Psychotherapy in the treatment of neurological diseases - Causes, symptoms and treatment. MF.
Feasibility of using psychotherapeutic methods for organic diseases of the nervous system.
In connection with the transformation of the clinical picture of neuroinfections, such forms of lesions of the central nervous system are increasingly encountered, which, with insignificant neurological disorders, are usually characterized by protracted, long-term course and therapeutic resistance. In these conditions, violations of cortical neurodynamics by an organic process, secondary neuroticism as a reaction of the individual to the underlying disease and accompanying psychogeny in many cases become inevitable companions of the organic pathological process. Widespread introduction into clinical practice of electrophysiological, contrast X-ray studies, computed tomography, magnetic resonance imaging, etc. greatly facilitated the diagnosis of erased, non-expressed forms of a number of organic diseases of the nervous system. In this regard, more often than before, it becomes possible in each case to correctly assess the ratio of organic and neurotic components in this disease and accordingly determine the place of somato- and psychotherapy in the most rational treatment and recovery complex. Diagnostic difficulties, underestimation of methods of clinical and psychological research by neurologists often lead to incorrect interpretation of neuropsychiatric disorders in organic diseases. Neurotic syndromes caused by psychogeny are considered as manifestations of a destructive process, as a result of which a reassessment of the role of somatotherapy and the ignoring or underestimation of the methods of psychotherapy are possible. This is all the more necessary to emphasize that, in addition to the therapeutic value, the use of psychotherapy in these cases is useful for differential-diagnostic delineation of organic lesions from disorders that occur psychogenically. However, mistakes of a different kind are also possible, when with neurotic-like debuts of organic lesions of the nervous system( multiple sclerosis, brain tumors, etc.), the elimination by psychotherapeutic methods of accompanying functional disorders leads to belated, untimely diagnosis.
The effectiveness of hypnotherapy in well-hypnotic patients aimed at weakening such purely organic manifestations as paresis, paralysis, dysarthria, intentional tremor, muscular tonus disorders, phantom pains, etc., are shown by studies of many authors. Referring to his own observations, the famous Russian psychotherapist Platonov noted the weakening of fresh and chronic organic paresis and paralysis of various etiology under the influence of training exercises in physiotherapy exercises conducted in a state of hypnotic sleep. At the same time, the process of restoring movements in the affected limb was accelerated. Bekhterev also pointed to a possible neurophysiological explanation of the effectiveness of hypnotherapy in organic diseases of the nervous system. In 1911, he wrote that "... with any organic disease of the nervous system, there are disorders due to concomitant functional changes in neighboring or more distant parts of the nervous system," and that therefore there is the possibility of "some influence of hypnotic suggestions on nerve lesions of organic origin".To regress not only subjective complaints, but also objective neurological symptoms in the hypnotherapy of patients with lesions of the nervous system of traumatic, vascular, infectious, toxic genesis pointed out Shogam. The author believed that in this case the psychotherapeutic effect is realized through the nonspecific structures of the limbic-reticular complex affecting the functional state of the nervous system at its different levels indirectly through the speech( second-signal) neocortical zones. High effectiveness of hypnotherapy with stem diencephalic forms of organic brain diseases was emphasized. In focal lesions of the brain, accompanied, for example, by spastic hemiparesis, according to the author, one can reduce their clinical manifestations - increase muscular strength, reduce tone, restore sensitivity to a certain extent, etc. - in particular, by mobilizing reserve compensatory possibilities on the part of nonspecificstructures of the limbic-reticular complex. The effectiveness of hypnotic suggestion in patients with Parkinsonism, explained by the special role of nonspecific brain systems in the pathogenesis of diseases and mainly by the neurodynamic disorders underlying symptom formation in this organic disease, Golubev pointed out. Hypnotherapy, as well as all other types of suggestive psychotherapy can successfully be used to relieve the neurosis-like symptoms of nonpsychogenic nature in organic diseases of the nervous system.
The effectiveness of these methods in cases of sleep and appetite disturbance, mood deterioration, memory loss, attention, and reduced mental performance are well known.
When carrying out psychotherapy in the general complex of therapeutic measures( dehydration, resolving, anti-inflammatory therapy), the period of the patient's stay in the hospital is of great importance. Undoubted psychotherapeutic value for the patient acquires the fact of establishing a certain disease in him after a carefully conducted examination. The main tasks of psychotherapy at this stage are persuasion of the patient in large compensatory possibilities of the nervous system, activation of the personality to overcome painful disorders and adaptation to the conditions of life. For this purpose, in addition to rational psychotherapy, all forms of suggestion, including hypnotherapy, drug therapy, etc. Of great importance is psychotherapy in the group, especially in the form of a "therapeutic perspective."The use of this technique is advisable, since the diagnosis of an organic brain disease, as a rule, frightens patients. It is necessary to give them an opportunity to make sure that they are promising for ongoing therapy. For this purpose, patients with similar morbid impairments are invited to the group who have completed treatment with favorable results, good social and labor re-adaptation after it.
One of the main goals of using psychotherapy in the complex treatment of patients with organic diseases of the central nervous system is to eliminate the neurotic component caused by the personality reaction to the disease, often in connection with iatrogenic, and also in the form of more complex co-occurring psychogenies. In some patients, the emergence of neurotic disorders is caused by a pathological reaction to the damage of the nervous system, and the experience of the disease acquires the character of psychogeny due to their personal characteristics( anxious suspiciousness, hypochondria).The genesis of these secondary neurotic symptoms in the clinic of organic brain lesions, especially in encephalitis with lesions of the interstitial brain, is closely related primarily to generalized systemic disorders of the sensory sphere. For these patients are characterized by shestopathies, frequent disturbances in the body and especially the visceral scheme of the body, vivid psychosensory disorders. These feelings patients are particularly acute and difficult, and they have a conviction in the reality of a life catastrophe, which can occur at any time against the assurances of the doctor. Often, patients completely deepen into the experiences associated with frightening bodily sensations, concentrate all their attention on them and turn out to be turned off from the usual circle of family and social problems( Leshchenko).The reaction to these disorders, as a rule, are neurotic fears of "going crazy", hemorrhages in the brain, the appearance of a tumor. The hypochondriacal mood of patients with these diseases, noted by many authors, is accompanied by persistent fixation on their sensations, excessive care of their health, and often iatrogenously supported by diagnostic errors. In the treatment of patients with neurotic fixation of organic disorders, indirect psychotherapy is of special importance, in particular, in the form of psychotherapeutic mediation and potentiation of various types of biological therapy. The expediency of the over-subject( indirect) psychotherapeutic effect has been known for a long time( Bekhterev, Platonov, etc.).
Psychotherapy plays an important role in the complex treatment of patients in whom a prolonged, prolonged course of organic disease of the nervous system becomes a factor contributing to the emergence of more complex psychogenies, which are revealed only when the patient's history of development is deeply studied and his relations to the surrounding reality are formed. As Myasishchev noted, with destructive lesions, the painfully altered brain substrate is characterized by a decrease in resistance and endurance, so the situation, insignificant for a healthy nervous system, is decompensating under these conditions. Such patients, being basically "organics", are prone to recurrence of the disease and decompensation along the psychogenic path and are well restored when solving the situation with the help of psychotherapy. In this case, it is not uncommon for an adverse factor in the life of a patient to acquire pathogenic significance only after an organic disease of the nervous system has been transferred. In organic diseases with significant neurotic disorders, psychotherapy should be conducted in a hospital where there are favorable conditions for this( long and constant contact of the physician with the patient, which is necessary for systematic individual psychotherapy, the possibility of conducting group psychotherapy and various types of so-called sociotherapy).Psychotherapeutic importance is the fact of the patient's receipt of an organic disease of the nervous system in the hospital for a thorough examination, as well as the medical atmosphere of the department or clinic. After discharge, supportive psychotherapy should be conducted, which in severe cases lasts for several months, and sometimes years. In the absence of sufficient opportunities for this purpose, the method of correspondence psychotherapy by correspondence can be used.
In a wide medical practice, patients are often found who are correctly diagnosed with organic disease of the nervous system from the very beginning, but often even long-term, long-term treatment is ineffective in these cases. Clinico-psychological study of the patient reveals a neurotic and hypochondriacal reaction and fixes the main painful symptoms. Only a careful elucidation of the patient's life history, peculiarities of his personality makes it possible to understand the content of this fixation and to reveal those psychogenic factors that determine it. One of the most basic and most appropriate methods of restorative treatment in these cases is psychotherapy in its various forms and, first of all, in the form of personality-oriented psychotherapy.
In a number of studies, the effectiveness of various types of psychotherapy - rational, in the form of suggestion, narco-psychotherapy, etc. - is noted in the complex treatment of neurological patients for the elimination of secondary neurotic and neurosis-like disorders against the background of infectious, vascular, traumatic diseases of the nervous system. Psychotherapy is useful for traumatic injuries of the spine and spinal cord, with secondary neurotic and neurosis-like disorders and neurological disorders characteristic of this group of patients( bowel, bladder, movement and sensitivity disorders).The effectiveness of hypnotherapy and other types of psychotherapy in patients with lesions of the nervous system at the spinal and peripheral levels is explained by the participation in the mechanisms of their compensation of cerebral structures, especially non-specific structures of the limbic-reticular complex;the downward corrective effects of the limbic system on the functional state of the spinal and peripheral formations, including their motor, sensory, and vegetative-trophic manifestations, also have significance. Yatskov long-term outpatient psychotherapy( up to 80-100 sessions) was used in patients with long-term consequences of cerebral-organic pathology and the presence of neurotic and neurosis-like disorders. The author points out the different effectiveness of psychotherapy, depending on the syndrome structure of neuropsychiatric disorders. Less effective was psychotherapy in patients with hypochondriac and senesto-cephalic syndromes.
In the treatment of neurological patients, autogenous training has become widespread. A review of the research on the use of this technique in the clinic of nerve diseases is given in the monograph of Panova et al. It is emphasized that autogenic training is more adequate for restorative therapy of residual phenomena of organic diseases of the central nervous system, primarily for the elimination of a wide range of functional disorders of a neurotic and neurosis-like nature. Special attention should be paid to the use of autogenic training in order to relax individual muscle groups in such therapeutically resistant forms of diseases as spastic torticollis, facial parapasm, etc. The number of examples of treatment of neuropsychological pathology using the principle of biofeedback increases. This method gives a good therapeutic result in the treatment of cerebral arachnoiditis with a predominantly convulsive syndrome, in patients with consequences of spine and spinal cord injuries, with active restorative therapy of patients with post-stroke motor impairment. Numerous literature is devoted to the use of this method in the treatment of migraine.
In Fig.8 shows pictures of a patient with facial paraspasm before and after the course of autogenic training.
The patient with facial paraspasm.
a - bilateral symmetric tonic spasm of facial muscles. Intensive convulsive contraction of the circular muscles of the eyes deprives the patient of the opportunity to see anything, spasm of the muscles of the mouth makes speech and food difficult;b - during very short( several seconds) intervals between spasm attacks there is still a tonic tension of the muscles, which is arbitrarily, by reducing antagonists, overcome with great effort and quickly tires the patient;c - after the course of treatment with autogenous training, only a certain tension of the circular eye muscles remains, which does not disturb the vision.(According to Lobzin).
The experience of group psychotherapy with various diseases of the nervous system, in particular, those suffering from vascular diseases, is accumulating. At the first lessons, the features of the disease( current, prognosis) are considered;further discusses the problems that usually concern these patients - the need and ways to increase their emotional-volitional and social activity, the correction of attitudes and attitudes to various social conditions, an adequate attitude to the symptoms of the disease, counteracting their occurrence. Problems related to the return of patients to the family are discussed( family psychotherapy is important here), preparation for retirement and, in this connection, a new way of life. With appropriate indications, group psychotherapy can be combined with hypnotherapy and other types of psychotherapy in the same group. When conducting psychotherapy in patients with vascular diseases of the nervous system, it is necessary to take into account their increased vulnerability and lability of the psyche;careless behavior of the therapist can lead to iatrogenic and didactic disorders.
Demidenko, Balunov applied the methods of psychotherapy in the system of complex restorative therapy of post-stroke patients. The object of the therapeutic effect was reactive-personal stratifications( decreased self-esteem, loss of faith in recovery), especially pronounced in patients with severe motor, sensory and other defects. The treatment was carried out in small groups and included various forms of rational psychotherapy - group sessions using "psychotherapeutic mirror", "scale of experience", "therapeutic perspective", music therapy, which help to develop adaptive settings and mobilize patients' own activity. Essential place was given to the elements of psycho-gymnastics, motor therapy, most appropriate for solving problems of emotional and motor activation of patients. In order to mediate the impact on the local defect, various gaming techniques and special techniques of ideomotor training were used. Great importance was acquired by family psychotherapy - outreach work with relatives of the patient with the aim of their orientation to an adequate attitude to the patient and his illness, as well as training in patient care skills. The peculiarity of group psychotherapy with patients who have suffered a stroke is participation in them( in addition to psychotherapists) of nurses. In group discussions( 30-minute sessions 5 times a week) the patient's misconceptions about paralysis, problems of recovery and prevention of repeated strokes are corrected. Before discharge, the psychotherapeutic efforts are directed at removing anxiety and relieving the painful thoughts associated with the fear of patients losing their care, instill confidence in the imminent improvement of the condition. Shklovsky points out the effectiveness of group psychotherapy in the rehabilitation system of patients with consequences of stroke and neurotrauma. To restore the communicative function of speech, patients with aphasia underwent logotherapy, combining logopedic and other group forms of work: classes using methods of group therapy proper;classes to restore speech disinhibition and stimulating nature, classes using differentiated techniques used in the practice of individual learning;classes to restore the speech of the club type and in the process of work. Currently, group psychotherapy is included in a set of treatment and recovery effects for a variety of neurological diseases, with its help, basically the same tasks as above are addressed. Group psychotherapy is also useful in cases of prolonged disability of patients. The experience of working with patients suffering from a chronic progressive form of neuromuscular dystrophy is described. Psychotherapy, which aimed to reduce dependence, prevent withdrawal from social activities, isolate and alienate patients, was performed once a week for 1.5 hours. After 9 months of study, a therapeutically favorable change in the settings and functioning of the members of the group( Bayrakal) was noted.
The role of psychotherapy in the system of restorative treatment of epilepsy patients is significant, taking into account the great medical and social significance of this disease. Psychotherapy for epilepsy( Gromov) is aimed at solving a number of problems that arise in the treatment of other organic diseases, such as fixing and potentiating the effect of biological therapy, strengthening the patient's belief in the success of treatment( especially those suffering from this disease), correcting patients' attitudes and prospectsthe future life in the conditions of the disease, the assimilation of more adequate, adaptive forms of behavior. Although there is no convincing evidence of the possibility of influencing convulsive seizures with the help of psychotherapy, however, mitigating affective tension, the general sedative effect of psychotherapy, increase the threshold of convulsive excitability, in some cases reducing the frequency of seizures. It emphasizes non-mandatory, more explanatory nature of suggestive influences. Methods of group psychotherapy are also applied.
To support psychotherapy in patients with organic diseases of the nervous system, club forms of work can be used. In clubs of former patients, therapeutic re-adaptation measures are carried out not only with patients, but also with their relatives, in particular, with the family.
In connection with the inclusion in the states of the rehabilitation neurological departments of psychologists, their role in the conduct of psychotherapy increases. Psychotherapeutic value has the very demonstration of the patient in the process of psychological investigation of the safety of y.his mental functions, the availability of reserves to counteract the disease. With the same therapeutic purpose, familiarization can be used, patients with positive dynamics under the influence of treatment of the studied psychological indicators.