针对患有复杂创伤后应激障碍（PTSD）的成年人的心理治疗：临床指南及五项带有荟萃分析的系统评价
Psychotherapies for adults with complex presentations of PTSD: a clinical guideline and five systematic reviews with meta-analyses.
作者信息
Schaug Julie Perrine, Møller Lise, Reinholt Nina, Illum Dyveke Bové, Græbe Frida Lau, Mikkelsen Line Bang, Austin Stephen Fitzgerald, Paulsen Nina Nørrelykke, Porsing Adrian Maria Tremel, Juul Sophie, Hovmand Oliver Rumle, Jørgensen Mie Sedoc, Arendt Ida-Marie Terese Pereira, Quistgaard Maria, Kristensen Magnus Tang, Døssing Sidsel Christine Buskbjerg, Rosenbaum Bent, Rosenberg Nicole Gremaud, Arnfred Sidse Marie, Storebø Ole Jakob
机构信息
Centre for Evidence-Based Psychiatry, Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark.
Department for Treatment of Borderline Personality Disorder and Self-Harm, Psychiatric Centre Glostrup, Capital Region Mental Health Services, Glostrup, Denmark.
出版信息
BMJ Ment Health. 2025 Apr 15;28(1):e301158. doi: 10.1136/bmjment-2024-301158.
OBJECTIVE
To develop a clinician-guided, research-based guideline for adult outpatient psychotherapy for complex presentations of post-traumatic stress disorder (PTSD).
METHODS
We used state-of-the-art methods to develop clinical guideline recommendations and conduct systematic reviews with meta-analyses for five research questions: (Q1) When treating adults with PTSD, should trauma-focused psychotherapy include exposure? Which psychotherapies are effective for PTSD with co-occurring: (Q2) personality disorder; (Q3) depression; and (Q4) dissociative disorder? (Q5) for complex PTSD (C-PTSD)?
RESULTS
(Q1) We found no evidence of a difference between trauma-focused psychotherapies with or without exposure on PTSD symptoms (standardised mean difference (SMD) 0.02, 95% CI -0.11 to 0.15, p=0.75, I=64%). (Q2) Dialectical behaviour therapy (DBT-for-PTSD) showed beneficial effects over cognitive processing therapy (CPT) on co-occurring borderline personality disorder (BPD) symptoms (mean difference (MD) -0.58, 95% CI -0.94 to -0.22, p=0.003). (Q3) Mindfulness and body-focused psychotherapies, prolonged exposure (PE), narrative exposure therapy (NET) and CPT showed beneficial effects on symptoms of PTSD and co-occurring depression. Results for present-centred therapy (PCT) were uncertain. (Q4) No statistically significant differences were found among psychotherapies for PTSD with co-occurring dissociation. (Q5) Skills training appeared promising for C-PTSD.
CONCLUSION
Weak clinical recommendations were reached for trauma-focused therapies with or without exposure for PTSD; DBT-for-PTSD for PTSD with co-occurring BPD; CPT, NET, PE and Mindfulness and body-focused psychotherapies for PTSD with co-occurring depression; and Skills training for C-PTSD. A weak recommendation was reached against PCT for PTSD with co-occurring depression. It is good practice to include interventions targeting dissociation for PTSD with co-occurring dissociation. Overall, the certainty of evidence was low; high-quality trials are needed to strengthen the recommendations.
PROSPERO REGISTRATION NUMBER
CRD42022376117.
目的
制定一项基于研究且由临床医生指导的针对创伤后应激障碍（PTSD）复杂症状的成人门诊心理治疗指南。
方法
我们采用了最先进的方法来制定临床指南建议，并针对五个研究问题进行了系统评价及荟萃分析：（问题1）在治疗成年PTSD患者时，以创伤为焦点的心理治疗是否应包括暴露疗法？对于共病以下情况的PTSD，哪些心理治疗方法有效：（问题2）人格障碍；（问题3）抑郁症；（问题4）分离障碍？（问题5）复杂性PTSD（C-PTSD）？
结果
（问题1）我们没有发现有暴露或无暴露的以创伤为焦点的心理治疗在PTSD症状上存在差异的证据（标准化均数差（SMD）0.02，95%置信区间 -0.11至0.15，p = 0.75，I² = 64%）。（问题2）辩证行为疗法（DBT - 用于PTSD）在共病边缘性人格障碍（BPD）症状方面比认知加工疗法（CPT）显示出更有益的效果（均数差（MD）-0.58，95%置信区间 -0.94至 -0.22，p = 0.003）。（问题3）正念和以身体为焦点的心理治疗、延长暴露疗法（PE）、叙事暴露疗法（NET）和CPT对PTSD及共病的抑郁症症状显示出有益效果。以当下为中心的疗法（PCT）的结果尚不确定。（问题4）对于共病分离障碍的PTSD患者，各心理治疗方法之间未发现统计学上的显著差异。（问题5）技能训练对C-PTSD似乎有前景。
结论
对于有或无暴露的PTSD以创伤为焦点的疗法、共病BPD的PTSD采用DBT - 用于PTSD、共病抑郁症的PTSD采用CPT、NET、PE以及正念和以身体为焦点的心理治疗、C-PTSD采用技能训练，我们达成了弱临床推荐。对于共病抑郁症的PTSD采用PCT，我们达成了反对的弱推荐。对于共病分离障碍的PTSD，纳入针对分离的干预措施是良好的实践。总体而言，证据的确定性较低；需要高质量试验来加强这些推荐。
PROSPERO注册号：CRD42022376117。
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