ORIGINAL ARTICLE pissn 1226-6396, eissn 2234-4942 J of Oriental Neuropsychiatry 2015;26(2):161-170 http://dx.doi.org/10.7231/jon.2015.26.2.161 공황장애치료에대한중의학의임상연구동향 이승환, 성우용 *, 임정화 * 부산대학교한방병원한방신경정신과, 부산대학교한의학전문대학원한방신경정신과교실 * A Review Study on the Treatment of Panic Disorder in Traditional Chinese Medicine Seung-Hwan Lee, Woo-Yong Seong*, Jung-Hwa Lim* Department of Neuropsychiatry, Pusan National University Korean Medical Hospital, *Department of Neuropsychiatry, School of Korean Medicine, Pusan National University Received: May 26, 2015 Revised: June 8, 2015 Accepted: June 8, 2015 Correspondence to Jung-Hwa Lim Department of Neuropsychiatry, Pusan National University Korean Medical Hospital, 20, Kumoh-ro, Mulkeum-eup, Yangsan, Korea. Tel: +82-55-360-5979 Fax: +82-55-360-5890 E-mail: suede22@hanmail.net Acknowledgement This work was supported by the year 2013 clinical research grant from Pusan National University Hospital. Objectives: This study was performed to review the research trends in the treatment of panic disorder in traditional Chinese medicine (TCM). Methods: We searched articles in the China National Knowledge Infrastructure (CNKI) from 2004 to 2014. Search key words were 惊恐 and 'panic disorder', and we selected eight studies except for non-clinical, unrelated studies, tests on animals. Results: We finally selected eight articles, and the results were as follows. CCMD-3 was most frequently used as a diagnostic criterion and HAMA was mostly used for outcome measurement. In TCM there are various ways, such as herbal medicine, acupuncture and psychotherapy, to treat panic disorder. Most of the studies showed effective results. Most of the treatment group reported that they had less side effects than the control group. However, the quality of these clinical studies was low. Conclusions: In TCM, research on panic disorder was being conducted more actively than in Korean medicine. According to this study, it seems that in TCM, the treatment of panic disorder might be more effective and have some advantages. Therefore, with this study, we hope to activate more clinical research on the treatment of panic disorder in Korean medicine. Key Words: Panic disorder, Traditional Chinese medicine, CNKI. Copyright 2015 by The Korean Society of Oriental Neuropsychiatry. All rights reserved. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
162 A Review Study on the Treatment of Panic Disorder in Traditional Chinese Medicine I. 서론 공황장애 (panic disorder) 는삽화적으로갑자기발생하는공황발작 (panic attack) 이주요특징인질환으로, 숨이막히거나심장이두근거리면서죽을것만같은극단적인공포증상이반복적으로나타나는장애이다. 평생유병률이 4.8% 로비교적흔한질환에속하며사회기피증, 광장공포증및우울증과같은정신질환과도흔히공존한다 1,2). 공황장애환자는공황장애의임상증상으로고통받을뿐만아니라, 전반적인삶에서도현격한장해를경험한다. 공황장애환자의절반이상은직업활동또는가정내생활기능을수행함에있어심각한장해를겪고있으며, 이로인한삶의질저하및경제적인손실은사회적으로큰부담을초래하고있다. 공황장애는조기에치료적개입을할경우, 상대적으로적은시간과사회적비용으로증상의감소및삶의질호전을기대할수있어, 조기진단과치료적개입의중요성이강조되고있다 3,4). 서양의학에서는공황장애의치료방법으로약물치료가가장많이활용되는데, World Federation of Societies of Biological Psychiatry의지침에따르면, citalopram, escitalopram, fluoxetine, paroxetine 등과같은 selective serotonin reuptake inhibitors (SSRI) 혹은 vemlafaxine과같은 serotonin norepinephrine reuptake inhibitors (SNRI) 가공황장애의 1차선택치료약물로권장되고있다 1). 또한인지행동치료와약물치료를병행하는것이약물단독치료보다, 공황증상개선에더효과적이며약물치료의종료에도효과적이라는연구결과가보고되고있다 5). 공황장애는관해와재발을반복하는만성적정신장애이다. 공황장애환자들의 20 60% 정도만관해상태에이르며 2 3 년후에는전체환자중 60 80% 가재발하거나공황장애의증상들을부분적으로가지고있는것으로보고되고있어, 환자는긴유병기간동안일상기능장해와삶의질저하등으로고통을받는다 3). 한의학에서는공황장애를경계 ( 驚悸 ), 정충 ( 怔忡 ), 공경 ( 恐驚 ), 초려 ( 焦慮 ) 의범주에서다루고있으며침구치료, 한약치료, 심신일여 ( 心身一如 ) 원리를기초로한한방정신요법, 부항치료, 향기치료등이치료방법으로활용되고있다 2,8). 현재까지공황장애에대해국내에발표된한의학계연구에는 Minnesota Multiphasic Personality Inventory (MMPI) 통해살펴본공황장애환자의성격특성에대한연구 6) 이외에 Emotional Freedon Techniques (EFT) 요법 7), 마음챙김명상과이정변기요법 8), 추나수기이완법 9), Stress Reduction Program (SRP) 10), 미술치료 11), 인지행동치료 12,13), 한약 Extract 제제 14) 등을활용하여치료한증례보고가주를이루고있으나, 다양한한의학치료방법의유효성을확인하는전향적임상연구는거의이루어지고있지않다. 이에반해중국에서는국내보다상대적으로활발한연구들이다양하게이루어지고있었다. 따라서본연구에서는공황장애에대한중의학임상연구들을조사, 분석하여향후국내임상연구를위한기초자료를마련하고자한다. II. 연구방법 1. 논문의검색과선별인터넷중국논문검색사이트인중국지식기초시설공정 ( 中國知識基礎施設工程, http://www.cnki.net) 에서 2015 년 1월에 2004년 1월에서 2014년 12월까지의공황장애임상치료에관한논문을검색하였다. 검색범위를중의학, 중약학, 중서의결합 ( 中醫學, 中藥學, 中西醫結合 ) 으로설정하였고, 검색어는공황장애를의미하는경공 ( 驚恐 ), panic disorder 로검색하였다. 2. 연구의질평가본연구에서선정된논문중대조임상연구의질을평가하기위해 Jadad Quality Assessment Scale을사용하였다. Jadad scale 은무작위배정순서의생성과배정, 이중맹검, 탈락자보고여부에대한 3가지항목에대해 0, 1, 2점으로평가하여무작위대조군임상시험을평가하는도구로, 총 0 5 점의범위에서평가한다. 3점이상이면질높은연구로, 2점이하일경우는연구의질이낮은것으로평가한다 15). III. 결과 본연구에서는경공 ( 驚恐 ), panic disorder의키워드로검색한결과, 출판된논문은총 38편이었고이중임상연구가아닌논문 21편, 공황장애를대상으로하지않는논문 8편, 동물실험연구논문 1편등총 30편을제외시켰다. 최종
SH Lee, WY Seong, JH Lim 163 적으로단일군전후비교임상연구 2편과대조임상연구 6편, 총 8편이선별되었다 (Fig. 1). 선정된논문 8편을단일군전후비교임상연구와대조임상연구로나누어연구대상, 진단기준, 치료방법, 평가도구, 결과, 연구질평가등을정리, 분석하였다. 1. 단일군전후비교임상연구분석 (Table 1) 2. 대조임상연구분석 (Table 2) 3. 연구의질평가본연구에분석한 8편의연구중대조임상연구논문 6편의연구질평가를위해 Jadad Quality Assessment Scale 을사용하였다. 5편에서무작위배정을명기하였으며, 이중 1 편에서난수표를사용하여무작위배정순서를생성하였다고언급하였다. 탈락과중도포기를기재한논문은 2편이었고, 참여자및연구자의눈가림에대해기술한논문은없었다. Jadad 점수는 3편이 2점이었고, 나머지는모두 1점이하로연구의질은대체로낮았다. 4. 진단기준본연구에서살펴본임상연구논문중공황장애의진단기준으로가장많이사용된도구는 The Chinese Classification of Mental Disorders, Third Edition (CCMD-3) 로총 7편의연구에서사용하였다. 그외, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), 경공장애적이성진단모식 ( 驚恐障礙的理性診斷模式 ), 중의내과학 ( 中醫內科學 ), 중의진단학 ( 中醫診斷學 ), 중약신약임상연구지도원칙 ( 中藥新藥臨床研究指導原則 ) 을참조한중의증후진단표준 ( 中醫證候診斷標准 ) 이각각 1편의연구에서진단기준으로사용되었다. 또한 CCMD-3, DSM-IV 와더불어 Hamilton Anxiety Rating Scale (HAMA) 를진단기준으로동시에사용한연구는 4편이었는데, 이중 3편의연구에서는 HAMA 점수가 14 점이상인환자를연구대상으로선정하였다. 5. 치료효과평가도구치료효과를판단하기위해가장많이활용된평가도구 Fig. 1. Flow diagram preferred reporting items for review. Table 1. Single Group Before and After Studies of Treatment on Patients with Panic Disorder in China First author (year) Cheng 16) (2007) Li 17) (2014) Sample size (Male/Female) Diagnostic criteria Treatments 21 (6/15) CCMD-3 1) Acupuncture: 1 time/day, 1 month 2) Psychotherapy: Cognitive psychology + psychological analysis, 2 times/week, 1 month 45 (20/25) CCMD-3 Ondam-tang(Wendan-tang): (Undocumented) 10 day/session, total 8 sessions CCMD-3: The Chinese Classification of Mental Disorders, Third Edition, HAMA: Hamilton Anxiety Rating Scale. Outcomes measurements Results 1) Effective rate 1) Total Effective rate : 90.48% 1) Effective rate 2) HAMA 1) Total Effective rate : 86.67% 2) The HAMA score had significantly decreased after treatment (p<0.05).
164 A Review Study on the Treatment of Panic Disorder in Traditional Chinese Medicine Table 2. Controlled Clincal Trials of Treatment on Patients with Panic Disorder in China First author (year) Chen 18) (2005) Shen 19) (2010) Liu 20) (2012) Gao 21) (2013) Sample size (Male/Female) 23 (10/13) 21 (8/13) 31 (11/19) 30 (14/17) 32 (14/18) 32 (13/19) 45 (22/23) 45 (23/22) Diagnostic criteria CCMD-3 Model of panic disorder rational diagnosis 24) CCMD-3 HAMA 14 CCMD-3 HAMA 14 DSM-4 HAMA Randomi-zation Treatments Control Group Intervention Group Randomized (A) Cognitive Therapy+Fluoxetine 20 mg/day, Alprazolam 0.8 2.8 mg/day: Active care (2 months), Self care (3 months) (B) Double syndrome differentiation treatment: Active care (2 months), Self care (3 months) +Jangchung-chung (Changchong-qing): 400 mg/day for 3 days, after 6 months, 400 mg/day for 3 days Randomized (A) Paroxetine hydrochloride: 20~40 mg/day, 1 time/day, 8 weeks +Cognitive behavioral therapy: 1 time/week, 40~50 min/time, 8 weeks (B) (A) +Shihogayonggolmoryeo-tang (Chaihujialonggumuli-tang): 2 times/day, 8 weeks Randomized (A) Tandospirone Capsule: 10 mg/time, 3 times/day, 6 weeks (B) (A) +Anxinjeongji-hwan (Anshendingzhi-wan) and Zusaanxin-hwan (Zhushaanshen-wan): 2 times/day, 6 weeks Randomized (A) Escitalopram citalopram: initial 10 mg/day, after 1 week 20 mg/day, 8 weeks (B) (A) +Shihosogan-san (Chaihushugan-san) and Sohamhyung-tang (xiaoxianxiong-tang): 2 times/day, 8 weeks Outcomes measurements 1) Cure rate 2) BAI 1) Effective rate 2) HAMA 3) TESS 1) Effective rate 2) HAMA 3) CGI 4) TESS 1) Effective rate 2) HAMA 3) TESS Results 1) Active care period - (A) group: cure rate 43.48%. (B) group: cure rate 100%. (B) group was significantly more effective than Self care period - (A) group: cure rate 26.09%. (B) group: cure rate 100%. (B) group was significantly more effective than 2) The BAI score of (B) group had significantly decreased than that of (A) group (p<0.001). 1) (A) group: Effective rate 86.7%, (B) group: Effective rate 87.1%, Between group A and B, There was no significant difference (p>0.05). 2) At the end of 2nd and 4th week, The HAMA score of (B) group had significantly decreased than that of At the end of 8st week, There is no significant differences between two groups (p>0.05). 3) (B) group showed significantly less side effects than 1) (A) group: Effective rate 84.37%, (B) group: Effective rate 93.75%, (B) group was significantly more effective than 2, 3) The HAMA and CGI score of (B) group had significantly decreased than those of 4) (B) group showed significantly less side effects than 1) (A) group: Effective rate 73.33%, (B) group: Effective rate 86.67%, (B) group was significantly more effective than 2) The HAMA score of (B) group had significantly decreased than that of 3) There was no significant difference in the side effect between two groups (p>0.05). CCMD-3: The Chinese Classification of Mental Disorders, Third Edition, HAMA: Hamilton Anxiety Rating Scale, BAI: Beck Anxiety Inventory, CGI: Clinical Global Impression scale, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, SAS: Self-Rating Anxiety Scale, TESS: Treatment Emergent Symptom Scale, RBANS: Repeatable Battery for the Assessment of Neuropsychological Status.
SH Lee, WY Seong, JH Lim 165 Table 2. Continued Control Group Results Outcomes measurements Randomi-zation Treatments Intervention Group Diagnostic criteria Sample size (Male/Female) First author (year) 1, 2) The HAMA and SAS score of (B) group had significantly decreased than those of (A) group, especially, after 3 days treatments, the differences had statistical significance between two groups (p<0.05). 3) (B) group showed significantly less side effects than 1) HAMA 2) SAS 3) TESS Randomized (A) Paroxetine hydrochloride: 20 mg/time, 1 time/day, 4 weeks (B) Chinese medicine: 2 times/day, 4 weeks CCMD-3 TCM syndrome diagnostic criteria 74 (26/48) 82 (28/54) Yang 22) (2013) 1) (A) group: Effective rate 85.00%, (B) group: Effective rate 95.00%, (B) group was significantly more effective than 2, 3) The HAMA and CGI score of (B) group had significantly decreased than those of 4) (B) group showed more significant improvement than 1) Effective rate 2) HAMA 3) CGI 4) RBANS Quasi-randomized (A) Paroxetine: 20~60 mg/time, 1 time/day, 6 weeks (B) (A) +Chinese medicine: 3 times/day, 6 weeks CCMD-3 HAMA 14 40 (22/18) 40 (21/19) Deng 23) (2014) CCMD-3: The Chinese Classification of Mental Disorders, Third Edition, HAMA: Hamilton Anxiety Rating Scale, BAI: Beck Anxiety Inventory, CGI: Clinical Global Impression scale, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, SAS: Self-Rating Anxiety Scale, TESS: Treatment Emergent Symptom Scale, RBANS: Repeatable Battery for the Assessment of Neuropsychological Status. 는 HAMA 로총 6편의연구에서사용되었다. 이중 5편의연구에서는 HAMA 총점수의감소율에따라전유 ( 痊愈 ), 현효 ( 顯效 ), 유효 ( 有效 ), 무효 ( 無效 ) 의등급을나눈후총유효율을평가하여제시하였다. HAMA 와같은평가도구에관한언급없이임상증상의개선만으로치료효과를판별한연구는 1편이었다. HAMA 이외, Beck Anxiety Inventory (BAI), Clinical Global Impression scale (CGI), Self-Rating Anxiety Scale (SAS), Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) 등이평가도구로사용되었다. 이상반응은총 4편의연구에서 Treatment Emergent Symptom Scale (TESS) 를사용하여보고하였다. 6. 연구대상수, 평균병정기간, 치료기간본연구에선정된 8편의논문을살펴본결과, 연구대상수는 21명에서 156명사이였으며, 피험자의평균병정기간은약 50.6일에서 31.35 개월까지다양하였다. 총치료기간은 28일에서 80일사이였다. 7. 연구설계및치료방법사용된치료방법으로는한약투여, 양약병용투여, 침치료, 정신요법등이있었으며, 한약투여만을치료방법으로사용한연구가 2편이었고, 여러치료방법을복합하여시행한연구는 6편이었다. 단일군전후비교임상연구에서는침치료와정신요법을병행한연구, 한약투여만을치료방법으로사용한연구가각각 1편이었다. 대조임상연구 6편중양약투여대조군과양약과한약을병행투여한시험군의치료효과를비교한연구는 3편이었다. 그외양약투여대조군과한약투여시험군의치료효과를비교한연구, 양약투여와인지행동요법을병행한대조군과양약투여와인지행동요법그리고한약투여를함께시행한시험군의치료효과를비교한연구, 인지요법과양약투여를병행한대조군과이중변증논치 ( 二重辨證論治 ) 를시행한시험군의치료효과를비교한연구가각각 1편씩이었다. IV. 고찰 공황장애의병태생리에대해서는아직까지불확실한부분이많으나, 서양의학에서는 norepinephrine, serotonin,
166 A Review Study on the Treatment of Panic Disorder in Traditional Chinese Medicine GABA 등신경전달물질의불균형, 말초자율신경계의과민성및과활동성 2), 편도, 전전두엽, 해마와같은불안과관련있는뇌구조물의기능적이상이과도한불안과공포를생성한다는주장이있다 25). 정신분석학에서는불안을야기하는충동에대한방어기제의작동실패를공황장애의원인으로인지하고있으며 26), 인지이론에서는공황장애에대한대부분의인지모델들을 불안에대한공포 개념에바탕을두며, 특정신체감각이나증상을과대해석하거나파국적으로오해석함으로써공황증상이발생하는것으로파악한다 5). 한의학에서는공황장애를경계 ( 驚悸 ), 정충 ( 怔忡 ), 공경 ( 恐驚 ), 초려 ( 焦慮 ) 등의범주에서이해하고치료하고있는데, 주요병인병기 ( 病因病機 ) 를심담허겁 ( 心膽虛怯 ), 심비양허 ( 心脾兩虛 ), 심기부족 ( 心氣不足 ), 간신음허 ( 肝腎陰虛 ), 담음내정 ( 痰飮內停 ), 혈맥어조 ( 血脈瘀阻 ) 등으로파악한다. 증후가대개허실 ( 虛實 ) 을서로겸하지만허 ( 虛 ) 가주 ( 主 ) 가되므로보허 ( 補虛 ) 를치료의기본원칙으로삼고있으며, 익기양혈 ( 益氣養血 ), 자음온양 ( 滋陰溫陽 ), 화담척음 ( 化痰滌飮 ), 활혈화어 ( 活血化瘀 ), 양심안신 ( 養心安神 ) 등이주요치법 ( 治法 ) 으로활용되고있다 2). 현재까지의공황장애치료에대한한의학계의연구에는한약, 침치료등과같은한방치료와더불어 EFT 요법 7), 마음챙김명상 8), 추나수기이완법 9), SRP 10), 미술치료 11), 인지행동치료 12,13) 등의심리치료방법이활용된증례보고가주를이루고있으며, 공황장애의한의학적치료방법에대한전향적임상연구는거의찾아볼수없었다. 이러한이유중하나로공황발작은빠른조치가요구되는응급상황이며, 서양의학의약물치료에비해한의학적치료체계가확립되어있지않고, 그치료효과에대한연구가검증되지못했기때문인것으로사료된다. 그러나우리와유사한한의학전통을가진중국에서는공황장애의중의학적치료방법에대한연구가국내한의학계보다활발히이루어져왔다. 따라서본연구에서는향후국내공황장애의한의학적치료방법의안전성과유효성을검증하는임상연구를위한기초자료를마련하고자, 공황장애에대한중국의임상연구를고찰하였다. 본연구에서는중국지식기초시설공정 ( 中國知識基礎施設工程, http://www.cnki.net) 에서검색된논문중총 8편의연구를선별하여분석및정리하였다. 선정된논문 8편중단일군전후비교임상연구가 2편, 대조임상연구가 6편이었고, 활용된치료방법으로는한약치 료, 한약과양약병행치료, 한약과정신요법병행치료, 한약 양약과정신요법병행치료, 침과정신요법병행치료등이있었다. 양약치료를대조군으로설정한논문은총 6편이었고, 투여된서양약물을살펴보면, paroxetine 이 3편의논문에사용되었고, escitalopram, fluoxetune, alprazolam, tandospirone이각각 1편의논문에사용되었다. 한약을투여한논문은총 7편으로사용된한약처방중중복되는처방은없었다. 활용한한약처방으로는시호가용골모려탕 ( 柴胡加龍骨牡蠣湯 ), 안신정지환합주사안신환 ( 安神定志丸合朱砂安神丸 ), 시호소간산합소함흉탕 ( 柴胡疎肝散合小陷胸湯 ), 온담탕 ( 溫膽湯 ) 등이있었다. 이중 Li 17) 의연구에서는 2가지변증에따라각기처방을사용하였는데담화호결 ( 痰火互結 ) 에는황련온담탕 ( 黃蓮溫膽湯 ) 을, 심담기허 ( 心膽氣虛 ) 에는십미온담탕 ( 十味溫膽湯 ) 을활용하였다. 그러나각각의처방을복용한피험자의수나변증특징에대해구분하여표기하지않았고, 모두시험군에포함하여치료효과를분석하였다. 한약을투여한연구중처방명을기술하지않고약물구성만기술한연구는 Yang 22) 의연구와 Deng 23) 의연구총 2편이었다. 또한 Chen 18) 의연구에서는한약을활용했다는언급만있을뿐, 처방명, 약물구성, 처치방법등에대한기술은없었다. Chen 18) 의연구와 Liu 20) 의연구를제외한모든연구에서약물구성성분과용량을제시하였다. 6편의연구에서사용된약물의빈도를살펴보면복령 ( 茯笭 ) 이 5회, 반하 ( 半夏 ), 황련 ( 黃蓮 ), 감초 ( 甘草 ), 용골 ( 龍骨 ) 이각각 4회, 당삼 ( 黨蔘 ), 원지 ( 遠志 ) 가각각 3회, 시호 ( 柴胡 ), 모려 ( 牡蠣 ), 산조인 ( 酸棗仁 ), 생강 ( 生薑 ), 진피 ( 陳皮 ), 지각 ( 枳殼 ) 각각 2회씩언급되었다. 가장많이활용된복령 ( 茯笭 ) 은성미는평감담 ( 平甘淡 ) 하고건비녕심 ( 健脾寧心 ) 하는효능이있어심신불안 ( 心神不安 ), 경계실면 ( 驚悸失眠 ) 등을치료하는데주로활용된다 27). Chen 28) 의연구에서는복령이 interleukin-1β, TNF-α 등과같은사이토카인 (cytokine) 의분비를촉진하며, 비렘수면 (non-rapid eyemovement sleep) 을증진시킨다고보고하고있다. 활용된약물중원지 ( 遠志 ) 는녕심안신 ( 寧心安神 ) 하는효능이있어심신불안 ( 心神不安 ), 건망경계 ( 健忘驚悸 ) 등을치료하는데사용되며, D2 수용체와 5-HT2 수용체를모두억제하여항정신병효과가있으며, serotonergic 신경계통에작용하여항불안효과를나타낼수있다고보고되고있다 27,29). 또한산조인 ( 酸
SH Lee, WY Seong, JH Lim 167 棗仁 ) 은보간담 ( 補肝膽 ), 양심안신 ( 養心安神 ) 하는효능이있어허번불면 ( 虛煩不眠 ), 심계다몽 ( 心悸多夢 ) 등을치료하는데빈용되는약물로서항불안, 항경련, 진정작용등이있다는실험연구결과가보고되고있다 27,30). 본연구에서정신요법은총 3편의논문에서활용되었는데, 인지요법, 행동요법, 심리분석등이사용되었다. 인지행동치료는공황장애에활용되는대표적인정신요법이며, 그효과를입증하는연구결과가다수보고되었다 31). 인지행동치료의주요목표중하나는공황장애환자들이신체적감각에대해파국적으로오해석하는인지도식을보다합리적으로재구조화하는것이며, 공황장애환자의예기불안과회피반응을감소시키는데효과적이라는보고가있다 32). Cheng 16) 의연구에서는인지요법, 심리분석을주 2회씩, 총 4회실행하였으나시행시간에대해언급하지않았다. Chen 18) 의연구에서는인지요법을시행하였으나, 치료시간및횟수에대해언급하지않았다. Shen 19) 의연구에서는인지행동요법을 40 50 분씩, 주 1회, 총 8회실행하였다. 3편의연구모두정신요법의시행방법에대한상세한기술은없었다. Chen 18) 의연구에서독창적으로사용된이중변증논치 ( 二重辨證論治 ) 는정신변증논치경공장애 ( 精神辨證論治驚恐障礙 ) 와구체변증논치 ( 軀體辨證論治 ) 를합한것이며, 중의변증에따른심리치료, 기공 무술훈련, 생활지도및훈련, 음식요법, 한약요법등을시행하는것이라는기술이있었으나변증방법과치료법각항목에대한상세한내용은기술되어있지않았다. 또한치료시기를병원에서의사와함께치료를진행하는 적극치료기 와적극치료기에서학습하였던치료방법대로병원및의사에게의존하지않고환자스스로시행하는 자유치료기 로구분지었다. 치료시기별로치료효과를구분지어분석하였는데, 두치료시기모두시험군이대조군보다우수한치료효과를보였다. 침을활용한연구는단일군전후비교임상연구 1편이었는데, 공황발작기와간헐기에따라치료혈위와침치료방법을다르게시행하였다. 발작기에는수구 ( 水溝 ) 에작탁보사 ( 雀啄瀉法 ), 용천 ( 湧泉 ) 에염전제삽보법 ( 捻轉提揷補法 ) 을시행하였고, 간헐기에는백회 ( 百會 ) 와사신총 ( 四神聰 ) 에평보평사 ( 平補平瀉 ), 인당 ( 印堂 ) 태양 ( 太陽 ), 합곡 ( 合谷 ), 태충 ( 太衝 ) 에염전사법 ( 捻轉瀉法 ), 족삼리에염전보법 ( 捻轉補法 ), 내관 ( 內關 ) 에염전제삽사법 ( 捻轉提揷瀉法 ), 삼음교 ( 三陰交 ) 에염전제삽보법 ( 捻轉提揷補法 ) 을시행하였으며동시에백회 ( 百會 ) 와인당 ( 印堂 ) 에전침치료를시행하였다. 침치료는매일 1회씩, 총 1개월간시행하였다. 혈위, 보사법, 득기법, 치료기간등은표기되었으나, 유침시간, 사용한침과전침기에대한정보, 자침깊이및시술자에대한정보등이명시되어있지않았다. 향후침치료연구설계시보다체계적인연구설계를위해 Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) 33) 와같은점검표를활용할필요가있으리라생각된다. 본연구에선별된 8편의논문중공황장애의진단기준으로는 CCMD-3, 평가기준으로는 HAMA를가장많이활용하고있었다. CCMD-3 는중국의독자적인진단기준이므로향후국내연구에서그대로사용하기에는적합하지않다고생각되며, 국제적으로통용되는진단기준인정신질환의진단및통계편람 (DSM) 을진단도구로활용하는것이적합하다고사료된다. 더불어한의학임상현장에서활용가능한공황장애의변증도구의개발도필요하리라생각된다. 본연구에선별된 8편의논문중대부분에서공황장애환자의불안증상에초점을맞춘 HAMA 를평가도구로사용하고있는데, 공황장애환자에게특화된평가도구또한향후임상연구수행시활용할필요가있다고사료된다. 현재까지개발된도구중공황장애환자의증상심각도를평가하기위한 Panic Disorder Severity Scale (PDSS) 34) 나, 광장공포증환자들이보이는공황발작에대한공포와회피행동을평가하기위한 Agoraphobic Cognition Questionnaire (ACQ) 35) 와 Body Sensation Questionnaire (BSQ) 35) 등을평가도구로활용할수있을것이라생각된다. 본연구에서살핀 8편의연구모두공황장애증상이치료전후를비교하였을때통계적으로유의미하게감소하였다. 단일군전후비교임상연구중한약치료를활용한연구에서 HAMA 점수가치료후유의미하게감소되었고, 침치료와정신요법을병행하여치료한연구에서도치료후통계학적으로유의미한증상개선을보였다. 대조임상연구 6편중양약투여대조군과양약과한약복합투여한시험군의치료효과를비교한연구 3편에서모두시험군이대조군에비해통계적으로유의미한치료효과를나타내었다. 또한양약투여대조군과한약투여시험군을비교한연구, 인지요법과양약투여를병행한대조군과이중변증논치 ( 二重辨證論治 ) 를시행한시험군을비교한연구역시시험군이대조군에
168 A Review Study on the Treatment of Panic Disorder in Traditional Chinese Medicine 비해유의미한치료효과를보였다. 그러나양약투여와인지행동요법을병행한대조군과양약투여와인지행동요법그리고한약투여를병행한복합시험군을비교한 Shen 19) 의연구에서는치료시작후 2주와 4주에서시험군이대조군에비해유의미하게우수한치료효과를보였으나, 8주간의치료가종료된후에는두군간치료효과가통계적으로유의미한차이를보이지않았다. 치료후이상반응에대해서는총 4편의대조임상연구에서 TESS 를활용하여평가하였는데, 3편의연구에서이상반응은시험군이대조군에비해유의미하게적게나타났다. 다만 Gao 21) 의연구에서는시험군과대조군에서모두경미한이상반응이발생하여, 두군간통계적으로유의미한차이를보이지않았다. 이상의연구결과를살펴보았을때, 중국에서는공황장애의다양한치료방법에대한임상연구가비교적활발히이루어지고있음을알수있었다. 본연구에서고찰한논문의편수가 8편밖에되지않았고모든논문의질이낮았으며치료후추적조사를시행한연구가전무하였으나, 공황장애환자를대상으로한전향적임상연구가미흡한국내한의학계현실을고려한다면, 본연구결과는다양한치료적접근및임상연구설계와시행에있어기초자료로활용될수있을것이라사료된다. 본연구에서고찰한치료방법인침, 한약, 정신요법은국내한의학임상현장에서도널리활용되는치료방법이다. 그러나그효과와임상적유의성에대한체계적인임상연구를통해마련된근거가부족한실정이다. 향후공황장애에대한한의학적치료접근의저변확대와치료효과의확증적인근거창출을위해서는체계적이고, 과학적으로설계된질높은임상연구가지속적으로이루어져야한다고사료된다. 중서의결합으로대부분의연구가진행되는중국과는다르게, 국내에서는한양방협진으로공황장애치료및연구를하는경우는찾아보기힘들다. 서양의학에서공황장애치료에사용되는 SSRI와 SNRI 와같은약물들은환자의증상감소에일정한효과를나타내지만, 성기능장애, 오심, 구토, 두통등과같은부작용이있고약물의존도와같은한계를지니고있다. 한약및침치료와정신요법은비교적안전한치료방법으로, 본연구에서살펴본치료방법이공황장애의치료효과증대, 양약투여량및기간단축, 양약부작용감소에기여할수있을것이라기대되며, 향후국내에서도한양 방협진연구와이를위한프로토콜개발이필요하리라사료된다. 이상에서살펴본바와같이국내에비해중국에서는공황장애에대한임상연구가비교적다양하게이루어지고있음을확인할수있었다. 본연구에서고찰한중의학임상연구들은향후국내한의학계에서공황장애임상연구의활성화와체계화를위한기초자료가될수있으리라생각한다. V. 결론 본연구는 2004 년 1월부터 2014 년 12월까지중국에서발표된공황장애치료관련임상연구논문 8편을분석하여다음과같은결론을얻었다. 1. 공황장애의진단기준으로 CCMD-3 가가장많이사용되었고, 치료효과를평가하기위한도구로 HAMA가가장많이사용되었다. 2. 연구에활용된치료수단으로한약치료가가장많이사용되었다. 그외정신요법, 침치료등이활용되었다. 치료수단은대부분복합적으로활용되었다. 3. 한약치료시에는복령 ( 茯笭 ), 반하 ( 半夏 ), 황련 ( 黃蓮 ), 감초 ( 甘草 ), 용골 ( 龍骨 ) 등의약재를주로사용하였고, 양약투여대조군에활용된약물로는 paroxetine 이가장많았다. 정신요법은인지요법, 행동요법, 심리분석등이사용되고있었다. 침치료는증상발작기와간헐기로구분하여처치하고있었다. 4. Jadad scale 을통한연구의질평가에서대조임상연구 6편중 3편이 2점이었고, 나머지는모두 1점이하로연구의질이낮은편이었다. 5. 양약투여한대조군과치료결과를비교하였을때, 한약을단독으로투여한시험군및한약투여와더불어정신요법혹은양약투여를병행하여복합치료를한시험군이대조군과비슷하거나더우수한치료효과를보였다. 또한대부분의연구에서치료후이상반응은시험군이대조군에비해적었다. REFERENCES 1. Suh HS. Evidence-based pharmacotherapy for panic disorder. J Korean Med Assoc. 2010;53(10):913-21.
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