Psychotherapeutic and psychoprophylactic help to somatic patients who use psychoactive substances in the family medicine practice

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Research Institute of Psychiatry of the Ministry of Health of Ukraine

Shupyk National Medical academy of Postgraduate Education

Donetsk National Medical University of the Ministry of health of Ukraine

Psychotherapeutic and psychoprophylactic help to somatic patients who use psychoactive substances in the family medicine practice

Tabachnikov S., Mishyiev V., Kharchenko E.,

Osukhovskaya O., Grinevich E., Vasylyeva G.,

Chepurna A., Salden V.

Kyiv, Liman

Abstract

In the article, there is described the system of psychotherapy and psychoprophylaxis in the complex treatment of persons, who use psychoactive substances and have somatic consequences in the family medicine practice.

Keywords: family medicine, psychoactive substances, somatic consequences, psychotherapy, psychoprophylaxis.

Резюме

Психотерапевтическая и психопрофилактическая помощь соматическим пациентам, которые употребляют психоактивные вещества, в практике семейной медицины

Табачников С.И., Мишиев В.Д., Харченко Е.Н., Осуховская Е.С., Гриневич Е.Г., Васильева А.Ю., Чепурная А.Н., Салдень В.И.

Научно-исследовательский институт психиатрии Министерства здравоохранения Украины, Киев, Украина

Национальная медицинская академия последипломного образования имени П.Л. Шупика, Киев, Украина

Донецкий национальный медицинский университет, Лиман, Украина

В статье изложена система психотерапии и психопрофилактики в комплексном лечении лиц, употребляющих психоактивные вещества и имеющих соматические последствия, в практике семейной медицины.

Ключевые слова: семейная медицина, психоактивные вещества, соматические последствия, психотерапия, психопрофилактика.

Introduction

the use of psychoactive substances is one of the most ancient, complex and unsolved medical and social problems in most countries of the world, in particular in Ukraine [1-3]. Despite the various counteractions - medical, legal, the total number of people with different stages of use of PAS is increasing. So, Ukraine belongs to a number of countries with a high level of patients with this pathology [4-5]. According to the WHO, more than 600 thousand people are registered in the country officially on drug registration, and these numbers, of course, do not reflect the actual situation. The threatening situation is not only in the drug intake and prevalence of PAS among the population, but also in the presence of somatic consequences - severe and varied, which leads generally to mental, somatic and social decompensation, disability or mortality [4]. The medical paradox is a long period of non-provision of qualified assistance to such patients, due to the active reluctance to apply to specialists (psychiatrists, narcologists, psychotherapists), concealing their passions. As a result, with a somatic deterioration in health, patients turn to the GP of a outpatient department, who is often unable to differentiate the genesis of somatic disorders, which is a reason in the PAS use, and its adversely affects the medical process and the subsequent patient state [6-8].

Modern medical reform in the our country has brought about significant changes in the volume of providing skilled care to all population segments by the family doctors, while taking as an example the similar medical care of most socially developed countries of the world. In this sense, it is imperative to provide sufficient tools for family physicians, that is, the system of diagnosis, treatment and rehabilitation of PAS users, who have somatic consequences, which will teach doctors the basics of narcological and psychotherapeutic qualified assistance to the mentioned above contingent of persons [9-11].

PURPOSE OF THE WORK

Develop a system of psychotherapeutic, psycho-correction and psychoprophylaxis for PAS users with somatic consequences.

MATERIALS AND METHODS

In accordance with the relevant methods (clinical, anamnestic, socio-demographic, psycho-diagnostic, clinical-psychopathological and statistical), 220 patients (54% men and 46% woman at age 18-60) were examined, who during 2017-2018 appealed with somatic complaints to the family doctor of the Primary Health Care Center N 1 in Kyiv. At the same time, patients used different PAS.

RESULTS

Deterministic analysis of the use of psychoactive substances by the AUDIT tests found that, the majority of the abuses in the patients accounted for tobacco smoking - 63.6%; slightly less - alcohol - 56.4%; psychostimulants - 9.1%; cannabinoids - 5.5%; the use of opiates (opioids) was not detected; combined forms of psychoactive substances using - 72%. According to the age the most common psychoactive substance (tobacco and alcohol) was the older age group (36-60 years), for narcotic substances - young (18-35 years). A significant number of respondents who hide the PAS abuse, especially drugs, should be taken into account. The alcohol using most patients tried to stipulate as a commonly used feature of behavior or mentality of the population. Accordingly smoking explanations for many are even more groundless in understanding illness or psychosomatic effects.

In the somatic plan, the growth of negative dynamics in alcohol abuse leads to an aggravation of cardiovascular (48%) and gastrointestinal pathology (32%); and smoking - pulmonary-respiratory pathology (20%). When combined with the use of different types of PAS, the severity of mental and somatic manifestations significantly exceeded.

The use of the system of AUDIT-like tests in the study of persons with addictive behavior who use psychoactive substances can characterize not only the nature of the affinity of PAS, but also the degree of its use. So, according to the levels of risk of mental and behavioral disorders associated with the use of psychoactive substances, we have allocated 4 degrees, according to the modification of the system of AUDIT-like tests [10]: "A" (1-7 points) - relatively safe use of psychoactive substances; "B" (8-15 points) - dangerous use (style of use of PAS, which increases the risk of harmful effects both for the person who consumes and for others); "C" (16-20 points) - use with harmful effects (the style of use of psychoactive substances, which leads to disorders of adaptation, as well as physical and mental health); "D" (>20 points) - dependence (according to the criteria of ICD-10). Examined clinical and psychopathological symptoms with alcohol abuse, the prevalence of depressive (12.5%) and anxiety (10%) syndromes was found in the initial stages ("A", "B"); in the course of intensification of the severity of mental and somatic pathology, the symptoms are transformed into anxiety-depressive (37.5% of the "C") and astheno-depressive (degree "D" - 40%). In smoking cases, the dynamics are somewhat similar, however, with an exacerbation of the psychosomatic state, the more disturbing component (in the degree of "C") dominates - 48.3%, and astheno-depressive (in the degree of "D") - 30.3%. Compared to the effects of alcohol use, the tobacco status of the asthenic background is slightly lower.

Proceeding from the revealed clinical features of the examined patients, as well as their personality traits, more often accentuation - 54%, in particular, anxiety - 29%, demonstration - 32%, exaltation - 16%, hyperthymia - 9%, cyclothymia - 7%, excitability - 5%, etc., in particular gender features, the system of provision of primary medical care to such patients in the practice of family medicine has been developed.

The algorithm for providing medical and social assistance, developed by us, specifies the correlation between the clinical characteristics and the recommended measures: psychotherapy psychoprophylaxis family medicine

1. Degree "A" - relatively safe PAS use - psychohygienic and psychoprophylaxis measures, which included:

¦ educational work according to the psychoactive substances use and their consequences;

¦ medical and psychological provision of professional and educational activities;

¦ counseling assistance for maladaptive behaviors forms (learning effective communication skills, decision making, and elaboration of a life position);

¦ development of counteracting various risk factors skills;

¦ formation of emotional regulation skills, conflict resolution;

¦ co-working of general practitioners, psychiatrists, narcologists, psychotherapists, and psychologists in the prevention of mental and behavioral disorders due to the PAS use through a comprehensive survey of risk groups, followed by socio-psychological rehabilitation and correction.

2. Degree "В" - dangerous use of PAS - psychoprophylaxis, psychocorrection and social-psychological help:

¦ monitoring - selection and registration of a narrow aspect of behavior that needs to be changed;

¦ stimulus control method - definition of environment and incentives of non-adaptive behavior trigger;

¦ solving problems therapy - helping the addict to find an adequate solve of problems;

¦ autotraining - preparation of the addict for dealing with severe stressful situations through self-control skills (coping strategies);

¦ positive instructing, which increases the ability to solve the problem.

3. Degree of "C" - the PAS use with harmful effects. Recommended psychocorrection and psychotherapeutic assistance aimed at: emotional-volitional sphere, communicative, cognitive, value-semantic, moral sphere of personality, formation of new constructive forms of motivation in society:

¦ emotional-volitional sphere of personality - self-observation, selforganization, self-management, frustration tolerance, inclusion of addict in socially useful work, increasing in the mood general background due to indirect influence;

¦ communicative sphere - the formation of skills of constructive communication and their coordination with communication needs and skills of the person to constructive communication; the ability to adequately perceive others, development of empathy, psychocorrection of family relationships;

¦ cognitive sphere - the development of self-awareness, the formation of adequate self-esteem and realistic world perception, the constructive completion of traumatic gestalt, the detection of irrational cognition and the wrong purpose and the replacement of it with constructive, changing stereotypes of the perception of cognitive reactions and attitudes;

¦ value-semantic sphere - awareness and restructuring of its own system of values, conscious assimilation of the system of higher values, which make sense to human existence in all conditions;

¦ moral sphere of personality - formation of internal locus-control, consciousness as a factor of self-regulation of behavior, human attitudes to others, ability to choose them in problem situations;

¦ formation ofmotivation and skills ofpsychological, psychotherapeutic work with person himself in the direction of constructive changes of the personality in order to correct the mental state, as well as personal development in general.

4. Degree "D" - dependence - psycho-pharmacotherapy (these patients should be direct by a family doctor to a specialist-narcologist):

¦ pharmacological correction (antidepressants, anxiolytics);

¦ individual psychotherapy (rational, indirect, person-oriented reconstructive, cognitive-behavioral, "psychotherapy through understanding", gestalt therapy), self-monitoring education (selfobservation, self-criticism, self-relaxation), autogenic training in conjunction with autosuggestion;

¦ group psychotherapy using the exercises: "feedback", "role-playing", "role-sharing", "psychodrama", family psychotherapy with exercises "family roles", "family law", "family chronology", emotional-stress psychotherapy (ESP) and others.

Prevention of the PAS use is divided into primary, secondary, tertiary.

In turn, primary prevention includes measures to prevent the causes of alcoholism and drug addiction long before they can occur.

The optimal period for the anti-drug facilities creation is the teenage age. taking into account the psychological characteristics of these age groups, the explanatory work should be aimed at demythologizing of alcohol and drugs as symbols of prestige, the breakdown of the association of alcohol consumption with positive personality traits: courage, bravery, "modernity", etc. In anti-drug propaganda for adults it is necessary to inform in an accessible form about the properties of an addiction substance and the possible consequences of its use. at the same time, effective methods are non-destructive foundations in healing, and constructive - aimed to the individual semantic orientations formation, for which PAS does not represent any value. In general, the primary psychoprophylaxis of alcoholism and drug abuse is carried out in the following areas: 1 - informing the population about psychoactive substances (their types and effects on the body, the psychic and behavior) and the formation of motivation for effective social and psychological, physical development; 2 - creation of motivation for social support behavior; 3 - projective factors of healthy socially effective behavior; 4 - problem solving skills, social support search, refusal from the proposed PAS. Methods of primary prevention become more effective in the elimination of psychological means of personal resources correction: the formation of social and personal competence and adaptive behavior strategies; functional family. In the primary psychoprophylaxis organization essential help is the institution of a family doctor.

Secondary psychoprophylaxis includes: 1 - early diagnosis; 2 - disclosure of the psychological person disadvantage associated with the drug abuse causes; 3 - a proposal for broad psychological assistance, communication groups, meetings with ex-patients with alcohol and drug addiction, work with the immediate environment and the addict family, etc. The main purpose of secondary psychoprophylaxis is to change the maladaptive and pseudo-adaptive risk behavior patterns into more adaptive healthy behaviors. The main directions of secondary psychoprophylaxis should be as follows: 1 - motivation formation for rational behavior; 2 - change of deadaptable forms of behavior on adaptive; 3 - formation and development of social support network.

In these areas, social, pedagogical and psychological technologies are used: the motivations formation for the complete PAS cessation, behavior change - the development and overcoming of problems and barriers, awareness of emotional states; developing emotional, cognitive and behavioral behavior strategies, overcoming problems, finding and accepting social support, recognition and modification of the avoidance strategy. Psychological correction at this stage of psychoprophylaxis involves the development of communicative resources, social competence, value orientations, taking responsibility for their own lives, behavior and their consequences; perception of social support; change of stereotypes of behavior and role interaction in the family, formation of psychological resistance to the pressure of the narcological environment.

Tertiary psychoprophylaxis refers to the help of patients who recover from alcohol or drug dependence. In this work can serve clubs of sobriety, societies such as anonymous alcoholics; the organization of psychological counseling for recovers, special therapeutic and rehabilitation programs and rehabilitation measures based on physiotherapeutic correction, nootropic and symptomatic therapy, respectively, the somatic effects of the PAS use. Such work can be largely carried out in the family medicine practice in parallel with the specialist-narcologist. The main areas of work for tertiary psychoprophylaxis are: the motivations formation to change behavior, inclusion in treatment, discontinuation of the psychoactive substances use; change of dependent desadaptive forms of behavior on adaptive; awareness of the values of personality and life style; development of communicative and social competences, personal resources and adaptive doping skills; formation and development of social support network. Psychological components of this direction are the following factors: awareness of personal, existential, spiritual and moral values; personal goals and ways of their achievement; attraction and dependence; change of life style in general, development of communicative and social competences, as well as cognitive, emotional and behavioral spheres; personal resources to combat with addiction. In general, medical technologies consist of a qualified psychopharmacological intervention at the stages of stabilization, remission and prevention of recurrence of illness with psychotherapy.

CONCLUSIONS

1. the leading somatization profiles are outlined (cardiovascular system disorders - 48%, gastrointestinal tract disorders - 32%, disorders of pulmonary-respiratory system - 20%), which are combined with mental pathology and, to some extent, the gender characteristics of respondents.

2. The criteria for the formation of the psychoactive substances use, as well as various pathogenic profiles of the somatic type with the consistent negative dynamics of the combination of the PAS effects and psychosomatisation of patients have been identified.

3. A system of step-by-step diagnostics of the psychoactive substances use (patients with somatic effects and their manifestations) on the example of using the system of AUDIT tests, etc., was developed.

4. With the help of characteristic features of anamnesis personality, clinical psychopathological and somatic data, a system of psycho-corrective, psychotherapeutic and psychoprophylaxis help to the patients in the general family medicine practice. The essence of the program: individual, group, family psychotherapy in a comprehensive medical and social approach. Leading methods of psychotherapy: cognitive-behavioral, gestalt-therapy, existential, autogenic, etc.

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