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Практична психосоматика: діагностичні шкали. Навчальний посібник
Abstract
У другій, оновленій та доповненій, редакції навчального посібника з позиції психосоматичної медицини представлено діагностичні підходи до курації пацієнтів загальносоматичної практики в умовах сучасного агресивного соціуму. Проаналізовано проблеми гіподіагностики психічних розладів у пацієнтів соматичної практики, особливо за наявності одного або декількох хронічних неінфекційних захворювань. Наведено та пояснено наявність психосоматичних розладів у класифікаціях МКХ-10 і DSM 5. Описані методи обстеження психосоматичного пацієнта, що дозволяють визначити його схильність до розвитку психосоматичного розладу, верифікувати наявність та ступінь виразності тривоги, депресії, суїцидальних тенденцій, безсоння, болю, когнітивного дефіциту тощо. Представлено методи визначення якості життя психосоматичних пацієнтів, у тому числі методи, розроблені авторами посібника. Наведені матеріали дозволяють провести всебічний аналіз основних психопатологічних феноменів задля обґрунтованої подальшої розробки стратегії й тактики комплексної терапії.
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Every day a physician encounters complex situations in his practice and communicates with patients in various emotional and psychological conditions. In most cases, patients are forced to seek medical advice, not because they want it. Sometimes they attend a visit to hospital by an advice of a family member or friend. This review article presents typical recommendations for interaction with patients in different clinical situations.
The overall current prevalence of clinically significant post-traumatic stress disorder (PTSD) symptoms across the sample was estimated at 20%. The mean symptoms severity was 15.98 (95% CI 12.67-19.27) with no statistically significant difference between men and women (p=0.251). The PTSD symptoms were twice more severe in the military exposed to war zone stress for 2 or more years, compared to others. Anxiety and alexithymia levels had significant gender differences. Anxiety was more pronounced in women compared to men (7.11 vs 5.29; p=0.041); and alexithymia levels were higher in men compared to women (63.17 vs 56.43; p=0,032). The problem of PTSD in the military is extremely relevant in Ukrainian reality. It requires urgent attention in the form of adaptation and implementation of effective therapeutic methods with proven efficacy for PTSD, such as Trauma-Focused Cognitive-Behavioral Therapy and/or Eye Movement Desensitization and Reprocessing
The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inner-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
Objectives
Violation of mental health is common in forced migrants. Lack of positive motivation to move and physical impossibility of further stay at home, mental trauma caused by the history and causes of migration; difficulties in adapting to new location determine the formation of specific experience IDPs. The most common are psychogenic depression, anxiety and somatoform disorders.
Methods
We had observed 60 IDPs aged 18 to 80 years: medical history, current complaints and mental state.
Results
We allocated 3 groups: persons of retirement age with severe chronic physical illness or disability on physical illness (1 group); persons with disabilities to mental disease (group 2) and persons without chronic diseases or disability (relatively healthy, caring for the sick) (group 3). Group 1 patients have anxiety (51.4%) and depression (42.8%) syndromes; 25.7% of subjects showed suicidal thoughts and intentions; 25.7% have some PTSD symptoms, including avoidance, overexcited, emotional numbness, pointing to adjustment disorder. In group 2 patients, changes were not found in mental state. Despite traumatic events delusional story does not change, recurrence and relapse rating was stable. In some cases, patients begin to abuse alcohol. In 3 group 31.3% persons experienced depression, 25%-anxiety symptoms, combined with a severe somatic symptoms; 12.5% showed suicidal thoughts; in 18.7% were diagnosed adjustment disorders. So among IDPs the individuals with severe medical conditions are most vulnerable population in the formation of stress-related and neurotic disorders.
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
ABSTRACT– A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
The Hamilton Anxiety Scale (HAM-A) was tested for reliability and validity in two different samples, one sample (n=97) defined by anxiety disorders, the other sample (n=101) defined by depressive disorders. The reliability and the concurrent validity of the HAM-A and its subscales proved to be sufficient. Internal validity tested by latent structure analysis was insufficient. The major problems with the HAM-A are that (1) anxiolytic and antidepressant effects cannot be clearly distinguished; (2) the subscale of somatic anxiety is strongly related to somatic side effects. The applicability of the HAM-A in anxiolytic treatment studies is therefore limited. More specific anxiety scales are needed.