Modern therapeutic approaches to treatment and rehabilitation of non-psychotic mental disorders

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V. N. Karazin Kharkiv National University

Modern therapeutic approaches to treatment and rehabilitation of non-psychotic mental disorders

UDC: 616.891-084-085.851:616-021

D. I. Dimshitc

Kharkiv, Ukraine

Summary

Nozogenic factors of mental traumatization, pathomorphosis and somatization of clinical manifestations of non-psychotic mental disorders as a result of physical diseases and surgical interventions, the prevalence of depressive and hypochondriacal inclusions in its structure requires significant changes in modern psychotherapy strategies. Over the past decade the development of psychotherapy in the world has led to numerous (over 1500) forms and methods that serve mainly as techniques or conditions and styles of the psychotherapy that put practical psychotherapists in the difficult position. In the main directions of social psychiatry, psychotherapy and medical psychology in Ukraine with the need to reform the psychotherapeutic care there is a need for further development of both classical methods and the development of new techniques and methods that were not previously used in national psychotherapy. It is necessary to combine the methods of psychotherapy, to form a coherent system. With the development of new methods of psychotherapy there is a need for organizational models that implement focus on psychohygienic and psychoprophylactic psychotherapeutic effects.

Key words: nonpsychotic mental disorders, surgical interventions, psychotherapy, sociotherapy, psychoprophylactic.

Nozogenic factors of mental traumatization, pathomorphosis and somatization of clinical manifestations of NMD (non-psychotic mental disorders) as a result of physical diseases and surgical interventions, the prevalence of depressive and hypochondriacal inclusions in its structure requires significant changes in modern psychotherapy strategies [1; 2]. Non- psychotic mental disorders cannot be treated successfully without psychotherapy, and this determines all the tactics of therapeutic effects on neurotic and neurosis-like states. The content of NMD psychotherapy and its goals and tasks are different and defined by the one concept followed by the therapist [3; 4].

In the most general terms, we can speak about two prerequisites of wide and effective use of psychotherapy. Firstly, a direct use of its therapeutic effect in a large circle of diseases in which etiopathogenesis significant or dominant role have psychological factors, and secondly, their therapeutic and prophylactic value.

Over the past decade the development of psychotherapy in the world has led to numerous (over 1500) forms and methods that serve mainly as techniques or conditions and styles of the psychotherapy that put practical psychotherapists in the difficult position [5]. The greatest development and recognition was gained by 3 psychotherapeutic trends and methods which have arisen on their basis:

1) psychoanalytic (psychodynamic, dynamic);

2) behavioral;

3) humanistic (existential-humanistic).

In these three directions that are focused on personality changes and not just one symptom, the presence of a personal concept has helped to create a psychotherapy system that is characterized by the logical orientation of views, which is inherent to other areas ofmedicine. In the framework of each of these psychotherapeutic directions new trends, approaches, forms, types, methods, procedures, techniques, names are created, which often are designed to reflect the uniqueness of each of them [6-8].

Aleksandrowicz J. W. [9] attempted to analyze the diversity of values in which concept of psychotherapy method is used:

¦ methods of psychotherapy that have the character of techniques (hypnosis, relaxation, psyhogymnastics, etc.);

¦ methods of psychotherapy that define the conditions that promote the optimization of achieving of psychotherapy goals (family therapy and others.);

¦ methods of psychotherapy within the meaning of the tool, which we use in the psychotherapeutic process (this tool can be a psychotherapist in case of individual or group psychotherapy);

¦ methods of psychotherapy within the meaning of psychotherapeutic interventions that are considered as options of style (directive, nondirective), or as the parameters of the theoretical approach (interpretation, interpersonal interaction (dialogue).In clinical practice the division of psychotherapeutic methods on symptom- centered, person-centered, integration of which often provides the best therapeutic effect is used [10]. The recent strengthening of integration movement in psychotherapy confirms the provision that the existing psychotherapeutic approaches do not only differ in relation to the same object - the human person, but also focus on its various aspects and problems, and this is caused by differences in methods of psychotherapy and many of their classification distributions [11-13].

The classification of psychotherapeutic methods should only be considered as an attempt of organizing that can help successfully navigate in field. A growing number of psychotherapists are using diverse psychotherapeutic methods, oblivious to their theoretical justification; so technical, non-theoretic synthesis of psychotherapeutic methods happens. The tasks of psychotherapy are determined by the individual characteristics of psychopathology, issues and personality of a particular patient and optimal suitability for certain therapeutic effects [14]. In terms of methodological classification such concepts as personality-oriented, symptomatic, group therapy and others are separated [15].

In conducting psychotherapy emphasis is placed on the need to compliance with certain principles. The first of them is the importance of taking into account the age levels. The dominance of the emotionally-intellectual level of mental response requires transition from symptom-oriented to personality- oriented psychotherapy. Another principle relates to considering the depth and duration of existing psychopathological disorders. In neurotic reactions a short course of treatment consisting of elements of suggestive, rational psychotherapy may well be enough.

Another important principle consists of a change its focus from nozocentic (focus on the disease) to the anthropocentric (focus on man) and then to sociocentric (focus on the relationship of the individual with the environment) setting. Finally, dynamic and changing nature of mentality demands from the therapist the possession of wide arsenal of techniques and ability to vary creatively their use based on the context of situation. According to S. Leder and Vysokinskoy-Honser T. [16; 17] in the psychotherapeutic process in terms of its essence there are two opposite phases. In the first phase, the major mechanism of therapeutic action is passive patient study by providing the necessary information and emotional support. In the second phase, healing personality changes are occurring mainly consciously, through active retraining. However, not all scientific schools agree with this interpretation of psychotherapeutic process. Each of them, by offering treatments comes from a particular understanding of not only the relationship "doctor-patient", but also etiopathogenetical mechanisms of NMD, based on more or less holistic concept of personality. Even using such techniques, these schools put different content and evaluate their effectiveness on various criteria [18].

Perhaps the only coherent and convincing domestic psychotherapy concept is reconstructive (pathogenetic) therapy by Myasishev V. N. [19]. In domestic literature of the latest period the largest numbers of works are devoted to psychotherapy of neurotic disorders, based on the principles of pathogenetic concept based on the psychology of relations [20]. In each of these relationships emotional, behavioral and cognitive components can identified. The main goal of pathogenic therapy is to change the broken system of relationships of the patient, restore normal social functioning of the individual, correct inappropriate emotional responses and behaviors, patient awareness of cause-effect relationships between the features of its system of relationships and the disease.

The following main principles of psychotherapy should be considered:

¦ orientation (targeting) on the functioning adaptive mechanisms of the individual; predisposition to pathogenic oriented psychotherapy [21];

¦ the use of non-legislative methods of influence; the use of mainly fast-acting methods that prevent the formation of prolonged form of non-psychotic disorders based on biological methods of influence;

¦ the use of therapeutic measures gradually (in stages), differentiated (with different pathogenic mechanisms of formation of forms) and in complex [22].

Recently more attention has been paid to personality-oriented psychotherapy that provides meaningful, reconstructive natu re of psychotherapy influences and personality development- oriented system of psychoprophylaxis and psychohygiene. If the personality-oriented psychotherapy is the foundation of any psychotherapeutic influence aimed at solving strategic challenges, the symptomatic methods solve more tactical tasks [23].

As noted, in the main directions of social psychiatry, psychotherapy and medical psychology in Ukraine with the need to reform the psychotherapeutic care there is a need for further development of both classical methods and the development of new techniques and methods that were not previously used in national psychotherapy. It is necessary to combine methods of psychotherapy, to form a coherent system. Integration of many approaches and methods, techniques and trends ofpsychotherapy should be noted. The main strategic development of modern psychotherapy lies in the synthetic approach. The goal of psychotherapy is to eliminate pathological symptoms, which have different hierarchical levels: mental; neurotic; vegetative [24].

In the preface to the third volume of "Yearbook of psychiatry and mental health problems" (1999), the research group Servier stated that despite the contradiction between biological therapy and psychotherapy, currently new connections are emerging.

Currently, the value of hipnosuggressive therapy as an outdated method that is opposed to methods that are more "modern" is artificially debated.Inthisregarditispossibletoconditionally distinguish methods of psychotherapy that appeal to neurophysiological somatogenic mechanisms (hypnosis, autotraining, indirect behavioral therapy) and methods that are mediating on the personal psychological level (analytical psychotherapy, Gestalt therapy, psychodrama etc.) [24].

Special attention is drawn to the current trend in the development of short forms of psychotherapy. In terms of probably the only meeting psychotherapist uses techniques that are the most appropriate for given patient such as suggestion, advice or interpretation. One of the conditions of their effectiveness at use of any of the methods of psychotherapy is the development of the best relationship "psychotherapist - patient", which was the most fully reflected in the principles of nondirective suggestion or Ericksonian psychotherapy and NLP techniques. The choice of forms and methods of psychotherapy should primarily consider the clinical approach, which is determined by the following factors: nosology of the pathology; personal characteristics of the patient; prevalence of any symptomatical level; conceptual and methodological basis of psychotherapeutic direction that determines the nature of corrective action. Personal preferences of the patient to a particular therapeutic technique should be taken into account [25].

Currently, the focus in working with patients suffering from NMD is shifting from traditional pharmacotherapy, traditional psychotherapy to staging of effective rehabilitation programs, because the use of routine psychotherapeutic techniques is not effective enough in these cases. The aim is to adapt the patient to the real conditions of existence [26].

The specifics of nosogenia as traumatic factor leads to decompensation in patients with signs of functional mental disorders and requires properly organized and qualified medical care. The use of traditional psychotherapeutic methods in today's conditions is difficult mainly because of their complexity. However, implementation of "rapid therapy" methods allows to compensate these limitations [27].

In the modern period of time the most affordable and easy-to-learn are various methods of self-regulation that allow you to remove the emotional stress, increase resistance to stress and speed up the social adaptation.

Determination of the effectiveness of psychotherapy is a complex issue and it depends on many factors. Not all experts resort to psychodiagnostics for the purpose of differentiated approach in the choice of psychotherapeutic techniques and their efficiency evaluation. Psychotherapy that is conducted without the identified but objective personal characteristics may not only be ineffective, but also may adversely effect on the patient's condition.

Research of Tashlykova V. A. and Valentika V. has shown that studies of the characteristics of the patient and the doctor that reflect their personal relationship interactions, degree of their psychological compatibility are essential for effective psychotherapy. The knowledge of these factors allows the doctor to predict treatment response features of the patient and the nature of psychotherapeutic influence, to achieve productive therapeutic contact, flexibly build psychotherapeutic tactics at different stages of the treatment process. This helps in selecting methods of psychotherapy, identifying personality characteristics and level ofintelligence of the patient, characteristics of such properties as conformity and suggestibility. Suggestibility is not a constant sign for a given individual and it varies in different periods in the same person depending on age, life situation, turns out differently in dealing with different people. Most importantly, suggestibility is different at different stages of the disease - in some cases it decreases during chronification of non-psychotic disorders. This fact underscores the importance of the early timing of psychotherapy that served as a basis of the principle of "emergency psychotherapy" or "emergency psycho therapeutic assistance." [28].

Urgent tasks of modern psychotherapy are further development and generalization of the results of theoretical researches and accumulation of empirical materials of clinical, psychological, social, and other aspects of the study of the mechanisms and effectiveness of psychotherapy. According to Karvasarskiy B. D. psychotherapy should be based on an integrative approach that involves the complementary synthesis of different approaches and ways. However, the basic principles should be: conscious understanding of responsibility for the choice of target and levels of changes in the course of treatment by the patient; focus on the system of values and needs of the patients in life and spiritual spheres.The main area of influence is personality, but not a symptom, multisignificant impact on all areas of personality [29]. nozogenic psychotic mental

As it was pointed by Tabachnykiv S. I., Napryeyenko A. K., Dombrovskaya V. V., Mikhailov B. V., Maruta N. A. etc., Goyda N. etc. long-term trend of social psychiatry is its further rapprochement with other clinical disciplines. The implementation of this provision is related to the shift in the treatment of mental patients from pharmacotherapy to psychotherapeutic and sociotherapeutic type of assistance [30].

Therefore, with the development of new methods of psychotherapy, especially the personality-oriented one, there is a need for organizational models that implement focus on psychohygienic and psychoprophylactic psychotherapeutic effects.

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Анотація

Сучасні підходи до терапевтичного лікування і реабілітації непсихотичних психічнних розладів

Д. І. Димшиць

Харківський національний університет імені В. Н. Каразіна

Нозогенні фактори психічної травматизації, патоморфоз і соматизація клінічних проявів непсихотичних психічних розладів внаслідок соматичних хвороб і хірургічних втручань вимагають істотних змін стратегії надання психотерапевтичної допомоги цій групі пацієнтів через переважання в їх структурі депресивних та іпохондричних включень. В основних напрямках розвитку соціальної психіатрії, психотерапії та медичної психології в Україні відбувається реформування психотерапевтичної допомоги з перенесенням акцентів у лікуванні психічнохворих з фармакотерапії на психотерапевтичний і со- ціотерапевтичний види допомоги. Але за останні десятиліття з'явилося більш ніж 1500 нових психотерапевтичних методів, що стає причиною розгубленості практикуючих психотерапевтів. Тому виникла потреба подальшого розвитку як класичних методів, так і розробки нових методик і методів, що раніше не використовувалися у вітчизняній психотерапії, які треба поєднати у чітку систему, що буде реалізовувати переважно психогігієнічну і психопрофілактичну спрямованість психотерапевтичних впливів.

Ключові слова: непсихотичні психічні розлади, хірургічні втручання, психотерапія, соціотерапія, психопрофілактика.

Аннотация

Современные подходы к терапевтическому лечению и реабилитации непсихотических психических расстройств

Д. И. Дымшиц

Харьковский национальный университет имени В. Н. Каразина

Нозогенные факторы психической травматизации, патоморфоз и соматизация клинических проявлений непсихотических психических расстройств вследствие соматических заболеваний и хирургических вмешательств требуют существенных изменений стратегии оказания психотерапевтической помощи этой группе пациентов из-за преобладания в их структуре депрессивных и ипохондрических включений. В основных направлениях развития социальной психиатрии, психотерапии и медицинской психологии в Украине происходит реформирование психотерапевтической помощи с перенесением акцентов в лечении психически больных с фармакотерапии на психотерапевтический и социо- терапевтический виды помощи. За последние десятилетия появилось более чем 1500 новых психотерапевтических методов, что приводит в замешательство практикующих психотерапевтов. Поэтому возникла потребность как дальнейшего развития классических методов, так и разработки новых методик и методов, которые ранее не применялись в отечественной психотерапии, с последующим их объединением в целостную систему, реализующую преимущественно психогигиеническую и психопрофилактическую направленность психотерапевтических влияний.

Ключевые слова: непсихотические психические расстройства, хирургические вмешательства, психотерапия, социотерапия, психопрофилактика.

Dmytro Dimshitc - Assistant of the Department of Psychiatry, Narcology, Neurology and Medical Psychology, School of Medicine, V. N. Karazin Kharkiv National University, Kharkiv, Ukraine; e-mail: Dimshitc@gmail.com.

Димшиць Дмитро Ігорович - асистент кафедри психіатрії, наркології, неврології та медичної психології, медичний факультет, Харківський національний університет імені В. Н. Каразіна, м. Харків, Україна; e-mail: Dimshitc@gmail.com.

Дымшиц Дмитрий Игоревич - ассистент кафедры психиатрии, наркологии, неврологии и медицинской психологии, медицинский факультет, Харьковский национальный университет имени В. Н. Каразина, г. Харьков, Украина; e-mail: Dimshitc@gmail.com.

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