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CraTra Hagmm^a go pega^ii 16.07.2020
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https://doi.Org/10.26641/2307-0404.2021.1.227999
CLINICAL AND PSYCHOPATHOLOGICAL FEATURES OF COURSE AND CORRECTION OF DEPRESSIVE DISORDERS IN PATIENTS WITH BRAIN TUMORS, PREVENTION AND REHABILITATION
SE «Dnipropetrovsk medical academy of Health Ministry of Ukraine» department psychiatry, narcology and medicopsychology FPE V. Vernadsky str., 9, Dnipro, 49044, Ukraine e-mail: gnennayolga@gmail.com
Dnipro Medical Institute of Traditional and Non Traditional Medicine department of internal medicine with a course of neuroscience Sevastopolska str., 17, Dnipro, 49000, Ukraine e-mail: grial2401@gmail.com
ДЗ «Днтропетровська медична академiя МОЗ Укра'ши» кафедра ncuxiampii, наркологи i медично'1' психологи ФПО (зав. - д. мед. н., проф. Л.М. Юр 'ева) вул. Вернадського, 9, Днтро, 49044, Укра'ша
Днтропетровський медичний тститут традицтно'1' i нетрадицтно'1' медицини
кафедра внутрiшньоi медицини з курсом нейродисциплiн
(зав. каф. - д. мед. н., доц. А.Г. Кириченко)
вул. Севастопольська, 17, Днтро, 49000, Укра'та
Цитування: Медичш перспективы. 2021. Т. 26, № 1. С. 175-184 Cited: Medicni perspektivi. 2021;26(1):175-184
Key words: brain tumors, mental and depressive disorders, experimental psychological research, psychotherapeutic correction, prevention, rehabilitation
Ключовi слова: мозковi пухлини, психiчнi та депресивнi розлади, експериментально-психологiчне до^дження, психотерапевтична корекщя, профтактика, реабШта^я
Ключевые слова: мозговые опухоли, психические и депрессивные расстройства, экспериментально-психологическое исследование, психотерапевтическая коррекция, профилактика, реабилитация
UDC 614.21:616.8:616.89
V.V. Ogorenko, A.G. Kyrychenko , O.M. Hnenna
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Abstract. Clinical and psychopathological features of course and correction of depressive disorders in patients with brain tumors, prevention and rehabilitation. Ogorenko V.V., Kyrychenko A.G., Hnenna O.M. The article studys the psychological characteristics in patients with brain tumors of different localization which allows to reduce the diagnostic period and, as a result, minimize the time of early detection and the consequences of the surgical treatment of this pathology, and to cause a positive effect on preventing the development of psychopathological disorders at the hospital stage. Analysis of the clinical manifestations of depressive disorders of the subclinical level revealed their polymorphism: depression was accompanied by various variants of asthenic (prevalence of dyssomnias, psychalgia, adynamia and anxiety component) and anxiety (prevalence of senestopathies, hypochondria, phobia) states. The revealed symptom complexes of psychopathological and pathopsychological characteristics of the patient's condition were the clinical justification for the choice of methods of psychotherapeutic correction. Adjuvant psychological therapy, individual rational and family psychotherapy were used as the basic method of psychotherapeutic influence. Pharmacological correction included: anxiolytics, antidepressants, atypical mild antipsychotics in low doses. The results of the SCL-90-R test demonstrate the effectiveness of the comprehensive treatment aimed at preventing and reducing the manifestations of psychopathological symptoms. Comparison of the mean values of the SCL-90-R test revealed significant differences in such indicators as somatization (p<0.05), depressiveness (p<0.01), anxiety (p<0.05); high statistical significance is noted in the "index of symptom severity " integral indicator (p<0.01). Obtained results of psychological and psychiatric research became the basis for the development of differential diagnostic criteria for the diagnosis and prevention of the development of mental disorders.
Реферат. Клшшо-психопатолопчш особливосп nepe6iry та удосконалення системи попередження i зниження розвитку депресивних розла^в у пащенпв з пухлинами головного мозку. Огоренко В.В., Кириченко А.Г., Гненна О.М. У cmammi наведено вивчення психологiчних характеристик na^eHmie з пухлинами головного мозку pimoi локалгзацИ, яке дозволило скоротити дiaгносmичний перюд i, вiдnовiдно, MimMisyeamu термти раннього виявлення та на^дки оперативного л^вання щег патологп, сприятливо впливати на запоб^ання розвитку nсuхоnamологiчнuх розлaдiв на госnimaльномy еmani. Анализ клiнiчнuх nроявiв депресивних розлaдiв сyбклiнiчного рiвня виявив гх nолiморфiзм: депре^я супроводжувалася разними вaрiaнmaмu астенчного (переважання диссомни, психалгИ, адинами i тривожного компонента) i тривожного (переважання сенестопатш, тохондри, фобп) сmaнiв. Вuявленi симптомокомплекси nсuхоnamологiчнuх i namоnсuхологiчнuх характеристик стану хворих стали клМчним обгрунтуванням вибору меmодiв психо-терапевтичног корекци. В якосmi базисного методу психотерапевтичного впливу застосовувалася ад'ювантна nсuхологiчнa тератя, iндuвiдyaльнa рацюнальна й сiмейнa психотерапИ. Фaрмaкологiчнa корекщя включала: aнксiолimuкu, антидепресанти, amunовi м'як нейролептики в малих дозах. Результати тесту SCL-90-R про-демонстрували ефективнсть комплексного лкування, спрямованого на попередження та зменшення nроявiв nсuхоnamологiчнuх сuмnmомiв. Порiвняння середнiх значень тесту SCL-90-R виявило сymmeвi вiдмiнносmi в таких показниках, як сомamuзaцiя (р<0,05), депресивнсть (р<0,01), тривога (р<0,05); висока статистична знaчyщiсmь вiдзнaчaemься в iнmегрaльномy показнику «тдекс вuрaженосmi сuмnmомiв» (р<0,01). Отримаш результати nсuхолого-nсuхiamрuчного до^дження стали основою для розробки диференцтно^агностичних критерпв дiaгносmuкu та профшактики розвитку nсuхiчнuх розлaдiв.
Brain tumors account for 6-8.5% of all human neoplasms and 6.1% of the total number of organic diseases of the central nervous system [4, 5, 7]. According to statistics, brain tumors take the second place among the causes of death due to malignant neoplasms in people aged 35 years and older. Over the past decades, there has been a clear tendency towards an increase in the incidence of primary and metastatic tumors. Brain tumors in men are more common than in women. This is especially obvious with increasing age [13, 14]. The diagnosis of a brain tumor is a powerful stressor and has an extremely powerful and long lasting psychotraumatic influence on the patient's personality [1, 10, 14].
In brain tumors of various localization, psychopathological symptoms are manifested in 40-90% of cases. Numerous studies reflect the incidence and variety of clinical and psychopathological manifestations that adversely affect the course of the disease, the degree of maladaptation, compliance
with traditional methods of treatment, quality and life expectancy of patients [1, 4, 5, 7, 10, 13, 14]. According to the literature, one in two patients suffers from various mental disorders, which in turn have an extremely negative impact on the course of most cancer diseases and contribute to premature death [5, 6, 8, 10, 11]. Therefore, many authors note the absolute need, along with using modern means of pharmacotherapy, to provide psychotherapeutic assistance to cancer patients in order to prevent the development of psychopathological disorders, and especially depressive states (due to the risk of suicidal behavior), as well as the formation of behavioral strategies that facilitate to optimize the treatment and rehabilitation process [3, 6, 8, 15].
The purpose of the study: to study the psycho-pathological structure and the possibility of psycho-therapeutic correction of depressive disorders in patients with brain cancer pathology in order to
improve the prevention of their progressing and rehabilitation of this group of patients.
MATERIALS AND METHODS OF RESEARCH
250 patients with primary brain tumors were examined. Selection criteria for the study: 1) non-psychotic level of clinical psychopathological disorders; 2) absence of premorbid aggravation by mental and behavioral disorders (ICD-10 code F00-F99); 3) absence of concomitant diseases of the nervous system (ICD-10 code G00-G99) and somatic diseases that cause early damage to the nervous system; 4) absence of impaired consciousness, symptoms of hypertensive-dislocation syndrome at the stage of clinical and diagnostic examination; 5) no cognitive disorders reaching clinical levels of mild dementia; depressive disorders in patients with primary brain tumors (PBT) of various localization. A comprehensive clinical and psychodiagnostics examination of 250 patients with primary brain tumors was carried out, which included objective data from accessible medical records and voluntary consent of the patients. Standardized diagnostic and expert scales of the psychopathological symptom severity questionnaire (SCL-90-R) were used as assessment tools [9]. In the experimental psychological study, modified versions of the LOBI method and the Luscher test (color choice) were used [2]. In the research process, short-term differentiated psycho-therapeutic and psychopharmacological treatments were applied. Psychotherapeutic treatment included
different types of psychotherapy: rational, family and adjuvant psychological therapy.
Statistical processing of results was performed using methods of descriptive and analytical statistics that are implemented in the STATISTICA 6.1 software (by StatSoft Inc., SN AGAR909E415822FA). Hypothesis testing for normal distribution of quantitative traits was assessed using Shapiro-Wilk test and Kolmogorov-Smirnov test, and equality of variances was checked using Levene's test. To describe the sample normal distribution of quantitative traits, the arithmetic mean (M) and standard deviation (SD) were used; for an asymmetric distribution, the median (Me) and the interquartile range of 25%-75% were used. The statistical significance of differences in mean values for quantitative traits in unrelated groups with normal distribution was assessed using the Student's t-test, and using the Mann-Whitney U test with different distribution. The statistical significance of differences in quantitative traits was assessed using Pearson's chi-squared (x2) test, including the Yates's correction for continuity [12].
RESULTS AND DISCUSSION
In all patients, primary supratentorial intrace-rebral tumors of the frontal, temporal and parietal localization were diagnosed and verified by magnetic resonance or computer tomography (Fig. 1). The histological structure of the tumors was verified by examination of the surgical material.
Fig. 1. MRI of a supratentorial primary tumor of the frontal localization on the left
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The cohort consists of 175 patients with mental disorders of non-psychotic level. Accordingly to histological data, primary supratentorial intracerebral single malignant neoplasms (MBT) were diagnosed in 72 patients and 103 patients were diagnosed with benign neoplasms (BBT).
Differential diagnostic period (from the appearance of psychopathological disorders to the diagnosis of the neoplasm) in the average for the group was from 7.2 up to 7.4 months (8.4-9.2 months for the group of patients with BBT and 2.95.6 months with MBT). At the time of diagnosis of brain tumors, a depressive register of psycho-
pathological disorders was remained in 134 patients aged 21 to 56 years, among whom women prevailed by gender indicators (71 persons; average age is 41.4±11.5 years and 44.6±12.3 years respectively).
Depressive disorders of the subclinical level, as clinical manifestations of brain tumors (BT) and the formation of initial psychopathological disorders were revealed in 78.3% of cases (n=137). Analysis of the clinical manifestations of psychopathological disorders revealed their polymorphism: during this period, various types of asthenic and anxiety states were most often observed at the same time as the depressive ones (Table 1).
Table 1
Frequency distribution of psychopathological components of depressive states at the initial stage of the diagnostic period of BT in groups of patients with BBT (n=75) and MBT (n=62)
Psychopathological components of depressive states % of cases p
BBT MBT
Asthenic
Asthenic with prevalence of dyssomnias
27.7
34.4
<0.001
Asthenic with psychalgic component
23.2
10.5
<0.001
Asthenic with adynamic component
25.3
35.8
<0.001
Asthenic with an anxiety component
23.8
19.3
<0.001
Anxiety
With the prevalence of cenestopathies
33.8
28.6
<0.001
With a hypochondriac component
38.0
45.7
<0.001
With a phobic component
28.2
25.7
0.006
Commenting on the table data, it should be noted that at the BBT of different localization, asthenic conditions indicated the progress of depressive symptom complexes and prevailed in comparison with other disorders. Asthenic conditions as initial manifestations of psychopathological disorders were detected in 56 patients (90.3%) with MBT.
In MBT, other proportions of the analyzed components of asthenic disorders were detected: the adynamic component (35.8%) and the dyssomnial disorders (34.4%) prevailed; asthenic states with anxious and psychalgic components (19.3% and 10.5%, respectively) were less presented.
Anxiety disorders that were combined with depressive states were found in 92 patients with BT (59.4%); at the same time in 96.7% of cases the transformation of asthenic reactions into an anxiety symptom complex was observed.
An analysis of the results of a survey of the severity of psychopathological symptoms confirmed the prevalence of depressive and anxiety spectrum disorders in the studied sample with their expressed somatization and interpersonal sensitivity in the studied sample (Table 2).
A comparative analysis of the results of the Luscher color selection test revealed a significant (p<0.05) prevalence of brown and gray in I and II choice positions; violet and yellow in the VII and VIII positions in patients with BBT; dark blue and red in the I and II positions of choice, yellow and gray in the VII and VIII positions in patients with MBT (Table 3). Such combination of colors in the choice of patients with BBT indicated a state of anxiety, worrying, feelings of conflict, fatigue and mental strain.
Mean severity of psychopathological symptoms (according to the SCL-90-R questionnaire) (n=175)
Table 2
Psychopathological symptoms
M(mx)
Somatization
0.75 (0.53)
Obsessive-compulsive disorders
0.42 (0.34)
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobic anxiety
0.85 (0.55) 0.98 (0.58) 0.55 (0.46) 0.50 (0.48) 0.58 (0.51)
Paranoiac symptoms
0.45 (0.45)
Psychoticism
0.38 (0.42)
Global Severity Index
0.75 (0.46)
Positive Symptom Distress Index
1.28 (0.34)
Revealed disorders characterized the presence of anxious fears for their health and for the destruction of social contacts, fear of the future, the need for understanding, rest and relaxation.
The analysis of test results clearly indicates the stress caused by a lack of interpersonal relationships, which is characterized by a lack of intimacy,
empathy, love and understanding, especially in the presence of this pathology.
The study of type of attitude towards the disease (TATD) (Table 4) in a sample of patients with BT revealed the following features. In the group of patients with benign brain tumors (BBT) only "pure" types of attitude to the disease were diagnosed.
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Among them, anxious (25.0%) and anosognosic (14.5%) TATD prevailed. Hypochondriac TATD was diagnosed in 12.1%, ergopathic in 8.1%, apathetic and sensitive in 11.2% of patients, neurasthenic in 3.2%, a harmonious type of attitude to the disease was observed in 2.8% of patients. In the MBT group
of "pure" TATD, anosognosic (24.6%) and ergopathic (15.1%) types of attitude to the disease prevailed. Apathetic, sensitive and paranoiac TATD are equally represented (by 5.5%), neurasthenic TATD was diagnosed in 4.8%, ergopathic - in 1.8% of patients with BN.
Table 3
Amount of color choice according to Luscher method in patients with BT and depressive spectrum mental disorders
Colors Groups Position I-II Position VII-VIII
1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0
BBT (n=81) 8 5 11 7 4 24 9 22 8 9 6 26 19 10 5 7
MBT (n=53) 14 5 12 4 4 7 3 5 2 7 3 16 4 4 6 12
The study of the types of attitude to the disease significant disruptions of social adaptation was iden-
revealed a slight prevalence of types with impaired tified. Thus, the internal picture of the disease is a com-
social adaptation: in 36.6% - intrapsychic type of so- plex structured reflection of the influence of personal
cial maladjustment orientation (SMO), in 34.3% - qualities of the patient in attitude to the disease. extrapsychic type of SMO; in 29.1% TATD without
Table 4
TATD frequency distribution in groups with BBT and MBT according to social maladjustment orientation
Social maladjustment orientation Type of attitude to the disease MBT BBT p
Intrapsychic orientation Anxious 4,8(4,8; 9,6) 25,0(17,8; 32,2) 0.001
Hypochondriacal - 12.1(6.7; 17.5) 0.002
Neurasthenic 4.8(4.8; 9.6) 3.2(0; 6.4) 0.287
Apathetic 5.5 (1.8; 6.2) 5.6 (2; 9.2) 0.756
Extrapsychic orientation Sensitive 5.5 (1.8; 6.2) 5.6 (2; 9.2) 0.876
Paranoiac 5.5 (1.8; 6.2) - 0.001
Egocentric 1.6 (0; 3.2) - 0.001
No significant disruption of social Harmonic - 2.8 (0; 5.6) 0.001
adaptation
Ergopathic 15.1 (10.5; 19.7) 8.1 (4.5; 11.7) 0.002
Anosognosic 24,6 (16,2; 33) 14.5 (10; 19) 0.002
Mixed harmonic 9.5(4.8; 14.2) - 0.001
Obtained results of the evaluation of syndromes and symptom complexes of psychopathological and pathopsychological characteristics of the patients' condition were the clinical rationale for the choice of methods of psychotherapeutic correction. Selected targets allowed to determine the appropriate methods of psychocorrection and tactics of psychotherapy. In particular, the limited time characteristics and the preoperative stage of the clinical diagnostic period served as the criteria for selecting intervention methods. During the study, patients of the considered group were provided with differentiated psychopharmacological and psychotherapeutic treatment. Taking into account the dynamics, polymorphism and syndromic incompleteness of psycho-pathological symptoms, during the pharmacological correction mainly anxiolytics, antidepressants of the SSRI group, as well as atypical mild antipsychotics in small doses were used.
As a basic method of psychotherapeutic influence, adjuvant psychological therapy (APT) was used, as well as methods of individual rational and family psychotherapy. The advantage of selected methods in the studied sample of patients was their eclecticity and the ability to cause limited but significant positive changes in a short time.
Rational psychotherapy was carried out both individually, using explanation, persuasion, distraction, as well as using a directive technique with the involvement of the authority, prestige and knowledge of a doctor. The main goal of rational psychotherapy is to help the patient go through five main stages of the psychological reaction associated with information about the diagnosis of a brain tumor.
Family psychotherapy was carried out taking into account the family microclimate, being aimed at overcoming the feeling of powerlessness and guilt in the relatives due to the inability to help the patient and irrational psychological detachment from the patient. Considering the time factor and the stage of the diagnostic process, the main task of family psychotherapy was the psychotherapeutic correction of destructions in family relationships and contacts, as well as the impact on maladaptive patterns of attitude to the disease, manifested, in particular, in demoralization. Assistance in coping with the diagnosis, transition of roles, the formation of a less catastrophic image of the disease, allowed us to form an adequate medical position focused on the adoption of medical recommendations, develop a joint solution in such a psychotraumatic situation as the necessity for surgical intervention and prepare relatives for the resolving of numerous psychological problems related with the further life of patients.
APT as a short-term, problem-focused cognitive-behavioral group program was aimed at ensuring that the patients, firstly, were able to revise their ideas about the disease and, secondly, to change the maladaptive style of behavior. Following APT techniques were used: 1. Learning to identify and write down negative thoughts that come to mind as if "automatically" and replace them with more realistic ones, which contribute to adaptation; 2. Reproduction of possible stressful events and how people will deal with them in the imagination and in role-playing games; 3. Planning of various behavioral strategies that will give a feeling of control over various aspects of your life; 4. Relaxing training in case of extremely manifested anxiety; 5. Learning to express your feelings openly; 6. Emphasizing personal strengths, increasing self-esteem, helping to overcome feelings of helplessness.
Positive dynamics of changes in the structure of psychopathological symptoms was detected in 130 patients (97.0%) as a result of psychotherapeutic influence. It was observed that the majority of patients had reduction in melancholy-depressive and anxious-depressive states, 48 cases were able to achieve regression phobic, hypochondriacal, cene-sthopathic and hypochondria components; 29 patients showed positive dynamics in the reduction of depressive disorders, which were combined with somatoform symptom complexes.
Minor dynamics was observed in patients with depersonalization-derealization states in the structure of anxiety and depressive disorders. The lack of results of psychotherapeutic influence was observed in patients with the prevalence of adynamic depression (all observations refer to further verified malignant BT mostly of frontal localization).
Clinical assessment of the mental state of the study group is confirmed by indicators of the SCL-90-R psychodiagnostic test (figure 2), which indicate the effectiveness of the complex treatment aimed at preventing and reducing manifestations of psychopathological symptoms.
Comparison of the mean values of the SCL-90-R test revealed significant differences in such indicators as somatization (p<0.05), depressiveness (p<0.01), anxiety (p<0.05); high statistical significance is noted in the "symptom severity scale" integral indicator (p<0.01).
Thus, the obtained clinical diagnostic criteria formed the basis for the development of an interdisciplinary treatment and diagnostic algorithm, which is aimed at the timely detection and correction of maladaptation with subsequent improvement in the quality of life of this category of patients. To prevent the development of depressive disorders
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regular, not only individual, but also family counseling are required. Prevention should be integrated, taking into account the individual characteristics of each patient, the conditions and possibilities of special methods of psychological correction.
In this regard, the study of risk factors for the formation of personal maladaptation of patients, and quality of life in general, acquire a special diagnostic and preventive value in neurooncology.
Before After
Fig. 2. Syndromic profile of patients with BT before and after complex psychopharmacological and psychotherapeutic treatment
CONCLUSIONS
1. The developed algorithm of clinical and psychopathological research using optimal psychodiagnostic tools, which are characterized by validity, multiplicity, ease of processing results, versatility, enables diagnostic use not only for screening but for assessment of the condition and course, as well as for prevention of mental disorders in patients with brain tumors.
2. Principles of the organization of psychothera-peutic care for neurooncological patients imply not only an individual-personal approach, but also a
family one. Conducting adjuvant psychological therapy and other psychotherapeutic interventions, as well as psychopharmacotherapy, helps to reduce the development of depressive disorders by 25-30%.
3. The inclusion of the structure of psycho-psychiatric care in the unified neurooncological service is especially important at the stages of early detection of brain tumors with subsequent correction of mental disorders.
Conflict of interests. The authors declare no conflict of interest.
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Crana Hagmm^a go pegaKmï 22.05.2020
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УДК 616.36-002.2-022.7+612.392.015.6:577.161.2:613.13:551.521.1]-047.44 https://doi.Org/10.26641/2307-0404.2021.1.228000
М.А. Нколайчук1, ВПЛИВ СЕЗОННОСТ1 НА Р1ВЕНЬ
Л.Р. Шостак°вич-Корецька 1, В1ТАМ1НУ D СЕРЕД ХВОРИХ
Ш Будаева НА ХРОН1ЧНИЙ ГЕПАТИТ C ТА ЗДОРОВИХ
С.В. Бтецька '
ДЗ «Днтропетровська медична академiя МОЗ Украгни» 1 кафедра тфекцшних хвороб
(зав. - д. мед. н., проф. Л.Р. Шостакович-Корецька)
вул. В. Вернадського, 9, Днтро, 49044, Укра'ша
Медичний центр « Unimed» 2
вул. Молодог Польщi, 7, Краюв, 30-131, Польща
SE «Dnipropetrovsk medical academy of Health Ministry of Ukraine» 1
Department of Infectious Diseases
V. Vernadsky str., 9, Dnipro, 49044, Ukraine
e-mail: nk.miroslava@gmail.com
Medical Center "Unimed" 2
Mlodej Polski str., 7, Krakow, 30-131, Poland
e-mail: biletskasv@gmail.com
Цитування: Медичш перспективы. 2021. Т. 26, № 1. С. 184-190 Cited: Medicni perspektivi. 2021;26(1):184-190
Ключовi слова: хронiчний вiрусний гепатит С, втамт D, сезонний чинник Ключевые слова: хронический вирусный гепатит С, витамин D, сезонный фактор Key words: chronic viral hepatitis C, vitamin D, seasonal factor
Реферат. Влияние сезонности на уровень витамина D среди больных хроническим гепатитом C и здоровых. Николайчук М.А., Шостакович-Корецкая Л.Р., Будаева И.В., Белецкая С.В. По данным ВОЗ, вирусом гепатита С в мире инфицировано сейчас около 150-200 млн человек. В последнее время в профессиональной литературе возросло количество публикаций, посвященных роли витамина D у больных вирусным гепатитом С, поскольку метаболизм витамина D происходит с участием печени, а его дефицит ассоциируется с повышением риска развития инфекционных заболеваний. Целью работы было изучить влияние сезонного фактора на уровень витамина D (25 гидроксикальциферол) у больных хроническим вирусным гепатитом С и здоровых лиц. В исследовании принимало участие 100 пациентов, находившихся в реестре больных хроническим вирусным гепатитом в Днепропетровском регионе. Проведено определение распространенности дефицита и недостаточности
