Kovalenko N.P., Madzhuga - D.Sc., PhD, Professor
Psychosomatic medicine and resource psychotherapy in practice.
Psychosomatic model of modern medicine is gradually added to a world view of doctors and develops in collaboration with such areas of knowledge as perinatal psychology, clinical psychology, resource psychotherapy, etc. The concept of psychosomatic relations is based on recognition of the critical importance of personal and environmental factors in the genesis of somatic diseases in their resistance to treatment in secondary prevention. Patient is rightly seen as not only the “owner” of the sick organ or function, but also a personality that operates in one way or another, quite often pathogenic, environment. The attitude of patients to the nature of their illness, the formation among them an adequate model of the expected results of treatment is of great importance for the prognosis of the disease and the level of re-socialization .
Psychosomatic experiences of a patient with the same disease can vary significantly depending on the characteristics of the individual and includes various levels of reflection of a patient's own state: sensual, emotional, intellectual, motivational. In addition, there are individuals who are prone to the organization of a certain style of life in which they put themselves in circumstances that increase the likelihood of occurrence of stressful events, leading to the emergence or worsening of a somatic disease. 
The concept of “psychosomatic disorders” in recent years has changed significantly [1, 5, 16], but the problem remains the same. To replace the actual psycho-somatic model, involving predominantly psychogenic factors, comes biopsychosocial model (Drozdova M. S., 2003).
There has been a departure from the interpretation of the term “psychosomatic”, uniting in the narrow sense the «holy seven» («the sacred seven»): peptic ulcer of a duodenum, ulcerative colitis, essential hypertension, rheumatoid polyarthritis, hyperthyrosis, atopic dermatitis and bronchial asthma . Clinical manifestations of psychosomatic disorders are characterized by considerable polymorphism and may be presented in different sections of mental disorders MKB-10, but they «have common indication: the overlap of disorders of mental and somatic sphere» . The modern concept of psychosomatic medicine due to the works of such researchers as W. Brautigam, G. Engel, Th. Uexkull, A. Jores, emphasizes the need for an integrative approach to understanding the etiology, pathogenesis and opportunities for treatment of various diseases with the psychological characteristics of the patient .
«The disease is not only somatic, but also mental suffering, not only biological, but also a social phenomenon both in origin and in its consequences. The modern physician should be considered as a mental patient, consider its relation to disease. It is also important for practitioners – to imagine a picture of the inside of the human disease» .
«Thanks to the inability and unwillingness of doctors to examine the psychology of patients and their experiences, the latest go away from them and go to the miracle-workers (wizards), – wrote D. D. Pletnev. – Doctors, unwittingly, cultivate quackery by these actions» . Unfortunately, this observation is also true for our contemporaries, seeking salvation from «extrasensory individuals» and «clairvoyant». The level of medical perception, medical education of the population clearly reflects the true state of the practical medicine, which forms the stereotypes of patient's behavior.
A famous neurologist K.F. Kanareykin wrote that the integral aspect of psychosomatic medicine – «is not psychiatry in medicine», since «every physician meets with various psychosomatic problems in their patients, and he must necessarily take them into account, developing a treatment strategy» (cited to ). According to him, psychosomatic orientation in the contemporary understanding of human pathology must be mandatory in practice of any physician.
It has long been arisen the changes in health care that can be directed to reorganize the training of doctors in view of teaching them a large amount of psychology and psychotherapy . Today, there is an accumulation of practical experience, connected with attempts to approach the professional interests of internists, psychiatrists, psychotherapists, medical psychologists in a wide range of medical practice. Such cooperation helps to complete knowledge in related specialties, the formation of a complete picture of the disease (its psychic and somatic components, «in such cases we are talking about integration, but not a simple summation or substitution of expert knowledge» .
The pathogenesis of psychosomatic disorders, described by D.N. Isaev , is determined by a combination and the interaction of the following key factors:
- Non-specific hereditary and congenital family history of somatic disorders and defects;
- A hereditary predisposition to psychosomatic disorders;
- Neurodynamic shifts (disorders of the central nervous system);
- Personal characteristics;
- Mental and physical condition during the term of traumatic events;
- Unfavorable family background and other social factors;
- Characteristics of traumatic events.
Psychosomatic orientation in medicine, suggesting an important role of biological, psychological and social factors in the occurrence, course and outcome of pathological conditions in humans, indicates the need for integrated approaches to integrated diagnosis, treatment, prevention and rehabilitation based on the cumulative knowledge . For patients, suffering from psychosomatic disorders, the prevalence of disorders of varying scope at this stage of the disease is crucial in the choice of forms and methods of correction, and in the degree of participation and emphasizing the role of a therapist or psychiatrist. The most tolerant model that performs all of the above requirements is the resource model of psychotherapy (Kovalenko-Madzhuga N.P.) [11, 12]. Application of the methods of resource psychotherapy with both preventive and general therapeutic value, can be an important tool for the doctor-internist. This is the direction in which research is implemented a research of a psychosomatic causal layer and the problem of targeted correction of the internal picture of the disease is solved. Resource psychotherapy integrated in it knowledge of such areas of medicine as obstetrics, pediatrics, as well as reflexology and neurozology. In a broad sense, the resource psychotherapy is part of psychology and humanistic medicine, which is based on the notion of the uniqueness of the human person and realizes in medical and counseling practice, the idea of unity of mental and physical (Drozdova M. S., 2008) . Thus, the most important place in the range of issues, related to the practice of psychotherapeutic approach, is the problem of the relationships between the doctor and his patient (psychologist and client). In perinatal psychology are described actual communications in a relationship of a woman-midwife, pregnant- doctor and identified or iatrogenic, or positive developmental impact. Everything depends on the quality of communications in this system of relations. Not every expert, even of a high professional level, is able to support patient in a human way, to be with him more a confessor, psychologist than a doctor. We must also remember that excessive psychotherapeutic activity of a physician may lead to iatrogenic mental reactions, disorders. It happens, for example, in the case with incorrect announcement of a cancer diagnosis, etc. The unconditional acceptance of all the same complaints and inability to reveal the true settings of the patient is fraught with not only the unpredictability of the patient's actions and intentions, but also the fall of the professional authority of the doctor in the eyes of his colleagues and patients.
By means of resource psychotherapeutic approach with an effective contact a physician or a psychologist with a patient the solution of a number of important tasks can be speed up. You can achieve optimal implementation of the general plan of diagnostic, therapeutic, rehabilitative measures. Primary course of resource psychotherapy has psychoprophylactic value and when using psycho-correction and the application resource psychotherapy in the case of psychogenic somatic disorders to the fore plan is put the actual therapeutic aspect.
Sensory component of the reaction of the person on the disease almost always includes the effect of nervousness, anxiety, fear, dreary depression or sometimes apathy. When any disease there are fears for its outcome, concerns about how it will affect the work, family life, fear of the forthcoming census, procedures or surgery are the emotional background that may complicate the course of the disease and have a negative effect on the results of the treatment. Therefore, reducing the severity of these experiences, the emotional stress is, in some cases, one of the main purposes of a psychotherapeutic approach . Pathogenicity of anxiety during pregnancy is well studied by psychologists and perinatal proved the need to prepare women for the regulation of emotional and behavioral responses to stress during pregnancy and the postpartum period (Kovalenko N.P.-Madzhuga, Shkuratenko O.S.).
The predominance of melancholy or apathetic passion can also act as a cause or as a consequence of the forced hypokinesy, so another important task is often the increased activity of the patient. The mobilization of all internal resources to fight the disease is necessary. In conversations with the patient the idea should be aggressively pursued that the healing process can be slowed down or sped up by his own attitude to the disease and treatment. To solve this problem in a resource psychotherapy are developed the programs “Resource potential”, “resource art- therapy”, etc. The use of these techniques for pregnant women with threatened miscarriage, with abnormalities during pregnancy has shown their accuracy and efficiency.
To awaken in the patient a feeling of lust for life, active desire to self-development, change of possibilities, the acquisition of skills that can be applied outside the hospital – it is a difficult task that requires time. Usually, in the case of hypernozognosy in the first stage of psycho-correction are shown the methods of “supporting” psychotherapy, aimed at the reduction of fear, despair and helplessness. This technique is effective in patients with significant “danger avoidance”, features of addiction, immaturity, anxiety, focus on the authority of a physician. Psychotherapy at this stage is mainly symptomatic and solves the problems of reducing the level of anxiety, distraction from hypochondriacal experiences, understanding of the treatment process . But this approach has a low efficiency, and the effect is kept for short time. The problem of resource psychotherapy is the formation of the patient active and independent installation on the possibility of recovery and active “participation” in the course of treatment, readiness for training and experimentation, the ability to actively participate in analyzing of the results and taking responsibility for the results of treatment.
In the case of hypognosy on the first stage of treatment, use of “rational” psychocorrection is appropriate with directive and suggestive elements, aimed at clarifying the treatment need for the patient, violations of the pernicious consequences and attempts to self-medication. Some authors have noted the effectiveness of this therapy primarily in patients with pronounced “search for new” low anxiety, high activity and self-control, the underestimation of the existing danger . For them is important a process of strengthening their resource potential, creative activity that provides resource psychotherapy.
At later stages of psychotherapy in these patients are shown techniques, aimed at correcting of the exaggerated view of the patient about his own competency in the disease situation, the development of his altruistic emotional strategies, empathy, the ability to cooperation and respect for others. Such patients require resource art-therapy to activate the creative potential through self-reflection.
Modern medicine is first of all evidence-based medicine, based on protocols and standards for diagnosis, treatment and prevention of specific diseases. But, on the one hand, the standards are a great achievement in preventing medical errors, and on the other – an instruction, which is not yet provided with psychosomatic relationships. In this regard, there is a need to develop clear, standardized programs of diagnosing mental disorders in general practice. So, in our view, taking into consideration the resource-based approach to psychotherapy, it is necessary to strengthen preventive programs that can develop and resource potential of citizens and implement corrective action at the time of the primary abnormalities, not allowing the form of pathology to be somatized.
For many years in St. Petersburg in the Russian Association of Perinatal Psychology of Medicine (RAPPM) deal with in the preparation and improvement of psychologists and physicians in resource and perinatal psychotherapy, conferences are organized with the support of SPb.SU, SRI AG mnamed after D.O. Ott. In recent years specialists of RAPPM found rapport with the doctors of traditional medicine clinic “Amrita”, which successfully combines methods of reflex therapy with psychotherapy and the department of Resource therapy under the scientific supervision of the author is organized.
To work with pregnant women in preparation for childbirth the “Gloria” program (Kovalenko N.P., 1998) is introduced. To provide preventive and therapeutic care for women in menopause (with co-pathologies) the “Camellia” program is introduced, which has a pronounced therapeutic effect in women with psychosomatic complications. Diagnostic methods have been developed to work with the patient family resource and to identify the causes of psychosomatic disorders because of emotional trauma, accumulated in the family.
A detailed study on the causes of psychosomatic complications gives a right to suggest that personal and environmental factors occupy one of the first places in the genesis of somatic diseases . The results of the research and clinical work during 15 years are discussed at scientific conferences of RAPPM and provide a basis to propose the following:
1. Teaching medical students the basics of psychosomatic medicine and resource psychotherapy should be started as early as possible (along with training of general nursing in the second year or propaedeutics of internal diseases in the third year).
2. For doctors of general somatic hospital, maternity wards, children's health medical centers and clinics – to improve their knowledge of medical psychology and resource psychotherapy.
3. In every city the budget Resource Centers should be organized, dealing with the resource potential of the individual, family, group, organization, as well as prevention programs, increasing awareness of the public about the direct relation between psyche and soma (spiritual and mental), and the responsibility for their health.
The health matters are provided by prevention – it is a truth, known to all. The human resources are the result of his efforts and concrete actions. It is this thesis, which is the basis of the tactics of the resource psychotherapy.
1. Badazhkov D.V., Bakhtina I.A., Zhuravlev F.A.et al. // Bull. RAMS. –
1999. – № 1. – P. 59-62.
2. Bräutigam V., Christian, P., Rad M. Psychosomatic Medicine. – M., 1999.
3. Burkovsky G.V., Kotsjubynsky A.P., Levchenko E.V., Lomachenkov A.S. Using the Quality of Life Questionnaire (WHO version) in psychiatric practice (Manual for doctors and psychologists). – St. Petersburg, 1998.
4. Vasilenko V.Kh. Introduction to the clinic of internal diseases. – M., 1985.
5. Garbuzov V.I. The concept of instincts and psychosomatic pathology: Nadnozological diagnosis and therapy of psychosomatic disorders and neuroses. – St. Petersburg, 1999.
6. Garganeeva N.P. // Siberian Journal of gastroenterology and hepatology. –
1999. – № 8. – P. 99.
7. Drozdova M.S., Nemtsov L.M., Mishchuk I.F. // Basic, clinical and pharmaceutical issues of human pathology: Coll. of scientific works of VSMU scientists. – Vitebsk, 2002. – P. 164–166.
8. Drozdova M.S., Fedorov A.P., Golovkin S.P. // Exper. and clin. gastroenterology. – 2003. – №1. – Pp. 89 – 90.
9. Isaev D.N. Psychosomatic disorders in children. – St. Petersburg., 2000.
10. Kabanov M.M., Lichko A.V., Smirnov V.M. Methods psychological diagnosis and correction in the clinic. – L., 1983.
11. Kovalenko N.P. Perinatal Psychology. – St. Petersburg., St. Petersburg State University, 2000.
12. Kovalenko – Madzhuga N.P. Resource art-therapy. – St. Petersburg., Petropolis, 2009.
13. Mendelevich V.D. Soloviev S.L. Nevrozology and psychosomatic medicine. – Moscow, 2002.
14. Pletnev D.D. // Favorites. – Moscow: Medicine, 1989. – P. 8–34.
15. Smulevich A.B., Syrkin A.L., Kozyrev V.N. and others // Journ. of neurology and psychiatry. — 1999.— № 4.— С. 4—16.
16. Tashlykov V.A. Psychological defense in patients with neuroses and psychosomatic disorders: A guide for physicians. – St. Petersburg, 1992.
17. Zimmerman Y.S., Belousov F.V. // Clin. medicine. – 1999. – №8. – P. 9-15.
18. Shkurotenko O.B. Psychosomatic disorders in pregnant women. Collected scientific articles of RAPPM. Ed. By Kovalenko N.P., St. Petersburg, - Petropolis, 2011.