikit, rogoric aris: zogadad sazogadoebasi gavrcelebuli azri da sazogadoebis gamocdileba wamebastan dakavsirebit, rom nebismier dakavebas aucileblad mohyveba wameba; aseve wamebis wina periodi, romelic xasiatdeba sxvadasxva saxis muqarit, rogorc pirovnebis, aseve misi ojaxis mimart; askara TvalTvaliTa da devnit, aseve pirovnebis Tavisuflebis sxva saxis SezRudviT; xsiri dakitxvebit Tu dabarebebit samartaldamcav organoebsi; saxlsi SevardnebiTa da ojaxis dawiokebit; dezinformacia da safrtxe tramvis Semdgomi SesaZlo Sedegebis Sesaxeb. yovelive arnisnuli iwvevs adamianis ukidures gadarlasa da dazabulobas, pirovnebis kompensatoruli funqciebis amowurvasa da fsiqo emociur astenizacias, uzilobas, gamouvali situaciis Seqmnas ; arnisnuli vitarebit xdeba «wamebisatvis pirovnebis Semzadeba», pirovnebis winaswari ertgvari gatexva da dasineba. amgvar qmedebebs mosdevs dapatimrebis aqti, romelic Tavisi formebit aseve damtrgunveli da sastikia : SeiaraRebuli nirbianebis Secvena ojaxsi an qucasi Tavdasxma, TvalSisacemi sisastike, yvelafris damsxvreva dalewva da pirovnebis sastiki cema dapatimrebis momentsive, rac SeiZleba ganxorcieldes CeqmebiT, mustebit, iararis tarebit Tu sxva blagvi sagnebit, xelborkilebis dadeba da damamcirebeli mouxerxebeli pozit Setenva manqanasi. amgvari wamebis wina periodi xels uwyobs pirovnebis Semzadebas gardauvali pirovnuli ganadgurebisatvis da ukiduresi uimedobis gancdis Camoyalibebas. dapatimrebis periodi Tavdeba Tavisuflebis arkvetit policiis izolatorsi an cixesi, sadac yvelaze xsirad adgili aqvs adamianis wamebas. dakavebis adgilze miyvanistanave iwyeba autaneli tanjvisa da sistematuri cemis periodi, rac gamoixateba xangrzliv, momqancvel, damamcirebel dakitxvebsi, pirovnebis bunebrivi motxovnilebebis SezRudvaSi, kerzod ki wylisa da sakvebis ar micemasi, sapirfaresosi ar gasvebasi; aseve adgili aqvs cemas, sxvadasxva mxridan moulodnel dartymebs fexebit, xelebit, xelketebit an sxva sagnebit, rasac uwodeben msxverplis egretwodebul «boqsirebas»; arctu isviatad dakavebuls 8

9 aizuleben dakitxvisa da wamebis molodinsi mdgomare pozasi dahyos ramdenime dris ganmavlobasi (egretwodebuli «planton» is poza). yvelaze xsirad gavrcelebuli fizikuri wamebis metodebi Semdegia : cema, sistematizirebuli da ara sistematizirebuli ; stomatologiuri wameba; Camokideba; ara fiziologiuri mdebareoba; eleqtro denit wameba; mogudva moxrcoba; seqsualuri wameba; farmakologiuri wameba; dardasma; damwvroba; cema rogorc ukve iqna arnisnuli, dakavebis adgilas miyvanistanave, iwyeba dakavebulis usistemo cema sxvadasxva mxridan da sxvadasxva sasualebebit, rogorc wesi, amgvar qmedebasi monawileobs ramdenime jalati ertdroulad. sistematizirebuli cemis magalitad SeiZleba gamoyenebul iqnas iseti metodebi, rogoric aris falanga an telefoni. falanga fartod aris gavrcelebuli axlo armosavletsi, Tumca Ceveni kvlevebis Tanaxmad, igi fartod aris gavrcelebuli saqartvelosic. am dros msxverpls urtyamen monotonurad an SiSvel terfebze an fexsacmlian terfze, ufro xsirad rezinis xelketit, an xis magari sagnit an sxva myari blagvi sagnit, amave dros msxverplis fexebi aweulia da fiqsirebulia an skamis zurgze an sxva sasualebebit aris Sekruli. amgvar mdgomareobasi adamians ara aqvs Tavdacvis sasualeba, rac fsiqologiurad azlierebs amgvari cemis efeqts da iwvevs panikuri SiSis mdgomareobas. xsirad, amis Semdeg msxverpls aizuleben iaros SiSveli fexit damsxvreul minebze an qvebze, idges yinulze da a.s., rac metismetad mtkivneulia da am dros saxis gamometyveleba auwerel tanjvas gamoxatavs. falangis usualo Sedegebia wvivebisa da terfis midamos tkivilebi, hematomebi da SeSupeba, siarulis SeuZlebloba, rac msxverpls aizulebs gadaadgildes dacoqil mdgomareobasi (skliuvi, 1992). telefonis gamoyenebisas ertdroulad xdeba dartymis miyeneba orive yuris midamosi, Cvens mier arweril SemTxvevebSi, es xorcieldeboda gasilili xelis SemortymiT ertdroulad orive mxridan, ris Sedegadac xsir SemTxvevaSi adgili aqvs dafis apkis gaxetqvas an dazianebas. amgvari dazianeba SemdegSi iwvevs smenis mxriv seriozul problemebs, xsirad gartulebas Cirqovani otitis saxit da atarebs qronikul xasiats. xsir SemTxvevaSi blagvi mkvrivi sagnit xorcieldeba cema motexilobis adgilebsi an dazianebul midamosi; xsiria dartymebi muclis aresi, gansakutrebit sayuradreboa cema Tavis midamosi, rac Cvens mier sakmaod xsirad iqna arwerili da rasac TiTqmis yoveltvis Tan axlavs 9

10 Tavis tvinis daxuruli travma, gonebis dakargva da xsirad Tavis tvinis seriozuli travma _ tvinis Seryevis an dajejilobis saxit. stomatologiuri wameba amgvar SemTxvevebSi msxverpls ugdeben kbilebs, es xdeba cemisas an xsirad xdeba janmrteli kbilebis amoreba stomatologiuri instrumentebit, an sxva arasteriluri iararebit, aseve xsiria kbilebis aresi eleqtro denis gatarebis SemTxvevebi. Camokideba xsir SemTxvevaSi am dros saubaria egretwodebul palestinur Camokidebaze, rodesac msxverpls kideben ukan Sekruli xelebit; ufro xsirad ki post sabwour qveynebsi gamoiyeneba egretwodebuli lastocka da misi modificirebuli variantebi, rodesac adamians, romelsac xelebi da fexebi ukan aaqvs Sekruli da am mdgomareobasi mas Camokideben. aseve Camokidebis saxea marao, rodesac msxverpls hkideben fexebit da atrialeben vertikalurad; wamebis amgvari metodi xsirad Serwymulia sxva metodebtan, rogoric aris eleqtro denit wameba da arafiziologiuri mdebareoba (mag. lastocka, rodesac msxverplis mdgomareoba arafiziologiuria da amave dros mas hkideben); eleqtro denit wamebisas Camokidebul mdgomareobasi myof msxverpls sxeulis mgrznobiare adgilebze: yuris bibiloebze, genitalur midamosi, enaze, kbilebze an TiTebis boloebze an dvrilebze _ uerteben eleqtrodebs da atareben eleqtro dens. amgvari metodebi, saertod naklebad toveben fizikur kvals, Tumca xangrzlivi droit da xsirad qronikulad iwveven mozraobata darrvevas, sxeulis sxvadasxva midamosi tkivilebs da xsirad tkivils mteli sxeulis aresi, gansakutrebit ki Tavis, kisrisa da zurgis midamosi. arafiziologiuri mdgomareoba aseti mdgomareobis magalitad SeiZleba moyvanil iqnas egretwodebuli ku, adamians agdeben mcire zomis galiasi, sadac mas ar SeuZlia gaimartos, amave dros ar azleven sakvebsa da wyals da igi am mdgomareobasi imyofeba dreebis ganmavlobasi; aseve SeiZleba Caagdon mcire zomis ormosi an sardafsi, sadac igi izulebulia dreebis ganmavlobasi imyofebodes sibnelesi, sakvebisa da wylis garese, mdgomare poziciasi; amave dros Cvens mier iqna arwerili SemTxvevebi, rodesac Tavze asxamen eqskrementebs, an ormosi amave dros aris Casxmuli didi raodenobit wyali; amgvari wameba xsir SemTxvevaSi iwvevs organota seriozul qronikul dazianebas; gansakutrebit ki (magalitad wylian ormosi sicivesi Cagdeba) iwvevs reproduqciis funqciebisa da organoebis seriozul problemebs, uro genitaluri sistemis dazianebas; rac jalatta miznita CanafiqriT, swored rom reproduqciis unaris dakargvas emsaxureba da am metodebs xsirad mimartaven etno konfliqtebis SemTxvevaSi. 10

11 eleqtrodenit wameba wamebis es saxe iwvevs gansakutrebit mtkivneul kruncxvebs, msxverpli am dros ikvnets enas, tucebs an loyas. igi xsir SemTxvevaSi tardeba sxeulis mgrznobiare areebsi eleqtrodebis dadebita da denis gatarebit. wamebis aparatebi sxvadasxvagvaria, magalitad eleqtrodenis joxi an maxvili fanqriseburi sagani; Cvens SemTxvevaSi xsirad iqna arwerili telefonis aparatit denis gatarebis metodi, aseve eleqtrodebis dadeba dasvelebuli Rrublis SemoxveviT majebsa da wvivebze, rac xsir SemTxvevaSi kruncxviti gantvirtvebis mizezi xdeba; am dros adamiani TiTqmis yoveltvis hkargavs gonebas, Semdeg mas asuliereben wlis dasxmit da kvlav ganagrzoben amgvar wamebas; amgvari metodi iwvevs Sokur mdgomareobas rogorc tkivilit, aseve stresit ganpirobebuls, Tumca kvalis datovebis TvalsazrisiT, SesaZloa datovos mcire damwvrobis kvali, romelic Znelad SesamCnevia. gagudva moxrcoba wamebis am metodis ert ert saxeobas ganekutneba submarino, rac gamoixateba SemdegSi: adamians TaviT usveben wyalsi da ase acereben iqamde, sanam ar daiwyeba moxrcobis simptomebi, rac Sesabamisad iwvevs sikvdilis sasinel SiSs. amave dros, CarTuli aris televizori an radio, imis gamo, rom SemdgomSi mudmivad am nivtebis xilvis an xmebis gagebisas msxverpls mudmivad hqondes wamebastan dakavsirebuli asociaciebi da mogonebani. seqsualuri wameba seqsualuri wamebis msxverplni SesaZloa gaxdnen rogorc qalebi, aseve mamakacebi, an bavsvebi. igi gamoixateba usveri sityvebit lanzrvasa da Seuracxyofis miyenebasi; aseve izulebit an Zaladobriv gasisvlebasi; damamcirebeli pozis mirebasi; masturbaciasa da ertmanetis gaupatiurebasi monawileobasi; gaupatiureba xdeba jalatebis mxridanac da upiratesad atarebs jgufur xasiats. amgvari wameba xsirad mimdinareobs sxva patimrebis an tyveebis TandaswrebiT, xsir SemTxvevaSi ki ojaxis wevrta TandaswrebiT. amgvari sasineli mopyroba upirveles yovlisa emsaxureba adamianis damcirebasa da pirovnul ganadgurebas da iwvevs xangrzliv da dauviwyar sulier travmas. aseve seqsuluri wamebis dros xsirad xdeba sxvadasxva mwreli da mcxvletavi sagnebit an eleqtro denit sqesobrivi organoebis dazianeba, rac xsir SemTxvevaSi reproduqcuiis unaris mospobas emsaxureba. imave miznit yinvasi mamakacebsa da qalebs xsirad ayeneben dreebis ganmavlobasi civ yinulian wyalsi. amgvari metodebi, Cveni dakvirvebit, ufro xsirad ixmareba etnikuri wmendis zonebsi da safuzvlad etnikuri an religiuri zizri udevs. 11

12 farmakologiuri wameba jalatebi izulebit asmeven patimars tabletebs an uketeben ineqcias; xsir SemTxvevaSi am miznit gamoiyeneba fsiqotropuli preparatebi, romelta didi dozebita da arasawiroebisamebr gamoyeneba iwvevs mzafr gverdit movlenebs. xsir SemTxvevaSi ki izulebit uketeben narkotikul sasulebebs, rac iwvevs micvevas da msxverpli xdeba damokidebuli jalatze, narkotikuli preparatistvis aketebs yvelafers, xdeba informatori da a.s. sabwota periodis egret wodebul КГБ - Si, fartod gamoiyeneboda farmakologiuri preparatebi informaciis misarebad da dakitxvis dros. daris dasma, dasaxicreba am miznit gamoiyeneba mravali metodi, rogoric aris frcxilebis dazroba, Tmebis amogleja, warziduli nawilebis mokveta magalitad yuris, Tvalis amotxra, TiTis mowra, enisa an gare sasqeso organoebis amputireba. damwvroba am miznit xsirad gamoiyeneba antebuli sigaretis miwva, gansakutrebit ki sxeulis mgrznobiare nawilebze; iyeneben aseve egretwodebul dautovebis metods, roca cxel utos adeben sxeulis sxvadasxva nawilebze; aseve akraven gisosebze, romelsac nel nela acxeleben; iyeneben gavarvarebuli SanTiT dadarvis metodsac. wamebis upiratesad fsiqikur/fsiqologiuri metodebi wamebis fsiqikuri metodebi metad fartod gamoiyeneba da iwvevs adamianis seriozul travmirebas, romlis Sedegebic SesaZloa qronikulad mimdinareobdes. amgvari metodebi gamoirceva didi mravalferovnebita da daxvewilobit, da drota ganmavlobasi isini ufro da ufro daxvewili xdeba, rac utyuarad miutitebs imaze, rom amgavari metodebis, iseve rogorc fizikuri metodebis, SemuSavebaSi monawileoben specialistebi. Cven aq moviyvant ramdenime matgans, rata nateli warmodgena Seiqmnas amgvari metodebis sisastikesa da pirovnebisatvis damangrevel rolze. deprivacia xsir SemTxvevaSi patimars dapatimrebistanave atavseben izolirebulad marto da mas ara aqvs sasuleba hqondes kontaqti an sxva patimrebtan an ojaxis wevrebtan, aseve ar azleven advokattan dakavsirebis sasulebas. patimari am dros Tavs grznobs gare samyarosagan mtlianad mowyvetilad, absoluturad daucvelad da umweod, igi mtlianad aris damokidebuli jalatebis neba survilze. mas ara aqvs informacia icis Tu ara vinmem misi dapatimrebis Sesaxeb, grznobs, rom igi SesaZloa moklan, daikargos ugzo-ukvlod, ise, rom mis Sesaxeb veravin ver gaigos veraferi. mas am dros ara aqvs aranairi moraluri Tu iuridiuli daxmarebis 12

13 sasualeba, arc imis sasualeba, rom sxva patimartagan mainc miiros Tanadgoma an raime saxis informacia. xsir SemTxvevaSi es metodi Serwymulia sxva saxis tanjvastanac, rogoric aris sibnele: sakansi ar aris natura, ar Semodis dris sinatle, ara aqvs saati an sxva piradi moxmarebis sagnebi; es, rogorc wesi, iwvevs dezorientacias drosa da garemosi, xsirad ki dre-ramis ritmis myar darrvevas, rac SemdgomSi irebs qronikul xasiats; amave dros, SesaZloa, amgvar vitarebasi damatebuli iqnas sxvadasxva saxis stereotipuli ritmuli komponentebi, iseti rogoric aris, magalitad: gafuwebuli onkani kamerasi, romlidanac wyali monotonurad wvetavs da romelic ar iketeba, aseve natura, romelic periodulad Tanabari intervalebit inteba da qreba, amgvari moqmedebebi iwvevs sakmaod mzime fsiqikur aslilobebsa da aseve pirobiti refleqsis gamomusavevas ama Tu im moqmedebaze, an pirovnebis STagonebadobis gazrdas, rac SemdgomSi dakitxvebisas gamoiyeneba efeqtis misarwevad, vinaidan qveitdeba TviTkontrolisa da yuradrebis koncentraciis unari. xsirad es metodi Serwymulia Zilis deprivaciastan: adamians ar azleven Zilis sasualebas sxvadasxva saxis xmauris mesveobit. xsirad mas esmis sxva patimrebis wamebis xmebi an SemaZrwunebeli xmauri, an gahyavt RameSi ramdenjerme dakitxvaze; Zilis deprivacia iwvevs seriozul fsiqikur aslilobebs da rogorc wesi Zilis funqciis myar darrvevas xsirad mteli sicocxlis manzilze. xangrzilivi izolacia xsirad iwvevs halucinaciuri gancdebis Camoyalibebas, Zlierdeba gagijebis SiSi, sxvadasxva saxis fobiebi da panikuri SfoTvis Setevebi. bunebrivi motxovnilebebis dakmayofilebis SezRudva patimars ar azleven saatobit an mteli dris ganmavlobasi sasulebas daikmayofilos bunebrivi motxovnilebebi, ar usveben sapirfaresosi, ara aqvs sasualeba daicvas piradi higiena, ar azleven sakvebsa da sasmel wyals, amgvari qmedebebi mimdinareobs xsirad permanentuli dakitxvis fonze da instruqciit, Tu miireben sawiro informacias an ariarebas, mas micemen amgvari motxovnilebebis dakmayofilebi sasualebas. agenti sakansi amgvari metodebi xsirad gamoiyeneboda sabwota cixeebsa da izolatorebsi, da xsirad dresac gamoiyeneba post - sabwota qveynebsi. metodis arsi imasi mdgomareobs, rom yvelam icis, rom ert-erti sakansi aris Sekruli agenti. es garemoeba iwvevs mudmivi dazabulobisa da ewvis safuzvels, urtiert agresias, TviTkontrolisa da mowarbebuli sifxizlis, mudmivi SiSis mdgomareobas, rom zedmeti araferi wamoscdes. amgvar situaciasi xangrzlivi periodit yofna umetes SemTxvevaSi iwvevs pirovnebis paranoialur ganvitarebas da literaturasi fartod arwerili cixis paranoiis, calkeul SemTxvevebSi, ki paranoiduli reaqtiuli fsiqozis, Camoyalibebas, rac praqtikulad sakmaod xsirad gantavisuflebis Semdeg irebs qronikul xasiats. 13

14 wamebaze daswreba Cvens mier arweril SemTxvevaTa umravlesobasi patimars miyvanistanave aswrebdnen wamebisatvis gankutvnil OoTaxSi, sadac aseve igi uyurebs gantavsebul specialur instrumentebs, sxvis wamebas, rac gamanadgurebel STabeWdilebas axdens pirovnebaze; xdeba identifikaciis gancdis Camoyalibeba da amiti xsirad swrafad miirweva Sedegi, adamiani tydeba da yvelaferze Tanaxmaa; xsirad ki amgvari metodis sisastike matulobs, da pirovnebas ayurebineben ojaxis wevris an axlo megobris wamebas. aseve Seqmnilia specialuri filmebi wamebaze, romeltac ayurebineben patimrebs da ucxadeben, rom mas igive moelis; xsirad ki saxelmwifosi gavrcelebuli wameba da amgvari metodebis Sesaxeb informacia iwvevs mteli mosaxleobis dasinebasa da wamebas; potenciurad yvela patimari ganixileba ukve rogorc wamebis msxverpli, vinaidan dakavebulma adamianma winaswarve icis, Tu ra elis da igi Tavidanve moralurad gatexilia; amgvari sazogadoebis informirebuloba iwvevs mteli Taobebisa da momdevno Taobebis travmirebas, datrgunvas, damoukideblobisa da Tavisuflebis motxovnilebis daqveitebasa da SiSs, uazro da gaucnobierebel morcilebas totalitaruli rejimebisadmi. molodini patimarma xsir SemTxvevaSi ar icis Tu rodis gaiyvanen dakitxvaze da rodis awameben; dakitxvebs Soris intervali specialurad yoveltvis varirebs, rata adamianma ar gansazrvros sworad _ Tu rodis miyavt dakitxvaze da ver moaswros moralurad Semzadeba; amgvari permanentuli wamebis molodini iwvevs mudmivi SiSisa da dazabulobis gancdas, da msgavsi gancda SesaZloa mudmivad Tan sdevdes wamebis msxverpls. ararealuri arcevani am metods Zalian xsirad mimartaven jalatebi. am dros sasineli muqaris qves, magalitad col Svilis gaupatiureba an ojaxis daxocva, patimars ezleva winadadeba gasces informacia, anu igi dgeba sasineli arcevanis winase, xsir SemTxvevaSi _ gasces megobrebi an gawiros ojaxi; es metodi kidev ufro daixvewa sabwota periodsi da amgvar situaciasi patimars aizulebdnen gamxdariyo Sekruli agenti informatori, daewera ararealuri sacivari an dasmenis werili mtavrobisatvis arasasurvel pirovnebaze, damdgariyo cru mowmed da a.s. amgvari metodebi gansakutrebit gamoiyeneboda stalinis rejimis periodsi da asaxva postsabwota periodsic hpova cru mowmeebis gavrcelebuli instituti sasamartloebze, saqmis Ziebisas da sxva. amgvari situacia iwvevs qronikulad mimdinare TviTdanaSaulis gancdis Camoyalibebas. muqara da cru sikvdili wamebisas fartod gamoiyeneba muqaris saxvadasxva da sastiki formebi. muqara ojaxis wevrebze; gaupatiurebis muqara, Cveni dakvirvebit, amgvari 14

15 muqara fartod da efeqturad gamoiyeneba kaci patimrebis mimart; aseve arsebobs sikvdilis muqara, samudamo patimrobis muqara, ojaxis wevrebis wamebisa da Tvalwin gaupatiurebis muqara. gamoiyeneba cru sikvdilit dasjis metodic, dakavebuls ucxadeben, rom mas xval gamteniisas daxvreten da stavzoben daweros anderzi, an ramdenjerme safetqeltan adeben iarars tyviebis garese (patimarma ar icis, rom iararsi tyviebi ar aris), da Caxmaxs gamokraven xels. amgvari qmedeba iwvevs gadaulaxavi SiSis gancdas, anadgurebs adamians pirovnulad, xsiria am dros uneblie Sardvisa da defekaciis movlenebi, rac SemdgomSi damatebit iwvevs sircxvilis gancdasac. aseve unda arinisnos, rom xsirad mimartaven iseti wamebis situaciebis fotografirebas an video audio Caweras, romelic iwvevs mzafr sircxvilis gancdas, magalitad gaupatiureba da seqsualuri wamebis sxva saxeebi da amis gamjravnebit asineben wamebis msxverpls da aizuleben mudmivad iyos mat daqvemdebarebasi, asrulos mati gankargulebebi; amgvari situaciisas gansakutrebuli mnisvneloba eniweba EeTnokulturul faqtors; calkeul etnikur jgufebsi gaupatiureba ariqmeba sasinel codvad da amgvari situaciis Semdeg adamianma Tavi unda moiklas an Suri izios da a.s. xsirad aset situaciebsi pirovneba yvelaferze Tanaxmaa. ertis mxriv isini xdebian TviTon saxelmwifos mier inspirirebuli teroristuli dajgufebis wevrebi da awyoben teroristul aqtebs, romelic emsaxureba calkeuli saxelmwifoebis politikur zraxvebs, rogoricaa qveynis dapyroba, genocidi da a.s., an meores mxriv, amgvari qalebi xdebian Saxidebi, sruliad brmad emorcilebian teroristta motxovnebs, mat amozravebt mzafri SurisZiebisa da sircxvilis dazlevis gancda. seqsualuri wameba konkretuli fizikuri aqspetebi wamebis Semdeg iwveven xangrzliv fsiqologiur tanjvas qalebsi. gaupatiurebis Sesaxeb Worebma an ewvebma SesaZloa gamoiwvios socialuri Sedegebi. amgvari fizikur/fsiqologiuri komponentis momcveli wamebis metodebi mravalgvaria, magalitad: qalwulobis dakargva, dafexmzimeba, `socialuri statusisatvis zianis miyeneba- ojaxis mimart pativiscemis dakargva, daojaxebis perspeqtivisatvis zianis miyeneba (mnisvnelovania aseve ekonomikuri TvalsazrisiT, Tu tradiciul sazogadoebasi arsebobisatvis qalebi damokidebuli arian qorwinebaze), fizikuri Sedegebi `mudam gvaxsenebs gancdil sircxvilsa da gamarizianebel mogonebebs. fsiqologiuri wamebis sxva magalitebs ganekutvneba: sxvebis wamebaze daswreba, msxverplis dadanasauleba, wamalze an mkurnalobaze uaris Tqma, im dros roca pacientisatvis cnobilia janmrtelobis Semdgomi gauaresebis Sesaxeb, urtiertgamomricxavi (`damabneveli ) brzanebebis gacema. 15

16 arsanisnavia, rom movlenebma wamebamde an mis Semdeg, rogoricaa magalitad devnis faqtebi an megobrebisa da ojaxis wevrebis gardacvaleba, SesaZloa gamoiwvios damatebiti travmuli steresi. arsanisnavia, rom farmakologiuri wamebis metodebi moicavs xsir SemTxvevaSi fsiqikuri zegavlenis komponents, amitom unda iqnas ganxiluli kompleqsurad fizikur/fsiqologiuri metodebis TvalsazrisiT. preparatebs xsirad iyeneben sxvadasxva qveynebsi fsiqologiuri wamebis an patimrebisa da sxva msxverplta damorcilebis miznit*, agretve rogorc fsiqikuri aslilobis mkurnalobis `kanonier sasualebad. biologiyuri gavlena Cveulebriv drosia SezRuduli, Tumca zogiert preparatsi SeimCneva moqmedebis xangrzlivi Sedegebi** preparatebis umravlesobis kvalis dadgena Zneldeba, roca mati gamoyeneba xdeba xangrzlivi intervalebit.. benzodiazepinebi nevroleptikebi halucinogenebi specialuri farmakologiuri jgufebi, Sxamebi arsanisnavia, rom xsirad mimartaven egretwodebuli dezinformaciis strategiebis gamoyenebas, msxverplis fsiqologiuri datrgunvis miznit, amis magalitebia: gancxadeba, rom mezobeli otaxidan gamosuli yvirili gamowveulia megobris wamebit. gancxadeba, rom is moatavses cixesi wamebagamovlili pirtan, dezinformacia an informacia nawameb pirta ojaxis wevrebtan an megobrebtan dakavsirebit da sxva. wamebis biofsiqologiuri strategiebs ganekutneba: zegarizianeba: xangrzlivi xmauri an Suqi, gadawedva (Zalian bevri xalxi ert otaxsi) gamrizianeblebis SezRudva, an dezorientacia, drois/sivrcis areva, izolacia, preparatebis mireba, romlebic iwvevs ususurobis, tkivilis da dezoriantaciis SegrZnebas, sakvebis an wylis mirebis SezRudva, Zilis deprivacia. gansazrvruli kulturuli TvasazrisiT `miurebel metodebs ganekutvneba: msxveplis izuleba Seasrulos kulturuli/moraluri TvalsazrisiT miurebeli qmedebebi (`tabus darveva), patimroba antisanitarul pirobebsi, kulturuli `tabus darrveva, sakutar sazogadoebasi msxverplis Sercxvena. (Thomas Wenzel, WPA, 2004). 16

17 Tavi III. wamebis Sedegebi fsiqikuri da fizikuri Sedegebi unda arinisnos, rom wamebis Sedegebi gamoirceva polimorfulobit da waruslel kvals tovebs rogorc adamianis fsiqikaze aseve mis fizikur janmrtelobaze. Zalzed Znelia moaxdino wamebit gamowveul SedegTa diferencireba fsiqikur da fizikur simptomebad, vinaidan es simptomebi mwidrod arian gadajawvuli ertmanetze da axdenen urtiertzegavlenas, rac metwilad ganapirobebs darrvevata mravalferovnebasa da qronikuli mimdinareobis tendenciebs. arnisnul nasromsi Cven, diagnostikis gaadvilebis miznit, calke ganvixilavt wamebis fsiqikur da fizikur Sedegebs, Tumca mowodebuli masalidan natelia mati mwidro da rtuli urtiertkavsiri. wamebis fsiqikuri Sedegebi rogorc cnobilia, wameba da gansakutrebuli stresuli movlenebi, romelic seriozul sasisroebas warmoadgens adamianis sicocxlisatvis, iwveven seriozul stresul darrvevebs, romelta simptomebic gamoirceva polimorfulobita da mravalferovnebit. amgvar travmul stresul movlenata Soris wamebas gansakutrebuli roli eniweba, vinaidan igi warmoadgens erti admianis an jalatta jgufis mier meore adamianis an adamianebis jgufis mizandasaxul da gegmazomier, winaswarganzraxul tanjvas, rac mnisvnelovan stress warmoadgens ara marto adamianis fizikuri arsebobisatvis, rac upirates faqtors warmoadgens bunebrivi katastrofebis an omis dros, aramed fundamentur safrtxes uqmnis mis sulier arsebobasa da normalur fsiqikur funqcionirebas, Seicavs ra upiratesad moralurad gamanadgurebeli travmis faqtors, rac dakavsirebulia Seuracxyofisa da ususurobis, damokidebulebisa da momavlis mxriv sruli gaurkvevlobis gancdebtan. adamianis fsiqikur janmrtelobaze gansakutrebit mzime stresuli faqtorebis, mat Soris wamebisa da araadamianuri mopyrobis zegavlenis Seswavlas didi istoria aqvs. Tumca unda arinisnos, rom amgvari samecniero kvlevebi upiratesad warmoebulia omisa da bunebrivi katastrofebis dros dazaralebulta Soris, an wamebis msxverplta Soris cixeebidan gantavisuflebis Semdeg da ar aris fartod Catarebuli kvlevebi wamebis mwvave SedegebTan dakavsirebit, kvlevebi cixeebsi arsebul wamebis msxverplta Soris da aseve specsamsaxurebis mier sabwota periodsi wamebagamovlil pirta Soris, vinaidan amgvari kvlevebis Catareba sabwota periodsi iyo SeuZlebeli da amjamadac sirtules warmoadgens im qveynebsi, sadac dremde fartod aris gavrcelebuli wamebis praqtika. ase rom wamebis fsiqikuri Sedegebis kvleva jerac ar aris srulyofili da sawiroebs mkvlevarta seriozul Zalisxmevas misi gafartoebis miznit. 17

18 travmuli stresis faqtoris istoriuli mimoxilva 1871 wlidan moyolebuli, franko - prusiis omidan dawyebuli, yvela gamokvleva miutitebda rom fsiqikuri aslilobebis ricxvi omis dros sagrznoblad matulobs. pirveli msoflio omis monacemebit, rusetis armiidan evakuirebuli iyo fsiqikuri problemebis mqone piri, mat Soris yvela fsiqiatriuli organizaciis statistikuri monacemebi miutitebda, rom fsiqozebis ricxvi ZiriTadad fsiqogeniebis, reaqtiuli formebis xarjze matulobs, masasadame daavadebebis, romelnic dakavsirebulia omis vitarebastan (60% yvela evakuirebulidan). gamokvlevebis safuzvelze, romelic pirveli msoflio omis dros iyo Catarebuli, ewvs arar iwvevda is garemoeba, rom: 1. omis dros fsiqikuri aslilobebit avadobis macvenebeli mnisvnelovnad izrdeba; 2. sruliad cxadi gaxda, rom avadobis macvenebeli izrdeba ara ZiriTadi fsiqozebis, aramed fsiqogenuri daavadebebis, e. i. nevrozebisa da reaqtiuli fsiqozebis xarjze. aseve, davas arar iwvevda is garemoeba, rom aravitari specifiuri omis fsiqozi ar arsebobs, omis pirobebi iyeneben Cveulebriv patologiur meqanizmebs. amaze miutitebda msvidobian periodsi, miwiszvrebis dros, SemaZrwunebeli situaciebis Sedegad, ganvitarebuli fsiqogenuri reaqciebis Sesaxeb uamravi sailustaracio masala: miwiszvrebi SansiSi (1556w.), kalkutasi (1667w.), mesinsi (1908w.), aseve _ 1916 wlis monacemebi Provence Tebervals gemis CaZirvisas ganvitarebuli fsiqogenuri reaqciebis Sesaxeb, romelsac akvirdeboda Clunet, aqve unda arinisnos, rom reaqciebi, romelnic man ixila, isteriuls ar ganekutvnebodnen. ase rom, 20-iani wlebisatvis ewvs arar iwvevda Zlieri matravmirebeli situaciebit gamowveul fsiqikur aslilobata mikutvnebis sakitxi fsiqogeniebisadmi. rogorc cnobilia, termini "fsiqogenia" mowodebul iqna jer kidev gasuli saukunis miwurulsi Somer mier, romelic misi Sinaarsis Sesaxeb werda Semdegs: "fsiqogeniis" saxelwodebis mirma me vgulisxmob daavadebata did jgufs, romelic arnisnulia krebiti saxelwodebit "isteria"". aqve unda arinisnos, rom TviTon Somer usvebda etiogenur faqtorta kombinirebas fsiqogeniis warmosobasi, rac ukve miutitebda im garemoebaze, rom axali cneba moicavda ara marto isterias, aramed mdgomareobebs mis farglebs mirmac. fsiqogenur faqtors cnobili germaneli fsiqiatri Grisinger (1881w.) gadamwyvet rols aniwebda da miicnevda rogorc "yvelaze mtavar da mdidar wyaros SeSlilobisa". magram am periodisatvis jer kidev sadavo iyo fsiqogeniata klasifikaciisa da nozologiis sakitxebi. rogorc ukve iqna arnisnuli, mravali mkvlevari mat ganixilavda rogorc isteriis gamovlinebebs, Tumca ukve cxadi iyo araisteriuli, wminda emociuri aslilobebis arsebobac, razedac TvalnaTliv miutitebs Clovis Vincent monacemebi, romelic omis wina xazze awarmoebda dakvirvebebs. igi wers: "iq, sadac didi raodenobit ecema narmebi, rac iwvevs sikvdilianobasa da Wrilobebs, arasodes minaxavs isteriuli gamovlinebebi kruncxvebis, kontraqturisa da erti an ramodenime kiduris paralicis saxit, me iq vxvdebodi mxolod emociuri rigis gamovlinebebs, yvelaze xsirad: cremlebs; kankals; gasesebis Setevebs (Un etat d'hebetude), romlis drosac avadmyofi gaunzrevelia, kitxvebze ar pasuxobs; taqikardias; suntqvis gaxsirebas; abnevas." 18

19 20-ian wlebsi klinikur fsiqiatriasi arinisna mnisvnelovani etapi fsiqogeniata im jgufis Seswavlisa, romelic cnobilia reaqtiuli fsiqozebis saxelwodebit, rac dakavsirebulia Karl Jaspers-is saxeltan. misi koncefciis Tanaxmad, reaqtiuli fsiqozebi vitardeba pirovnebasa da mistvis gausazlis realobas Soris konfliqtis safuzvelze da, amave dros, es realoba aucileblad aisaxeba daavadebis klinikur suratsi. Jaspers mixedvit, gausazlisi realoba SeiZleba iyos patimroba, ubeduri SemTxvevebi, miwiszvrebi da saertod katastrofani, dardi samsobloze, seqsualuri Zaladoba, Zlieri SiSi, SeZrwuneba, samxedro samsaxuri, enobrivi izolacia da sxv. mizezis mixedvit, igi Sesabamisad ganasxvavebda situaciis mixedvit provocirebul fsiqozebs: cixis fsiqozi; nostalgiuri fsiqozi; "guvernantis" paranoia; miwiszvrit gamowveuli fsiqozi da a.s. igi, mizezta garda, ganasxvavebda agretve reaqciata struqturas: isteriuli, paranoiduli, depresiuli, cnobierebis Secvla, primitiuli da sxva. "WeSmariti reaqtiuli fsiqozebisgan, albat, Cven unda ganvasxvavot, garda spontanuri da inspirirebuli fsiqozebisa, aseve mxolod sulieri SeZrwunebiT kauzalurad ganpirobebuli normidan gadaxris mdgomareobani, yovelgvari gasagebi kavsiris garese, rogoric aris mag. vazomotoruli, nevrasteniuri sindromi, Tanmxlebi SiSis gancdit da a.s. katastrofis Semdeg." _ wers Jaspers nasromsi "swavleba reaqtiuli fsiqozebis Sesaxeb". mis mier mowodebuli reaqtiul mdgomareobata kliniko - diagnostikuri kriteriumebi: patologiuri reaqciis kavsiri fsiqikur travmastan misi warmosobis drois, Sinaarsisa da mimdinareobis mixedvit, dremde klinikuri fsiqiatriisatvis Zalze mnisvnelovania. Tumca unda arinisnos, rom 60 -iani wlebisatvis arwerili iqna reaqtiul mdgomareobata mogvianebuli formebi, anu travmuli momentidan Zalze dasorebuli formebi, romelta drosac irrveva Jaspers "drois kavsiris" kriteriumi, Tumca travmuli movlena sruliad aisaxeba klinikur suratsi. mogvianebul reaqciata SemTxvevaSi "latenturi" dro fsiqikur travmasa da patologiur reaqcias Soris Zalze gaxangrzlivebulia da SesaZloa ramodenime welsac ki arwevdes. (Шувалов, Гиляровский, WiTava). amis mizezad ZiriTadad travmis intrafsiqikuri gadamusavebisa da saboloo gacnobierebis gaxangrzlivebuli procesi miicneva, "aseve misi Sedegis asaxva pirovnebis sayofacxovrebo situaciasi, rodesac pirovneba yoveli fexis nabijze grznobs ukve momxdari usiamovnebis, an ubedurebis Sedegs." (WiTava). Semdgomi mnisvnelovani etapi globaluri travmebit gamowveuli fsiqogeniebis Seswavlisa dakavsirebulia meore msoflio omtan (1939 _ 1945 ww.) amerikeli da ingliseli avtorebis mier ww. nervul - fsiqiatriuli aslilobebi warmodgenilia umtavresad fsiqonevrozebis jgufit, romelsic Sedis fsiqogeniebis rogorc nevrozuli, aseve fsiqozuri formebi. fartod aris warmodgenili omis periodis kvlevebi rusi avtorebis mier. fsiqogenuri aslilobani mat mier ZiriTadad warmodgenilia mwvave reaqtiuli fsiqozebit: afeqtogenuri stuporita da fugiformuli reaqciit. ufro xsirad, vidre mwvave reaqciebi, gamovlenil iqna gaxangrzlivebuli reaqtiuli fsiqozebi ww. - Si mati ricxvi rusetsi samxedro mosamsaxureta Soris Seadgenda yvela reaqtiul fsiqozta 93%. arweril iqna Semdegi formebi: a) fsiqogenuri cnobierebis bindiseburi asla (cnobierebis afeqturi Seviwroeba), Ф.И. Иванов 19

20 monacemebit, am jgufma Seadgina 16 - dan 27% - mde yvela reaqtiuli fsiqozisa. b) reaqtiuli depresia, romelic ganisazrvra rogorc omis drois wamyvani fsiqogenuri reaqcia (Е.О. Левикова, Е.Б. Мягкина, Н.И. Фелинская, Е.А. Попов, И.И. Веденский.). amave dros arnisnavdnen, rom fsiqogenurad ganpirobebuli depresia xsirad gvxvdeboda rtuli sindromebis struqturasi, mag. SiSis nevrozis dros, sadac adgili hqonda SfoTvis afeqts (А.Н. Молохов); gamoxatuli asteniebisas, rac uflebas azlevdat gamoekvetat asteno - depresiuli mdgomareobani (Г.Е. Суханова, В.А. Гиляровский). reaqtiulma depresiebma Seadgina reaqtiul mdgomareobata 40% meore msoflio omis dros rusetis armiasi. g) aseve fartod iqna arwerili da ganisazrvra rogorc wamyvani asliloba reaqtiuli paranoidi, romelmac Seadgina 12% reaqtiuli mdgomareobebisa rusetis armiasi. igi gamoirceoda mwvave dasawyisit, simptomta gamoxatuli fsiqoturobita da ketilsaimedo gamosavlit. С.Г. Жислин reaqtiuli paranoidis ganvitarebasi gadamwyvet mnisvnelobas miakutvnebda "droebit Secvlil niadags", rac ganpirobebuli iyo egzogenuri da somatogenuri faqtorebit,. С.Г. Жислин nasromsi "mwvave paranoidebis Sesaxeb" gamotqvamda Semdeg mosazrebebs: 1. ekzogenuri zegavlena (gadarla, xangrzlivi uziloba, araregularuli kveba, msubuqi gaciveba), rac droebit cvlis pirovnebas adre mistvis aranisandoblivi mgrznobiarobis mimartulebit, ganapirobebs situaciis diferencirebuli Sefasebis gartulebasa da rtuli konfliqtebis warmoqmnas. travmuli situaciis adgilas, romelic SesaZloa arc arsebobdes, Caenacvleba garegani vitareba, "garese gancdata mozrvaveba". 2. aset pirobebsi ganvitarebuli mwvave paranoiduli reaqciebi _ garegani vitarebis paranoidi _ xasiatdeba devnis bodviti ideebit, gamoxatuli SiSis afeqtit, daavadebis mwvervalze cnobierebis SecvliT, mwvave movlenata gavlis Semdgomi amneziit. meore msoflio omis SemaZrwunebel movlenata mravalferovnebam, rac dakavsirebuli iyo kolosalur msxverpltan da fasistur banakta gamocdilebastan, deportirebulta did raodenobastan, gamoiwvia fsiqopatologiur aslilobata iseti saxeebi, romlebic warmoadgendnen gadatanili fsiqikuri travmatizaciis Soreul Sedegebs. gadatanili fsiqikuri travmis Soreuli nervul - fsiqikuri Sedegebi yofil deportirebulta Soris pirvelad, frangi eqimebis mier iqna Seswavlili w. Dreifus da 1957w. Fishes miutitebdnen Seqcevad da Seuqcevad asteniebze arnisnul kontingentsi. daavadebis ZiriTad nisnebs warmoadgenda: wonasi dakleba, naadrevi da swrafi dabereba, vazomotoruli aslilobebi da darrvevebi sawmlis momnelebel sistemasi w. frangma fsiqiatrma Targowla arwera asteniis mzime forma paroqsizmuli, emociuri ekmneziis SetevebiT yofil deportirebulebsi. Setevebi xasiatdeboda miwaze uecari dacemita da cnobierebis dakargvit: avadmyofi borgavda an iwva umozraod, sxva SemTxvevebSi gamoxatuli iyo zomieri motoruli agzneba, saxviti mozraobebita da garkveul wilad SezRuduli metyvelebit. Setevebis Semdeg vitardeboda sruli amnezia. frangi eqimebi, danieli eqimebisagan gansxvavebit, xazs usvamen upiratesad fsiqogenuri faqtoris rols msgavsi aslilobebis ganvitarebasi (Misere Morale). fiziologiur danaklista Serwyma moralur 20

21 tanjvastan arweril iqna rogorc deportirebulta asteniuri sindromi, romelic iyo kvalificirebuli rogorc fsiqikuri travmis Soreuli Sedegi. Targowla mixedvit, yofil frang deportirebulta Soris asteniis sindromi arinisneboda 65-70% - Si. Fishes miutitebda deportirebulta Soris sikvdilianobis maral procentze mosaxleobis ukiduresad gawirvebul fenebtan SedarebiTac ki frang deportirebultagan 16000, TiTqmis 50%, gardaicvala repatriaciis Semdeg (Desual 1957 w.). ungretsi gantavisuflebis Semdeg gardaicvala yofil deportirebulta 20% - ze meti (В.М. Морозов 1958w.). Michel (1957w.) Tvlida, rom "postbanakuri astenia" SesaZloa ganixilebodes rogorc garkveuli nozologiuri erteuli ww. danielma eqimebma P. Helweg-Larsen et al., (1952w.) da K. Herman, P. Thygesen (1954 w.) arweres nevrasteniuli mdgomareobani yofil deportirebul danielta Soris, rac arenisneboda eqspatimarta 75%. travmuli stresisa da misgan gamowveuli fsiqikuri darrvevebis Seswavlis sakitxtan dakavsirebit SeuZlebelia ar arinisnos im fsiqiatrta da fsiqoterapevtta Rvawli, romelnic TviTve armocndnen sakoncentracio banakta tyveebi da sakutar Tavze gamoscades fasizmis mteli rigi ubedurebani meore msoflio omis dros. gansakutrebul yuradrebas imsaxurebs Viktor Frankl, Adler, Cohen da Kolle dakvirvebebi. nasromsi "fsiqologi sakoncentracio banaksi", V. Frankl sakutari gancdebisa da gamocdilebis safuzvelze tyveobisas osvencimis, dahaus da terezienstadtis sakoncentracio banakebsi, arnisnavs rom tyveta reaqciebi SesaZloa daiyos sam fazad: 1. sakoncentracio banaksi moxvedris Soki; 2. banaksi xangrzlivad yofnisas xasiatis tipiuri cvlilebebi; 3. gantavisufleba. Cohen mixedvit gamoyofilia Semdegi stadiebi: 1. pirveladi reaqciis faza; 2. adaptaciis faza; 3. apatiis faza. Sokis fazas Cohen arwers Semdegnairad: "me mqonda SegrZneba, rom me aravitari kavsiri ar maqvs am yovelivestan, ToTqos yvelaferi ertad arebuli me ar mexeba. Cemi reaqcia mjravndeboda subieqtisa da obieqtis disociaciasi. Tumca, bolosdabolos, mdgomareoba midioda uzlieres fsiqikur travmamde, roca axalmosuli igebda gazis kamerebis Sesaxeb, rac iwvevda SeZrwunebis mwvave reaqcias." V. Frankl Sokis fazas miakutvnebs anomalur gancdata reaqciebs, Tumca iqve daszens: "amave dros ar unda daviviwyot, rom iset anomalur situaciasi, romelsac warmoadgens sakoncentracio banaki amgvar gancdata anomaluri reaqciebi aris rarac normaluri." meore, xasiatobrivi cvlilebebisa da adaptaciis faza xasiatdeboda apatiita da agresiit; fsiqoanalitikosta SefasebiT, fsiqologiuri regresit; pirovnebis Sizoiduri tipit xasiatobrivi cvlilebit; xolo sakoncentracio banaksi yofnis uvadobis gancda iwvevda "momavlis dakargvis" SegrZnebas (Frankl, Cohen). Tumca Adler amis Sesaxeb werda: "ar SeiZleba ganvixilot xasiatis cvlileba rogorc pirovnebis azrebis saxecvlileba an moraluri dacema. Cveulebriv, uecrad ikargeboda, TiTqos arc yofiliyos, mxolod garegnuli arzrdiloba". Frankl exeba suicidebis problemasac sakoncentracio banakebsi, romelic, jer kidev pirveli msoflio omis droidan, cnobilia rogorc "mcxvletavi mavtulis (mavtulxlartis) sindromi" (Vischer 1918w.). gantavisuflebis fazis Sesaxeb Frankl werda: "banakidan gantavisuflebuli jer isev ar aris gamosuli 21

22 depersonalizaciis SegrZnebidan. mas jer kidev ar SeuZlia datkbes sicocxlit _ man jer unda iswavlos es, is amas gadaecvia". aseve igi Hoffmeyer da Hertel-Wulff monacemebis gatvaliswinebit, arnisnavs, rom gantavisuflebis Semdeg damaxasiatebeli simptomebi iyo: mousvenroba, darlilobis SegrZneba, koncentraciis gauareseba, agznebadoba, ert adgilze yofnis gartuleba, mexsierebis daqveiteba, gamrizianebloba, vegetatiuri simptomebi, depresiebi da Tavis tkivilebi. amgvari simptomebi arenisneboda 78%; aqedan 47% ucioda "Ramis kosmarebs sakonctracio banakis saxit". Kolle monacemebit, fartod iyo warmodgenili arnisnul kontingentsi qronikuli depresia. igi werda 1958 w.: "bevrs dresac ar SeuZlia daiviwyos TavianTi axloblebis dapatimrebasa da daxocvastan dakavsirebuli gancdebi; es gancdebi sdevnian mat drisit da RamiT, sizmrebsic ki." jer kidev masin igi ewvis qves ayenebda am kontingentsi depresiis qronikuli formisa da sxva fsiqoreaqtiul darrvevata mikutvnebis sakitxs "nevrozis" zogad krebit mcnebastan, vinaidan saxeze iyo am adamianta cxovrebis sruli kraxi. mat depresiaze, Cveulebriv, naklebad moqmedebda gantavisuflebis faqtic ki. posttravmul stresul aslilobata warmosobis preistoriasi arsanisnavia E. Lindemann (1944w.) gamokvlevebi. igi miutitebda ra gaxangrzlivebuli stresis Semdgomi aslilobebis garkveul Taviseburebebze, Semoitana "patologiuri mwuxarebis" (Pathological Grief) cneba. misi azrit, am sindroms SesaZloa mivakutvnot subieqtis anomaluri reaqcia ubedurebaze, romlis Sedegadac vitardeba sxvadasxva fsiqikuri da fsiqosomaturi aslilobani, mat Soris "sufta nevrozebi". "patologiuri mwuxarebis" sindromi, mkvlevaris azrit, SesaZloa ganvitardes usualod ubedurebis Semdeg, an garkveuli drois gavlis Semdeg, SeiZleba mkafiod iyos gamoxatuli, an piriqit Zalze sustad. avtorma es aslilobebi daajgufa Semdegnairad: 1. fsiqogenurad ganpirobebuli somaturi aslilobebi (yelsi moweris SegrZneba, qosini, amooxvra, mucelsi sicarielis SegrZneba, kuntovani sisuste, tansi texvis SegrZneba, Tanmxlebi Tavis tkivilit, gemovnebis mosla); 2. danaklisis mudmivi warmodgenit Sewuxebuloba (micvalebulis da a.s.); 3. mwuxarebis grznoba; 4. mtruli damokidebulebisa da gamrizianeblobis reaqciebi; 5. adre damaxasiatebeli qcevis stereotipebis darrveva. SemdgomSi W. Niderland nasromsi "gadarcenilta sindromis klinikuri mimoxilva" da R. Lifton statiasi "gadarcenilni hirosimasi", gaketebulia daskvna imis Sesaxeb, rom stresuli movlenebi da katastrofani iwveven xangrzliv fsiqikur aslilobebs. aseti mdgomareobani mat mier iqna kvalificirebuli rogorc "gadarcenilta sindromi" (Survivor Syndrome). ufro mogvianebit, A. Burgess da L. Holmstrom Semoitanes "gaupatiurebulta sindromis" (Rape-trauma Syndrome) cneba. am sindroms gansazrvravdnen rogorc specifiur fsiqosomatur sindroms, romelic uvitardeba gaupatiurebulta daaxloebit mesameds mogvianebit periodsi da xasiatdeba Cveuli emociurobis dakargvita da "travmatofobiit", momatebuli agznebadobita da gamrizianeblobit, ganmeorebadi Ramis kosmarebit. gasuli saukunis 70 - ian wlebsi klinicistta gansakutrebuli yuradreba kvlav miipyro adamianis fsiqikaze omis periodis stresebis 22

23 gavlenis sakitxma, rac dakavsirebuli iyo vietnamis omis masalebtan, romelta safuzvelzec, C. Figley mier mowodebuli iqna termini "postvietnamis sindromi" (Post-Vietnam Syndrome), romelic Soreul periodsi xasiatdeba upiratesad ganmeorebadi akviatebuli mogonebebit, xsirad mkvetri warmosaxvebit (Flashbacks), Tanmxlebi datrgunulobisa da SiSis gancdit, somaturi aslilobebit; gaucxoebisa da indiferentulobis mdgomareobit, Cveuli interesebis dakargvita da danasaulis gancdit; SemaSinebeli sizmrebit, rac dakavsirebulia omis gamocdilebastan; momatebuli agznebadobit, gamrizianeblobit, fetqebadobit. amgvarad, 70 - iani wlebis bolosatvis dagrovili masala miutitebda im garemoebaze, rom gansakutrebuli travmuli stresit gamowveuli fsiqikuri aslilobani, matravmirebel faqtorta sxvadasxvaobis miuxedavad, xasiatdebian ertgvarovnebita da specifiurobit da ar Tavsdebian fsiqikur aslilobata arcert sayoveltaod mirebul nozologiasi. swored amitom, M. Horowitz da Tanaavtorebis mier es aslilobebi gamoyofil iqna damoukidebel sindromad, saxelwodebit "posttravmuli stresuli asliloba" (Posttraumatic Stress Disorder - PTSD) da pirvelad 1980w. Setanil iqna amerikul diagnostikur klasifikaciasi DSM - III - Si rogorc calke klinikuri forma; SemdgomSi, imave avtorta mier, SemuSavebuli iqna am aslilobis kliniko - diagnostikuri kriteriumebi, romlebic 1987w. Setanil iqna DSM - III - R - Si. amjamad es kriteriumebi fartod aris warmodgenili DSM - IV - Si (rubrikasi "SfoTviTi aslilobani") da 1991w. - dan Setanilia rogorc calke klinikuri forma msoflio jandacvis organizaciis daavadebata saertasoriso klasifikaciis me - 10 gadasinjvasi (ICD - 10), rubrikasi "reaqcia mzime stresze da adaptaciis darrvevebi" da Seesabameba Semdegi kodi: F rogorc ukve iqna arinisnuli wamebis fsiqikuri Sedegebi ara sakmarisad aris Seswavlili, mat Soris arsanisnavia, rom kvlavac daudgenelia korelacia wamebis calkeul metodebsa da mat mier gamowveul fsiqikur aslilobebs Soris (Basoglu, 1992). aseve arsebobs azri da unda arinisnos, rom es azri figurirebs yvela gansakutrebuli stresuli situaciit gamowveuli aslilobebis genezis analizsic, rom wamebit gamowveuli fsiqikuri gartulebebi damokidebulia asakze, sqesze, etnokulturul Taviseburebebsa da politikur Tu religiur Sexedulebebze (Somnier da sxva, 1992). samecniero literaturaze dayrdnobita da Cveni gamokvlvebis analizis Sedegad cxadi gaxda, rom yvelaze metad gavrcelebul fsiqikur aslilobas wamebis SemTxvevaSi warmoadgens posttravmuli stresuli asliloba da aseve xsiria misi qronikuli da gartulebuli an kombinirebuli variantebi, romlis Sesaxebac SemdgomSi iqneba saubari. posttravmuli stresuli aslilobis epidemiologiis sakitxebi PTSD-is cnebis klinikuri Sinaarsis dadgenisa da dazustebis Semdeg Seswavil iqna misi gavrcelebis xarisxi. dreisatvis gamoqveynebulia mravali epidemiologiuri kvlevis monacemi, romelic PTSD-is gavrcelebis saorientacio surats gvazlevs. Tumca aqve unda arinisnos, rom amgvari epidemiologiuri kvlevebi mwiria wamebis SemTxvevaSi. 23

24 H.C. Archibald, R.D. Tuddenham (1965) mier Seswavlili iqna asakobrivi procesebis gavlena stresul reaqciata gamovlinebebze. meore msoflio omis dros travmirebulta Soris gamokvlevebisas omidan 20 wlis Semdeg mat ivaraudes, rom posttravmuli stresuli darrvevebis simptomebi asaktan ertad ufro ikveteba. meore msoflio omis damtavrebis 40 wlis Semdeg yofil samxedro tyveebsi PTSD arinisneboda 67% - Si (Kluznik J.C., 1986). PTSD-is gansakutrebit marali xarisxi arwerilia yofil deportirebulta da sakoncentracio banakebis yofil tyveta Soris, 90%-dan 100%-mde. arnisnuli kvlevebi Catarebuli iqna koreis omis yofil patimarta Soris (P.B. Sutker, Daniel K. et al., ), meore msoflio omis yofil patimarta Soris (Z. Solomon, Y. Neria, O. Abraham et al., ), aseve sparsetis yuris samxedro konfliqtis dros holokavis msxverplta Soris (Z. Solomon, E. Prager, ). xolo amerikis samsvidobo misiis jarebsi sparsetis yuris konfliqtis dros PTSD arweril iqna 8% - Si. (What Is PTSD? The American Jurnal of Psychiatry, Editorial, 1997) damwvrobit hospitalizirebul pacientta Soris Catarebuli gamokvlevebis Sedegad 2, 6 da 12 Tvis Semdeg, ww, Sesabamisad PTSD armocenil iqna 35,2%, 40%, 45,2%. mnisvneloba eniweboda damwvrobis fartobs, saxis dazianebasa da subieqtur prediqtorebs. (S. Perry, et al., 1992). seqsualuri Zaladobis msxverplta Soris PTSD varirebs 46% - 66% farglebsi. (Becker I.V. et al., 1984, Browne A., Finkelhor D. 1986, Nadelson C.C. 1989, Bowners I.T. et al., 1991). gansakutrebit maralia PTSD-is gavrcelebis xarisxi ltolvilta Soris. genocidis msxverpl kambojel ltolvilta Soris PTSD armocenil iqna 86%. (Carlson E.B., Rosser - Hogan R., 1991). indo-cinetis ltolvilta Soris 322 pacientidan 226 arweril iqna mimdinare PTSD, xolo kidev 15 asliloba ganuvitarda mogvianebit (Kinril, Frederikson, Rath, Fleck, Karls., 1984). ltolvilta Soris PTSD-is yvelaze marali procenti, 93%, arwerilia laosel mtis xalxsi (Main), xolo yvelaze dabali vietnamis ltolvilebsi _ 54% (R.C. McKelvey, J.A. Webb, 1996). "etnikuri wmendis" msxverpl bosniel ltolvilta Soris PTSD arwerilia 65%, xolo SemTxvevaTa 35% _ depresia (S.M. Weine, D.F. Becker, et al., 1995). PTSD -is gavrcelebis xarisxi amerikelta monacemebit (C.S. North, E.M. Smith et al., 1994) sasualod varirebs 19%-dan _ 80%-mde. amgvarad, epidemiologiuri monacemebi SesamCnevad varirebs 3,5% dan 67% procentamde sasualod sxvadasxva faqtorebis gatvaliswinebit (travmis xasiati, asaki, sqesi, socio-kulturuli da etno-kulturuli gansxvavebani da sxva). rig avtorta azrit, aseti sxvaobis mizezad ertiani zusti kriteriumebis ararseboba gvevlineba. mteli rigi avtorebi miicneven, rom gansakutrebit sastiki wamebis SemTxvevaSi posttravmul stresul aslilobata simptomebi gvxvdeba praqtikulad 100 % SemTxvevaSi. Tumca unda arinisnos, rom wamebis Sedegebis gamovlenis sixsire sxvadasxvagvaria: yvela adamiansi ar aisaxeba Sedegebi nebismier garemoebebsi gadatanili wamebis Semdeg. 24

25 wamebamdeli cxovreba, Tavdacva, wamebisas gancdili SegrZnebebi da iseti Semdgomi pozitiuri da negatiuri faqtorebi, rogoricaa, usafrtxoeba, martlmsajuleba an socialuri mxardaweris sxva formebi SeiZleba zegavlenas axdendes im SemTxvevaSi, Tu simptomebi vlindeba an qronikuli xdeba. gamokvlevebma acvena, rom gansakutrebul garemoebebsi da intensiuri wamebis an devnis aqtebis Semdeg gamovlenili Sedegebis gavrcelebis macvenebeli 100%-s arwevs yvela aris seriozulad travmirebuli. aslilobis yvelaze gavrecelebul saxeobas warmoadgens depresia da posttravmuli stresuli asliloba.. daavadebata SeTanawyobis macvenebeli sakmaod maralia gansakutrebit iset daavadebebs Soris, rogoricaa posttravmuli stresuli asliloba da depresia - romelta SeTavsebis macvenebeli 90%-s arwevs. viqtor franklma, sakoncentracio banaksi gadarcenilma adamianma da fsiqoterapevtma, gaaketa Semdegi komentari: mas, visac aq `goneba ar daukargavs~ arar aqvs `dasakargi goneba~. (Thomas Wenzel, WPA, 2004). posttravmuli stresuli aslilobis etiologiisa da patogenezis sakitxebi gansakutrebuli stresuli situaciit ganpirobebuli fsiqikuri darrvevebis, reaqtiul mdgomareobata etiologiisa da patogenezis sakitxi pirveli msoflio omidan moyolebuli, farto ganxilvis sagans warmoadgenda. am sakitxebtan dakavsirebit mdidari masala mogvca pirveli da meore msoflio omis gamocdilebam, romlis drosac safuzvlianad iqna Seswavlili travmuli da omis periodis nevrozebi, aseve sxva fsiqoreaqtiuli darrvevebi. pirveli msoflio omis droidan moyolebuli im sakitxis Sesaxeb, Tu ra roli eniweba travmuli fsiqo-nevrozebis ganvitarebasi fsiqikur travmas, aqvs Tu ara mas patogenezuri mnisvneloba, Tu mxolod provokaciuli, arsebobda didi utanxmoeba, romelic daiyvaneboda imaze, Tu romeli momenti _ egzogenuri Tu endogenuri _ aris gadamwyveti gansakutrebuli stresit gamowveul fsiqikur darrvevata warmoqmnasi w. W. Sargant, E. Slater arnisnavdnen travmuli nevrozis ganvitarebasi garegani agresiis gadamwyvet mnisvnelobas da amtkicebdnen, rom garkveul vitarebasi, roca adamianebi Zalzed travmirebulni arian, "aravis gaacnia imuniteti". PTSD etiologiisa da patogenezis Tanamedrove koncefciebi metnaklebad asaxaven travmul nevroztan dakavsirebit warsulsi arsebul koncefciata Soris konfliqts. mtel rig avtorta mixedvit (Brett E.A., Spitzer R.L., Williams J.B.; Green B.L., Lindy J.D.; Horowitz M.J.; Millier T.W.), PTSD is safuzvels warmoadgens fsiqikuri travma, romelic arinisneba rogorc gansakutrebuli movlena (Life Stress Event) da romelic iwvevs mzime fsiqikur stress. aseti "movlena" yvela SemTxvevaSi ucveuloa pirovnebisatvis da Tan axlavs SiSi, SeZrwuneba da umweobis gancda. 25

26 fsiqikuri travma _ "movlena" _ SesaZloa iyos rogorc piradi, individualuri: gaupatiureba, axlobeli adamianis darupva, wameba, Zaladoba, aseve _ masobrivi, saerto: omi, bunebrivi katastrofani da sxva. zogierti travmuli movlena, mag. wameba, yoveltvis iwvevs PTSD, xolo sxva, mag. satransporto katastrofa, mxolod zogiert SemTxvevaSi. rac ufro xangrzlivia fsiqikuri travmis "movlenis" moqmedeba, mit ufro didia PTSD ganvitarebis albatoba (П.В. Каменченко). Tanamedrove midgomebit (Thomas Wenzel, WPA, 2004) stresisa da gadarcenis fsiqologiis arsi ganisazrvreba Semdegi modulebit: safrtxesi moxvedra aaqtiurebs reaqciebs, romelnic Cveulebriv sasargebloa gadarcenisatvis da SeiZleba mivicniot aranormaluri movlenebis mimart normalur reaqciebad ukidures safrtxestan brzola aaqtiurebs organizmis yvela `sistemas da warmoadgens fizikur da fsiqologiur process_ adaptacias. xangrzlivi stresis dros vitardeba fizikuri da fsiqologiuri `gadawva (gamofitva) reaqciis saxeebi icvleba, rata SenarCunebuli iqnas gadarcenisatvis sawiro ZiriTadi energia mogvianebit gamovlenili mravali simptomi asaxavs am, orgvari tipis, adaptaciis reaqciebs. PTSD warmosobis ert-ert yvelaze ufro mnisvnelovan da seriozul mizezad itvleba admianis ZiriTad uflebata darrveva, rac Cveulebriv organizebuli Zaladobis saxit vlindeba. (Inge Genefke; Lone Jacobsen, Knud Smidt-Nielsen, Rachel Yehuda, boasz Kahana, James Schmeidler, Steven M. Southwick, Skye Wilson, Earl l. Giller; Zahava Solomon, Yuval Neria, Abraham Ohry et al.; Edward Prager) es koncefcia fartod aris ariarebuli msoflio jandacvis organizaciis mier. damkvidrebulia Semdegi gansazrvreba: "adamiantasorisi miyeneba gamoxatuli tkivilisa da tanjvis, romelic ar warmoadgens aucileblobas, organizebuli jgufis mier deklarirebuli an nagulisxmebi strategiis Sesabamisad da/anu ideata da damokidebulebis sistemit. es TavisTavSi moicavs yovelgvar Zaladobriv qmedebas, romelic miurebelia zogadsakacobrio standartebis poziciidan da aqvs kavsiri msxverplis SegrZnebebTan." organizebuli Zaladoba, gaeros adamianis uflebata sayoveltao deklaraciis Sesabamisad, aseve moicavs "wamebas, sastik, arahumanur an damamcirebel mopyrobas an dasjas". sasamartlos garese patimroba, cru ekzekuciebi, mzevalta ayvana an sxva nebismieri forma Tavisuflebis Zaladobrivi wartmevisa agretve ganxilulia organizebuli Zaladobis gansazrvrebasi (Э. Хофф). faqtorta mteli rigi azlierebs fsiqikur travmas. mat Soris upiratesad mnisvnelovania _ sikvdilis usualo albatoba, msxverpltan identifikacia, socialuri kavsirebis dakargva, Soreuli Sedegebis mxriv gaurkvevloba, dagvianebuli mkurnaloba, an mkurnalobis ar arseboba, umweobis gancda, gancdebit urtiertinducireba (Durham T.W., Horowitz M.J., Wilner N., Kaltreider N., McDeniel E.G., Ковалев В.В., Асанова Н.К.). iyo mcdeloba ganesazrvrat travmis fizikuri da emociuri Semadgenloba, Tumca armocnda, rom xsir SemTxvevaSi PTSD uvitardebodat pirebs, romeltac ar miuriat sxeulis dazianeba, magram romelnic intensiurad ganicdidnen fizikuri ganadgurebis potenciur risks. mravali 26

27 mkvlevari fizikur da emociur travmas Soris amgvar dayofas miicnevs xelovnurad da Tvlis, rom am or komponents Soris yoveltvis arsebobs mwidro urtiertkavsiri. (Padovoni L., 1950, Fenichel O., 1953; Kardiner A., Karonyi E.K., 1977; Weil F., 1985). 15 wlis, , ganmavlobasi, warsulsi travmul nevroztan dakavsirebit Bonhoffer - Oppenheim davis msgavsad, arsebobda didi konfliqti PTSD etiopatogeneztan dakavsirebit travmul da konstituciur koncefciebs Soris. mkvlevarta erti jgufi askvnis, rom PTSD ganvitarebasi gadamwyveti roli ganekutvneba konstitucias, ganvitarebis fiqsacias, an genetikur predispozicias. kerzod ki pirovnebebs isteriuli pirovnuli organizaciita da warsulsi ganumuxtavi emociuri stresebit, disociaciuri tendenciebit ufro xsirad uvitardebat PTSD, amitom isini PTSD ganixilaven, rogorc naklovani pirovnebis reaqcias (Ch.R. Marmar, D.S. Weiss, W.E. Schlenger, J.A. Fairbank, K. Jordan, R.A. Kulka, R.L. Hough). xolo Breslau N., Davis G.C., Andresski P., Peterson E. Tvlian, rom PTSD upiratesad uvitardebat mamakacebs bavsvobasi deviaciuri darrvevebit da ganvitarebis dabali donit, romelta natesavebsi gamovlenilia fsiqikuri patologiisa da alkoholizmis SemTxvevebi. Andreasen N.C., Horowitz M.J., Figley C.R., Green B.L., Lindy J.D., Rahel Yehuda, Alexander C. McFarlane patogenezur rols PTSD ganvitarebasi eqstremalur travmul movlenas aniweben (Extremely Traumatic Event) da miicneven, rom PTSD warmoadgens adaptaciis bunebriv proces eqstraordinarul situaciasi da misi simptomta paterni ar aris damokidebuli konstituciur midrekilebaze. mati azrit, PTSD warmoadgens normaluri pirovnebis reaqcias aranormalur, araordinarul cxovrebis pirobebze. Resnick H.S., Kilpatric D.G., Kramer T.L., Best C.L.; Yehuda R., Pitman R.K., Foy D.W. miicneven, rom PTSD ganvitarebis riski ufro metia ganmeorebiti travmatizaciis SemTxvevaSi, vidre pirveladi travmis SemTxvevaSi. aseve PTSD ganvitarebis riski metia premorbidulad alkoholizmita da narkotikuli nivtierebebit datvirtul pirovnebebsi, rasac adasturebs rogorc vietnamis, aseve avranetis omis veteranta Soris Catarebuli gamokvlevebi. (Tom Williams, Jelinek J.M., James Newman, П.И. Сидоров, М.Ф. Лукманов.) V. Charlot et al, aseve Краснянский А.Н., romelsac didi wvlili miuzrvis avranetis omis veteranta kvlevasi, did mnisvnelobas PTSD ganvitarebasi stresis momentsi pirovnebis fiziologiur mdgomareobas aniwebs. "gansakutrebit mnisvnelovania fizikuri gamofitva, arasakmarisi Zili, sakvebisa da wylis ukmaroba (deficiti), anu yovelive, rac iwvevs darlilobas brzolasi" _ wers igi. Atkinson B., Henderson J.M., Sparr B.W., Deal R., vietnamis omis veteranebze dakvirvebis Sedegad miicneven, rom ert-erti wamyvani faqtori PTSD etiologiasi aris travmirebulis araswori Sefaseba da araketilganwyobili damokidebuleba. mnisvnelovani roli PTSD etiopatogenezsi eniweba moralur da msoflmxedvelobriv faqtors, vinaidan axlad mirebuli eqstraordinaruli gamocdileba ar Tavsdeba pirovnebis adre arsebul sqemebsi da iwvevs 27

28 faseulobata sistemis msxvrevas, iseti bazisuri fenomenebis xelhyofas, romlis safuzvelzec pirovneba qmnis warmodgenebs sakutar Tavze, samyaroze da am samyarosi Tavis adgilze. (Weil F., Jonathan Shay). mkvlevarta nawili PTSD etiologiasi mnisvnelovan rols aniwebs etno-kulturul Taviseburebebs, Tumca es sakitxebi dreisatvis arasakmarisadaa Seswavlili (J. Marsella, Matthew J. Friedman). D msoflio jandacvis organizaciis gadawyvetilebit, PTSD gansakutrebuli riskis jgufebs miekutvneba: 1. bavsvebi da mozardebi, romelta msoblebic iqnen moklulni, an oblebi, an bavsvebi da mozardebi, romelta msoblebic gasorebulni arian, dangreuli ojaxebidan da romelnic cxovroben saomar zonasi, an ltolvilni da izulebit gadaadgilebulni. 2. martoxela moxucebi, mcxovrebni omis zonasi, ltolvilni, an izulebit adgilnacvalni, romeltac esawiroebat socialuri daxmareba. 3. qalebi, romeltac ganicades pirveladi travmatizacia (gaupatiureba, wameba), an meoradi travmatizacia (bavsvebis an qmris mokvla, ojaxis struqturis darrveva da cxovrebis socio-ekonomiuri pirobebis mkvetri gauareseba). 4. mamakacebi, romeltac ganicades omis fsiqologiuri Tu fizikuri travmebi (moicavs sakoncentracio banakebsi yofnas, wamebas; agretve ltolvilni da izulebit adgilnacvalni). 5. pirovnebebi Sereuli etnikuri warmosobit, an mcxovrebni Sereul ojaxebsi, Sereuli qorwinebebit, etnikuri wmendis msxverplni. aseve unda arinisnos, rom dazaralebulni SesaZloa iyos aramarto "movlenis" usualo monawileni. msgavs gancdebsi ertvebian ojaxis wevrebi, mezoblebi, masvelni da sxv. (K. Cormie, J. Howell), aseve D. Jones azrit _ savadmyofoebisa da prozeqturebis TanamSromelnic. amgvarad, PTSD etiologiasi dreisatvis kauzaluri mnisvneloba eniweba araordinarul travmas da es asliloba ganixileba, rogorc kanonzomieri reaqcia aranormalur situaciaze da SeiZleba ganuvitardes nebismier individs. mnisvnelovan rols PTSD ganvitarebasi TamaSobs: pirovnebis istoria, fsiqikuri Tu somaturi mdgomareoba travmatizaciis momentsi, msoflmxedveloba, faseulobebi da moraluri dayenebebi travmamde. aseve mnisvnelovani roli eniweba "movlenis" Serwymas socialur-fsiqologiur problemebtan: uziloba, SimSili, wylis nakleboba, sicive, energetikuli problemebi da sxv., rac iwvevs pirovnebis damcavi meqanizmebis ganlevadobasa da qmnis patologiurad Secvlil niadags. etnokulturaluri Taviseburebani, tradiciuli, religiuri Sexedulebani, romelta msxvrevac ganskutrebit mnisvnelovania ama Tu im etnikuri jgufisa Tu pirovnebisatvis, aseve garsemomyofi sociumis damokidebuleba, sazogadoebis reaqcia, socialuri pirobebi, meoradi travmebi "movlenis" damtavrebis Semdgom gansakutrebit moqmedeben PTSD mimdinareobasa da simptomta simyareze. did sirtules warmoadgens PTSD patogenezuri meqanizmebis gansazrvra, vinaidan dreisatvis arsebobs sxvadasxva Sexedulebani am sakitxisadmi da ramdenime principulad gansxvavebuli midgoma Seswavlisadmi. (П.В. Каменченко). aqedan gamomdinare E. Brett ganasxvavebs patogenezis fsiqologiur, biologiur da kompleqsur modelebs. 28

29 patogenezis fsiqologiur modelebs Soris gansakutrebit sayuradrebo da dreisatvis ariarebulia M. Horowitz modeli, igi eyrdnoba Z. Freud ideebs, aseve sakutar klinikur Tu eqsperimentul gamocdilebas. Z. Freud ikvlevda ra pirveli msoflio omis monawile jariskacebs, romeltac arenisnebodat Ramis kosmarebit, ivarauda, rom es sizmrebi gamoxataven "travmul xatebs" pirvelad lokalizacias, xolo mati ganmeorebadoba _ dacvis infantilur formas, roca ubedurebis mudmivi aracnobieri ardgena mexsierebasi iwvevs damcavi gamocdilebis formirebas. sqematurad es gamoiyureba Semdegnairad: garegani zemoqmedeba _ mogonebebi _ avadmyofuri efeqti _ dacva. xolo am SemTxvevebSi gamovlenili darrvevebi mis mier kvalificirebul iqna rogorc nevrozuli _ "travmuli nevrozi". ufro mogvianebit 1939 w., nasromsi "mose da monoteizmi", Z. Freud arnisnavs, rom travmuli nevrozis dros adgili aqvs negatiur da pozitiur reaqciebs. pirvelni, TiTqosda gandevnian travmas datrgunvit, gaqcevita da fobiebit, xolo meoreni _ piriqit, axseneben mas mogonebebis, xatebisa da fiqsaciebis saxit. M. Horowitz reaqciata am jgufebs Seesabameba "uaryofisa" da "ganmeorebadi gancdis" simptomta jgufebi. garegani zemoqmedebis faqtori M. Horowitz gansazrvra, rogorc "absoluturad axali informaciis Semcveli "travmuli stresuli movlena", romelis integraciac unda moaxdinos pirovnebam winamorbed cxovrebiseul gamocdilebasi." mtlianobasi M. Horowitz sqema gamoiyureba Semdegnairad: travmuli stresi _ uaryofa _ ganmeorebiti gancda _ SeTviseba. klinikuri dakvirvebebisa da specialurad SemuSavebuli kitxvaris safuzvelze M. Horowitz daaskvna, rom simptomurad "uaryofa" vlindeba amneziit, yuradrebis darrvevit, zogadi fsiqikuri SeboWilobiT, SenelebiT, travmis momagonebeli nebismieri movlenidan, an mastan dakavsirebuli asociaciebidan gaqcevis tendenciit. "ganmeorebadi gancdis" simptomebi xasiatdeba ganmeorebadi akviatebuli azrebit, Zilis darrvevit, Ramis kosmarebit, "Flashbacks" disociaciuri epizodebit, SfoTvis SegrZnebiT. Z. Freud, M. Horowitz Sexedulebebma ganvitareba hpova E. Brett, R. Ostroff SromebSi, romeltac PTSD patogenezuri meqanizmi warmoadgines, rogorc "gandevnisa" da "ganmeorebiti gancdis" fsiqologiur movlenata urtiertobis Sedegi. stambolis protokolis specialuri treningebisatvis momzadebuli msoflio fsiqiatrta asociaciis seqciis «wamebis fsiqologiuri Sedegebi da arkveta» masalebsi arwerilia wamebis Sedegad ganvitarebuli stresuli darrvevebis Semdegi meqanizmebi : I etapi: safrtxe: usualo safrtxis damusaveba, rac Semdegi meqanizmit ganisazrvreba: 29

30 1) safrtxe 2) SiSi (ra xdeba?) 3) aqtivacia : reaqcia: sxeulis safrtxis mravalmxrivi `sistemebi aqtivirebulia ; 4) Sefaseba (ra SeiZleba moxdes) ; 5) brzola reagirebis tipebi : Tavis momkvdaruneba, gaseseba, disociacia, ( fantaziebsi gansvla ) ; 6) gadafaseba. II etapi: reaqcia Semdgom kontaqtze 1) msgavis signali (SeiZleba ar iyos vefxvi); 2) SiSi, orientirebuli reagireba, 3) aqtivacia - vefxvis bolo Setevis, travmebis Sesaxeb mogoneba 4) brzola, Tavidan acilebis mcdeloba, Tavis momkvdaruneba, gaseseba, disociacia. 5) Zlieri reaqcia, panika. III etapi: Semdgom cxovrebasi gaxsenebadi reaqcia 1) vefxvis Tavidan acileba, gaxseneba (msgavsi situacia): ar arsebobs safrtxe, aramed msgavsi situacia; 2) aqtivacia-oflianoba, swrafi majiscema, dazabva, gaznelebuli suntqva; 3) akviatebuli mogonebebi: vefxvis bolo Setevis travmebi, tkivilebi, ZilSi kosmarebi; Zlieri reaqcia, panika - Tavis momkvdaruneba, gaseseba, disociacia, SemdgomSi Tavis arideba, gamofitva; 4) qronikuli mdgomareoba warmoqmnis `posttravmul stresul aslilobas an `sxva asliobebs ar aris adaptacia amgvarad wamebis gadatana da momdevno fsiqologiuri meqanizmebi Semdegi sqemebit SeiZleba gamoisaxos: SiSi/orinetirebuli reagireba aqtivacia reaqcia: sxeulis safrtxis `sistemebi aqtivirebulia Sefaseba: adrindeli wamebis gaxseneba, molodini garduvaloba brzola mkvdris rolis TamaSi, gaseseba, disociacia,. umweobis qronikuli mdgomareoba gamofitva 30

31 wamebis gadatana: disociacia wameba garduvaloba Semdgomi cxovreba gamaxsenebeli: mogonebebi, msgavsi situaciebi, mrgvali TariRi adaptaciuri reaqcia xdeba `avtomaturi adaptacia-magaliti: disociacia disociacia aris tipuri reagirebis nimusi, Tu realobidan gaqceva SeuZlebelia: fantaziebsi gansvla arsebul realobisgan mowyveta :Thomas Wenzel/ WPA, 2004 disocirebuli simptomebi: xanmokle amnezia wamebis garemoebebis daviwyeba, mexsierebis `amovardnebi Tavdacvis formebs ganekutvneba: aqtiuri Tavdacva winaarmdegobis gaweva (es SesaZloa saxifato iyos) mnisvnelobis micema, pirad religiur da politikur rwmenasi integrireba, jgufuri mxardawera patimrebs Soris wamebis iseti fsiqologiuri Sedegebis armofxvra, rogoricaa msxverplis `dadanasauleba an Sercxvena gamocdilebis aqtiuri asaxva da integracia TviT gansazrvra, rogorc wamebagamovlilis da ara msxverplis Tavdacvis sxva formebi uaryofa _ (`es ar momxdara. es mxolod Cemi fantaziaa. es male dasruldeba da me Tavisufali viqnebi ) agresortan gaigivebis dawyeba an misi gancxadebebi an qceva xsirad warmoadgens arapirdapir reaqcias mzevlis mdgomareobasi da Zalian isviatad SeiZleba gadaizardos wamebasi*, gansakutrebuli formaa `tramvuli kavsiri (jalattan emociuri urtiertobis damyareba). isini xsirad ganmartebulia rogorc Tavdacvis (dacva) strategia, romelmac SeiZleba eqstremalur garemoebebsi uzrunvelyos 31

32 gadarcena. riskebi SesaZloa gamovlindes Semdgom fsiqologiur mdgomareobasi, roca konfliqti dasruldeba. arsanisnavia, rom Tu Tavdacva Sewydeba travmireba gaxdeba SesaZlo Sedegi (Thomas Wenzel, WPA, 2004). ukanaskneli wlebis neirofiziologiuri da bioqimiuri gamokvlevebis Sedegebi daedo safuzvlad PTSD biologiuri modelis Seqmnas (Davidson J., Walker J.I., Kilts C., Mendelson G.), romelta mixedvit PTSD patogenezuri meqanizmi ganpirobebulia endokrinuli sistemis funqciis darrvevit, rac gamowveulia zezrurblovani stresuli zemoqmedebit. dreisatvis ufro metad perspeqtiulad itvleba patogenezis Teoriuli modelebi, romelnic itvaliswineben PTSD ganvitarebis rogorc fsiqologiur, aseve biologiur aspeqtebs. am pirobebs yvelaze metad Seesatyviseba L. Kolb, B. Green, J. Lindy, T. Miller neirofsiqologiuri hipotezebi. kerzod, vietnamis omis veteranebze Catarebuli fsiqofiziologiuri da bioqimiuri kvlevebis Sedegebis ganzogadebit, miutiteben, rom intensivobita da xangrzlivobit gansakutrebuli mastimulirebeli zemoqmedebis Sedegad warmoiqmneba Tavis tvinis qerqis neironebsi cvlilebebi, sinafsur gadacemata blokireba da neironta darupvac ki. am dros, upirveles yovlisa, ziandeba tvinis zonebi, romlebic pasuxismgebelia agresiulobasa da Zilis ciklze. avtorta klinikuri dakvirvebebi dadasturebuli iyo laboratoruli diagnostikis SedegebiT. amgvarad, travmis gansazrvreba wamebis konteqstidan gamomdinare Semdegia : travmireba aris procesi, roca gansakutrebul garemoebebsi warmoqmnili stresuli faqtorebi (stresorebi) ufro Zlieria, vidre pirovnebis adekvaturi damusavebis an Tavdacvis resursebi da sakutari gancdis msoflmxedvelobasi integracia, rasac Sedegad mohyveba pirovnebis ketildreobis sistemuri ngreva. travmireba ar iwvevs mxolod ptsa (posttravmuli stresuli asliloba)- s, aramed, SeiZleba gamoxatuli iyos mraval sxva simptomsi an aslilobasi, rac damokidebulia pirovnebis istoriaze, stresuli reaqciis nimusebze da daucvelobaze, gadatanili travmis tipze, da kulturaze yvelaze xsirad, ptsa, depresia, somatoformuli, disociaciuri da kvebiti aslilobebi dakavsirebulia adre gadatanil `travmastan. travmis tipebi Semdegi SeiZleba iyos: tipi I (a): erteuli SemTxveva tipi II (b): ganmeorebiti SemTxveva tipi III: ganmeorebiti SemTxvevebi. xangrzlivi muqara an bavsvobidan gamoyolili SiSi, pozitiuri (damcavi) faqtorebis ararseboba. (Thomas Wenzel, WPA, 2004). 32

33 wamebis fsiqikuri Sedegebis upiratesad gamovlenili klinikuri formebi calkeul literaturasi gamoyofen «wamebis sindroms», Tumca`wamebis sindromi~ ganisazrvra SedegebTan dakavsirebuli ganxilvebis adreul etapze, da moicavs iset simtomebs, romelta didi nawili Setanilia posttravmuli stresuli aslilobisa (ptsa) da kompleqsuri posttravmuli stresuli aslilobis gansazrvrebebsi. es sindromi ZiriTadad amorebulia da Secvlilia standartuli diagnostikuri terminebit (Thomas Wenzel, WPA, 2004). miuxedavad imisa, rom gamokvleva iwyeba gamovlenili da armocenili fsiqologiuri reaqciisa da simptomebis doneze, sasamartlo-samedicino eqspertizis miznebisatvis,zusti kriteriumebis safuzvelze dasmuli diagnozi SeiZleba gansakutrebit mnisvnelovani armocndes. zogierti atipiuri an gansakutrebuli kulturisatvis damaxasiatebeli simptomebis aseve, wamebaze askara reaqciebis an jer kidev gaurkveveli simptomebis gamo, aseve gansakutrebuli mnisvneloba eniweba arwerilobas simtomebis doneze an ubralo arwerilobas diagnostikuri kategoriis gansazrvris garese. stambolis protokoli : wamebis efeqturi gamoziebisa da dokumentirebis saxelmzrvanelo, emyareba klasifikaciis or diagnostikur sistemas, romlebic msgavsia magram ar aris ertnairi. sawiroa gadawyvetilebis mireba imis Sesaxeb, Tu romeli sistema unda iqnas gamoyenebuli. ICD 10: daavadebata saertasoriso klasifikacia, me-10-e gadasinjva. jandacvis msoflio organizacia. V (F) Tavi exeba fsiqikuri da qceviti aslilobebis diagnostikas. DSM IV: diagnostikuri da statistikuri saxelmzrvanelo, gamocema IV (axali: IV TR). amerikis fsiqiatrta asociacia. SeniSvna: DSM IV exeba mxolod fsiqikuri diagnostirebas. ori sistema: : ICD 10, DSM IV (TR) ICD 10 Tavi V + integrirebulia somaturi diagnostikis kodebsi, gamoiyeneba mravali qveynis klinikur praqtikasi, jandacvis msoflio organizaciis oficialuri dokumenti, itvaliswinebs Sedegebis sasargeblo kategoriebs (F 62.0, pirovnebis qronikuli cvlileba wamebis Semdeg), gansazrvravs ptsa-s kategoriebs, saxelmzrvanelos klinikur versiasi*. DSM IV + mravalferovani gamokvlevis monacemebi ptsa-is Sesaxeb am sistemasi, garkvevit operacionalizebuli (aseve, SezRudva Tavdapirvelad kvlevisatvis sawiro kriteriumi SesaZloa Zalian mkacri iyos), mravali kvleviti da diagnostikuri dokumentebi sxvadasxva enebze, ptsa DESNOES kategoria ganxilvis processia. 33

34 ICD 10 sistema Tavi V yvelaze mnisvnelovani kategoriebi, romelic SeiZleba iyos asocirebuli wamebastan mocemulia Semdeg sqemaze: xanmokle reaqtiuli fsiqozi Zaladobis Semdgomi sindromi reqaciebi Zlier stresze ptsa pirovnebis Secvla gunebaganwyobile bis asliloba `Sinagani~ SfoTva gunebaganwyobile bis fonis somatofor muli asliloba asliloba SfoTvis komponenti T disociaciu ri asliloba Z 65.4: danasaulis an terorizmis, mat Soris wamebis msxverpli, Z 65. 3: Tavisuflebis arkveta, Z 65.5 katastrofis an omis zemoqmedeba, X 85- Y09: sastiki mopyrobis, mat Soris wamebis sxva Sedegebi, S 06-iT gatvaliswinebuli sxva kodebi. yvelaze fartod gavrcelebuli reaqciebi eqstremalur cxovrebiseul movlenebze: ICD 10 - is mixedvit Semdegia: (aucilebeli ar aris, rom yvela gamovlindes TiToeul SemTxvevaSi) mwvave stresuli reaqcia/asliloba ICD 10: 43.0, ramdeni saati an dre movlenis Semdeg 34

35 posttravmuli stresuli asliloba (ptsa): ICD 10: F 43.1, ramdenime dris an wlis gavlis Semdeg. pirovnebis Secvla katastrofis gadatanis Semdeg ICD 10: weli da meti wamebis mwvave periodis Sedegebis Seswavla, rogorc ukve arvnisnet Zalzed limitirebulia da am gancdata Sefaseba Tu analizi upiratesad eyrdnoba anamnezur da postfaqtum monacemebs. Cvens mier Catarebuli kvlevebis Sedegad fsiqo reabilitaciis centri «empatia»s monacemebit, yvelaze xsirad mwvave periodsi gvxvdeba emociur Sokuri reaqciebi (saerto ricxvidan #255 amgvari reaqcia arenisneboda %), romelsac xsir SemTxvevaSi Tan sdevda suiciduri azrebi, an para suiciduri qmedebani an TviT dazianebis faqtebi (56 SemTxvevaSi 21,9 %), aqve unda arinisnos, rom fsiqikuri movlenebs Tan sdevda xsir SemTxvevaSi somaturi darrvevebi, romelic gamoixateboda: Tavis tvinis travmit, gonebis dakargvit (146 SemTxveva 57,30 % saerto ricxvidan 255), sxvadasxva saxis hemoragiuli sindromi cemis an sxva saxis wamebis Sedegad ganvitarebuli (87 SemTxveva 34,10 %) da tkivilit gamowveuli travmuli Sokis sindromi (128 SemTxvevaSi 50, 2 %). Cvens mier warmoebuli kvlevebis Sedegad cxadi gaxda, rom wamebis mwvave periodsi vxvdebit afeqtur Sokuri reaqciebis rogorc stuporozul variants, aseve eqsploziur agznebit reaqciebs. stuporozuli variantis dros upiratesad warmodgenili iqna iseti simptomebi rogoric aris : «fsiqikis gayinva» - gaseseba, rogorc fsiqikuri funqciebis, aseve fizikuri, rasac xsir SemTxvevaSi Tan axlda ukiduresi gamofitvisa da gadarlis gancda, xsirad Tanmxlebi insomniit; yovelive arnisnuls xsirad Tan sdevda cnobierebis Seviwroebisa da dezorientaciis, depersonalizaciis gancdebi. amgvar situaciasi wamebis msxverplni verar ariqvamen Seqmnil situacias, ver wvdebian kargad SekiTxvis an saubris Sinaars, SezRudulia moqmedebebi da TviTkontrolis meqanizmebis funqcionireba, am dros igi meqanikurad advilad awers xels yovelgvar SemoTavazebas, ar swevs winaarmdegobas aravitar qmedebaze ; ukiduresad Senelebulia, SezRuduli an ararsebulia reqciebi. amgvar mdgomareobas xsirad win uswrebs zezrurblovani fizikuri Tu fsiqikuri zemoqmedebis momenti, aseve ukiduresi umweobisa da situaciaze damokidebulebis gancda. amgvari aslilobebi upiratesad vlindeba qalebsi, igi aseve fartod warmodgenilia mozardebsi, Tumca sakmaod xsirad gvxvdeba mamakacebsic. msxverplis amgvari «gayinuli» mdgomareoba umeteswilad arasworad ariqmeba jalatebis mier da ganixileba «mdumare protestisa da winaarmdegobis reaqciad», rac iwvevs mat kidev ufro garizianebasa da sisastikes. reaqciis agznebadi tipi xasiatdeba eqsploziuri brutaluri reaqciebit, agzneba atarebs qaosur xasiats. xsiria am SemTxvevaSi suicidis mcdeloba an suicidi, Tan sdevs cnobierebis Seviwroeba, ar xdeba situaciis swori arqma, daqveitebulia TviTkontroli, mosalodnelia TviTdazianebis SemTxvevebi ; fsiqlogiuri meqmizmi am dros upiratesad Semdegia: autaneli tanjva, iwvevs fsiqikis zezrurblovan garizianebas, am yvelafridan Tavis 35

36 darwevis cnobier Tu aracnobier survilsa da xsirad situaciis Sewyvetis motivit gauazrebel ukontrolo qmedebas, rasac mohyveba suicidi an TviTdazianeba; Tumca aqve unda arinisnos, rom xsirad amgvari qmedeba sruliad gacnobierebulia da mizanmimartulia situaciis Sewyvetaze: wamebis msxverpli amjobinebs sikvdils amgvari tanjvis gagrzelebas, vinaidan mistvis situacia, fizikuri Tu moraluri tkivili gausazlisi xdeba. amgvari reaqcia Cvens mier upiratesad arweril iqna mamakacebs Soris. rara Tqma unda, igi iseve, rogorc stuporozuli varianti jalatebis kidev ufro gasastikebas iwvevs. unda arinisnos, rom amgvari reaqciebi warmoadgens normaluri adamianis normalur reaqcias aranormalur da sastik movlenaze da mis ganvitarebasi wamebas unda mieniwos gadamwyveti mnisvneloba. M mwvave stresuli reaqcia (mwvave stresuli asliloba DSM IV sistemasi) xsiria stresis fonze, da ar SeiZleba ganxilul iqnas, rogorc ZiriTadi samedicino problema, radgan is Cveulebriv ixsneba mkurnalobis garese. DSM IV: mwvave stresuli asliloba. msr-is dokumentireba SeiZleba mnisvnelovani iyos kvlevis processi, arsebuli simtomebisa da Tavisuflebis arkvetis, wamebis an sxva faqtorebis Sedegad warmoqmnili dazianebis ganmartebis miznit, radgan is pirdapir kavsirsia stresis gamomwvev SemTxvevasTan. Tavisuflebis arkvetisa da wamebis dros an cota xnis Semdeg, reaqciebi vlindeba xsirad, da TandaTan SeiZleba ganvitardes ptsa an sxva qronikuli mdgomareoba. ptsa SeiZleba ufro xsiri iyos adrindeli Zlieri stresuli reaqciis Semdeg. «stresze mwvave reaqciis» diagnostikuri kriteriumebi mocemulia daavadebata saertasoriso klasifikaciis me 10 gadasinjvis (ICD 10) TavSi F (fsiqiatria), kerzod ki F 43 reaqcia MmZime stresze da adaptaciis darrveva. arnisnuli darrvevis kodia F mwvave reaqcia stresze klinikuri gamovlinebebi «es aris mnisvnelovani simzimis tranzitoruli asliloba, romelic uvitardebat pirebs, romeltac ara aqvt gamoxatuli fsiqikuri asliloba, pasuxad gansakutrebul fsiqikur an fsiqologiur stresze da romelic, Cveulebriv, amoiwureba ramodenime saatis an dris ganmavlobasi. amgvar stresul faqtorad SesaZloa gvevlinebodes Zlieri matravmirebeli garemoeba, romelic emuqreba adamianis an mistvis Zvirfasi adamianis usafrtxoebas, sicocxles, fizikur mtlianobas (mag. bunebrivi katastrofa, ubeduri SemTxveva, brzola, danasaulebrivi qmedeba, gaupatiureba) an ucveulod mkvetri da SemaSinebeli socialuri mdgomareobis / an garemocvis cvlileba, magalitad uamravi axloblis dakargva an saxlsi xanzari. aslilobis ganvitarebis riski izrdeba fizikuri gamofitvisa da organuli faqtorebis arsebobisas» 36

37 komentari : rogorc vxedavt, naklebad aris asaxuli wamebis faqtori da misi roli am daavadebis ganvitarebasi, rac metyvelebs kvlevata naklebobaze. diagnostikuri kriteriumebi unda iyos gansazrvruli da mkafio kavsiri drosi ucveulo stresoris zegavlenasa da simptomta gamovlinebas Soris; dasawyisi Cveulebriv ar aris TandaTanobiTi an iwyeba ramdenime wutsi. amastanave simptomebs: a) aqvt Sereuli xasiati da surati aris cvalebadi ; inicirebis stadiaze gabruebis simptomebtan ertad vlindeba depresia, SfoTva, sibraze, umweobis gancda, hiperaqtiuloba da gariyuloba, magram arcerti matgani ar prevalirebs xangrzlivad. b) amoiwureba swrafad (yvelaze didi ramodenime saatsi) in SemTxvevebSi, sadac SesaZlebelia stresuli faqtoris mosoreba. im SemTxvevebSi, roca stresi xangrzlivdeba an Tavisi bunebidan gamomdinare ar SeiZleba Sewydes, simptomebi lagdeba saatidan sami dris ganmavlobasi TandaTanobiT. moicavs : krizisul mdgomareobas ; mwvave krizisul mdgomareobas ; sabrzolo gadarlas ; fsiqikur Soks (ICD ) rogorc ukve iqna arnisnuli, fsiqikuri asliloba, romelic upiratesad xsirad gvxvdeba wamebis msxverplta Soris aris posttravmuli stresuli asliloba, misi mwvave Tu qronikuli variantebi. posttravmuli stresuli aslilobis klinika da diagnostika rogorc cnobilia, PTSD pirvelad, mteli rigi gamokvlevebis safuzvelze, M. Horowitz mier 1980 w. iqna SemoRebuli da amave wels igi iqna Setanili, rogorc calke klinikuri forma amerikul diagnostikur klasifikaciasi _ DSM-III (Diagnostic and Statistical Manual of Mental Disorders _ fsiqikur aslilobata diagnostikuri da statistikuri saxelmzrvanelo). DSM-II gamoxatuli stresit gamowveuli fsiqikuri aslilobebi, gamoxatuli stresuli reaqciebi da tranzitoruli situaciuri darrvevebi miekutvneboda mwvave simptomatur distress, xolo gaxangrzlivebuli formebi SfoTvisa da depresiul nevrozebs. xolo wamyvani roli am darrvevata ganvitarebasi ganekutvneboda fiqsaciis movlenasa da genetikur predispozicias, ekzogenur stresi ki micneuli iyo, rogorc araspecifiuri faqtori, romelic avlenda, gamoaaskaravebda da axangrzlivebda fsiqiatriul simptomta mimart diatezs. filosofiuri, socialuri, fsiqologiuri da klinikuri mosazrebebisa da koncefciebis 37

38 gatvaliswinebit, SemoRebuli iqna PTSD diagnozi, romlis ganvitarebasic kauzaluri mnisvneloba eniweba eqstraordinarul travmas, romelic ganisazrvreba rogorc travmuli stresuli movalena (Life Stress Event) da SesaZloa ganuvitardes nebismier normalur adamians. PTSD warmoadgens bunebriv process adptaciisa eqstraordinarul stresul situaciasi da missi simptomta paterni ar aris damokidebuli premorbidul konstituciaze. (M. Horowitz, Rachel Yehuda, Alexander McFarlane). James Neuman, Tomas Williams et al. arnisnaven, rom PTSD aris bunebrivi, Seqcevadi procesi, normaluri reaqcia aranormalur SemTxvevaze 6 Tvis ganmavlobasi da am periodsi igi ganixileba, rogorc mwvave asliloba, xolo PTSD gadazrdisas qronikul processi monawileobs faqtorta kompleqsi da mat Soris premorbiduli fsiqopatologiuri ganwyoba. travmuli stresis Semswavleli sauniversiteto centris mier es faqtorebi identificirebuli iqna "sam WrilSi _ travmuli stresorebi, pirovnebis Taviseburebani da socialuri da garemomcveli faqtorebi _ romelta mudmivi kompleqsuri urtiertoba TamaSobs gadamwyvet rols aslilobis gaxangrzlivebasi." (Lindy, Grace, Green, 1984). amerikis fsiqiatrta asociaciis mier 1980 wlidan PTSD gaxangrzlivebuli da qronikuli formebi ganixileba, rogorc "nevrotizaciis procesi". pirovnebebsi, romeltac ar arenisnebodat premorbidulad fsiqikuri aslilobebi da gamoxatuli stresis Sedegad ganuvitardat PTSD, igi ganixileba, rogorc "reaqtiuli nevrozi". im pirta Siris, romeltac premorbiduli pirovnuli organizacia aris normaluri an mcired nevrotuli PTSD ganixileba, rogorc ZiriTadi diagnozi. James Newman "ZiriTad diagnozsi" gulisxmobs fsiqikur aslilobas, romelzedac unda iqnas ZiriTadad fokusirebuli mkurnalobis strategia, aset SemTxvevebSi PTSD ZiriTad simptomebad micneulia travmuli movlenis mtkivneuli mogonebebi. xolo im pirta Soris, romeltac premorbidulad arenisnebodat gamoxatuli nevrotuli organizacia PTSD ZiriTad simptomebtan ertad arenisnebat "fiqrebi travmamdel konfliqtebze. PTSD yoveltvis iwvevs amgvari intrapersonaluri konfliqtebis egzacerbacias, rac aqtualuri rceba PTSD simptomta reducirebis Semdegac. itvleba, rom PTSD upiratesad uvitardebat pirovnebebs Sesustebuli adaptaciis unarit. im pirta Soris, romeltac arenisnebat ZiriTadi diagnozi PTSD, gamoyofen, am aslilobis or umtavres faqtors: travmis pirovnebisatvis aqtualuri movlenebis akviatebuli mtkivneuli mogonebani da xasiatobrivi cvlilebebi, romelic uvitardeba pirovnebas am mogonebata gavlenit. mogonebani klinikurad gamoxatulia sxvadasxva formit; romeltagan upiratesad gavrcelebulia: 1. akviatebuli fiqrebi, romelta drosac uneblied kvlav ganicdeba travmuli movlena, an fiqrebi dakavsirebuli trvmul movlenastan. 2. Ramis kosmarebi, romlis drosac travmuli movlena xelaxla ganicdeba mkafiod da detalurad. Ramis kosmarebi epizodebis saxit gansakutrebit vlindeba stresul situaciebsi, an rodesac axlovdeba travmuli movlenis saiubileo TariRebi. Zilis darrveva TiTqmis yoveltvis PTSD damaxasiatebeli paternia, im SemTxvevebSic ki, roca ar vlindeba Ramis kosmarebi da igi gamoixateba CaZinebis gaznelebasa da gamorvizebisas gamouzinarobis SegrZnebaSi. es xsirad warmoadgens alkoholisa da narkotikebis gamoyenebis mizezs, "TviTmkurnalobis" miznit, 38

39 rac iwvevs "ukukavsiris efeqts", romlis gamoc Ramis kosmarebi vlindeba ufro intensiurad. akviatebuli mogonebebi vlindeba ufro isviatad, vidre Ramis kosmarebi da ZiriTadad realurad, nateli cnobierebis fonze, Tumca SesaZlebelia gaxangrzlivebuli disociaciuri mdgomareobis ganvitarebac, romelic cnobilia "Flashbacks" epizodebis saxelwodebit (disociaciuri epizodi, rodesac travmuli movlena an mastan dakavsirebuli situaciebi TiTqos kvlav meordeba). amgvari disociaciuri epizodebi damaxasiatebelia metad Zlieri travmatizaciis SemTxvevaSi, rodesac travmul movlenas warmoadgens mzime fizikuri travma, wameba, incesti da sxva. "Flashbacks" epizodebi upiratesad uvitardebat narkotizaciis, an alkoholizaciis, an sxva saxis intoqsikaciis fonze. disociaciis epizodebis arseboba miutitebs PTSD mkvetrad gamoxatul, mzime formaze. akviatebulobata simptomebi aseve vlindeba qcevasic. travmis msxveplt aqvt mzime, usiamovno emociebi, rodesac isini fiqroben an gaixseneben travmul movlenas, rac iwvevs SfoTvis momatebas da amitom damaxasiatebelia im situaciebisgan gaqceva, Tavisarideba, romelnic axseneben travmis Sesaxeb. qcevis es paterni amerikis fsiqiatrta asociaciis mier ganixileba, rogorc "kontr-fobiuri" (Counter Phobic) qceva, romelic xsir SemTxvevaSi iwvevs pirovnebis ganmartoebisaken tendenciebis, garemosagan izolirebasa da TavisTavSi Caketvas, urtiertobebis problemebs. zemot moyvanili simptomebi damaxasiatebelia M. Horowitz mier mowodebuli ganmeorebis fazisatvis (Intrusive/Repetive Phase). upiratesad PTSD qronikuli da rtuli formebistvis damaxasiatebelia M. Horowitz mixedvit gandevnis/uaryofis (Avoidance/Denial Phase) fazis simptomta arseboba, romelic xasiatdeba travmastan dakavsirebuli, Tu mimdinare problemebis gandevnit, rac vlindeba depresiul an piriqit agresiul reaqciasi, gansakutrebit im situaciebsi, romelnic stimulacias uweven travmuli movlenis gaxsenebas. am SemTxvevaSi pacientebi Tavs arideben mkurnalobas, im motivit, rom amaze saubari, ver Secvlis verafers, da acxadeben, rom mat ar gaacniat raime emocia. gandevnis, uaryofisa da emociuri "gayinvis" (Psychic Numbing) simptomebi mnisvnelovani da damaxasiatebelia PTSD klinikuri suratisatvis. am simptomta arsebobisas klinicistta varaudit saqme gvaqvs xasiatobriv cvlilebebtan, ristvisac damaxasiatebelia adaptaciis unaris daqveiteba. aseti xasiatobrivi cvlilebebi premorbidulad arsebuli pirovnuli, xasiatobrivi darrvevebisagan gansxvavebit, gamoirceva TviTkritikis marali macveneblita da danasaulis, TviTgvemis gancdit. PTSD ertert centralur simptomad micneulia TviTbraldebis gancda, rac gulisxmobs travmul situaciasi pirovnebis sakutari qcevit, moqmedebit ukmayofilebas. "me rom ase movqceuliyavi da a.s." amgvari TvTbraldebis "laqa" arenisnebat im pirt, romeltac ganicades Zalze mzime travma, romelnic gaxdnen adamianebis sikvdilis an damaxinjebis TviTmxilvelni. amgvari gancdebi fartod aris arwerili masalebsi vietnamis omis veteranebis Sesaxeb, aseve holokavis msxverplta Soris da sxva masobrivi travmatizaciis SemTxvevebisas. TviTbraldebis, danasaulis gancada upiratesad vlindeba Semdegi postulirebit _ "me ratom gadavrci, 39

40 roca sxva dairupa". amgvari gancdis arseboba miutitebs depresiul simptomatikaze. depresia warmoadgens PTSD Tanmxleb Taviseburebas. (T. Williams). Semdgomi simptomi, romelic gvexmareba diferencialuri diagnostikisas, aris TviTkontrolis dakargvis SiSi, rac vlindeba momatebuli gamrizianeblobisa da agznebadobis simptomebsi, impulsur emociebsa da qcevasi da iwvevs adaptaciis darrvevebs, urtiertobebis problemebs, rac ukidures SemTxvevaSi vlindeba eqsploziur xasiatobriv cvlilebebsi, rac SesaZloa atarebdes gamudmebuli "fetqebadobis", an isviati fetqebadobis xasiats. mravali avtoris azrit, PTSD ar warmoiqmneba "vakuumsi", yvela adamians axasiatebs garkveuli premorbiduli pirovnuli Taviseburebani, magram itvleba, rom janmrtelni avaddebian ufro isviatad, vidre premorbidulad fsiqikuri problemebis mqone pirebi, iseti anamnezit, rogoric aris alkoholizmi da narkotikebis an sxva nivtierebebis gamoyeneba, Tavis qalas travmebi, pirovnuli aslilobani da sxva. aqedan gamomdinare xsir SemTxvevaSi PTSD Serwymulia sxva darrvevebtan, alkoholizmi da narkomania, pirovnuli aslilobani, da sxva fsiqikuri aslilobani. aset SemTxvevebSi itvleba, rom PTSD ufro mzime xasiatisaa. (Card J.J., Domash M.D., Sparr L.F., Figley C.R., Hedlin H. et al., Horowitz M.J., Symonds M., Van Der Kolk et al.). unda arinisnos, rom rigi avtorebi PTSD klinikasi upiratesobas aniweben ara "akviatebul mogonebata", aramed "gandevnisa da uaryofis, emociuri gayinvis" simptomebs da mat miicneven am aslilobisatvis patognomurad, centralur fenomenad. (Edna B. Foa, Davis S. Riggs, Beth S. Gershuny, 1995). P PTSD diagnostikuri kriteriumebi pirvelad 1987 w. iqna Setanili DSM-III damatebasi DSM-III-R, xolo amjamad srulyofilad aris mocemuli DSM-IV, rubrikasi "SfoTviTi aslilobani, sadac Seesabameba kodi _ DSM-IV mixedvit es kriteriumebi Semdegia: A. pirovneba ganicdis stresis zemoqmedebas, roca ertdroulad arsebobs Semdegi ori garemoeba: 1. pirovneba usualod ganicdis an mxilveli da monawilea gansakutrebuli stresuli movlenisa, es "movlena" SesaZloa iyos: sikvdili, sicocxlis safrtxe, seriozuli dazianeba, Seurachyofa, fizikuri ganadgurebis muqara. 2. pirovnebis sapasuxo reaqcia moicavs: intensiur SiSs, umweobisa da sasinelebis gancdas. SeniSvna: bavsvebsi SeiZleba gamovlindes dezorganizebuli da ajitirebuli qceva. B. matravmirebeli movlena mudmivad, persistentulad ganicdeba Semdegi gzebit: 1. momxdaris xelmeore da dajinebuli ganmeoreba, warmodgenebis, azrebisa da SegrZnebebis saxit. SeniSvna: bavsvebsi ganmeorebad TamaSebSi vlindeba travmis Tema da aspeqtebi. 2. akviatebuli damtrgunveli sizmrebi travmis Sesaxeb. Senisvna: bavsvebsi SesaZloa iyos gaucnobierebeli kosmaruli sizmrebi. 3. SegrZneba da qveva, TiTqos pirovneba kvlav imyofeba matravmirebel situaciasi (gacocxlebuli warmodgenebi, iluziebi, halucinaciebi, "Flashbacks" epizodebi). SeniSvna: bavsvebi TamaSSi aradgenen matravmirebel situacias. 4. intensiuri fsiqologiuri gancda im Sinagan an garegan mizezebze, romlebic 40

41 axseneben, an simbolurad gamoxataven travmas. 5. intensiuri fsiqologiuri reaqcia im Sinagan an garegan gamrizianeblebze, romlebic axseneben, an simbolurad gamoxataven travmas. C. travmastan asocirebul stimultagan mudmivi gaqceva da ganurcevloba garsemo momdinare movlenebisadmi, rac pirovnebas travmamde ar arenisneboda. es SesaZloa gamovlindes Semdegi sami /an meti/ saxit: 1. travmastan dakavsirebuli azrebis, gancdebisa an saubrisagan gaqcevis mcdeloba. 2. im saqmianobisagan, adgilebisa da adamianebisgan Tavis arideba, romelnic iwvevs mogonebebs travmis Sesaxeb. 3. travmis umnisvnelovanesi aspeqtebis ardgenis SeuZlebloba. 4. mnisvnelovan saqmianobasi monawileobis, an interesta gamoxatuli Sesusteba. 5. gaucxoebisa da sxvebisagan ganmartoebis SegrZneba. 6. afeqtebis SezRudva (siyvarulis grznobis gancdis SeuZlebloba). 7. momavlis uperspeqtivobis gancda (fiqrebi, rom ar eyoleba ojaxi, Svilebi, ar eqneba kariera an normaluri adamianuri cxovreba). D. gamorvizebis persistentuli simptomebi, romelic ar arinisneboda travmamde, rac vlindeba Semdegi ori an meti nisnit: 1. CaZinebis gazneleba an Zilis darveva. 2. gamrizianebloba an ganrisxeba. 3. koncentraciis gazneleba. 4. sifxizlis momateba. 5. momatebuli SiSis grznoba. E. B, C, D kriteriumta simptomebis xangrzlivoba unda arematebodes 1 Tves. F. arelveba iwvevs klinikurad mnisvnelovan mdgomareobas an socialuri da adaptaciuri meqanizmebis moslas, an funqcionirebis sxva mnisvnelovani mxareebis moslas. DSM-IV mixedvit, PTSD mimdinareobis mixedvit, gamoyofilia mwvave, qronikuli da dagvianebuli formebi. mwvave _ diagnostirdeba, Tu simptomebi arinisneba araumetes 3 Tvisa. qronikuli _ Tu simptomebi grzeldeba 3 Tveze metxans. dagvianebuli: Tu stresul movlenasa da simptomatikis gamovlenas Soris gasulia ara nakleb 6 Tvisa wlidan PTSD diagnozi Setanil iqna msoflio jandacvis organizaciis daavadebata saertasoriso klasifikaciis me-10 gadasinjvasi (ICD-10 /International Classification of diseasis - 10 Revision/), rubrikasi reaqcia gamoxatul stresze da adaptaciuri aslilobani da Seesabameba kodi _ F 43.1., moicavs travmul nevrozs. ICD-10 mixedvit PTSD warmoadgens dagvianebul, gaxangrzlivebul reaqcias, gamowveuls mxolod da mxolod sicocxlisatvis sasisi stresuli movlenebita da situaciebit, romeltac SesaZloa gamoiwvion zogadi distresi nebismier adamiansi. ICD-10 mixedvit tipiur, patognomur simptomebad micneulia travmis ganmeorebadi gancdis simptomebi, xolo "gandevnis" simptomebi ar aris micneuli diagnostikisatvis aucileblad, aseve vegetatiuri darrvevebi, emociuri aslilobani da qcevis darrvevebi SesaZloa arsebobdes, magram ar itvleba pirvelxarisxovnad diagnostirebisas. latenturi periodi SesaZloa arsebobdes ramdenime kviridan 6 Tvemde, Tumca SesaZlebelia PTSD diagnostireba mogvianebitac, Tu saqme gavaqvs tipiur nisnebtan. winaswarganwyobis faqtorebad micneulia pirovnuli Taviseburebani, kerzod ki kompulsuri da asteniuri, aseve nevrologiuri darrvevebi, Tumca ar itvleba diagnozis ganvitarebis aucilebel pirobad. 41

42 ICD 10: F PTSD vlindeba, rogorc mogvianebiti da/an gaxangrzlivebuli reaqcia stresis gamomwvev, gansakutrebit sasis an katastroful movlenaze an situaciaze (mokle an xangrzlivi), romelmac SeiZleba gamoiwvios sulieri tanjva TiTqmis yvela adamiansi (mag. stiqiuri an antropogenuri katastrofa, brzola, seriozuli avaria, sxvebis Zaladobrivi sikvdilis mowmed yofna, an wamebis, terorizmis, gaupatiurebis an sxva dros msxvrplad yofna). winaswar gansazrvrulma faqtorebma, rogoricaa pirovnebis xasiatis Tvisebebi (mag. avadmyofuri midrekilebis mqone, susti adamiani) an fsiqo-nervuli avadmyofobis pre-istoria, SeiZleba Seamciron sindromis ganvitarebis SesaZlebloba an gaartulon misi mimdinareoba, magram es faqtorebi arc aucilebelia da arc sakmarisi arnisnuli sindormis warmoqmnis mizezis asaxsnelad. tipiuri simptomebi moicavs akviatebul mogonenebsi (`warsulis gaxseneba~) an sizmrebsi travmis ganmeorebit gacocxlebis epizodebs, romlebic vlindeba, rogorc: `gasesebis~ grznoba da emociuri daclungeba, sxva adamianebisagan gariyva, garemosi reagirebis arqona, anhedonia, da travmis gamaxsenebeli moqmedebebisa da situaciebisgan Tavis arideba. Cveulebriv arsebobs SiSi da xdeba Tavis arideba iseti faqtorebisgan, romlebic wamebis msxverpls Tavdapirvel travmas agonebs. isvitad, SeiZleba Zlierad ifetqos SiSma, panikam an agresiam, romelic inicirebulia travmis an masze Tavdapirveli reaqciis uecari mogonebis da/an ganmeorebis gamomwvevi stimulit. Cveulebriv arsebobs hiperagznebadobis mdgomareoba, romelic gamoxatulia zedmeti sifxizlit, SiSis reaqciis momatebuli donit da uzilobit. SfoTva da depresia Cveulebriv dakavsirebulia zemoarnisnul simptomebtan da nisnebtan, da msxverpli xsirad fiqrobs TviTmkvlelobaze. alkoholis an narkotikebis didi raodenobit moxmareba SeiZleba sakmaod rtuli faqtori iyos. 42

43 posttravmuli stresuli aslilobis ZiriTadi simptomo kompleqsebi akviatebuli mogonebebi (Tanmdevi simptomebi: danasaulis/s ircxvilis grznoba) simptomis jgufebi agznebadoba Tavis arideba 43

44 posttravmuli stresuli asliloba DSM IV Zlieri. simptomebi arinisneba 3 Tveze naklebi periodis ganmavlobasi. ICD 10 F simptomebis mogvianebit gamovlena. qronikuli. simtomebi arinisneba 3 Tvis an meti periodis ganmavlobasi. miutitet, Tu: simptomebi vlindeba mogvianebit. simptomebi ar gamovlenila SemTxvevis dridan minimum 6 Tvis Semdeg. A :Thomas Wenzel/ WPA, 2004 arsanisnavia, rom posttravmuli stresuli aslilobis arsebobisas, travmis gaxseneba SeiZleba moxdes fragmentulad an fotografiuli sizustit. mexsierebis mxriv problemebi SeiZleba dakavsirebul iqnas disociaciuri simptomebis arsebobastan: amnezia, rasac mohyveba fragmentuli mexsiereba, koncentraciastan dakavsirebuli sirtuleebi da sxva. travmis srulyofili gaxsenebisas upiratesad warmodgenilia: akviatebuli mogonebebi, warsulis gaxseneba, Ramis kosmarebi, akviatebuli fiqrebi, fizikur travmastan asocirebuli tkivili da sxva. ptsa-s damaxasiatebeli simptomebi ufro detalurad Semdegia: akviateba (akviatebuli mogonebebi), ganmeorebiti gancda, mogonebebi brundeba Zalauneburad, an fiqrebi trialebs mexsierebasi. akviatebuli mogonebebi SeiZleba inicirebuli iyos askara stimulit, an SeiZleba warmoiqmnas damaxasiatebeli mizezebis garese. Zlier (arasasurveli) akviatebul mogonebebs ewodeba `warsulsi dabruneba~. es SeiZleba iyos SemTxvevis iseti elementebis gaxseneba - rogoricaa: xmebi, gamosaxulebebi an is SeiZleba iseti Zlieri iyos, rom pacienti `CamorCes dros~ da drosi an sivrcesi dezorinetirebuli iyos. arnisnul simptomebs xsirad SeiZleba Tan sdevdes SfoTvis Zlieri fizikuri nisnebi, mat Soris gaseseba, taqikardia, suntqvis gaxsireba, gaxsirebuli guliscema, da isini SeiZleba gamovlindes fsiqofiziologiur ganzomilebebsi (SPEC, energetikul-spetraluri ECG). 44

45 ruminescencia an SemTxvevis Sesaxeb zedmeti fiqri SeiZleba ganxilul iqnas, rogorc akviateba. Aaseve Ramis kosmarebi, rac sakmaod xsiria, SeiZleba ganxilul iqnas, rogorc akviatebis forma. isini SeiZleba moicavdes konkretul mogonebebs momxdaris Sesaxeb da stresis, SiSis an - xsirad devnis zogad warmodgenebs. akviatebulobata inicirebas SeiZleba hqondes sxvadasxva forma, rogoricaa xmauri, xmis toni, vizualuri dakvirveba (joxebi, skamebi), an situacia (lodini, kitxvis dasma = dakitxva), sityvebi (mokluli megobris saxeli). Tavis arideba xsirad xdeba Tavis arideba mogonebebis, cixesi gatarebuli drois Sesaxeb saubris, wamebis an devnis sxva aqtebis momagonebeli sagnebis, situaciebis an adgilebisagan. gadarcenili adamianebi cdiloben Tavi gairton saqmianobit da musaobit, Tumca koncentracia SeiZleba dairrves disociaciit an akviatebuli mogonebebis gafantvis mcdelobit. gariyuloba, rac aseve nisandoblivia msxverplisatvis, SeiZleba gamovlindes momavlis uperspeqtivobisa da socialuri izolaciis grznobit. sakutari Tavis rwmenis dakargva, daqveitebuli TviTSefaseba da sakutari Tavis pativiscema wamebagadatanil da gadarcenil adamianebs, xsirad awuxebt umomavlobis SegrZneba, isini arar awyoben gegmebs, ar aqvt pozitiuri movlenebisa da piradi warmatebis imedi. wamebagamovlili da gadarcenili adamianis qmedebani TviTdajerebulobas moklebulia, misi politikuri saqmianoba SezRudulia, sakutari Tavis pativiscemis daqveiteba aisaxeba mis grznobebsa da qcevasi, zogiert SemTxvevaSi es `gulisxmobs~ TavdacviTi an agresiuli saxis urtiertqmedebas. is Tavs aridebs daxmarebas, mas SesaZlioa hqondes iseti grznoba, rom mas ar exmarebian an yuradrebas ar aqceven. SeniSnva: sakutari Tavis pativiscemis daqveiteba da gariyuloba SeiZleba aisaxebodes mravali faqtorebit, rogoricaa: sircxvili, wamebagamovlili da gadarcenili adamianis danasaulis grznoba, depresia, da es faqtorebi xsirad wamebis mizans warmoadgens. Tu arnisnuli simptomebi mudmiv xasiats atarebs (da mkurnalobas ar eqvemdebareba?) SeiZleba daisvas F 62.0 diagnozi. Zilis darrveva Zilis darrveva xsiria wamebagamovlil da gadarcenil adamianebsi. aseve xsiria Ramis kosmarebi, romlebic wamebis SemTxvevebs an zogadad safrtxes exeba. 45

46 darrveuli III da IV REM fazebi, Zilis Seferxeba da darrveuli Zilis `struqturis~ da xarisxis sxva aspeqtebi tipiuria. cvlilebebi SeiZleba mudmivi iyos. Zilis darrveva azlierebs an iwvevs gadarlilobis SegrZnebas mteli dris ganmavlobasi, umweobis grznobas, mexsierebis daqveitebas da sxva simptomebs. Zilis darrvevis gamomwvevi faqtorebi: daavadebis Tanmxlebi depresia, nevrologiuri (fizikuri) cvlilebebi qronikul ptsa-si, SeZenili reagireba (`Zili saxifatoa~), warsulsi dabrunebis, Ramis kosmarebisa da Zilis dros kontrolis dakargvis SiSi. mogonebebidan raime saqmianobaze yuradrebis gadatanis unaris dakargva, rac SeiZleba daexmaros dris ganmavlobasi. zedmeti sifxizle zedmeti sifxizle da hiperagznebadoba warmoadgens mudmiv `SfoTvas safrtxis gamo~, romelic miutitebs usualo safrtxesi yofnisas gamovlenil mudmivi gangasis reaqciaze. aman SeiZleba gamoiwvios Zilis darrveva, SfoTvis qronikuli fizikuri simtomebis gamovlena, gadametebuli SiSis da SfoTvis reaqcia iset stimulebze, rogoricaa xmauri, da garizianebadoba, rac warmoqmnis ojaxur konfliqtebs an sxva socialur Sedegebs. agznebadoba Sekavebadi mrisxaneba da SiSi, romelic guldasmit aris dafaruli wamebisgan gadarcenis miznit. SesaZlo Tavis tvinis travmis macvenebeli, garizianebadoba, rogorc gadametebuli agznebadobis nawili ptsa-is arsebobisas. wamebagamovlili da gadarcenili adamianis danasaulis grznoba danasaulisa da sircxvilis grznoba warmoadgens sastiki mopyrobis an wamebis xsir da paradoqsul Sedegs. masin, roca jalats unda hqondes danasaulis grznoba, amgvari grznoba `eufleba~ msxverpls. im SemTxvevaSic ki, Tu mocemul situaciasi mas SeeZlo safrtxesi Caegdo Tavi an Tu ar SeeZlo emoqmeda sakutari survilisamebr, danasaulis grznoba gadawarbebuli xdeba imastan SedarebiT, rac realurad moxda da qronikul saxes irebs, da es iwvevs depresias, simptomebis momatebas da warsulsi dabrunebas, sakutar Tavze 46

47 warmodgenis dakargvas, sakutari Tavis rwmenis dakargvas da daxmarebisa da mkurnalobisagan Tavis aridebas. gamokitxvis processi wamebagamovlili adamianis mier mowodebuli informacia SeiZleba arasruli an urtiertsawinaarmdego iyos, xolo misi qceva SeiZleba gulcatxrobili, cvalebadi an TavdacviTi iyos. rigi avtorebis azrit, PTSD diagnostikur kriteriumebsi ar aris warmocenili fsiqosomaturi komponentebi, rac itvleba ert-ert damaxasiatebel fenomenad gansakutrebuli travmit gamowveuli darrvevebisatvis, isetebi rogoric aris astma, kuw-nawlavis da gulsisxlzarrvta sistemis patologia da sxva. (Jacob D. LIndy, Bonnie L. Green, Mary Grace). PTSD etno-kulturaluri aspeqtebi arasrulyofilad aris Seswavlili, Tumca arsebuli etno-kulturaluri kvlevebis safuzvelze gamovlenil iqna travmis ganmeorebadoba, magalitad mravaljeradi seqsualuri Zaladoba bavsvebze, evro-amerikul kulturasic ki, cema koreel diasaxlisebsi da sxva, ris safuzvelzec SemoRebul iqna "Complex PTSD" cneba. (Antony J. Marsella, Matthew J. Friedman). etnikur wmenda gadatanil bosniel ltolvilebze Catarebuli gamokvlevebis Sedegad, avtorta nawilis azrit, omis dros adgili aqvs mravaljerad travmatizacias, rac xsirad xdeba mizezi mravalferovani aslilobebisa, romelic scildeba PTSD sazrvrebs, ris gamoc SemoRebuli iqna cneba "travmuli stresuli asliloba" (TSD /Traumatic Stress Disorder/), rasac ganekutvneba 1. medikamentebis, narkotikebisa da alkoholis gamoyeneba. alkoholizmis, narkomaniisa da toqsikomaniis ganvitareba. 2. eqsploziur reaqciebi travmis msgavs, an situaciis simbolurad gamaxsenebel umnisvnelo stimulze, romelic amnezirdeba pirovnebis mier. 3. eqsploziuri reaqciebi kombinirebuli alkoholis, an narkotikebis xmarebastan, rac iwvevs suicidur an asocialur qmedebebs an kriminalur Zaladobas ojaxis an sazogadoebis wevrebze. 4. sxva SemTxvevaSi TSD iwvevs qr. invalidizacias fsiqikuri aslilobebit. 5. fsiqo-somaturi simptomebi da daavadebani. 6. reaqtiuli fsiqozuri qmedeba. 7. travmis transmisia TaobebSi. TSD dros PTSD simptomebi xsirad Tan erwymis iset aslilobebs, rogoricaa depresia, disociaciuri fenomeni, pirovnebis Secvla, destruqciuli qmedebani, sxvadasxva usiamovno SegrZnebebi, agznebadoba da disforiuloba agresiul fantaziebtan kombinaciasi. (Steven M. Weine, Daniel F. Becker et al.) Александровский miwizvrebis Sedegebisa da Cernobilis avariis Sedegebze dakvirvebis safuzvelze arwers socialur-stresul darrvevebs da PTSD atipiur formebs, romeltatvisac ar aris nisandoblivi TvalsaCino "ganmeorebadi gancdis" simptomta arseboba. somxetis miwiszvris (1988 w.) da baskiretsi gazsadenze avariis (1989w.) Sedegad dazaralebulta dakvirvebebis Sedegad В.В. Ковалев da Н.К. Асанова mier post-stresuli darrvevebi kvalificirebul iyo, rogorc "panikurdepresiuli aslilobani". avranetis omis veteranebze Catarebuli dakvirvebebis Sedegad П.И. Сидоров., М.Ф. Лукманов askvnian, rom omis veteranta Soris upiratesad damaxasiatebelia pirovnuli aslilobani. 47

48 amgvarad, dreisatvis PTSD klinikastan da diagnostikis sakitxebtan dakavsirebit ar arsebobas ertiani midgoma. H. Glover azrit, PTSD klinikastan dakavsirebuli farto speqtris problemebis analizi miutitebs imaze, rom PTSD an warmoadgens aslilobas polimorfuli klinikuri gamovlinebebit, an unda vivaraudot, rom arsebobs am aslilobis sxvadasxva tipebi. unda arinisnos, rom wamebis SemTxvevebSi, xsirad posttravmuli stresuli daavadebis simptomebi Serwymulia sxva aslilobebtan, iseti rogoric aris fobikuri sindromi Tavisi sxvadasxva formita da gamovlinebebit, gansakutrebit amgvari fobiebi asocirebuli wamebis situaciebtan, magalitad vitardeba klaustrofobia, sibnelis SiSi, marto yofnis SiSi da a. S.; amgvarad diagnostikisatvis mnisvnelovania Semdeg sakitxebze yuradrebis gamaxvileba : - daavadebata SeTanawyoba gansakutrebit maralia depresiuli aslilobisa da SfoTvis komponentit gamoxatuli aslilobis SeTavsebis macvenebeli. aseve xsiria simptomebis nawilobrivi damtxveva (gansakutrebit, ptsa, SfoTvis komponentit gamoxatuli aslilobebi depresia Zaladobis Semdgomi sindromi (ZSs)). ormagi diagnozi depresias, ptsa-sa da ZSs-s Soris adekvaturia im SemTxvevaSi, Tu kriteriumebi dakmayofilebulia. zogierti ptsa simptomi SeiZleba xsirad specifikurad ukavsirdebodes wamebis konkretul SemTxvevebs an Zaladobis sxva aqtebs. magaliti: iararis srolis zemoqmedebis qves yofna iwvevs warsulis gaxsenebisa da intensiur fsiqofiziologiur reaqcias. gadarcenil pirovnebas esroles fexsi, rodesac is gaqcevas cdilobda da amis Semdeg sastikad awames. SesaZlebelia, rom zogierti ptsa simptomi SeiZleba ufro xsiri iyos wamebis specifikuri formebis Semdeg, magram am etapze sakmarisi monacemebi ar arsebobs. *1. ptsa-s diagnozis ararseboba ar nisnavs imas, rom pacienti ar aris travmirebuli. kompleqsuri ptsa/ptsd kompleqsuri ptsa / PTSD S (Zlieri stresuli aslilobebi, romlebic sxvagvarad ar aris klasificirebuli) warmoadgens iset koncefciebs, romlebic SemoRebul iqna Zlier stresgamovlil adamianebsi xsirad gamovlenili im simptomebis uketesad asaxvis miznit, romlebic adekvaturad ar aris Setanili ICD10 da ptsa-s koncefciebsi. isini moixsenieba, rogorc Tanmxlebi simptomebi srul DSM IV saxelmzrvanelosi; zogierti simptomi Sedis ICD 10 F 62.0 kategoriasi. 48

49 orive kategoria msgavsia, magram detalebi gansxvavebulia. yvelaze gavrcelebuli simptomebia: sircxvilis grznoba danasaulis grznoba somatizaciis tendenciebi sxva gamovlenili simptomebi da qcevis cvlilebebi momatebuli riskis Zebna (isviatad), qceva, romelic potenciurad sazianoa wamebagamovlili da sxva adamianebisatvis, sazogadoebisatvis damaxasiatebeli reaqciebi an `simptomebi~. masinac ki Tu arnisnuli simptomebi ar warmoadgens specifikuri ICD 10/DSM IV kategoriis nawils, isini SeiZleba iyos kvlevis Sedegebis nawili, Tu isini arinisneba wamebis Semdeg. DSM-IV gansxvavebit, ICD-10 mixedvit itvleba, rom sxva simptomebtan ertad yoveltvis gvxvdeba SfoTva da depresia, mosalodnelia suicidaluri ideaciebis arseboba, gamoyofilia vegetatiuri komponentic, Tumca ar aris mocneuli patognomurad. am or klasifikacias Soris gansxvaveba aris aseve mimdinareobis sakitxebsi. ar aris gamoyofili mwvave da dagvianebuli formebi, xolo qronikuli forma aris drosi Semofargluli da Semotanilia Soreuli Sedegebis cneba. kerzod "pirovnebis damacarielebeli stresis Soreuli qronikuli Sedegebi, anu isini, romelnic manifestirdebian stresuli zemoqmedebidan atwleulebis Semdeg, unda ganisazrvros F F warmoadgens axal diagnozs, romelic ganisazrvreba, rogorc "pirovnebis qronikuli cvlilebebi katastrofis gadatanis Semdeg". es darrveva vitardeba im SemTxvevebSi, roca stresi imdenad Rrma aris, rom ar sawiroebs pirovnuli Taviseburebebis gatvaliswinebas. amgvar stresebs miekutvneba sakoncentracio banaksi yofna, wameba, stiqiuri ubedureba, sicocxlisatvis sasis garemoebasi xangrzlivad yofna (mag. mzevali, tyveoba). da itvleba, rom es asliloba SesaZloa ganvitardes PTSD manifestirebuli, Sualeduri fazis garese. mistvis patognomurad aris micneuli Semdegi kriteriumebi, romlebic pirovnebas manamde ar arenisneboda: 1. samyarosadmi mtruli damokidebuleba, undobloba. 2. socialuri gamijvna. 3. uimedobisa da sicarielis SegrZneba. 4. gamudmebuli mrelvarebis, ToTqosda gamudmebuli safrtxis, "ufskrulis piras arsebobis" qronikuli gancda. 5. gaucxoebis gancda. ICD 10: F pirovnebis qronikuli cvlileba katastrofis gadatanis Semdeg `pirovnebis amgvar cvlilebas, rasac minimum ori weli Wirdeba, SeiZleba mohyves katastroful stress. stresi imdenad Zlieri unda iyos, rom sawiro arar gaxdes pirovnebis daculobis donis gansazrvra, pirovnebaze misi Zlieri zemoqmedebis Sedegis ganmartebis miznit. amgvari aslilobisatvis 49

50 damaxasiatebelia mtruli an undobeli damokidebuleba samyaros mimart, socialuri TviTizolacia, sicarielis an uimedobis grznoba, `garizianebulad yofnis~ qronikuli SegrZneba, TiTqos mudmivad safrtxesia an izolirebulia.. posttravmuli stresuli asliloba (F43.1) SeiZleba win uswrebdes pirovnebis Secvlis am tips... gamonaklisi: posttravmuli stresuli asliloba (F43.1) adaptaciastan dakavsirebuli problemebi: ICD 10: diagnostikuri kriteriumebi: F43.2 SeguebasTan dakavsirebuli problemebi simptomebi Cveulebriv vlindeba stresuli SemTxvevis an cxovrebis Secvlis dridan 1 Tvis ganmavlobasi, da simptomebis xangrzlivoba Cveulebriv 6 Tves ar aremateba, Tu ar CavTvliT xangrzlivi depresiuli reaqciis SemTxvevas. Tu simptomebis xangzlivoba arnisnul periods aremateba, diagnozi unda Seicvalos arsebuli klinikuri suratis Sesabamisad, da nebismieri xangzlivi stresi SeiZleba kodirebul iqnas ICD-10 is XXI TavSi warmodgenili ertierti Z kodis mesveobit. samedicino da fsiqiatriul samsaxurebtan kontaqti Zlieri danaklisis normaluri reaqciebis gamo, romelic Seesabameba gansaxilveli pirovnebis kulturas da, romlis xangrzlivobac Cveulebriv 6 Tves ar aremateba, ar unda arinisnos am wignsi warmodgenili kodebis mesveobit, aramed ICD-10 is XXI TavSi warmodgenili kodebis gamoyenebit unda ganisazrvros, rogorc Z63.4 (ojaxis wevris gaucinaureba an gardacvaleba) da, rogorc magalitad Z71.9 (konsultireba) an Z73.3 (stresi sxvagan ar aris klasificirebuli). nebismieri glovis gaxangrzlivebuli reaqciebi, romlebic mati formis an Sinaarsis gamo anomalurad miicneva, kodirebul unda iqnas, rogorc F43.22, F43.23, F43.24 an F43.25, xolo is reaqciebi, romlebic jer isev intensiuria da, romelta xangrzlivobac 6 Tves aremateba, kodirebul unda iqnas, rogorc F43.21 (xangrzlivi depresiuli reaqcia). diagnostikuri saxelmzrvanelo principebi: diagnozi damokidebulia Semdeg faqtorebs Soris arsebuli kavsiris yuradrebit Sefasebaze: (a) simptomebis forma, Sinaarsi da simwvave; (b) wina istoria da individualoba; da (g) stresuli SemTxveva, situacia, an krizisi cxovrebasi 50

51 am mesame faqtoris arseboba yuradrebit unda dadgindes da unda arsebobdes Zlieri - Tumca SesaZloa uaryofili - mtkicebuleba imisa, rom problema ar warmoiqmneboda mis garese. Tu, stres-faqtori SedarebiT msubuqia, an Tu droebiti kavsiri (3 Tveze nakleb periodsi) ver vlindeba, problema klasificirebul unda iqnas sxva adgilas, misi warmodgenili maxasiateblebis Sesabamisad. moicavs Semdegs: * kulturaluri Soki * glovis reaqcia * hospitalizmi bavsvebsi ICD 10: diagnostikuri kriteriumebi: F43.2 SeguebasTan dakavsirebuli problemebi mwuxarebis subieqturi mdgomareoba da emociuri asliloba, rac Cveulebriv xels uslis sazogadoebriv funqcionirebasa da saqmianobas, da, romelic warmoiqmneba mnisvnelovan cxovrebiseul cvlilebastan an stresuli cxovrebiseuli SemTxvevis SedegebTan Seguebis periodsi (mat Soris seriozuli fizikuri avadmyofobis arseboba an SesaZlebloba). stres-faqtorma SesaZloa zemoqmedeba moaxdinos socialur garemosi (mzime danaklisis an izolirebis gamo) an sazogadoebis mxardawerisa da faseulobebis ufro farto sistemasi (migracia an ltolvilis statusi) pirovnebis integrirebis unarze. stres-faqtori SeiZleba Seexos mxolod pirovneba an aseve mis jgufs an sazogadoebas. pirovnebis ganwyobileba an daucveloba ufro did rols TamaSobs riskis warmoqmnasi da SeguebasTan dakavsirebuli aslilobis gamovlinebebis formirebasi, vidre F43 Si gansazrvrul sxva pirobebsi, magram mainc ar ivaraudeba, rom amgvari piroba ar warmoiqmneboda stres-faqtoris garese. gamovlinebebi gansxvavdeba, da gulisxmobs datrgunil ganwyobas, wuxils (an mat narevs), arsebuli situaciis mogvarebis, winaswar dagegmvis an aqtivitetebis gagrzelebis uunarobis grznobas, da yoveldriuri saqmianobis warmartvis garkveul uunarobas. pirovneba SeiZleba grznobdes pasuxismgeblobas arabunebriv qcevaze an Zaladobis Sedegebis gamovlenaze, magram es isviatad xdeba. magram, agresiuli an qcevastan dakavsirebuli aslilobebi (agresiuli an aramegobruli qceva) SeiZleba iyos Tanxmlebi maxasiatebeli, gansakutrebit axalgazrdebsi. arcerti simptomi ar aris sakmarisi simwvavis an mnisvnelobis imisatvis, rom dadasturdes ufro specifikuri diagnozi. bavsvebsi, iseti regresuli fenomeni, rogoricaa: RamiT Sardis Seukavebloba, bavsvuri metyveleba (puerelizmi), an cera TiTis wova, xsirad am simptomis nimusis nawils warmoadgens. 51

52 adaptaciastan dakavsirebuli problemebi: DSM IV: diagnostikuri kriteriumebi: F 309 emociuri an qceviti aslilobis simptomebis ganvitareba cnobili stres-faqtoris (stres-faqtorebis) sapasuxod, romelic vlindeba stres-faqtoris (stres-faqtorebis) zemoqmedebidan 3 Tvis ganmavlobasi. amgvari simptomebi an qceva klinikurad mnisvnelovania, radgan dasturdeba ert-erti Semdegi aslilobit: askara mwuxareba, romelic imaze metia, rac mosalodneli iqneboda stres-faqtoris arsebobisas socialuri an profesiuli (akademiuri) funqcionirebis mnisvnelovani darrveva strestan dakavsirebuli darrveva ar akmayofilebs I RerZze mocemuli sxva darrvevebis (klinikuri asliloba) kriteriumebs da ubralod ar warmoadgens manamde arsebuli I da II RerZze mocemuli aslilobis gamwvavebul (xasiatis anomalia an oligofrenia) formas. simptomebi ar moicavs mzime danaklisis simptoms stres-faqtoris (an misi Sedegebis) Sewyvetis Semdeg, simptomebi ar grzeldeba Semdgom 6 Tveze meti periodis ganmavlobasi. DSM IV: F 309 qvetipebi miutitet Tu: mwvave; Tu darrveva 6 Tveze met xans ar grzeldeba qronikuli: Tu darrveva 6 Tve an met xans grzeldeba SeguebasTan dakavsirebuli problemebis qvetipebi SeirCeva predominantuli simptomebis Sesabamisad: datrgunuli ganwyoba SfoTva Sereuli SfoTva da datrgunuli ganwyoba qcevis Secvla emociebisa da qcevis Sereuli darrveva daudgeneli simptomebi ar grzeldeba Semdgom 6 Tveze meti periodis ganmavlobasi. ICD 10: reaqciebi Zlier stresze da adaptaciastan dakavsirebuli problemebi Tu ar arsebobs `tipiuri~ ptsa, Zlieri stresuli asliloba an pirovnuli cvlileba, wamebis an sxva Zaladobis askara Sedegebi SeiZleba kodirebul iqnas Semdegnairad: 52

53 F43.8 sxva reaqciebi Zlier stresze F43.9 sxva reaqciebi Zlier stresze, romelic ar aris mititebuli. xsiria wamebagamovlilta Soris konversiuli simptomebisa da aslilobata gamovlenis albatoba. termini disociacia gamoiyeneba diagnozis doneze ICD 10-Si, rogorc disociaciuri (`konversiuli~) asliloba, romelic miutitebs `warsul mogonebebs Soris integraciis, pirovnebis Semecnebis unaris, swrafi SegrZnebebisa da sxeulis mozraobis kontrolis nawilobriv an srul dakargvaze~. KeTnoulturuli fenomeni mnisvnelovan rols TamaSobs disociaciuri simptomebis ganvitarebisa da interpretirebisas. Sedegobrivi simptomebi Cveulebriv `nevrologiuri~ darrvevebis formas irebs, rogoricaa: hemiplegia, anestezia, amnezia, fuga, an orientaciis dakargva. disociaciuri simptomebi SeiZleba ganxilul iqnas, rogorc magaliti imisa, Tu rogor SeiZleba adaptaciuri reaqciebi gaxdes qronikuli da `avtonomiuri~ da warmoqmnas darrvevebi momaval cxovrebasi, Tu isini ganagrzoben arsebobas. miuxedavad imisa, rom disociaciam SeiZleba xeli Seuwyos ukiduresi fsiqologiuri da fizikuri stresisagan Tavis darwevas, is SesaZloa Semdgomi posttravmuli stresuli aslilobis ganvitarebaze winaswarmetyvelebdes. mnisvnelovania disociaciis armocena gamokitxvis processi. macveneblebi: yuradrebis gadatana, defokusireba, suntqvis sistemis Secvla. disociacia SeiZleba iniciirebuli iyos wamebis msgavsi signalebit an stresuli mogonebebit gadatvirtvis gamo. Semdgom yoveldriur cxovrebasi gamovlenili disociaciuri simptomebi gulisxmobs iset gamotqmebs, rogoricaa: `ver vixseneb rogor mivedi...~, `uecrad gavige.. ~, `xsirad ver vixseneb, ra gavakete gusin..~ disociaciuri aslilobebi ICD 10: F44 [konversiuli] aslilobebi disociaciuri F 44.0 disociaciuri amnezia F 44.1 fuga F 44.3 transi da Sepyrobilobis mdgomareobebi F 44.4 motorikis disociaciuri aslilobebi F 44.5 disociaciuri konvulsiebi F 44.6 disociaciuri anestezia da mgrznobelobis dakargva F 44.7 Sereuli disociaciuri aslilobebi 53

54 disociaciuri aslilobebi DSM IV depersonalizaciuri asliloba disociaciuri amnezia disociaciuri asliloba NOS disociaciuri fuga (disociaciuri pirovnuli asliloba ) gansxvaveba: zogadi somaturi mdgomareobit gamowveuli amnestiuri asliloba somatoformuli aslilobebi ICD 10: ` fizikuri simptomebis ganmeorebit warmodgena samedicino gamokvlevebze mudmiv motxovnebtan ertad, miuxedavad ganmeorebiti negatiuri Sedegebisa da eqimebis gancxadebebisa, rom simptomebs ar aqvt fizikuri safuzveli. Tu arsebobs raime saxis fizikuri dazianebebi, isini ar xsnian am simptomebis xasiatsa da moculobas an pacientis mwuxarebisa da Sefiqrianebis mizezs.~ wamebis Semdeg fizikuri xelseuxeblobis Sesaxeb wuxili bunebrivia, radgan ziani xsirad Zalian mnisvnelovania da moicavs sxeulis mraval sistemas. ziani fsiqologiurad SeiZleba daukavsirdes sxvebsi SesamCnev Zlier travmebs, da jalatebis muqaras mudmivi zianis miyenebis Sesaxeb (`Tqven verasdros gaivlit~). sxeulis, xelebis an fexebis mozraobam an dazianebul adgilebze Sexebam SeiZleba gamoiwvios im drosi da situaciasi dabruneba, rodesac travma warmoisva an axali iyo. somatoformuli aslilobebis yvelaze mnisvnelovan aspeqts aucileblad fizikuri Sedegebis ararseboba ki ar warmoadgens, aramed is, rom SesaZlo fizikuri Sedegebi srulad ar xsnis tanjvis an simptomebis xarisxs. masze SeiZleba zegavlenas axdendes kulturisatvis damaxasiatebeli mwuxarebis gamoxatvis manera. `somatoformuli~ simptomebi yuradrebit unda iqnas gamokvleuli imisatvis, rom SeumCneveli ar darces fizikuri Sedegebi. fizikuri Sedegebi SeiZleba `dafaros~ `somatoformulma~ simptomebma ramdenime iseti faqtoris gamo, rogoricaa: wamebis ucveulo metodebis gamoyenebis Sedegad miyenebuli atipiuri travmebis arseboba, kulturuli faqtorebi, satanado mkurnalobis ararseboba, an gamoyenebuli diagnostikuri sasualebebis SezRudva. es faqtorebi yuradrebit unda iqnas ganxiluli wamebagamovlil da gadarcenil adamianebsi, somatoformuli dazianebis diagnozis dasmamde. somatoformuli dazianebebi xsirad vlindeba travmagadatanil adamianta jgufebis umravlesobasi, ase rom es SeiZleba mnisvnelovani diagnozi iyos. DSM IV Si somatizacia aseve ganxilulia, rogorc Tanmxlebi simptomi. 54

55 `somatoformuli~ aslilobebi wamebis Semdeg savaraudod `somatofrmuli~ aslilobebi SeiZleba gamowveuli iyos SemdegiT: travma, romelic pacientma damala wina gamokvlevebisas aradiagnostirebuli atipiuri travma kulturisatvis damaxasiatebeli emociebis gamoxatva ptsa: warsulis mogonebebi, rac dakavsirebulia sxeulis dazianebul adgilebtan (sxeulis mexsierevba) wamebis Sedegad miyenebuli gaurkveveli dazianeba (Thomas Wenzel, WPA, 2004). somatoformuli aslilobebi DSM IV -Si sxeulis dismorfuli dazianeba konversiuli asliloba ipoqondria fsiqologiur faqtorebtan da saerto samedicino mdgomareobastan asocirebuli tkiviltan dakavsirebuli asliloba fsiqologiur faqtorebtan asocirebuli tkiviltan dakavsirebuli asliloba somatizaciuri asliloba somatoformuli asliloba NOS aradiferencirebuli somatoformuli asliloba somatoformuli aslilobebi ICD 10-Si F 45 somatoformuli aslilobebi: F45.0 somatizaciuri asliloba arsebobs mravali ZiriTadi maxasiatebeli, recidivuli da xsirad cvalebadi simptomebi, romelta xangzlivoba minimum ori welia. F45.1 aradiferencirebuli somatoformuli asliloba rodesac somatoformuli Civilebi mravalgvari, cvalebadi da mudmivia, magram somatizaciuri dazianebis sruli da tipiuri klinikuri surati jer ar aris dasrulebuli, ganxilul unda iqnas es kategoria. F45.2 ipoqondruli asliloba ZiriTad maxasiatebels warmoadgens mudmivi CaZiruloba erti an meti seriozuli da progresuli fizikuri daaavadebis SesaZleblobiT, romelic vlindeba mudmivi somaturi CivilebiT an pirovnebis garegnobastan dakavsirebuli mudmivi zrunvit. F45.3 somatoformuli vegetatiuri disfunqcia simptomebs pacienti warmoadgens ise, TiTqos isini gamowveuli iyos im sistemis an organos fizikuri dazianebit, romelic umeteswilad an mtlianad avtonomiuri inervaciisa da kontrolis qvesaa (e..i gulsiszarrvta, kuw-nawlavis, sasuntqi da sasarde-sasqeso sistemebi). 55

56 F45.4 mudmivi somatoformuli tkiviltan dakavsirebuli asliloba predominantuli Civili dakavsirebulia mudmiv, Zlier da Semawuxebel tkiviltan, romelic ar SeiZleba srulad aixsnas fsiqologiuri procesit an fizikuri dazianebit da, romelic warmoiqmneba emociur konfliqttan an fsiqosocialur problemebtan ertad, rac sakmarisia, rata gaketdes daskvna imis Taobaze, rom isini warmoadgenen mtavar mizezobriv faqtorebs. xsiria wamebis msxverplta Soris SfoTviT panikuri aslilobani, gansakutrebit ki situaciebsi, romelic agonebs wamebis faqtebs, magalitad policiis danaxvisas, samedicino instrumentebis danaxvisas da a. S. SfoTvasTan dakavsirebuli aslilobebi SfoTvasTan dakavsirebuli sxva iseti aslilobebi, rogoricaa fobiebi da SfoTvasTan dakavsirebuli zogadi asliloba, ptsa-is garda, rogorc Cans, xsiria devnis Semdeg, Tumca kvlevebis umravlesoba fokusirebulia ptsa-sa da depresiaze. simptomebi, romlebic ptsa-is nawils warmoadgens, calke unda iqnas kodirebuli. (magaliti: SfoTvis mwvave mdgomareoba panikis reaqciit xsiria ptsa-s dros, panikuri tipis aslilobis damatebiti diagnozi SeiZleba ar iyos sawiro) SfoTvasTan dakavsirebuli aslilobebi DSM IV Zlieri stresuli asliloba agorafobia panikuri tipis aslilobis istoriis garese saerto samedicino mdgomareobit gamowveuli SfoTvasTan dakavsirebuli asliloba SfoTvasTan dakavsirebuli asliloba NOS SfoTvisgeneralizebuli asliloba obsesur-kompulsiuri asliloba panikuri tipis asliloba agorafobiit panikuri tipis asliloba agorafobiis garese posttravmuli stresuli asliloba sociofobia specifikuri fobia SfoTvasTan dakavsirebuli asliloba ICD 10 F40.0 agorafobia F40.1 sociofobia F40.2 specifikuri (izolirebuli) fobiebi F41.0 panikuri tipis asliloba [epizoduri paroqsizmuli SfoTva] F41.1 SfoTvis generalizebuli asliloba 56

57 F41.2 Sereuli SfoTvisa da depresiuli asliloba F41.3 SfoTvasTan dakavsirebuli sxva Sereuli aslilobebi (SfoTvasTan dakavsirebul aslilobebtan Sereuli SfoTvis simptomebi) F42 obsesur-kompulsuri asliloba wamebis Sedegad xsirad vitardeba depresiuli mdgomareoba DSM IV is mixedvit imisatvis, rom Rrma depresiis diagnozi daisvas, aucilebelia ori kviris ganmavlobasi yuradreba mieqces Tundac xut qvemotcamotvlil faqtors : 1) datrgunuli ganwyoba; 2) interesis sagrznobi daqveiteba da interesis dakargva an TiTqmis dakargva cxovrebiseul siamovnebebze ; 3) wonis dakargva an madis Secvla ; 4) uziloba an gadametebuli Zili ; 5) fsiqomotoruli agzneba an daqveiteba ; 6) darliloba an Zalis gamocla ; 7) usargeblobis SegrZneba da zedmetad an usafuzvlod Tavis dadanasauleba; 8) fiqris an azris mokrebis daqveitebuli unari ; 9) akviatebuli fiqri sikvdilze an TviTmkvlelobaze. simzimis mixedvit depresiuli mdgomareoba SeiZleba iyos msubuqi, sasualo simzimisa da mzime, fsiqozuri simptomebis garese, Tumca aseve diagnostirdeba mzime depresia fsiqozuri simptomebit. wamebis SemTxvevaSi SesaZloa ganvitardes sxvadasxva simzimis depresia. diagnostikuri kriteriumebi, romelta mixedvitac SeiZleba vixelmzrvanelot depresiis simzimisa da tipis gansazrvrisatvis mocemulia ICD 10 Si, TavSi afeqturi aslilobebi ; msubuq depresias Seesabameba Semdegi kodi: F 32.0 msubuqi depresiuli epizodi. sasualo depresiul epizods Seesabameba kodi F 32.1; mzime depresiul epizods fsiqozuri simptomebis garese F 32.2 ; xolo MmZime depresiul epizods fsiqozuri simptomebit, iseti rogoric aris bodva, halucinaciebi, stuporis mdgomareoba, Seesabameba kodi F 32.2; simzimis gansazrvra Semdegi sami depresiisatvis damaxasiatebeli kriteriumis gamoxatvis xarisxit xdeba: 1) guneba ganwyobis daqveiteba; 2) fsiqikuri funqciebis Seneleba; 3) motoruli funqciebis Seneleba; amave dros depresia SesaZloa mimdinareobdes somaturi komponentis TanxlebiT, an Tanxlebis garese; aseve SesaZlebelia ganvitardes Sereuli depresiuli sindromebi SfoTviT - depresiuli; disforiuli komponentit, aseve ajitirebuli depresia motoruli Senelebis komponentis garese, maskirebuli depresia somatoformuli da hipoqondriuli gamovlinebebit da sxva; guneba-ganwyobilebis aslilobebi (afeqturi aslilobebi) DSM IV depresiuli aslilobanos 311 distimiuri asliloba Rrma depresiuli asliloba, recidivuli 296.3x Rrma depresiuli asliloba, erti epizodi 296.2x saerto samedicino mdgomareobit gamowveuli guneba-ganwyobilebis asliloba

58 guneba-ganwyobilebis asliloba NOS SeniSvna: aseve ixilet adaptaciuri aslilobis depresiuli qvetipi guneba-ganwyobilebis aslilobebi (afeqturi aslilobebi) ICD 10 ICD 10 F32: depresiuli epizodi `qvemot mocemul tipiur msubuq, zomier an mwvave epizodebsi, subieqti ganicdis guneba-ganwyobilebis daqveitebas, energiis Semcirebas da aqtivobis vardnas. siamovnebis, interesisa da koncentraciis unari daqveitebulia, da odnavi Zalisxmevis Semdegac ki Zlieri motentiloba Cveulebrivi movlenaa. Zili Cveulebriv darrveulia, xolo mada - daqveitebuli. sakutari Tavis pativiscema da sakutar ZalebSi rwmena TiTqmis yoveltvis daqveitebulia, da msubuq formasic ki, xsirad warmoiqmneba danasaulis an uvargisobis grznoba. daqveitebuli guneba-ganwyobileba odnav icvleba dridan dremde, ar reagirebs garemoebebze da mas SeiZleba Tan axldes e.w `somaturi~ simptomebi, rogoricaa: interesisa da siamovnebis grznobis dakargva, dilit Cveul droze ramdenime saatit adre garvizeba; depresiis gauareseba dilit, SesamCnevi fsiqomotoruli Sekaveba, ajitacia, madis dakargva, wonasi dakleba da libidos dakargva. simptomebis raodenobisa da simwvavis gatvaliswinebit, depresiuli epizodi SeiZleba ganisazrvros, rogorc msubuqi, zomieri an Rrma.~ moicavs Semdegs: depresiiuli reaqciis calkeuli epizodebi, fsiqogenuri depresiis calkeuli epizodebi, reaqtiuli depresiis calkeuli epizodebi. F32.0 msubuqi depresiuli epizodi F32.1 zomieri depresiuli epizodi F32.2 Rrma depresiuli epizodi fsiqozuri simptomebis garese (ajitirebuli depresiis calkeuli epizodi fsiqozuri simptomebis garese. Zlieri depresiis calkeuli epizodi fsiqoturi simptomebis garese. vitaluri depresiis calkeuli epizodi fsiqozuri simptomebis garese) F32.3 Rrma depresiuli epizodi fsiqozuri simptomebit. guneba-ganwyobilebis aslilobebi (afeqturi aslilobebi) ICD 10 F34 guneba-ganwyobilebis [afeqturi] aslilobebi xangrzlivi da Cveulebriv cvalebadi guneba-ganwyobilebis aslilobebi, rodesac individualuri epizodebis umravlesoba sakmarisad mwvave ar aris imisatvis, rom ganxilul iqnas, rogorc hipomaniakaluri an msubuqi depresiuli epizodi. imis gamo, rom ramdenime wlis da, zogjer ki subieqtis cxovrebis didi nawilis ganmavlobasi grzeldeba, isini dakavsirebulia mnisvnelovan sulier tanjvastan da uunarobastan. zogiert SemTxvevaSi, 58

59 recidivuli an ertjeradi maniakaluri an depresiuli epizodebi SeiZleba Tan daertos xangrzliv afeqtur aslilobas. formebi: F34.1 distimia F34.0 ciklofrenia unda arinisnos, rom wamebis SemTxvevaSi ganvitarebuli depresia umetes SemTxvevaSi ganekutvneba reaqtiul mdgomareobebs da igi Tavisi registrit SesaZloa iyos rogorc nevrozuli, aseve fsiqozuri. Ffsiqozi fsiqozi wamebis dros an Semdeg SeiZleba gamovlindes, rogorc: reaqtiuli fsiqozi, romelic gamowveulia Zlieri stresis gamo (rogoric fsiqologiuri wamebis an xangrzlivi patimrobis dros), SeiZleba miiros kulturul-specifiuri formebi. adre arsebuli fsiqozis `inicireba~ (egzacerbacia), rogoricaa Sizofrenia an Sizoafeqturi asliloba, fizikuri faqtorebit gamowveuli organuli fsiqozi. wamebis msxverplta SemTxvevaSi aseve mosalodnelia mwvave reaqtiuli paranoidis ganvitareba, romelic xasiatdeba mwvave afeqturi gancdebita da bodviti arqmit; qronikuli travmatizaciis Sedegad an wamebis qronikul Sedegebs SesaZloa mivakutvnot qronikuli paranoialuri sindromis ganvitareba; aseve wamebis SemTxvevaSi nisandoblivia qronikuli depresiuli aslilobis ganvitarebac. unda arinisnos, rom reaqtiuli mdgomareobebis ganvitarebisas travma aisaxeba gancdebsi, mas wamyvani roli mieniweba darrvevata ganvitarebasi da bodviti azrebi an sxva gancdebi da gamonatqvamebi ar scildeba matravmirebeli situaciis farglebs. aseve unda arinisnos, rom wamebis Sedegad ganvitarebuli fsiqikuri aslilobebi gamoirceva mravalferovnebit da isini SesaZloa iyos rogorc nevrozuli aseve fsiqozuri registris. wameba xsir SemTxvevaSi xels uwyobs endogenuri fsiqozebis manifestaciasac, iseti rogoric SeiZleba iyos Sizofreniuli fsiqozebi an depresiul maniakaluri mdgomareoba, aseve am daavadebata gamwvavebas; xsir SemTxvevaSi ki igi xdeba qronikuli pirovnuli cvlilebebis an pirovnul aslilobata ganvitarebis mizezi, gansakutrebit ki im SemTxvevebSi, roca fsiqikuri travma Serwymulia Tavis tvinis organul dazianebastan; igi SeiZleba gaxdes aseve travmuli epilefsiis mizezi, fsiqikuri da nevrologiuri komponentebis mkafio gamoxatulebit. fsiqikur aslilobata xasiati Tu mimdinareoba da xangrzlivoba damokidebulia wamebis simzimesa da xangrzlivobaze, aseve garemo socialur situaciaze da mtel rig damatebit stresul faqtorebze, romelsac gansakutrebuli travma iwvevs adamianis cxovrebasi; 59

60 fsiqozi DSM IV Sesabamisi kategoriebi xanmokle fsiqozuri asliloba bodviti asliloba fsiqozuri asliloba, gamowveuli [miutitet saerto samedicino mdgomareoba], bodviti ideebit fsiqozuri asliloba, gamowveuli [miutitet saerto samedicino mdgomareoba], halucinaciebit fsiqozuri asliloba NOS xanmokle fsiqozuri asliloba diagnostikuri kriteriumebi erti (an meti) Semdegi simptomis arseboba: bodviti ideebi, halucinaciebi, areuli metyveleba (mag. xsiri gadaxveva an aratanmimdevruloba), sakmaod araorganizebuli an katatoniuri qceva. SeniSvna: ar moicavs simptoms Tu is kulturulad nebadartuli reagirebis nimusia. aslilobisas epizodis xangrzlivoba minimum 1 dre da maqsimum 1 Tvea, ris Semdegac sabolood xdeba funqcionirebis avadmyofobamdel mdgomareobasi dabruneba. amgvari asliloba ar aixsneba mxolod fsiqozuri maxasiateblebit gamoxatuli guneba-ganwyobilebis aslilobit, Sizoafeqturi aslilobit an SizofreniiT da ar aris gamowveuli alkoholisa da narkotikebis borotad gamoyenebis fiziologiuri SedegebiT (mag. narkotikebis, medikamentebis borotad moxmareba) an saerto samedicino mdgomareobit. miutitet, Tu: gamowveulia mnisvnelovani stres-faqtorit (stres-faqtorebit) (xanmokle reaqtiuli fsiqozi): Tu simptomebi warmoiqmneba male im SemTxvevebis Semdeg da sapasuxod, romlebic, calke an ertad, askarad stresuli iqneboda TiTqmis yvelasatvis msgavs situaciebsi, pirovnebis sazogadoebasi. Sesabamisi kategoriebi Ffsiqozi ICD 10 F23.9 mwvave da tranzitoruli fsiqozuri aslilobebi (ixilet momdevno slaidi) F22.0 bodviti asliloba 60

61 adreul literaturasi xsirad ganxiluli devnis Semdgomi aslilobebi SeiZleba F 62.0 is nawili iyos (pirovnebis qronikuli cvlilebebi katastrofis gadatanis Semdeg). F23.9 mwvave da gardamavali fsiqozuri asliloba (a) mwvave simptomebis gamovlena (2 kviris ganmavlobasi) ; (b) tipiuri sindromebis arseboba; (g) Tanmxlebi Zlieri stresis arseboba. mwvave simptomebis gamovlena ganisazrvreba, rogorc normaluri mdgomareobidan askarad aranormalur fsiqozur mdgomareobasi gadasvla (fsiqozuri maxasiateblebis garese) 2 kviris an naklebi periodis ganmavlobasi. dadasturebulia, rom mwvave simptomebis gamovlena dakavsirebulia ketilsaimedo gamosavaltan, da SeiZleba itqvas, rom rac ufro uecrad vlindeba simptomebi mit ufro kargia gamosavali. amitom, rekomendebulia, rom sawiroebis SemTxvevaSi (48 saatis an naklebi periodis ganmavlobasi) ganisazrvros simptomebis uecari gamovlena. SerCeuli tipiuri sindromebi, nisnavs pirvel rigsi, swrafad cvalebad da aramdgrad mdgomareobas, romelsac aq ewodeba `polimorfuli~ da, romelic ramdenime qveyanasi cnobili gaxda mwvave fsiqozur mdgomareobastan dakavsirebit, da meore rigsi, tipiuri Sizofreniuli simptomebis arsebobas. Tanmxlebi Zlieri stresi aseve SeiZleba ganisazrvros mexute maxasiateblit (Tu sawiroa)... Tanmxlebi Zlieri stresi imas nisnavs, rom pirveladi fsiqozuri simptomebi warmoiqmneba iseti erti an meti movlenis dridan daaxloebit 2 kviris ganmavlobasi, romelsac gansaxilveli pirovnebis sazogadoebis warmomadgenel adamianta umravlesoba stresul SemTxvevad miicnevda msgavs garemoebebsi. tipiur movlenad miicneva mzime danaklisi, partnioris an samsaxuris moulodneli dakargva, ganqorwineba, an omis, terorizmis an wamebis Sedegad miyenebuli fsiqologiuri travma. gaxangrzlivebuli cxovrebiseuli problemebi am konteqstsi ar unda iqnas ganxiluli, rogorc stresis wyaro~. kvebastan dakavsirebuli aslilobebi mimoxilva nervuli anoreqsia da kvebastan dakavsirebuli sxva tipiuri aslilobebi, mat Soris bulimiit da lotobit gamoxatuli kvebastan dakavsirebuli aslilobebi Cveulebriv vitardeba bavsvobasi an axalgazrdobasi, da xsirad dakavsirebulia travmastan. garda amisa, amgvari aslilobebi vlindeba mozrdilebsi, wamebis an devnis Semdeg, Tumca cnobili SemTxvevebi kvebastan dakavsirebuli `atipiuri~ aslilobebia. 61

62 kulturuli faqtorebi da seqsualuri wameba SeiZleba pirdapir ukavsirdebodes kvebastan dakavsirebuli aslilobebis warmoqmnas. kvebastan dakavsirebuli aslilobebi DSM IV, ICD 10 DSM IV nervuli anoreqsia nervuli bulemia kvebastan dakavsirebuli asliloba NOS ICD 10 nervuli anoreqsia F 30.0 nervuli bulemia F 50.2 madis dakargva ( R63.0 ), anoreqsia NOS ( R63.0 ), atipiuri nervuli anoreqsia F 50.1, kvebastan dakavsirebuli sxva aslilobebi ( F50.8 ), sxva fsiqologiur aslilobebtan dakavsirebuli pirrebineba (F 50.2). (Thomas Wenzel, WPA, 2004). fsiqikur aslilobebs wamebis dros Tan sdevs xsirad wamaldamokidebulebisa da alkoholizmis movlenebi, romelta mirebasac xsirad safuzvlad udevs akviatebul gancdata da mogonebebisagan Tavis darwevis survili an myari uzilobis problema; narkotikebis an alkoholis borotad moxmareba SeiZleba wamebis Sedegebis gartulebul formas warmoadgendes. wamebagamovlili adamianebi Zilis darrvevebs, ptsa-s (warsulsi dabruneba) an depresias SeiZleba `mkurnalobdnen~ mat sazogadoebasi xelmisawvdomi narkotikebis aseve, alkoholis, nikotinis, an farmakologiuri preparatebis mesveobit, rac warmoqmnis matze damokidebulebis risks (ZiriTadad benzodiazepinebit, romelsac unisnavs eqimi). Tavis tvinis travmis an dazianebis SesaZlo faqtorebi (Thomas Wenzel, WPA, 2004). blagvi sagnit miyenebuli travma (daxuruli) cemis Sedegad mirebuli Ria travma seriozuli da xangrzlivi SimSiloba daxrcobastan da cerebralur (Tavis tvinis) hipoqsiastan (Jangbadis ukmarisoba, ixilet momdevno magalitebi) dakavsirebuli specifikuri simptomebi mtkivneuli da xangrzlivi njrreva 62

63 `submarino~ `sveli submarino~: saxesxvaoba: `wyalsi CaSveba~ `msrali submarino~ magaliti: polietilenis paketi :Thomas Wenzel/ WPA, 2004 `submarino~ fizikuri Sedegi: moxrcoba/hipoqsia, SesaZloa mavne nivtirebebis mireba xangrzlivi zemoqmedeba Tavis tvinze, romelic ar aris kargad gamokvleuli fsiqologiuri Sedegi: xanmokle: Zlieri SiSi, umweoba, dezorientacia gaxangrzlivebuli: ptsa, panikuri Setevebi :Thomas Wenzel/ WPA, 2004 Tavis tvinis travmis aspeqtebidan unda arinisnos: fokaluri Tavis tvinis travma: lokalizebuli dazianeba, difuzuri Tavis tvinis travma. damatebiti difuzuri Tavis tvinis travma Cveulebriv arsebobs Tavis tvinis travmis yvela formasi. 63

64 postkomociuri sindromi (PCS) xsiria, simptomebi nawilobriv hgavs depresiisa da ptsa-is zogiert simptoms. DSM IV SemoTavazebuli diagnostikuri kriteriumebi postkomociuri sindromisatvis (PCS) Tavis travmis istoria, romelmac gamoiwvia tvinis seriozuli Seryeva (mag. gonebis dakarvva, posttravmuli amnezia, an kruncxviti gantvirtvebi). yuradrebastan an mexsierebastan dakavsirebuli problemebis neirofsiqologiuri nisani. sami an meti simptomi, romlis xangrzlivoba 3 Tveze metia da, romelic Tavis travmis miyenebidan Zalian male warmoiqmneba an, romelic adre arsebuli simptomebis mnisvnelovan gauaresebaze miutitebs. motentiloba mouwesrigebeli Zili Tavis tkivili Tavbrusxveva garizianebadoba SfoTva, depresia an afeqturi labiluroba pirovnebis cvlileba apatia an spontanurobis dakargva ICD-10 SemoTavazebuli diagnostikuri kriteriumebi postkomociuri sindomisatvis (PCS) ICD 10: F 07.2 anamnezsi Tavis travma, romelsac Tan axlda gonebis dakargva miutitebs imaze, rom simptomebi warmoiqmneba maqsimum 4 kviris ganmavlobasi. sami an meti simptomi: Tavis tkivili, Tavbrusxveva, SeuZlod yofna, motentiloba, xmauris autanloba garizianebadoba, depresia, SfoTva, emociuri labiluroba koncentraciis gazneleba, mexsierebis an gonebrivi SesaZleblobebis daqveiteba, mnisvnelovani darrvevis neirofsiqologiuri nisnebis garese uziloba daqveitebuli tolerantuloba alkoholisadmi zemoarnisnul simptomebze fiqri da Tavis tvinis dazianebis ipoqondriuli SiSi da avadmyofis rolis TamaSi. 64

65 Tavis tvinis travmis an dazianebis SesaZlo `ZiriTadi~ macveneblebi klinikuri simptomebi: koncentracia unaris darrveva da/an xanmokle mexsierebis darrveva, garizianebadoba, guneba-ganwyobilebis cvalebadoba, amnezia, energiis arqona. Tavis tkivili arasakmarisi kveba da SimSiloba (Thomas Wenzel, WPA, 2004). arasakmarisi kvebis an SiSmilobis zemoqmedeba xsirad ugulebelyofilia diagnostikis dros da ar eqceva yuradreba amgvari zemoqmdebis Sedegebs. xanmokle zemoqmedeba uaryofit zegavlenas axdens fsiqologiur parametrebze, mat Soris mexsierebaze, yuradrebaze, aqtivaciasa da guneba-ganwyobilebaze, rac aisaxeba laboratoriuli gamokvlevis monacemebit (eleqtrolitebi da sxva parametrebi); cvlilebebi Cveulebriv Seqcevadia. xangrzlivma zemoqmedebam SeiZleba gamoiwvios centraluri da periferiuli nervuli sistemis dazianeba. orive faqtorit gamowveulma darrvevam SeiZleba xeli SeuSalos srul da saboloo gamokitxvas; SesaZloa mkurnaloba aucilebeli armocndes. wamebis Sedegebi aisaxeba ara marto fsiqikur funqciebze, aramed xsirad mas Tan sdevs seqsualuri disfunqciis komponenti, rac SeiZleba gamowveuli iyos rogorc fizikuri, aseve fsiqikuri zemoqmedebit da TiTqmis yoveltvis, uvitardebat seqsualuri wamebis msxverplebs. unda arinisnos, rom fsiqikuri problemebi, romelic wamebis msxverpls uvitardeba, aisaxeba mis ojaxsa da garemocvaze; socialuri TvalsazrisiT vlindeba konfliqtebi ojaxsi, zogadi xasiatis sirtuleebi interpersonaluri urtiertobebis mxriv, Sromis unaris daqveiteba da sxva, rac kompleqssi warmoadgens fsiqo socialur problemata ertobliobas, romelic safrtxes uqmnis rogorc wamebis msxverplis, aseve misi ojaxisa da sazogadoebis normalur funqcionirebas. aqedan gamomdinare, es problema ara marto samedicino fsiqologiuri xasiatis, aramed socialuri Tu politikuri da zogadsakacobrio xasiatisaa. centri «empatia»s mier Catarebuli kvlevebis Sedegad gamovlenil iqna calkeul riskis jgufebsi klinikuri Taviseburebani da damatebiti stresorebi, romelic safuzveli xdeba kompleqsuri polimorfuli da qronikul darrvevata ganvitarebisatvis. 65

66 samedicino daxmarebis nakleboba, umetes SemTxvevaSi wamebis msxverplta mimart arahumanuri mopyroba da damokidebuleba iwvevs mwvave fizikur da fsiqikur darrvevebs. arnisnul darrvevebs kidev ufro arrmavebs Tanmxlebi araadamianuri cxovrebis pirobebi, rasac adgili aqvs rogor winaswari dakavebis saknebsa da sapyrobileebsi, aseve ltolvilta da izulebit adgilnacval pirta Sorisac. yovelive amgvari situacia, warsulis matravmirebel stresul SemTxvevebTan ertad iwvevs kompleqsuri travmuli stresuli sindromis qronizacias, Tanmxlebi somaturi da fsiqo somaturi darrvevebit, rac vlindeba pirovnebis qronikuli cvlilebebisadmi tendenciebis CamoyalibebaSi. yovelive arnisnuli iwvevs socialur sferosi adaptaciis darrvevebs, xsir konfliqtebs da azlierebs agresiul reaqciebs. araswori damokidebuleba da Seusabamo samedicino daxmareba, cixeebsi reabilitaciis sistemis ar arseboba da specifikuri daxmarebis ar arseboba wamebis msxverpltatvis aris mizezi Semdegi fsiqikuri da fsiqologiuri darrvevebisa : wamebis mimdinare da qronikuli Sedegebi wamebis fsiqikuri (fsiqologiuri) Sedegebi (ICD - 10-is Sesabamisad) da gamoyenebul fsiqologiur testebze dayrdnobit. zrdasrulebisatvis (sul raodenoba 204) diagnozi Mmwvave stresuli reaqcia kodi (ICD 10) F - Code patimrebi yofili patimrebi N109/ sixsire F ltolvilebi CeCneTidan 24 /FsixSire izulebit adgalinacvali pirebi afxazetidan da samxret osetidan N 29 /FsixSire galis regioni N 42 F Nnomeri./ / sixsire 204-s Soris F / 0, / 0, 02 7 / 0, 03 PTSD F / 0, 15 8 / 0, / 0, / 0, / 0, 23 PTSD F43.1 ; 15 / 0, 14 8 / 0, / 0, / 0, / 0, 21 depresiit F PTSD somaturi aslilobit PTSD post komociuri S sindromit qronikuli pirovnuli cvlilebebi (wamebis Semdeg) emociuri pirovnuli aslilobebi PTSD-Tan ertad pirovnuli organuli asliloba (epilefsia PTSD-sTan ertad) PTSD fsiqozuri sindromit F43.1 F45. F43.1. F / 0, 10 2 / 0, 08 2 / 0, / 0, / 0, / 0, 21 3 / 0, 12 2 / 0, / 0, 14 F / 0, 12 3 / 0, 12 4 / 0, 14 4 / 0, / 0, 12 F60.3. F43.1. F07.0. F / 0, / 0, 02 8 / 0, 04 3 / 0, / 0, 02 4 / 0, 02 F43.1? 8 / 0, / 0, 02 9 / 0, 04 konversiul- F 44 2 / 0, / 0,

67 disociaciuri asliloba PTSD-Tan ertad demencia (Tavis tvinis travmit gamowveuli (wamebis dros mirebuli travmis Sedegad) Sizofrenia disocialuri pirovnuli asliloba F 43.1 F / 0, 03 1 / 0, 02 2 / 0, 009 F 20.0x0 3 / 0, F / 0, rogorc cxrilebidan Cans, yvelaze gavrcelebuli diagnozi iyo posttravmuli stresuli asliloba, romelic vlindeboda ganmeorebitobis fazis simptomebsi: (travmuli stresuli movlenis wamebis - Sesaxeb akviatebuli gancdebis, mogonebebis, Ramis kosmarebisa da Zilis darrvevasi) da gaqcevis fazisatvis damaxasiatebel simptomebsi depresiita da fsiqo somaturi, vegetatiuri reaqciebit. unda arinisnos, rom umetes SemTxvevaSi gamovlinda sxvadasxva fsiqo-somaturi sindromi, rogoric aris: qronikuli tkivilis sindromi (Tavis, zurgis, kisris aresi): 204 SemTxveva _ 82,93%; centraluri nervuli sistemis fuqnciuri darrvevebi: 142 SemTxveva _ 56,34%; arteriuli wnevis cvalebadoba (88-34,92%) da tkivili gulis aresi (139-55,16%); rogorc specifikuri darrveva qal patimrebsi dismenorea, mozardebsi ki _ enurezi. zogierti Taviseburebani, romelic gamovlinda mozard wamebis msxverplta Soris ( ww. kvlevebi): mozardebisatvis (sul N 43) Ddiagnozi kodi F TavSi pirebi (sul N 35 ) Ppatimari / sixsire patimrebi galis N35 / s raioni N sul N43/ s 8 / s araorganuli enurezi PTSD istan F F / 0, 06 2 / 0, 25 4 / 0, 09 ertad socialurad integrirebuli qceviti F F / 0, 23-8 / 0, 19 asliloba PTSD - stan ertad socialurad dezintegrirebuli F F / 0, 26-9 / 0, 21 asliloba PTSD - stan ertad PTSD depresiastan ertad F F / 0, / 0, 28 epilefsia PTSD -stan ertad, enurezit F F / 0, 08-3 / 0, 07 qcevis depresiuli asliloba F / 0, 37 3 / 0, 07 PTSD F / 0, 03 3 / 0, 37 4 / 0, 09 toqsikomania arasrulwlovan patimrebsi - 20 SemTxveva. unda arinisnos, rom mozardebsi gamovlenili patimrobamde arsebuli problemebi: ojaxsi da qucasi Zaladobis marali done, hipokontroli, ganatlebisa da elementaruli socialuri unar-cvevebis nakleboba, toqsokomaniis marali done da narkotikebis moxmareba an alkoholis gamoyeneba, cixesi cud damokidebulebastan ertad xsir SemTxvevaSi iwvevs gamoxatul pirovnul cvlilebebs, rac umetes SemTxvevebSi vlindeba 67

68 stabiluri saxis socialur qcevit aslilobasi da adaptaciis SesaZleblobebis SesustebaSi. mozardebsi zemot moyvanil sindromebs arenisneba zogierti mnisvnelovani Tavisebureba, romelsac Cven vuwodet BbavSvi didis fenomeni, rac gulisxmobs konfliqts bavsvis fsiqo-fizikur SesaZleblobebsa da bavsvebis garsemo arsebuli sastiki realobis obieqtur motxovnebs Soris. socialuri dacvis sistemis ararseboba da adeqvaturi sasamartlo sistemis deficiti Sans ar utovebs arasrulwlovan damnasaveebs ganvitardnen da daiwyon axali cxovreba gatavisuflebis Semdeg. patimrebs Soris Catarebulma kvlevebma acvena, rom cixeebisatvis damaxasiatebeli bunebrivi Taviseburebani: Tavisuflebis SezRudva, ojaxis wevrebisagan izolacia, arcevanisa da interesta sferos SezRudva, sasamartlos gadawyvetilebis molodini winaswari patimrobis izolatorsi yofnis dros _ mudmivi faqtorebia, romlebic amzafrebs pirovnebis dazabulobas da iwvevs pirovnebis kompensatoruli meqanizmebis Sesustebas. post-sabwota, cixeebsi cixeta bunebriv negatiur faqtorebs emateba post sabwota cixis specifiuri negatiuri faqtorebi, rogoric aris banakis sistema, cixeebis gadavsebuloba, kriminaluri garemo, pirovnuli SesaZleblobebis realizaciis nakleboba, operatiuli-saagento sistema da patimrebis mimart aradamianuri damokidebuleba, xsirad arakvalificirebuli samedicino daxmareba da samedicino etikis normebis uxesi darrveva, rac kidev ufro Rrma matravmirebeli faqtori xdeba pirovnebisatvis. es faqtorebi uaryofit gavlenas axdenen pirovnebis adaptaciis SesaZleblobebze da, wamebasa da araadamianur an Rirsebis Semlaxav mopyrobasa da dasjastan ertad, umetes SemTxvevaSi, iwveven pirovnebis qronikul cvlilebebs, rac upiratesad vlindeba pirovnebis izolaciasi, fsiqologiur autizaciasi, undoblobasa da samyarosadmi ukiduresad mtrul damokidebulebasi. yovelive zemot moyvanili xsir SemTxvevaSi mizezi xdeba myari mtris xatis fenomenis Camoyalibebisa, rac xdeba mizezi reabilitaciis gartulebisa. Cveni dakvirvebis Sesabamisad, ltolvilebis SemTxvevaSi mzime fsiqofizikuri aslilobebis warmoqmnaze mnisvnelovan gavlenas axdens damatebiti (travmis Semdgomi) stresuli faqtorebi, romlebic ganvitarebad da Ratak qveynebsi metad TvalsaCino xdeba, rogoric aris: arsebuli saomari mdgomareobani; msoflio sazogadoebis mxridan ltolvilebis tragediis mimart yuradrebis nakleboba; sazogadoebis am nawilisatvis dacvis meqnizmebis ararseboba; sikvdilis an gaurkvevlobis mudmivi SiSi, sasineli informaciis molodini (ojaxis wevris an axlo natesavis gardacvaleba; mati dapatimreba; vinmes gaupatiureba da wameba); daucvelobis, usargeblobisa da uzlurebis SegrZneba, etnikuri devna Seviwroeba, samyarosagan da sazogadoebisagan gariyul mdomarebasi yofna. adamianis gatacebisa da dakargvis SemTxvevebi. socialuri motxovnebisa da pirovnuli motivaciebis SezRudva 68

69 ukiduresad SezRuduli humanitaruli daxmareba, romelic ganxiluli unda iyos, rogorc araadamianuri cxovrebis pirobebi. unda arinisnos, rom aseti dramatuli situacia iwvevs pirovnebis qronikul sulier da fizikur travmirebas, rac vlindeba qronikul posttravmul stresul aslilobasi an somatur daavadebebsi, qronikul depresiasa da SiSSi, romelsac Tan axlavs sxva samyaros da garemos mimart undobloba da mtruli ganwyoba, interpersonaluri da intrapersonaluri konfliqtebi da sirtuleebi. ukiduresad krizisuli mdgomareoba qmnis adaptaciasa da reabilitaciastan dakavsirebul sirtuleebs. garda amisa, umetes SemTxvevebSi ltolvilebs gaacniat Zlieri undobloba da autoizolaciis an TavianT TemSi izolaciis tendenciebi. Cveni azrit, es aris Sedegi Zlieri da xangrzlivi distresisa da momavlis gaurkevlobisa. aseve unda arinisnos, rom mimdinare konfliqtis zonebsi wamebis msxverplta Soris wamebis Sedegebs Tan ertvis fartod gamovlenili permanentuli SfoTviT fobikuri sindromi, romelsac Tan sdevs relaqsaciis miznit alkoholisa da narkotikebisadmi ltolva. Cveni azrit, amis mizezi aris mudmivi sasisroebis molodinis mdgomareoba da usafrtxoebis garantiebis ararseboba. wamebis fizikuri Sedegebi wamebis mwvave fizikuri Sedegebi rogorc ukve wina TavSi mokled iqna arnisnuli, metad xsiria sxvadasxva saxis hemoragiuli sindromis arseboba, aseve Tavis tvinis mwvave travma gonebis dakargvit, aseve xsiria sxvadasxva lokalizaciis motexilobani da amovardnilobani, tkivilit gamowveuli an sisxldenit gamowveuli travmuli Soki; sxvadasxva saxis mwvave sqesobrivi gzit gadamdebi infeqciebi. centri «empatia»s mier wlebsi Catarebuli kvlevebis Sedegad dadgenil iqna, rom wamebis mwvave Sedegebs Soris upiratesad gvxvdeba Semdegi darrvevebi Semdegi TanafardobiT : wamebis mwvave fizikuri Sedegebi fizikuri travma sul # 535 sixsire F kranialuri travma gonebis dakargvit Wriloba damwvroba mwvave sisxldena, hemoragia motexilobani da amovardnilobani gul sisxlzarrvta mwvave ukmarisoba travmuli Soki sasuntqi sistemis mxriv darrvevebi infeqciuri daavadebebi : TB,

70 fararati, mwave prostatiti da sxva. uro genitaluri sistemis mwvave dazianeba Tirkmlis dazianeba dajejiloba, hematoma nevrologiouri darrvevebi parezi, paralici, kruncxviti movlenebi da sxva okularuli sistemis mwvave dazianeba oto laringologiuri sistemis mwvave dazianeba rogorc mocemuli cxrilidan Cans, xsiria sxvadasxva organos mxriv sxvadasxva darrvevebi, rac upiratesad ukavsirdeba wamebis gamoyenebul metodebs, ase magalitad : yel yur cxviris sistemis dazianebatagan yvelaze xsiria dafis apkis dazianeba gaxetqva «telefonis» metodis gamoyenebisas. amgvari dazianebani upiratesad arwerili iqna patimrebsi. damwvroba Tavisi lokalizaciisa da formis mixedvit miutitebs gamoyenebul wamebis metodze; magalitad sigaretit damwvrobis kvali an utoti damwvrobis kvali da a.s. okularuli sitemis mxriv xsiria cemis Sedegad mxedvelobis mwvave mosla an baduris CamoSlis Sedegad ert an orive TvalSi mxedvelobis dakargva; Tirkmelebis saproeqcio aresi cemis Sedegad xsiria pasternackis dadebiti sindromis arseboba, hematuriit, Sardvis gazneleba an SexuTva. fizikuri cemis Sedegad sxvadasxva blagvi sagnebit TiTqmis yoveltvis gvxvdeba sxeulis sxvadasxva nawilis dajejiloba da sisxlnajrentebi, xsiria sxeulis universaluri dajejilobac. mwreli an mcxvletavi sagnit dazianebisas xsiria sxvadasxva aresi Wrilobebi; Zalzed xsirad, rogorc ukve iqna arnisnuli, gvxvdeba hemoraguli sindromi da travmuli Soki, rac dakavsirebulia cemastan an sxva saxis wamebis metodebis gamoyenebastan : motexilobebi, amovardnilobani an sxva Zlieri tkivilit gamowveuli Soki; arweril iqna SemTxvevebi kombinirebulad TavSi cemisa da eleqtro Sokis metodebis gamoyenebisas kruncxviti movlenebisa da gulyris ganvitarebisatvis, rac SemdgomSi Camoyalibebul iqna travmuli epilefsiis diagnozad; agretve arsanisnavia, rom xsiria eleqtrodenze SeerTebiT da airwinarit mogudvamoxrcobis kombinirebuli wamebis SemTxvevebi. wamebis mogvianebiti da qronikuli fizikuri Sedegebi wamebis gamoyenebuli metodebis mravalferovnebidan gamomdinare, fizikuri Sedegebic gamoirceva mravalferovnebit da xsirad ertsa da imave wamebis msxverpls arenisneba sxvadasxva organota sistemis mxriv darrvevebi. aqedan gamomdinare, xsirad ismeba kombinirebuli diagnozi (ramodenime ertdroulad) da diagnostiksatvis gamoiyeneba sxvadasxva metodi. amave dros, unda arinisnos, rom iseti zogadi xasiatis arahumanuri da araadamianuri mopyrobis metodebi, romelnic fartod aris danergili im qveynebis sapatimroebsi, sadac intensiurad gamoiyeneba wamebis praqtika, 70

71 aqveitebs organizmis reaqtiulobas an TviTonve xdeba calkeul qronikul daavadebata mizezi. amgvar pirobebs SesaZloa mivakutvnot : sanitarul higienuri pirobebis arqona da motxovnilebata dakmayofilebis xsiri SezRudva, rac sxvadasxva saxis infeqciuri daavadebebisa Tu kanis daavadebebis safuzveli xdeba; ase magalitad Cvens mier fartod iqna gamovlenili munis SemTxvevebi, aseve xsiria tuberkulozis am gzit gavrcelebis SemTxvevebi, romelsac xels uwyobs sakanta gadavsebuloba, rodesac ert 20 adgilian sakansi morigeobit szinavs 60 patimars; rara Tqma unda, amgvari situaciebi iwvevs agresiulobis zrdasa da Zaladobas TviTon patimrebs Sorisac ; sakansi xsirad ar arwevs dris sinatle, patimrebi ver xedaven mzes, aris gadawarbebuli sineste da a.s amgvar pirobebsi xangrzlivad moxvedrili pirovneba arc ert SemTxvevaSi ar rceba janmrteli da miuxedavad imisa, rom SesaZloa raime daavadeba mwvaved ar iqnas gamovlenili, amgvar pirobebsi moxvedrili adamiani cixidan gamosvlis Semdeg qronikulad xdeba daavadebuli, SeiZleba itqvas, rom misi TiTqmis yvela organo da organota sistema met naklebad gamosulia mwyobridan, iseve rogorc misi fsiqika. sxvadasxva sistemis mxriv gamovlenili dazianebebi : mxedvelobis sistema okularuli sistemis mxriv, rogorc arvnisnet, xsiria dazianebebi mwvave periodsi, Tumca es dazianebani ukuganvitarebas ganicdis; qronikul formebsi upiratesad gvxvdeba koniunqtivitebi, aseve SesaZloa mxedvelobis gauareseba. Tumca xsirad pacientebi ucivian TvalebSi gaorebas da akomodaciis darrvevas, okulistis konsultaciisa da gamokvlevis Semdeg nateli xdeba, rom aq organul dazianebas ara aqvs adgili. aset SemTxvevaSi unda vivaraudot, rom saqme gvaqvs egret wodebul «Soltis sindromtan», romelic SemdegSi iqneba arwerili. yel yur cxviris sistema yvelaze xsiria am SemTxvevaSi dafis apkis gaxetqva dazianeba, rac mizezi xdeba Cirqovani otitebisa da smenis qronikuli dazianebisa. otiti atarebs qronikul xasiats da mimdinareobs xsiri gamwvavebebit. xsiria Zgidis gamrudebis SemTxvevebi, rac xdeba cxvirit suntqvis gaznelebis, Zilis problemebis warmoqmnis mizezi. arsanisnavia aseve Tavbrusxvevis movlenebi. yovelive arnisnuli dazianeba dgindeba otolaringologis konsultaciis Sedegad. aucilebelia smenadobis gansazrvrisatvis timpanitometriuli da audiometriuli gamokvlevebis Catareba, aseve srulfasovani surdologiuri gamokvleva. im SemTxvevaSi Tuki adgili ara aqvs raime organul dazianebas, an nevrologiuri xasiatis dazianebas SesaZloa vivaraudot «Soltis sindromis» arseboba. 71

72 Kkbilebi vinaidan Zalzed xsirad gamoiyeneba cema saxis midamosi, xsiria kbilebis dazianebis SemTxvevebi, rac gamoixateba kbilebis amogdebasi, CalewvaSi; aseve unda arinisnos, rom arwerilia wamebis metodebi, rodesac gautkivarebis garese ara stomatologiuri da ara steriluri instrumentebit, magalitad «ploskogufcis»(brtyeltucas) an «gazis» mesveobit, xdeba kbilebis amoreba ; rac xsir SemTxvevaSi xdeba qronikuli infeqciis mizezi, vitardeba RrZilebis qronikuli anteba, kariesi, rasac xels uwyobs sanitarul higienuri pirobebis ar qona da normebis darrveva. amgvarad, TiTqmis yvela wamebis msxverpls arenisneba stomatologiuri problemebi, rac sawiroebs stomatologiur metvalyureobas mudmivad, da xsirad amgvari problema xdeba dispefsiur darrvevata mizezic. sasuntqi sistema respiratoruli daavadebebis mxriv zogadi reaqtiulobis daqveitebis fonze xsiria respiratoruli infeqciebi, adamiani xsirad civdeba, xsirad emarteba surdo, filtvebis anteba. aseve am TvalsazrisiT xsirad vxvdebit tuberkulozis SemTxvevebsac, ris gavrcelebasac ganapirobebs is araadamianuri pirobebi, romelsic wamebis msxverpli an zogagad patimari xvdeba, gansakutrebit ki iset cixeta sistemasi, romelic gavrcelebulia post sabwota qveynebsi. gul sisxlzarrvta sistema wamebis msxverplta Soris TiTqmis yoveli gadarcenili warmoadgens Civilebs gul sisxlzarrvta sistemis mxriv, rac metwilad fsiqo somaturi xasiatisaa da Sedegia gadatanili mzime stresisa an SesaZloa ganvixilot maskirebuli depresiis sindromsi, rac gansakutrebit nisandoblivia mamakacebsi. Tumca aucilebelia Catarebul iqnas srulfasovani kardiologiuri gamokvleva organuli dazianebis gamoricxvis miznit. gulsisxlzarrvta patologiis mxriv sakmaod gavrcelebulia iseti daavadebebis SemTxvevebi, rogoric aris hipertonuli daavadeba, aseve gulis qronikuli isemiuri daavadeba, miokardiodistrofia. amgvari daavadebebis ganvitarebasi mravali faqtori monawileobs da igi ert erti wamyvania xangrzlivad araadamianur pirobebsi, yovelgvari ukmarisobis pirobebsi adamianis yofnisas ganvitarebul sxvadasxva organota mxriv ganvitarebul qronikul disfunqciata Soris. Tumca arsebobs gavrcelebuli azric, rom gamokvleulta 72 % - Si 0% armoacnda organuli cvlilebebi gul sisxlzarrvta sistemis mxriv (Juler, Shmidt-Nielsen, 1995). amis gamo xsirad amgvar Civilebs miakutvneben «Soltis sindroms». kuw nawlavis sistema literaturul monacemebze dayrdnobit, gamokvleulta 70% warmoadgens Civilebs kuw nawlavis sistemis mxriv, Tumca amgvari 72

73 darrvevebi obieturi kvlevis Sedegad ar dasturdeba, mxolod gamokvleulta 30% arenisneba obieqturad dadasturebuli darrvevebi (Juler, Shmidt-Nielsen, 1995). upiratesad warmodgenilia wylulovani daavadebisatvis damaxasiatebeli Civilebi: tkivili epigastriumis midamosi, msieri tkivilis simptomi, boyini, gulisrevis SegrZneba, Tumca statistikurad gastroskopiuli gamokvleva mxolod 2 % - Si avlens darrvevebs. centri «empatia»s monacemebit, fartod aris warmodgenili gastritebi, dispepsiuri movlenebi, kolitebi, xsirad dgindeba disbaqteriozis diagnozic. infeqciur daavadebata Soris vlindeba qronikuli hepatitebi (gadatanili A hepatitis Sedegad) aris SemTxvevebi B da C hepatitebis diagnostirebisa. kuw nawlavis sistemis mxriv darrvevata ganvitarebis mnisvnelovan safuzvels rogorc gaxangrzlivebuli stresuli situacia, aseve araadmianuri yofiti pirobebi, ara kondiciuri kveba, usuftaoba da sxva faqtorebi warmoadgens. Sard sasqeso sistema gamokvleulta umravlesoba warmoadens am sistemata mxriv Civilebs. upiratesad amgvari darrvevebis mizezi xdeba cema Tirkmelebisa da muclis an welis aresi, seqsualuri Zaladoba, eleqtro Sokis gamoyeneba genitalur midamosi. centri empatia s monacemebit xsiria Tirkmelebis saproeqcio aresi tkivilebi, dadebiti pasternackis sindromit. Sardis laboratoruli gamokvlevisas dgindeba mikrohematuriis sindromi; eqoskopiuri gamokvlevisas armocenil iqna Tirkmlis dawevis sindromic, rac dakavsirebulia aseve cemastan. devnilta SemTxvevaSi metad xsirad iqna gamovlenili qronikuli prostatitebi mamakacebsi, seqsualuri da reproduqciuli unaris daqveitebit; aseve qalebsi qronikuli antebiti movlenebi Sard sasqeso sistemis mxriv; armocenil iqna sasvilosnos fibromiomis SemTxvevebi, romelic metad xsiria patimar qalta Soris, Tumca arnisnuli daavadebebis pirdapiri kavsiris dadgena wamebastan metad rtulia. xsiria sakvercxeebis qronikuli antebis klinikuri gamovlineba; metad xsirad patimar qalta Soris gamovlenil iqna dismenoreis SemTxvevebi; naadrevi klimaqsi; amgvari darrvevebi upiratesad SeiZleba mivakutvnot fsiqo somatur darvevata ricxvs. seqsualuri Zaladoba Tavis fsiqikuri Tu fizikuri komponentebit, usatuod iwvevs libidos daqveitebas, seqsualur disfunqciasa da urtiertobebis darrvevas. mamakacebsi gaupatiurebis Sedegad xsirad vitardeba swori nawlavis midamosi sxvadasxva saxis darrvevebi: naxetqebi, Wrilobebi; aseve xsiria yabzoba, nawlavuri disfunqciis movlenebi. zogadi monacemebit am sistemata disfunqciaze Civilebi Seadgens 10 %, Tumca monacemebi ar SeiZleba CaiTavlos zustad, vinaidan xsir SemTxvevaSi etnokulturuli Taviseburebebidan gamomdinare, xdeba gaupatiurebisa da seqsualuri Zaladobis Sesaxeb informaciis damalva wamebis msxverplis mxridan, es upiratesad gamovlenilia armosavletis kulturebsi, musulman 73

74 qalebsi. centri empatia -s monacemebit amgvari informaciis damalva gansakutrebit xdeba mamakacebsi; aseve es informacia imaleba arasrulwlovan wamebis msxverpl mamarobiti sqesis mamakacebsi, da xsirad amis Sesaxeb varaudit xvdeba eqimi klinikuri da paraklinikuri gamokvlevebis Sedegad; sakitxis dazusteba pacienttan moitxovs Zalze delikatur midgomas, Tavisufali arcevanis uflebisa da konfidencialobis aucilebel dacvas. simsivnuri daavadebani centri empatia s mier gansakutrebit qal patimrebsi arweril iqna simsivnuri daavadebebis ganvitarebis SemTxvevebi, gansakutrebit ki sasvilosnosa da mkerdis sxvadasxva saxis simsivnis saxit. anamnezuri monacemebit adgili hqonda cemas muclisa da mkerdis aresi; Tumca pirdapiri kavsirisa da kanonzomierebis dadgena, ra Tqma unda, amgvari mwiri gamokvleveit ar xerxdeba. unda arinisnos, rom mnisvnelovani iqneba am mimartulebit kvlevebis gaxsireba da gafartoeba. centraluri da periferiuli nervuli sistema samecniero literaturidan da Cvens mier Catarebuli kvlevebis Sedegad nateli gaxda, rom wamebis Sedegad Zalian xsirad vlindeba nevrologiuri darrvevebi, rac SeiZleba Sedegi iyos wamebis sxvadasxva metodebis gamoyenebisa, gansakutrebit ki iseti metodebisa, rogoric aris TavSi cema, eleqtrodenit wameba da a.s. zogierti mkvlevaris azrit 85 % SemTxvevaSi wamebis msxverplebs arenisnebat centraluri nervuli sistemis mxriv darrvevebi, aqedan TiTqmis naxevarsi es darrvevebi obieqturadac dasturdeba; centri empatia s monacemebit, ww. gamokvleul 535 wamebis msxverplta Soris 347 pirovnebas 65 % armoacnda klinikur paraklinikuri kvlevis Sedegad dadasturebuli c.n.s. darrveva. xolo c.n.s. funqciuri darrvevis nisnebi: Tavbrusxvevis, Tavis tkivilebis, Zilis darrvevis saxit, gamovlinda praqtikulad yvela SemTxvevaSi; aseve praqtikulad yvela SemTxvevaSi iqna gamovlenili periferiuli funqciuri moslilobani vegetatiuri disregulaciisa da tremoris saxit. yvelaze xsiria Civlebi garizianebadobisa da agznebadobis momatebaze, Tavis tkivilebze, Zilis darrvevaze, aseve yuradrebis koncentraciis unarisa da mexsierebis daqveitebaze, ganlevadobasa da advilad darlaze. diagnostikuri TvalsazrisiT yvelaze xsirad gavrcelebuli diagnozi qala tvinis travmis myari narceni movlenebia. paraklinikuri gamokvlevebis safuzvelze (Tvalis fskeris gamokvleva, CT, Ro grafia) gvxvdeba intrakranialuri hipertenziisatvis damaxasiatebeli gamovlinebani, aseve atrofiuli kerebi; rogorc ukve iqna arnisnuli eleqtrosokisa da TavSi cemis an mzime, rkinis sagnis Cartymis (magalitad otxkutxedi formis boqlomi) Sedegad rig SemTxvevebSi adgili aqvs konvulsiur sindroms, diagnostiredeba travmuli epilefsiis sindromi, romelic dasturdeba e.e.g. gamokvlevitac. 74

75 fizikuri wameba xsir SemTxvevaSi iwvevs periferiuli tipis darrvevebsac, rac iwvevs senso motorul disfunqcias. xsirad igi vlindeba mwreli an mcxvletavi sagnit miyenebuli Wrilobebisas, Camokidebisas, mizanmimartuli travmebis Sedegad. ZiriTadad pacienetebi ucivian nawilobriv parestezias, romelic mgrznobelobis daqveitebasi gamoixateba (Rasmussen, 1990). xsiria neirogenuli tkivilebis ganvitarebis SemTxvevebic. gansakutrebit ki samwvera nervis midamosi, aseve adgili aqvs xsir SemTxvevaSi sajdomi nervis qronikuli antebis ganvitarebasa da sxvadasxva saxis nevralgiebs, rasac ganapirobebs ara marto gegmazomieri dartymebi, aramed araadamianur pirobebsi yofna, sicive, sineste da a.s. Zalian xsiria radikulopatiebi. yovelive arnisnuli atarebs qronikul xasiats da sawiroebs periodul mkurnalobas, SesaZloa mteli sicocxlis manzilezec; aseve sayuradreboa, rom arnisnuli mdgomareobani SesaZloa periodulad gaumjobesdes mkurnalobis fonze; xsiria sezonuri gamwvavebebic. sayrden mamozravebeli sistema rogorc cnobilia, sayrden mamozravebeli sistema wamebis Sedegad mnisvnelovnad ziandeba. daniis wamebis msxverplta reabilitaciis saertasoriso sabwos monacemebis Tanaxmad, gamokvleul pacientta 90 % - Si arinisneba am sistemis mxriv Civilebi, romlebic (86 % - dan 74 % - Si) mtkicdeba obieqturadac (Juler, Shmidt-Nielsen, 1995); centri empatia s monacemebit, wlebsi gamokvleul 535 wamebis msxverplta Soris 20 % armoacnda obieqturad dadasturebuli Zval saxsrovani sistemis mxriv dazianeba, xolo Civilebs kuntebisa da saxsrebis qronikuli tkivilebis Sesaxeb warmoadgenda 89 %. aseve unda arinisnos, rom Cvens mier Catarebuli kvlevebis Sedegad upiratesad gamovlinda xerxemlis malebis motexilobebi da diskozebi an mankieri Sexorcebis Sedegad ganvitarebuli tkivilisa da mozraobis SezRudvis mdgonmareobani, rac xsir SemTxvevaSi gamowveuli iyo xerxemlis, gansakutrebit ki welis midamosi gegmazomieri dartymebit. gamovlenili iqna aseve muxlis saxsris dazianebebi, rac klinikurad tkivilsi, muxlis saxsris Sesivebasa da SewiTlebaSi, mozraobis SezRudvaSi vlindeboda. unda arinisnos, rom xsirad Zvalsaxsrovani sistemis mxriv darrvevebi Serwymulia nevralgiebtan, radikulopatiasa da sxva nevrologiur darrvevebtan. aseve arsanisnavia is garemoeba, rom TiTqmis yvela SemTxvevaSi pacients arenisneba fizikuri wamebis Sedegad qronikulad mimdinare tkivilis, dazabulobisa da darlilobis sindromi, gansakutrebit kisris, Tavisa da zeda kidurebis midamosi, Tumca xsirad igi vrceldeba mtels sxeulsi. amave dros, obieqturi dazianebis nisnebi wamebidan mogvianebit periodsi ar vlindeba. amgvari sindromi cnobilia Soltis sindromis saxelwodebit da warmoiqmneba gansakutrebit avtokatastrofebis dros horizontaluri dawimvis Sedegad. amgvari sindromi xsirad warmoiqmneba uknidan TavSi cemis Sedegad da misi qronikuli Sedegebi vlindeba sakmaod gamoxatul simptomokompleqssi, vinaidan ziandeba ara marto xerxemlis kisris midamo diskebita da myesebit, aramed aseve Tavis tvinisaken mimavali nervebi, sisxlzarrvebi da rbili qsovilebi. aqedan gamomdinare, kisris midamos tkivilebis garda, romelic xsiradd iradirdeba zemo kidurebsi, pacients arenisneba mxedvelobis daqveiteba, Tavbrusxveva, yurebsi Suilis SegrZneba, 75

76 Sakikis magvari Tavis tkivilebi, saxis nervta parestezia, kbilis tkivili, tkivili gulmkerdis aresi, gansakutrebit gulis aresi, kuw nawlavis sistemis mxriv darrevevebi da sxva. Tuki arnisnul simptomebs obieqturad dadasturebuli sxva safuzveli ar gaacniat, isini metyveleben Soltis sindromis Camoyalibebaze. kani xsirad Ria Wrilobebis Sedegad rceba nawiburebi da Sramebi, aseve xsiria nawiburebi miyenebuli damwvrobis Sedegad. magram unda arinisnos, rom xsirad araadamianur pirobebsi moxvedris Sedegad, vitardeba kanis qronikuli infeqciebi, romelnic xangrzliv mkurnalobas sawiroebs, isetebi rogoric aris piodermia; xsiria stresul niadagze da Secvlili reaqtiulobis fonze alergiuli dermatitebisa da neirodermitis ganvitarebis SemTxevebic. Cvens mier Seswavlil pacientta Soris, gansakutrebit ki arasrulwlovan patimrebsi,, armocenil iqna qronikuli piodermitebi, romelic ganvitarda xangrzlivad munit daavadebis SemTxvevebSi. endokrinuli sistema unda arinisnos, rom Cvens mier Catarebul kvlevebsi 535 wamebis msxverplidan 42 adamians (7 %) armoacnda endokrinuli darrvevebi. isini arnisnavdnen, rom msgavsi darrvevebi mat adre ar arenisnebodat; Cveni dakvirvebebit Zalzed xsiria wamebis Sedegad an wamebis processive sisxlsi glukozis donis momateba, rac SemdgomSi rig SemTxvevebSi yalibdeba Saqriani diabetis saxit; aseve gamovlenil iqna Tireotoqsikozis an farisebri jirkvlis funqcionirebis sxva darrvevebi, endokrinopatiuli simsuqne da sxva. Tumca Zalze Znelia zustad gansazrvro am darrvevata zusti mizez Sedegobrivi kavsiri wamebastan, SesaZloa vivaraudiot faruli formebis an midrekilebebis manifestireba wamebis Sedegad. fsiqo somaturi darrvevebi unda arinisnos, rom xsir SemTxvevebSi wamebis Sedegebi fsiqo somaturi warmosobisaa da miutitebs mzime da qronikuli stresuli situaciis Sedegad ganvitarebul somatizaciaze. centri empatias mier Catarebuli kvlevebis Sedegad fsiqosomatur simptomta Soris upiratesad fartod iqna gamovlenili somato vegetatiuri disregulaciis movlenebi: simptomuri hipertenziis, pulsis acqrebis, oflianobis, hipersalivaciis, libidos cvlilebis, madis moslisa da sxva gamovlinebata saxit, rac Serwymuli iyo xsirad c.n.s. funqciur darrvevebtan Tavbrusxvevis, koordinaciis moslis, Zilis darrvevis, Tavis tkivilebis saxit. wamebis msxverpl qalta Soris specifiurad gamovlinda dismenorea da naadrevi klimaqsi, xolo bavsvebsa da mozardebsi funqciuri enurezis SemTxvevebi. xsirad amave tipis aslilobebs SesaZloa mivakutvnot kuw nawlavis sistemis mxriv gamovlenili darrvevebi, romelnic upiratesad yabzobis, an piriqit, xsiri diareebis saxit iqna gamovlenili. 76

77 Tavi IV. diagnostika da eqspertiza rogorc ukve iqna arwerili, wamebis fizikuri Tu fsiqikuri Sedegebi SesaZloa gamoirceodes mravalferovnebit, rac safuzveli xdeba diagnostikisatvis mravali metodis gamoyenebisa. pirveladi interviu metad sayuradreboa wamebis msxverpltan intervius dros Semdegi principebis dacva, rata SeZlebisdagvarad wamebis msxverpls SeuqmnaT usafrtxo garemo da movipovot misi ndoba: konfidencialobis principis sruli dacva motxovnis SemTxvevaSi anonimurobis sruli dacva profesiuli damoukidebloba da miukerzoebloba informirebuli Tanxmoba piveladi intervius Catarebisas, mtavari mizania urtiertndobaze dafuznebuli kontaqtis damyareba. amisatvis aucilebelia wamebis msxverpls zedmiwevnit aexsnas gamokvlevis gegma, metodebi, momsaxurebis saxeebi da mosalodneli SesaZlo Sedegebi. wamyvani sakitxi wamebis msxverplis gamokvlevisas da gansakutrebit ki pirveladi intervius Catarebisas aris SeZlebisdagvarad usafrtxo garemos Seqmna; am miznit aucilebelia, rom interviu Tu samedicino gamokvleva mimdinareobdes konfidencialurad, mxedvelobisa da smeniti distanciis aris mirma, yovelgvari samartaldamcavi struqturebis warmomadgenelta Tu ucxo pirta garese. usafrtxo garemos Seqmna im qveynebsi, sadac wamebis praqtikas aqvs adgili, met naklebad Znelia. rara Tqma unda, amgvari garemos Seqmna policiis izolatorsi, sadac wamebas hqonda adgili, Zalzed Znelia. amitom samedicino intervius dros eqimma unda moitxovos sruli konfidenciuroba, da Tuki ar arsebobs patimris Tanxmoba an situaciis Sefasebisas usafrtxoebis garantiebi ver moizebneba, Tavi unda Seikavos yovelgvari komentarisagan da sagamomzieblo organoebs unda ganucxados, rom isini werilobit daskvnas miireben mxolod oficialuri momartvis Semdeg da, patimris Tanxmobis SemTxvevaSi, igi mogvianebit gaegzavnebat. samedicino gamokvlevebi da eqspertiza unda mimdinareobdes samedicino dawesebulebasi, sadac pacienti met-naklebad usafrtxod igrznobs Tavs, Tumca totalitaruli rejimebis pirobebsi wamebis msxverpli wamebis praqtikis mqone qveyanasi yoveltvis daucvelad grznobs Tavs. aseve sayuradreboa, rom wamebis Sesaxeb detaluri informaciis misarebad erti viziti SesaZloa sakmarisi ar iyos, unda iqnas gatvaliswinebuli wamebis saxe da etnokulturuli Taviseburebanic, ase magalitad gaupatiurebis SemTxvevaSi, xsirad wamebis msxverplebs ar surt am Temaze saubari da gaxmaureba, isini moitxoven am faqtis damalvas ojaxis wevrebisganac. amisatvis Terapevts, romelic usualo kontaqtsi imyofeba wamebis msxverpltan, unda hqondes mosmenis unari da motmineba, rata pacientma SeZlos bolomde gaxsna da, amave dros, ar iqnas ganmeorebit travmirebuli. 77

78 Zalze mnisvnelovania wamebis msxverplisatvis mxardamweri garemos Seqmna. Aam TvalsazrisiT aucilebelia gamomkitxvelis sworad SerCeva, genderuli faqtorebis, asakis, etnikuri faqtorebis, piradi istoriisa da sxva faqtorebis gatvaliswinebit. ase magalitad seqsualuri wamebis SemTxvevaSi Tiki msxverplia qalia, umjobesia gamomkitxveli iyos qali. Aseve unda arinisnos, rom mxardamweri garemos SeqmnaSi SeasaZloa didi roli Seasrulos ojaxis wevrma, advokatma, uflebata damcvelma, me4gobarma an Tarjimanma. Didi mnisvnelopba eniweba TarjimnebTan musaobas: gamokitxvis dros Tarjimnebi SesaZloa kritikuli monawileebi iyvnen, isini ar arian `carieli kedeli. Tarjimnebma SesaZloa gamomkitxvels daxmareba gauwion rogorc kulturis sakitxebis `mrcevlebma Tarjimnebi wamebagadataniltatvis unda iyvnen ndobis armzvrelebi, ar iwvevdnen sircxvils, akmayofilebnen gamomkitxveltan dakavsirebuli kriteriumebis msgavs kriteriumebs. Tarjimnebs SesaZlo hqondet gamomkitxvelebis msgavsi reaqciebi, mat Soris kontr-transferensi da iribad gadacemadi travmatizacia.. isini - Tu SesaZlebelia - uzrunvelyofil unda iyvnen treningit, daxmareba-zrunvita da metvalyureobit. ukidures SemTxvevaSi Tarjimans unda Cautardes instruqtaji gamokitxvebamde, xolo gamokitxvis Semdeg Cautardes `gamokitxva. damxmareta mimart undobloba, rac xsirad nisandoblivia wamebis msxverplisatvis SesaZloa gamowveuli iyos Semdegi mizezebit: wamebasi monawile eqimebi an daxmarebis sferos sxva eqspertebi damxmaris gaurkveveli funqcia gaurkvevelia konfidencialobis sakitxi devnis Semdgomi reaqtiuli paranoia fsiqiatriuli/fsiqologiuri stigmatizacia gansxvavebuli/ igive etnikuri/politikuri/genderuli jgufi warmatebuli gamokitxvisatvis Zalze mnisvnelovania SeZlebisdagvarad pozitiuri garemos Seqmna, romelic ar iqneba msgavsi dakitxvisa an sasamartlo procesisa da Tavisi konstruqciita da manerit ar moagonebs msxverpls amgvar procedurebs. Aamgvarad, gamokitxvisas aucilebelia megobruli garemos Semna, romlis mokle sakontrolo CamonaTvali Semdegia: garkveuli da saimedo informaciis micema, kitxvebis dasmisa da ewvebis gamotqmisatvis drois micema, aslilobis mauwyebel signalebis (disociacia, dazabuloba, oflianoba, mousvenroba) amocnoba da `usityvo enis (araverbaluri komunikacia) codna, ususurobis SegrZnebis gamwvavebis Tavis arideba wamebagadatanilebsi, kontrolirebadoba: wamebagamovlili unda imyofebodes adeqvaturi kontrolis qves kritikul momentebsi, manzilis uzrunvelyofis miznit Sesaferisi zomis otaxi, droisa da usafrtxoebis signalebis mnisvneloba. 78

79 gamoavlinet iseti situaciebi da obieqtebi, romlebic iwveven Zalian intensiur mogonebebs, gaecanit fsiqologiur faqtorebs urtiertqmedebis dros, mat Soris kontr-transfersis reaqciebs, uzrunvelyavit sakmarisi dro yvela saxis gamokitxvisatvis, Tu sawiroa, dayavit ufro mokle gamokitxvebad, daasrulet gamokitxva misarebi an pozitiuri saxis gancxadebit, SeqmeniT pozitiuri garemo gamomkitxvelisatvis. ariaret Tqveni sakutari dazabuloba an arakomfortulobis SegrZneba. miendet Tqvens sxeuls. Tavi aaridet gadawvas. U unda arinisnos, rom `umtkivneulo samedicino procedurebma SesaZloa warmoqmnas wamebis Sesaxeb mogonebebi. magalitebi: eleqtrokardiologiurma eleqtrodebma SesaZloa gamoiwvios denit wamebis mogonebebi, Semowmebis miznit fexebis gaweva warmoqmnis gaupatiurebastan dakavsirebul mogonebebs, gastroskopia an kbilebis mkurnaloba iwvevs oraluri gaupatiurebis mogonebebs. Semowmebis an fizioterapiis dros mklavis mozraobam SesaZloa gamoiwvios warsulsi gadatana (arasasurveli mogonebebi). Uunda arinisnos, rom Tu intervius Catareba ganxorcielda kargad da satanado pirobebsi, Semowmebam an gamokitxvam SesaZlebelia gaaumjobesos fsiqiologiuri mdgomareoba da iqonios Terapiuli efeqti (Tumca ver Secvlis SemdgomSi aucilebel mkurnalobas), rac SeiZleba SemdegSi gamoixatos: mogonebebtan da situaciebtan martvadi (xsirad TandaTanobiTi) brzolit, fsiqologiuri wamebis an wamebagadatanilis TviTdanaSaulis grzonobebis Sedegad warmoqmnili damaxinjebuli faqtebis garkveva da dabneulobis dazleva, damnasavis winaarmdeg Cvenebis micemita da fragmentuli mogonebebis srulad ardgenit warmodgenis Seqmna. amis Sedegad wamebagadatanili xelaxla rwmundeba Tavis socialur statussa da RirebulebebSi. faqtorebi, romlebic gavlenas axdens gamomkitxvelisa da wamebagamovlilis urtiertobaze, SeiZleba sruliad SemTxveviT gaxdes SesamCnevi an saertod gamorcenili iqnas mxedvelobidan. magram gamocdili gamomkitxveli gulmodgined unda daakvirdes aset faqtorebs, rom mati daxmarebit miiros damatebiti informacia.. es faqtorebi gavlenas axdenen gamokitxvaze gaucnobiereblad da umartavad, aman SeiZleba ganapirobos gamokitxvis dabali xarisxi, mnisvnelovani informaciis dakargva, brzola, da gadawva. 79

80 magalitiebi: transferi kontr-transferi proeqciuli identifikacia saidumloze dafuznebuli urtiertobani gamokitxvis fsiqo dinamiuri faqtorebidan arsanisnavia: kontr-transferis reaqcia. amjamad arsebuli gagebit eqimsi/ gamomkitxvelsi gamowveuli yvela emociuri reaqcia, asaxavs rogorc wamebagadatanilis/klientis, aseve eqimi/gamomkitxvelis (an sxva damswreebis, magalitad Tarjimnebis) personalur fsiqologiur istorias (mat Soris `mexsierebidan amovardnili momentebi ). grznobebis martva aset SemTxvevaSi umnisvnelovanesia: gaerkviet Tqvens grznobebsi, magram nacqarevad nu moaxdent reagirebas, Tqvenma grznobam SesaZloa gagaxsenot wamebis mteli procesi - msxverplis damokidebuleba, wamebaze damkvirvebeli, an jalati da sxva. gadatanis reaqcia: pacientsi arsebuli yvela emociuri reagirebisa da qcevis saxeebi, mat Soris adre gancdili momentiebidan (magalitad wamebidan) awmyo drosi `gadmotanili emociebi da reaqciebi. SemTxvevis magalitebi: msxverplis dakitxvisas jalatis mimart gamovlenili risxva an uaryofiti damokidebuleba axla mimartulia gamomkitxvelis mimart. gamomkitxveli Riziandeba, mas xom daxmareba surs.. saidumloze dafuznebuli urtiertobani utyvi da xsirad gaucnobierebeli `SeTanxmeba msxverplsa da gamomkitxvels/eqims Soris arasasaimovno an safrtxilo momentebis Tavidan acilebis Sesaxeb. es amcirebs gansaxilveli sawirboroto sakitxebis ricxvs, magram icavs msxverpls xelaxali travmirebisagan, an sxva pirs travmirebisagan. magalitebi: gamomkitxvelma Tavad gadaitana omis travma da SeiZleba moeridos am sakitxis wamowras gamokitxvis dros, Tavis omisdroindeli mogonebebis SiSiT. am dros ikargeba mnisvnelovani informacia. martva: ezie daxmareba, gaerkvie sakutari SiSis grznobasi da gadatanil mtkivneul warsulsi ( mexsirebidan amovardnili momentebi ). mnisvnelovan informacias wamebagadataniltatvis warmoadgens Semdegi axsna ganmartebani, rom zogierti simptomis armoceneba normaluri reaqciaa. zogierti simptomi arinisneba wamebagadatanilta umravlesobis SemTxvevaSi. simptomebi, xsirad asaxaven wamebis gadatanis strategiebs, da aset SemTxvevaSi xdebian `megobrebi simptomebi aseve SesaZloa asaxavdes damnasavis ganzraxvas. 80

81 araadeqvaturi an Zalian Zlieri sircxvilis an danasaulis grznoba Cveulebrivi movlenaa da unda iqnes dazleuli megobrebisagan yuradrebasa da mxardaweras da saubars Sesaferis pirobebsi SeuZlia daxmareba, bevri simptomi SeiZleba dazleuli iqnas. gamokitxvisas da zogadad dagnostkis dros yuradreba unda daetmos egret wodebuli arapirdapiri travmirebis movlenebs. zegavlena matze, romlebic kavsirsi arian wamegadatanilebtan. mat gamocdilebastan an wamebis damswreebtan moicavs: damxmareebs, da mat vinc awarmoebs gamokitxvas: ojaxis wevrebs da natesavebs, mat Soris sayuradreboa, meore da mesame Taobis fenomeni (travma) _ uxesi Zaladobis gavlena SesaZloa iseti mwvave iyos, rom bavsvebs _ da SviliSvilebsac ki SesaZloa ganuvitardet travmis gansakutrebuli saxis simptomebi. rasi SeiZleba gamovlindes es problemebi da ra unda iqnas gaketebuli: damxmareebi, gamomkitxvelebi: stresis gavlena, kontr-tranferis reaqcia, `daqanculoba (gadawva xangrzlivi kontaqtis Sedegad: gadarlilobis SegrZneba, garizianebadoba, cinikuroba, partnioruli problemebis warmoqmna), sxvadasxva simptomebis gamovlena. ra unda gaketdes: SemuSavdes stresis martvis strategiebi, gamoyenebuli iqnas supervizia an jgufis mxardawera Tqven da Tqveni ojaxis janmrteloba da gamokitxvis xarisxi damokidebulia imaze, Tu rogor dazlevt am problemebs. ojaxi: SesaZloa sawiro gaxdes daxmareba imisatvis, rom gagebuli da dazleuli iqnas wamebagadatanilis problemebi. (Thomas Wenzel, WPA, 2004). zemot moyvanilidan gamomdinare, aucilebelia arinisnos, rom wamebis msxverplis samedicino fsiqologiuri eqspertizis SemTxvevaSi, sakitxi unda dadges reabilitaciis Sesaxebac, vinaidan pacientma miiros pozitiuri stimuli da daxmareba, aucilebelia saeqsperto daskvna moicavdes rekomendaciebsac da pacients mieces informacia, Tu sad SeuZlia daxmarebis mireba, amave dros, unda iqnas ganmartebuli, rom saeqsperto daskvna mas moexmareba sasamartlo davis gadawyvetasa da wamebis mtkicebulebebis dokumentirebasi. Zalze mnisvnelovania wamebis msxverplis zusti diagnostireba. amas mnisvneloba aqvs rogorc swori mkurnalobisa da reabilitaciis gegmis Sedgenisa da CatarebisaTvis, aseve eqspertizisa da sasamartlostvisac. rogorc zemot araertxel iqna moyvanili, wamebis Sedegebi gamoirceva mravalferovnebit da moicavs rogorc fizikur, aseve fsiqikur komponentsac, amis gatvaliswinebit eqspertiza, iseve rogorc samedicino diagnostika, Catarebul unda iqnas specialistta multidisciplinuri jgufis mier; aucilebelia massi monawileobdes rogorc zogadi profilis Terapevti, aseve fsiqiatri, nevrologi, travmatologi, fsiqologi, da klinikur simptomta analizis gatvaliswinebit _ sxva calkeuli dargis 81

82 specialistebi: kardiologi, stomatologi, otolaringologi, ginekologi da sxva; sasamartlo samedicino eqspertizis Catarebisas igive jgufs unda daematos sasamartlo eqspertebic. Sesabamisad, paraklinikuri gamokvlevebi aseve gamoirceva mravalprofilurobit da amgvari gamokvlevebis gegmas ertad adgens SemTxevis mmartvelis TaosnobiT specialistta multidisciplinuri jgufi. amgvarad, diagnostika moicavs: pirvelad intervius klinikur gamokvlevas, romelsac, rogorc ukve iqna arwerili, atarebs specialistta multidisciplinuri jgufi. igi moicavs garegnul datvalierebas, klinikur gasinjvas sxvadasxva specialistta mier, pacientis komentarebis Sesabamisad cal calke unda iqnas ganxiluli adrindeli dazianebebis mdebareoba da gamomwvevi mizezebi da is dazianebebi, romelic pacientis mier ariwereba, rogorc wamebis Sedegebi; klinikuri gamokvleva Terapiuli da sxva specialistta konsultaciebis garda unda moicavdes pacientis fsiqikur statuss da aseve nevrologiur statuss; fsiqikuri statusis arwerisas sayuradreboa fsiqologiuri gamokvlevis Sedegebis CarTvac; kitxvarebisa da Sefasebis Skalebis gamoyeneba: klinikur diagnozta umravlesoba, gansakutrebit afeqturi aslilobebisa da ptsa-s diagnozi, SeiZleba daisvas klinikuri gamokitxvebisa da gamokvlevis safuzvelze, magram SesaZloa sasargeblo armocndes satanado TviTSefaseba an Semfaseblis mier Catarebuli gamokitxvebi an aucileblobis SemTxvevaSi, Tu gamoyenebul unda iqnas obieqturi an damatebiti sasualebebi, mosalodnelia skriningis Catareba, an unda Sefasdes xangrzlivi kursi. gamoyenebulma sasualebebma unda asaxos Zlieri travmis gamomwvev stresgadatanili adamianebis enisa da wera-kitxvis codna, kultura da matsi gamovlenili somaturi da fsiqiatriuli aslilobebisa da reaqciebis SeTavsebadoba. struqturuli klinikuri gamokitxvebi: fsiqiatriul aslilobebtan dakavsirebuli struqturuli da naxevrad struqturuli gamokitxvebi SeiZleba daexmaros gamomkitxvels gaecnos diagnostikur kategoriebs da warmoadginos kvlavwarmoebiti standarti ganmeorebiti testirebis Sedegebis satanado mdgradobit. CamoTvlili sasualebebi damtkicebulia mraval enaze da ganixileba, rogorc `oqros standartebi~. yvela exeba posttravmul stresul aslilobas. SezRudvebi: zogierti asliloba ar aris ganxiluli; orientacia kvlevazea; kvlevis sasualebebi ar unda iyos 82

83 sazogadoebisatvis miurebeli; sawiroa treningi. arnisnuli sasualebebi aseve sicocxlisndeli diagnozis dasmis SesaZleblobas izleva! (xangrzlivi retrospeqtuli Sefaseba). yuradreba gamaxvilebulia aslilobebze; sxva Sedegebi ar aris ganxiluli; aranairi kompleqsuri ptsa. SCID (struqturuli klinikuri gamokitxva DSM-IV Tan dakavsirebit): DSM IV, gamocdili SemfaseblebisaTvis. CIDI (kompozituri saertasoriso diagnostikuri gamokitxva): ICD 10, DSM IV, naklebad gamocdili Semfaseblebisa da epidemiologiuri kvlevebisatvis. SCAN (klinikuri Sefasebis Skalebi neirofsiqiatriasi): ICD 10, DSM IV. PSE 10 dayrdnobit, gamocdili SemfaseblebisaTvis. CAPS (klinicistis mier gamosayenebeli ptsa Skala) satanadod damtkicebuli ptsa-s Sesafasebeli sasualeba (aseve, mravali travmis an patimrobis Semdeg, da xangrzlivi kursisatvis) moicavs `kompleqsur~ ptsa-tan dakavsirebul nawils (`Tanmxlebi simptomebi~). SeniSvna: DSM IV-is safuzvelze. travmis Sefasebis harvardis kitxvari (HTQ): zogierti nawili, mat Soris movlenebisagan, Tavis tvinis travmisagan, zogadi ptsa-s Tanmxlebi simptomebisagan. sayuradreboa aseve sxva Skalebis arsebobac., romlebic fartyos gamoiyeneba kvlevebisatvis: ptsa Sefasebis vatsonis kitxvari, misisipis ptsa Sefasebis kitxvarebi da sxva. fsiqologiuri gamokvleva SesaZloa mimdinareobdes sxvadsaxva subieqturi da obieqturi kitxvarebis gamoyenebit; amisatvis xsirad gamoiyeneba posttravmuli stresuli aslilobis simptomta Sefasebis sxvadasxva kitxvari, romelnic zevit iqna moyvanili. aseve depresiisa da SfoTvis Skalebi, agresiisa da pirovnuli profilis Semswavleli testebi, mnisvnelovania proeqciuli testebis gamoyenebac, magalitad, bavsvebsi xelis testis; rezidualuri da klinikurad Znelad gamosavleni Tavis qalas travmebis narceni movlenebis gamosavlenad xsirad gamoiyeneba neirofsiqologiuri testebi. ptsa diagnostikis sxva specialuri metodebi Cveulebriv ar arsebobs an ar aris aucilebeli, da SeiZleba sawiro gaxdes mxolod gansakutrebul SemTxvevebSi. magalitebi: qcevaze orientirebuli fsiqofiziologiuri da vizualizaciis metodebi. Cveulebriv ar aris aucilebeli, SeiZleba gamoyenebul iqnas gansakutrebul SemTxvevebSi (mtrulad ganwyobili sasamartlo, Sedegebi sakamatoa); xsirad dafinanseba rtulia; moaridet pacients stresi; mkurnaloba unda 83

84 Catardes da integrirebul iqnas diagnostikasi. SPECT, PET, energetikul speqtraluri ECG, pupilometria. kanis galvanuri reagireba, sxva periferiuli macveneblebi. sruli anamnezuri monacemebis Segroveba, rogorc wamebamde periodze, aseve wamebis faqtebtan dakavsirebit da wamebis Semdgom periodtan dakavsirebit; anamnezi unda moicavdes informacias yvela gadatanili daavadebis Sesaxeb wamebamde, aseve im daavadebebisa Tu dazianebebis Sesaxeb, rac wamebis Sedegad ganvitarda; wamebis istoria SeZlebisdagvarad detalurad unda moicavdes informacias Tu sad, vis mier, rodis da ra metodebit iqna nawamebi adamiani, aucilebelia misive frazebi iqnas moyvanili am istoriis arwerisas. laboratoriuli da instrumentuli kvlevebi, iseti, rogoric aris Tavis qalas encefalografia, gansakuteebit ki gulyriti movlenebis SemTxvevaSi; komputeruli tomografia, rodesac pacienti acxadebs, rom adgili hqonda TavSi cemas, gonebis dakargvit, rentgenologiuri gamokvleva, sxvadasxva organota eqoskenireba, kardiografia da sxva kardiologiuri sfecifikuri gamokvlevebi, ginekologiuri gamokvlevebis Catareba mnisvnelovani xdeba gaupatiurebis da sxva sasqeso organoebis dazianebis dros. gansakutrebuli mnisvnmeloba unda mieniwos Tavis tvinis travmis diagnostikas, rac moicavs Semdeg komponentebs: klinikuri gamokitxva, SeiZleba monawileoba miiron natesavebma an megobrebma, radgan wamebagadatanilma adamianma SeiZleba ver SeamCnios garkveuli cvlilebebi qcevasi an funqcionirebasi, wamebis Semdeg. neirofsiqologiuri testirebas, eleqtro encefalografias (EEG), radio vizualizaciis metodebis gamoyenebas: : - rentgeni, otoskanireba - CAT (tomograma) - NMR (vizualizacia birtvul-magnituri rezonansis metodit) neirofsiqologiuri testireba miuxedavad imisa, rom mxedvelobasi unda iqnas mirebuli stambolis protokolsi xsenebuli SezRudvebi, neirofsiqologiuri testireba warmoadgens saertasorisod ariarebul standartul proceduras Tavis tvinis travmis mravali formis diagnostikasi, romlis ganxorcielebac SesaZloa rtuli iyos umetes situaciebsi (rogoricaa cixe). aseve gatvaliswinebul unda iqnas, rom wamebis dros miyenebuli Tavis tvinis travma SeiZleba atipiuri iyos da, rom standartuli diagnostikuri procedurebis gamoyenebit SeiZleba ar gamovlindes iseti metodebit 84

85 miyenebuli dazianeba, rogoricaa `submarino~ (gudva). dazianebis nebismieri forma SeiZleba gamovlindes gansakutrebit difuzuri Tavis tvinis travmis Semdeg, romelic aseve arsebobs fokaluri travmebis dros. testireba SeiZleba iyos stresuli (wamebis gaxseneba) an SezRuduli enisa da kulturuli faqtorebis gamo. mini fsiqikuri statusi: mini fsiqikuri statusi warmoadgens kognitiuri funqciis, Sefasebis gavrcelebul, araspecifikur da SezRudul sasualebas. zogierti SekiTxva SeiZleba ar Seesabamebodes kulturul an socialur fons. SeiZleba gamoyenebul iqnas ufro Zlieri darrvevis miaxloebiti diagnozis misarebad. Zlieri darrvevis SemTxvevaSi, adekvaturi gamokitxva SeiZleba rtuli armocndes da aset dros, Tavis tvinis travma yvelaze Cveulebriv ganmartebas izleva. glasgos komis Skala (GCS) GCS Sefaseba xdeba 3-15 qulebit, romeltagan 3 aris yvelaze cudi Sefaseba, xolo 15 yvelaze kargi. is sami parametrisagan Sedgeba: sauketeso mxedvelobiti reaqcia, sauketeso verbaluri reaqcia, saukteso motoruli reaqcia, rogorc es mocemulia qvemot: sauketeso mxedvelobiti reaqcia (4) Tvalis saertod ar gaxela. Tvalis gaxela tkivilis dros. Tvalis gaxela verbalur brzanebaze. Tvalis gaxela spontanurad. sauketeso verbaluri reaqcia (5) aranairi verbaluri reaqcia gaurkveveli xmebi. uadgilo sityvebi. areuli. orientirebuli. sauketeso motoruli reaqcia (6) aranairi motoruli reaqcia. reagireba tkivilze. mozraoba tkivilze. tkivilisatvis Tavis arideba. tkivilis lokalizeba. emorcileba brzanebebs. Sefaseba xdeba, rogorc magalitad - E4V4M6 = GCS 14. komis 13 quliani an ufro marali Sefaseba Seesabameba Tavis tvinis msubuq travmas, 9-12 sasualos, xolo 8 da naklebi Tavis tvinis Zlier travmul dazianebas. uaryofiti Sedegi SesaZloa ar gamoricxavdes Tavis tvinis difuzur travmas, radgan mikro-dazianebebi zogjer SeiZleba rtuli 85

86 armosaceni iyos NMR vizualizaciis drosac ki (vizualizacia birtvul-magnituri rezonansis safuzvelze). subduraluri hematoma gaitvaliswinet SesaZlo mnisvnelovani dazianebis Sedegebi, gansakutrebit subduraluri hematoma, ramac SeiZleba ara mxolod zemoqmedeba moaxdinos gamokitxvaze, aramed moitxovos gadaudebeli daxmareba. (Thomas Wenzel, WPA, 2004). dokumentacia wamebis mtkicebulebebis mirebisatvis da misi Sedegebis armofxvrisatvis mnisvnelovani roli eniweba samedicino dokumentaciis srulad da sworad Sedgenasa da momzadebas. gansakutrebit mnisvnelovania wamebis msxverplis pirveladi samedicino Semowmebis monacemebi. amgvarad, im eqimta pirveladi Semowmebis daskvnas, romeltac pirveladi Sexeba aqvt wamebis riskis jgufebtan, gansakutrebuli roli eniweba. eqimta amgvar kategorias pivel rigsi ganekutvnebian cixis eqimebi, vinaidan mat aqvt pirveladi Sexeba policiidan Semosul patimrebtan. CPT rekomendaciis Tanaxmad, yoveli patimari cixesi SesvlisTanave da SemdgomSi yoveltvis, adgilis cvlilebisas, unda iqnas gasinjuli eqimis mier, unda Cautardes piveladi samedicino gamokvleva. rekomendaciebis Sesabamisad amgvari gamokvleva unda tardebodes mkacrad konfidecialurad da sxva pirebisatvis smeniti distanciis mirma, aseve mxedvelobiti distanciis mirma im SemTxvevebis garda, Tuki metvalyureobas ar itxovs eqimi. aseve unda arinisnos, rom pirveladi samedicino SemowmebisaTvis saxelmzrvanelo principebad SesaZloa gamoyenebul iqnas stambolis protokolis principebi, romelic warmoadgens saxelmzrvanelo principebs wamebis msxverplis eqspertizisatvis. ras unda moicavdes pirveladi samedicino dakvna? daskvnasi unda iqnas mititebuli gamosakvlevi piris monacemebi; unda iqnas mititebuli Tu vis mier da sad tardeba pirveladi samedicino Semowmeba; SeZlebisdagvarad unda iqnas arwerili otaxi, ganateba da sxva sayuradrebo detalebi, sadac tardeba gamokvleva; aucileblad unda iqnas mititebuli Tu vin eswreba gamokvlevas; arsebobs Tu ara raime saxis zewola an SezRudva pirveladi samedicino Semowmebis Catarebisas; dakvna unda moicavdes fizikuri da fsiqikuri klinikuri gasinjvis monacemebs ; detalurad unda iqnas arwerili yoveli dazianeba, rac sxeulis garegnuli datavlierebit vlindeba, mati feri, 86

87 formebi, zomebi, aseve palpatoruli gasinjvis monacemebi, mtkivneuloba da a.s. aseve detalurad klinikuri gasinjvisas unda iqnas arwerili Sinagani organoebis mdgomareoba; unda ariweros fsiqikuri statusi; aseve nevrologiuri statusi; aucilebelia ariweros gamosakvlevi piris Civilebi misi janmrtelobis mdgomareobis Sesaxeb da detaluri komentarebi yovelgvar xilul Tu uxilav darrvevastan dakavsirebit; aucilebelia gaketebul iqnas samedicino daskvna savaraudo an sindromuli diagnozis mititebit; da Sesabamisi rekomendaciebit: Tu ra saxis specialistta konsultaciebia sawiro, ra saxis gamokvlevebia sawiro da ra saxis pirveladi daxmareba an Semdgomi daxmareba aris mizansewonili; amgvari daskvna unda moicavdes specialur rekomendaciebsac, magalitad gansakutrebuli yuradrebis Sesaxeb suicidaluri tendenciebis gamovlenis SemTxvevaSi; daskvna aseve unda moicavdes pirveladi daxmarebis RonisZiebebsac, Tuki amgvari Cautarda gamosakvlev pirs; aucielebelia amgvari daskvna gaecnos TviTon gamosakvlev pirs an mis warmomadgenels da dafiqsirebul iqnas mati komentarebic; daskvnas aucileblad xels unda awerdes gamokvlevis Camtarebeli eqimi da unda iqnas dafiqsirebuli gamokvlevis TariRi da dro; aucileblobisa da sawiroebis SemTxvevaSi cixis eqims unda hqondes sasuleba gamoizaxos sxva specialobis eqimi konsultanti an moitxovos saswrafod raime saxis gamokvleva, an gamosakvlevi pirisatvis stacionaruli mkurnaloba, an sxva saxis gadaudebeli daxmareba; aseve, gamosakvlevi piris Tanxmobis SemTxvevaSi, samedicino eqspertizis Catareba qveynis kanonmdeblobis gatvaliswinebit. aseve aucilebelia moxdes yovelgvari dazianebis fotografireba da SesaZloa diqtofonze gaketdes audio Canaweri (gamosakvlevi piris Tanxmobis SemTxvevaSi). aqve unda arinisnos, rom specialurad samedicino eqspertizisatvis mowodebulia stambolis protokolis principebi, romlis mixedvitac standartuli gamokvlevis sqema Semdegia: 87

88 danarti IV wamebisa da sastiki mopyrobis mimart samedicino eqspertizis Catarebis saxelmzrvanelo principebi qvemot moyvanili saxelmzrvanelo principebi wamebisa da sastiki, araadamianuri an adamianis Rirsebis Semlaxavi mopyrobisa da dasjis efeqtiani gamokvlevisa da dokumentirebis principebis saxelmzrvanelos efuzneba (stambulis oqmi). es principebi uryev mititebas ar nisnavs da mati gamoyeneba, eqspertizis miznebidan gamomdinare, arsebuli sasualebebis Sefasebis Semdegaa SesaZlebeli. wamebisa da sastiki mopyrobis fizikuri da fsiqologiuri mkicebulebebis eqspertiza SeiZleba Caataros, mati kvalifikaciidan gamomdinare, ertma an ramdenime eqimma. I. informacia gamosakvlev SemTxvevaze gamokvlevis TariRi: Catarebulia motxovnit (gvari/tanamdeboba): avadmyofobis istoria/angarisi #: gamokvlevis xangrzlivoba st. wt. gamosakvlevis saxeli: dabadebis TariRi: dabadebis adgili: gamosakvlevis gvari: - sqesi: mamr./mdedr. gamokvlevis Catarebis mizani: gamosakvlevis saidentifikacio # (ИН): eqimis gvari: Tarjimnis monawileobit (diax/ara), gvari: warmodgenili informaciis safuzvelze Tanxmoba mirebulia: diax/ara Tu ar aris mirebuli, ra mizezit? gamosakvlevs Tan axlavs (gvari/tanamdeboba): eqspertizaze damswre pirebi (gvari/tanamdeboba): gamokvlevis dros dasakitxi piri imobilizebuli iyo: diax/ara; Tu diax, masin ra saxit/ra mizezit? samedicino daskvna gagzavnilia (gvari/tanamdeboba/ ИН): gagzavnis TariRi: gagzavnis dro: samedicino eqspertiza/gamokvleva SezRudvebis garesea Catarebuli (patimrebis mimart): diax/ara arweret dawvrilebit nebismieri SezRudva: II. eqimis kvalifikacia (sasamartloze CvenebisaTvis) samedicino ganatleba da klinikuri momzadeba fsiqologiuri/fsiqiatriuli momzadeba wamebisa da sastiki mopyrobis mtkicebulebebis dokumentirebis gamocdileba regionsi adamianis uflebebis dacvis sferosi mocemul gamokvlevastan dakavsirebuli specialobis codna da gamocdileba publikaciis kvlevastan dakavsirebuli sajaro gamosvlebi da profesiuli momzadebis kursebi mokle biografia III. gancxadeba Cvenebebis utyuarobis Sesaxeb (sasamartloze CvenebisaTvis) 88

89 magalitad: piradad CemTvis qvemot moyvanili faqtebi nacnobia, da vtvli sarwmunod im informaciis garda, romlis sisworis Sesaxebac aq varaudi gamoitqva. CemTvis nacnobi da sarwmuno informaciidan gamomdinare, mzad var davamowmo zemot natqvami. IV. sawyisi informacia saerto monacemebi (asaki, saqmianobis saxe, ganatleba, ojaxis Semadgenloba da a.s.) wamzrvarebuli samedicino anamnezi wamebisa da sastiki mopyrobis winasamedicino eqspertizis ganxilva fsiqosocialuri anamnezi dapatimrebamde (i) gancxadeba wamebisa da sastiki mopyrobis Sesaxeb 1. dakavebisa da sastiki mopyrobis mokle arwera 2. dakavebisa da dapatimrebis garemoebebi 3. patimrobis Tavdapirveli da momdevno adgilebi (TariRebi, transportirebisa da cxovrebis pirobebi) 4. sastiki mopyrobisa da wamebis Sesaxeb Tavisufali Txroba (cixesi yofnis yvela adgilze) 5. wamebis metodebis ganxilva (ii) fizikuri simptomebi da Sromisunarianobis mosla arweret mwvave da qronikuli simptomebisa da Sromisunarianobis moslis ganvitarebisa da gamojanmrtelebis momdevno procesebi. 1. mwvave simptomebi da Sromisunarianobis mosla 2. qronikuli simptomebi da Sromisunarianobis mosla (iii) fizikuri gamokvleva 1. saerto garegnuli ieri 2. kanis safari 3. saxe da Tavi 4. Tvalebi, yurebi, cxviri da yeli 5. piris Rru da kbilebi 6. gulmkerdi da muceli (sasicocxlo mnisvnelobis funqciebis macveneblebis CaTvliT) 7. Sard-sasqeso sistema 8. Zvlovan-kunTovani sistema 9. centraluri da periferiuli nervuli sistemebi (iv) fsiqologiuri anamnezi/gamokvleva 1. Sefasebis metodebi 89

90 2. fsiqologiuri xasiatis Civilebi gamokvlevis dros 3. anamnezi wamebis Semdeg 4. anamnezi wamebamde 5. Tavdapirveli fsiqologiuri/fsiqiatriuli anamnezi 6. alkoholisa da narkotikebis xmarebisa da mati borotad gamoyenebis anamnezi 7. fsiqikuri mdgomareobis gamokvlevis Sedegebi 8. socialuri funqcionirebis Sefaseba 9. fsiqologiuri testireba (Cvenebebi da SezRudvebi ix. nawili VI. C 1) 10. neirofsiqologiuri testireba (Cvenebebi da SezRudvebi ix. nawili VI. C 4) (v) fotosuratebi (vi) diagnostikuri gamokvlevis Sedegebi (Cvenebebi da SezRudvebi ix. danarti II) (vii) konsultaciebi (viii) mocemuli gamokvlevis intergretacia 1. fizikuri monacemebi a) daadginet mwvave da qronikuli simptomebisa da Sromisunarianobis moslisa da sastiki mopyrobis Sesaxeb gancxadebebis Sesabamisobis xarisxi. b) daadginet fizikuri gamokvlevebis monacemebisa da sastiki mopyrobis Sesaxeb gancxadebebis Sesabamisobis xarisxi (SeniSvna: fizikuri monacemebis ararseboba ar gamoricxavs wamebasa da sastik mopyrobas). c) daadginet pacientis gamokvlevis Sedegebisa da konkretul regionsi wamebis metodebsa da mat momdevno Sedegebs Soris Sesabamisobis fsiqologiuri monacemebi a) daadginet fsiqologiuri gamokvlevis Sedegebisa da vitomda wamebis Sesaxeb cnobis Sesabamisobis xarisxi. b) SeafaseT, eqstremaluri stresis dros tipur an mosalodnel reaqciad mirebuli fsiqologiuri monacemebi aris Tu ara gamosakvlevi piris kulturuli da socialuri wris konteqstsi. c) miutitet gamosakvlevi piris faqtobrivi mdgomareoba fsiqikuri moslilobis dinamikis mimart, romelic dakavsirebulia travmastan, anu gamokvlevis momenti drois mixedvit ra TanafardobaSia wamebis momenttan da gamojansarebis ra etapze imyofeba gamosakvlevi. d) daadginet paralelurad arsebuli stresis faqtorebis zemoqmedeba gamosakvlev pirze (magalitad, gaxangrzlivebuli devna, izulebiti 90

91 migracia, gasaxleba, ojaxis dakargva, socialuri rolis dakargva da a.s.). e) miutitet fizikuri mdgomareobis aspeqtebze, romelic SesaZlebelia aisaxos klinikur suratze da romelic gansakutrebulad aris dakavsirebuli wamebis an patimrobis periodsi mirebuli Tavis travmis SesaZlebel monacemebtan. (ix) daskvnebi da rekomendaciebi 1. mogvecit daskvna yvela zemot dasaxelebuli wyaroebis monacemebis Sesabamisobis Sesaxeb. 2. daamowmet simptomebi da Sromisunarianobis mosla, romelic savaraudo, sastiki mopyrobis Sedegad, gamosakvlev pirtan kvlav SeiniSneba. 3. rekomendaciebsi CarTeT gamosakvlevi piris Semdgomi eqspertiza da mkurnaloba. (x) gancxadeba simartlis Cvenebis Sesaxeb (sasamartloze CvenebisaTvis) magalitad: vici ra, crumowmeobis pasuxismgeblobis Sesaxeb kanonis Tanaxmad (qveyana) vacxadeb, rom zemot natqvami simartles Seesabameba da zustia da rom warmodgenili Cveneba ficis qves iyo micemuli (TariRi) (qalaqi) (Stati an olqi). (xi) gancxadeba samedicino eqspertiza/gamokvlevis Catarebis dros arsebuli SezRudvebis Sesaxeb (patimrobasi myof pirtatvis) magalitad: qvemore xelis momweri eqimebi amowmeben, rom hqondat Tavisufali da damoukidebeli moqmedebis sasualeba, SeeZloT esaubrat (gamosakvlevtan) da gaesinjat yovelgvari SezRudvebis garese daxurul kars mirma da sapatimro dawesebulebis Tanamdebobis pirta mxridan aravitari formis izuleba ar hqondat, an qvemore xelis momweri eqimi izulebuli var eqspertiza Cavataro Semdegi SezRudvebiT. (xii) eqimis xelis mowera, TariRi, adgili (xiii) Sesabamisi danarti eqimis namsaxurobis nusxis asli, anatomiuri ilustraciebi wamebisa da sastiki mopyrobis dokumentirebisatis, fotosuratebi, konsultaciisa da diagnostikuri gamokvlevebis Sedegebi da a.s. «(stambolis protololi, 2001) «damatebiti informaciis mireba SesaZlebelia adamianis uflebata dacvis gaertianebuli erebis organizaciis umarlesi komisris sammartvelodan, erebis sasaxle, 1211 Jeneva 10, Sveicaria tel.: (+41-22) faqsi: ((+41-22) interneti: 91

92 Tavi V. mkurnaloba da reabilitacia rogorc zemot iqna moyvanili da arnisnuli, wamebis Sedegebi gamoirceva polimorfulobita da mravalferovnebit da moicavs, rogorc fsiqikur/fsiqologiur, aseve somatur-nevrologiur komponentebsac. aqedan gamomdinare iseve rogorc diagnostika, mkurnaloba da reabilitaciac unda emyarebodes multidisciplinarul midgomas da gadamwyveti mnisvneloba unda eniwebodes wamebis msxverplis kompleqsur mkurnalobasa da reabilitacias. metad mnisvnelovania multidisciplinaruli reabilitaciisatvis calkeuli SemTxvevis martva menejmenti. swori menejmentis warmoebas gadamwyveti mnisvneloba eniweba xarjtefeqturi da zogadad efeqturi mkurnalobisa da reabilitaciisatvis. SemTxvevis menejmenti gulisxmobs calkeuli klientis sawiroebebze orientirebuli RonisZiebebis dagegmvasa da ganxorcielebas specialistta multidisciplinaruli gundis mier. SemTxvevis martva warmoadgens process an metods, romlis sasualebitac uzrunvelyofilia klientisatvis sawiro servisebis koordinirebuli, efeqturi da racionaluri gzit miwodeba. SemTxvevis martva xorcieldeba sistemuri midgomis safuzvelze, klientis motxovnilebebze orientirebuli servisebis integraciis (urtiertdakavsirebuli servisebis) miwodebit sistemur operaciebs axasiatebs: 1) Senatani (Semavali) monacemebi (Input); 2) gamtanunarianoba gamoyenebis koeficienti (throughtput) 3) gamomavali monacemebi an/da produqti (output) 4) ukukavsiri (feed back) pirobitad SeiZleba gamoiyos SemTxvevis martvis, rogorc sistemis Semdegi ZiriTad funqciebi: Sefaseba klientis sawiroebebis, motxovnilebebis da individualuri resursebis Sefaseba. dagegmva _ momsaxurebis srulyofili, kompleqsuri gegmis SemuSaveba. miwodeba gegmit gatvaliswinebuli servisebis miwodeba. monitoringi miwodebuli servisebis monitoringi da Sefaseba. evaluacia momsaxurebis efeqturobis Sefaseba. wamebis msxverplta reabilitaciisas gamoiyeneba klientze centrirebuli midgoma. egzistencialuri TvalTaxedvis gatvaliswinebit, upriania TviToeul SemTxvevaSi individualuri midgoma da individualuri reabilitaciisa da mkurnalobis gegmis Sedgena da ganxorcieleba. multiprofiluri diagnostikis Semdeg reabilitaciis gegmas SemTxvevis martvasi monawile specialistebis gundi adgens jgufuri konsultaciebis Sedegad. arnisnuli gegmis SedgenaSi monawileobs klientic. aucilebelia mirebul iqnas misi informirebuli Tanxmoba gansaxorcielebel RonisZiebebze. 92

93 wameba ara marto pirovnebaze aisaxeba, aramed aisaxeba fsiqo socialur da samedicino problemebze mtlianad ojaxsi; amitomac aucilebelia, ra Tqma unda mati TanxmobiT, reabilitaciis processi ojaxis wevrebis CarTva. reabilitacia gulisxmobs kompleqsur RonisZiebebs, romelnic Semdegia: (Tumca gansakutrebit SevniSnavT rom, klinentis sawiroebebis da motxovnilebebis prioritetulobis mixedvit, ar eqvemdebareba limitirebas da SezRudvebs) samedicino momsaxureba, sxvadasxva saxis samedicino manipulaciebisa da medikamentozuri mkurnalobis gatvaliswinebit: samedicino momsaxurebis saxeebi da medikamentozuri mkurnaloba ganisazrvreba im patologiit an patologiata jgufit, romelic gamovlenil iqna calkeul SemTxvevaSi; wamebis SemTxvevaSi xsiria Zval saxsrovani patologiebi, aseve nevrologiuri, stomatologiuri, ginekologiuri problemebi, aseve Sardsasqeso sistemis; gulsisxvlzarrvta sistemisa da sawmlis momnelebeli sistemis mxriv patologiebi; xsirad amgvari patologiebi urtiertserwymulia, aset SemTxvevaSi mkurnalobisa da reabilitaciis gegmis SedgenaSi aucilebelia calkeuli specialistebis ertoblivi monawileoba. metad mnisvnelovani da xsirad reabilitaciis aucilebeli metodia fizioterapia da masaji, romelic gansakutrebit Zval saxsrovani da nevrologiuri patologiebis dros aris aqtulauri. fsiqikuri/fsiqologiuri reabilitacia da mkurnaloba travmuli stresis sxvadasxva klinikuri gamovlinebebis dros mkurnalobasi mnisvnelovan rols TamaSobs farmakoterapia. rigi avtorebis azrit (F. Weil et al.), PTSD qronizaciis Tavidan acilebis miznit, aucilebelia fsiqo-travmis Semdeg dauyovnebeli mkurnaloba. yvelaze efeqtur sasualebebad, gansakutrebit SfoTvis marali xarisxis dros, micneulia benzodiazepinis rigis preparatebi, rogoricaa qlordiazepoqsidi (libriumi), diazepami (valiumi), flurazepami (dalmani) da oqsazepami (seraqsi). es preparatebi itvleba naklebad toqsiurad da ar iwveven damokidebulebis warmoqmnas. (Swonger A., Constantine L., BassuckE., Shchoonover S., Shader R.). Tumca Tanamedrove midgomebidan gamomdinare arnisnuli preparatebis xangrzlivi droit danisvna mizansewonili ar aris, aseve benzodiazepinis jgufis preparatebis danisvna mizansewonili ar aris Tuki adgli aqvs midrekilebas wamaldamokidebulebis problemebisadmi. zogierti avtori mizansewonilad miicnevs beta - adrenoblokatorebis gamoyenebas (propranoli, inderali, anaprilini), gansakutrebit im SemTxvevebSi, rodesac SfoTva da fsiqo-fiziologiuri stresuli aslilobebi vlindeba pirvel rigsi periferiuli avtonomiuri simptomatikit. (Kolb, Burris, et al). PTSD mkurnalobasi warmatebit gamoiyeneba tricikliuri antidepresantebi, gansakutrebit SfoTvisa da depresiuli komponentis mosaxsnelad. (amitriptilini, melipramini). umetesi mkvlevarebis azrit, tricikliuri antidepresantebi efeqturia momatebuli agznebadobis, akviatebuli gancdebisa da kosmarebis, disociaciuri 93

94 epizodebis mosaxsneladac. preparatis sasualo dozaa 140 mg. dresi, xolo mkurnalobis sasualo xangrzlivoba _ 8 kviridan 6 Tvemde. sxva monacemebit upiratesoba eniwebat maos inhibitorta jgufis antidepresantebs, kerzod fenelzins. preparatis doza 75 mg. dan 45 mg. mde. meryeobs. Tumca amjamad upiratesoba posttravmuli stresuli aslilobis mkurnalobasi eniweba seotoninis ukumitace3bis inhibitorebs axali Taobis antidepresantebs, romelta moqmedebas gverditi movlenebi nakleb axasiatebs. Axali Taobis antidepresantebi micneulni arian rogorc pirveli arcevis preparatebi ptsa s mkurnalobisatvis. Aamgvar preparatebs miekutvneba (egret wodebuli SSRI s jgufis preparatebi : sertralini, paroqsetini, fluoqsetini, fluoqsamini, citaloprami. Axali Taobis antidepresantebs, romelic aseve warmatebulad gamoiyeneba ptsa s mkurnalobisatvis ganekutvneba aseve nefazodoni da venlafaqsini. (eqspertta SeTanxmebuli gaidlaini, posttravmuli stresuli aslilobis mkurnaloba, 1999, Jurnali klinikuri fsiqiatria, tomi 60). Zlieri agznebis mosaxsnelad gamoiyeneba fenotiazinis jgufis preparatebi qlorpromazini (aminazini, Torazini) da Tioridazini (melerili) mcire dozebit. M. Wolf et al. did mnisvnelobas aniweben antikonvulsant karbamazepins. PTSD mkurnalobis ZiriTad metods warmoadgens fsiqoterapia. gamoiyeneba individualuri, ojaxuri da jgufuri fsiqoterapiis sxvadasxva metodi. mwvave mdgomareobebis da PTSD qronizaciis profilaqtikis miznit, umnisvnelovanesia sami klasikuri principi (Coleman, Butcher, Carson, Kentsmith). es principebia: gadaudebloba, daaxloeba da imedi. gadaudebloba gulisxmobs adreul diagnostikasa da mkurnalobas. daaxloeba moicavs Terapiis Catarebas saomari moqmedebebisa da masiuri katastrofebis zonastan axlos; da bolos, imedi gulisxmobs «gamamxnevebel damokidebulebas», roca dazaralebuls STaegoneba momavlis rwmena. R. Grincer omissemdgomi reaqciebis samkurnalod SemogvTavaza individualuri fsiqoterapiis dros natriumis pentonalis gamoyeneba, rac xels uwyobs pirovnebis gaxsnas da ganapirobebs emociuri ganmuxtvisa da katarzisis swrafad mirwevas. eqstremalur situaciebsi, individualuri da jgufuri fsiqoterapiis saxit, warmatebit gamoiyeneba travmaze orientirebuli neirolingvisturi programirebis metodi, aseve HhipnoTerapia, msubuqi transis mdgomareoba da STagoneba. farto gavrceleba hpova Mitchel metodma, rac gulisxmobs travmirebultagan homogenuri urtierttanadgomis jgufebis Seqmnas emociuri ganmuxtvis miznit. mocemul etapze mnisvnelovania dazaralebultan srul ndobaze damyarebuli kontaqtis damyareba, romlis mizania strestan dakavsirebuli emociebisagan gantvirtvisa da stresidan disociaciis mirweva, rac metad mnisvnelovania "ganmeorebadi gancdis" simptomta mosaxsnelad da PTSD qronizaciis profilaqtikisatvis. mocemul etapze aseve mnivnelovania socialuri Tanadgoma da daxmareba. // 94

95 PTSD qronikuli mimdinareobisas individualuri fsiqoterapiis saxeoba ZiriTadad damokidebulia fsiqoterapevtis orientaciaze. fartod gamoiyeneba bihevioristuli (qceviti) da kognitiuri (SemecnebiTi) Terapiis metodebi. iseti metodebi, rogoricaa sistematiuri desensibilizacia da rekurentuli matravmirebeli mogonebebisatvis azrovnebis damuxruweba (Miller T. 1981). rigi avtorebis azrit, PTSD dros umtavresia, matravmirebeli movlenebis Sedegad armocenebuli intrafsiqikuri, Sinagani konfliqti, rac xsirad iwvevs faseulobata sistemis msxvrevasa da cxovrebiseuli krizisis SegrZnebas; ris gamoc aucileblad miicneven, rom dazaralebulma gaacnobieros misi problemis Sinaarsi da genezi. am midgomis safuzvelze SemuSavebulia Terapiuli midgoma (Meichenbaum, Novaco, Everly, Girdano et al.), romelic 6 safexurisagan Sedgeba: 1. stresuli reaqciebis Sesaxeb yvelaze xsirad gavrcelebuli warmodgenebis koreqcia; 2. stresuli reaqciebis Sesaxeb, mis bunebaze pacientisatvis informaciis miwodeba; 3. aslilobis ganvitarebasi gansakutrebuli stresis rolze fokusireba; 4. pacientis miyvana stresuli reaqciebisa da misi simptomebis gamovlinebis damoukidebel Secnobamde; 5. pacientsi TviTanalizis unaris ganvitareba, mistvis nisandoblivi stresorebis identifikaciis miznit; 6. klinicistis mier pacientisatvis im mnisvnelovani rolis gansazrvra, romelsac es ukanaskneli asrulebs mnisvnelovani stresis TerapiaSi. rogorc cnobilia, PTSD qronikuli formebisatvis erterti umtavresi komponentia adaptaciis darrveva, realobis sworad Sefasebis unaris daqveiteba, aseve interpersonaluri urtiertobebis darveva, rig SemTxvevaSi arakontrolirebadi agresiuloba da mrisxaneba, gaucxoeba, emociuri gamijnva. am darrvevata koreqciisatvis aucilebelia interpersonalur urtiertobebze orientirebuli jgufuri fsiqoterapiis gamoyeneba. jgufuri fsiqoterapiis metodi dreisatvis itvleba PTSD mkurnalobis wamyvan metodad (William, Brende, Walker, Nash). jer kidev 70-iani wlebis dasawyissi samecniero literaturasi gamocnda calkeuli rekomendaciebi jgufuri fsiqoterapiis Casatareblad ertgvarovani jgufebis Seqmnis Sesaxeb (Archibald, Lomg, Miller), magram vietnamis omamde am metodma ver hpova farto gamoyeneba. 70-ian wlebsi Lifton, musaobda ra vietnamis omis veteranebtan, Camoayaliba "urtiertgagebis jgufebi". mati saqmianobis gaanalizebit igi mivida daskvnamde, rom jgufsi swrafad xdeba urtiertndobisa da SekavSirebulobis Camoyalibeba, ris Sedegadac vitardeba ertianoba cnebebisa "is, rasac vgrznob me" da "is, rasac vgrznobt Cven", magram amastanave gamoxatulad ikveteba mtruli ganwyoba mat mimart, visac ar gaacnia identuri travmuli gamocdileba, ris gamoc TvalsaCinoa jgufsi Caketvis tendencia. am faqtis gatvaliswinebit Parson mier SemuSavebul iqna PTSD jgufuri fsiqoterapiis samfaziani modeli. pirvel fazasi iqmneba "urtiertgagebis jgufebi" mxolod ertnairi darrvevebis mqone, identur mdgomareobasi myofi pacientebisgan (veteranebi, ltolvilebi, Zaladobis msxverplni da a.s.). meore fazasi jgufsi emateba aranakleb ori axali 95

96 wevri araidenturi travmuli gamocdilebita da ramdenadme gansxvavebuli problemebit. warmoqmnil jgufs ewodeba "fsiqoterapiuli jgufi". axali wevrebis Seyvana xels uwyobs travmirebuli "me"-ti yvelaze ufro metad dezorganizebul pacientebsi emociur afetqebas, ris Sedegadac iwyeba jgufis wevrebsi gamarizianebeli qcevebi, «Cven vgrznobt' cnebis Sesustebas da garizianebas da mrisxanebas "realobastan" Sejaxebis gamo. Terapevtis xelmzrvanelobit jgufis wevrebi swavloben TavianTi emociebis martvasa da gancdata analizs». amis Semdeg iwyeba mesame faza, anu "fsiqoanalizurad orientirebuli jgufi". Lindy, Green, Grace azrit, somatizaciisa da fsiqo-somatur simptomta samkurnalod aucilebelia "pirovnebaze orientirebuli fokusuri fsiqoanalizis gamoyeneba. fokusuri fsiqoanalizi zogadad moicavs Semdeg fazebs: "gaxsnis fazas", romelic moicavs pacientsa da Terapevts Soris ndobis kontaqtis da Terapevtis mimart rwmenis Camoyalibebas, travmis im detalebis gacnobas TerapevtisaTvis, rac wamyvan rols TamaSobs da mnisvnelovania da gantvirtvis mirwevas. meore, "Sualedur" fazasi, Terapevti exmareba pacients identficireba moaxdinos da gamokvetos travmuli movlenis specifiuri konfiguraciis konturebi: «movlenis romeli sakvanzo detalebi agondeba mimdinared da romeli arsebobs gamudmebit, myarad». mesame, bolo fazasi, Seqmnili wyvili musaobs travmis gaazrebasa da pirovnebis mier sakutari pirovnuli organizaciis gacnobierebaze da momavalisatvis gamosadegi jansari azris SemuSavebaze. iugoslaviis omis Sedegad ltolvilta Soris warmatebit iyenebdnen "realobit Terapiis" models, romelic SemuSavebulia Glasser mier. es metodi mnisvnelobas aniwebs adamianis qcevas mimdinare momentsi da misi qcevis efeqturobas sasurveli miznebis misarwevad. aqcenti ketdeba "arcevanze". Glasser mixedvit, Cveni qcevebi, gansakutrebit ki Cveni morvaweobis saxeebi da fiqrebi xasiatdeba arcevitobit. es metodi SesaZloa gamoyenebul iqnas rogorc individualurad, aseve jgufurad da moicavs ramdenime etaps. pirveli etapi moicavs jgufis Serwymas, koncentrirebas jgufsi urtiertndobisa da megobruli atmosferos Sesaqmnelad. meore stadia warmoadgens individis mier sakutari Sinagani samyaros gamokvlevas. mesame stadiasi aqcenti ketdeba qcevaze mtlianobasi. meotxe stadiasi fsiqoterapevti exmareba pacients dagegmos da SeimuSaos qcevis efeqturi formebi. gansakutrebit mnisvnelovania PTSD dazaralebulta Soris ojaxuri fsiqoterapiis gamoyeneba, radgan Zalian xsiria ojaxis wevrta Soris urtiertobebsi cvlilebebi travmis Sedegad, aseve damaxasiatebelia ojaxis wevrta Soris gancdebit urtiertinducireba, ris Sedegadac pirvel rigsi zaraldebian bavsvebi. ojaxuri fsiqoterapia gulisxmobs fsiqoterapiul musaobas mtel ojaxtan, rogorc jguftan. fsiqoterapevti exmareba mis wevrebs armoacinon Tavisi funqcionirebis axali SesaZleblobebi, rac mimartulia ojaxis SigniT urtiertobebis gaumjobesebaze. mnisvnelovania, rom ojaxis yvela wevrma miarwios emociur 96

97 gantvirtvas. igi orientirebulia ojaxis Sida urtiertobebsa da ojaxis urtiertobebze garemomcvel adamianebtan, samyarostan. xsirad PTSD ganapirobebs urtiertobebis darrvevebs meurleebsa da wyvilebs Soris, rac ganpirobebulia travmis SinaarsiT. aqedan gamomdinare mkurnalobisas didi yuradreba etmoba wyvilebis Terapias, rac ZiriTadad fokusirebulia aratravmirebuli meurlis mier damxmaris rolis sakutar Tavze arebaze, Tumca dazaralebulis gamojansarebis Semdeg mosalodnelia damxmaris rolis dakargvastan dakavsirebit frustraciisa da depresiis gancdebi, ris gamoc fsiqoterapevti exmareba wyvilebs axali rolebis gansazrvrasi, axali gegmebis SemoSavebasa da mirwevasi. ojaxuri da wyvilebis fsiqoterapiis dros fartod gamoiyeneba "rolebit Terapiis" metodi. SeuZlebelia ar arinisnos travmuli stresis mkurnalobasi egzistencialuri analizis roli, romelsac Viktor Frankl warmatebit mimartavda TviT sakoncentracio banaksic ki. es metodi gansakutrebit efeqturia, vinaidan travmuli stresis dros xsirad vlindeba depresiuli simptomatika, adgili aqvs msoflmxedvelobis msxvrevasa da xsir SemTxvevaSi suicidur tendenciebs. egzistencialuri analizis metodi damyarebulia faseulobata sami ZiriTadi sistemis: 1. SemoqmedebiTi faseulobani; 2. gancdis faseulobani; 3. damokidebulebis faseulobani, mixedvit cxovrebis sazrisis armocenaze da am faseulobata sistemebis realizaciaze. aseve unda arinisnos, rom Viktor Frankl akviatebulobata mosaxsnelad warmatebit iyenebda logoterapiis paradoqsuli intenciis metods. mnisvnelovania arinisnos, rom dreisatvis ar arsebobs ertiani midgoma PTSD mkurnalobis sakitxisadmi, an raime specifiuri mkurnaloba, ris gamoc PTSD mkurnaloba atarebs simptomur xasiats. fsiqoterapiis metodis da mkurnalobis taqtikis arcevisas aucilebelia pirovnebis individualuri Taviseburebebis, misi msoflmxedvelobis, faseulobata sistemis, ganvitarebis donis, aseve etno-kulturuli Tu socio-kulturuli maxasiateblebis, asakis, sqesisa da fsiqotravmis xasiatis gatvaliswineba. fsiqologiur reabilitaciasi mnisvnelovani roli eniweba art- Terapias rac sayuradreboa ori mimartulebit: 1) igi mnisvnelovan warmodgenas gvazlevs pirovnebis SigniT arsebul, dafarul konfliqtebsa da tendenciebze, aseve fsiqo travmis pirovnebiseul warmodgenaze, 2) amave dros, dinamikasi warmodgenas gvazlevs Tu rogor vitardeba zogadad reabilitacia, ra iqna mirweuli da ra rceba sayuradrebod. amave dros art-terapiis metodi umnisvnelovanesia travmuli stresisagan emociuri ganmuxtvisatvis; igi mnisvnelovan rols TamaSobs akviatebuli mogonebebisa da gancdebisagan Tavis darwevis processi. socialuri reabilitacia da garemosi daxmareba, iuridili konsultacia: 97

98 wamebis msxverplta reabilitaciis sakitxebi moicavs mravalferovan kompleqsur RonisZiebebs, romelta Sorisac erterti mnisvnelovani adgili uwiravs socialur reabilitacias, rac pirvel rigsi gulisxmobs socialur Tanadgomas. socialuri Tanadgoma moicavs Semdeg komponentebs: 1. TviTdaxmarebis jgufebis organizacia dazaralebulta Soris, bunebrivi lideris gamovlenit. aseti jgufebis UumTavresi amocanaa TanagrZnobisa da Tanadgomis atmosferos mirweva, emociuri urtiertketilsaimedo ganwyoba, rac mnisvnelovania emociuri ganmuxtvisa da Seqmnili rtuli mdgomareobidan Tavis darwevisatvis _ momavlis dagegmva arsebuli realobis swori SefasebiT. 2. materialuri daxmarebis organizeba yvelaze ufro metad gaubedurebuli adamianebisatvis. 3. dasaqmebisa da funqciebis ganawilebis organizeba. 4. sainformacio samsaxuris organizacia da urtiertobebis damyareba sxvadasxva organizaciebtan da struqturebtan, rata moxdes dazaralebulta informireba sakutari uflebebisa da Tavisuflebebis Sesaxeb, aseve movaleobebis Sesaxeb, adgilobriv da saertasoriso sakanonmdeblo aqtebs, rac warmoadgens pirovnebis dacvis ert-ert umtavres pirobas. 5. bavsvebisa da mozardebis reabilitaciis sakitxsi travmuli stresit gamowveuli iseti specifiuri problemebidan gamomdinare, rogoric aris yuradrebis koncentraciis unaris daqveiteba, swavlasi CamorCena, interpersonaluri urtiertobebis problemebi, mnisvnelovania specialuri programebis SemuSaveba, romlebic moicaven unarebis ganvitarebisa da armzrdelobit-saganmanatleblo jgufebis formirebas, kulturul-sportuli da samkurnaloprofilaqtikuri, Tu gamajansarebeli RonisZiebebis SemuSavebas. gamomdinare wamebis situaciebis specifikidan aucilebelia garemosi socialuri daxmarebis organizeba, rata SeZlebisdagvarad daculi iqnas wamebis msxverplisa da misi ojaxis wevrta usafrtxoeba, amgvari qmedebebi gulsixmobs fasilitatorul aqtivobas calkeul saxelmwifoebriv organoebtan, mat Soris Zalovani struqturebis warmomadgenlebtan; reabilitaciis aucilebel komponents warmoadgens wamebis msxverplis iuridiuli konsultireba, daxmareba sasamartloebsi saqmis msvlelobisas; amave daxmarebis umnisvnelovanes samedicino iuridiul komponents Seadgens wamebis msxverplisatvis samedicino daskvnis momzadeba da gacema; amgvari daskvnis gadacema sasamartloebisa Tu prokuraturisatvis, aseve wamebis msxverplis advokatisatvis. amgvarad, reabilitaciisatvis aucilebelia kompleqsuri midgoma, rac gulisxmobs janmrtelobis dacvisa da socialuri uzrunvelyofis organizaciebis, ganatlebis sistemis, adgilobrivi Tu saertasoriso samartaldamcavi da sakanonmdeblo institutebis, samtavrobo da arasamtavrobo saertasoriso Tu adgilobrivi struqturebis aqtiur koordinirebul Cabmas reabilitaciis processi. 98

99 samkurnalo-profilaqtikuri da reabilitaciuri RonisZiebebis efeqturad ganxorcielebisatvis aucilebelia kvalificiuri daxmarebis samsaxuris organizacia. aseti samsaxuris umtavres rgols warmoadgens eqstremaluri daxmarebis jgufebis Seqmna, romelic yalibdeba Semdegi specialistebisagan: zogadi profilis eqimebi, fsiqiatrebi, fsiqologebi, samedicino debi, socialuri musakebi. isini gadaudebel daxmarebas armoucenen dazaralebulebs krizisul situaciebsi (magalitad cixeebsi). aseti jgufebis mtavari amocanaa: swori da swrafi diagnostireba, gadaudebeli daxmarebis armocena da dazaralebulta Semdgomi ganawileba klinikur-dinamiuri gamovlinebebis gatvaliswinebit. Semdgom rgols warmoadgens specialuri programebis SemuSaveba kvalificiuri samedicino da fsiqo socialuri reabilitaciis armosacenad da moicavs ambulatorul da stacionarul daxmarebasa da mkurnalobas. amgvari programebis gansaxorcieleblad aucilebelia specialstebis momzadeba, vinaidan wamebis dros xsirad adgili aqvs fsiqikuri da fizikuri travmebis Serwymas, aseve fsiqo-somatur darrvevebs, mnisvnelovania sxvadasxva profilis specialistta gatvitcnobiereba travmuli stressa da mis mier gamowveul darrvevebis sakitxebsi. xsir SemTxvevaSi wamebit gamomwveuli ubedurebebis polimorfuli xasiatidan gamomdinare mnisvnelovania araspecifiuri daxmarebis armosacenad moxaliseta CarTva reabilitaciur RonisZiebebSi; amisatvis aucilebelia mati gatvitcnobiereba travmuli stresisa da mastan dakavsirebuli fsiqikuri Tu fizikuri problemebis Sesaxeb. kompleqsuri midgomis aucilebelobis gatvaliswinebit, mnisvnelovania specialistebis mier im organizaciebisa da struqturebis informireba, romelnic imyofebian mwidro kavsirsi dazaralebulebtan. eseni SesaZloa iyvnen: pedagogebi, armzrdelebi, masobrivi sainformacio sasualebebis warmomadgenelni, sazogadoebisa da oficialuri struqturebis warmomadgenelni da sxvani; yovelive es aucilebelia, rata SemuSavdes swori midgoma dazaralebulta problemebisadmi, mimdinare stresuli situaciebis Semcirebis miznit. wamebis msxverplta reabilitaciasi mnisvnelovani roli eniweba wamebis prevenciuli RonisZiebebis SemuSavebasac, vinaidan zogadad qveyanasi wamebis prevenciaze yuradrebis gamaxvileba da satanado klimatis Seqmna aadvilebs wamebis msxverpltatvis usafrtxo garemos Seqmnas da aseve aadvilebs samartlebrivi Sefasebebis mirwevas, rac Tavis mxriv mnisvnelovani komponentia wamebis msxverplis sruli reabilitaciisatvis. multtidisciplinaruli jgufi, romelic aris aucilebeli reabilitaciis gansaxorcieleblad : zogadi profilis eqimi (Terapevti) eqimi-fsiqiatri nevrologi travmatolgi fizioterapevti fsiqoterapevti 99

100 art Terapevti fsiqologi socialuri musaki eqtani sxadasxva konsultantebi (ginekologi, narkologi, kardiologi, dermato venerologi, otolaringologi, oftalmologi, qirurgi, pulmonologi da sxva sawiroebisda mixedvit). iuristi bavsvebtan musaobisatvis aucilebelia reabilitaciasi CarTuli iqnan : bavsvta fsiqiatri bavsvta fsiqoterapevti da fsiqologi pediatri pedagogebi danarti 1 : posttravmuli stresuli aslilobis mkurnalbis eqspertta SeTanxmebuli gaidlainebis zogierti sqema (Expert Consensus Guideline Series, Treatment of Posttraumatic Stress Disorder: The Journal of Clinical Psychiatry, V. 60, Supplement 16, 1999; Editors for the guidelines: Edna B. Foa, Jonathan R.T. Davidson, and Allen Frances.) gaidlaini I : rogor SevicnoT posttravmuli stresuli asliloba : 1 A: eqstremaluri stresisi tipebi, romelnic iwveven posttravmul stresul aslilobas: stresoris tipebi magalitebi seriozuli SemTxveva sagzao, sahaero, sazrvao an industriuli avaria. Bbunebrivi katastrofa qarborbala, qarisxali, wyaldidoba, miwiszvra Kkriminaluri SemTxveva Ffizikuri Setevis msxverpli, dawra, cema da a.s. samxedro saomar moqmedebata TeatrSi monawileoba seqsualuri Zaladoba Ggaupatiureba an mcdeloba bavsvobisdroindeli seqsualuri incesti, gaupatiureba, seqsualuri Zaladoba kontaqti didtan an gacilebit did mozardtan. 100

101 bavsvobisdroindeli Zaladoba an cema, damwvroba, SimSiloba, seiozuli ugulvebelyofa SezRudvebi (uyuradreboba, mitovebuloba) tyveoba, patimroba, wameba gataceba an tyved ayvana, teroristuli Seteva, wameba, dapatimreba rogorc samxedro tyve an sakoncentracio banaksi yofna, devniloba travmuli movlenebis Sesaxeb gageba an amgvari movlenis xilva daxvretata xilva, msxverplad SewirvaTa xilva, moulodneli ucabedi sikvdili sayvareli adamianis I B stresoris gavlena stresori unda iyos eqstremaluri da ara mxolod Zlieri stresori iwvevs Zlier subieqtur pasuxs SemTxveva, romelic moicavs sikvdilis movlenas an sikvdilis muqaras, Zlieri dazianeba, gaupatiureba an bavsvobisdroindeli seqsualuri Zaladoba. Aar moicavs xsirad gavrcelebul stresorebs, romelic SeiZleba iyos Zlieri, magram ara eqstremaluri (magalitad: samsaxuris dakargva, ganqorwineba, skolasi warumatebloba, sayvareli adamianis mosalodneli sikvdili). Ppirovneba ganicdis Zlier SiSs, umweobisa (UuZlurebis) da sasinelebis gancdas. I C: ptsa ZiriTadi simptomebi ZiriTadi simptomebi travmuli movlenis ganmeorebiti gancda magalitebi Aakviatebuli, distresis gamomwvevi mogonebebi travmuli movlenis Sesaxeb flesbeqis (Flashbacks) epizodebi gancda, rom travmuli movlena kvlavac meordeba Ramis kosmarebi, rodesac movlena an sxva sasinelebani xsirad sizrebsi meordeba. Ggamoxatuli fizikuri da 101

102 emociuri reaqciebi trigerta mimart, romelnic pirovnebas gadatanil movlenas moagoneben Ggandevnis simptomebi Ggaqceva im moqmedebebisagan, adgilebis, fiqrebis, gancdebis, Sexvedrebisagan, romelnic dakavsirebulni arian travmastan Eemociuri gayinva interesebis dakargva sxvebze damokidebulebis gancda emociata SezRudva (emociuri rezonansis daqveiteba) mowarbebuli sifxizlis gancda Zilis mxriv sirtuleebi garizianebadoba an sibrazis afetqebebi koncentraciis gazneleba mowarbebuli sifxizle gazviadebuli myisieri pasuxi I D: simptomta xangrzlivoba Tuki simptomta Ddiagnozia aris Kkomentari xangrzlivobaa ert Tveze naklebi Mwvave stresuli Ees aris simptomebi, asliloba (ara ptsa) romelnic vitardeba dauyovnebliv stresoris ganvitarebisas an mis Semdeg da SeiZleba iyos tranzitoruli an TavisTavad amowurvadi, Tumca jerjerobit ar SeiZleba diagnostirdes rogorc ptsa, magram gamoxatuli simptomebi am periodis ganmavlobasi warmoadgens risk faqtors ptsa s ganvitarebisatvis. 1 3 Tve Mmwvave ptsa Aaqtiuri mkurnaloba am fazasi, SeiZleba dagvexmaros Tavidan avicilot ptsa s qronizacia 3 Tve an/ da meti qronikuli ptsa xangrzlivi simptomebi SeiZleba itxovdes ufro 102

103 xangrzliv da Semtev mkurnalobas da midrekilia asocirebul iyos sxva Tanmxleb daavadebebtan 1 E: upiratesad gavrcelebuli Tanmxlebi aslilobani ptsa s mqone pacientebsi: vinaidan xsir SemTxvevaSi ptsa s Tan axlavs sxva qvemot moyvanili aslilobani, sawiroa CavataroT skriningi mati gamovlenisatvis ptsa Ti daavadebul yvela pacientsi da gavitvaliswinot es aslilobani mkurnalobis dagegmvisas. Tanmxlebi mdgomareobani Ddamokidebulebisa da wamaldamokidebulebis problemebi Ddidi depresiuli asliloba Ppanikuri asliloba/agorafobia Ggeneralizebuli SfoTviTi asliloba Oobsesiur kompulsuri asliloba socialuri fobia bipolaruli asliloba II. mkurnalobis sawyisi strategiebis SerCeva gaidlaini 2: ZiriTadi mkurnalobis strategiis SerCeva 2 A: mkurnalobis Tanmimdevroba: daviwyot fsiqoterapiit, medikamentozuri TerapiiT Tu orives kombinirebit es gaidlaini moicavs informacias fsiqoterapiisa da medikamentebit mkurnalobis Tanmimdevrobis Sesaxeb ptsa s mqone pacientebsi. Ggidlainis momzadebisas ertidaigive SekiTxva daesva fsiqoterapiisa da medikamentebis gamoyenebis eqspertebs. Oorive jgufis eqspertebma rekomendacia gauwies fsiqoterapias, rogorc ptsa s mkurnalobis pirvelad metods, magram eqspertebi, romelnic medikamentozur mkurnalobas ewevian arian momxre orive mkurnalobis metodis ertdrouli gamoyenebisa dasawyissive, gansakutrebit im pacientebsi, romeltac aqvt ufro gamoxatuli ptsa s simptomebi an qronikuli ptsa. asaki simzime Mmwvave ptsa qronikuli ptsa bavsvebsi da sasualo pirvelad pirvelad ufro axalgazrda fsiqoterapia fsiqoterapia mozardebsi ufro mzime fsiqoterapia fsiqoterapia pirvelad an pirvelad an medikamentozuri medikamentozuri Terapiisa da Terapiisa da 103

104 Uufrosi asakis mozardebsi da didebsi Ggeriatriul pacientebsi sasualo ufro mzime sasualo ufro mzime fsiqoterapiis kombinireba pirvelad fsiqoterapia fsiqoterapia pirvelad an medikamentozuri Terapiisa da fsiqoterapiis kombinireba pirvelad fsiqoterapia fsiqoterapia pirvelad an medikamentozuri Terapiisa da fsiqoterapiis kombinireba fsiqoterapiis kombinireba fsiqoterapia pirvelad an medikamentozuri Terapiisa da fsiqoterapiis kombinireba fsiqoterapia pirvelad an medikamentozuri Terapiisa da fsiqoterapiis kombinireba pirvelad fsiqoterapia fsiqoterapia pirvelad an medikamentozuri Terapiisa da fsiqoterapiis kombinireba 2. B: mkurnalobis Tanmimdevroba, rodesac ptsa Serwymulia saxva fsiqiatriul aslilobebtan rodesac ptsa s Tan axlavs sxva fsiqikuri aslilobebi, eqspertebi rekomendacias uweven medikamentozuri mkurnalobisa da fsiqoterapiis kombinirebas. amastanave Zalian mnisvnelvania, rom ptsa diagniostikisas aucileblad unda iqnas gatvaliswinebuli sxva Tanmxlebi fsiqikuri aslilobebisa da wamaldamokidebulebis problembis Sefaseba. Tanmxlebi mdgomareoba rekomendirebuli strategia Ddepresiuli asliloba Ddasawyisidanve medikamentozuri Terapiisa da fsiqoterapiis kombinireba bipolaruli asliloba Ddasawyisidanve medikamentozuri Terapiisa da fsiqoterapiis kombinireba sxva SfoTviTi aslilobani (mag., Ddasawyisidanve medikamentozuri panikuri asliloba, generalizebuli Terapiisa da fsiqoterapiis SfoTviTi asliloba kombinireba wamaldamokidebuleba an sxva M1) mkurnaloba orive aslilobis damokidebulebis problemebi 1)saSualod gamoxatuli problemebi ertdeoulad wamaldamokidebulebisa da ptsa s, 2) ufro mzimed gamoxatuli 2) wamaldamokidebulebis pirvel problemebi rigsi an orivesi ertdroulad 104

105 2 C: daxmarebis done mkurnalobis inicialur fazasi (pirveli sami Tve an stabilizaciis mirwevamde) Mmkurnalobis sawyis etapze eqspertebis rekomendaciit fsiqoterapia unda tardebodes yovelkvireulad 60 wutis xangrzlivobit individualuri seansebis saxit; pirveli Tvis ganmavlobasi aseve rekomendirebulia medikamentozuri mkurnalobis miznit yovelkvireuli vizitebi da SemdgomSi yovel or kvirasi. fsiqoterapiuli seansebis sixsire fsiqoterapiuli seansebis xangrzlivoba fsiqoterapiuli seansebis formati Mmedikamentozuri mkurnalobis vizitebis sixsire rekomendirebulia yovelkvireuli 60 wuti (ufro xangrzlivi seansebi SesaZloa sawiro iyos eqspoziciuri TerapiisaTvis) individualuri Yyovelkvireuli pirveli Tvis ganmavlobasi da Semdeg yovel or kvirasi Aaseve ganixileba Oorjer kvirasi > 60 wutze an 45 wuti individualuri, jgufuri an ojaxuri Terapiis kombinireba Yyovelkvireuli 3 Tvis ganmavlobasi an yovel or kvirasi 3 Tvis ganmavlobasi gaidlaini 4: sawyisi medikamentis SerCeva 4 A: medikamentebis upiratesi klasebi sxvadasxva samizne simptomebisatvis TiTqmis yvela SemTxvevaSi eqspertebi upiratesobas aniweben axali Taobis antidepresantebs, iseti rogoric aris seleqtiuri serotoninis ukumitacebis inhibitorebi (SSRI). Ggunebganwyobis stabilizatorebi aseve SeiZleba iyos gamoyenebuli garizianebadobisa da agresiis problemebis mosaxsnelad. Baseve benzodiazepinebi SeiZleba iyos efeqturi xanmokle droit gamoyenebisas, magram unda iqnas danisnuli sifrtxilit wamaldamokidebulebis problemebis riskis gatvaliswinebit. upiratesad gamoxatuli rekomendirebuli simptomi medikamenti akviatebuli fiqrebi SSRI Nnefazodoni venlafaqsini Aaseve ganixileba tricikluri antidepresantebi 105

106 flesbeqis epizodebi SSRI Nnefazodoni venlafaqsini travmastan dakavsirebuli SiSi, SSRI panika da gandevnis simptomebi Nnefazodoni venlafaqsini tricikluri antidepresantebi tricikluri antidepresant ebi benzodiazepine bi (mag., klonazepami) zogadi SfoTva (mowarbebuli SSRI tricikluri sifxizle, SekrToma, gafaciceba) Nnefazodoni antidepresantebi venlafaqsini benzodiazepinebi antiadrenerguli buspironi gayinva /sxvebze SSRI tricikluri damokidebuleba/interesebis Nnefazodoni antidepresantebi dakargva venlafaqsini Ddisociaciuri simptomebi SSRI Nnefazodoni venlafaqsini Tricikluri antidepresantebi Zilis darrveva trazodoni zolpidemi Bbenadrili tricikluri antidepresant ebi benzodiazepine bi garizianebadoba/agznebadoba/sib SSRI Gunebganwyobis 106

107 brazis afetqebebi Nnefazodoni venlafaqsini koncentraciis gazneleba SSRI Nnefazodoni venlafaqsini danasaulisa da sircxvilis SSRI gancda Nnefazodoni venlafaqsini stabilizatorebi (mag., divalproeqsi) tricikluri antidepresantebi antiadrenerguli tricikluri antidepresantebi tricikluri antidepresantebi 4. C: adeqvaturi sawyisi medikamentozuri kursis gansazrvra iqamde vidre ganvsazrvravdet medikamentozuri mkurnalobis rezistentobis mizezebs, unda vicodet darwmunebit, rom medikamentis doza da kursis xangrzlivoba sworad iyo gansazrvruli. xsir SemTxvevaSi pacienti Rebulobs sxadasxva medikaments, magram arasistematurad adeqvaturi kursis mixedvit, rac ar azlevs klinicists imis sasulebas sworad gansazrvros, micemuli medikamenti moqmedebs Tu ara miznobrivad. Eeqspertebi rekomendacias uweven, rom im pacientebs, romeltac aqvt nawilobrivi pasuxi mkurnaloibaze, daetmos meti dro mkurnalobisatvis, vidre mat vis SemTxvevaSic pasuxi ar iqna mirebuli. Ddrois xangrzlivoba vidre SevcvlideT medikaments an davamatebdet sxva medikaments Aar aris efeqturi Nnawilobriv efeqturia antidepresanti 6 kvira 8 kvira antifsiqotiki 3 kvira 4 kvira benzodiazepini 2 kvira 3 kvira buspironi 4 kvira 5 kvira 107

108 Gguneb ganwyobis stabilizatorebi 4 kvira 6 kvira antiadrenerguli 2 kvira 3 kvira gaidlaini 9: medikamentebis dozireba warmodgenil cxrilsi Sejamebulia eqspertebis mier rekomendirebuli dozebi. es aris zogadi saxelmzrvanelo da rekomendirebulia ufro meti informaciisatvis Sesabamisi farmakologiuri teqstebisa da saxelmzrvaneloebis gacnoba. klinikuri gadawyvetileba aris aucilebeli, rata ganvsazrvrot dozireba specifikur pacientebsi, gansakutrebit bavsvebsi,. moxucebsi, pacientebsi Tanmxlebi aslilobebita da aseve kombinirebul mkurnalobaze myof pacientebsi. medikamenti Mmwvave faza * sasualo samizne doza (mg. dre) SSRIs Citalopram (Celexa) fluoxetine (Prozac) fluvoxamine (Luvox) paroxetine (Paxil) sertraline (Zoloft) Other antidepressant s nefazodone (Serzone) venlafaxine (Effexor XR) Yyvelaze sawyisi dozebi mozrdilebsi (mg. dre) mozrdili bavsvebi xansisesuli marali dozebi (mg. dre)

109 Mood stabilizers divalproex (Depakote) Antipsychotics haloperidol (Haldol) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) Anti-anxiety medications buspirone (BuSpar) alprazolam (Xanax) clonazepam (Klonopin) pacientebsi wamaldamokidebulebis problemebit, an/da amgvari problemebis istoriit rekomendirebulia sifrtxilit gamoyeneba. (gamosvebis formis gatvaliswinebit) eqspertta rekomendaciit ar gamoiyeneba *rekomendirebuli SemanarCunebeli dozebi, romelic rogorc wesi eqvivalenturia mwvave fazis dozebis (gamosvebis formis gatvaliswinebit) gaidlaini 10: damyolobis gazrda pacientis sruli TanamSromloba mkurnalobis processi xsirad gadamwyveti mnisvnelobisaa. mocemuli cxrili warmoadgens eqspertta rekomendacias Terapiuli urtiertobebis gaumjobesebis Sesaxeb da pacientis rolis gazlierebaze mkurnalobis processi. 109

110 strategiis tipi zogadi rekomendacia fsiqoganatleba pacienttan samkurnalo intervenciis racionalobis xsiri ganxilva mkurnalobis SerCevisas mxedvelobasi unda iqnas mirebuli, Tu ras aniwebs pacienti upiratesobas unda iqnas CarTuli natesavi an mnisvnelovani pirovneba mkurnalobis adreul stadiaze programuli medikamentozur mkurnalobaze myofi pacientebisatvis wamaldamokidebulebis problemis Seswavla da mkurnaloba swarafi da advilad xelmisawvdomi mkurnalobis uzrunvelyofa medikamentis SerCeva gverditi movlenebisadmi tolerantobis gatvaliswinebit daviwyot dabali dozidan da nela avwiot doza, rata tavidan avicilot gverditi efeqti gaidlaini 11: ptsa s prevencia da qronizaciis Tavidan acileba prevenciis wveti (uncia) xsirad udris mkurnalobis zrvas (funts). adamianebis daxmarebam, eqstremalur stresorze TavianT myisier reaqciebs efeqturad miudgnen, SeuZlia kargad aicilos Tavidan ptsa mtlianad an rogorc minimum Seamoklos simptomta xangrzlivoba. yvalas visac uvitardeba eqstemalur stresorze simptomebi, eqspertebi rekomendacias 110

111 uweven, uzrunvelyofil iqnan fsoqo ganatlebit, normalizebis pirobebit, danasaulis gancdidan gantavisuflebita da emociuri katarzisit. Tu simptomebi 1 Tveze met xans grzeldeba, eqspertebi izlevian rekomendacias damatebit gamoyenebul iqnas specifikuri fsiqoterapiuli teqnikebi da mowodebuli medikamentozuri Terapia, rata Tavidan iqnas acilebuli qronizaciis problema. rekonediacia Pptsa s prevencia pacientebsi mwvave stresuli aslilobit Ffsiqo- ganatlebis uzrunvelyofa Mmovlenaze reaqciis normalizeba iracionaluri TviTdanaSaulis gancdis Semsubuqeba movlenis emociuri gacocxlebisa da xelaxali gadmocemis xelsewyoba Qqronikuli simptomebis prevencia pacientebsi mwvave ptsa - Ti Ffsiqo- ganatlebis uzrunvelyofa Mmovlenaze reaqciis normalizeba iracionaluri TviTdanaSaulis gancdis Semsubuqeba movlenis emociuri gacocxlebisa da xelaxali gadmocemis xelsewyoba kognitiuri Terapia eqspoziciuri Terapia SfoTvis martvis teqnikebi Aaseve ganixileba SfoTvis martvis teqnikebi jgufuri krizisuli intervencia kognitiuri Terapia mkurnalobis antidepresantit dawyeba 111

112 danarti # 2: warmodgenilia gamokvlevisa da reabilitaciis anketa, romelic SemuSavebulia centri «empatia»s mier da asaxavs identifikaciis, monitoringisa da reabilitaciis yvela komponents: danarti #2 wamebis msxverplta monitoringisa da reabilitaciis samedicino da fsiqo - socialuri programa I. anketuri monacemebi 1. saxeli, gvari anonimurobis SemTxvevaSi gadadit 2 punqtze. 2. kodi G - XX - 000N 3. gamokvlevis TariRi 4. sqesi mdedr. / mamr. 5. asaki 6. erovneba: 7. moqalaqeoba 8. amjamindeli adgilsamyofeli 9. mudmivi sacxovrebeli adgili 10. amjamindeli statusi devnili patimari yofili patimari sxva (miutitet) II. wamebis istoria 1. wamebis msxvepli / 1.1. aris ara eswreboda natesavebis an ojaxis wevrebis wamebas eswreboda sxvis wamebas. 2. wamebis adgili / 2.1. policiis izolatori cixis izolatori usisroebis izolatori jaris izolatori samxedro konfliqtis zonasi yofnisas sxa (miutitet) 3. wamebis TariRi da xangrzlivoba 112

113 4. wamebis intensivoba / 4.1. sistematiuri ertjeradi. 5. vis mier iqna ganxorcielebuli / 5.1. policiis mxridan Zalovani sxva struqturis mxridan (romeli miutitet) 5.3. erti adamianis mier jgufis mier (jalatebis jgufi Tu sxva miutitet). 6. saxelmwifo moxelis davalebit 7. sxva (miutitet vis mier da ra vitarebasi) 8. eswreboda Tu ara eqimi an sxva samedicino personali 9. irebda Tu ara monawileobas samedicino personali 10. wamebis mizani / informaciis mireba danasaulis ariareba damatebiti danasaulis (an romelic ar Caudenia) ariareba fulis gamozalva pirovnuli damcireba pirovnebis damorcileba, datrgunva ideologiuri Sexedulebebi armsarebloba etnikuri kutvnileba mwamebelta sadisturi tendenciebi sxva (arweret) damatebiti informacia arweret 1. fizikuri metodebi III. gamoyenebuli metodebi 1.1. cema ("dubinkebit", CeqmebiT, iararis tarit, sxva blagvi sagnit, xelit sxva) - gaxazet romeli. a) sistematizirebuli b) arasistematizirebuli 1.2. eleqtrodenit wameba a) piris Rrudan b) sasqeso organoebidan (an mkerdi) g) kidurebidan (falangebi) d) sxva (miutitet) Camokideba 1.4. arafiziologiuri mdebareoba 1.5. seqsualuri wameba a) gaupatiureba b) gasisvleba g) izulebiti ananizmi d) izulebit monawileoba sxvis gaupatiurebasi e) damamcirebeli pozis mireba v) sasqeso organoebis dazianeba z) sxva (miutitet) samedicino - stomatologiuri wameba (kbilebis dazroba da a.s.) 1.7. moxrcoba (airwinari an wyalsi Cayuryumalaveba TaviT - arnisnet romeli) ki Ara 113

114 1.8. farmakologiuri wameba (narkotikit an sxva preparatit - SeZlebisdagvarad miutitet, an ar icis riti) 1.9. daris dasma (frcxilebis dazroba, falangis mowra, yuris mowra, Tvalis amotxra, xorcebis atla, sxva (miutitet romeli an arweret sxva) damwvroba (sigaretit, cxeli SanTiT, gavarvarebul "resotkaze" dakvra, sxva - miutitet romeli an arweret sxva cxovelebit wameba (ZaRlebis miseva da a.s.) sxva (arweret) miutitet damatebiti informacia miutitet, iqna Tu ara gamoyenebuli iseti metodebi, romelnic ar toveben fizikur kvals, romeli arweret 2. fsiqologiuri metodebi 2.1. deprivacia, izolacia ki ara 2.2. sibnele, Jangbadis nakleboba, sicive 2.3. cxovelebi (mrrrnelebi), mwerebi izolatorsi sanitaruli pirobebis uqonloba 2.5. sakansi agentis arseboba 2.6. sxva wamebis msxverplebtan yofna 2.7. sxvisi wamebis xmebis gageba 2.8. sxvis wamebaze daswreba 2.9. megobris an ojaxis wevris wameba Zilisi deprivacia wamebis gaurkveveli molodini muqara: 1. gaupatiurebis. 2. ojaxis darbevis. 3. ojaxis wevris wamebis. (arnisnet romeli an daamatet da arweret sxva sityvieri Seurachyofa, dasineba, damcireba cru sikvdilit dasja sasmeli wylisa da sakvebis ar micema bunebrivi motxovnilebebis dakmayofilebis SezRudva ararealuri arcevani (ariareba, gacema, Sekvra muqaris qves - miutitet romeli an daamatet) samedicino daxmarebis uqonloba sxva (arweret) damatebiti informacia arweret IV. mwvave Sedegebi 1. fizikuri Sedegebi 1.1. Tavis tvinis mwvave travma gonebis dakargvit ki ara 1.2. Wriloba (Tavis aresi, saxisa da kisris aresi, mkerdis 114

115 aresi, zurgis aresi, kidurebze sxva - miutitet) damwvroba (Tvais aresi, saxisa da kisris midamosi, mkerdis aresi, zurgis aresi, kidurebze, falangebze, kanze Tu lorwovan garsze an sxva aresi miutitet) mwvave sisxldena (miutitet saidan) motexiloba (saxis Zvlebis, kidurebis, falangebis, sxva - miutitet) tkivilit gamowveuli Soki 1.7. gul - sisxlzarrvta mwvave ukmarisoba (infarqti, stenokardia) 1.8. suntqvis ukmarisoba 1.9. Tirkmlis mwvave ukmarisoba infeqciuri daavadeba sasqeso organoebis dazianeba nerv - kuntovani dazianeba (parezi, kruncxva, myesebis dazianeba) dajejiloba (miutitet midamo) mxedvelobis dazianeba smenis aparatis dazianeba sxva (arweret) miutitet mwvave fazis xangrzlivoba 2. fsiqikuri reaqciebi 2.1. afeqtur - Sokuri reaqcia a) stuporozuli varianti (Sekaveba, garindebuli yofna ert pozasi, umweobisa da sicarielis SegrZneba, Zilis darrveva - miutitet da arweret b) mwvave agzneba (ajitaciit, suiciduri aqtivobit, parasuicidi, TviTdazianeba - mcdeloba Tu survili, Zilis darrveva, fsiqo - motoruli agzneba - arweret g) cnobierebis Secvla (gabrueba, Seviwroeba, Secvla sxva - arweret ki ara 115

116 2.2. gamyavit calke _ suicidis mcdeloba, suicidaluri azrebi, TviTdazianebis mcdeloba, TviTdazianebis faqti, TviTdazianebis azrebi - (arnisnet romeli da arweret) sxva (arweret gancdebi) miutitet mwvave fazis xangrzlivoba V. samedicino daxmareba mwvave periodsi 1.1. samedicino daxmareba armoecina wamebistanave 1.2. samedicino daxmareba armoecina kvalis dafarvis miznit 1.3. samedicino daxmareba armoecina im miznit, rom SeeSindaT ar momkvdariyo 1.4. samedicino daxmareba ar armocenia 1.5. arakvalificirebuli daxmareba armoucines sxva patimrebma an sxva adamianebma 1.6. iqna Tu ara gaformebuli samedicino dokumentaciasi misi mdgomareobis Sesaxeb da Tu ris Sedegad ganvitarda arnisnuli dazianeba 1.7. patimrebis SemTxvevaSi: cixeze gadmoyvanis Semdeg inaxula Tu ara samedicino komisism da ariwera Tu ara mati mdgomareoba samedicino dokumentaciasi 1.8. visgan Sedgeboda samedicino komisia, eswreboda Tu ara fsiqiatri 1.9. ganacxada Tu ara vinmestan, rom igi wamebis msxverplia Tu ganacxada vistan da ra reagireba mohyva Tu ar ganacxada, ra mizezit ra saxis gamokvlevebi an mkurnaloba iqna Catarebuli da ra periodsi VI. wamebis qronikuli Sedegebi 1. fizikuri Sedegebi 1.1. arenisneba Tu ara pacients Srami an nawiburi an sisxlnajrenti 1.2. Tu arenisneba, ra midamosi saxe Tavis are kisris midamo mkerdi zurgi sasqeso organoebi piris Rru muceli 116

117 kidurebi falangebi sxva 1.3. arenisneba Tu ara pacients motexilobis kvali (mozraobis SezRudva da a.s) 1.4. Tu arenisneba ra midamosi saxis Zvlebi xerxemlis malebi kidurebi falangebi sxva 1.5. arenisneba Tu ara amputaciis kvali 1.6. Tu arenisneba ra midamosi cxviri yuri TiTebi kidurebi kbilebi frcxilebi sasqeso organoebi sxva 1.7. arenisneba Tu ara pacients nevrologiuri darrvevebi 1.8. Tu arenisneba ra saxis Tavis tkivili mozraobis SezRudva nevralgia parezi parestezia, mgrznobelobis daqveiteba patologiuri refleqsebi miutitet ra midamosi 1.9. arenisneba Tu ara qronikuli tkivilis sindromi Tu arenisneba ra midamosi saxis aresi kisris, zurgisa da Tavis midamo mkerdis aresi muclis aresi Tirkmelebis saproeqcio aresi sasqeso organoebis midamosi mtels sxeulsi sxva tkivili mwvavdeba amindis cvlilebisas tkivili mwvavdeba sezonurad tkivili mwvavdeba travmastan asocirebulad (travmis mogoneba, travmastan dakavsirebuli TariRebi da a.s.) miutitet sxva somaturi darrvevebi ganvitarebuli wamebis Semdeg gul - sisxlzarrvta sistema sasuntqi sistema 117

118 alergiuli daavadebebi infeqciuri daavadebebi simsivneebi sawmlis momnelebeli sistema Sard - sasqeso sistema mxedvelobis sistema yel - yur - cxviri endokrinuli sistema sxva mimarta Tu ara samedicino daxmarebisatvis vinmes Tu mimarta an mimartvis garese Cautarda Tu ara samedicino daxmareba ra saxis samedicino daxmareba Cautarda (operacia, konservatoruli mkurnaloba Tu sxva) aris Tu ara asaxuli samedicino dokumentaciasi sadme misis mdgomareoba Cautarda Tu ara obieqturi gamokvlevebi Tu Cautarda sad, rodis da ra saxis sawiroebs Tu ara damatebit gamokvlevasa da mkurnalobas (operacias an sxva) 2. fsiqo - somaturi darrvevebi 2.1. arteriuli wnevis labiloba (hipertenzia, hipotonia) 2.2. tkivilebi gulis aresi 2.3. haeris ukmarisoba periodulad 2.4. menstrualuri ciklis darrveva 2.5. naadrevi klimaqsi 2.6. libidos daqveiteba an sxva cvlileba 2.7. wonasi dakleba an momateba 2.8. oflianoba 2.9. hipersalivacia an piriqit hiposalivacia (piris gasroba) Zilis darrveva Tavbrusxveva, koordinaciis darrveva kuntovani dazabulobis SegrZneba smenis daqveiteba, yurebsi Suili mxedvelobis daqveiteba advilad darla zogadi saerto sisuste kankali cieb - cxeleba hiperhidrozi Sardis gamoyofis gazliereba an Semcireba diarea an yabzoba sxva 118

119 3. fsiqikuri simptomebi 3.1. uziloba da Ramis kosmarebi 3.2. depresia 3.3. agresia 3.4. disforia 3.5. emociuri labiloba 3.6. SiSebi 3.7. SfoTva 3.8. dazabuloba 3.9. mowarbebuli sifxizle yuradrebis koncentraciis unaris daqveiteba mexsierebis daqveiteba akviatebuli mogonebebi, warmodgenebi afeqturi reaqciebi travmastan asocirebuli situaciebisa da mogonebebis dros pirovnuli cvlilebebi (samyarosadmi mtruli ganwyoba, undobloba, kontaqtebis gartuleba, xmauris autanloba, martoobis survili, Caketiloba, TviTdazianebisaken midrekileba, suiciduri azrebi an qmedebebi, sircxvilis an sakutari pirovnebisadmi pativiscemis dakargva, umweobis gancda, sxva) miutitet da arweret gamorvizebisas gancda, rom kvlev meordeba matravmirebeli movlena halucinaciuri gancdebi matravmirebeli movlenis asaxvit 3.17.sxva VII. damatebiti travmebis istoria (es Tavi ivseba wamebis ar arsebobis SemTxvevaSic, an ojaxis wevris SemTxvevaSic) damatebiti travmebi arnisvna, komentari sad da rodis Oomis travmebi Aaxloblebis darupva Oojaxis wevrebis darupva saxlis mitoveba/dakargva Dojaxis devna/seviwroeba Aaxloblis an ojaxis wevris gaucinareba mzime socialuri pirobebi migraciis Sedegad ucxo moxvedra/migracia samsxuris dakargva/socialuri garemosi rolis dakargva ojaxis wevrebtan 119

120 deprivacia daqvriveba, daobleba, Svilis darupva Ppatimroba, tyveoba izolacia, kontaqtebis SezRudva xsiri konfliqtebi ojaxsi samedicino daxmarebis nakleboba Ggadavsebul kamerasi yofna Kkonfliqtebi cixesi/kamerasi socialuri samsaxurebis uyuradreboba sxva VIII. Civilebi 8.1 fizikuri/somaturi 8.2. fsiqikuri 8.3. socialuri/iuridiuli problemebi IX. anamnezi (yvela daavadebis mititebit, rac warsulsi hqonda gadatanili, miutitet daavadebis an travmis dro, saxeoba da sxva detalebi; aseve unda mititebuli iyos vis mier aris mowodebuli anamnezi) X. obieqturi statusi pirveladi gasinjvisas somaturi statusi: P T/A T fsiqikuri statusi: aris Tu ara misi mdgomareoba asaxuli warsulsi arsebul samedicino dokumentaciasi sakmarisad (miutitet dokumentebi da sakmarisi iyo Tu ara Catarebuli gamokvlevebi da mkurnaloba) XI. fsiqologiuri kvlevis Sedegebi mozrdiltatvis 1. harvardis travmis Sefasebis kitxvari 2. PTSD kitxvarebi (Watson; Mississipi Civilian PTSD) 3. hamiltonis depresiis kitxvari 4. bekis depresiis kitxvari 5. Sixanis SfoTvis Skala 6. baas - darkis agresiis kitxvari 120

121 7. MMPI 8. sawiroebis SemTxvevaSi sxva kitxvarebi bavsvebsi 1. PTSD 2. xelis testi 3. luseris testi 4. sawiroebis SemTxvevaSi sxva daskvna: winaswari diagnozi: somaturi: fsiqologiuri/fsiqikuri XII. Ppirveladi gamokvlevis daskvna da winaswari diagnozi XIII. rekomendaciebi 1. fsiqoterapia (individualuri, jgufuri, ojaxuri) 2. art Terapia 3. socialuri Terapia 4. specialistta konsultaciebi (miutitet romeli) 5. laboratoriuli da paraklinikuri gamokvlevebi (miutitet romeli) 6. damatebit konsultaciata da gamokvlevata winaswari ganfaseba (lari/dolari) 7. winaswari diagnostirebisa da konsultaciebis Catarebisas ganxoecielebuli vizitebis raodenoba: 7.1. SemTxvevis martveli (fsiqiatri/terapevti) 7.2. Terapevti an fsiqiatri 7.3. nevrologi 7.4. travmatologi 7.5. sxva miutitet romeli 7.6. socialuri musaki 7.7. eqtani xelmowera: SemTxvevis martveli / / centris xelmzrvanelebi: 121

122 XIV. Catarebul konsultaciata da gamokvlevata Sedegebi 1. konsultaciata Sedegebi: (CaakariT damatebiti furceli) 2. laboratoriul da paraklinikur gamokvlevata Sedegebi (CaakariT daskvnebi) 3. SemTxvevis martvelis ganmeorebiti konsultacia da SemTxvevaze momusave jgufis daskvna (vin irebda monawileobas da ra iqna wamyvani simptomebidan gamovlenili) XV. daskvna fsiqo - fizikuri mdgomareobis Sesaxeb XVI. saboloo diagnozi somaturi/nevrologiuri fsiqikur/fsiqologiuri XVII. danisnuleba (sawiroebis SemTxvevaSi CaakariT damatebiti furceli) 1. farmakoterapiuli mkurnaloba (CaakariT danisnulebis /dinamikasi) furceli 2. ganmeorebiti konsultaciebi (specialistta mititebit) 3. fsiqoterapia (individualuri, jgufuri, ojaxuri) 4. art Terapia 5. socialuri Terapia 6. gansazrvret mkurnalobisa da reabilitaciis kursis xangrzlivoba TariRi: xelmowera: SemTxvevis martveli / / centris xelmzrvanelebi: 122

123 XVIII. mkurnaloba da reabilitacia 1. SemTxvevis wamyvanis Canawerebi (sawiroebis SemTxvevaSi CaakariT damatebiti furceli), aseve sawiroebis SemTxvevaSi CaakariT damatebitoi kvlevebisa da konsultaciebis Sedegebi) 1 viziti 2 viziti 3 viziti 4 viziti 5 viziti 6 viziti 7 viziti 8 viziti da a.s. 2. fsiqoterapiis sessiebis raodenoba da Canawerebi (CaakariT damatebiti furceli) 3. art Terapiis sesiebis raodenoba da Canawerebi (CaakariT damatebiti furceli) 4. socialuri Terapiis RonisZiebebi da Canawerebi (CaakariT damatebiti furceli) 5. fsiqologis konsultaciebi (raodenoba, CaakariT Canawerebi) 6. iuridiuli konsultaciebi (raodenoba, CaakariT Canaweri) XIX. evaluacia (Sefaseba) XIX.1 ganmeorebiti fsiqologiuri konsultacia mozrdilebsi 1. PTSD (Watson) 2. Beck Depression Inventory 3. Mississipi Civilian PTSD: 4. Baas Durky Aggressive Test 5. Shikhan Anxiety Test 6. Hamilton Depression Questionnaire 7. MMPI 8. Other -- bavsvebsi 1. PTSD 2. Lusher Test 3. Hand Test 123

124 XIX.2. pacientis subieqturi Sefasebis kitxvari (gtxovt CaakraT) XIX.3. SemTxvevis martvelisa da SemTxvevaSi monawile jgufis wevrta daskvna pacientis fsiqo fizikur mdgomareobaze mkurnalobis Semdeg XX. Semdgomi rekomendaciebi Terapiuli fsiqologiuri socialuri/iuridiuli sxva (miutitet ra saxis) TariRi: xelmowera: SemTxvevis martveli / / centris xelmzrvanelebi: / / XXI. Catarebuli mkurnaloba da reabilitacia (epikrizi) SemTxveva: klientis kodi: Semosvlisa da gaweris TariRi: (sqesi, asaki, erovneba/moqalaqeoba, statusi) 1. msxverplis personaluri istoria _ ra konteqstsi iyo nawamebi - vin uyo Cabmuli am wamebasi - ra metodebi iqna gamoyenebuli (fizikuri, fsiqologiuri) - wamebis Sedegebi (fizikuri, fsiqikuri/fsiqologiuri) 2. organizaciis mier gaweuli daxmareba - rogor moxvda am organizaciasi - ra saxis daxmareba gaewia fsiqiatris konsultacia (ramdeni) fsiqologis konsultacia (ramdeni) fsiqoterapia (saxeoba, ramdeni sessia) socialuri Terapia (saxeoba ra gauketda, sesiata raodenoba) Terapevtis konsultacia (ramdeni) travmatologis konsultacia nevrologis konsultacia farmakoterapia Catarebuli gamokvlevebi damatebiti sxva saxis konsultaciebi - SemTxvevis martvis wevrebis (Tanamdebobebi) 124

125 - sad Cautarda mkurnaloba (miutitet dawesebulebebic sadac damatebiti gamokvlevebi da konsultaciebis iqna Catarebuli) - Catarebuli RonisZiebebis saboloo ganfaseba (xelfasiani Statebis garda) lari/dolari/evro 3. Sedegebi - ra Sedegebi iqna mirweuli 4. momavali daxmarebis gegma - apirebs Tu ara Semdgomi daxmarebis gagrezelebas organizacia - ra saxis daxmareba aris rekomendirebuli da igegmeba - ra xangrzlivobis daxmarebaa rekomendirebuli - ra Sedegebia mosalodneli TariRi: xelmowera: SemTxvevis martveli : / / centris xelmzrvanelebi: / / komentarebis furceli 125

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130 nawili II fizikuri sakitxebi levan labauri - medicinis mecnierebata kandidati, Tbilisis saxelmwifo samedicino universitetis operaciuli qirurgiis asistent profesori, saqartvelos eqimta asociaciis generaluri mdivani, gaertianebuli erebis ganvitarebis programis (UNDP) samedicino eqserti, wamebis msxverplta reabilitaciis centr empatia s konsultanti qirurgi Address: 7 Asatiani Str. Tbilisi, 0177, Georgia Phone: + ( ) Fax: + ( ) E mail : levan@tsmu.edu / levanlabauri@ombudsman.ge URL: rusudan beriasvili - medicinis mecnierebata kandidati, Tbilisis saxelmwifo samedicino universitetis sasamartlo medicinis asocirebuli profesori, saqartvelos sasamartlo eqimta asociaciis generaluri mdivani Address: 33 Vazha-Pshavela Avenue. Tbilisi, 0177, Georgia Phone: + ( ) E mail : rusudan29@yahoo.com 130

131 თავი 1 sasamartlo samedicino eqspertiza saqartvelosi asist. profesori - levan labauri gaertianebuli erebis ganvitarebis programis (UNDP) proeqtis saxalxo damcvelis aparatis gazliereba samedicino eqsperti, medicinis mecnierebata kandidati sasamartlo medicina - aris mecniereba, romelic ixilavs, amusavebs da wyvets yvela im samedicino-biologiur sakitxs, romelic arizvreba iuridiuli organoebis winase gamoziebis an sasamartlos mimdinareobis processi sisxlis samartlis an samoqalaqo saqmeebis ganxilvis dros. sasamartlo samedicino eqspertiza - aris kanonit gansazrvruli da eqimis mier Catarebuli gamokvlevebi Cadenili danasaulis irgvliv warmosobili konkretuli samedicino sakitxebis gadasawyvetad, e.i. sasamartlo samedicino eqspertiza sasamartlo medicinis praqtikuli nawilia. im pirs, romelic awarmoebs sasamartlo saeqsperto gamokvlevas da izleva daskvnas, eqsperti ewodeba. saqartvelos kanoni janmrtelobis dacvis Sesaxeb ganmartavs, rom sasamartlo samedicino eqspertiza es aris saproceso moqmedebis warmoebisas wamowrili samedicino biologiuri sakitxebis dadgenis procesi. imave kanonis mixedvit, sasamartlo samedicino da sasamartlo fsiqiatriuli eqspertizis Catareba satanado licenziis mqone samedicino dawesebulebasi SeuZlia mxolod Sesabamisi specialobis mqone eqims. sasamartlo medicinis ganvitareba saqartvelosi: daiwyo sasamartlo reformis (1864) SemoRebis Semdeg; mis umarles organos 1917 wlamde warmoadgenda mefisnacvalis kancelariastan arsebuli samoqalaqo medicinis sammartvelo; 1920 wels centraluri klinikuri saavadmyofos prozeqturis bazaze daarsda saxelmwifo universitetis samedicino fakultetis patanatomiis katedra, 1922 wlidan ki - sasamartlo medicinis katedra wlidan sasamartlo samedicino eqspertiza Sedis janmrtelobis dacvis sistemasi, kerzod yalibdeba jandacvis komisariatis sasamartlo samedicino ganyofileba; 1941 wels Seiqmna Tbilisis saxelmwifo samedicino institutis damoukidebeli sasamartlo medicinis katedra wels saqartvelos ssr jandacvis ministris brzanebit Camoyalibda saqartvelos sasamartlo samedicino eqspertizis biuro; 2004 wlis dekembridan sasamartlo samedicino eqspertizs samsaxuri gadaeca saqartvelos iusticiis saministros. 131

132 sasamartlo medicinis samsaxuris struqturisa da regulirebis Sesaxeb saqartvelos prezidentis da saqartvelos iusticiis ministris mier gamocemulia araerti normatiuli aqti. mat Soris arsanisnavia Semdegi brzanebulebebi da brzanebebi: saqartvelos prezidentis brzanebuleba #136, 2000 wlis 8 aprili. saqartvelos janmrtelobisa da socialuri dacvis sistemasi sajaro samartlis iuridiuli pirebis Camoyalibebis Sesaxeb (Zaladakargulia - iusticiis ministris 12/08/2004 N 1549 brzanebit) saqartvelos iusticiis saministros eqspertizisa da specialur gamokvlevata centris debuleba (Zaladakargulia biuros debulebis damtkicebis Sesaxeb saqartvelos iusticiis ministris brzanebis ZalaSi SesvlisTanave) saq. prezidentis 11/04/2004 N 482 brzanebulebit saqartvelos prezidentis brzanebuleba # wlis 9 seqtemberi q.tbilisi - saqartvelos janmrtelobisa da socialuri dacvis sistemasi sajaro samartlis iuridiuli pirebis Camoyalibebis Sesaxeb saqartvelos prezidentis 2000 wlis 8 aprilis N136 brzanebulebasi cvlilebis Setanisa da sajaro samartlis iuridiuli piris - sasamartlo-samedicino eqspertizis centris debulebis damtkicebis Sesaxeb saqartvelos iusticiis ministris brzaneba N wlis 8 dekemberi q. Tbilisi - sajaro samartlis iuridiuli piris - sasamartlo eqspertizis erovnuli biuros debulebis damtkicebis Sesaxeb sajaro samartlis iuridiuli piris - sasamartlo eqspertizis erovnuli biuros debuleba (Zaladakargulia iusticiis ministris 09/04/2006 N 705 brzanebit biuros debulebis damtkicebis Sesaxeb) saqartvelos iusticiis ministris brzaneba N 705, 2006 wlis 4 seqtemberi q. Tbilisi - sajaro samartlis iuridiuli piris levan samxaraulis saxelobis sasamartlo eqspertizis erovnuli biuros debulebis damtkicebis Sesaxeb (Setanilia cvlilebebi). საქართველოს შრომის, ჯანმრთელობისა და სოციალური დაცვის მინისტრის 2007 წლის 21 აგვისტოს ბრძანება N245/ნ - სასამართლო სამედიცინო ექსპერტიზის ჩატარების და სასამართლო სამედიცინო ექსპერტიზის სამედიცინო პერსონალის საქმიანობის წესების შესახებ საქართველოს შრომის, ჯანმრთელობისა და სოციალური დაცვის მინისტრის 2008 წლის 19 ივნისის ბრძანება N 142/ნ სასამართლო ფსიქიატრიული ექსპერტიზის ჩატარების წესის შესახებ საქართველოს კანონი «საჯარო სამართლის იურიდიული პირის ლევან სამხარაულის სახელობის სასამართლო ექსპერტიზის ეროვნული ბიუროს შექმნის შესახებ» (2008 წლის 31 ოქტომბერი.) საქართველოს მთავრობის 2008 წლის 31 დეკმბრის N 267 დადგენილება - საჯარო სამართლის იურიდიული პირის ლევან სამხარაულის სახელობის სასამართლო ექსპერტიზის ეროვნული ბიუროს დებულების დამტკიცების შესახებ saqartvelosi sasamartlo medicinis ganvitarebaze saubrisas aucilebelia arinisnos Tbilisis saxelmwifo samedicino universitetis sasamartlo medicinis katedra (2006 wlidan ewodeba sasamartlo medicinis departamenti ). amjamad departamentis xelmzrvanelia - profesori besarion kilasonia. saqartvelosi aseve moqmedebs saqartvelos sasamartlo eqimta asociacia. asociaciis ZiriTadi mizania saqartvelosi sasamartlo samedicino eqspertizis ganvitarebisatvis xelsewyoba, mosaxleobis uzrunvel-yofa marali xarisxis obieqturi eqspertizebit. 132

133 saqartvelos umarles sakanonmdeblo organos qveynis damoukideblobis mopovebis Semdgom periodsi jerjerobit ar miuria raime sakanonmdeblo aqti, romelic daaregulirebs qveyanasi sasamartlo samedicino eqspertizis Catarebis wessa da pirobebs. sabwota mmartvelobis wlebsi, saqartvelosi moqmedebebda ssrk janmrtelobis dacvis ministris b.v. petrovskis, 1978 wlis 21 ivnisis brzanebit damtkicebuli instruqcia - sasamartlo samedicino eqspertizis warmoebis, sasamartlo samedicino eqspertizis biuros da sasamartlo samedicino eqspertizis sxva normatiuli aqtebis Sesaxeb. arnisnuli brzanebis mixedvit, sasamartlo samedicino eqspertizis organizaciisa da Semdgomi srulyofili warmoebis miznit, aseve, eqspertizis xarisxis gaumjobesebis interesebidan gamomdinare, mtkicdeba instruqciebi sasamartlo samedicino eqspertizis warmoebis, sasamartlo samedicino eqspertizis biuros da sasamartlo samedicino eqspertizis sxva normatiuli aqtebis Sesaxeb (sul 9 danarti). brzanebis ZalaSi Sesvlis paralelurad Zaladakargulad cxaddeba winamdebare 1952 wlis 13 dekembris ssrk jandacvis ministris brzaneba qveyanasi sasamartlo samedicino eqspertizis Catarebis Sesaxeb da 1962 wlis 10 aprilis #166 brzaneba sasamartlo samedicino eqspertizis biuros Sesaxeb wlis 21 ivnisis #694 brzanebit damtkicebuli instruqcia SeTanxmebulia ssrk prokuraturastan, umarles sasamartlostan, iusticiis saministrostan, Sinagan saqmeta saministrostan da ssrk ministrta sabwostan arsebul saxelmwifo usisroebis komitettan. instruqcia - ssrk-si sasamartlo samedicino eqspertizis Catarebis Sesaxeb moicavs 3 Tavs. I Tavi zogadi debulebebi gansazrvravs sasamartlo samedicino eqspertizis miznebsa da amocanebs. instruqciis II Tavi aregulirebs sisxlis samartlis saproceso kanonmdeblobis ZiriTadi mdgomareobebis Sesabamisobas eqspertizis Catarebis westan da organizaciastan. rogorc zemot moyvanili faqtobrivi masalidan Cans qveynis kanonmdebloba sasamartlo samedicino eqspertizis dargsi Zireul cvlilebebs sawiroebs. am mimartebit ukve arsebobs kanonis proeqti sasamartlo samedicino eqspertizis Sesaxeb, Tumca qveyanasi ukanasknel wlebsi ganvitarebulma movlenebma, politikurma da socialur-ekonomikurma fonma ganapiroba rom umarlesma sakanonmdeblo organom - parlamentma jer-jerobit ver daiwyo kanonproeqtis ganxilva. garda warmodgenili instruqciisa, sasamartlo samedicino eqspertizis dargsi arsebul sakanonmdeblo vakuums SeiZleba itqvas rom nawilobriv avsebs saqartvelos sisxlis samartlis saproceso kodeqsi, და 2007 წელს გამოცემული საქართველოს შრომის, ჯანმრთელობისა და სოციალური დაცვის მინისტრის 21 აგვისტოს ბრძანება N245/ნ - სასამართლო სამედიცინო ექსპერტიზის ჩატარების და სასამართლო სამედიცინო ექსპერტიზის სამედიცინო პერსონალის საქმიანობის წესების შესახებ. 133

134 თავი 2 sxeulis dazianebis sasamartlo samedicino eqspertizis sakitxebi პროფესორი ბესარიონ კილასონია თბილისის სახელმწიფო სამედიცინო უნივერსიტეტის სასამართლო მედიცინის დეპარტამენტის ხელმძღვანელი; saqartvelos sasamartlo eqimta asociaciis prezidenti sasamartlo medicinasi dazianebis qves igulisxmeba garese faqtorebis zemoqmedebit organos (qsovilis) anatomiuri mtlianobis darrveva an misi fiziologiuri funqciis mosla, ris gamoc vitardeba janmrtelobis mosla an sikvdili. yvela sasualeba, romlitac SesaZlebelia ganvitardes dazianeba, iyofa: iararebad (sasualebebi, romlebsac specialurad dazianebis an Tavdacvis danisnuleba aqvs) da sagnebad. sagnis xasiatis, misi zedapirisa da dazianebis Taviseburebebis mixedvit ansxvaveben: mkvrivi sagnis moqmedebit, maxvili sagnis da cecxlsasroli iararit miyenebul dazianebebs. blagvi sagnebi Tavisi zomit, formita da masalis SemadgenlobiT mravalgvaria da fartod aris gavrcelebuli rogorc bunebasi, ise warmoebasa da yofacxovrebasi. amitom sasamartlo samedicino praqtikasi arnisnuli sagnebit miyenebuli dazianebebi sakmaod xsiria. travma ZiriTadad vitardeba an mozravi blagvi sagnis moqmedebit mosvenebul mdgomareobasi myof adamianze an blagv saganze mijaxebit. mkvrivi-blagvi sagnebis arsebul klasifikaciata Soris SedarebiT misarebad vtvlit popovis mier mowodebul klasifikacias: I. adamianis,,naturaluri iarari: TiTebi, musti, xelisguli, fexi, kbilebi, xseulis sxva nawilebi. II. xelit saxmari blagvi iarari: 1. brtyelzedapiriani blagvi sagnebi: a. fartomoqmedi zedapirit, b. mciremoqmedi zedapirit, g.sereuli moqmedi zedapirit. 2. mrgvalzedapiriani sagnebi: a. cilindruli zedapirit, b. sferuli zedapirit. 3. kutxovanzedapiriani sagnebi: prizmuli, piramiduli, konisisebri. 4. uswormasworo zedapiris mqone sagnebi. III. metad didi sagnebi: manqanata nawilebi, cxovelebi da sxv. IV. simarlidan vardna. maxvili ewodeba sagans, romelsac aqvs maxvili wveri an/da mwreli piri. maxvili sagnebi iyofa: 1. mcxvletavi 2. mwreli 3. mcxvletav-mwreli - a. calmxrivlesili; b. ormxrivlesili 4. mcexavi 134

135 5. mxerxavi. klinikur-morfologiuri Tvisebebis mixedvit arsebobs meqanikuri dazianebis Semdegi saxeebi: nawdevi, sisxlnajrenti, Wriloba, RrZoba, amovardniloba, motexiloba, organoebis mowyveta, gaskdoma, gasresa da sxeulis danawevreba. nawdevi kanis zerele Sris epidermisis dazianebas nawdevi ewodeba; Tu nawdevi arwevs kanis dvrilovan Sres, masin mas Rrma nawdevs uwodeben. misi zedapiri namiani, kriala, mowitalo-movardisfro ferisaa, kanis zedapiridan ase Tu ise amoweulia. xazovani formis nawdevebs ganakawri ewodeba. nawdevidan Cveulebriv sisxldena ar vitardeba, magram Rrma nawdevis SemTxvevaSi limfastan ertad sisxlic gamojonavs. nawdevi tramvidan ramdenime saatis gavlis Semdeg ifareba fufxit. erti-ori dris Semdeg nawdevi TandaTanobiT kanis zedapirs uswordeba da fufxis warmosobis Semdeg kanis zedapiris zemotaa amoweuli. nawdevis epitelizacia fufxis TandaTanobiTi mocilebit iwyeba periferiidan centrisaken. nawdevis alageba damokidebulia sqesze, asakze, mis lokalizaciasa da sxva faqtorze. Tavisa da kisris midamosi arsebuli nawdevebis Sexorcebas swirdeba daaxloebit 12, sxeulis wina zedapirisa da kidurebze , qveda kidurebze - 17 da zurgze dre. lorwovan garsze arsebuli nawdevebi fufxit ar ifareba. am midamosi lorwovani garsis nawili scildeba qvemdebare qsovilis motetro feris garsis saxit da mis adgilas vitardeba zerele wyluli, romelic Zalian male 2-5 dresi xorcdeba. 1. nawdevi, romlis forma damazianebeli sagnis zedapiris negatiuri gamoxatulebaa 2. Rrma nawdevi nawdevis forma da odenoba sxvadasxvanairia. umetes SemTxvevaSi usworo formisaa, zogjel sworxazovani, isviatad varskvlavisebri. zogjer nawdevis forma damazianebeli sagnis zedapiris negatiuri gamoxatulebaa. nawdevis xasiatis da misi formis mixedvit eqspertma SeiZleba imsjelos nawdevis xandazmulobaze, damzianebeli sagnis Taviseburebebsa da sxv. 135

136 sisxlnajrenti sxeulze mkvrivi, blagvi sagnis moqmedebisas kansa da mis qves mdebare rbil qsovilebsi skdeba sisxlzarrvebi, sisxlit ijrinteba qsovilebi, grovdeba kanqves da vlindeba sisxlnajrentis saxit. sisxlnajrentebi pirvel saatebsi sisxlnajrenti mowitalo ferisaa, xolo Semdgom - mowitalo-molurjo, mogvianebit ki - mwvane ferisaa, me-5-6 dres sisxlnajrenti moyvitalo-mwvane fers Rebulobs, me-6-8 dres sisxlnajrenti sami ferisaa: periferiaze - moyavisfro, SuaSi - mwvane elferisa da centrsi - mowitalo-molurjo. mcire zomis sisxlnajrenti or kvirasi mtlianad qreba. sisxlnajrentis feris intesivoba damokidebulia mis zomaze, lokalizaciaze, dazaralebulis asakze da a.s. Rrmad mdebare sisxlnajrentebi SedarebiT ufro gvian gamovlindeba. sisxlnajrentis forma xsirad dazianebuli sagnis negatiuri gamosaxulebaa. Wriloba kanis safaris mtlianobis darrvevas, romelsac Tan sdevs qvemdebare rbili qsovilebis, nervuli bowkoebis, sisxlis ZarRvebis dazianeba, Wriloba ewodeba. RruSi Semavali Wrilobis dros ziandeba, agretve, Sinagani organoebi. moqmedi iararis saxis da agretve tramvis ganvitarebis meqanizmis mixedvit arceven: mkvrivi-blagvi sagnit miyenebul Wrilobebs - dajejil (agretve nafletovani da nakbeni Wrilobebi); maxvili iararebit - nakvet, nacxvlet, nacxvlet-nakvet, nacex; cecxlsasroli iararit - tyviit, safantita da namsxvrevebit miyenebul Wrilobebs. eqspertizisatvis didi mnisvneloba aqvs Wrilobis detalur datvalierebas. yuradreba eqceva lokalizacias, mimartulebas, kideebis xasiats, mis irgvliv arsebul cvlilebebsa da WrilobaSi arsebul ucxo sxeulebis arweras, xolo Semdeg formis, sigrzisa da 136

137 qsovilebis defeqtis dasadgenad Wrilobis kideebi unda mivuaxlovot ertmanets sawyisi mdgomareobis arsadgenad. Wrilobebi Wrilobis sirrmis gasinjva zondit ar SeiZleba, erti mxriv - cocxalze infeqciis SeWris sasisroebis gamo, meore mxriv (gansakutrebit gvamze), qsovilebis SesaZlebeli damatebiti dazianebis gamo. zondit SeiZleba moxdes agretve WrilobaSi arsebuli ucxo sxeulis gadanacvleba, Wrilobis kideebi damatebiti dazianeba, mis irgvliv arsebuli damatebiti faqtorebis wasla da sxv. Wrilobebis Sexorceba damokidebulia qsovilebis vaskularizaciasa da mis inervaciaze. vinaidan is yvela qsovilsi ertnairi intesivobit ar aris gamoxatuli, amitom sxvadasxva qsovilsi Wrilobebis Sexorceba ertnairi siswrafit ar mimdinareobs. ase magalitad, Tavis aresi Wrilobebis Sexorcebas swirdeba sasualod 7 dre, zurgisas - 8, mucelze arsebul Wrilobebs - 10, kidurebisas dre da a.s. inficirebuli Wrilobebis Sexorcebas ki gacilebit meti dro swirdeba. qirurgiuli damusavebis Semdeg mcire zomis Wrilobebi xorcdeba 5-9 dris ganmavlobasi (pirveladi dawimvit), didi zomis da inficirebul Wrilobebs ki - ramodenime kvira an Tveebi (meoradi dawimvit). 1-1,5 Tvis nawiburovani qsovili vardisferi an mowitalo ferisaa, konsistencia rbilia. am periodsi saorientaciod nawiburovani qsovilis SeswavliT SesaZlebelia dazianebis xandazmulobis dadgena Tvis gavlis Semdeg nawiburovani qsovilis mesveobit dazianebis xandazmulobis dadgena SeuZlebelia. dazianebis simzimis xarisxis gansazrvra sxeulis dazianebis gansazrvrisas jer unda davadginot dazianebis simzimis xarisxi, xolo Semdeg ganvsazrvrot dazianebis miyenebis meqanizmi da sasualebebi. sisxlis samartlis danasauls janmrtelobis winaarmdeg ezrvneba saqartvelos sisxlis samartlis kodeqsis XX Tavi. am kodeqsis mixedvit, janmrtelobis ganzrax dazianeba SesaZlebelia iyos mzime, naklebad mzime da msubuqi. 137

138 saqartvelos sisxlis samartlis kodeqsis Sesabamisad, sxeulis dazianebani iyofa sam xarisxad: mzime, naklebad mzime da msubuq dazianebebad. sxeulis dazianebis simzimis xarisxis gansazrvra xdeba dadgenili samedicino kriteriumebit, romeltagan ert-ertis arsebobac sakmarisia simzimis xarisxis gansazrvrisatvis. sxeulis mzime xarisxis dazianebis (saqartvelos ssk, muxli 117) kriteriumebia: 1. dazianebis miyenebis momentsi sicocxlisatvis saxifato dazianebebi, dazaralebulisatvis armocenili samedicino daxmarebis da kargi gamosavlis miuxedavad; 2. mxedvelobis, smenis, metyvelebis an romelime sxva organos an misi funqciis dakargva; 3. travmastan dakavsirebuli fsiqikuri avadmyofoba; 4. travmastan dakavsirebuli orsulobis Sewyveta; 5. saerto Sromisunarianobis myari, aranakleb erti mesamedit dakargva; 6. saxis warusleli damaxinjeba. sicocxlisatvis saxifato dazianebebi ganisazrvreba zemoarnisnul wesebsi arsebuli CamonaTvlis mixedvit. sxeulis naklebad mzime xarisxis dazianebis (saqartvelos ssk, muxli 118) kriteriumebia: sicocxlisatvis arasaxifato dazianebebi, romlebic iwvevs: 1. janmrtelobis xangrzliv moslas (21 dreze met xans); 2. saerto Sromisunarianobis myar dakargvas 10%-dan 33%-mde. sxeulis msubuqi xarisxis dazianebis (saqartvelos ssk, muxli 120) kriteriumebia: 1. dazianebebi, romlebic iwvevs janmrtelobis xanmokle moslas 21 dremde; 2. dazianebebi, romlebic iwvevs saerto Sromisunarianobis umnisvnelo myar dakargvas 10%-mde. sxeulis dazianebis miyenebis Semdeg manamde arsebuli daavadebebis gamwvaveba an sxeulis dazianebis sxva Sedegebi, romlebic warmoisoba SemTxveviTi garemoebebis gavlenit organizmis individuri Taviseburebebis an samedicino daxmarebis arasrulfasovnebis gamo da a.s., sxeulis dazianebis simzimis kvalifikaciis Secvlis safuzvels ar warmoadgens. aset SemTxvevaSi sasamartlo samedicino eqsperti valdebulia daskvnasi arnisnos gauaresebis an gartulebis xasiati da ganmartos, ra mizezobriv kavsirsi imyofeba igi mocemul dazianebastan. Semowmeba iwyeba sxeulis detaluri datvalierebit. sxeulze arsebuli dazianebebis datvalierebis da arweris dros sasamartlo samedicino eqsperti yuradrebas aqcevs dazianebis Semdeg maxasiateblebs: 1. dazianebis xasiats; 2. lokalizacias; 3. formas; 4. zomas; 5. mimartulebas; 6. fers; 138

139 7. reliefs; 8. sirrmes; 9. ucxo sxeulebis arsebobas; 10. dazianebis irgvliv arsebul Taviseburebebs; 11. sisxldenis xasiats; 12. Sexorcebis nisnebs da sxv. eqspertma unda gamoiyenos sxeulis sqematuri gamosaxva (sxeulis konturuli rukebi) yvela dazianebis lokalizaciisa da xasiatis registraciisatvis. gamokvlevas, Cveulebriv, Tan unda axldes fotografia; sawiroebis SemTxvevaSi, sasurvelia, rentgenografiuli, tomografiuli da sxva instrumentuli gamokvlevis monacemebis Tanxlebac. sxeulis dazianebis eqspertizis Sedegad eqspertis daskvnasi gasuqebuli unda iyos: 1. dazianebis xasiati samedicino TvalsazrisiT (nawdevi, sisxlnajrenti, Wriloba, Zvlis motexiloba da sxv.), mati lokalizacia da Taviseburebani; 2. iararis an sagnis tipi, romlitac miyenebuli unda iyos dazianebebi; 3. dazianebis ganvitarebis meqanizmi; 4. dazianebis xandazmuloba; 5. sxeulis dazianebis simzimis xarisxi, kriteriumis arnisvnit sicocxlisatvis saxifato, janmrtelobis mosla, Sromis unaris myari dakargva da a.s. sasamartlo samedicino eqsperti Tavs ikavebs sxeulis dazianebis simzimis xarisxis gansazrvrisagan Semdeg SemTxvevebSi: 1. bundovani klinikuri suratis an dazaralebulis arasakmarisi klinikuri da laboratoriuli gamokvlevis dros; 2. sicocxlisatvis arasaxifato dazianebis gamosavlis bundovanobis dros; 3. damatebiti gamokvlevebis Catarebaze Sesamowmeblis uaris an ganmeorebit Semowmebaze misi gamoucxadeblobis dros, Tu uamisod sasamartlo samedicino eqsperts ar aqvs SesaZlebloba sworad Seafasos dazianebis xasiati, misi klinikuri mimdinareoba da gamosavali; 4. samedicino sabutebis, mat Soris, damatebiti gamokvlevebis Sedegebis ararsebobis dros, romelta garese SeuZlebelia sxeulis dazianebis xasiatze da simzimis xarisxze msjeloba. msgavs SemTxvevebSi sasamartlo samedicino eqsperti Tavis daskvnebsi arnisnavs im mizezebs, romelta gamoc SeuZlebeli gaxda sxeulis dazianebis simzimis xarisxis gansazrvra. sasamartlo medicina sxeulis dazianebis SemTxvevaSi ganixilavs agretve simulacias, disimulacias, agravacias, dezagravacias, asotmavneblobas da TviTdazianebas. asotmavnebloba an TviTdazianeba miekutvneba Tavis Tavze miyenebul dazianebebs mkvrivi blagvi, maxvili, cecxlsasroli iararebit da sxv. aseve SesaZlebelia TviTdazianeba miyenebuli iyos ubeduri SemTxvevisas an fsiqikuri avadmyofobis dros. 139

140 TviTdazianeba zemotqmulis gatvaliswinebit eqims ufleba ara aqvs daweros, rom pirovneba asotmavnebelia an simulanti. eqimma mxolod umda daadginos dazianebis xasiati da warmosobis meqanizmi, an gansazrvros janmrtelobis mdgomareoba. asotmavneblobisa da TviTdazianebis dros sasamartlo samedicino eqspertizam unda gaitvaliswinos: 1. Seswavlili iqnas dazianebis xasiati, dadgindes ra pirobebsi, rogori meqanizmit da rodis ganvitarda dazianeba; 2. ganisazrvros armocenili dazianebis ganvitarebis SesaZlebloba da SeuZlebloba im pirobebsi, romelsac warmoadgens, xolo zogjer gvacvenebs, ewvmitanili Sesamowmebeli. თავი 3 წამების ფიზიკური მტკიცებულებები rusudan beriasvili - sasamartlo medicinis asocirebuli profesori; Tbilisis saxelmwifo samedicino universitetis sasamartlo medicinis departamenti; saqartvelos sasamartlo eqimta asociaciis generaluri mdivani; sasamartlo medicinis saertasoriso akademiis (IALM) wevri; sasamartlo eqspertizis dawesebulebata evropuli qselis dnm jgufis (ENFSI DNAWG) wevri; sasamartlo mecnierebata saertasoriso sazogadoebis (FSS) wevri wameba warmoadgens arahumanuri, adamianuri Rirsebis Semlaxavi mopyrobisa da dasjis ukidures formas. gaeros wamebis sawinaarmdego konvenciis muxli #1-is Tanaxmad wamebis definiciaa: gansazrvreba wameba nisnavs nebismier moqmedebas, romlitac romelime pirs ganzrax ayeneben tkivils an tanjvas, fizikurs an zneobrivs, rata misgan an mesame pirisgan miiron cnobebi an ariareba, dasajon qmedebisatvis, romelic man an mesame pirma Caidina an romlis 140

141 CadenaSic igi ewvmitanilia, agretve daasinon an aizulon igi an mesame piri an nebismieri mizezit, romelsac safuzvlad udevs nebismieri xasiatis diskriminacia, roca aset tkivilsa da tanjvas ayenebs, saxelmwifos Tanamdebobis piri an sxva oficialuri piri, an mati waqezebit, nebartvit da mdumare TanxmobiT. fizikuri wamebis yvelaze gavrcelebuli metodebia: cema; stomatologiuri wameba; Camokideba; arafiziologiuri mdebareoba; eleqtrodenit wameba; mogudva moxrcoba; seqsualuri wameba; farmakologiuri wameba; dardasma; damwvroba da sxv. saqartvelosi moqmedi kanonmdeblobit wamebis SemTxvevaTa sasamartlo samedicino eqspertizas gaacnia garkveuli SezRudebi, razec qvemot mogaxsenebt. saqartvelos sisxlis samartlis saproceso kodeqsis mixedvit, eqspertis winase dasmuli sakitxebi da misi daskvna ar unda scildebodes eqspertis specialuri codnis farglebs (saqartvelos sssk, Tavi 44, muxli 365). Camokideba falanga cema, tkivilebis miyeneba sasamartlo samedicino eqspertis, rogorc umarlesi samedicino ganatlebis mqone piris, kompetencia moicavs mxolod samedicinobiologiur sakitxebs, romlebic arizvreba iuridiuli organoebis winase gamoziebis an sasamartlos mimdinareobis processi sisxlis samartlis an samoqalaqo saqmeebis ganxilvis dros. saqartvelos sssk 358-e muxlis Tanaxmad, sasamartlo samedicino eqspertizis Catareba savaldebuloa sikvdilis mizezis, sxeulis dazianebis xasiatisa da simzimis xarisxis dasadgenad. 141

142 saqartvelosi moqmedi sxeulis dazianebis simzimis xarisxis sasamartlo samedicino gansazrvris wesebis (Tavi IV, $24) mixedvit, sasamartlo samedicino eqsperti ar axdens dazianebis wamebad kvalifikacias. am sakitxis gadawyveta Sedis mokvlevis, winaswari gamoziebis, prokuraturis da sasamartlo organoebis kompetenciasi. sasamartlo samedicino eqspertma unda gadawyvitos mxolod: 1. dazianebis arsebobis faqti da misi xasiati; 2. dazianebis miyenebis xandazmuloba; 3. dazianebis mimyenebeli iarari da dazianebis miyenebis xerxi (samedicino monacemebit); 4. dazianebis simzimis xarisxi. dazianebis miyenebis xerxis qves igulisxmeba: 1. moqmedeba, romelic ayenebs tanjvas sakvebis, sasmelis an sitbos xangrzlivi Sewyvetis gzit, an msxverplis janmrtelobisatvis mavne pirobebsi motavsebit an datovebit da sxva msgavsi moqmedebebi (gvema); 2. moqmedeba, romlis drosac msxverpls miyendeba tkivilebi mravaljeradi an xangrzlivi zemoqmedebit Cqmeta, garozgva, mravlobiti, magram mcire zerele dazianebebis miyeneba blagvi an maxvili iararit, Termuli faqtorebit zemoqmedeba da sxva analogiuri moqmedeba (wameba). aset SemTxvevaSi sxeulis dazianebis simzimis xarisxis sakitxis gadawyvetisas sasamartlo samedicino eqsperti xelmzrvanelobs zemoxsenebuli wesebis Sesabamisi debulebebit. samedicino TvalsazrisiT, sxeulis dazianebad itvleba organoebis da qsovilebis anatomiuri mtlianobis an mati fiziologiuri funqciis darrveva, rac ganvitarda gare samyaros faqtorebis zemoqmedebis Sedegad. cema dazianebis gansakutrebuli saxe ar aris da saqartvelos ssk 125-e muxlit ganisazrvreba, rogorc Zaladoba (dartymebis araertjeradad miyeneba), romelic iwvevs fizikur tkivils, magram ar tovebs dazianebis raime kvals, kerzod, nawdevebs, sisxlcaqcevebs da sxv. Tu cemis Sedegad dazaralebulis sxeulze rceba dazianebis kvali, igi Sefasdeba dazianebis Sesabamisi xarisxit, xolo Tu cemis Sedegad sxeulze dazianebis raime obieqturi nisani ar rceba, masin sasamartlo samedicino eqsperti Tavis daskvnasi arnisnavs Sesamowmeblis Civilebs da miutitebs, rom dazianebis obieqturi nisnebi armocenili ar aris. aset SemTxvevebSi cemis faqtis dadgena miekutvneba momkvlevi, sagamoziebo da sasamartlo organoebis kompetencias. gartyma gulisxmobs saxesi xelis Semokvras, rasac mosdevs am midamos anemia da SemdegSi hiperemia, romelic male ukvalod qreba. Tu Sesamowmebeli gartymidan mcire drois gasvlis Semdeg, araumetes erti saatisa, mivida Sesamowmeblad, SeiZleba nanaxi iqnas kanis hiperemia paralelurad ganlagebuli zolebis saxit, rac warmoadgens gaslili TiTebis moqmedebis kvals. zogjer SesaZlebelia loyis lorwovani garsis qves inaxos sisxlcaqcevebi, gansakutrebit kbilta mwkrivebs Soris darcenili napralis Sesabamisad. savaraudo wamebis Sedegad sxeulis dazianebis xasiatisa da simzimis xarisxis dasadgenad sasamartlo samedicino eqsperti atarebs kompleqsur samedicino gamokvlevas, romelic moicavs klinikur, morfologiur, funqciur, instrumentul da mravali sxva saxis gamokvlevebs, ris 142

143 safuzvelzec igi adgens mecnierulad dasabutebul saeqsperto dakvnas. aseti eqspertizis warmoeba marto samedicino sabutebis (avadmyofobis istoria, ambulatoriuli avadmyofis individualuri barati da sxv.) mixedvit dasasvebia mxolod gamonaklis SemTxvevebSi, da isic srulfasovani sabutebis arsebobisas, romlebic Seicavs amomwurav monacemebs dazianebis xasiatze, mis klinikur mimdinareobaze da eqspertizisatvis sawiro sxva monacemebs. dazaralebulis Semowmebisas eqsperti arkvevs dazianebis miyenebis garemoebebs, Civilebs da, sawiroebis SemTxvevaSi, sxva cnobebs; ecnoba arsebul saqmis masalebs da samedicino sabutebs. saqmis ZiriTadi garemoebebis dasazusteblad man unda gaarkvios: 1. sad da rodis miiro dazianeba Sesamowmebelma; 2. vin miayena dazianeba (gvari, saxeli, sqesi, asaki, fizikuri ganvitareba, garegnoba); 3. ra sagnit da ra meqanizmit miayenes dazianeba (mustit, maxvili an blagvi sagnit, damwvrobit da sxv.); 4. sxeulsi ra nawilsi ayenebdnen dazianebas; 5. dazianebis miyenebis Semdeg pirvel periodsi rogori iyo dazaralebulis mdgomareoba (gonebis dakargva, gulisreva, pirrebineba, Tavbrusxveva, sisxldena); 6. mimarta Tu ara samedicino daxmarebas, romel samedicino dawesebulebas da sxv. samkurnalo dawesebulebis xelmzrvanelebi da eqimebi valdebulni arian sasamartlo samedicino eqspertizis dros sasamartlo samedicino eqsperts gauwion daxmareba klinikuri gamokvlevis, konsultaciebis, laboratoriuli analizebis CatarebaSi. gamokvlevisas mnisvnelovania mititebuli iqnas yoveli simptomis intensivoba, sixsire da xangrzlivoba. gamokitxvisas Seamowmebels ar unda mieces misaxvedri kitxvebi, radgan SesaZlebelia adgili hqondes winaswar ganzraxul agravacias da simulacias. sasamartlo samedicino eqsperti dazianebastan dakavsirebuli daavadebis an funqciis darrvevis xasiatis da xangrzlivobis Sefasebis dros unda daeyrdnos eqspertizis Catarebis processi dadgenil obieqtur samedicino monacemebs da dazianebis simzimis xarisxi gansazrvros faqtiurad arsebuli monacemebis Sesabamisad. savaraudo wamebis Sedegad sxeulis dazianeba SeiZleba sxvadasxva simzimis iyos, rac gansxvavebul samartlebriv pasuxismgeblobas itvaliswinebs, amitom sasamartlo samedicino eqsperti, pirvel rigsi, dazianebis simzimis xarisxs gansazrvravs. Semowmeba iwyeba sxeulis detaluri datvalierebit. sxeulze arsebuli dazianebebis datvalierebis da arweris dros sasamartlo samedicino eqsperti yuradrebas aqcevs dazianebis Semdeg maxasiateblebs: dazianebis xasiats; lokalizacias; formas; zomas; mimartulebas; fers; reliefs; sirrmes; 143

144 ucxo sxeulebis arsebobas; dazianebis irgvliv arsebul Taviseburebebs; sisxldenis xasiats; Sexorcebis nisnebs da sxv. eqspertma unda gamoiyenos sxeulis sqematuri gamosaxva (sxeulis konturuli rukebi) yvela dazianebis lokalizaciisa da xasiatis registraciisatvis. gamokvlevas, Cveulebriv, Tan unda axldes fotografia; sawiroebis SemTxvevaSi, sasurvelia, rentgenografiuli, tomografiuli da sxva instrumentuli gamokvlevis monacemebis Tanxlebac. sxeulis dazianebis eqspertizis Sedegad eqspertis daskvnasi gasuqebuli unda iyos: dazianebis xasiati samedicino TvalsazrisiT (nawdevi, sisxlnajrenti, Wriloba, Zvlis motexiloba da sxv.), mati lokalizacia da Taviseburebani; iararis an sagnis tipi, romlitac miyenebuli unda iyos dazianebebi; dazianebis ganvitarebis meqanizmi; dazianebis xandazmuloba; sxeulis dazianebis simzimis xarisxi, kriteriumis arnisvnit sicocxlisatvis saxifato, janmrtelobis mosla, Sromis unaris myari dakargva da a.s. daskvnasi eqspertma Tavisi azri unda gamoxatos dazianebis warmosobis Sesaxeb: miyenebulia Tu ara sxva piris mier, an TviT gamokitxulis mier, SemTxveviT Tu patologiuri procesis Sedegad da sxv. dazianebis gamomwvevi sagnis xasiats sasamartlo samedicino eqsperti adgens travmis morfologiuri Taviseburebebis mixedvit. Tu eqsperti naxulobs gansakutrebuli tkivilis miyenebis nisnebs, rogoricaa mravlobiti nacqmeti, nacxvleti dazianebebi, mowvis kvali da sxv., igi miutitebs daskvnasi am faqts. Tu Semowmebisas armocndeba sxvadasxva xandazmulobis dazianebebi (nawdevebi, sisxlnajrentebi, nawiburebi da a.s.), sasamartlo samedicino eqsperti daskvnasi arnisnavs mati miyenebis araertdroulobas. dazianebis xandazmulobas eqsperti adgens qsovilta regeneraciuli procesebis (sisxlnajrentis feris cvlilebis, nawdevis da Wrilobis Sexorcebis) maxasiateblebis mixedvit. Tumca am procesebis dinamika TiToeuli organizmisatvis individualuria da uamrav gare Tu Sida faqtorzea damokidebuli, rogoricaa, magalitad, temperatura, radiacia, damazianebeli faqtori, dazianebis lokalizacia da sxv., rac garkveul sirtuleebs qmnis dazianebis xandazmulobis dadgenisas da moitxovs sasamartlo samedicino eqspertis maral kvalifikacias da ganswavlulobas. swored dazianebis xandazmulobis dadgena warmoadgens Tbilisis saxelmwifo samedicino universitetis sasamartlo medicinis katedris samecniero musaobis ert-ert Tematikas, razedac sul cota xnis win katedraze damusavda sakvalifikacio samecniero nasromi sakandidato disertacia: nacxvleti Wrilobis xandazmulobis dadgena, romlis Sedegebic, vfiqrobt, garkveul wvlils Seitans am saxis dazianebebit wamebisa da sxva Zaladobis kvlevis umnisvnelovanes saqmesi. 144

145 თავი 4 wameba da misi prevencia stambolis protokolis mixedvit asist. profesori - levan labauri gaertianebuli erebis ganvitarebis programis (UNDP); proeqtis saxalxo damcvelis aparatis gazliereba სამედიცინო ექსპერტი, medicinis mecnierebata kandidati; IPIP is (stambolis protokolis ganxorcielebis programa) samedicino koordinatori saqartvelosi wameba - es aris erterti yvelaze arahumanuri qmedeba, rac ki SeiZleba ertma individma meores miayenos. miuxedavad imisa, rom saertasoriso samartlit wameba akrzalulia, igi jer kidev mwvave problemad rceba msoflios bevr qveyanasi wels gamoqveynebulia saertasoriso saxelmzrvanelo wamebis samedicino-fizikuri mtkicebulebebi, stambolis protokolis gamoyeneba samedicinofizikuri gamokvlevisatvis. arnisnuli gamocemis avtorebi arian: ole vedel rasmuseni, stain amrisi, margret blaauvi da liz danielseni. saxelmzrvanelo dawerilia wamebis msxverplta reabilitaciis saertasoriso sabwos mier (IRCT), rogorc stambolis protokolis ganxorcielebis proeqtis nawili, romlis iniciatorebi arian: eqimebi adamianis uflebebisatvis ass (PHR USA), TurqeTis adamianis uflebebis dacvis fondi, msoflios eqimta asociacia (WMA), da wamebis msxverplta reabilitaciis saertasoriso sabwo (IRCT). miuxedavad stambolis protokolis saertasoriso statusisa, iuridiul, jandacvis da adamianis uflebebis dacvis eqspertebs Soris is jer kidev SezRudulad aris mirebuli. umetes SemTxvevebSi samedicino da iuridiuli sauniversiteto saswavlo programebi ar itvaliswinebs instruqciebs wamebis msxverplta gamokvlevisa da eqspertizis Sesaxeb. amis gamo jandacvis da sisxlis samartlis bevr specialists an sul ar aqvs, an aqvs mxolod mwiri ganatleba wamebis kvlevasi da mis dokumentur gaformebasi, rac moitxovs gansazrvruli teqnikuri Cvevebs da codnas samedicino da iuridiuli procedurebis efeqturi gamoyenebisatvis. pirveli saertasoriso gaidlaini wamebis gamoziebisa da dokumentirebisatvis; misi Seqmnis iniciatorebi iyvnen amerikuli organizacia eqimebi adamianis uflebebisatvis da TurqeTis adamianis uflebata fondi musavdeboda 3 wlis ganmavlobasi; am processi monawileobda 15 qveynis 40 dawesebulebis 75 sasamartlo eqsperti dokumenti warmoadgens srulyofil praqtikul gaidlains samedicino da iuridiul specialisttatvis; mis farglebsi aucilebelia samedicno da iuridiuli sferos eqspertta ertoblivi Tanamonawileoba stambolis protokolis istoria moicavs ramdenime etaps: proeqts safuzveli Caeyara 1996 wlis maissi saertasoriso simpoziumze, 145

146 romelic TurqeTis eqimta asociaciis organizebit iqna Catarebuli adanasi, Cukurova -is universitetis samedicino fakultetze. pirveli proeqti momzadebul iqna Vincent Iacopino-is mier (Physicians For Human Rights USA). proeqtma kulminacias miarwia 1999 wels, rodesac stambolsi, martsi Catarebul sxdomaze dasrulebuli saxit iqna wardgenili; UNHCHR (Palais Wilson)-is SenobaSi Catarebuli ertdriani Sexvedris Semdeg, stambolis protokoli waredgina gaeros adamianis uflebata dacvis umarles komisars Mary Robinson s, 1999 wlis 9 agvistos. stambolis protokoli waredgina gaeros adamianis uflebata dacvis umarles komisars Mary Robinson s, (1999 wlis 9 agvisto). gaeros wamebis sakitxta sagangebo momxsenebelma, Sir Nigel Rodley-m, CarTo stambolis protokoli mis yovelwliur moxsenebasi, romelic waredgina gaeros generalur asambleas 1999 wlis 4 noembers. gaeros adamianis uflebata komisiam, 2000 wlis 20 aprils daamtkica da miiro stambolis protokoli da misi principebi, rac aisaxa UNCHR is rezoluciasi wamebis Sesaxeb (2000/43) da UNGA is rezoluciasi (55/89); gaeros adamianis uflebata umarlesi komisris mier gamoqveynda profesiul treningta seriasi gaeros eqvsive oficialur enaze (2001 weli); gaeros wamebis sagangebo momxsenebelma stambolis protokoli oficialurad daafiqsira mis rekomendaciebsi wamebastan brzolisa da arkvetis sakitxebsi (2002 wlis dekemberi); stambolis protokols daefuzna UNCHR is 2003 wlis rezolucia adamianis uflebebi da sasamaartlo eqspertiza da wameba. stambolis protokoli warmoadgens saertasoriso gaidlains rata: Seswavlil iyos is pirebi, romlebic gaxdnen wamebis da sxva sastiki araadamianuri mopyrobisa da dasjis msxverplni, gamoziebul iyos wamebis SemTxvevebi da Sedegebi waredginos samartaldamcav an sxva saxelmwifo organoebs. saxelmzrvanelosi mocemuli gamoziebis metodebi aseve gamoyenebul unda iyos Semdegi miznebit. mat Soris: adamianis uflebata Seswavla da monitoringi, politikuri TavSesafaris maziebel individuumta saqmeebis ganxilva, im individuumta dasacavad, romlebic wamebis gzit ariareben danasauls, wamebis msxverplta Semdgomi mkurnalobisa da reabilitaciis sawiroebata Sesafaseblad. im SemTxvevaSi Tu janmrtelobis dacvis musaki izulebulia an gaufrtxileblobit eswreba amgvar saqmianobas an ayalbebs wamebis mtkicebulebebs, saxelmzrvanelo aseve izleva im saertasoriso RonisZiebaTa ganmartebas ra Sedegic unda mohyves amgvar qmedebas jandacvis sferos an sasamartlo organoebis mxridan. saxelmzrvanelos mizania, gauadvilos jandacvis da iuridiul sferosi morvawe specialistebs musaoba stambolis protokolis danergvis gzit. wamebis savaraudo msxverplta gamokvlevis yvela aspeqti jer kidev ar aris sabolood SemuSavebuli. saxelmzrvanelo ver cvlis TviT stambolis protokols, - misi gamoyeneba unda moxdes mxolod arnisnul dokumenttan ertad. stambolis protokolis msgavsad, saxelmzrvanelosi wameba gansazrvrulia wamebis winaarmdeg gaeros konvenciis (UNCAT) #1 muxlis mixedvit: termini wameba nisnavs nebismier qmedebas, romlitac adamians winaswarganzraxulad adgeba Zlieri tkivili an fizikuri an gonebrivi tanjva, Semdegi miznit: informaciis mopoveba an ariarebis mireba misgan an mesame 146

147 pirisagan; adamianis dasja im qmedebisatvis, rac man an mesame pirma Caidina, an ewvia, rom Caidines; misi an mesame piris dasineba, an mati izuleba; an kidev sxva nebismieri mizezi, rac efuzneba diskriminaciis nebismier saxes, rodesac aseti tkivili da tanjva miyenebulia sazogadoebrivi moxelis mier an misi monawileobit an sxva adamianis mier, romelic moqmedebs oficialuri statusis farglebsi. definiciasi ar igulisxmeba tkivili an tanjva, romelic gatvaliswinebulia kanonier sanqciebsi an am ukanasknelistvisaa damaxasiatebeli. saxelmzrvanelos gamoyeneba wamebastan da adamianur uflebebis sxva darrvevebtan dakavsirebit Catarebul fizikur gamokvlevebs SeiZleba qondes ori mizani: wamebis dokumenturi dadastureba; Selaxuli janmrtelobis mkurnaloba. saxelmzrvanelo yuradrebas amaxvilebs pirvel mizanze. massi wamebis mwvave da qronikuli somaturi Sedegebi arwerilia organota sistemebis mixedvit. janmrtelobis dazianebastan dakavsirebuli samedicino somaturi gamokvleva ar SeiZleba calke iqnas ganxiluli; igi kombinirebuli unda iyos fsiqologiur da fsiqiatriul gamokvlevebtan da, agretve, socialuri aqtivobis SefasebasTan. saqartvelos kanonmdebloba janmrtelobis dacvis sferosi, garkveulwilad Seicavs zogoert prevenciul meqanizms samedicino wamebis arkvetastan dakavsirebit. saqartvelos kanonsi saeqimo saqmianobis Sesaxeb (muxli 54. akrzalvebi) gatvaliswinebulia, rom: damoukidebeli saeqimo saqmianobis subieqts ekrzaleba: a) pirdapiri an arapirdapiri kavsiri iset qmedebebtan, romlebic dakavsirebulia wamebasi an sxva sastik, araadamianur, Rirsebis Semlaxav mopyrobasi an/da sasjelsi monawileobastan, TanamonawileobasTan, waqezebastan an waqezebis mcdelobastan, agretve, amgvar moqmedebebze daswreba; b) patimartan, dakavebultan an datyvevebultan profesiuli urtiertoba, Tu amis ertaderti mizani ar aris misi fizikuri da fsiqikuri janmrtelobis Sefaseba, dacva an gaumjobeseba da es urtiertoba ewinaarmdegeba samedicino etikis principebs; g) profesiuli codnisa da unar-cvevebis gamoyeneba patimris, dakavebulis an datyvevebulis dakitxvis xelsewyobisatvis iseti metodebit, romlebic uaryofitad imoqmedeben mis fizikur an fsiqikur janmrtelobaze an mdgomareobaze; d) profesiuli codnisa da unar-cvevebis gamoyeneba, instrumentis an nivtierebis gacema patimris, dakavebulis an datyvevebulis wamebis an sxva sastiki, araadamianuri an Rirsebis Semlaxavi mopyrobis xelsewyobis miznit, an amgvari moqmedebebis mimart misi winaarmdegobis Sesasusteblad. amgvarad, sasamartlo samedicino eqspertiza, miuxedavad erovnuli sakanonmdeblo instrumentebis arasrulyofilebisa, mainc unda gamoyenebul iqnas, rogorc wamebis da sxva sastiki araadamianuri mopyrobisa da dasjis arkvetis ert-ert qmedit berketad. 147

148 = = = = = = = = = = = = = = = თავი 5 საკანონმდებლო საკითხები წამების, მისი პრევენციის და სასამართლო ექსპერტიზის საკითხებთან დაკავშირებით საქართველოს სისხლის სამართლის საპროცესო კოდექსი მუხლი 12. პიროვნების ხელშეუხებლობა, მისი პატივისა და ღირსების დაცვა 3. პირის დაპატიმრება ან ექსპერტიზისათვის სამედიცინო დაწესებულებაში მოთავსება შეიძლება მხოლოდ მოსამართლის ბრძანებით ან სასამართლოს განჩინებით (დადგენილებით) მუხლი 13. პირადი ცხოვრების ხელშეუხებლობა 3. შემოწმების, ექსპერტიზის, სხვა საპროცესო მოქმედების ჩატარებისას არ უნდა გამჟღავნდეს ცნობები პირადი ცხოვრების შესახებ, ასევე პირადი ხასიათის ცნობები, რომელთა საიდუმლოდ დაცვაც პირს საჭიროდ მიაჩნია. გამომძიებელი, პროკურორი, მოსამართლე, სასამართლო ამ კოდექსით გათვალისწინებული საპროცესო მოქმედების მონაწილეს ხელწერილის ჩამორთმევით აფრთხილებს, არ გაამჟღავნოს აღნიშნული ცნობები. ( N1204) მუხლი 20. სისხლის სამართლის პროცესის უშუალობა და ზეპირობა ( N1204) 1. ორგანო ან თანამდებობის პირი, რომელიც პროცესს აწარმოებს, ვალდებულია დაკითხოს დაზარალებული და მოწმე, შეისწავლოს და მოისმინოს ექსპერტის დასკვნა, შეამოწმოს ნივთიერი მტკიცებულებები. ამ წესისაგან გადახვევა დასაშვებია მხოლოდ ამ კოდექსით გათვალისწინებულ განსაკუთრებულ შემთხვევებში. ( N936) მუხლი 29. სისხლისსამართლებრივი დევნის შეჩერების საფუძვლები და ვადები ( N1204) 1. სისხლისსამართლებრივი დევნა ჩერდება: გ) თუ ბრალდებული მძიმე ავადმყოფობით დაავადდა, რაც დადასტურებულია სახელმწიფო სასამართლო-სამედიცინო ექსპერტიზის დასკვნით დაუყოვნებლივ ამ ფაქტის დადგენიდან ბრალდებულის გამოჯანმრთელებამდე, ხოლო თუ ბრალდებული ფსიქიკურად დაავადდა, რაც დადასტურებულია სახელმწიფო სასამართლო- 148