The concept of the internal picture of the disease. The levels of the internal picture of the disease (according to V.V.

5.6. The internal picture of the disease as a psychological problem.
The term “internal picture of the disease” (IKB) was proposed by R. A. Luria and defined by him as “everything that the patient experiences and experiences, the whole mass of his sensations, not only local painful ones, but his general well-being, self-observation, his idea of about his illness, about its causes - everything that is connected for the patient with his coming to the doctor, all that huge inner world of the patient, which consists of very complex combinations of perception and sensations, emotions, affects, conflicts, mental experiences and traumas.
There are two approaches to the internal picture of the disease: medical and psychological.
Within the framework of the psychological approach, VKB is considered from the point of view of general psychological knowledge, from the point of view of the sick place occupied in the mental and social life. That is, the attitude, the nature of experiences is associated not with a specific diagnosis, but with the personality of the patient, with his individually typical, age-related characteristics.
A disease is not something external, abstract for a person: it is not a disease in general, but his “personal”, concrete disease, manifesting itself through certain symptoms, having its own dynamics, etc. There is always a “reference of ideas ... to oneself, refraction through emotional and motivational sphere” (Sultanova, 2000). Therefore, it is appropriate to correlate the VKB and the image of the Self: on the one hand, the image of the Self affects the formation of the VKB, and on the other hand, taking into account the characteristics of the VKB, further construction of the image of the Self takes place. illness.
VKB is a universal human response to a situation of a functional disorder in the body. The content of the VKB is the whole complex of experiences, sensations, forecasts associated with the disease and its treatment.
The main function is to adapt the personality to changed internal and external conditions (although the disease is an internal event for the body, it also leads to external consequences). The patient's ideas about his condition are influenced by many factors: biological, psychological, social. Their role is different and changeable. Sources of influence form a mobile system, which, when the contribution of one part changes, tends to rearrange itself in such a way as to ensure the best adaptation to the new situation.
VKB is a psychic formation that obeys the laws of development and personality formation. In the process of its formation, the VKB is included in the image of the Self (or initially formed as part of this image), after which the formation proceeds through the interaction and mutual influence of these two structures.
The most important characteristics of the VKB:
1. universality (occurs with any disease);
2. the ability to trace the formation of all this neoplasm in an adult;
3. VKB is a product of the patient's own activity. Knowing oneself as a patient.
4. Secondary, psychological in nature phenomenon. A psychological neoplasm that has a complex structure and equally complex hierarchically organized mechanisms of functioning;
5. Dynamic education, that is, changing its content depending on many factors: gender, age, severity and duration of the disease, the degree of its vital threat, the severity and duration of the treatment situation;
6. The VKB itself, having taken shape, becomes the most important condition for the further existence and functioning of a person;
7. VKB in some cases begins to determine the success of treatment and recovery;
8. At the initial stages of the formation of the VKB, it can be used as a method, a means of diagnosing the patient's personality.
9. VKB is available for "correction" in the process of psychotherapy.
WKB structure:
I. Sensory component (the totality of all sensations, complaints):
Actually bodily sensations
Emotional tone of sensations
II. Rational, intellectual component:
Information about the disease
own experience disease
expected results of treatment
III. Emotional.
One of the factors influencing the formation of ICD and psychosomatic development in general is age.
In the formation of VKB, individual-typical properties play a major role in maturity, while in childhood, age-related features are more important. As the personality develops, the ratio of the structural components of the WKB is also rebuilt: the sensual aspect becomes less significant against the background of the growing influence of other aspects (motivational, intellectual). The attitude to the disease is formed through the correlation of sensations with the system of values, the patient's ideas about himself. It should not be forgotten that the further construction of the image of the Self (and the development of the personality as a whole) takes into account the characteristics of the VKB.
The contribution of the family is especially clearly seen in the material of children who underwent early surgery to eliminate heart disease. Their entire internal picture of the disease is formed under the influence of the attitude of adults (there are no sensations as such). When raising a child as “sick”, with limiting his activity, overprotection and excessive concern for well-being, an objectively healthy child becomes a subjectively sick person. He assimilates, internalizes the ideas of others about his condition and builds his behavior in accordance with them. Peculiarities of parental upbringing to a large extent determine the nature of HKB in the early stages of personality development.
At a more mature age, the family and the immediate environment retain significant influence. For example, leaving a job or getting divorced can seriously change the patient's attitude towards their illness.
Features of VKB at different ages:
Younger age (6-10/11 years old) Adolescence
There is no consciousness of illness. Depression does not occur.
The child cannot rely on the data of introspection, reflection, he does not have the mental means for this. There is no standard idea of ​​health/illness. There is an activity of self-knowledge, it relies on a system of external restrictions that the disease creates.
The disease appears for the child as a system of restrictions, one of the main ones is the frustration of physical activity. Another limitation is the frustration of the cognitive need (especially in the case of stationing). The treatment situation also represents the disease.
the main role belongs to the nearest adults. The analysis of the bodily states of the child is carried out by the mother, and she means them, gives a dictionary of description. Primary and secondary signification is carried out by the nearest adult. It depends on the quality of the VKB. This vocabulary may contain iatrogenic characteristics.
There are no special coping strategies for the child. Depressive states of a somatogenic nature, hypochondria. A sufficient level of mental development for the awareness of the disease and the means for cognitive mediation of bodily sensations.
Analysis of one's own bodily well-being. Complaints become similar to the complaints of an adult.
A purely situational context imposes restrictions on which the adolescent is guided. The leading limitation is the frustration of the need for communication. Isolation acts as a factor that increases depression and leads to secondary autism.
The nearest adult is the bearer of meanings.
Various psychological coping strategies:
1. the development of certain behavioral stereotypes that allow you to hide the defect from others;
2. withdrawal into fantasies that deny the disease;
3. family self-isolation (family artificial symbiosis);
4. over-actualization of the future: the disease is temporary, in principle surmountable. Realistic plans for the future, taking into account the disease factor.

Another possible answer:
Dynamics of ICD during treatment.
VKB is a dynamic formation. The dynamics of the WKB is associated with its restructuring, a change in the hierarchy of its levels, and a change in the leading level of the WKB. A good model for studying the dynamics of ICD is the situation of treating patients with chronic renal failure with hemodialysis. Features of hemodialysis: a person gets in a serious condition; this is the only thing that can prolong life; a long stay in the hospital is required. The treatment process can be represented as consisting of 3 stages: the stage of preparation for treatment, the stage of initiation of treatment, the stage of chronic treatment.

Stage Levels of WKB Content characteristics of the levels
Stage of initiation of treatment sensual Complaints, retrospective reassessment of one's health
emotional Tension to start treatment, fear; feeling guilty about asking for help late; illness is perceived as an obstacle to life goals
intellectual Just beginning to form; negative assessment of hemodialysis
motivational Negative coloring of the whole situation in the hospital; trying to delay treatment
Treatment initiation stage Patients were delivered in a serious condition, hemodialysis was quickly undertaken (they have a developed emotional level) sensual Improvement in general well-being, a decrease in the number of complaints
emotional Good mood (sometimes to euphoria)
intelligent Hope for recovery, favorable assessment of hemodialysis
motivational Actualization of former life goals; inadequately overestimated self-assessment of the results of hemodialysis; believe that they will soon return to the old way of life
Patients have been preparing for treatment for a long time (they have a well-formed intellectual level) sensual Decrease in the number of complaints; subjective picture corresponds to the objective
emotional Decreased fear of hemodialysis; improves mood without euphoria
Intelligent Neutral Hemodialysis Rating
motivational Allocate a doctor to whom they listen; premorbid interests return
Stage of chronic treatment General dissatisfaction (this stage is longer in those patients who were delivered in serious condition) sensual Complaints correspond to objective data
emotional Irritability, conflict, negative assessment of the future
intellectual They look for evidence of dishonesty of the staff, ask questions about their condition
motivational
Sensory adaptation Complaints correspond to objective data
emotional
intelligent Actively collect information about their condition; trying to control themselves
motivational Expanding the scope of interests; The importance of kidney transplantation
Fragmentary ICD (its formation depends on the premorbid: a narrow circle of interests, limited contacts, the main meaning of the work) sensual No complaints
emotional The prospect of the future is estimated inconsistently
intellectual Monitor their condition
Motivational Violation motivational component of thinking
On the different stages it is possible to carry out psycho-correctional work. At the stage of preparation for treatment, it is necessary to form a therapeutic environment (do not place in the same ward with unsuccessful kidney transplants). On the initial stage prevent the formation of an overly optimistic assessment of treatment outcomes; adequate knowledge of the disease and its consequences is necessary (i.e., to form the intellectual level of VKB). At the stage of chronic treatment, it is important to reduce the period of general discontent, to develop the motivational sphere: to expand the range of interests and communication.
Kvasenko, Zubarev
Formation of somatognosia:
1. Sensological stage: the patient's reactions to discomfort (general, local), pain and a sense of insufficiency (following a violation of biosocial adaptation, deficiency).
2. Evaluative stage, which is the result of intrapsychic processing of sensory data.
3. Attitude towards the disease: it is formed even before the onset of the disease as such, the disease acquires significance. Attitude to painful manifestations, to the fact of the presence of the disease, to what awaits, to what could help. The stage of attitude including experiences, statements and actions, the general pattern of behavior, criticality, the degree of awareness are important.
The development of somatognosia in the process of development of a somatic disease:
 initial stage: emotional reactions of negative content, threat assessment, stress. The predominance of the feelings of the component; mental adaptation does not reach its formalization and stability, psycho-stress manifestations (anxiety, fear) are characteristic.
 The stage of the height of the disease: anxiety, confusion > calm, expectation, adaptation to a new life. In the subacute type, anxiety and fear may occur, maladaptation against the background of relapse. Psychological adaptation of an incomplete and unstable type. Chronic type of course: not only the stage is important, but also the situation. hospitalism. certain emotional condition in the hospital, an increase in the instability of adaptation, distortion is possible.
 Recovery: not always biological at the same time as psychol., especially in case of protracted illnesses. Inevitable dying: mobilization of the psychological reserves of the dying, to live with dignity.
Patient management:
1. Diagnostic stage: subjectivity of complaints, negative emotional background, anxiety in a situation of uncertainty, a new life situation. That. there is a formation of sensological and evaluative stages. The attitude is still ambiguous, only being formed - various options.
2. Stress is replaced by psychological adaptation, there are hopes, the development of compensation. Treatment is very important. Options. At the end of the treatment process, protective and adaptive mechanisms are clearly manifested (here and psychotherapy).
3. Rehabilitation: the creation of substitute functions for an existing defect, compensatory techniques, overcoming negative reactions. Psychologically, it begins with the first contact with a doctor. attitude towards rehabilitation.
stress > adaptation > one or another degree of psycho-rehabilitation.

Course work

Internal picture of the disease

Introduction

In domestic psychology, there is a pledged by A.R. Luria tradition of studying the internal picture of the disease.

The study of the problem of the internal picture of the disease in various diseases due to the need to take into account the role of the individual in the development, course and outcome of the disease, the nature of personality changes in the conditions of the disease, which is of great importance for the correct and timely resolution of issues of diagnosis and treatment, as well as for the adequate construction of rehabilitation measures, one of the areas of which is the psychotherapeutic correction of distorted subjective reflection by patients of the manifestations of their disease.

The topic is relevant for the graduate nurse, which plans to engage in nursing care and organize nursing care in health care facilities.

Purpose of the work: collection of literary material on the topic and its presentation in graphical form.

1.Selection of literature on the topic.

.Make a literature review on the topic.

.Present the collected material in graphical form.

.Present the collected material in a visual form possible for presentation.

.Formulation of coursework.

1. Theoretical part

.1 The concept of the internal picture of the disease and its diagnosis

When talking with a patient, collecting information about the disease, discussing treatment tactics, one should not forget that the doctor and the patient consider the disease from different positions. This often becomes an obstacle in achieving mutual understanding, leads to dissatisfaction with the results of treatment, and sometimes to a deterioration in health.

The position of the patient differs in that only he experiences those sensations (pain, discomfort, itching) that are caused by the disease. In addition, he cannot be indifferent to the disease, because he feels threatened and infringed on his basic needs. Each patient also has his own unique life experience, individual baggage of knowledge, beliefs and delusions developed in his youth, a set of habitual strategies for coping with stress. All this makes him form his own position in relation to health disorders, which we call the internal picture of the disease.

Internal picture of the disease- this is a purely individual system of sensations, emotional experiences and thoughts (judgments) that determine the patient's attitude to health problems and the behavior associated with it. (Tyulpin Yu.G. 2004)

The concept of "internal picture of the disease" was introduced by the famous Russian therapist Roman Albertovich Luria (1874-1944), who was based on the works of A. Goldsheider on the "autoplastic picture of the disease." These authors tried, on the one hand, to emphasize the subjectivity of a person's perception of his illness, its danger and consequences, and on the other hand, to pay attention to the influence that the psychological attitude towards the disease has on its course. R.A. Luria called for caution both in evaluating the complaints of patients and in discussing his disease with the patient, since inaccurate perception of the doctor’s words, colored by subjective emotions, can worsen the patient’s condition and even cause a mental disorder (iatrogenic). The internal (autoplastic) picture of the disease is opposed to the alloplastic picture of the disorder, which summarizes its objective manifestations, which can be examined using special medical methods and devices.

Alloplastic picture- these are the objective signs of the disease, the functional and organic changes caused by it; the rate of the disease, its dynamics, prognosis, effectiveness of therapy. Manifestations of the alloplastic picture of the disease can also lead to a change in the patient's psyche; most often, severe diseases lead to asthenia (fatigue, irritable weakness, insomnia, memory and attention impairment, etc.). Even more severe and acute processes may be accompanied by clouding of consciousness (delirium, amentia, stupor).

The mental personality of the patient is determined by autoplastic picture of the disease, which is a superstructure over the alloplastic basis. It is the features of the autoplastic picture of the disease that require the intervention of a psychologist and / or psychotherapist, dictate the need to create a certain psychotherapeutic environment around the patient with the indispensable participation of a mid-level health worker. Objective (alloplastic) and subjective (autoplastic) assessments of the severity of the disease rarely coincide.

The need for attention to the soul of the patient was emphasized by many eminent clinicians, starting with Hippocrates, who argued that such an approach brings the healer closer to God.

“Symptoms, sensations, suffering, disorders should be analyzed with the same thoroughness with which the chemical body is examined,” argued the French psychophysiologist Labori, the founder of the use of hibernation and the discoverer of chlorpromazine, which made a revolution in psychiatry. Russian doctor A.F. Bilibin said that the activity of a doctor flows between two rocks - the heart and the mind (of the patient). I. Hardy (1981), author of the capital study "Doctor, Nurse Sick", called inattention to the experiences of the patient "medical scotoma" (blind spot). When the patient's personality is underestimated, the health worker becomes an appendage of a tool (in modern conditions - a computer); the basic theses of medicine are ignored to treat not the disease, but the patient; take into account the unity of the soma and the psyche

1.2 Autoplastic picture of the disease

Sensitive levelsuggests the presence of painful sensations (weakness, nausea, dizziness, pain, etc.). It is important to understand that each person has their own individual threshold of perception. The same changes in the internal organs can be accompanied by completely different sensations in different patients. Suffice it to mention that women in childbirth describe the pain during childbirth in very different ways, some claim that they did not feel almost anything unpleasant. Prescribed medications (analgesics) can significantly affect the pain and temporarily change the person's attitude towards the disorder. So, patients with myocardial infarction, frightened by sudden pain and fear for their lives, often become overly careless after prescribing painkillers, they believe that the danger has passed, they cease to fulfill the requirements of doctors. Sometimes the disease proceeds without obvious sensations ( latency period, remission). This does not mean that patients currently consider themselves healthy, because they can evaluate the disease on other levels.

Emotional levelreflects the general sensory impression of the situation caused by the disease. So, for different patients, the appearance of symptoms can be perceived not only as a threat, challenge, loss, but also as a punishment or even gain (deliverance). So, one woman will perceive a delay in menstruation as a chance to have a desired child, and another - as an unfortunate obstacle or as a punishment for negligence. The appearance after this bleeding for the first woman will mean the loss of illusions, and for the second - deliverance. A schoolboy who, before a difficult test, will find that he has a fever and rashes on his body will also rejoice. But with depression, emotions are practically the main and only leading manifestation of the disease. Pessimism, feelings of irreparable loss and hopelessness arise in such patients without any organic reason.

Intellectual levelinvolves a logical assessment of the situation of the disease from the position of existing knowledge of the experience of intellectual abilities. Especially noticeable is the difference in the attitude towards the disease of adults, burdened with experience and knowledge, and children, for whom a disease that does not cause unpleasant sensations always seems less dangerous. An important factor influencing the attitude towards the disease is considered to be medical information distributed on television, gleaned from special literature, found in annotations to purchased drugs. This imposes a special responsibility on the compilers of such information. A gross violation of moral principles should be considered the distribution of unreliable, unconfirmed or emotionally distorted medical information for advertising purposes. Personal life experience also largely determines the position of the patient in relation to the disorder. So the daughter of a patient who died of lung cancer will perceive the streaks of blood that appeared in her sputum as a catastrophe, although their real cause may be banal tracheitis.

Behavioral levelexpressed in the actions that the patient takes or plans to take in connection with the presence of the disorder. So, the disease forces one patient to actively look for ways to treat and protect against unpleasant consequences, another one is paralyzed: he gives up and he resignedly waits for the end, the third one is left indifferent, and he continues to do what he was interested in before the illness. A person's behavior is to some extent influenced by the prevailing circumstances, the opinion of those around him, the doctor's advice, but to the greatest extent his actions are determined by his personality and the established system of coping strategies. The patient will compare the actions and advice of the doctor with his idea of ​​how to act in this situation ( internal picture of the treatment process). So, for example, the patient is unlikely to agree that because of a small tumor in the mammary gland, it is necessary to remove the entire breast, and even part of the muscles in addition. It is also difficult for the patient to understand that with some injuries it is better not to save the damaged eye, but to remove it.

A person’s attitude to illness cannot be considered in isolation from his attitude to health, therefore, in order to assess the patient’s position, it is important to analyze inner picture of health. This concept can also be considered from the sensitive, emotional, intellectual and behavioral sides. So, a person may not attach significant importance to headaches that appeared at the end of the working day, since he considers it quite normal that a successful working day can cause some fatigue and inconvenience, respectively, such a person will most likely not be interested in the level of blood pressure, although in fact, it can be significantly increased. But a patient interested in maintaining harmony may be frightened if, with a height of 170 cm, she finds that her body weight is more than 50 kg, she will take special means for losing weight, follow a diet and torture herself exercise. People have different attitudes towards their health: some make incredible, often futile efforts to maintain it (this is especially characteristic of stuck individuals), others show carelessness, not thinking about the consequences, abuse food, alcohol, smoking.

It should not be forgotten that, unlike the doctor, the patient has a very vague idea of ​​the anatomical structure of his body. He uses his own "body scheme", which is very different from reality. Any changes other than the prevailing idea of ​​\u200b\u200bhis body can scare and upset a person. This is especially noticeable in the behavior of adolescents during puberty, when girls are afraid of growing breasts and the appearance of menstruation, and boys are worried about the growth of pubic hair, changes in body proportions and the appearance of erections. Patients can also explain internal sensations based on misconceptions. Yes, the pain chest often regarded as a sign of heart disease, and the patient is genuinely surprised if the doctor claims that their cause lies in the defeat of the spine. The importance of many organs (spleen, adrenal glands, thyroid gland, lymph nodes etc.) is generally a mystery to most of the inhabitants.

Let us give an example of a very peculiar idea of ​​the patient about the work of internal organs.

A 46-year-old man, engineer-physicist, married, has an adult daughter. About 5 years ago I became interested in the system of recovery according to Porfiry Ivanov. In accordance with this system, regularly doused ice water, jogged, sometimes starved for 2-3 days. In the last 2 months, due to the deterioration of health and the appearance of pain and a feeling of pulsation in the head, I decided to increase physical activity, performed exercises with weights. Since this did not help, he began to read medical literature and discovered that he had nephritis. He substantiated his point of view by the fact that the book said that jade arises from hypothermia and physical exertion. Another evidence of the presence of nephritis was that he had a “disturbed excretion system”: for example, after eating, food lingers in the stomach for a long time, constipation is often observed. After talking with the doctor, he realized his mistake and made sure that he had "vegetovascular dystonia." I understood this because I felt enlarged nodes under lower jaw.

Interestingly, each person has his own idea of ​​which organs are more important and which ones play a secondary role. Often this is due to a person’s profession (for example, a pianist takes care of his hands, a ballerina takes care of his legs, an artist takes care of his face and throat, and a pilot knows that heart and eye diseases will deprive him of the opportunity to fly). Sometimes organs that were affected in deceased loved ones are considered the most important. A patient with alcoholism is always interested in what happens to his liver. People show special attention to the work of organs that they consider more important, they are often frightened by even insignificant deviations in the work of these organs, they seek help from doctors, they remain deaf to dissuasion and words of support.

The internal picture of the disease can develop in a person who does not have any significant changes in the internal organs ( fictitious internal picture of the disease). This may be the result of false painful sensations: for example, in mental illness, patients sometimes complain of strange sensations inside the body (senestopathies): twisting of the intestines, softening of the bones, tickling in the cerebellum, magnetization of the heart. A fictitious model of the disease can also be based on an incorrect interpretation of information: for example, the patient may mistakenly calculate the temperature 37 0With a sign of illness. Often the cause of errors in assessing one's health is excessive anxiety, a particular tendency to search for various disorders(hypochondria) are distinguished by people with an anxious and suspicious (pedantic) character. Finally, the patient can simply invent a non-existent disease (simulation), if he considers that it is useful to him.

What is more important for a doctor: to know about objective changes in the internal organs (alloplastic picture of the disease) or to feel the subjective world of the patient's experiences in connection with the health disorders that have arisen (autoplastic picture of the disease)? The only correct answer is: both are equally important! First, many symptoms cannot be ascertained by objective means. Thus, the description of pain, the study of pain sensitivity, the measurement of hearing and visual acuity are impossible without assessing the subjective sensations of a person. Secondly, many of the findings made with the help of objective methods may have no effect on the health of the patient. It is known, for example, that osteochondrosis, mitral valve prolapse, enlargement of the thyroid gland, etc., in many people do not show any symptoms and do not disrupt adaptation. And in people who have had a myocardial infarction, ECG changes persist until the end of their lives, even if they do not have an exacerbation of the disease. Often, violations of the internal organs occur secondary to a painful psychological state: for example, anxiety and depression are often accompanied by an increase in blood pressure and tachycardia.

The doctor will get the most accurate idea of ​​the disease by comparing objective findings with their subjective description. The discrepancy between complaints and objective information can help the doctor either to detect his own mistake in the diagnosis, or to substantiate the presence of a mental disorder in the patient, or to confirm the fact of simulation. An accurate understanding of the internal picture of the disease helps to satisfy precisely those needs of the patient that were most affected by the disease. So, for a woman and a teenager, maintaining an attractive appearance may be in the first place. Ignoring this fact can result in a conflict with the doctor, an official complaint, or even the patient's suicide.

All this determines the need, along with the diagnostic methods adopted for each specialty, to conduct a study of the internal picture of the disease.

For diagnosticsthe internal picture of the disease, it is recommended to ask the patient a few additional questions regarding his attitude to the existing disorders:

• What do you think about your illness? (any, even the most bizarre ideas are interesting)
• What event prompted you to see a doctor? (the appearance of discomfort, the requirement of relatives, the warning of the boss, the decrease in working capacity, etc.)
• Try to describe your feelings without using medical language (simulators often cannot find any expressions other than what they read in a book)
• Arrange the complaints you have listed in order from the most significant to the least significant (complaints that are the first in this row should always be given more attention in the conversation)
• What have you read about your illness, heard from friends or on TV?
• What are your expectations for recovery? What path does it open for you in life? (often the patient attributes more restrictions to the disease than it actually imposes)
• How do you imagine the treatment of your disease? Which methods do you find most attractive and which are unacceptable? (negative attitude towards the method often makes it ineffective)
• How long have you already coexisted with the disease, how did you endure exacerbations and courses of treatment before? (an experienced patient may know more about his illness than an inexperienced doctor)
• How concerned are you about your appearance? How do you rate the condition of your body? Show with your hand which part of the body bothers you the most (for example, with depression, patients often point to the chest)
• What result do you expect from the treatment? (recovery, remission, getting rid of the most unpleasant symptom)
• How long do you expect? (often patients are in a hurry, and some lonely patients, on the contrary, want to spend more time in the hospital)
• 1.3 Conscious and involuntary distortion of the picture of the disease
• In the literature, the concept of a harmonious internal picture of the disease is often used, but it is very difficult to determine what exactly should be considered a sign of a harmonious attitude towards the disease. After all, the presence of a somatic disease is already a sign of a pathology that interferes with human adaptation, and therefore causes psychological discomfort. sickness like stressful situation defines an inclusion psychological defensesthat prevent you from fully realizing the danger of the situation and taking the necessary actions. The very use of psychological defenses, from the point of view of a psychologist, is not a sign of disharmony and is characteristic of all healthy people.
• An important sign of a harmonious attitude to the disease is that a person’s behavior at the time of illness does not disrupt the lives of other people (relatives, colleagues, friends, doctors), does not interfere with helping him. One gets the impression that doctors tend to call harmonious the model of the patient's behavior that is convenient for them, does not cause them unnecessary trouble. However, it is not always possible to agree with this: after all, the tastes of different doctors in this regard can vary significantly. In addition, it often happens that a passive patient who does not resist treatment is actually immersed in hopelessness and experiences suffering that he does not express in any way, but this suffering interferes with his recovery.
• A.E. Lichko (1983) offers the following definition:
• Harmonious typeattitude towards the disease is a sober assessment of one's condition without a tendency to exaggerate its severity and without reason to see everything in a gloomy light, but also without underestimating the severity of the disease. This is the desire to actively contribute to the success of treatment in everything, unwillingness to burden others with self-care, and in the case of disability, switching interests to those areas of life that remain accessible to the patient.
• It should be borne in mind that a harmonious internal picture of the disease does not at all mean a complete coincidence of the opinions of the doctor and the patient, does not imply the absence of a contradiction in their interests. Its study is just as useful for effective medical practice as the analysis of disharmonious patterns. Such a model is that successful case when the patient and the doctor, by joint efforts, can achieve the maximum in the correction of all existing disorders, to miss this chance means to deprive ourselves of the pleasure that our profession brings us.
• Unfortunately, in many cases one has to deal with a disharmonious, disorganizing reaction of the patient to the disease. All possible variants of the distorted model of the disease can be conditionally divided into two main types: exaggeration and underestimation of the severity of the disease. Of particular note are cases of deliberately misrepresenting the disease to the doctor: simulation, aggravation and dissimulation.
• Simulation- intentional and purposeful demonstration of signs of a non-existent disease. Simulation is always based on the desire to obtain a specific material benefit (to avoid criminal liability or military service, to receive exemption from work, material compensation or benefits). Simulation should be distinguished from the desire of demonstrative personalities to attract attention and arouse sympathy, which is a sign of inner suffering and dissatisfaction with life. The simulator does not experience any suffering - he is driven only by the anticipation of benefits. The data of an objective examination cannot always reveal the fact of a simulation, since the simulator can affect the result of the examination (take medications that increase blood pressure and temperature, increase the pulse rate, etc.). The absence of signs of illness during the examination is also not a reliable criterion for simulation, since the possibilities of objective methods are limited; in addition, many diseases are of a functional nature (mental illness, dyskinesia of internal organs, vegetative-vascular dystonia).
• Diagnosis of simulation should be based on the contradiction between the examination data and the patient's complaints. Quite characteristic is the exact reproduction in the patient's speech of the classical descriptions presented in special medical manuals. It is important to ask the patient to describe the sensations in their own words. This is a difficult, often impossible task for a person who does not really experience anything. Finally, simulation diagnostics will be incomplete without an attempt to determine the patient's true goals. Usually this is not difficult, because the “disease” arises directly in connection with the approaching term of service, before criminal proceedings, on the eve of leaving on a business trip, etc. It is better not to ask the patient about his problems, but to let him speak out himself. As a rule, the patient himself will ask questions that will lead the doctor to the idea of ​​a simulation, for example: “Am I not entitled to a sick leave?”, “Is it possible to serve in the army with such a disease?”, “Well, you just let me go without any help?"
• Sometimes physicians tend to find sham where there is none. Patients with some mental disorders make a strange impression with their ridiculous, helpless actions. A dissonance is often found between the preservation of the ability to count, write and the patient's severe helplessness in the simplest situations. This behavior may be a manifestation of isolated damage. frontal lobes brain, malignant variants of schizophrenia or hysteria.
• Aggravation- this is a deliberate increase and demonstration of signs of an existing disorder in the expectation of obtaining benefits and benefits. As in the case of simulation, there is a definite goal and desire for a material result. However, an objective examination clearly reveals clear signs of the disease, which is not always easy to determine the true severity of. Aggravation should be the subject of analysis by doctors - specialists of the highest class. Only extensive experience and observation will allow you to accurately assess the severity of the painful defect.
• dissimulation- intentional concealment of existing disorders, caused by fear for one's fate. Dissimulation is always based on anxiety and fear: fear of losing your favorite job, the desire to avoid conflict in the family, unwillingness to spend long time in the hospital, fear of surgery or other active treatment. Cases of dissimulation are especially common in psychiatry, in infectious and tuberculosis patients, under the threat of quarantine, in expert professional commissions.
• In general, cases of deliberate distortion of the picture of the disease do not cause much concern among doctors, since a correct understanding of the situation allows a person to make a decision that does not cause him great harm: avoid unnecessary surgery during simulation or continue taking medication despite hiding the fact of the disease during dissimulation.
• An unconscious, involuntary distortion of the true situation requires much more attention and effort from the doctor, since many of the actions or inaction of patients in this case cause them obvious harm.
• Hypernosognosia- this is an overestimation of the severity and danger of existing disorders, an erroneous recognition of phenomena that are actually normal as a disease, disbelief in recovery. The behavior of patients with hypernosognosia can be different - from confusion and crying out for help to doom and inaction. It will be useful to describe each of the variants of hypernosognosia in more detail.
• Hypochondria called an exaggerated attention to their physical health and an erroneous feeling of the presence of a somatic disease in the absence of real manifestations of the disease. Patients with hypochondria constantly listen to the work of their body, attach special importance to any sensations that occur inside the body, suspect the occurrence of a dangerous disease, build complex concepts about the nature of the sensations that arise in them. In this regard, they often turn to doctors, require special examinations. Hypochondria is characteristic of people of an anxious and suspicious warehouse with features of introversion.
• Anxiety for his health is expressed in rather vague feelings. Such patients cannot articulate exactly what they are most afraid of. Any casual words of the doctor cause them fears, a sense of impending danger.
• Carry out warning additional surveys and manipulation deprive them of sleep and rest. They really want and at the same time are afraid to know the results of the examination, believing that they will be unfavorable, they constantly look at the doctor with hope, as if praying to be reassured and explained what is happening. This behavior indicates a weak, dependent temperament.
• Depression manifested by a sense of doom and passivity. Such patients often do not attract the attention of a doctor, as they are silent, they can constantly lie in bed without sleep and look at the ceiling. They are not interested in other patients, do not communicate with anyone, often refuse the offered help, eat poorly. Depression is often the cause of late seeking medical help. Only under pressure from relatives will it be possible to bring such patients to the doctor. Patients with depression should be of particular concern to the doctor, because without the active participation of others, they will not report the onset of complications and side effects of therapy. We must not forget that depression is one of the most common causes of suicide.
• Fear of publicity and condemnation typical for patients with disorders that cause others to neglect, fear, disgust, condemnation. So, many patients are afraid that others will find out about their mental, venereal, infectious, skin disease. Sometimes these feelings are not based on anything. Thus, many women are afraid of operations to remove the ovaries and uterus, believing that they will lose their sexual attractiveness, while studies show that adult sexuality does not disappear even after the removal of hormonally active organs. Fear of losing hair often becomes the reason for not taking anticancer drugs.
• Finding the culprit characteristic of egocentric personalities with a strong active temperament. Such people pay more attention to finding evidence of other people's misdeeds than to actually treating them. They stick out the side effects that have arisen, see them as confirmation of the incompetence of doctors, reproach everyone for negligence and selfishness. The attitude towards any proposed method is cautious, often suspicious. To convince such patients to begin the proposed treatment can only be some particularly reputable doctors who enjoy their special confidence. An attempt to dissuade them often ends with the fact that the doctor is attributed to the clan of enemies and accused of conspiracy.
• Manipulation manifested by emphasizing one's weakness, helplessness, need for help and support. Existing disorders are flaunted, as they indicate the need for sympathy and care. Such patients do not tolerate attention being given to anyone else in their presence, so any deterioration experienced by any other patient in the ward is likely to cause them to also deteriorate. It is not uncommon to see them cared for by relatives or roommates who actually have a much more severe disorder. Demonstrative personalities are especially often manipulated by those around them.
• Irritability manifested by impatience, endless grumbling, reproaches that the condition is not improving, the demand to show sympathy, to protect from everything unpleasant. Such patients are constantly asked to turn down the sound of the radio, close the window, remove strong-smelling flowers. They are unhappy that the bed is too hard, that the food offered to them is too hot, that the doctor touches them with cold hands, that the pills get stuck in their throats. They are also annoyed that relief does not come for so long, despite the medications they have taken. This behavior is typical for patients with a weak temperament.
• From hypernosognosia, the behavior of patients with nosophilia.Such patients are constantly being treated for something, reading popular and special literature about diseases and medicines. They willingly listen to the complaints of other patients, find with pleasure that they are familiar with such a disorder, offer their own methods of dealing with the disease, tested by themselves or heard from others. Such patients like to go to sanatoriums, make great efforts to ensure that they are prescribed maximum amount medical procedures, despite the fact that their disorder is not at all dangerous and, in fact, does not particularly interfere with their life.
• Not uncommon are the various options underestimation of the severity of the disease. Most often, the reason for this is the inclusion of various psychological defense mechanisms that protect the patient from thoughts that frighten him. However, in some cases, the reason for the non-criticality of the patient are obvious mental disorders, especially damage to the frontal lobes of the brain.
• Hyponosognosiacalled the underestimation of the severity of the disease, the avoidance of treatment, the recognition of the fact of the disease, while emphasizing its insignificant position in the hierarchy of needs.
• Hyponosognosia can be indifference , i.e. indifference, calmness, apathy, lack of interest in the results of the examination and treatment. Such a patient does not object to the prescribed procedures, however, without a reminder, he forgets about the need to take the medicine, shows surprising passivity, goes to the doctor only at the request of his relatives, who are frightened by the noticeable progression of the disease. This position is more typical for patients with introversion traits, who pay little attention not only to their health, but also to their appearance, do not prosthetics of lost teeth, do not seek to remove benign tumors that disfigure them, and do not treat nails damaged by a fungus. The disease does not bother them as long as it does not interfere with their occupation of interest (reading, research work).
• Employment demonstration - this is another variant of hyponosognosia, which consists in the fact that a person recognizes the need for treatment, but constantly postpones it because of responsible affairs, which, in his opinion, cannot be performed without his participation. So, the patient may postpone the operation, allegedly due to the fact that he cannot leave the enterprise until the annual report is submitted. A housewife may consider illness very untimely, as she is busy preparing children for school, treating parents, or serving a husband who is in a difficult financial situation. Such an attitude towards the disease is typical for people with an altruistic position. Quite often, behind the demonstrated employment lies an extreme fear that the disease will actually be much more dangerous than it seems.
• Anosognosiacalled the absence of a sense of illness, the complete denial of the very fact of its existence, confidence in one's health and well-being. Extreme degrees of anosognosia indicate the presence of a mental disorder. So, anosognosia is quite typical for patients with manic syndrome, delirium (persecution, jealousy, greatness, etc.), dementia (dementia). Often the fact of the disease is denied by patients with alcoholism and drug addiction. They try to convince the doctor that they can control the use of drugs, that they can stop using them at any time, they do not notice the dangerous damage to the internal organs or deny their connection with the use of drugs. This behavior is typical for people with hyperthymic accentuation. They demonstrate complete satisfaction with their condition, begin to reassure the doctor, claim that treatment is not required at all, since everything will pass by itself.
• Quite often, anosognosia becomes the only way to protect your psyche from the constant threat of death. So, many patients with oncological diseases claim that doctors made a mistake in making a diagnosis. Such patients do not notice the progression of the disease, they explain the deterioration of their condition by the addition of a banal infection. The inclusion of psychological defenses means that subconsciously the sick retain a sense of unhealthiness. Denying the presence of the disease in this case does not mean refusing to help. A contradictory situation is created when the patient declares that there is no illness, but still calmly, without objection, takes the prescribed medications, does not refuse the prescribed procedures. This situation should satisfy the doctor, there is no need to unnecessarily violate the established system of defenses if the patient does everything necessary for recovery, and we cannot offer him another way to avoid intolerable psychological suffering.
• 1.4 Determinants and correction methods
• attitude disease distortion internal
• The internal picture of the disease is influenced by many factors. Knowledge of these factors makes it possible to better understand the patient's inner experiences and, if necessary, to influence the patient's attitude to his illness. (Kabanov M.M., Lichko A.E., Smirnov V.M. 1983)
• The internal picture of the disease is determined by:
• the nature of the disease itself
• stage of its course
• personality type (temperament, hierarchy of needs, typical set of psychological defenses, locus of control)
• intelligence and brain health
• age
• attitude to this disease in a significant microenvironment
• conditions in which the disease occurs

The severity of the disease itself.

The nature of the disease (assessment of its alloplastic picture), its severity, the rate of development, the likelihood of a cure, the available effective treatments, the intensity of the discomfort caused by the disease; finally, the ensuing change in appearance, especially the face.

Naturally, subjective experience, emotional changes in a curable and incurable disease will be different. The same goes for possible changes performance, mobility, communication. An illness that creeps up gradually with clear objective symptoms will be experienced differently than an illness that comes on suddenly, “like a bolt from the blue” (“asymptomatically” according to L.L. Rohln to a domestic psychiatrist who devoted many works to the VKB). Skin or burn or chronic ulcerative lesions on the extremities will be experienced differently than the same lesions on the face.

So, acute attack coronary heart disease is almost always accompanied by a fear of death. Constant debilitating pain in some joint lesions, with growing malignant tumors does not allow ignoring the disease. But outside of acute pain, patients with coronary heart disease often show imprudence, take on tasks that clearly exceed their capabilities, go headlong into work, show carelessness and confidence that everything will be fine. Such hyponosognosia is completely uncharacteristic of patients with bronchial asthma and peptic ulcer disease. In these diseases, patients usually show hypochondria, constantly focus on unpleasant sensations, are often dissatisfied with the results of treatment, show grumbling and capriciousness, take offense at other patients, and believe that they are not given enough attention. Particularly painful experiences fall to the lot of patients with malignant tumors. It is known that anxiety and depression in these patients often occur before the doctor establishes a frightening diagnosis.

When characterizing a person's attitude to the disease, it is important to take into account stage of its course. Describe the characteristic dynamics of the psychological state observed in many disorders. (Tyshykov V.A. 1984)

Pre-medical phasecharacterized by a suspicion of a possible disease, doubts about the need to see a doctor, blaming oneself for paying too much attention to trifles, fear of the unknown, fear that the disease will turn out to be really dangerous. Attempts to calm oneself down by taking sedatives, painkillers and alcohol, the active use of psychological defenses delay the visit to the doctor and, in fact, increase internal anxiety. When talking with such a doubting patient, one should draw his attention to the fact that, most likely, he is torturing himself over trifles: after all, an examination can show that there is no danger, which means that going to a doctor is the only way to dispel anxiety.

Acute disease manifestation often causes emergency hospitalization. Sharp pain, violation of vital important functions leave no doubt about the severity of the disease. Fear and confusion in this case are supported by the fact that doctors do not yet have enough information to accurately determine their tactics, they often limit themselves to vague remarks: "We'll get the results of the examination - then we'll say." The actions of the patient during this period are often careless and illogical. So, a patient with a myocardial infarction begins to run around the apartment to find his insurance policy. To help the patient, medical workers must at this moment show equanimity and calmness, self-confidence. Their instructions should be as short and clear as possible: “Don't worry! You are in the hands of professionals and we know how to help you. Follow all our commands exactly, do not fuss, and then everything will be fine.

Active adaptation period occurs no later than on the 5th day of treatment, it is associated with the relief of the most dangerous manifestations of the disease: the disappearance of acute pain, restoration of breathing, the disappearance of interruptions in the work of the heart, a decrease in temperature, etc. A pronounced improvement in well-being gives the patient hope, which is not always justified. He begins to show carelessness and excessive enthusiasm (the euphoria of a convalescent). Sometimes he forgets to take antibiotics (“After all, there is no more temperature”), he tries to start being active ahead of time (does not follow a diet and bed rest, tries to use a broken limb). One has to deliberately exaggerate in a conversation with such a patient, to insist on the inadmissibility of deviation from the rules, to point out that the danger is still very significant.

If the disease continues long enough, it is not uncommon to see signs mental decompensation . At this stage, the patient realizes that the success achieved in the first days of treatment was incomplete, and all subsequent efforts did not lead to the final restoration of health. Since the main acute manifestations of the disease have disappeared, such a patient is largely deprived of the close attention of doctors, he feels a clear excess of free time. In order to save the patient from unnecessary experiences, it is recommended to actively involve him in the treatment process. It would be nice to give him a fairly complex instruction, the implementation of which would require time and his attention. This may be a system of exercises that must be performed many times during the day, a complex of skin care, oral cavity, nasopharynx. It is important to include physiotherapy, classes in a group of therapeutic gymnasts or psychological relief in the treatment complex. Even if the effect of these methods is not very pronounced, they create the necessary mode of employment and distract the patient from meaningless experiences.

In incurable diseases, it is often observed stage of passive adaptation (surrender) . This stage is characterized by a lottery of hope for recovery, a decrease in interest in medical and rehabilitation activities. The patient gets used to being sick and does not strive for a healthy life, because he does not believe in its possibility. This corresponds to the situation of "revolving doors", when the patient seeks to return to the hospital a few days after discharge. Pessimism and melancholy (depression) become his main experiences. The doctor's task at this stage is to switch the patient's attention to those areas of life that remain accessible to him. To overcome depression, it is often necessary to resort to the appointment of special drugs (antidepressants).

Undoubtedly, an important role in the formation of the internal picture of the disease is played by patient's personality traits.

Personality features. The manifestations of the disease can be assessed adequately, but there may be constant anxiety related to both the symptoms already present and those that seem to be future, the patient can constantly listen to his body and invariably find some changes. On the other hand, certain individuals or in certain situations may develop an underestimation of the severity of the disease, up to its denial. It should be noted that the disease most often sharpens personality traits.

It is important to take into account the existing hierarchy of human needs. So, people who have devoted themselves to self-realization, on the one hand, perceive the disease as a significant obstacle, and on the other hand, they can show great resistance to pain, inconvenience, try to continue their life's work, despite the illness, and under the threat of death, seek opportunities to transfer their knowledge to followers so that they can complete what they started. The change in the hierarchy of needs in patients with alcoholism is indicative. At the beginning of the disease, the role of the family and the profession is so great that relatives and employees manage to persuade the patient to treatment and abstinence, however, as the disease progresses, the degradation of the personality becomes obvious and the alcoholic need for the person becomes the only important one, he is no longer concerned about family problems, his professional failure , does not feel the severity of the consequences of the disease (euphoria, anosognosia). Another important feature is considered locus of control . A person who considers himself the culprit of the disease often shows more desire to fight the disease and overcome its consequences. A patient who feels like a victim of fate is often passive, hopes for a miracle, resignedly bears the failures of treatment, does not try to achieve more, to compensate (rehabilitate) himself in some new activity.

We should not forget about organic diseases that can affect the patient's intelligence , and hence the ability to realize the severity of the disease.

Intelligence and medical culture of the patient. A dual effect is possible; awareness in medicine, in particular in a sick health worker, strengthens his anticipatory independence. On the other hand, the piling up of medical knowledge without its selection can lead to increased anxiety, uncertainty, pessimism.

The most severe anosognosia is observed when the frontal parts of the brain are affected. Psychiatrists are well aware of the carelessness and euphoria in many types of dementia (Alzheimer's disease, Pick's disease, tumors and injuries of the frontal lobes, progressive paralysis, etc.). Organic lesions of some subcortical regions (for example, parkinsonism), on the contrary, are manifested by anxiety, depression, and consciousness of the particular severity of the disease. Specific violations of the "body scheme" in combined thalamoparietal lesions are described. Studies on interhemispheric asymmetry have shown that individuals with dominance of the right hemisphere are more likely to experience various types of hypernosognosia.

Patient's agealso often has a significant influence on his attitude towards the disease.

Children perceive the disease primarily at a sensitive level. The disappearance of pain and malaise makes them forget about the disease; they start playing, naughty, having fun. The appearance of unpleasant sensations makes them capricious, they do not want to let go of their mother. Lack of understanding of the danger makes all painful and unpleasant procedures (injections, bitter medicines, dental treatment) meaningless for them.

Adolescence and adolescence characterized by the fact that the foreground is concern for their external attractiveness and sexuality. During this period, diseases that affect the appearance (skin diseases, alopecia, age spots, obesity) are most severely experienced. This forces teenagers to make extraordinary, sometimes painful efforts to improve their appearance. One of the dangerous disorders in girls can be anorexia nervosa. When carrying out operations at this age, care must be taken about the cosmetic qualities of scars.

AT maturity period Career and family come to the fore in the hierarchy of needs. A sense of responsibility for one's own business often makes the patient put off going to the doctor for a long time, neglect the advice of doctors, and forget about taking medication. Interestingly, exacerbations of diseases at this age are also often associated with problems at work. In this case, the disease can be perceived as a welcome respite, and recovery as a return to hell.

Period involutions corresponds to menopause in women, in men it can be observed at about the same years or later. At this time, the fear of coming old age comes to the fore, one of the components of which is often the fear of loss of sexuality and potency. There is little reason for such fear, since most healthy people retain sexual functions throughout their lives, however, among the complaints of these patients, there is often concern about the effect of drugs and operations on potency. Women who have undergone ovarian surgery often hide it from their husbands.

AT old age illnesses often become the main way to fill free time, get the attention of busy children, and communicate. Therefore, so often in the elderly we observe the desire to regularly visit doctors, discuss their health with friends. At the same time, the attitude towards diseases becomes more calm, filled with worldly wisdom.

The attitude of othersto diseases has changed in different eras and in different cultures. Everyone remembers the hatred of the sick in ancient Sparta, where a kind of health cult was formed. Mental illness in medieval Europe was seen as a demon, and in many northern cultures was considered a divine gift. In ancient manuscripts, epilepsy is called the "royal disease", and today it is often considered as a sign of inferiority. Among adolescents, venereal disease can become a sign of early growing up and a source of pride, while mature people carefully hide it from everyone. Interestingly, "fashionable" diseases often become the subject of simulation, often copied in hysterical disorders. So, in the XIX century. hysterical reactions were dominated by seizures, fainting, and at the end of the 20th-beginning of the 21st century, headaches, heart attacks, complaints of shortness of breath, and back pain were much more common. Let us give one example of the dependence of the patient's behavior on the attitude of those close to his illness.

A 39-year-old man, laborer, suffers from alcoholism for about 10 years, was treated for this disease more than 10 times. There were long periods of abstinence, during which he found extra work to provide for the family. He is married to a woman with a higher education, whom he loves very much, but is a little afraid of. Has a 14 year old daughter. After another breakdown, he turned on an outpatient basis to the narcological office with a request to treat him. He refused hospitalization because he wanted to hide the fact of treatment from his wife. He asked to make all appointments in the form of tablets, because if the wife sees traces of injections, she will understand that he is being treated for alcoholism. He also asked in detail about the effects of drugs, whether they affect potency, because he is afraid of becoming impotent, I am sure that in this case his wife will definitely leave him.

Conditions, in which the disease occurs, and the treatment also determine the position of the patient.

Opinions around the patient, judgments, rumors, etc., they can be presented to patients by their relatives, little knowledgeable in medicine, nurses, roommates, offering “miraculous cures” or reminding the patient that it was on his bed that the patient recently died, or setting the patient against medical staff.

For example, a cold in an athlete will cause very different feelings, depending on whether it occurs during the competition or during the rest period. Admirable is the resilience of some athletes who, overcoming pain, achieve amazing results. The attitude towards treatment of a working patient and one who is in a hospital will be completely different. The very message of the need for hospitalization makes a person believe in the severity of the disease. The statement of the doctor that it is possible to be treated at home often gives hope to the patient, helps him to cope with the disease faster. Creating ideal conditions in the hospital can interfere with the patient's quick recovery, as he does not really want to part with the comfort and rest from household chores.

Features of the behavior of a doctor and nursing staff. It is difficult to overestimate the harm of inattention, answers "on the go", situations when a doctor or nurse stubbornly refuses to remember the patient's name and patronymic. The formation of a certain VKB is influenced by the microclimate of the ward, in which a “leader” will certainly form; his statements and behavior can encourage and support the patient, but they can also worsen his emotional state.

The burden of responsibility for loved ones; for their material well-being due to the incapacity of the patient and emotional experiences because of this; for excessive and intractable problems at work, exacerbated by illness. All this leads to anxiety and pessimism of the patient. Doom loved one is able to instantly transform the WKB (from an adequate assessment to an overestimated one).

Premorbid interests of the patient: excessive enthusiasm can lead either to ignoring the disease, or to "health paranoia", to narrowing of interests limited to the disease, to conflicts with the medical staff, to whom the patient dictates "his" methods of treatment.

Patient-Determined “Benefits” of the Disease- removal of responsibility for solving family issues, difficult problems at work. The disease in the eyes of colleagues often allows you to maintain prestige. Awareness of the "benefits" can lead to "hospitalism" - the desire to stay as long as possible in the hospital, as well as to "fear of recovery" - returning to the familiar environment.

Awareness of the "benefit" or disadvantage of the disease can lead to its manipulation. The patient can consciously intensify the manifestations of the disease (mainly subjective complaints), which is called aggravation; can demonstrate a non-existent illness (simulation), which is common when solving expert issues - in military medical, forensic psychiatric examinations; finally, hide an existing illness (dissimulation), which is especially common in psychiatric practice.

Although not determining VKB in the main, but introducing certain nuances into it, the factors are: gender, age, profession, temperament, upbringing and worldview of the patient.

Floor.Women tolerate pain better due to physiological characteristics. In addition, activity and mobility restrictions are less traumatic for them (they are still less preoccupied with work). However, their subjective experience of the disease is exacerbated by the restriction of communication.

Profession. The severity of subjective experiences is often determined by the type of employment: for example, diseases of the upper respiratory tract lead to severe anxiety in an opera singer; osteochondrosis - in an athlete; hypertonic disease- for people engaged in operator activities.

Temperament(In fact, it is included in personal characteristics). Note that pain and mobility restrictions are more difficult to tolerate by individuals with a choleric and melancholic temperament.

parenting factor. In certain families, either a “stoic” or “hypochondriac” attitude towards the disease is brought up. A "stoic" upbringing rejects increased attention to one's own body, and the teenager is required to continue to lead the same lifestyle as before the illness. "Hypochondriacal" education prescribes increased attention to one's body, catching the very first signs of illness, turning to others for help, which, of course, will take place in a hospital or outpatient observation.

Worldview.Deeply and sincerely believing people are calmer, with less anxiety and uncertainty about the disease. Militant atheists are more likely to look for the "culprits" of their illness and start conflicts. Among sincere believers, the following opinions about the origin of their illness are common: punishment; test sent from above; retribution for the sins of ancestors, edification to others; disease is often seen as an inevitability or a consequence of one's own mistakes.

On the other hand, among superstitious people, but not necessarily believers, judgments about the origin of the disease as a result of envy, jealousy, the "evil eye", etc., are common, which gives rise to the patient's paranoid mood.

The disease inevitably changes the patient's psyche, as life begins in other conditions. The time spent by the patient, his opportunities for self-realization, and often his mobility are changing. The disease changes the life of the patient's family, its structure, a change in the leading position (for example, a man, the former leader of the family, is forced to occupy a dependent position). When the patient's performance declines, his authority suffers. He meets less with friends, sometimes limits communication due to purely physiological reasons.

Knowledge of all these factors helps in correcting the disharmonious internal picture of the disease. Most often, various psychotherapeutic techniques are used for this. Often, indirect methods of influencing the patient's opinion are used: for example, loud praise of the patient in a conversation with one of the doctors, nurses, roommates or relatives can inspire him. A transfer from one ward to another (for example, from an intensive care unit to a regular one) also makes a strong impression on the patient. Of great importance for all patients are the position of the doctor, his self-confidence, consistency in defending his point of view, openness to discussion, accessibility, truthfulness. Finally, we should not forget that in many cases, psychotropic drugs can have a quick and reliable effect on the psychological state of the patient. medicines Psychoactive substances are especially useful for correcting the emotional component of the internal picture of the disease. So, tranquilizers allow you to quickly stop anxiety; in the case of depression, antidepressants, although relatively slow-acting, are considered more reliable than psychotherapeutic methods.

An essential issue is a clear definition of the type of ICD (relationship to the disease according to A.E. Lichko and N.Ya. Ivanov). An experienced nurse can identify it after one or more conversations (for example, touching on questions: what made you see a doctor or for what reasons did you not go to the doctor for a long time); with careful observation of the patient, paying attention to the features of speech: its harmony, pace, volume; on the liveliness of facial expressions and gestures.

However, the most reliable is the use of the LOBI method (personality questionnaire of the Bechterev Institute), as a result of which 14 types of attitudes towards the disease are revealed. Each type of such “relationship” requires an appropriate psychotherapeutic approach and communication techniques.

.5 Classification of types of attitude to the disease according to the LOBI test

Nursing Process Differences

The LOBI test contains 12 questionnaires, 10-15 questions each. Questionnaires concern well-being, mood, state of sleep and awakening from sleep; appetite and attitude to food; attitudes towards illness and attitudes towards treatment; relations with doctors and medical staff; relationships with family and friends; attitude to work (study); attitudes towards others; attitudes towards loneliness; relationship to the future. In each of the 12 questionnaires, the option “0” is provided (“none of the definitions suits me”). Individual columns (but not more than three of 12) the patient may not fill out.

Establishing a diagnostic code requires plotting and complex mathematical processing; conducting LOBI provides for the participation of a psychologist and a specialist in mathematical statistics. The LOBI is not intended to be used in the nursing process, but it is desirable that the nursing nurse be aware of its results and take them into account.

During the LOBI (both at the V.M. Bekhterev Institute, and together with it in a number of other institutes, clinics and sanatoriums), 14 types of “relationships” were identified, i.e. respectively, and 14 types of ICD (internal, "autoplastic", picture of the disease).

Harmonic type (symbol "G"). The main feature is realism, a sober assessment of one's condition; disease is neither underestimated nor exaggerated. The patient has a clear “anticipatory independence”, develops for himself models of behavior in several variants of the development of the disease; with the effectiveness or failure of treatment. Behavior patterns concern both his “business” (work) and his loved ones, for whom he sincerely cares and whom he tries to burden as little as possible, even in the event of his death.

When using LOBI, the harmonic type is diagnosed both directly and when all other types of relationships are denied. Testing in a number of hospitals and at various pathologies showed that the "harmonic type of relationship" is the most common (with the exception of patients with malignant neoplasms) and occurs in 1/4-1/7 patients.

Nursing care for patients with a harmonious type of relationship, including in terms of solving their spiritual and social problems, is the easiest. Patients are polite, correct, not intrusive, they ask only the necessary questions, they appreciate the work of the medical staff.

Ergopathic type (symbol "P").The main sign is leaving the illness to work, subordinating oneself to the work, and not to the illness. The patient considers the disease as a challenge to himself and believes that there is no such disease that could not be overcome on his own. Such patients consider diagnostic and therapeutic procedures as an annoying hindrance to their work and perform them reluctantly and with a delay.

Vivid examples of the ergopathic type of relationship are the behavior of atomic scientists in the famous film by M.M. Romm "Nine days of one year".

Patients exhibiting the ergopathic type of ICD are often people with unexpressed paranoid accentuation or deviant behavior in the form of "supervaluable pathopsychological drives". They show a firm independent character, but, nevertheless, they certainly need to carry out persistent psychotherapeutic work, which includes the nursing staff. The main thesis of the psychotherapeutic approach is that excessive preoccupation with work and neglect of medical services can sooner or later have a mutually detrimental effect; the deterioration of the patient's health, which inevitably follows the neglect of the disease, will lead to a loss of working capacity.

Nurses (paramedics) when communicating with such patients should not show importunity, command tone, etc.; All this can irritate the patient.

The ergopathic type of relationship is especially characteristic of patients with cardiovascular disorders, including those with myocardial infarction (which is especially dangerous).

Anosognosic type (symbol "3").The main symptom is the active rejection of thoughts about the disease, the rejection of the status of "sick", the denial of the obvious; patients attribute the origin of the disease to chance and consider it a trifle. Characterized by an active refusal of treatment, the invention of "their" means of therapy (herbs, dousing with water, certain doses of alcohol).

The anosognosic type of ICD is one of the rarest. Its formation may be the result of delusion (sometimes actively supported by relatives and friends). Quite often it is observed in patients with habitual drunkenness and other forms of addictive deviant behavior who do not want to deprive themselves of pleasure. Finally, sometimes the denial of the disease is one of the forms of "avoidance of unbearable reality" (collapse of health). Then it is comparable to "the behavior of an ostrich burying its head in the sand."

Psychotherapeutic work in such patients should be carried out persistently, but it is far from always effective. Delusions can be dispelled relatively easily, but it is very difficult to turn the patient to face reality or to force him to give up activities that bring pleasure.

Alarm type ("T" symbol).The patient is haunted by constant internal anxiety concerning everything related to the disease: its outcome, the effectiveness of drugs, their possible danger, the preservation of working capacity, etc. He does not build clear models of his own behavior for the future; his “anticipatory independence” is not great; he eagerly catches rumors, judgments of his roommates, relatives, eagerly observes the slightest nuances of the behavior of the medical staff - voice, gestures, the duration of the conversation - and often interprets everything wrongly (“I spoke on the go, which means I can’t do anything, which means I’m doomed ( a)"). The patient can reach out for literature relating to his disease (often unscrupulous advertising), find "new treatments" and ask for their immediate use. For such patients, it is common to see several specialists in parallel; tendency to repeat (or ask for repetition) laboratory or instrumental research. They can shift their anxiety to relatives and friends, while ignoring their condition.

In the anxious variant of ICD, anxiety extends to the objective signs of the disease, and not to subjective sensations. Deterioration of the underlying disease or poor quality care can lead to the development of depression in patients.

The anxious type of relationship most often develops on the streets with an anxious-fearful character accentuation or the corresponding type of personality disorder. It is one of the most frequent, but not entirely due to the premorbid character traits of patients. Some diseases (for example, Basedow's disease) by themselves can produce anxiety, which, when faced with the same type of accentuation, intensifies. Psychotherapeutic work in persons with an anxious type of ICD should be combined with pharmacotherapy (tranquilizers, antidepressants) or preceded by it.

Hypochondriacal type (symbol "I").In these cases, anxiety also predominates in patients, but it is directed not at the objective signs of the disease, but at their own discomfort. Patients constantly listen to their body, classify their diverse sensations, often write them down in order to tell the doctor about everything.

Patients with a hypochondriacal type of attitude towards somatic illness, as a rule, exaggerate its severity and rarely fully trust the doctor and nursing staff. They may complain about substandard treatment and care (sometimes in writing), they are very painful even to a minor side effect medicines. Allusions to their exaggeration of the severity of their own illness cause anger and a flood of complaints.

The hypochondriacal type of ICD rarely develops, in any case, much less often than the anxious one. It is common in persons with an appropriate hypochondriacal upbringing and with mixed accentuations with a combination of paranoid and anxious features.

Psychotherapeutic interventions, as in the previous case, should be combined or preceded by pharmacotherapy (antidepressants with a stimulating component of action).

Neurasthenic type (symbol "H").The main feature is "irritable weakness". Outbursts of irritation can occur for the slightest reason (the nurse passed, did not say hello, the table lamp burned out; roommates are watching football, etc.). An irritable outburst of anger is replaced by a sharp fatigue or is discharged with tears. Such outbursts with tears and repentance also occur during visits with loved ones. Patients are characterized by impatience (which is also associated with weakness of inhibitory processes in the central nervous system). They are waiting for "immediate improvement and drug effect", "immediate diagnosis". They can stop health workers several times a day with a request to report the results of tests, x-rays, etc. Patients do not tolerate sharp external stimuli: loud sounds, conversations and laughter in the ward, bright light. Unbearable pain is clearly expressed, which creates difficulties in the work of nursing staff, especially in the surgical department.

The neurotic type of relationship is one of the most frequent; it is nonspecific, occurs in any pathology. Psychotherapeutic interventions in such patients are combined with the appointment of sedatives; when leaving, the nurse must maintain maximum restraint - the timbre of the voice should be soft, the gestures should be smooth. It should be remembered that a long conversation can irritate and exhaust the patient.

The neurasthenic type of relationship develops in individuals with asthenoneurotic or emotionally unstable accentuations.

Obsessive-phobic type (symbol "O").Anxiety is also characteristic, but it is not directed at the state of the disease at the current moment and not at internal sensations, but at possible (often unlikely) complications of the disease, severe disability in the future, illness of family members. Real dangers are less exciting than imagined ones. Rituals, often absurd (walking along one side of the corridor, tapping on the bed while waiting for the nurse or doctor to arrive), as well as signs (if the doctor or nurse is not the first to approach him, then it’s not bad, etc.) serve as protection against imaginary troubles. . Thoughts about the complications of the disease become obsessive over time, the patient longs to get rid of them and seeks help. Obsessions usually cannot be overcome on their own and even with the help of psychological influence, therefore psychotherapy is also combined with pharmacotherapy (strong tranquilizers and / or antipsychotics). Caring for patients with obsessive-phobic HRC can be challenging: patients can be pushy, voicing their concerns one after the other at short intervals. The manner of communicating with such patients should also be gentle and soothing. It is especially harmful to show haste and impatience.

Obsessive-phobic HRC often develops in individuals with the same accentuation or personality disorder, i.e. it is due to the premorbid features of the patient. However, the non-uniform frequency of such a WKB at different pathology suggests that the disease itself often contributes to its appearance, not only premorbid.

Melancholic type (symbol "M").Such patients are characterized by constant dejection, they express disbelief in recovery, even in some degree of improvement. In passing (for fear of being suspected of mental illness), they express suicidal thoughts (“I wish it would all end ... is this life ... to end it all at once”, etc.). They also look pessimistically at the future of their families. Even if the objective data show positive dynamics of the disease, they remain pessimists.

Sometimes (in relatively mild cases) this type of relationship is due to negative information from the outside, sometimes the dishonest behavior of medical staff at any level plays a role. However, most often we are talking about the development of real depression, and if little attention is paid to the patient, he can realize his suicidal thoughts and intentions. Depression is more often due to the interweaving of the nature of the disease and the patient's premorbid characteristics (for example, cancer, even curable in a dysthymic personality). In these patients, pharmacotherapy (antidepressants) initially takes precedence over psychotherapy; the latter should be actively used in the subsidence of depression.

Fortunately, the development of the melancholic type of ICD is very rare.

Apathetic type (symbol "A").Manifestations are similar to type "M". Patients are apathetic, inactive, indifferent to their fate. They passively obey diagnostic procedures and treatment, sometimes they get up only with external prompting. Ordinary interests are also lost (work, "hobbies", reading, watching TV), even visiting relatives, patients show little interest.

In fact, in these cases we are talking about the development of one of the variants of depression, and pharmacotherapy (antidepressants of the stimulating type) should precede active psychotherapy. The development of this type of ICD is more likely due to the characteristics of the pathology (malignant tumors, peptic ulcer with a severe course) than to the premorbid personality traits of patients. Apathetic type of attitude towards the disease is rare.

Euphoric type (symbol "F").Patients with this type of ICD have a constantly elevated mood, they are careless about diagnostic and therapeutic procedures, they can miss time, or even ignore them altogether. They profess the principles: “what will be, will be”, “let everything go as it goes”, “whatever is done, everything is for the better” - both in routine life and in a situation of illness. Such patients often violate the regime in the evenings, when there are fewer health workers; they can become alcoholic, without thinking in the slightest that this is not beneficial to the treatment; sometimes they are discharged from hospitals for violating the regime. In dealing with them, you often have to use direct orders. Psychotherapy is best done with the participation of loved ones.

It should be specially mentioned that in some patients a cheerful mood can be feigned, hiding anxiety and even serious depression.

Dysphoric type (symbol "D").It is not distinguished in all classifications, it is indicated by V.T. Volkova (1995). This refers to patients with a constantly gloomy-embittered mood, gloomy, showing envy and hostility towards their neighbors in the ward, conflicting, distrustful of the medical staff, procedures and treatment, despotic and aggressive towards visiting their relatives, often humiliating them. Naturally, they are extremely difficult to care for and may actively resist psychotherapy. This type of attitude can be observed in individuals of an excitable or epileptoid type.

Sensitive type (symbol "C").Anxiety and concern do not extend to the disease itself and not to bodily sensations, but to the impression that the patient and information about his illness can make on others: relatives, colleagues, acquaintances. The fear concerns that the patient will be shunned, considered inferior, treated with disdain or apprehension, and unfavorable information about the cause or nature of the illness will be spread. In addition, such patients are afraid of becoming a burden to others.

As a rule, both in life and in the conditions of a medical institution, these are timid, shy, delicate people. They are prone to an "apologetic" style of behavior, are afraid to disturb the medical staff "over trifles" (even if this is not trifles) and do not present difficulties in care. They gratefully accept psychotherapeutic recommendations.

The sensitive type of ICD is not that common, but it's not that rare either. Its prevalence is approximately the same in any pathology, i.e. decisive in the formation of this type; relation to the disease are the premorbid features of the patient (astheno-neurotic, emotive types of accentuations).

Egocentric type (symbol "I").It follows from the very designation of the symbol that the main feature of such patients is the desire to put themselves at the center of the interests of the medical staff and loved ones, to capture their attention and put their suffering on display. Their complaints are various, exaggerated; are presented with a theatrical tone and gestures in order to arouse pity, to show their exclusivity and the rare nature of their illness. When making rounds, they try to translate the conversations of the medical staff to their suffering, and they see competitors in truly seriously ill patients. They are extremely selfish. If they suffer from cerebral vascular pathology, they say that the lesion is in the most unusual place; for example, an aneurysm in the very depths of the brain tissue. If they suffer from an infectious disease, they claim that it was caused by the most unusual exotic microbe or the newest virus.

The purpose of such behavior is “creating a conditional pleasantness or desirability of illness” (IP Pavlov) as a way out of a difficult situation. Naturally, patients are extremely difficult to care for, and any, even a minor manifestation of inattention is used as a pretext for conflicts or blackmail. Their petty quarrels with their roommates are common. Constant conflicts with loved ones, so the latter is difficult to use as an aid in psychotherapy. When communicating with such patients, the best are the utmost correctness, reticence, references to extreme employment.

Decisive in the formation of the egocentric type of BKB. are premorbid features - demonstrative accentuation, hysterical personality disorder. At the same time, this type of relationship is more common in one pathology than in another (for example, with bronchial asthma incomparably more often than with myocardial infarction or malignant neoplasms); those. plays the role and nature of somatic suffering.

Paranoid type (symbol "P").Patients are sure that the disease occurred as a result of someone's malicious intent ("evil eye", "damage", even poisoning by neighbors or relatives who hate them). Accordingly, when they get into a hospital or are under long-term outpatient observation, they also show a noticeable paranoid attitude: they are distrustful of each newly prescribed drug or procedure, especially asking a lot about the possible harmful consequences of the appointment. They are suspicious of staff, especially newcomers. They almost never believe in the legitimacy of the diagnosis, suspecting that another serious illness is being hidden from them. Such patients are characterized by "querulant behavior" (litigation) - they constantly write complaints about nurses and doctors, even about student interns, not forgiving the slightest slips. If their complaints are not satisfied, they apply in writing to ever higher authorities. They also clash with their neighbors in the ward.

As a rule, psychotherapeutic measures are ineffective, and they are distrustful of psychotropic drugs prescribed to mitigate aggressiveness and refuse to accept them. When dealing with them, maximum caution and correctness should be observed - do not give rise to complaints. However, with the rough unbridled behavior of such patients, in case of conflicts, one should not follow their lead, but hint at a forced transfer to another ward, under the supervision of another doctor, nurse, the need for psychiatric counseling, even for discharge. Often a confident imperative tone leads, according to at least, to a temporary normalization of the patient's behavior.

The paranoiac type of ICD is mostly due to premorbid features, but it is more common in some types of somatic pathology.

2. Empirical part

Target:presentation of theoretical material in graphical form.

According to the review of the literature on the topic "Internal picture of the disease", diagrams, graphs, tables were compiled. Yu.G. Tyulpin's schemes were also used. (2004)

2.1 Internal picture of the disease

2.2 Levels of human perception of disease

2.3 Variants of the distorted disease model

Exaggeration of the severity of the disease Underestimation of the severity of the disease Conscious distortion: simulation aggravation Involuntary distortion: hypernosognosia (hypochondria, anxiety, depression, fear of publicity, search for the guilty, manipulation, irritation) nosophilia (addiction to treatment) Conscious distortion: dissimulation Involuntary distortion: hyponosognosia (indifference, employment with work or family) anosognosia (denial, euphoria)

2.4 Dependence of the internal picture of the disease on the type of personality accentuation

Type of accentuation Typical variants of the attitude towards the disease Introverted Stuck Excitable Pedantic (anxious and suspicious) Demonstrative Hyperthymic Hypothymic Indifference, hypochondria Guilty search, nosophilia, manipulation, fear of publicity Irritability, manipulation. Hypochondria, anxiety, fear of publicity, demonstration of employment Manipulation, irritation Denial, demonstration of employment, depression Depression, anxiety

2.5 Factors affecting WKB

2.6 Stages of the course of the disease

.7 Types of CHD, their origin and prevalence

Name Association with accentuations or anomalies Association with a form of deviant behavior Specificity for a particular pathology Premorbid condition Frequency Harmonic -- Not YesMost commonErgopathic - Overvalued pathocharacterological hobbies Yes YesVery commonAnosognostic - Often addictive behavior No YesRare Anxious Anxiety-fearful accentuation or personality disorder Yes YesQuite oftenHypochondriacal, too -Yes YesRare Neurasthenic Astheno-neurotic or emotionally unstable No YesVery common Obsessive-phobic The same type of accentuation, anomalies -Yes YesAlso Melancholy Dysthymic. DepressionAutoaggressive Yes YesVery rareApatheticDepression YesNoTooEuphoricHyperthymicAddictive Behavior Yes YesVery common Dysphoric Epileptoid, excitable Aggressive No YesVery rare Sensitive Emotive, astheno-neurotic - Not YesRareEgocentric Demonstrative, hysterical -Yes YesToo Paranoid Paranoid, paranoid. Aggressive Yes Yes Rare

Conclusion

Knowledge of medical psychology for registered nurses cannot be overestimated. Understanding that each patient reacts differently to their own disease will allow the future health worker to provide differentiated care for the patient. The study of the internal picture of the disease allows you to largely consider the entire difficult process self-knowledge of a sick person, to identify the means that a person uses to carry out this cognitive process. At the same time, the study of the internal picture of the disease opens up the possibility of understanding special ways, methods of overcoming, mastering one's own behavior, used by a person in a difficult life situation. Thus, the analysis of the internal picture of the disease opens up the possibility of penetrating into the compensatory potential of the individual. Naturally, a different approach is needed in the communication of a nurse with a patient, but there is also general rules behavior of healthcare workers in caring for patients. That is why the study of this topic is necessary for future graduate medical workers in the pedagogical field and managerial activities to inform mid-level nurses.

Bibliography

1.Abramova T.S., Yudchits Yu.A. Psychology in medicine: Proc. allowance. - M.: LPA "Department-M", 1998.

2.Kabanov M.M., Lichko A.E., Smirnov V.M. Methods of psychological diagnostics and correction in the clinic. - L .: Medicine, 1983.

.Tyulpin Yu.G., Medical psychology: Educational literature for students of medical universities. - Moscow "Medicine" 2004

.Sprints A.M., Mikhailova N.F., Shatova E.P. - Medical psychology: Textbook for secondary medical schools. - St. Petersburg "SpetsLit" 2005

.Luria R.A. Internal picture of the disease and iatrogenic diseases: 2nd ed. - M., 1977.

.Lichko A.E. Internal picture of the disease. - Chisinau, 1980.

.Tyshlykov V.A. Psychology of the healing process. - L., 1984.

.Volkov V.G. Patient personality and disease. - Tomsk, 1995.

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5.6. The internal picture of the disease as a psychological problem.
The term “internal picture of the disease” (IKB) was proposed by R. A. Luria and defined by him as “everything that the patient experiences and experiences, the whole mass of his sensations, not only local painful ones, but his general well-being, self-observation, his idea of about his illness, about its causes - everything that is connected for the patient with his coming to the doctor, all that huge inner world of the patient, which consists of very complex combinations of perception and sensations, emotions, affects, conflicts, mental experiences and traumas.
There are two approaches to the internal picture of the disease: medical and psychological.
Within the framework of the psychological approach, VKB is considered from the point of view of general psychological knowledge, from the point of view of the sick place occupied in the mental and social life. That is, the attitude, the nature of experiences is associated not with a specific diagnosis, but with the personality of the patient, with his individually typical, age-related characteristics.
A disease is not something external, abstract for a person: it is not a disease in general, but his “personal”, concrete disease, manifesting itself through certain symptoms, having its own dynamics, etc. There is always a “reference of ideas ... to oneself, refraction through emotional and motivational sphere” (Sultanova, 2000). Therefore, it is appropriate to correlate the VKB and the image of the Self: on the one hand, the image of the Self affects the formation of the VKB, and on the other hand, taking into account the characteristics of the VKB, further construction of the image of the Self takes place. illness.
VKB is a universal human response to a situation of a functional disorder in the body. The content of the VKB is the whole complex of experiences, sensations, forecasts associated with the disease and its treatment.
The main function is to adapt the personality to changed internal and external conditions (although the disease is an internal event for the body, it also leads to external consequences). The patient's ideas about his condition are influenced by many factors: biological, psychological, social. Their role is different and changeable. Sources of influence form a mobile system, which, when the contribution of one part changes, tends to rearrange itself in such a way as to ensure the best adaptation to the new situation.
VKB is a psychic formation that obeys the laws of development and personality formation. In the process of its formation, the VKB is included in the image of the Self (or initially formed as part of this image), after which the formation proceeds through the interaction and mutual influence of these two structures.
The most important characteristics of the VKB:
1. universality (occurs with any disease);
2. the ability to trace the formation of all this neoplasm in an adult;
3. VKB is a product of the patient's own activity. Knowing oneself as a patient.
4. Secondary, psychological in nature phenomenon. A psychological neoplasm that has a complex structure and equally complex hierarchically organized mechanisms of functioning;
5. Dynamic education, that is, changing its content depending on many factors: gender, age, severity and duration of the disease, the degree of its vital threat, the severity and duration of the treatment situation;
6. The VKB itself, having taken shape, becomes the most important condition for the further existence and functioning of a person;
7. VKB in some cases begins to determine the success of treatment and recovery;
8. At the initial stages of the formation of the VKB, it can be used as a method, a means of diagnosing the patient's personality.
9. VKB is available for "correction" in the process of psychotherapy.
WKB structure:
I. Sensory component (the totality of all sensations, complaints):
Actually bodily sensations
Emotional tone of sensations
II. Rational, intellectual component:
Information about the disease
own experience of illness
expected results of treatment
III. Emotional.
One of the factors influencing the formation of ICD and psychosomatic development in general is age.
In the formation of VKB, individual-typical properties play a major role in maturity, while in childhood, age-related features are more important. As the personality develops, the ratio of the structural components of the WKB is also rebuilt: the sensual aspect becomes less significant against the background of the growing influence of other aspects (motivational, intellectual). The attitude to the disease is formed through the correlation of sensations with the system of values, the patient's ideas about himself. It should not be forgotten that the further construction of the image of the Self (and the development of the personality as a whole) takes into account the characteristics of the VKB.
The contribution of the family is especially clearly seen in the material of children who underwent early surgery to eliminate heart disease. Their entire internal picture of the disease is formed under the influence of the attitude of adults (there are no sensations as such). When raising a child as “sick”, with limiting his activity, overprotection and excessive concern for well-being, an objectively healthy child becomes a subjectively sick person. He assimilates, internalizes the ideas of others about his condition and builds his behavior in accordance with them. Peculiarities of parental upbringing to a large extent determine the nature of HKB in the early stages of personality development.
At a more mature age, the family and the immediate environment retain significant influence. For example, leaving a job or getting divorced can seriously change the patient's attitude towards their illness.
Features of VKB at different ages:
Younger age (6-10/11 years old) Adolescence
There is no consciousness of illness. Depression does not occur.
The child cannot rely on the data of introspection, reflection, he does not have the mental means for this. There is no standard idea of ​​health/illness. There is an activity of self-knowledge, it relies on a system of external restrictions that the disease creates.
The disease appears for the child as a system of restrictions, one of the main ones is the frustration of physical activity. Another limitation is the frustration of the cognitive need (especially in the case of stationing). The treatment situation also represents the disease.
The main role belongs to the closest adults. The analysis of the bodily states of the child is carried out by the mother, and she means them, gives a dictionary of description. Primary and secondary signification is carried out by the nearest adult. It depends on the quality of the VKB. This vocabulary may contain iatrogenic characteristics.
There are no special coping strategies for the child. Depressive states of a somatogenic nature, hypochondria. A sufficient level of mental development for the awareness of the disease and the means for cognitive mediation of bodily sensations.
Analysis of one's own bodily well-being. Complaints become similar to the complaints of an adult.
A purely situational context imposes restrictions on which the adolescent is guided. The leading limitation is the frustration of the need for communication. Isolation acts as a factor that increases depression and leads to secondary autism.
The nearest adult is the bearer of meanings.
Various psychological coping strategies:
1. the development of certain behavioral stereotypes that allow you to hide the defect from others;
2. withdrawal into fantasies that deny the disease;
3. family self-isolation (family artificial symbiosis);
4. over-actualization of the future: the disease is temporary, in principle surmountable. Realistic plans for the future, taking into account the disease factor.

Another possible answer:
Dynamics of ICD during treatment.
VKB is a dynamic formation. The dynamics of the WKB is associated with its restructuring, a change in the hierarchy of its levels, and a change in the leading level of the WKB. A good model for studying the dynamics of ICD is the situation of treating patients with chronic renal failure with hemodialysis. Features of hemodialysis: a person gets in a serious condition; this is the only thing that can prolong life; a long stay in the hospital is required. The treatment process can be represented as consisting of 3 stages: the stage of preparation for treatment, the stage of initiation of treatment, the stage of chronic treatment.

Stage Levels of WKB Content characteristics of the levels
Stage of initiation of treatment sensual Complaints, retrospective reassessment of one's health
emotional Tension to start treatment, fear; feeling guilty about asking for help late; illness is perceived as an obstacle to life goals
intellectual Just beginning to form; negative assessment of hemodialysis
motivational Negative coloring of the whole situation in the hospital; trying to delay treatment
Treatment initiation stage Patients were delivered in a serious condition, hemodialysis was quickly undertaken (they have a developed emotional level) sensual Improvement in general well-being, a decrease in the number of complaints
emotional Good mood (sometimes to euphoria)
intelligent Hope for recovery, favorable assessment of hemodialysis
motivational Actualization of former life goals; inadequately overestimated self-assessment of the results of hemodialysis; believe that they will soon return to the old way of life
Patients have been preparing for treatment for a long time (they have a well-formed intellectual level) sensual Decrease in the number of complaints; subjective picture corresponds to the objective
emotional Decreased fear of hemodialysis; improves mood without euphoria
Intelligent Neutral Hemodialysis Rating
motivational Allocate a doctor to whom they listen; premorbid interests return
Stage of chronic treatment General dissatisfaction (this stage is longer in those patients who were delivered in serious condition) sensual Complaints correspond to objective data
emotional Irritability, conflict, negative assessment of the future
intellectual They look for evidence of dishonesty of the staff, ask questions about their condition
motivational
Sensory adaptation Complaints correspond to objective data
emotional
intelligent Actively collect information about their condition; trying to control themselves
motivational Expanding the scope of interests; The importance of kidney transplantation
Fragmentary ICD (its formation depends on the premorbid: a narrow circle of interests, limited contacts, the main meaning of the work) sensual No complaints
emotional The prospect of the future is estimated inconsistently
intellectual Monitor their condition
motivational Violation of the motivational component of thinking
At different stages it is possible to carry out psycho-correctional work. At the stage of preparation for treatment, it is necessary to form a therapeutic environment (do not place in the same ward with unsuccessful kidney transplants). At the initial stage, prevent the formation of an overly optimistic assessment of the results of treatment; adequate knowledge of the disease and its consequences is necessary (i.e., to form the intellectual level of VKB). At the stage of chronic treatment, it is important to reduce the period of general discontent, to develop the motivational sphere: to expand the range of interests and communication.
Kvasenko, Zubarev
Formation of somatognosia:
1. Sensological stage: the patient's reactions to discomfort (general, local), pain and a sense of insufficiency (following a violation of biosocial adaptation, deficiency).
2. Evaluative stage, which is the result of intrapsychic processing of sensory data.
3. Attitude towards the disease: it is formed even before the onset of the disease as such, the disease acquires significance. Attitude to painful manifestations, to the fact of the presence of the disease, to what awaits, to what could help. The stage of attitude including experiences, statements and actions, the general pattern of behavior, criticality, the degree of awareness are important.
The development of somatognosia in the process of development of a somatic disease:
 Initial stage: negative emotional reactions, threat assessment, stress. The predominance of the feelings of the component; mental adaptation does not reach its formalization and stability, psycho-stress manifestations (anxiety, fear) are characteristic.
 The stage of the height of the disease: anxiety, confusion > calm, expectation, adaptation to a new life. In the subacute type, anxiety and fear may occur, maladaptation against the background of relapse. Psychological adaptation of an incomplete and unstable type. Chronic type of course: not only the stage is important, but also the situation. hospitalism. A certain emotional state in the hospital, an increase in the instability of adaptation, distortion is possible.
 Recovery: not always biological at the same time as psychol., especially in case of protracted illnesses. Inevitable dying: mobilization of the psychological reserves of the dying, to live with dignity.
Patient management:
1. Diagnostic stage: subjectivity of complaints, negative emotional background, anxiety in a situation of uncertainty, a new life situation. That. there is a formation of sensological and evaluative stages. The attitude is still ambiguous, only being formed - various options.
2. Stress is replaced by psychological adaptation, there are hopes, the development of compensation. Treatment is very important. Options. At the end of the treatment process, protective and adaptive mechanisms are clearly manifested (here and psychotherapy).
3. Rehabilitation: the creation of substitute functions for an existing defect, compensatory techniques, overcoming negative reactions. Psychologically, it begins with the first contact with a doctor. attitude towards rehabilitation.
stress > adaptation > one or another degree of psycho-rehabilitation.

Location: educational audience.

Duration: 2 hours

Target: To study the typology of attitude to the disease. Disassemble the levels of WKB.

The student must know:

1. Levels of the internal picture of the disease.
2. The scale of the experience of the disease.
3. Types of reaction to the disease.
4. Types of attitude to the disease (Lichko E.A., Ivanov N.Ya.)
5. Psychosocial responses to illness.

The student must be able to:

1. During a conversation with a patient in practical classes, determine the type of attitude he has towards the disease.
2. To identify the type of patient's attitude to the disease using the TOBOL technique.

Topics of projects, abstracts:

Main literature:

1. Sidorov P.I., Parnyakov A.V. Clinical psychology: textbook. - 3rd ed., revised. and additional - M.: GEOTAR-Media, 2008. - 880 p.: illustration.
2. Clinical Psychology: Textbook / Ed. B.D. Karvasarsky. - St. Petersburg: Peter, 2002.
3. Mendelevich V.D. Clinical and medical psychology. - M.: MED-press, 1998.
4. Abramova G.S. Yudchits Yu.A. Psychology in medicine. - M.: Department-M, 1998.

Additional literature:

1. Anastasi A. Psychological testing: Per. from English. - M., 1982.
2. Shapar V.B. Workbook practical psychologist/ Victor Shapar, Alexander Timchenko, Valery Shvydchenko. - M.: AST., Kharkov: Torsing, 2005.
3. Sidorov P.I., Parnyakov A.V. Clinical psychology: textbook. - 3rd ed., revised. and additional - M.: GEOTAR-Media, 2008. - 880 p.: ill.

Initial knowledge level control:

1. What is the definition of "health"?
2. What effect does the somatic state have on the human psyche?
3. What types of patient response to the disease do you know?
4. How do long-term or chronic diseases affect the patient's mental state?
5. Do you think the age of the patient affects his attitude to the disease?

The main questions of the topic:

1. Internal picture of the disease
2. The impact of illness on the human psyche.
3. Types of reaction to the disease (Yakuboa B.A., Lichko A.E.)
4. The ambivalence of the patient's attitude towards the disease.
5. Experience of illness in time.
6. Age features of the internal picture of the disease.

Final control of the level of knowledge:

1. What are the types of pathogenic influence on the human psyche of a somatic disease? What is the difference between the concepts of "somatogeny" and "psychogeny"?
2. How does the degree of awareness of the patient of his illness change with some focal lesions of the brain?
3. How are the types of personal reaction to the disease classified? What is the concept of "ambivalence of attitude to the disease" of the patient?
4. What phases in the experiences and attitude of a person to his illness can be distinguished in dynamics in chronic diseases?
5. What are the features of the internal picture of the disease in children and in old age?

Internal picture of the disease

The influence of the somatic state on the human psyche can be both pathogenic and sanogenic (healing). As for the latter aspect, doctors are well aware of how every day, when recovering from a severe somatic illness, the mental state of the patient improves (sanation): mood improves, cheerfulness and optimism appear. It is probably no coincidence that the well-known expression is widely spread: "A healthy mind in a healthy body." Physically healthy people are always easier to endure life's troubles than the sick. Apparently, in some cases it is even possible to talk about the “internal picture of health” and its influence on the mental sphere of a person (Nikolaeva V.V., 1987).

The positive definition of health given by the WHO is widely accepted: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO Charter, 1946). Thus, health consists of three components: physical, mental and social. And at present, health is interpreted as the ability to adapt, the ability to resist and adapt, the ability to self-preservation and self-development, to an increasingly meaningful life in an increasingly diverse environment (Lishuk V.A., 1994). Thanks to the positive definition of health in medicine, along with the pathocentric approach (the fight against diseases), the sanocentric approach (focus on health and its provision) is also being established.

It is believed that to determine the degree physical health of a person is quite simple - a healthy person is satisfied with the functioning of his body. This degree of health is reliably established by medicine, using appropriate examination methods, laboratory research. It is more difficult to assess the mental state of a person, to find criteria for the mental and social well-being of a person. In particular, one of the central concepts in health psychology is the concept of the norm of mental development, which allows us to talk about the correspondence of the biological and psychological ages of a person. It seems that a psychologist and a doctor who work with indicators of human health should proceed from the fact that any person at the level of everyday psychology has his own ideas about the normality of a person in any particular period of his life. In this sense, a person's everyday idea of ​​age, of the possibilities of age - feeling, action, self-relationship - is the specific material that determines the content of the inner picture of health.

How a person relates to his health, i.e. without understanding his inner picture of health, it is impossible to understand the inner picture of disease, which is supposed to be only a special case of the former. The experience of a sense of health is connected not only with the absence of illness and disability, but also with the presence of a full-fledged physical, mental and moral state, which allows you to optimally, without any restrictions, carry out social and, above all, labor activities. The internal picture of health is an integral part of self-consciousness, an idea of ​​one's physical condition, accompanied by a peculiar emotional, sensual background.

When assessing the psychology of health, it is important to distinguish between the concepts of "state of health" and "well-being". Health status- the true state of affairs in the body according to the data medical examination. well-being subjectively and not always accurately reflects the objective state of health. Incompleteness and distortions of the internal picture of the disease are possible in young children, and also due to the peculiarity of the personality structure - the instability of self-esteem, the "I-image" in general and the physical "I", the dependence of one's own self-esteem on the assessments of other people.

1st group- perfectly healthy, no complaints;

2nd group- mild functional disorders, episodic complaints of an astheno-neurotic nature associated with specific psycho-traumatic events, tension of adaptive mechanisms under the influence of negative micro-social factors;

3rd group- persons with preclinical conditions and clinical forms in the stage of compensation, persistent astheno-neurotic complaints outside the scope difficult situations, overstrain of adaptation mechanisms (in the anamnesis of such persons, troublesome pregnancy, childbirth, diathesis, head injuries and chronic infections);

4th group - clinical forms diseases in the stage of subcompensation, insufficiency or breakdown of adaptive mechanisms.

Mental Health Criteria based on the concepts of "adaptation", "socialization" and "individualization".

concept "adaptation" includes the ability of a person to consciously relate to the functions of his body (digestion, excretion, etc.), as well as his ability to regulate his mental processes (control his thoughts, feelings, desires). There are limits to individual adaptation, but an adapted person can live in geo-social conditions familiar to him.

Socialization is determined by three criteria related to human health.

• The first criterion is related to the ability of a person to respond to another person as an equal to himself (“the other is as alive as I am”).
• The second criterion is defined as a reaction to the fact of the existence of certain norms in relations with others and as the desire to follow them.
• The third criterion is how a person experiences his relative dependence on other people.

There is a necessary measure of loneliness for every person, and if a person crosses this measure, then he feels bad. The measure of loneliness is a kind of correlation of the need for independence, solitude from others and one's place among one's environment.

individualization, according to K.G. Jung, allows you to describe the formation of a person's relationship to himself. A person himself creates his own qualities in his mental life, he is aware of his own uniqueness as a value and does not allow other people to destroy it. The ability to recognize and maintain individuality in oneself and others is one of the most important parameters of mental health.

Every person has the possibilities of adaptation, socialization and individualization, the degree of their implementation depends on the social situation of his development, the ideals of a normative person of a given society at a given particular moment. However, one can also note the insufficiency of these criteria for complete description internal picture of health. In particular, it is also connected with the fact that any person potentially has the opportunity to look at his life from the outside and evaluate it (reflection).

An essential feature of reflexive experiences is that they arise against the will and individual efforts. They are the prerequisites for the spiritual life of man, in which, unlike mental life, the result is the experience of life as a value. The spiritual health of a person, as emphasized by many psychologists (Maslow A., Rogers K. and others), is manifested primarily in the connection of a person with the whole world. This can manifest itself in various ways - in religiosity, in feelings of beauty and harmony, admiration for life itself, joy from life. Experiences in which communication with other people is carried out, compliance with a specific ideal of a person, constitute the content of the inner picture of health as a transcendental holistic view of life.

The impact of the disease on the human psyche

The most important for the practice of a doctor is pathogenic influence somatic state on the psyche, which means nothing more than a violation of the mental activity of a person in conditions of somatic illness.

To date, it is fairly established that there are two main types of pathogenic effect of somatic disease on the human psyche: somatogenic and psychogenic. In reality, both types of influences are presented in the unity of mental disorders, however, the somatogenic and psychogenic components can act in different proportions depending on the disease.

Somatogenic influence of the disease on the psyche. It is associated with a direct effect on the central nervous system of somatic hazards (hemodynamic disturbance or intoxication) and the intense pain sensations themselves. Somatogenic influences on the psyche play a particularly large role in birth defects heart and kidney disease. Excruciating pain occurs with metastases of malignant tumors in the spine. Intense pain, harmful substances accumulating in the blood or oxygen deficiency, directly affecting the brain, cause disorders in the nervous system. mental sphere. Whole

a complex of disorders in the neuropsychic sphere is often referred to as the term "somatogeny". According to their structure, somatogenies are characterized by a polymorphism of manifestations - from neurosis-like disorders to psychotic (with delusions, hallucinations) disorders.

Psychogenic influence of the disease on the psyche. It should be recognized that intoxication effects on the central nervous system are observed only in some somatic diseases, their severe course and are not clinically specific for internal diseases. The main form of influence of a somatic disease on the human psyche is psychological reaction personality on the very fact of the disease and its consequences, asthenia, painful sensations and disturbances of general well-being present in the disease.

The subjective-psychological side of any disease is most often denoted by the concept "internal (or autoplastic) picture of the disease". The latter is characterized by the formation in the patient of a certain kind of feelings, ideas and knowledge about his disease.

In domestic literature, the problem of a holistic consideration of personality and illness was raised in the works of such internists as M.Ya. Mudrov, SP. Botkin, G.A. Zakharyin, N.I. Pirogov and others. Subsequently, this clinical and personal approach developed on the basis of the provisions of nervism (Sechenov I.M., Pavlov I.P.) and cortico-visceral theory (Bykov K.M., Kurtsin I.T.).

The somatopsychic direction as such, which focuses on the issue of the influence of a somatic disease on a person, was incorporated in domestic medicine in the works of psychiatrists S.S. Kor-sakova, P.B. Gannushkina, V.A. Gilyarovsky, E.K. Krasnushkina, V.M. Bekhterev.

The disease as a pathological process in the body is involved in the construction of the internal picture of the disease in two ways:

1. Bodily sensations of a local and general nature lead to the emergence of a sensory level of reflection of the picture of the disease. Degree of participation biological factor in the development of the internal picture of the disease is determined by the severity of clinical manifestations, asthenia and pain.
2. The disease creates a difficult life-psychological situation for the patient. This situation includes many different moments: procedures and medication, communication with doctors, restructuring of relationships with relatives and work colleagues.

These and some other moments leave an imprint on one's own assessment of the disease and form the final attitude towards one's disease.

In the mechanisms of the relationship between the psyche and the soma, the so-called mechanisms "I'll close that circle." Disturbances that initially arise in the somatic (as well as in the mental) sphere cause reactions in the psyche (soma), and the latter are the cause of further somatic (mental) disorders. So in a "vicious circle" a holistic picture of the disease unfolds. The role of the "vicious circle" in the pathogenesis of psychosomatic diseases and masked depression is especially great.

In the scientific literature, to describe the subjective side of the disease, a large number of terms that have been introduced by various authors but are often used in very similar ways.

Autoplastic picture of the disease(Goldsheider A., ​​1929) - is created by the patient himself on the basis of the totality of his sensations, ideas and experiences associated with his physical condition (“sensitive” level of the disease is based on sensations, and the “intellectual” level of the disease is the result of the patient’s thoughts about your physical condition).

Internal picture of the disease- in the understanding of the famous therapist Luria R.A. (1944-1977) does not correspond to the usual understanding of the patient's subjective complaints; its structure in relation to both the sensitive and the intellectual part of the autoplastic picture of the disease, according to Goldstein, is very dependent on the personality of the patient, his general cultural level, social environment and upbringing.

Experiencing Illness(Shevalev E.A., Kovalev V.V., 1972) - a general sensual and emotional tone, on which sensations, ideas, psychogenic reactions and other mental formations associated with the disease manifest themselves. "Experiencing the disease" is closely related to the concept of "consciousness of the disease", although not identical to it.

Attitude towards illness(Rokhlin L.L., 1957, Skvortsov K.A., 1958) - follows from the concept "disease consciousness" which forms the appropriate response to the disease. The attitude towards the disease is made up of the patient's perception of his illness, its assessment, the experiences associated with it, and the intentions and actions arising from such an attitude.

Internal picture of the disease

The deepening of knowledge about the psychological side of diseases in the domestic theory and practice of medicine has led to the emergence by now of many different conceptual schemes that reveal the structure of the inner world of a sick person. The variety of terms that describe the subjective side of the disease is also characteristic of foreign researchers. However, in most modern psychological studies of the internal picture of the disease in various nosological forms of diseases, several interrelated aspects (levels) are distinguished in its structure:

1. pain side of the disease(level of sensations, sensory level) - localization of pain and other unpleasant sensations, their intensity, etc.;
2. emotional side of illness connected with various types emotional response to individual symptoms, the disease as a whole and its consequences;
3. the intellectual side of the disease(rational-informational level) is associated with the patient's ideas and knowledge about his disease, reflections on its causes and consequences;
4. volitional side of the disease(motivational level) is associated with the patient's definitive attitude to his disease, the need to change behavior and habitual lifestyle, and the actualization of activities to return and maintain health.

Based on these aspects, a model of the disease is created in the patient, i.e. understanding of its etiopathogenesis, clinic, treatment and prognosis, which determines "scale of experience" and behavior in general.

There is often no equal sign between the true state of affairs with health and the “disease model” of the patient. The significance of the disease in the perception of the patient can be either exaggerated or diminished.

With an adequate type of response (normonosognosia) patients correctly assess their condition and prospects, their assessment coincides with the assessment of the doctor.

At hypernosognosia patients tend to overestimate the significance of individual symptoms and the disease as a whole, and when hyponosognosia tend to underestimate them.

At dysnosognosia patients have a distortion of perception and denial of the presence of the disease and its symptoms for the purpose of dissimulation or because of fear of its consequences. Anisognosia- complete denial of the disease as such, typical for patients with alcoholism and cancer.

The internal picture of the disease, characterizing a holistic attitude to the disease, is closely related with the patient's awareness of his illness. The degree of awareness of one's disease largely depends on the education and general cultural level of the patient, although a complete correspondence is often not observed here (as, for example, with anisognosia). Even with mental illness, the patient cannot but give natural, psychologically understandable and characteristic of his personality reactions to his illness. Moreover, some patients sometimes have a vague and indistinct awareness of their illness, but it also happens that a clear awareness of the illness can be combined with an indifferent, stupid attitude towards it.

The degree of awareness of their illness by the patient may be disturbed by some focal lesions of the brain. For example, lesions of the posterior sections of the left hemisphere are more often accompanied by an adequate internal picture of the disease, while with lesions of the posterior sections of the right hemisphere, there was a combination of an adequate cognitive level of awareness of the internal picture of the disease with an inadequate emotional representation of patients about their prospects, a discrepancy between plans for future and real opportunities. Inadequate internal picture of the disease (incomplete understanding of one’s condition) in combination with its insufficient emotional experience is typical for people with damage to the left frontal region, and damage to the right frontal lobe of the brain is also accompanied by a discrepancy between the cognitive and emotional plans of the internal picture of diseases -ni (Vinogradova T.V., 1979).

The doctor's task is to correct the model of the disease, to correct the "scale of experiences." However, when correcting the internal picture of the disease, many factors should be taken into account. For example, if for the successful treatment of alcoholism anisognosia needs to be eliminated, then whether it is necessary to eliminate it in oncological diseases, there is no unequivocal answer.

Types of response to illness

There are three main types of the patient's reaction to his disease: sthenic, asthenic and rational.

With an active life position of the patient for treatment and examination, they talk about sthenic reaction to illness. There are, however, also negative side this type of behavior, since the patient may be weakly capable of fulfilling the necessary restrictions on the stereotype of life imposed by the disease.

At asthenic reaction to the disease, patients have a tendency to pessimism and suspiciousness, but they are relatively easier than patients with sthenic reaction, psychologically adapt to the disease.

At rational type of reaction there is a real assessment of the situation and a rational avoidance of frustration.

A number of authors (Reinvald N.I., 1969; Stepanov A.D., 1975; Lezhepekova L.N., Yakubov P.Ya., 1977) describe the types of attitudes towards the disease, bearing in mind the nature of the interaction that develops between the doctor and the patient.

Types of personal response to a disease (Yakubov B.A., 1982)

Friendly response. This reaction is typical for people with a developed intellect. It is as if from the very first days of the disease they become the "assistant" of the doctor, demonstrating not only obedience, but also rare punctuality, attention, goodwill. They have unlimited trust in their doctor and are grateful for his help.

Calm reaction. Such a reaction is typical for persons with stable emotional-volitional processes. They are punctual, adequately respond to all the doctor's instructions, accurately perform medical and recreational activities. They are not just calm, but even seem “solid” and “powerful”, easily come into contact with medical staff. They may sometimes not be aware of their illness, which prevents the doctor from identifying the influence of the psyche on the disease.

unconscious reaction. Such a reaction, having a pathological basis, in some cases plays the role of psychological protection, and this form of protection should not always be eliminated, especially in severe diseases with an unfavorable outcome.

follow-up reaction. Despite the fact that the disease ends safely, patients are in the grip of painful doubts, in anticipation of a relapse of the disease. After the illness, they are asthenic, depressed, even depressive, prone to hypochondriacal reactions, continue to visit a medical institution and consider that they have become chronic, incurable patients.

Negative reaction. Patients are in the grip of prejudice, tendentiousness. They are suspicious, distrustful, hardly come into contact with the attending physician, do not attach serious importance to his instructions and advice. They often have conflict with medical personnel. Despite their mental health, they sometimes demonstrate the so-called "double orientation."

panic reaction. Patients are in the grip of fear, easily suggestible, often inconsistent, treated simultaneously in different medical institutions as if checking one doctor with another doctor. Often treated by healers. Their actions are inadequate, erroneous, affective instability is characteristic.

destructive reaction. Patients behave inappropriately, carelessly, ignoring all the instructions of the attending physician. Such persons do not want to change their usual way of life, professional workload. This is accompanied by a refusal to take medications, from inpatient treatment. The consequences of such a reaction are often not-good-for-yat-us-mi.

In the typology of response to the disease, N.D. Lakosina and G.K. Ushakov (1976), as a criterion taken as the basis for classifying types, distinguishes a system of needs that are frustrated by the disease: vital, social-professional, ethical, aesthetic or associated with intimate life. Other authors believe that the response to the disease is largely determined by the prognosis of the disease.

In any case, in order to overcome the changed state of health and various manifestations disease, a person develops a complex of adaptive (adaptive) techniques. E.A. Shevalev (1936) and O.V. Kerbikov (1971) define them as adaptation reactions, which can be either compensatory (artificial limitation of contacts, subconscious masking of symptoms, conscious change in the daily routine, nature of work, etc.) or pseudo-compensatory character (denial and ignoring disease).

In other words, a sick person, on the basis of his concept of illness, in a certain way changes his habitual way of life, his work activity, and in this regard, a variety of somatic diseases can create the same life circumstances for a person.

R. Barker (Barker R., 1946) distinguishes 5 types of attitude towards the disease: avoidance of discomfort with autism (typical for patients with low intelligence); substitution with finding new means to achieve life goals (persons with high intelligence); ignoring behavior with the displacement of the recognition of a defect (in persons with an average intellect, but a high educational level); compensatory behavior (tendencies to aggressively transfer inadequate experiences to others, etc.), neurotic reactions.

Pathological forms of response to the disease (experiencing the disease) are described by researchers in psychiatric terms and concepts: depressive, phobic, hysterical, hypochondriacal, euphoric-anisognosic and other options (She-valev E.A., 1936; Rokhlin L.L. , 1971; Kovalev V.V., 1972; Kvasenko A.V., Zubarev Yu.G., 1980 and others). In this aspect, the classification of types of attitude to the disease, proposed by A.E. LichkoiNL. Ivanov (1980). Types of attitude to the disease of this classification can also be identified with the help of a special psychological technique (questionnaire) proposed by the authors.

Type of attitude towards the disease (Lichko A.E.)

1. Harmonious (G)(realistic, balanced). Evaluation of one's condition without a tendency to exaggerate its severity, but also without underestimating the severity of the disease. The desire to actively contribute to the success of treatment in everything. The desire to ease the hardships of caring for loved ones. In the case of understanding the unfavorable prognosis of the disease - switching interests to those areas of life that will remain available to the patient, focusing on one's affairs, caring for loved ones.

2. Ergopathic (P)(sthenic). "Escape from illness to work." A super-responsible, sometimes obsessive, sthenic attitude to work is characteristic, which in some cases is even more pronounced than before the illness. Selective attitude to examination and treatment, primarily due to the desire, despite the severity of the disease, to continue working. The desire at all costs to maintain professional status and the possibility of continuing an active labor activity in the same quality.

3. Anosognosic (Z)(euphoric). More active rejection of thoughts about the disease, about its possible consequences, up to the denial of the obvious. When recognizing the disease - discarding thoughts about its possible consequences. Distinct tendencies to consider the symptoms of the disease as manifestations of "non-serious" diseases or random fluctuations in well-being. In this regard, the refusal of medical examination and treatment, the desire to “figure it out yourself” and “do it yourself”, the hope that “everything will work itself out” are often characteristic. With the euphoric variant of this type - an unreasonably elevated mood, a dismissive, frivolous attitude towards the disease and treatment. The desire to continue to receive from life everything that was before, despite the illness. The ease of violations of the regimen and medical recommendations that adversely affect the course of the disease.

4. Alarm (T)(anxious-depressive and obsessive-phobic). Continuous anxiety and suspiciousness regarding the unfavorable course of the disease, possible complications of ineffectiveness and even the dangers of treatment. The search for new treatments, the thirst for more information about the disease and methods of treatment, the search for "authorities", the frequent change of the attending physician. In contrast to the hypochondriacal type of attitude towards the disease, interest in objective data (test results, expert opinions) is more pronounced than in subjective feelings. Therefore, there is a preference to listen about the manifestations of the disease in others, and not to present your complaints endlessly. The mood is anxious. As a result of anxiety - depression of mood and mental activity.

In the obsessive-phobic variant of this type - anxious suspiciousness, which, first of all, concerns fears that are not real, but unlikely complications of the disease, treatment failures, as well as possible (but unfounded) failures in life; work, relationships with loved ones in connection with the disease. Imaginary dangers excite more than real ones. Signs and rituals become protection from anxiety.

5. Hypochondriacal (I). Excessive focus on subjective painful and other unpleasant sensations. The desire to constantly tell doctors, medical staff and others about them. Exaggeration of real and seeking out non-existent diseases and suffering. Exaggeration of discomfort due to side effects of drugs and diagnostic procedures. A combination of a desire to be treated and disbelief in success, constant demands for a thorough examination by reputable specialists and fear of harm and painful procedures.

6. Neurasthenic (N). Behavior of the type of "irritable weakness". Flashes of irritation, especially with pain, with unpleasant sensations, with failures of treatment. Irritation often pours out on the first person who comes across and ends with repentance and remorse. Inability and unwillingness to endure pain. Impatience in examination and treatment, inability to wait patiently for relief. Subsequently - a critical attitude to their actions and thoughtless words, requests for forgiveness.

7. Melancholy (M) (vitally sad). Overwhelmed by the disease, disbelief in recovery, in a possible improvement, in the effect of treatment. Active depressive statements up to suicidal thoughts. A pessimistic view of everything around. Doubt about the success of treatment even with favorable objective data and satisfactory health.

8. Apathetic (A). Complete indifference to their fate, to the outcome of the disease, to the results of treatment. Passive obedience to procedures and treatment with persistent prompting from the outside. Loss of interest in life, in everything that previously worried. Lethargy and apathy in behavior, activity and interpersonal relationships.

9. Sensitive (C). Excessive vulnerability, vulnerability, concern about possible adverse impressions that information about the disease can make on others. Fears that others will become sorry, considered inferior, dismissive or wary, spread gossip and unfavorable rumors about the cause and nature of the disease, and even avoid communication with the patient. Fear of becoming a burden for loved ones due to illness and unfriendly attitude on their part in connection with this. Mood swings associated mainly with interpersonal contacts.

10. Egocentric (E)(hysterical). "Accepting" the illness and seeking benefits from the illness. Exposure to relatives and others of their suffering and experiences in order to arouse sympathy and completely capture their attention. Demanding exclusive care of oneself to the detriment of other matters and concerns, complete inattention to loved ones. The conversations of others are quickly translated “on themselves”. Other people who also require attention and care are considered as "competitors", the attitude towards them is hostile. A constant desire to show others one's exclusivity in relation to the disease, dissimilarity to others. Emotional instability and unpredictability.

11. Paranoid (P). Confidence that the disease is the result of external causes, someone's malicious intent. Extreme suspicion and alertness to talking about oneself, to medicines and procedures. The desire to attribute possible complications or side effects of drugs to the negligence or malice of doctors and staff. Accusations and demands for punishments in connection with this.

12. Dysphoric (D)(aggressive). An angry-gloomy, embittered mood dominates, a constant gloomy and dissatisfied look. Envy and hatred of healthy people, including relatives and friends. Outbursts of anger, with a tendency to blame others for his illness. Demanding special attention to yourself and suspicion of procedures and treatments. Aggressive, sometimes despotic attitude towards loved ones, the requirement to please in everything.

Ambivalence of the patient's attitude towards the disease

The dual (ambivalent) attitude of the patient to his disease should be taken into account. The traditional understanding of the disease is associated with its negative side. However, the observations of psychologists show that there is a positive side of the disease. The doctor's task search positive side disease and show it to the patient. This often helps to establish the necessary psychotherapeutic contact and encourages the patient.

The "advantages" of the disease are clear in places of detention. But even in everyday life, the disease can “remove” the patient from the need to make any decisions in the service or at home, get rid of certain difficulties, give certain advantages (psychological, social) over other people, can serve as compensation feelings of inferiority.

There are classifications of types of response to the disease, which take into account social consequences of the disease. According to Z.J. Lipowski (1983), psychosocial responses to illness are made up of responses to information about the illness, emotional responses (such as anxiety, grief, depression, shame, guilt), and responses to coping with the illness.

Reactions to information about the disease depend on the "significance of the disease" for the patient:

1. disease- threat or challenge and the type of reactions is opposition, anxiety, withdrawal or struggle (sometimes paranoid);
2. disease- loss, and the corresponding types of reactions are depression or hypochondria, confusion, grief, an attempt to attract attention, violations of the regime;
3. disease- gain or deliverance and the types of reactions in this case are indifference, cheerfulness, violations of the regime, hostility towards the doctor;
4. disease- punishment and thus there are reactions of type of oppression, shame, anger.

The reactions of overcoming the disease are differentiated by the predominance of their components: cognitive (downplaying the personal significance of the disease or close attention to all its manifestations) or behavioral (active resistance or capitulation and attempts to "avoid" the disease).

Experiencing illness over time

In the experiences and attitude of a person to his illness in dynamics, the following stages can be observed:

1. The pre-medical phase lasts until the start of communication with the doctor, the first signs of the disease appear and the sick person faces the decision to seek medical help.
2. The phase of breaking the life stereotype is the transition to such a stage of the disease when the patient becomes isolated from work, and often from the family during hospitalization. He has no confidence in the nature and prognosis of his disease and is full of doubts and anxieties.
3. The phase of adaptation to the disease, when the feeling of tension and hopelessness decreases, because. acute symptoms of the disease gradually decrease, the patient has already adapted to the fact of the disease.
4. The phase of "surrender" - the patient reconciles with fate, does not make active efforts to search for "new" methods of treatment and understands the limited possibilities of medicine in his complete cure. He becomes indifferent or negatively sullen.
5. The phase of the formation of compensatory mechanisms for adapting to life, the attitude to receive any material or other benefits from the disease (rental attitudes).

Age features of the internal picture of the disease

The greatest discrepancies between the subjective assessment of the disease and its objective manifestations are expressed in young and senile age (Kvasenko A.V., Zubarev Yu.G., 1980).

When assessing the subjective side of diseases in children, one should always take into account the age of the child, the correspondence of the degree of his mental development to the passport age. Long-term somatic disease in children often becomes a source of delay in overall physical and mental development. In addition, in diseases in childhood, not only developmental delay often occurs, but also regression phenomena (a return to the types of mental response characteristic of younger age periods), which is considered as a protective psychological mechanism. The protective activity of the personality of children contributes to the fact that the objective meaning of the concept of "disease" is often not assimilated by them, there is no awareness of its severity and consequences for later life.

In children under 6 years of age, one can often come across fantastic ideas about the disease, inspired by the experience of fear of injections and other medical manipulations. Adolescents most often develop protective phenomena such as “going into the past”, which they evaluate as a standard of happiness, or “leaving” the disease in fantasy and a kind of aspiration to the future (then the disease is perceived as a temporary barrier).

For a relatively sudden serious illness that is not accompanied by long-term asthenia, the opinion of L.S. Vygotsky (1983) that any defect is always a source of strength. Simultaneously with the defect, “psychological tendencies of the opposite direction are given, compensatory possibilities are given for overcoming the defect; ... it is they who come to the fore in the development of the child and should be included in the educational process as its driving force. Orientation to compensatory possibilities, to the tendency to overcompensate is very important in rehabilitation work with children suffering from chronic severe diseases.

Diseases in the elderly are physically more difficult to tolerate and for a long time worsen the general well-being of patients. With age, a whole range of age-related psychological phenomena comes to a person: here is indignation against old age, and a significant transformation of personal reactions and life stereotype. There is uncertainty, pessimism, resentment, fear of loneliness, helplessness, material difficulties. There is a noticeable decrease in interest in the new and in general in the outside world with fixation on the experiences of the past and their reassessment. With aging, the mental reactivity of a person decreases. However, even here it is impossible to speak unambiguously only about the regression of the personality in old age, since many people retain their positive qualities and creative possibilities.

The doctor should remember that in old age the somatogenic effects of physical illness on the psyche are much more pronounced. Sometimes the first sign of a somatic disease or worsening of its course are signs of a deterioration in the mental state of an elderly person. A particularly frequent sign of a worsened somatic condition in individuals old age are nocturnal delirium- restlessness and hallucinations at night.

Practical part

Methodology: TOBOL

The purpose of the methodology: psychological diagnostics of types of attitude to the disease. The method allows diagnosing the following 12 types of attitude: sensitive, anxious, hypochondriacal, melancholic, apathetic, neurasthenic, egocentric, paranoid, anosognosic, dysphoric, ergopathic and harmonious.

Rules for the work of the subject with the questionnaire

The subject is asked to choose the 2 statements most suitable for him in each table-set and circle the numbers of the choices made in the registration sheet. If the patient cannot choose two statements on any topic, then he must mark the last statement in the corresponding set table. There is no time limit for completing the registration form. The study can be carried out simultaneously with a small group of subjects, provided that they do not consult with each other.

In addition, data on the patient is entered in the registration sheet in accordance with the practical and research tasks facing the doctor and clinical psychologist, for example: a detailed clinical diagnosis and leading syndrome, duration of the disease, disability, prognosis of the disease, changes in social and family status due to disease, etc.

Text of the TOBOL questionnaire

1. Feeling good

Since I got sick, I almost always feel unwell 1

I almost always feel alert and full of energy 2

Feeling bad I try to overcome 3

I try not to show my bad health to others 4

I almost always have some pain 5

I feel bad after being upset 6

I feel bad from expecting trouble 7

I try to patiently endure pain and physical suffering 8

My health is quite satisfactory 9

Since I got sick, I have been feeling unwell with bouts of irritability and feelings of melancholy 10

My well-being is very dependent on how others treat me 11

2. Mood

As a rule, my mood is very good 1

Due to illness, I am often impatient and irritable 2

My mood deteriorates from the expectation of possible troubles, anxiety for loved ones, uncertainty about the future 3

I do not allow myself to indulge in despondency and sadness due to illness 4

Due to illness, I almost always have a bad mood 5

My bad mood depends on bad health 6

I became completely indifferent mood 7

I have bouts of gloomy irritability, during which others get hurt 8

I do not have despondency and sadness, but there can be bitterness and anger 9

The smallest troubles make me very sad 10

Because of my illness, I have an anxious mood all the time 11

None of the definitions fit me 12

3. Sleep and awakening from sleep

When I wake up, I immediately force myself to get up 1

Morning is the hardest time of the day for me

If something upsets me, I can't sleep for a long time 3

I don't sleep well at night and feel sleepy during the day 4

I sleep little, but wake up refreshed. I rarely see dreams

In the morning I am more active and it is easier for me to work than in the evening 6

I have poor and restless sleep and often have excruciatingly dreary dreams 7

I wake up in the morning refreshed and energetic

I wake up thinking about what to do today 9

At night I have attacks of fear 10

In the morning I feel complete indifference to everything 11

At night, I am especially haunted by thoughts of my illness 12

In my dreams I see all sorts of illnesses 13

4. Appetite and attitude to food

I am often embarrassed to eat strangers 1

I have a good appetite 2

I have a bad appetite 3

I like hearty food 4

I eat with pleasure and do not like to limit myself in food 5

I can easily spoil my appetite 6

I am afraid of spoiled food and always carefully check its good quality 7

I am primarily interested in food as a way to maintain health 8

I try to stick to a diet that I have developed myself 9

Food doesn't give me any pleasure 10

5. Attitude towards the disease

My illness scares me

I'm so tired of the disease that I don't care what happens to me 2

I try not to think about my illness and live a carefree life 3

My disease most of all depresses me because people began to shun me 4

I think endlessly about all the possible complications associated with the disease 5

I think that my disease is incurable and nothing good awaits me 6

I believe that my illness is neglected due to the inattention and inability of doctors 7

I think that doctors exaggerate the danger of my illness 8

I try to overcome the disease, work as before and even more 9

I feel that my illness is much more severe than doctors can determine 10

I am healthy and illness does not bother me 11

My illness proceeds in a completely unusual way - not like others, and therefore requires special attention 12

My illness irritates me, makes me impatient, quick-tempered 13

I know whose fault I got sick and I will never forgive this 14

I try my best not to succumb to the disease 15

None of the definitions fit me 16

6. Attitude towards treatment

I avoid any treatment - I hope that the body will overcome the disease itself if I think about it less 1

I am afraid of the difficulties and dangers associated with the upcoming treatment 2

I would be ready for the most painful and even dangerous treatment just to get rid of the disease 3

I do not believe in the success of the treatment and consider it in vain 4

I am looking for new ways of treatment, but, unfortunately, I am constantly disappointed in all of them 5

I think that they prescribe a lot of unnecessary drugs and procedures, they persuade me to have a useless operation 6

All new drugs, procedures and surgeries give me endless thoughts about the complications and dangers associated with them 7

Medicines and procedures often have such an unusual effect on me that it amazes doctors 8

I believe that among the methods of treatment used there are so harmful that they should be banned 9

I think that I am being treated incorrectly 10

I don't need any treatment 11

I'm tired of endless treatment, I just want to be left alone 12

I avoid talking about treatment with other people 13

I am irritated and embittered when treatment does not improve 14

7. Attitude towards doctors and medical staff

I consider the main thing in any medical worker to be attention to the patient 1

I would like to be treated by a doctor who is very famous 2

I think that I fell ill, first of all, due to the fault of doctors 3

It seems to me that doctors understand little about my illness and only pretend to treat 4

I don't care who treats me and how 5

I often worry about not telling the doctor something important that could affect the success of the treatment 6

Doctors and medical staff often cause me dislike 7

I turn to one doctor, then another, because I am not sure of the success of the treatment 8

I have great respect for the medical profession 9

I have been convinced more than once that doctors and staff are inattentive and dishonestly perform their duties 10

I get impatient and irritable with doctors and nurses and later regret it 11

I am healthy and do not need the help of doctors 12

I think that doctors and medical staff are wasting their time on me 13

None of the definitions fit me 14

8. Attitude towards relatives and friends

I am so absorbed in thoughts about my illness that the affairs of loved ones ceased to excite me 1

I try not to show my family and friends that I am sick, so as not to darken their mood 2

Relatives in vain want to make me seriously ill 3

I am overwhelmed by thoughts that because of my illness, difficulties and hardships await my loved ones 4

My relatives do not want to understand the severity of my illness and do not sympathize with my suffering 5

Relatives do not consider my illness and want to live for their own pleasure 6

I am ashamed of my illness even in front of my relatives 7

Due to illness, I lost all interest in the affairs and worries of loved ones and relatives 8

Due to illness, I became a burden to my relatives 9

Healthy appearance and carefree life of loved ones makes me dislike 10

I believe that I got sick because of my relatives 11

I try to bring less hardships and worries to my loved ones because of my illness 12

None of the definitions fit me 13

9. Attitude towards work (study)

Illness makes me a worthless worker (incapable of learning) 1

I am afraid that due to illness I will lose a good job (I will have to leave a good educational institution) 2

My work (study) has become completely indifferent to me. 3

Due to illness, now I have no time for work (not before school) 4

I worry all the time that due to illness I can make a mistake at work (not cope with my studies) 5

I think that I got sick due to the fact that work (study) harmed my health 6

At work (at the place of study) they do not take into account my illness at all and even find fault with me 7

I do not think that the disease can interfere with my work (study) 8

I try to make people at work (at the place of study) know and talk less about my illness 9

I believe that despite the illness, one must continue to work (study) 10

Illness made me restless and impatient at work (at school) 11

At work (at school) I try to forget about my illness 12

Everyone is surprised and admired by how I successfully work (study), despite the illness 13

My health does not prevent me from working (studying) where I want 14

None of the definitions fit me 15

10. Attitude towards others

Now I don't care who surrounds me and who is around me 1

I wish people around me would just leave me alone

Healthy appearance and cheerfulness of others irritate me 3

I try not to notice my illness 4

My health does not prevent me from communicating with others as much as I want 5

I would like the people around me to experience how hard it is to get sick 6

It seems to me that others avoid me because of my illness 7

Others do not understand my illness and my suffering 8

My illness and how I bear it surprises and amazes others 9

I try not to talk about my illness with others 10

My environment has made me sick, and I will not forgive it 11

Communication with people now began to quickly bother me and even annoy me 12

My illness does not prevent me from having friends 13

None of the definitions fit me 14

11. Attitude towards loneliness

I prefer loneliness, because alone I feel better 1

I feel that the disease dooms me to complete loneliness 2

When alone, I strive to find some interesting or necessary work 3

In loneliness, sad thoughts about illness, complications, and forthcoming suffering begin to haunt me especially.

Often, left alone, I rather calm down: people began to annoy me a lot 5

Being embarrassed by the disease, I try to move away from people, and when I am alone, I miss people 6

I avoid loneliness so as not to think about my illness 7

It didn't matter to me what to be among people, what to be alone 8

The desire to be alone depends on my circumstances and mood 9

I am afraid of being alone due to fear of illness 10

None of the definitions fit me 11

12. Attitude towards the future

Illness makes my future sad and bleak 1

My health does not yet give any reason to worry about the future 2

I always hope for a happy future, even in the most desperate situations 3

With careful treatment and adherence to the regimen, I hope to achieve better health in the future 4

I do not think that the disease can significantly affect my future 5

I associate my future entirely with success in my work (study) 6

I didn't care what happened to me in the future

Because of my illness, I am constantly worried about my future 8

I am sure that in the future the mistakes and negligence of those who made me sick will be revealed 9

When I think about my future, melancholy and. irritation with other people 10

Due to illness, I am very worried about my future 11

None of the definitions fit me 12

Registration sheet for the TOBOL questionnaire

Full Name ____________

Age________ Gender_____M_____W

(strike out unnecessary)

In the column "Numbers of the selected answers" circle those numbers of statements from the tables that are most suitable for you. Two choices are allowed for each topic.

Survey results

G R G T I N M A S E P D

Diagnosed type of attitude towards the disease: _____________________________

Test control of knowledge

1. Restore sequence

Stages of experiencing a person's illness in time.

1. premedical phase
2. phase of breaking the life stereotype
3. phase of adaptation to illness
4. phase of "surrender" - reconciliation with the disease
5. phase of formation of compensatory mechanisms

2. Determine the type of response: patients correctly assess their condition and prospects, their assessment coincides with the doctor's assessment

1. normonosognosia
2. hyponosognosia
3. anosognosia
4. hypernosognosia

3. Patients who tend to overestimate the significance of individual symptoms of the disease, this type of response to the disease is called:

1. normonosognosia
2. hypernosognosia
3. anosognosia
4. dysnosognosia

4. Type of response to the disease, in which the patient underestimates his condition and the severity of the disease:

1. normonosognosia
2. hyponosognosia
3. anosognosia
4. hypernosognosia

5. Complete denial of the disease as such, active rejection of thoughts about the disease, this

1. normonosognosia
2. hypernosognosia
3. anosognosia
4. dysnosognosia

6. What type of response is characteristic of the hypernosognosic type of response to the disease?

1. panic
2. adequate response
3. disease denial

7. What type of response is characteristic of the hyponosognosic type of response to the disease?

1. panic
2. adequate response
3. disease denial
4. distortion of perception for the purpose of dissimulation

8. What type of reaction is typical for the normonosognosic type of reaction to the disease?

1. panic
2. adequate response
3. disease denial
4. distortion of perception for the purpose of dissimulation

9. Situation: a patient at a doctor's appointment has difficulty making contact, showing suspicion and distrust. Subsequently, he does not attach serious importance to his instructions and recommendations, complicating the interaction, which can lead to conflict with medical personnel. What type of personal reaction of the patient is described?

1. friendly reaction
2. panic reaction
3. backlash
4. unconscious reaction

10. Situation: after the injury, the athlete returns to intensive training again, ignoring the doctor's instructions to reduce the intensity of professional loads for the period of rehabilitation. What type of personal reaction is described in the patient?

1. calm reaction
2. destructive reaction
3. unconscious reaction
4. trace reaction

11. Situation: the patient is simultaneously being treated in different medical institutions, after watching a TV show about her illness she is in the grip of fear, on the advice of a neighbor she turns to a healer. What type of personal reaction is described in the patient?

1. friendly reaction
2. panic reaction
3. backlash
4. unconscious reaction

12. Situation: the patient always comes to the doctor's consultation on time, treats all recommendations and prescriptions with attention and obedience. He infinitely trusts his doctor and is grateful for his help. What type of personal reaction is described in the patient?

1. friendly reaction
2. calm reaction
3. backlash
4. unconscious reaction

13. Situation: a patient with stable emotional-volitional processes takes his illness very calmly, although he accurately performs therapeutic and health-improving measures and always comes to the doctor's consultations on time. Often such a patient is not aware of his illness. What type of personal reaction is described in the patient?

1. friendly reaction
2. calm reaction
3. backlash
4. unconscious reaction

14. Situation: the patient successfully completed the course of treatment, but he is constantly in the grip of painful doubts in anticipation of a relapse of the disease. What type of personal reaction is described in the patient?

1. calm reaction
2. destructive reaction
3. unconscious reaction
4. trace reaction

15. Type of attitude towards the disease (according to Lichko). Correct, sober assessment of the state, unwillingness to burden others with the burdens of self-care.

1. dysphoric
2. paranoid
3. harmonic
4. ergopathic

16. Type of attitude towards the disease (according to Lichko). A gloomy embittered mood dominates, envy and hatred of the healthy. Outbursts of anger with demands from loved ones to please everything.

1. apathetic
2. dysphoric
3. anisognosic
4. anxious

17. Type of attitude towards the disease (according to Lichko). “Escape” from the disease to work, the desire to maintain working capacity.

1. ergopathic
2. apathetic
3. hypochondriacal
4. melancholic

18. Type of attitude towards the disease (according to Lichko). Confidence. That the disease is the result of someone's malicious intent, and complications in treatment are the result of the negligence of medical personnel.

1. dysphoric
2. paranoid
3. harmonic
4. ergopathic

19. Type of attitude towards the disease (according to Lichko). Active rejection of thoughts about the disease, ignoring all symptoms.

1. apathetic
2. dysphoric
3. anisognosic
4. anxious

20. Type of attitude towards the disease (according to Lichko). “Departure into illness” with exposing one’s suffering, demanding constant attention and special treatment.

1. apathetic
2. harmonic
3. paranoid
4. egocentric

21. Type of attitude towards the disease (according to Lichko). Continuous anxiety and suspiciousness, belief in examples and rituals, search for new ways of treatment, thirst for more information about the disease.

1. apathetic
2. dysphoric
3. anisognosic
4. anxious

22. Type of attitude towards the disease (according to Lichko). Sensitive to interpersonal relationships, very vulnerable and impressionable, full of fears that those around him are avoiding him due to illness, fear of becoming a burden for loved ones.

1. sensitive
2. anisognosic
3. apathetic
4. hypochondriacal

23. Type of attitude towards the disease (according to Lichko). Exaggeration of real and seeking out non-existent diseases and suffering. The desire to constantly talk about their experiences to the doctor and everyone around.

1. ergopathic
2. apathetic
3. hypochondriacal
4. melancholic

24. Type of attitude towards the disease (according to Lichko). Complete indifference to one's fate, passive obedience to procedures and treatment, loss of interest in life.

1. apathetic
2. harmonic
3. paranoid
4. egocentric

25. Type of attitude towards the disease (according to Lichko). Behavior of the type of "irritable weakness". Impatience and outbursts of irritation at the first comer (especially with pain), then - tears and repentance.

1. dysphoric
2. neurasthenic
3. harmonic
4. ergopathic

26. Type of attitude towards the disease (according to Lichko). Disbelief in recovery, dejection by the disease, depressive mood (danger of suicide).

1. anisognosic
2. apathetic
3. hypochondriacal
4. melancholic

Answers