Boris dmitrievich karvasarsky clinical psychology. Personality types and predisposition to certain diseases The theory of personality profiles is associated with the name

For the problem of the specificity of psychosomatic disorders, the following questions are usually posed: are persons with a certain personality structure predisposed to a certain psychosomatic disease; whether certain conflict and general life situations lead to a certain psychosomatic illness; whether there is a relationship between a person's behavioral characteristics and the risk of contracting a certain psychosomatic illness. The largest number of works performed by both clinical and experimental psychological methods is devoted to the search for a "personality profile" specific to a particular psychosomatic disorder. The view that such personality profiles have diagnostic, prognostic and therapeutic significance are usually associated with Dunbar's research, presented in the well-known monographs "Emotions and Somatic Changes", "Psychosomatic Diagnosis". In the Anglo-American literature of different years, characteristic personality profiles have been described for patients with angina pectoris (I20), essential hypertension (I10), bronchial asthma (F54), gastric ulcer (K25), spastic colitis (F45.3), rheumatoid arthritis (M05 ), migraine (G43), etc.

The overall result of these studies was, rather, the denial of personality structures characteristic of individual diseases. Many authors tend to abandon the search for personality profiles, replace this aspect of research with a description of the personality characteristics of a psychosomatic patient in general, considering the presence of an infantile personality structure, a neurotic life position as a basic characteristic, since the somatic expression of emotional experiences is an infantile form of their expression.

As for specific conflict and life situations, the search for them was also unsuccessful. Ultimately, Stokvis emphasizes, it is not at all important what a person is experiencing, it is much more important how he recycles what he has experienced, therefore, not the conflicts themselves, but only the type and nature of their processing can reveal similarities and only in this respect and it would be possible to talk about them specificity. To this question, one of the most relevant for further development The problems of psychogenetic analysis, and the psychotherapy based on it, have been repeatedly addressed by authors who adhere to the most diverse views on the nature of psychogenic disorders in humans. The complex of pathological symptoms, usually used in the diagnostic and therapeutic plan, is contrasted with more significant emotional and motivational disorders of perceptual cognition of the world and attitudes towards people and events. In this case, Fortuna notes, it is the specific nature of the processing of conflict experiences that would be the basis for classification and therapy (for example, "neurosis with a mechanism for suppressing emotions and rationalization," "neurosis with a conflict of rivalry, compensated by the mechanism of striving for self-affirmation," etc.). ). One of the attempts to solve these the most difficult questions From the standpoint of the psychology of relationships, the works of Myasishchev appeared, in which he considered the main clinical forms of neuroses (F40-F48) as fixed features of individual mechanisms of painful perception and processing of life difficulties experienced by a person.

The concept of alexithymia.

At present, the attention of researchers is drawn to the so-called alexithymic radical in the structure of a premorbid personality, as one of the possible psychological risk factors for psychosomatic disorders. Methods are being developed for determining the level of alexithymia in patients with psychosomatic diseases, as well as psychotherapeutic methods aimed at reducing alexithymia by overcoming its defining personality traits. Further study of alexithymia in the system of other risk factors of a biological and psychosocial nature is important for a better understanding of the role psychological mechanisms in the pathogenesis of these diseases, long-term prognosis and the organization of preventive measures in the framework of preventive epidemiology.

The term "alexithymia" was introduced by Sifneos in 1973. In his work, published back in 1968, he described the features of patients in a psychosomatic clinic that he observed, which were expressed in a utilitarian way of thinking, a tendency to use actions in conflict and stressful situations, a life impoverished with fantasies , narrowing of affective experience and, especially, in the difficulty of finding the right word to describe your feelings. Alexithymia literally means: "without words for feelings" (or in a close translation - "there are no words for the names of feelings"). The term has been criticized, including for lack of relevance, but has firmly taken its place in the literature on psychosomatic diseases, and the concept of alexithymia associated with it is gaining popularity, which is reflected in the ever-increasing number of publications in different countries... The development of the concept of alexithymia was preceded by earlier observations, which established that many patients suffering from classical psychosomatic diseases and characterized by an "infantile personality" show difficulties in verbal symbolic expression of emotions.

Alexithymia is psychological characteristics determined by the following cognitive-affective features: 1) difficulty in identifying (identifying) and describing own feelings; 2) difficulty in distinguishing between feelings and bodily sensations; 3) a decrease in the ability to symbolize, as evidenced by the poverty of fantasy and other manifestations of the imagination; 4) focusing more on external events than on internal experiences.

The concept of alexithymia, as formulated by Siphneos, has generated interest in studying the relationship between levels of identification and description of one's own emotions and susceptibility to psychosomatic disorders. A hypothesis was put forward according to which the limited awareness of emotions and cognitive processing of affect leads to focusing on the somatic component of emotional arousal and its intensification. This probably explains the tendency of alexithymic individuals, established by a number of authors, to develop hypochondriacal and somatic disorders (Taylor). It has been suggested that the inability of alexithymic individuals to regulate and modulate the emotions that cause them suffering at the neocortical level may result in increased physiological responses to stressful situations, thereby creating conditions leading to the development of psychosomatic diseases.

To explain the alexithymia syndrome and its role in the formation of psychosomatic disorders, Neymiakh identified two models: “denial” and “deficiency”. The model of "denial" presupposes a global inhibition of affects. If denial is viewed as a psychological defense, then theoretically it is possible to admit the reversibility of the protective process and the subsequent disappearance of the alexithymia syndrome and somatic symptoms. In this case, we can talk about "secondary alexithymia", that is, a condition that is found in some patients who have undergone severe trauma and in patients with psychosomatic diseases, who, after psychotherapy, acquire feelings and fantasies that were previously so strikingly absent in them.

However, as clinical experience shows, in many patients with psychosomatic disorders, alexithymic manifestations are irreversible, despite prolonged, intensive and skillful deep psychotherapy. Such patients remain totally incapable of affect and fantasy. For them, the scarcity model seems to be more acceptable. According to this point of view, there is no inhibition, but the absence of functions and the underlying mental apparatus. In the deficit model, the emphasis is on the disorder of instinct, which, bypassing mental processing due to a reduced ability to symbolize instinctive needs and fantasize, directly affects the somatics with adverse consequences. The author of the term alexithymia Sifneos also adheres to this model.

Clinical experience supports the concept of alexithymia in the sense that many somatic patients exhibit a limited ability to describe, differentiate affects, and produce fantasies.

The question of the origin of the alexithymic features themselves remains open to the founder of the concept himself. Is alexithymia caused by birth defects, is it the result of a biochemical deficiency, is it due to developmental delays - familial, social or cultural? There is no answer to these questions. There is, however, preliminary evidence indicating that genetic factors are of primary importance, and that this phenomenon itself can most likely be understood within the framework of neurophysiology.

Since alexithymia can occur in both healthy people and patients with various diseases, it should be borne in mind that alexithymia is not “motivated forgetting”, which can be explained by simple repression or negation and which can be found in clauses, recognizable transference. It should be distinguished from this kind of mental numbness, which can develop as an active motivated process due to massive mental trauma, threatening isolation, disintegration and depression; it should also be distinguished from those types cognitive activities and expressions that characterize similar types of psychiatric syndromes such as habitual affective disorders in sluggish schizophrenia (F21), as well as from the type of operational thinking that is characteristic of semi-literate or cognitively undeveloped, according to Piaget, people. What qualifies as alexithymia may in some cases turn out to be a cultural or subcultural characteristic.

While there is controversy over whether alexithymia is a situational condition or a stable personality trait, a number of methods have been developed to measure it. While some of them take into account only certain aspects of alexithymia, others try to measure all the components of this multidimensional characteristic. However, researchers have not always subjected the developed measurement techniques to rigorous and repeated assessments of their reliability and validity.

On the idea of ​​psychosomatic specificity, i.e. the presence of a predisposition of people characterized by certain psychological characteristics to the corresponding psychosomatic disorders, the theory of Flanders Dunbar is also based (F. Dunbar, 1939). However, if F. Alexander believed that specific emotional conflicts belong to the psychological characteristics that determine a person's tendency to a particular psychosomatic disease, then F. Dunbar suggested that the predisposition to psychosomatic disease lies in the characteristics of a person's personality.

According to Dunbar, "emotional responses are derived from the patient's personality, and this suggests the development of certain somatic diseases, depending on the personality profile." The results of 20 years of work as a psychiatrist, including a detailed study of the life stories and personal characteristics of 1600 patients with various pathologies, Dunbar summarized in the book "Psychosomatic Diagnosis", where she highlighted the characteristic personality profiles contributing to the development of related diseases: "Coronary", "hypertensive", "allergic" and "injury-prone" personality types.

In addition, Dunbar drew attention to the fact that people suffering from various psychosomatic diseases are characterized by common features , namely :

• tendency to distract from reality and lack of involvement in the current situation;
• insufficient ability to verbally describe the nuances of their emotional experiences (later this feature was studied within the framework of the concept of alexithymia).

The concept of "personality profile" has become widespread, and later in different countries, many authors have conducted numerous studies of the relationship between personality types of patients and psychosomatic diseases characteristic of these types.

The most famous are the results of the study of the so-called type A, subject to cardiovascular disease(ischemic heart disease, myocardial infarction, high blood pressure, angina pectoris): “The empirical relationship between the so-called a model of behavior according to type A and heart disease was first reported ... by Friedman and Rosenman (1974), who followed the health status of more than 3,000 men for over 8 years. The results of their observations showed that men belonging to the risk group for heart disease could be attributed to type A: they always tried to achieve maximum results As soon as possible. In addition, type A men were invariably characterized by a competitive spirit, impatience, hostility, restlessness and alertness, as well as a strong need to move forward. The earliest descriptions of Type A personality syndrome portray a person with increased anxiety and compulsiveness and lack of time to relax. ... Over the past few decades, significant progress has been made in understanding the psychological factors that can predict the occurrence of heart disease. Whereas before the most reliable predictors of cardiovascular disease were the various components of the type A behavior model, it is now commonly argued that negative emotional reactions, anger / hostility ... are closely associated with a predisposition to heart disease. " Recent studies of type A behavior associate only one personality trait with it, and not the entire complex of the listed characteristics. This trait is called "potential for hostility."

Despite the fact that the results of numerous studies reflect the existence of certain correlations between personality traits and the nature of psychosomatic disorders, the concept of a "personality profile" is generally considered unconfirmed... At first, cause-and-effect relationships between the disease and the psyche have different directions(as personality traits determine a predisposition to certain diseases, so the disease itself leads to mental changes), and statistical correlations indicate only the presence of an interconnection, but conclusions about which of the interrelated variables is the cause and which is the effect can only be subjective assumptions.

Secondly, the analysis of the data obtained indicates that the identified relationships between personality traits and psychosomatic diseases are particular cases of a single general pattern : “The general result of these studies was ... the denial of personality structures characteristic of certain diseases. Many authors are inclined to abandon the search for personality profiles, replace this aspect of research with a description of the personality characteristics of a psychosomatic patient in general, considering the presence of infantile personality structure, neurotic life position, because the somatic expression of emotional experiences is the infantile form of their expression. "

^ Personality profile concept. For the problem of the specificity of psychosomatic disorders, the following questions are usually posed: are persons with a certain personality structure predisposed to a certain psychosomatic disease; whether certain conflict and general life situations lead to a certain psychosomatic illness; whether there is a relationship between a person's behavioral characteristics and the risk of contracting a certain psychosomatic illness. The largest number of works performed by both clinical and experimental psychological methods is devoted to the search for a "personality profile" specific to a particular psychosomatic disorder. The view that such personality profiles have diagnostic, prognostic and therapeutic significance are usually associated with Dunbar's research, presented in the well-known monographs "Emotions and Somatic Changes", "Psychosomatic Diagnosis". In the Anglo-American literature of different years, characteristic personality profiles have been described for patients with angina pectoris (I20), essential hypertension (I10), bronchial asthma (F54), gastric ulcer (K25), spastic colitis (F45.3), rheumatoid arthritis (M05 ), migraine (G43), etc.

The overall result of these studies was, rather, the denial of personality structures characteristic of individual diseases. Many authors tend to abandon the search for personality profiles, replace this aspect of research with a description of the personality characteristics of a psychosomatic patient in general, considering the presence of an infantile personality structure, a neurotic life position as a basic characteristic, since the somatic expression of emotional experiences is an infantile form of their expression.

As for specific conflict and life situations, the search for them was also unsuccessful. Ultimately, Stokvis emphasizes, it is not at all important what a person is experiencing, it is much more important how he recycles what he has experienced, therefore, not the conflicts themselves, but only the type and nature of their processing can reveal similarities and only in this respect and it would be possible to talk about them specificity. This issue, one of the most relevant for the further development of the problem of psychogenetic analysis, and the psychotherapy based on it, have been repeatedly addressed by authors who adhere to a variety of views on the nature of psychogenic disorders in humans. The complex of pathological symptoms, usually used in the diagnostic and therapeutic plan, is contrasted with more significant emotional and motivational disturbances in perceptual cognition of the world and attitudes towards people and events. In this case, Fortuna notes, it is the specific nature of the processing of conflict experiences that would be the basis for classification and therapy (for example, "neurosis with a mechanism for suppressing emotions and rationalization," "neurosis with a conflict of rivalry, compensated by the mechanism of striving for self-affirmation," etc.). ). One of the attempts to solve these complex issues from the standpoint of the psychology of relationships was the work of Myasishchev, in which he considered the main clinical forms of neuroses (F40-F48) as fixed features of individual mechanisms of painful perception and processing of life difficulties experienced by a person.

^ The concept of alexithymia. At present, the attention of researchers is drawn to the so-called alexithymic radical in the structure of a premorbid personality, as one of the possible psychological risk factors for psychosomatic disorders. Methods are being developed for determining the level of alexithymia in patients with psychosomatic diseases, as well as psychotherapeutic methods aimed at reducing alexithymia by overcoming its defining personality traits. Further study of alexithymia in the system of other risk factors of a biological and psychosocial nature is important for a better understanding of the role of psychological mechanisms in the pathogenesis of these diseases, long-term prognosis and organization of preventive measures within the framework of preventive epidemiology.

The term "alexithymia" was introduced by Sifneos in 1973. In his work, published back in 1968, he described the features of patients in a psychosomatic clinic that he observed, which were expressed in a utilitarian way of thinking, a tendency to use actions in conflict and stressful situations, a life impoverished with fantasies , narrowing of affective experience and, especially, in the difficulty of finding the right word to describe their feelings. Alexithymia literally means: "without words for feelings" (or in a close translation - "there are no words for the names of feelings"). The term has been criticized, including for lack of relevance, but has firmly taken its place in the literature on psychosomatic diseases, and the concept of alexithymia associated with it is gaining popularity, which is reflected in an ever-increasing number of publications in different countries. The development of the concept of alexithymia was preceded by earlier observations, which established that many patients suffering from classical psychosomatic diseases and characterized by an "infantile personality" show difficulties in verbal symbolic expression of emotions.

Alexithymia is a psychological characteristic determined by the following cognitive-affective features: 1) difficulty in identifying (identifying) and describing one's own feelings; 2) difficulty in distinguishing between feelings and bodily sensations; 3) a decrease in the ability to symbolize, as evidenced by the poverty of fantasy and other manifestations of the imagination; 4) focusing more on external events than on internal experiences.

The concept of alexithymia, as formulated by Siphneos, has generated interest in studying the relationship between levels of identification and description of one's own emotions and susceptibility to psychosomatic disorders. A hypothesis was put forward according to which the limited awareness of emotions and cognitive processing of affect leads to focusing on the somatic component of emotional arousal and its intensification. This probably explains the tendency of alexithymic individuals, established by a number of authors, to develop hypochondriacal and somatic disorders (Taylor). It has been suggested that the inability of alexithymic individuals to regulate and modulate the emotions that cause them suffering at the neocortical level may result in increased physiological responses to stressful situations, thereby creating conditions leading to the development of psychosomatic diseases.

To explain the alexithymia syndrome and its role in the formation of psychosomatic disorders, Neymiakh identified two models: “denial” and “deficiency”. The model of "denial" presupposes a global inhibition of affects. If denial is viewed as a psychological defense, then theoretically it is possible to admit the reversibility of the protective process and the subsequent disappearance of the alexithymia syndrome and somatic symptoms. In this case, we can talk about "secondary alexithymia", that is, a condition that is found in some patients who have undergone severe trauma and in patients with psychosomatic diseases, who, after psychotherapy, acquire feelings and fantasies that were previously so strikingly absent in them.

However, as clinical experience shows, in many patients with psychosomatic disorders, alexithymic manifestations are irreversible, despite prolonged, intensive and skillful deep psychotherapy. Such patients remain totally incapable of affect and fantasy. For them, the scarcity model seems to be more acceptable. According to this point of view, there is no inhibition, but the absence of functions and the underlying mental apparatus. In the deficit model, the emphasis is on the disorder of instinct, which, bypassing mental processing due to a reduced ability to symbolize instinctive needs and fantasize, directly affects the somatics with adverse consequences. The author of the term alexithymia Sifneos also adheres to this model.

Clinical experience supports the concept of alexithymia in the sense that many somatic patients exhibit a limited ability to describe, differentiate affects, and produce fantasies.

The question of the origin of the alexithymic features themselves remains open to the founder of the concept himself. Is alexithymia caused by birth defects, is it the result of a biochemical deficiency, is it due to developmental delays - familial, social or cultural? There is no answer to these questions. There is, however, preliminary evidence indicating that genetic factors are of primary importance, and that this phenomenon itself can most likely be understood within the framework of neurophysiology.

Since alexithymia can occur in both healthy people and patients with various diseases, it should be borne in mind that alexithymia is not “motivated forgetting”, which can be explained by simple repression or negation and which can be found in clauses, recognizable transference. It should be distinguished from this kind of mental numbness, which can develop as an active motivated process due to massive mental trauma, threatening isolation, disintegration and depression; it should also be distinguished from those types of cognitive activity and expression that characterize similar types of psychiatric syndromes, such as habitual affective disorders in sluggish schizophrenia (F21), as well as from the type of operational thinking that is characteristic of the illiterate or cognitively undeveloped, according to Piaget, of people. What qualifies as alexithymia may in some cases turn out to be a cultural or subcultural characteristic.

While there is controversy over whether alexithymia is a situational condition or a stable personality trait, a number of methods have been developed to measure it. While some of them take into account only certain aspects of alexithymia, others try to measure all the components of this multidimensional characteristic. However, researchers have not always subjected the developed measurement techniques to rigorous and repeated assessments of their reliability and validity.

Currently available methods for measuring alexithymia include: questionnaires assessed by observers, self-report scales, projective techniques.

The Toronto Alexithymic Scale (TAS) is given in the psychological workshop for this chapter for measuring alexithymia. Based on the literature data, it can be assumed that today it is one of the few methods of measuring alexithymia that meets the requirements for a test suitable for both clinical and research purposes, and which is superior to other measurements of alexithymia (built on the principle of self-reporting).

^ Psychiatry of counseling-interaction as one of the directions of modern psychosomatics. In the early 70s. XX century research and clinical practice based on modern approaches, contributed to an increase in interest in psychosomatic medicine, which by that time was in crisis. Psychosomatic medicine has previously focused on psychological factors. In the 70s. the prevailing biomedical model, in which there was no place for the social, psychological, and behavioral, is being replaced by the biopsychosocial model, first proposed by Engel in 1977, synthesizing the achievements of psychosomatic medicine, and suggesting the importance of biological, psychological and social factors in development, course and outcome physical and mental disorders.

Three interrelated aspects are decisive in the definition of psychosomatics.

1. This is a scientific discipline that studies the relationship of biological, psychological and social factors in health and disease.

2. This is a collection of postulates that embody a holistic approach in clinical practice.

3. It is a discipline that includes consultation-liaison psychiatry - PCV.

PCV has long been considered a special area of ​​psychiatric practice, which has developed as one of the branches of psychosomatic medicine. This trend originated in Germany and Austria in the 20-30s. XX century and then successfully developed in the United States of America, where its development was largely influenced by the psychobiological school of psychiatry, founded by A. Mayer. His approach, which he called psychobiology, emphasized the importance of studying the patient's biography as a means of understanding the personality as a whole. Psychobiology studied man as an individual in health and disease. It logically follows from this that, from such a holistic point of view, general medical practice and psychiatry should be united rather than separated. This integration involves the development of psychiatric wards in general hospitals and collaboration between psychiatrists and their non-psychiatric counterparts in the treatment of both physical and psychological disorders.

In the 20-30s. the first psychiatric departments in general hospitals appear in the United States. One of these most significant departments, based at the University of Colorado, has been called the Department of Psychiatric Interaction. This is probably where the term "psychiatric interaction" originates. Patients in such departments made up the contingent that was used for educational purposes and included in research work. Activities of this kind can be viewed as the application of psychosomatic approaches in clinical practice. Similar departments have been set up in most university hospitals to serve three purposes.

1. To enable doctors and students to familiarize themselves with each patient, regardless of what he complains about and what he is sick, and reasonably apply a psychiatric approach in order to improve the patient's condition and help him understand his problems - be it somatic or personal, or both.

2. Recognize psychology as an integral part of the professional thinking of doctors and students in all branches of medicine.

3. To bring to the consciousness of doctors and students the need for an accessible concept of personality and social functioning.

In 1973, Lipowski defined PCV as “the field of clinical psychiatry, which encompasses the clinical, educational and research activities of psychiatrists and related professionals in the field of mental health in non-psychiatric departments of a general hospital ”. This definition contains two interrelated aspects:

1. Counseling. It provides expert diagnostic advice and advice on how to treat a patient based on their mental health and behavior. Such counseling is provided at the request of a non-psychiatric professional.

2. Interaction. It means connecting groups of professionals in order to effectively collaborate.

Thus, PCV arose as a result of the fusion of psychobiology and psychosomatics, that is, two conceptual directions that advocate a holistic point of view of the person and the collaboration between psychiatry and general medicine. This conclusion was reached by Lipovski in 1990 and, on this basis, defined PCV as a subspecialization of psychiatry, dealing with the clinical field of activity, education and research work in non-psychiatric health care settings.

Clinical activities include counseling, interaction, and therapy. Psychiatric counseling of non-psychiatrists is a cornerstone of the clinical practice of a psychiatrist in the field of counseling-interaction.

There are three main types of psychiatric counseling in general medical institutions:

Patient-centered counseling where the focus is on patients;

Counselor-centered counseling, when the focus is on the counselor's problems and is discussed without the patient being present;

Situation-oriented counseling where the focus is on the relationship between the patient and the members of the medical team that treats and cares for the patient.

The second aspect of clinical activity - interaction - has caused a lot of controversy. At the core of communication work in general is close contact between key players in the clinical field: patients, families, doctors, psychologists, nurses, social workers, administrators, and other caregivers. Interaction through such contact is called counseling-interaction, and the main participant in this process is the psychiatrist. His task is to be an expert in the psychological and social parameters of the disease, he needs to have additional knowledge regarding various characteristics at the intersection of psychiatry and other medical disciplines.

Proponents of interaction argue that such counseling facilitates faster data collection for the medical history, helps prevent ward crises caused by conflicts between patients and staff or patient behavior, and allows the counselor to provide training on psychosocial and psychiatric aspects of patient care. Conversely, opponents of such intense interaction object to it, arguing that such work is time-consuming and therefore expensive. The counselor can easily become a kind of itinerant preacher with little to offer for the treatment and care of the patient. In addition, staff may feel that they are intruding on other people's activities. Indeed, interaction requires human resources, money and motivation. But such work is necessary, because only the counseling service - interaction can significantly improve diagnosis and treatment and reduce costs (for example, reduce the length of a patient's stay in the hospital).

The third important aspect of the clinical work of psychiatrists in the field of counseling-interaction is the direct therapy of patients referred to him. This usually occurs either in the form of intervention during a crisis or in the form of brief psychotherapy at the patient's bedside.

This view reflects the American view of clinical practice. In Europe, this concept is viewed from a slightly different perspective, very similar in basic positions, but generally reflecting it more broadly. This is also evident in the name - "Psychosomatic Interaction Service". Three organizational models are used:

Consulting model. Consultations are carried out only on request, the consultant usually gives a written opinion based on the patient's own examination;

Interaction model as such. The consultations are carried out independently of or in addition to a specific request. The consultant at least once a week participates in rounds, in medical conferences, sometimes he can prescribe therapy within the department or observe the activities of the doctor and his assistants in integrating psychological and social aspects in treatment;

Model of a psychosomatic working group. Within the somatic department, a group of professionals, often proficient in two specialties - psychosomatic medicine and psychotherapy - work as a unit.

An important function of the PCV is training. There are clinical problems at the intersection of psychiatry and general medicine that a specialist in the field of counseling-interaction should be aware of and must be able to solve them. Since PCV encompasses knowledge about the complex interaction of psychological, social and biological factors, which to a large extent determine the course and outcome of a wide range of diseases, the training of a specialist in this area is of particular importance.

The location and methods of psychiatric practice have influenced the remedicalization of psychiatry. Psychiatric care has moved to general hospitals, allowing the hospital's psychiatrist to use a wide range of treatment approaches for patients of all ages with myriad clinical problems. The psychiatrists of the general hospital, using both somatic and psychological treatment, can work in parallel with colleagues from other specialties, which provides great opportunities for the integration of biological, psychological and social factors in health care.

Links between psychiatry and others medical specialties have become apparent over the past decade. Facts such as the rebirth of medical internships for those wishing to specialize in psychiatry, the expansion of interaction psychiatry services, the emergence of new psychiatric wards in general hospitals, all indicate that artificial boundaries between mental and physical health are breaking. It is not enough to be just a psychiatrist in order to conduct training in this field of activity. Psychiatric counseling and strategy for treating the physically ill, training staff and developing a care system as an expert with a focus on the many factors of psychobiological as well as psychosocial aspects of health care, all go beyond traditional psychiatry.

Another important function of PCV is research at the intersection of psychiatry and general medicine. "Interaction is the clinical application of psychosomatic medicine."

The research opportunities in PCV are virtually endless, as they cover almost all areas of clinical medicine. This area of ​​research at different times was called by different terms: psychosomatics, psychobiology, psychophysiology. Relatively recently, the term "biopsychosocial research" has appeared.

PCV research is influenced not only by economic and political changes, but also by scientific advances, in particular new biomedical technologies and methodological advances in diagnosis and treatment. Counseling-interaction psychiatrists are increasingly involved in research that can be classified as clinical psychosomatic research. Despite their apparent similarities, it should be borne in mind that psychosomatic research focuses on the presumably etiological role of various psychological variables of disease, such as cancer or coronary heart disease. Interaction counseling psychiatrists investigate the psychosocial and psychiatric consequences of a pre-existing physical illness and its treatment.

The most significant areas in counseling-interaction research are diagnostics, disease mechanisms, biological treatment, health services research, psychosocial treatment of physical disorders.

Patients with a psychiatric disorder, presented initially as somatic symptoms - somatization, are of particular difficulty. This term has arisen relatively recently to describe patients with somatic complaints that do not have an organic basis. The factors contributing to somatization are very diverse. They can be lined up, starting with biological, through psychological - to social and cultural. The term is now used to describe a wide range of processes that force patients to seek medical attention for bodily symptoms that are incorrectly classified as organic diseases. The World Health Organization (WHO) drew attention to the need to understand somatized symptoms, which should be considered as the most important deciding factor in the effectiveness medical care in institutions of a wide profile, since there somatic manifestations of mental illness are the norm. This requires psychiatrists to undertake the research of patients with non-organic disorders in general medical settings.

Originating in America in the 1930s, PCV has gradually spread throughout the world. Mental disorders are an important social issue, and a growing body of research highlights a significant relationship between social factors and many mental disorders. Professionals of various specialties - internists, psychiatrists, psychiatrists in the field of counseling-interaction, psychosomatics, clinical psychologists, specialists in the field of behavioral medicine, sociologists, etc. are engaged in research at the intersection of sciences. The fact that psychiatrists in the field of counseling-interaction were in relative isolation, was detrimental to the quantity and quality of research, as well as the development of the field as a whole. In September 1988, Marburg was elected working group, named "European Working Group for Counseling-Interaction on Psychiatry and Psychosomatics in General Hospitals". Its main goal is to collaborate in clinical and research programs in order to improve psychological and psychiatric care in general medical institutions.

Excul and Vesiak went further than Engel and use the concept of man as an open system that exchanges between internal activity (organism) and external activity (the world around us). This concept is based on the psychosomatic model of illness. Based on this position, the disease can be considered not as a "breakdown in the car", but as a response of a living system to various factors influencing it.

As a subspecialty of medicine that has difficulty navigating unfamiliar paths and sometimes working with reluctant patients and even more reluctant professionals, PCV should keep in mind some of the caveats it tried to give colleagues in other medical fields: Physicians are not omnipotent; patients are not immortal; recovery sometimes, relief often, support always.

Dunbar introduced the concept of a personality profile, that is, a certain constellation of personality characteristics inherent in a person.

3. Hypothesis of specificity

In 1934, Alexander F. formulated principles called the “specificity hypothesis”. Here are its main provisions.

1. Psychological factors leading to somatic illness are of a specific nature; 2. Conscious mental processes play a subordinate role in the occurrence of somatic symptoms, since they can be freely expressed and realized through an arbitrary system; 3. The actual life situation has only an accelerating effect on the disease. Understanding of causal factors should be based on knowledge of the development of the patient's personality.

In 1950, Alexander defined "specificity" as "a physiological response to emotional stimuli, normal and pathogenic, that varies with the quality of the emotion" (cited in Pollock 1978, p. 233).

Each emotional state has its own physiological syndrome. Alexander did not consider individual psychological factors specific for the disease, but their psychodynamic constellations.

4. The hypothesis of a specific relationship to conflicts

Grace W.J., Graham D. T. (1952) consider the influence of conscious attitudes on stress and onset of illness.

Occurring life events are perceived and evaluated differently by psychosomatic patients and healthy people. Stressful psychosocial events, interacting with other factors - heredity, behavior patterns, create prerequisites for the disease.

6. Psychology of physicality The psychology of corporeality - one of the areas of clinical psychology, located at the junction of psychological, cultural and semiotic problems and involving the expansion of the laws of the mental to the field of the bodily. In the process of ontogenesis, corporeality, without ceasing to possess its natural essence, becomes the first universal sign and instrument of man. Corporeality receives its subjective existence in the system of interceptive categorization, body language. The body is not an absolutely "transparent" instrument, completely subordinate to consciousness, it is not always limited to the role of a kind of "probe" of consciousness, existing for it (being aware) only at the level of its boundaries separating the world from the subject. The body is characterized by activity and in ontogenesis requires its development, constant adaptation to it. In the case of pathology, its normal functioning is disturbed, it begins to appear for the individual as an objectified reality that has a certain sensory content, "sensory tissue". At the first stages of bodily perception, mainly emotional-evaluative coordinates, categories of well-being are used (sensations are unsteady, uncertain, labile, poorly localized). Thanks to the primary meaning, bodily sensations are transformed into a perceptual image, the core of which is the body scheme (bodily sensations become concrete, stable, localized, comparable in intensity, modality, can be verbalized and correlated with cultural perceptual and linguistic standards). The specific subjective features of the categorical network impose appropriate restrictions on intraceptive perception, which can serve as a source of distortion. The sensory fabric receives a secondary meaning through the creation of a "concept of illness": sensations become symptoms that signify illness and are signified by it. The meaning of the disease for the sick person is formed through the refraction of its subjective picture in the structure of his needs, motives, thereby acquiring a personal meaning. The personal meaning of the disease (for example, the "unacceptability" of the disease or, on the contrary, its "conditional desirability" and the secondary benefits it brings) can also lead to a distortion of intraceptive perception. The objective (subject to physical laws) and subjective (subject to psychological laws) sides of the disease and treatment coincide only in extreme abstraction. The bodily intraceptive sensation should be viewed as a complex sign-symbolic structure, and not as a reflex reflection of the natural state, a simple excitation of interoreceptors. According to WHO experts, one of the most important medical problems in the coming decades is the impossibility of effective treatment of a large number of patients who come to health care institutions with constant complaints that are difficult to correlate with one or another organic lesion (N. Sartorius, 1983). Traditional methods of treatment should be supplemented by measures to increase the subjective value of a healthy lifestyle, responsibility for one's health, taking into account the personal meaning of health and illness, correcting inadequate myths, etc.

7. Psychological ontogenesis of bodily functions (corporeality).

Infancy... Man is born as an individual, he still has a path of development ahead of him. Each stage of the path is a transition from a variety of possible forms of development to one specific path chosen for it closest adults.

The main factor in the development of an infant is the closest adult with his experience, his personality, which are fixed in the cultural experience of all mankind. This inclusion through the adult also contributes to the reorganization of the infant's bodily process.

Interaction with an adult is organized around the needs of the child, in the process of caring for which the adult comprehends and evaluates the physical condition of the child. The child instills (internalizes) the mother's position to his manifestations. Needs act as the language of communication between the infant and the mother. At this stage, first sign system- language of the body!

Growing up: the child begins to take possession of his body (the ability to imitate, imitate, assimilate bodily stereotypes of regulation of the nearest adults - to blow on a burn, etc.). There is a borrowing of bodily symptoms from nearby adults; behavioral stereotypes of emotional experience are acquired (facial expressions, intonations, gestures, etc.). Ex: foster children who are similar to foster parents.

Important: the more the bodily function is included in the plan of external behavior, the more it is regulated by social norms and the higher the degree of psychosomaticity of this function.

Language acquisition stage... The child is given the opportunity to cognitively evaluate his original bodily manifestations. Child myself begins to realize the meaning of his bodily states. The child gets the opportunity to relate to his bodily well-being through the prism of linguistic meanings. Gradually, there is a differentiation of the concept of the body and its parts, which is expressed in the expansion of the vocabulary of description, the actual bodily and emotional categories begin to differ.

Formation of a reflective plane of consciousness... There is a possibility of voluntary and conscious regulation of bodily processes. After differentiation, the integration of ideas about one's own body takes place - the category of an integral body is formed, which cannot be reduced to the sum of separate parts, i.e. the bodily self is formed.

Important: deviations in communication with an adult in the early stages of development can be expressed in somatic disorders. Ex .: hospitalism.

Thus, the psychosomatic development of a person is carried out along with physical and other development.

The natural formation in ontogenesis of the mechanisms of psychological mediation and regulation of bodily functions. It manifests itself in two aspects:

External plan of psychosomatic development... The process of vital socialization of corporeality. It consists in the development by a person in ontogenesis of the cultural skills of the administration of bodily functions.

Internal plan of psychosomatic development Development of psychological mechanisms of regulation of bodily processes

The result of psychosomatic development: either the formation of psychosomatic unity in the norm (psychosomatic phenomenon), or the formation of a psychosomatic symptom in pathology. A psychosomatic symptom is a way of expressing in body language a problem (deviation) in communication with another person or with oneself.

conclusions: If during ontogenesis psychological changes in bodily functions are made, if psychological means of regulating bodily processes are formed, therefore, in any bodily process there is a psychological component, therefore, in somatic pathology, in any bodily symptom, this psychological component must be present.

If we believe that there is a certain psychological norm for the development of bodily functions, then, therefore, we can talk about the dysontogenesis of the psychosomatic development of a person.

8. Features of the psychosomatic family.

In favor of the concept of a psychosomatogenic family, E.G. Eidemiller and V.V. Justickas. They see violations of the main spheres of life of the family, where the child grows and develops, as a source of mental traumatization of the personality, leading to psychosomatic diseases.

The classification of mechanisms of development of psychosomatogenic families developed by H. Stierlin (1978) includes: 1) "Bondage" - a family with rigid stereotypes of communication; children in such a family become infantile, lag behind in emotional development... The formula for communication in such a family is: “Do as I told you”; 2) “Refusal (rejection)” - the child, as it were, “renounces himself, his personality; he develops autism and a tendency towards autonomy; 3) "Delegation" - parents have lost a realistic perception of the achievements of their children; they perceive their children as an extension of themselves, pin their hopes on them for the implementation of their unfulfilled plans.

As a rule, five characteristics of psychosomatogenic families are distinguished: 1) the over-involvement of parents in the child's life problems, which interferes with the development of independence, therefore, protective mechanisms are weaker and contribute to the development of internal conflict; 2) hypersensitivity of each family member to the distress of another; 3) low ability to change the rules of interaction under changing circumstances, in which family relationships are rigid; 4) the tendency to avoid expressing disagreement and openly discussing conflicts; the risk of internal conflicts; 5) the child and his illness often play the role of a stabilizer in latent marital conflict.

For a psychosomatogenic family, it is characteristic not to encourage the free expression of feelings and the free response of negative emotions, as a result of which the child assigns stereotypes of suppressing negative emotions, which leads to their somatization. The suppression of negative emotions may be due to the fact that it is not customary in the family to openly react to pain - a stereotype of patience, an attitude towards illness as a state in which a person is to blame.

In the experience of a psychosomatogenic family, there may be some pathogenic features: inability, unwillingness, lack of education of parents (first of all, mothers) to early recognition of the child's bodily states and meaning them (unobservant and inattentive mother, or simply does not have time); the inability of the family, as an integral organism, to verbal or other constructive resolution of the conflict and the child's inclusion in the family conflict. The bodily symptom of a child is often born in a situation of family conflict, as an unsuccessful way to resolve it.

Somatization of affect, emotions acts as a style of family adaptation to difficulties, problems, as a stereotype, as a factor in avoiding failures or avoiding responsibility. The use of the symptom for gaining benefits begins to be actively involved in the child's life as a reaction to any difficulties.

Psychosomatogenic families are characterized by a poverty of psychological language and a tendency to deny the presence of psychological problems. Parents may discourage or prohibit the expression of a number of psychologically conditioned emotions, considering it unacceptable. Thus, the child learns that the attention, love and support of a parent can be obtained only through the use of "patient behavior". The role of the patient turns out to be attractive, among other things, due to the release from the usual duties without blaming it. The child's illness can bring a secondary benefit to the parents: altering the relationship between them, sidetracking from the conflict, which they do not want to admit, and thereby stabilizing the situation in the family.

The leading role in the early stages of development belongs to the mother, who forms the body language in the child. M. Mahler (1965) first described the psychosomatic mother as authoritarian, over-included, dominant, openly anxious and latently hostile, demanding and obsessive. The father, as a rule, in such a family is a weak personality, unable to resist the dominant and authoritarian mother, is at a distance from the mother-child dyad. Any attempts to separate, that is, to separate from the mother, on the part of the child are rejected by the mother. The qualities of mothers that are especially significant for the formation of psychosomatic pathology include: high personal anxiety of the mother; the internal conflict nature of the mother, that is, the disharmonious makeup of the personality (neurotic mother); a tendency to suppress, restrain negative feelings, the predominance of guilt feelings in the mother's psyche, a contradictory emotional attitude towards loved ones in the family; a strong emotional response to problem situations with disorganization of activity (stress instability), as well as an inability to constructively resolve conflicts, which leads to chronicity and, consequently, somatization of affect in the mother; disorganization of one's own activity in case of a child's illness due to high anxiety, fears, inability to make a radical decision; the mother's own bodily experience is negatively colored, the phenomena of rejection of her own body or its parts are observed, associated with the early experience of the grandparent family; disturbed interactions between the mother and the child at an early stage of its development.

Perhaps, there are two types of mother's attitude to the child: 1) latent, unconscious rejection - in this case, the child uses body language to attract the mother's attention (the mother, as it were, stimulates the child to use this language more massively); 2) symbiosis - the mother, as it were, conserves bodily contact, inhibiting the formation of later forms of interaction.

Thus, the psychosomatogenic type of family is the first fractal in the formation of psychosomatic diseases.

Features of psychological rehabilitation of psychosomatic patients.

Psychological rehabilitation in psychosomatic pathology should be based on active psychological and physical techniques focused on the formation and growth of a healthy personality. Suggestive techniques, including hypnotherapy, are of very limited value, since most patients in a subdepressive state are already suggestible and dependent. Only the use of methods that involve the patient's active participation in psychological training and physical development can save him from mental dependence and somatic suffering, restore a full-fledged personality with healthy interests and a critical attitude to his diseases. Psychological rehabilitation programs should be based on the use of methods of individual and group psychotherapy, communication training, play therapy, participation in creativity (design, drawing, modeling, embroidery, etc.). The joy of creativity, attention, recognition are the most powerful healing factors.

A prerequisite for successful rehabilitation is the formation of a patient's mindset for the active restoration of his health, confidence in the effectiveness of rehabilitation programs. And this work should begin even before entering the rehabilitation department, i.e. in territorial health care facilities (medical and preventive institution).

Children and adults are interested in undergoing rehabilitation after becoming familiar with its goals and methods;

Correction of stress and neurotic disorders by psychotherapeutic methods leads to a significant improvement in the somatic state of adults and a reduction in the symptoms of functional disorders in children;

Psychotherapeutic, cultural and educational techniques are highly effective in the correction of personality disorders;

Medical and psychological rehabilitation is based on the postulate of the primacy of psychological factors in maintaining health, their leading role in the development of psychosomatic pathology and the possibility of restoring health mainly through the impact on the psychological state of a person. Based on this, in this specialty, practical work is carried out with the patient's personality and is aimed at forming a healthy lifestyle for him. The final stage of medical and psychological rehabilitation is scientifically based individual recommendations to the patient regarding the nature, volume and intensity of mental and physical stress, optimal activities and real life goals.

The concept of personality profiles in psychosomatics. Dunbar. This is within the psychoanalytic approach. Those. not just a conflict of a certain content, but with which personality. Additional question - and what other attempts to search for specificity do you know. - the phenomenon of alexithymia. - this is the next round in the search.

Dunbar - personality profile theory

Dunbar - a contemporary of Alexander. She also emigrated from Germany. She founded a psychosomatic center in England. The doctor is a clinician. She worked with patients throughout her life. Her approach draws on her practical experience. This experience made it possible to take a step similar to what Kretschmer did. She took a step towards the personality of patients with various forms of the disease, psychosomatic specificity - ulcer, asthma. She put forward a hypothesis regarding the formation of symptoms, the cat received the name in the literature - personality profile theory(this is more a hypothesis than a theory).

Observing the patient, she drew attention to the fact that the personal profile of patients, suffering from this or that disease of psychosomatic specificity, is different. Eg coronary insufficiency and asthma

She suggested that the conflict and its dynamics are important for understanding the nature of the symptom. But this is not enough. It is important to know in which person this conflict arises. She offered a description at the level of clinical and everyday descriptions personality traits, suffering from this or that disease.

Examples of

Coronary personality- heart diseases are people who are energetic, authoritarian, power-hungry, with a focus on success, high achievements. Those who highly appreciate their capabilities and merits. By virtue of their activity, they are simultaneously involved in a large number of cases, lead a stressful lifestyle. They are characterized by aggressiveness in achieving goals.

Ulcerative personality... Straightforwardness in behavior and attitude towards people, rigidity of behavioral programs. Categorization in assessments, judgments. With a formal understanding of duty. Disturbing. Anxiety is often combined with aggressiveness, with hidden hostility towards people.

Bronchial personality... Sensitivity, especially in relationship systems. Experiencing dependence on people. Uncertainty. Lowered mood background. Often those who rate themselves low, their capabilities, achievements. With the instability of desires, aspirations, intentions. Often with feelings of guilt.

Diabetes mellitus... Somewhat inhibited, punctual, epileptoids. Comprehensiveness, pedantry. Propensity for affective outbursts.

Rather purely everyday descriptions, if analyzed, superimposed psychological grid- we will see that

it's about the amount of motivation.

Nekot emots quality she describes - the experience of guilt, anxiety, aggressiveness, hostility.

There are signs, har features of self-esteem- stable - unstable, high - low

Nekot character characteristics- dependence, punctuality, rigidity, rigidity in behavior and communication.

This psychological analysis is not contained in Dunbar's writings.

Question - what does she rely on... On the data of anamnesis, in the cat she pays attention to

1.some key points from t sp psychoanalysis

the presence of trauma.

Localization of psychotraumas in time - early childhood or later age

Control methods, coping.

She is interested in the style of family education.

Relationship in the dyad with the mother at different stages of ontogenesis.

Characteristics of the mother. Features of early identification.

2.The 2nd topic, the cat is interested in Dunbar when observing patients - relationship with the environment... Dominant type interpersonal relationships(human environment).

3. social status of the patient... At the same time, she draws attention not only to the formally occupied place in society. But she is interested in a person's satisfaction with the place they occupy. We find the prerequisites for what in what follows is called the quality of life.

4. she is interested personality traits, manifestations in the broadest life context

The role of personality profiles... She assumes that these personality profiles can be of diagnostic value, that is, she believes that the presence of appropriate personality characteristics can be considered as signs of psychological risk of the possibility of a particular disease. She believes that personality type suggests the possibility of an objectified conflict... It has:

Psychoprophylactic value

It is assumed that these profiles may have a prognostic value in relation to the course of the disease.

It is personal profiles that determine the content of the conflict, its possible depth. They can make it possible to diagnose the nature of the conflict and the nature of its processing by the patient.

Then a number of questions arise - to what extent Dunbar's profiles, which are descriptive in nature, can fulfill a diagnostic and prognostic role. Why can't they? They did not receive psychological qualifications, there was no expert, there was no identification of psychological parameters. She is a clinician and has observed those who have already fallen ill with this or that disease. Patients with a certain experience of the disease, of different duration. We can assume that she was dealing with people, the personality of the cat has already been changed in the conditions of the disease. This is an old honey postulate, comes from old psychiatrists - the patient's personality, no matter what he suffers, always changes. The question is whether it is possible to transfer the data obtained on sick chronicles to characterize the personality of healthy people.

In this regard, it cannot be said that we are talking about a theory (it is rather a hypothesis).

During the 20th century, there were attempts to apply her observations to work with clinical patients, but they did not receive confirmation. The approach remained problematic. Why are we talking about this? This cycle of works is a special direction. Al complements the school, fixing attention on personality problems.

Summary

Launcher Sieve - Conflict, Pairing with Emotions

Ind differences are due to the personality profile, its warehouse

The choice of the organ of defeat - the x-factor - is congenital or genetic due to the weakness of a particular bodily system.

For psychologists, this context of Dunbar's work can serve as a problem field.

Psychological aspects of studying the internal picture of the disease (VKB).

Psychic aspects of studying the WKB. What is this phenomenon. If the phenomenon passes the stage of formation, then it is necessary to talk about the factor of formation, severity, age of onset of the disease, the factor of the severity of the disease, the factor of treatment, duration and different models. We were introduced to 2. Different ideas about the essence, structure.

Internal picture of the disease.

Any disease, especially if it acquires a chronic course, creates a special life situation, cannot but cause a person's increased attention to the sieves, to their own destiny. That somatic disease, riveting the attention of the kids again. As in the early stages of ontogenesis, it encourages a person to self-knowledge - to know himself as a patient. T e again arises in a newly ill person - the problem of mastering his own body in its new quality. It is similar to mastering your body in the early stages of ontogenesis.

The activity of knowing oneself as a patient gives rise to a special psychological phenomenon, which has received the name - a subjective or internal picture of the disease

The first attempts to isolate this phenomenon were made by doctors.

Zakharyin.

Goldsheider - the cat described the phenomenon of the autoplastic picture of the disease - that is, the picture of the disease created by the person himself.

A few years later, in the mid-30s, a therapist RA Luria - father of AR Luria - suggested the term internal picture of the disease. He was work-oriented. Treatment of a person as a person.

In the literature, parallel to the concept of autoplastic, internal, the concepts are used - consciousness of the disease, the experience of the disease, the concept of the disease.

Luria - calls the internal picture of the disease everything that the patient experiences and experiences. The whole mass of his sensations, experiences, assessments of his own illness. He contrasts the internal picture of the disease with the objective picture that the doctor receives.

T about vkb - reflecting the internal representation of the kids, on the one hand, characterize the boy as a person. On the other hand, noise the objective picture of the disease

Vkb is an image of a disease, as an element of the image of the I, the image of the bodily I (if we are talking about a bodily illness).