System of medical-psychological support of the family where a patient with endogenous mental disorder lives Текст научной статьи по специальности «Клиническая медицина»

Conclusions.

1. CT with bolus contrast enhancement is effective in detecting signs of portal hypertension, its shape, and evaluating portacaval anastomoses.

2. In patients with suspected portal hypertension, it is necessary to change the protocol for conducting multiphase scanning due to a slowdown in blood flow. If necessary, supplement the standard phases with a late venous phase.

3. Using the system for modeling and combining the phases of the study allows you to choose the best method of surgical intervention for decompression of the portal system;

4. After surgery, CT with modeling allows you to visually assess the patency of shunts and anastomoses

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SYSTEM OF MEDICAL-PSYCHOLOGICAL SUPPORT OF THE FAMILY WHERE A PATIENT WITH ENDOGENOUS MENTAL DISORDER LIVES

Kaminska A.

MD, PhD, Associated professor

Department of Medical Psychology and Psychiatry with the Course of Postgraduate Education of

National Pirogov Memorial University, Vinnytsya, Ukraine

Abstract

Family, where a patient with endogenous mental disorder lives, experiences deep psychosocial stress; changes in patients behavior and social losses, caused by the disorder, lead to the disruption of inter-family interaction and increased emotional tension; attitude of the family to the disease and their perception of the patient depend on clinical and psychopathological features of mental disorder, which determines the type of family response to the diagnosis and affect its ability to cope with stress; self-stigmatization of family, social isolation, lack of psychological support increase disadaptation of family.

Family caregivers of patients with endogenous mental disorder often lack adequate information about mental disorders, as well as appropriate medical-psychological support services.

Taking into consideration above listed, there are four aspects of family interventions included into complex medical-psychological support system:

1) psychoeducation;

2) stress management and development of adaptive coping behavior;

3) mastering effective communication skills;

4) activation of resource components and adaptive potential of individuals.

The work model, described in this article, is based on interactive thematic groups, using integrative approach, combining the following methods:

- cognitive-behavioral psychotherapy;

- mindfulness-oriented cognitive therapy;

- psychotraining;

- art therapy.

Keywords: medical-psychological support system, psychoeducation, family caregivers, endogenous mental disorders, family burden.

Introduction. In current biopsychosocial model of therapy and rehabilitation of patients with endogenous mental disorders (EMD), pathogenesis of EMD is considered as a result of complex interaction of biological, psychosocial and behavioral factors [1, 2]. This approach involves flexible combination of psychophar-macotherapy to provide effective control of psycho-pathological symptoms and preserve cognitive and social functions, as well as psychosocial interventions aimed at expanding the repertoire of coping strategies of patients and their family caregivers [3, 9, 10].

Development of mental disorder in one of the family members affects all aspects of family life as it is a severe psycho-emotional stress due to the situation of the beginning of the disease, loss of short-term and long-term family plans for the future, difficulties of daily care of the patient, additional financial burden, constriction of social network, stigmatization and self-stigmatization [8, 12,13, 16, 17,20]. With the duration of EMD up to 4 years, the impact of the disease is due not only to the fact of having a diagnosis of mental disorder in a family member, but also to significant changes of the whole system of previous intrafamily interaction in response to changes in behavior and personality of the patient.

Materials and methods. As a part of the study, in 2015-2019, 243 family caregivers (FC) of patients with paranoid schizophrenia and affective disorders were examined on the basis of informed consent according to the principles of medical bioethics and deontology, using specially designed questionnaire and psychological testing tools. Inclusion criteria to the study were: informed consent for clinical-psychological examination and psychological testing, no prior requests for help from a psychiatrist, no traumatic brain injury in anamnesis. Control group included 55 mentally healthy persons, in whose families there was no mentally sick patient, and who never sought for the help of a psychiatrist.

The study was performed in three stages: at first stage we examined the respondents in order to study in depth social-psychological, individual-psychological, interpersonal-communicative and behavioral predictors of family disadaptation. At the second stage of work we performed substantiation, development and implementation of appropriate system of medical-psychological support for families, where patients with EMD live, based on data obtained during the previous stage of work. At third stage, the efficiency of implemented system was evaluated.

Strategies and principles of medical-psychological support system for FC of patients with EMD. Proposed medical and psychological support system for families is intended to help FC to integrate the experience of having a family member with EMD, and is focused on four key positions:

1. installation of hope;

2. maintaining self-identity;

3. determining the new sense of life;

4. accepting responsibility for the recovery process.

The purpose of family interventions is to refocus

the family from fixation on losses caused by the disease, to the preserved sides of patient's personality, psychosocial support, restoration of life quality, positive aspects of interpersonal interaction. This opens up new goals for the family, activates search for new models of interaction with the patient, facilitates adaptation and re-socialization.

In these circumstances, family is ready to cooperate with specialists and is able to provide patients with the support they need.

Thus, the system of medical and psychological support is based on four main strategies:

1) learning skills of overcoming stress and understanding patient's behavior in context of understanding symptoms of the underlying mental disorder;

2) developing adaptive coping behaviors and enhancing activities towards personal goals (by combination of psychoeducation with stress management skills training, cognitive correction and problem-solving techniques).

3) mastering skills of effective interpersonal communication for adequate interpersonal interaction in family;

4) creation of preconditions for the formation of value-based attitudes, aimed at preserving health and activation of personal adaptive capacity.

In implementing this process, the following principles must be followed:

- early inclusion of FC into the system of medical and psychological support;

- differentiated approach, considering the type of family response to the fact of presence of the disease;

- family orientation on the psychoprophylactic nature of rehabilitation;

- strengthening the adaptive capacity of each family member's personality;

- mastering experience of helping to a family member, who is suffering from EMD.

The system of medical and psychological support is aimed at enhancing the family competence in understanding the essence of endogenous mental disorders, expanding the arsenal of constructive coping strategies, developing the skills of effective interpersonal communication and effective intrafamily interactions, that will lead to:

- reduction of family burden, associated with the disease and problems of care;

- overcoming the loss reaction;

- reduction of emotional tension in family relationships;

- building therapeutic alliance with health care professionals, who treat the patient;

- formation of adequate ideas about the disease;

- reduction of excessive emotional involvement in life and affairs of the patient;

- adequate perception of the patient;

- understanding of patient's capabilities and adequate expectations of the family;

- formation of an adequate attitude to the need for long-term therapy;

- understanding the nature of patient's behavior and developing the effective response skills;

- strengthening of existing structural elements of

inter-family interaction and ways of solving problems;

- reduction of self-stigmatization;

- communicative competence in interactions inside and outside of the family system;

- family consolidation, determination of new values, goals and meaning of family life;

- restoring and expanding family's social network.

Implementation of the system of medical and psychological support includes the following steps:

1. Identifying the potential program participants.

2. Detailed study of medical records of patients of the specified group, interviews with doctors.

3. Initial interview of FC.

4. Providing medical and psychological support in the format of thematic interactive group sessions.

5. Setting booster group sessions.

Format and methodology of thematic groups. Groups should be homogeneous by nosological affiliation of patients (separate groups for FC of patients with paranoid schizophrenia and for FC of patients with affective disorders), but heterogeneous by social characteristics (gender, age, education, etc.), types of response

of FC to the fact of disease and duration of the disease in family member. This increases the therapeutic potential of the group. If patient's parents are divorced, both are invited to participate in the group.

Contraindications to joining the group sessions

are:

- refusal of FC to participate in group work;

- aggressive or hostile attitude towards the leaders and other members of the group;

- presence of mental disorder or severe somatic disease in FC of the patient;

- age under 18 years old.

FC with the contraindications for group work, should be offered individual sessions.

The system of medical and psychological support for FC of patients with EMD is provided in closed groups with a number of participants from 8 to 12 people.

The system consists of 10-12 sessions (table 1). Total number of sessions varies depending on the needs of the participants. Frequency is 1 time per week. The duration of one session is 90 minutes.

Table 1

Indicative structure of the recommended system of medical and psychological support for families

№ Aims Means, techniques, exercises Form of work

1 2 3 4

Module I - psychoeducational. Task: psychoeducation on the problem of mental disorders, motivation for further group work (2 meetings).

1 Primary individual meeting - building therapeutic contact - identification of specific problems and targets of work with the family Analysis of medical records Motivational interview Introducing the main principles of CBT One-on-one interview, semi-structured interview

2 Introducing and involvement into medical-psychological support system - presentation of the system of medical and psychological support, its goals and potential benefits - motivation to participate in group thematic sessions Psychoeducation Active listening technique General meeting

Module II - Cognitive interventions. Tasks: development of self-regulation skills, creation of conditions for activation of personal adaptive potential, activation of communicative resources of personality, formation of communicative competence and effective coping behavior. (6 meetings).

3 Causes of mental disorders, myths about mental illness, prognosis in mental disorders. - identification and correction of false beliefs about the nature of mental disorders - reducing self-stigmatization of the family Psychoeducation STEB-analysis of family situations Technique of diary of thoughts. Thematic group session

4 Symptoms of mental disorders. - information about depression and mania, information on manifestations of thinking disorders, delusions and hallucinations; - strategies for effective response to unusual or aggressive behavior in patient The technique of distancing Thought testing technique Behavior modeling technique Thematic group session

5 Effective response to manifestations of mental disorders; signs of exacerbation and "safety net" actions in case of relapse. - signs of disease recurrence - strategies are developed for the behavior of the FC in the acute situation Technique for evaluating the usefulness of worries Thematic group session

6 Methods of treatment; recovery from mental disorders; stigma and self-stigma in mental disorders. - information about the principles of psychophar-macotherapy in mental disorders - understanding strategies of actions in the situation of refusal of the patient from medical treatment Techniques for dealing with anxiety Cognitive restructuring Thematic group session

7 Social and legal aspects; choice of medical institution and problem of trust to the doctor - discussing legal aspects - information on organizations that provide various forms of assistance in mental disorders (medical institutions, public organizations, social services) Psychoeducation Problem solving technique Decision making technique Thematic group session

8 Solving problems of daily life (organization of leisure, rest, holidays; problems of employment and finances) - developing strategies for effective interaction with the person experiencing EMD - mastering communication skills Communication skills training Decision making technique Mindfulness Art therapy Thematic group session

Ill module - behavioral activation. Objectives: enhancing constructive behavioral coping strategies, increase of stability, determination of priority life goals, activation of personality adaptation resources (4 meetings).

9 Stress management and psychological resilience - mastering skills of stress management - discussing ways of relaxation and relieving psycho-emotional stress List of resource activities Behavioral activation technique with a weekly activity schedule form Mindfulness Thematic group session

lOll Quality of life, values and goals for a family with a mentally sick family member - installation of hope - awareness of values and goals of the family Group discussion Art therapy Mindfulness Thematic group session

12. Summarizing the group work - evaluation of the effectiveness of the program - discussion of results, planning further booster group meetings Feedback Psychological testing Thematic group session

Primary individual meeting. With the consent of FC to participate in group sessions, the leaders have an initial one-on-one meeting with them. The objectives of this meeting are:

a) identification of specific targets for work with the family;

b) building a therapeutic alliance with the family.

Specific targets for work with the family are identified in a semi-structured interview format, which includes three blocks of questions.

First block allows the assessment of level of awareness about mental disorders and reveals the relatives' perceptions of mental disorders. These include the following issues: knowledge of manifestations of mental disorders; understanding causes of mental disorders; prognosis of disease (short and long term); knowledge of current approaches and methods of treatment; knowledge of medical institutions, where psychiatric care is provided; previous experience of communication with people with mental disorders; sources of information about the disease; perceptions, that are different from the medical model.

Second block is focused on assessing the impact of mental disorder on the family system and includes questions about the objective and subjective aspects of family burden.

Third block of questions focuses on identifying leading coping strategies and family resources in coping with family crisis. These include the question of what coping strategies family has used before and which uses now, how effective these coping strategies are in the current situation, what are the strengths and resources of the family.

Analysis of specific family problems, based on the initial interview, is supplemented by the analysis of medical records (medical history, outpatient card, results of additional examinations, psychologist's findings, psychological testing, etc.), as well as the following set of scales and questionnaires:

1. Experience of Caregiving Inventory (ECI) [1], developed by G. Szmukler et al. to assess the level of family burden;

2. Structured Interview Scale of Family Members' Attitudes toward Illness (psychiatric diagnosis) in a Relative by V.A. Abramov, I.V. Zhigulina, T.L. Rya-polova to study the subjective attitude of FC towards patients with EMD;

3. "Analysis of Family Anxiety" questionnaire (AFA) by E.G. Eidemiller and V. Yustitskis [6] to assess family anxiety level and components;

4. PANSS scale for evaluation of dynamics of psychopathological symptomatology of the patient;

5. Hamilton Depression Rating Scale (HDRS)

for evaluation of psychopathological symptoms in affective disorders.

At the same time, the initial conversation with FC is aimed at building therapeutic alliance, motivating family members to participate in group sessions. Often, this meeting enables family members to talk about their experiences and ideas about the illness for the first time. Recognition and support of family strengths are the basis for developing partnership between professionals and the family. However, there may be difficulties in involving FC into group work. They are due to personal characteristics and the type of family response to the illness. Reactions, such as denial of the disease, lead to the refusal to participate in group work due to underestimation of problems. In the hyperbolization reaction, self-stigmatization, unwillingness to interact with other relatives of patients complicate the inclusion of FC into the group program. Some families need time to understand the changes, that are happening and to embrace the need to participate in groups. A number of factors may be related to lack of knowledge about psychological interventions, their value and goals. Relatives are anxious to share their experiences with professionals and other group members. Clarification of possible reasons for failure, constructive discussion of goals and methods of group work help FC to overcome the resistance to participation in the program.

The main stage of family intervention in proposed medical-psychological support system is implementation of thematic group sessions.

The style of conducting thematic group sessions is directive, with active guidance of the leaders. At the same time, it is important to maintain partnerships with group members, and to use a person-centered approach that considers the needs and expectations of participants.

Thus, the following guidelines should be followed, when conducting thematic group sessions for FC of patients with EMD:

1. providing information, corresponding to the needs of the group.

2. information should be based on the type of family response to the development of mental disorder;

3. separation of disorder manifestations and psychological reactions of the individual;

4. structured leadership style of the group with active guidance;

5. gradual transition from directive style to active intragroup interaction;

6. prohibition of criticism and judgmental statements;

7. encouraging participants to practice new coping and communication skills;

9. stimulating relatives to expand social network;

10. motivation of FC to receive information and to share experience after completion of group program.

The last stage of the system involves attending booster groups for FC. Duration of booster group is up to 1 year. Frequency of meetings is once a month. Duration of session - 90 minutes.

Structure of the thematic group session. Thematic group session includes traditional session stages in group psychotherapy:

1. Introductory part:

a) discussing homework;

b) sharing current mood, achievements, worries and expectations;

c) formulation of the topic and agenda of the session;

d) formulating the needs of the participants within the topic of the session.

2. Main part:

a) discussion of the topic of the session;

b) gaining new skills by practicing tecniques;

c) summary of the session made by the leader

d) feedback from the participants of the group session.

3. Home task.

Length of each part of the session may vary depending on the needs of the participants and the topic of the session.

The purpose of the introductory part of the session is to identify the needs of the participants within the topic. This allows to adjust the session to the needs and experiences of each participant, to motivate them to participate actively in group work. To do this, each participant speaks a few words about what issues are most important to him or her in today's topic.

The main part of the lesson is devoted to the topic of the session and is a thematic interactive group discussion. The information delivery model consists of several steps:

1. At the first stage, leaders invite the participants to express their views on the topic of the session.

2. The members of the group express their own views on the subject.

3. Leaders provide information, using techniques of cognitive restructuring, helping to form alternative thoughts on the problem in group members.

In addition, the main part of the session includes practicing techniques of problem-oriented coping, behavioral training, stress-management and mindfulness. One of the main strategies is correction of relatives' behavioral patterns in situations involving patient interaction. This section examines existing family interactions as well as the desirable behaviors, that family members expect from each other. Based on the material obtained, correction of ineffective interactions is performed through techniques of cognitive restructuring and behavioral experiments. At the end of the session, participants are given home task to consolidate new skills.

Developing problem-solving skills is necessary to provide families with a structured approach to dealing with the issues of daily interaction with the patient. It involves several stages: formulating the problem, dividing the problem into smaller ones, identifying specific tasks, finding different ways to accomplish these tasks by a group in a "brainstorm" format.

One of the peculiarities of family interventions is work with coping behavior of FC. It involves investigating the coping strategies that FC use most often in stressful situations, to the extent that they are constructive and effective in this situation. The following discussion focuses on alternative ways of coping with the expansion of coping strategies.

Thematic plan of interactive group sessions. The program includes the following thematic sessions:

1. causes of mental disorders, myths about mental illness, prognosis in mental disorders;

2. manifestations of mental disorders, considering how the patient is subjectively experiencing symptoms of mental disorder;

3. effective response to manifestations of mental disorders; signs of exacerbation and "safety net" actions in case of worsening of the patient;

4. methods of treatment; recovery from mental disorders; stigma and self-stigma in mental disorders;

5. social and legal aspects; choice of medical institution and problem of trust to the doctor;

6. solving problems of daily life (organization of leisure, rest, holidays; problems of employment and finances);

7. stress management and psychological resilience;

8. quality of life, values and goals for a family with a mentally sick family member.

In essence, each session is a logical continuation of the previous one. The sequence of presentation of the material varies depending on the needs of the group members. The material under study is supported by visual presentation. To do this, notes on the board or slides, handouts, self-help books, guides for FC patients with mental disorders, videos are widely used.

During all sessions, the leaders stimulate development of constructive patterns of behavior and communication inside and outside the group. To do this, they use home tasks, that involve performing collaboratively, meeting participants, communicating on the phone or the Internet. Thus, group members should see the possibility of support, including emotional or informational, from other FC of patients with mental disorders. It will reduce the feeling of isolation, helplessness and, at the same time, this kind of communication can further form the basis for mutual support groups or parent associations.

As a result of the program, FC should receive the following insights:

1. The patient's family is not impotent, it is able to help the patient to recognize exacerbation in the early stages, thus reduce the risk of re-hospitalization and other negative effects of exacerbation.

2. Effective treatment and rehabilitation of the patient requires active collaboration of the family and mental health professionals.

3. Mental disorders have a clear and demonstrable biological component. Family members are not the blame of relatives being ill.

4. Typical symptoms in mental disorders are known, described, can be recognized and successfully treated.

5. Processes, that occur in the patient's family are caused by the disease, not the other way around.

6. The disease often leads to social isolation not only of the patient, but of the family as a whole, which complicates the process of re-socialization of the patient.

7. In the situation of occurrence and detection of mental disorder, stress is experienced not only by the patient, but by the whole family.

8. Stress can be managed by using effective and adaptive coping strategies, enhancing psychological resilience and internal resources of family members.

9. Emotional state of family is reflected in patient's recovery process; whereby family members should be attentive to their needs and actively use existing forms

of care (including medical and psychotherapy) to support their own adaptive resources and to provide psychological resistance in the presence of a patient with EMD in the family.

The effectiveness of proposed system of medical-psychological support for families of patients with EMD lies within the increase of family awareness of various aspects of mental disorders; reducing family burden, family members' denial, hyper-involvement and dominance; empowering families to adapt to family crisis situation; reducing the incidence of exacerbations; maintaining compliance; restoring social functioning and quality of life for the patient and the family.

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THE RELATIONSHIP OF THYROID FUNCTION AND THE DEVELOPMENT OF ANDROGEN

DEFICIENCY IN MEN

Krytskyу T.

Assistant at the Department of Internal Medicine No. 1 I.Ya.Horbachevskyi Ternopil National Medical University

Ternopil, Ukraine Pasyechko N.

Doctor of Medical Science, Professor Department of Internal Medicine No. 1 I.Ya.Horbachevskyi Ternopil National Medical University

Ternopil, Ukraine

ВЗАИМОСВЯЗЬ ФУНКЦИИ ЩИТОВИДНОЙ ЖЕЛЕЗЫ И РАЗВИТИЕМ АНДРОГЕННОГО

ДЕФИЦИТА У МУЖЧИН

Крицкий Т.И.

Асистент кафедры внутренней медицины №1, Тернопольский национальный медицинский университет имени И.Я. Горбачевского

Тернополь, Украина Пасечко Н.В.

доктор мед.наук, професор кафедры внутренней медицины №1 Тернопольский национальный медицинский университет имени И.Я. Горбачевского

Тернополь, Украина

Abstract

Resume. Background. The results of modern researches specify on the role of thyroid hormones, metabolic disbalance, psychical stress, participating in maintenance of general and hormonal homoeostasis. At the same time interrelation between thyroid and sexual hormones in men with hypothyroidism remains the article of discussions. Research aim - to study frequency of clinical and laboratory signs of androgenic deficiency, as well as influence of insufficient level of thyroid hormones on an androgenic function in men with primary hypothyroidism. Material and methods. Under a supervision there were 55 men with primary hypothyroidism aged from 36 to 60 years, and also 25 practically healthy men. Results. In patients with hypothyroidism was significant decreased concentration of sex steroid-binding globulin(SSBG), total testosterone, and also free and bioaccessible testosterone, in relation to healthy men. In patients with hypothyroidism the serum concentration of free thyroxine positively correlates with SSBG. Negative correlations of middle degree of expressiveness are educed between SSBG and free and bioaccessible testosterone. Conclusions. For the men of middle age with hypothyroidism determination of androgens content is recommended for the exposure of syndrome of androgenic deficiency.

Аннотация

Результаты современных исследований указывают на роль тиреоидных гормонов, метаболического дисбаланса, психического стресса, участвующих в поддержании общего и гормонального гомеостаза ор-ганизму.У то же время взаимодействие трудных и половых гормонов при гипотиреозе у мужчин остается предметом дискуссий. Цель исследования - изучить частоту клинических и лабораторных признаков анд-