Psychology of medical workers. Psychology of treatment – diagnostic process. Psychosomatic disorders
The success of the medical influence does not depend only upon the psychological peculiarities of the patient, but first of all is determined by the moral make-up of the doctor whose professional activity radically differs from that of any other specialist. The life makes great demands of the doctor as a specialist. First of all, they include a high professionalism, an aspiration for a constant enrichment of his own knowledge. The doctor must be a person of high moral standards whose authority is established by profound knowledge in his field, a personal charm, modesty, optimism, honesty, truthfulness, justice, selflessness and humanism.
A sincere and deep personal interest of the doctor in elimination of the patient’s ailments gives rise to inventiveness in the forms of help. Confidence in the doctor often depends upon the first impression which develops in the patient during the first meeting with his doctor, the doctor’s urgent facial expression, gesticulation, tone of his voice, expressions, as well as his appearance: if the patient sees that his doctor is untidy and sleepy for some reasons which are not caused by his work, he looses any belief considering that a person who is not able to take care of himself cannot care for others and be reliable in his work. The patients are rather inclined to excuse different deviations in the external manifestations and appearance of those medical workers whom they already know and in whom they already have confidence.
The medical worker gains his patients’ confidence in the case if, as a personality, he is harmonious, quiet and positive, but not haughty, and if his manner of behaviour is rapid, persistent and decisive, accompanied by humane sympathy and delicacy. Taking every serious decision, the doctor must imagine the results of its effect on the patient’s health and life. The necessity of having patience and control over himself makes particular demands of him. He must always consider various possible ways in the development of the disease. It is not easy for the doctor to combine in his work the necessary thoughtfulness and reasonableness with the required decisiveness and coolness, optimism with a critical attitude and modesty.
For the patient, an even-tempered personality of the doctor is a complex of harmonious external stimuli whose effect participates in the patient’s recovery. The medical worker must bring up and form his personality, firstly, observing a direct response to his behaviour (by the talk, assessment of the facial expression and gestures of the patient) and, secondly, in an indirect way, when his behaviour is assessed by his colleagues. It requires some effort, a certain critical attitude towards himself and a necessary measure of culture which must go without saying for the medical worker.
The patients’ confidence in a younger medical worker with a less life experience and less skills becomes more perfect owing to his honesty, modesty and readiness to render help.
The patient looses his confidence and the medical worker loses his authority in the case when the patient gains the impression that the medical worker is a so-called «bad person». Such an impression may be created by the doctor’s behaviour if he speaks bad about his colleagues, treats his subordinates haughtily and toadies up to his bosses, displays vanity, lack of criticism, garrulity and malicious joy. The vanity is demonstrated, for instance, when the doctor does not apply to his more experienced colleague for consultation or exaggerates the severity of the disease for the patient in order to receive more recognition and admiration after the patient’s recovery. More serious personal shortcomings of the medical worker may lead the patient to the suggestion that a doctor or a nurse with such streaks cannot be honest and reliable in serving their duties either.
The literature describes some possible psychological types of doctors:
1. «Compassionate» – tender-hearted, merciful, easily responsive to the patient’s sufferings.
2. «Pragmatic» – taking into consideration only the objective side of the disease in the work with his patients, does not pay any attention to the patients’ sufferings.
3. «Moralist» – inclined to moral admonitions and indignant if the patient doubts or does not follow his doctor’s recommendations.
4.«Diligent» – honest in his work, serious, assiduous, industrious and not inclined to joke with the patients.
5.«Activist» («public worker») – prefers solving of various organizational problems and serving of social duties in the medical institution to work with his patients.
6.«Dogmatic» – strictly follows the mastered diagnostic and therapeutic directions and schemes, hardly apprehends any new things.
7.«Technocrat» – overestimates the significance of laboratory and apparatus data, does not attach any importance to the patients’ sufferings and other subjective aspects of the disease.
8.«Psychotherapist» – tries to grasp the patient’s sufferings, help him with a piece of advice or making him change his mind.
9.«Sybarite» – likes cosiness and comfort, the patients irritate him with their complaints, he does not consider much their opinion and is inclined to the Bohemian mode of life.
10.«Artist» – inclined to demonstration of his knowledge and professional skills to the patients and their relatives, depending upon the conditions he plays parts of various doctors, namely: «hesitating», «attentive», «luminary», etc..
11.«Bored idler» – a high self-estimation with a rather modest stock of knowledge, stereotyped diagnosis and administration of treatment, a scornful attitude towards his inquisitive colleagues.
12.«Misanthrope» – a doctor under compulsion: a lack of any calling for the doctor’s activity is displayed through the absence of such streaks as mercifulness, kindness, as well as through rudeness, a disgusted attitude towards the patients and malicious jokes.
The above scheme does not exhaust the whole variety of psychological types of doctors. It should be taken into account that formation of some or other type of the doctor is to a considerable extent dependent upon his upbringing.
Some prerequisites for establishing positive relationships between the doctor and the patient appear even before they come into direct contact. As a rule, the patient coming to the doctor knows about him more than the doctor about the patient. Reputation of the health service in general and the medical institution where the patient comes in particular is of importance too. Tension, dissatisfaction and anger of the patient who had to get to the doctor by an uncomfortable transport and, moreover, wait his turn for a long time at the reception room may often become inadequately apparent when meeting a nurse or a doctor who have not the slightest idea of the causes of this reaction and groundlessly explain it as a hostile attitude towards them.
It is also necessary to mention a possible action of «the transfer of the aesthetic stereotype». Beautiful people rather arouse sympathy and confidence, while plain ones stir up antipathy and uncertainty. In this way, the notion of beauty is associated with good features, and ugliness with evil. Despite the fact that this supposition is groundless, it subconsciously produces a rather strong effect: an outwardly attractive patient arouses more sympathy in the doctor even if in reality he requires less help than a patient whose appearance stirs up antipathy. And, on the contrary, the doctor acting esthetically positively arouses more confidence.
In making contact with the patient, the first impression created by the doctor on him is important. It is also influenced by the general atmosphere of the medical institution and behaviour of all its workers: auxiliary personnel, administrative staff, the nurse on reception and registration of the patient. During the first contact with the doctor the patient must gain the impression that the doctor wants to help him. The doctor is obliged to control himself to such an extent that all commoorms of the social contact were observed. It means that he must personally introduce himself to the patient, if the latter is not acquainted with him, and hold out his hand. Such behavior calms the patient, develops a feeling of safety in him and increases his consciousness of the personal dignity.
To give the patient an opportunity for a free and uninterrupted account of his sufferings, problems, complaints, troubles and fears is one of the prerequisites for developing a positive attitude. The doctor should not demonstrate that he is very busy, though it may be in reality. The doctor must «resound to the patient’s statements» with his own personality. If the patient is not given an opportunity to express his opinion to a necessary extent, he often complains that the doctor «has not listened to him at all» and he has not been examined in compliance with all the rules, though in reality all the necessary things were made. From the patient’s side, such cases reveal dissatisfaction that he is neglected as a personality. A talkative patient, an extroverted type achieves psychic ventilation easier; moreover, he even excites curiosity of the doctor in his account if it is entertaining. But actually the above psychic ventilation is more necessary for a concealed introverted type who conceals his problems, complaints and sometimes even signs of a disease as a result of timidness, shame or exaggerated modesty.
Confidence is the main component in the patient’s attitude to his doctor. Nevertheless, gaining of the confidence does not proceed only from the psychological aspect of the relations between the doctor and the patient, but it also has a broader social aspect. The doctor can gain the confidence of his patient and establish positive contact with him through satisfying his groundless demands. Development of such relations usually proceeds from the mutual satisfaction of the interests, where one side is presented by the doctor and the other one with the patients who may render him some service, but thereby affecting the effective and actually necessary examination of all the patients that in the first place must be performed from the viewpoint of their diseases, but not depending upon their social standing or abilities.
A psychological problem arises also in those cases when the doctor notices that his relations with the patient develop in an unfavourable direction. Then the doctor should behave with restraint and patience, resist any provocations, do not provoke himself and try to gradually gain his patient’s confidence with calmness and understanding.
Medical practice knows cases when the doctor experiences diagnostic difficulties that sometimes result in medical mistakes. There are objective and subjective causes of these mistakes.
A medical mistake means a delusion of the doctor with absence of any negligence, carelessness or a thoughtless attitude to his duties. Medical mistakes are often caused by peculiarities in the doctor’s personality and character, as well as by how he feels rather than by his insufficient professional training and qualification. This subjective factor accounts for 60 – 70 % of the total number of mistakes.
Sometimes mistakes are caused by the doctor’s sluggishness, indecision, diffidence, insufficient constructiveness of his thinking, inability to correctly and rapidly orientate himself in a difficult situation, an insufficiently developed ability to correctly and logically compare and synthesize all the elements of the information obtained about the patient. Unwarranted caution taken by the doctor may be extremely dangerous in situations when the patient’s state requires prompt and decisive actions.
On the other hand, unwarranted self-confidence which is not supported by real evidence sometimes results in making «popular» florid diagnoses.
Such peculiarities in the doctor’s character as optimism or pessimism may play a part in a wrong prognostic assessment of the severity of a disease. The doctor must always really assess the true situation and should not take the desired thing for the real one. Diagnostic mistakes may also result from the fact how the doctor feels, his asthenic states, the feeling of tiredness and sleepiness.
The paramount significance of personality peculiarities in the medical profession must be assessed during the professional selection for higher medical schools. If the applicant’s individual personality peculiarities, interests and inclinations do not satisfy the demands of medical deontology he should not choose the profession of a doctor.
The work of the nurse who spends much more time in direct contact with the patient than the doctor is of great importance at in-patient medical institutions. The patient seeks for understanding and support from her. She must both professionally master the skills of caring for her patients and know the rules of the psychological approach to them, as a lack of knowledge of these rules often results in the fact that the patients express their «displeasure» and protest against the «formal» and «barrack» behaviour of some nurses despite the fact that from the physical viewpoint the care for them was good. On the other hand, the development of relationships between the nurse and the patient is sometimes fraught with appearance of both a danger of not keeping a certaiecessary distance and an aspiration to a flirt or helpless sympathy, The nurse must be able to manifest her understanding of the patient’s difficulties and problems, but should not seek to solve these problems.
Depending upon their character and attitude to the work, the following individual types of nurses are separated.
1.The practical type, characterized by accuracy and strictness, sometimes forgetting the humane side of the patient. In a paradoxical form it may be sometimes manifested by the fact that she awakens a sleeping patient in order to give him some soporific.
2.The artistic type, characterized by affected behaviour; without any sense of proportion, such a nurse tries to impress the patient and be pompous.
3.The nervous type; such a nurse is often tired, irritated and the patients do not feel calmness near her. She subconsciously tries to evade some duties; for example, out of apprehension to be infected.
4.The male type of the nurse, with a strong constitution: she is resolute, energetic, self-confident and consistent. The patients characterize her behaviour as «military». In a favourable case, she becomes a good organizer and successfully trains young nurses. In an unfavourable case, such nurses may be primitive, aggressive and despotic.
5.The maternal type of the nurse, a «sweet nurse», often with a pyknic constitution.
6.Nurses-specialists who work, e.g., on an electrocardiograph or electroencephalograph; sometimes they have a feeling of superiority over the nurses working at departments; if they do not conceal this attitude, it may result in tense relations between them and other personnel.
Medical deontology
Organizing the work of different medical institutions, one should proceed from the basic statements of the medical deontology and ethics.
Medical deontology and ethics are the whole complex of principles of regulation and standards of behaviour for the doctor and other medical workers conditioned by the specific character of their activity (care for other people’s health, treatment, etc.) and position in the society.
Deontology (the science about the due) is the teaching of behaviour principles of the medical personnel contributing to creation of the necessary psychoprophylactic and psychotherapeutic situation in the diagnostic and medical process excluding negative consequences (it is a part of the medical ethics).
Medical deontology and ethics also envisage a high level of training of the nurses, their accuracy and honesty in carrying out the doctor’s administrations with regard for the age, individual peculiarities, disease and morbid state of the patients, tactfulness and a psychotherapeutic approach of the nurses and practical nurses in attending to the patients and work with their relatives.
The very atmosphere of the medical institution should dispose the patients to a frank and heart-to-heart talk, arouse their faith in recovery; as early as in the registry the patients should understand that everything at the polyclinic is directed to help them and alleviate their sufferings. It is necessary to calm the patient and give him the feeling of confidence. One should exclude any conditions of strictness and ostentatious business-like efficiency. Visual aids at the polyclinic (stands, posters) must not arouse any feelings of fear and alertness in the patients or remind them of their diseases. The polyclinic should be comfortable and clean, the rooms should be located proceeding from the patients’ comfort.
It is also very important to establish the protective regimen at the in-patient departments. Much depends upon the patients’ contact with their doctor. It is necessary to start a conversation with the patient talking to him but not looking through results of his analyses; the doctor should thoroughly think over every word addressed to his patient and avoid using slangy words. The round of wards at the departments should be made every day and better at the same time; it is not recommended to ask and elucidate any intimate details in other patients’ presence during the rounds, as these details are connected with the patient’s life and disease.
The doctor should display great tact and delicacy in the case when he has to change the treatment administered by another doctor. It is prohibited to tell the patient that he was treated incorrectly as it may shake his faith in medicine on the whole.
An important aspect of the doctor’s activity consists in the medical secret which is defined as follows: the medical secret means any information which is not to be made public and includes data about the patient’s disease and personal life obtained from him or revealed in the process of his examination and treatment, i.e. when the medical worker performs his professional duties. Any data concerning the functional peculiarities of the patient’s organism, corporal defects, bad habits, peculiarities of his mentality and, finally, his private property, circle of acquaintance, interests, hobbies, etc., rather than only the disease itself should not be made public. The purpose of the medical secret is to prevent cases of causing the patient and other persons any possible moral, material and medical harm.
Lack of satisfying the requirements of deontology and medical ethics results in development of iatrogenies.
Iatrogenies
Iatropathogeny, contracted to iatrogeny (iatros = doctor, gennao = to do, to produce), is such a method of examination, treatment or carrying out prophylactic measures that results in causing harm to the patient’s health by the doctor. In the broader sense of the word, it means the harm to the patient done by a medical worker. In this connection, the term «sorrorigeny» is used; it means the harm caused by a nurse (sorror = nurse), like other fields use the term «didactogeny», or «pedagogeny», i.e. causing of harm to a pupil by his teacher in the process of training.
Somatic iatrogeny is distinguished, where the harm maybe done by using drugs (e.g. allergic responses after administration of antibiotics), mechanical manipulations (surgical operations),, irradiation (X-ray examination and radiotherapy), etc. Somatic iatrogeny which is through no fault of medical workers may result from an unusual and unexpected pathological responsiveness of the patient, e.g. to the drug which causes no complications in other cases.
Sometimes they are due to an insufficient skill of the doctor, peculiarities in his personality, temperament and character, as well as his mental state, e.g. inability to focus his attention in cases of tiredness and haste. The cause of a harmful effect of some unsuccessfully chosen drug consists, first of all, in the person who administered it rather than in the drug itself.
Psychic iatrogeny is a type of psychogeny. The latter means the psychogenic mechanism in the development of a disease, i.e. development of the disease caused by psychic effects and impressions. Psychic iatrogeny includes a harmful psychic effect produced by the doctor on his patient through words and all means of contacts among people which have their effect on the whole organism of the patient rather than on his mentality only.
Possible sources of iatrogenies are mentioned below.
An incorrect provision of medical education and popularization of data of the medical science may become a collective source of psychic iatrogeny. In the process of sanitary-instructive work, it is prohibited to describe the signs of a disease without their purposeful selection and give a full objective description of the treatment. It is necessary to focus attention only on those facts and circumstances that can help persons without any medical education get a real idea of the disease and the necessary information how to prevent it. If the listeners have no medical education, the medical worker should not discuss the differential diagnosis even if they ask questions concerning their personal signs and complaints, but the whole picture of the disease and its treatment is unknown. Such explanations may be given during individual sanitary-instructive work with sick and healthy persons.
In the process of preventive medical examinations at factories, examinations of the men called up for military service, donors, sportsmen, expectant mothers (these measures are directed at promoting good health for the population) doctors may often reveal some accidental and insignificant abnormalities, e.g. unimportant deviations on an electrocardiogram, minute gynaecological or neurological signs, etc. If the examinee gets to know about these deviations, their meaning should be immediately explained to him, otherwise he may think that they are very serious and it is for this reason that he was not informed about them. However it is better to do preventive examinations in such a way that the examine ( does not get any information about these insignificant deviations.
Mentality is affected by a «medical labyrinth». The patient seeks for medical advice but is sent from one doctor to another, and everywhere he is said that he «should be treated by another doctor», with different degrees of politeness he is not rendered any aid. The feelings of dissatisfaction, tension and anger begin to grow in the patient, he is afraid that for this reason his disease will become neglected and difficult for treatment.
The following types of iatrogeny are distinguished:
1.Etiological iatrogeny, e.g. iatrogeny due to overestimation of heredity; the doctor’s phrase «It is hereditary» causes hopelessness in the patient, the latter fears that the same bad fate will overtake the other members of his family.
2.Organolocalistic iatrogeny develops in the case where the doctor explains undiagnosed neurosis, i.e. a functional psychogenic disease, as an organic local process in the brain, e.g. thrombosis of the cerebral vessels.
3.Diagnostic iatrogeny, when an ungrounded diagnosis which later undergoes unsuccessful changes becomes a source of a psychic trauma for the patient.
Some words produce, so to say, a «toxic» effect on the patient; first of all, these are «infarction, paralysis, tumour, cancer, schizophrenia» . Therefore it is better to avoid these expressions. Sometimes iatrogenies are caused by unclear statements made by the doctor,
Even seemingly harmless statements made in the patient’s presence at an X-ray room result in his unexpected traumatism, particularly if they are pronounced with some significance or surprise.
♦ Therapeutic iatrogeny develops in the process of treatment. Its example can be provided by the use of some drug about which the patient knows that it did not help him in the past. Here a negative placebo effect is produced. Therefore prior to administration of any treatment it is recommended to check the case history how effective was the treatment previously used. As a rule, it is often forgotten because of a lack of time. Therapeutic iatrogeny is facilitated by a so-called therapeutic nihilism, i.e. a pessimistic viewpoint of the doctor on the supposed results of the treatment.
♦ The process of treatment may be characterized by pharmaceutogeny, i.e. causing of some harm to the patient by a lame statement of the pharmacist. Patients often demand from the pharmacist to explain the features and effects of the drug administered by the doctor. It is dangerous to use such statements as «It is too potent for you» or «It is no good at all, but I have got something better».
♦ Prognostic iatrogeny proceeds from an unsuccessfully formulated prognosis of the disease. From this viewpoint, such cynical and openly traumatizing statements as, e.g. «You have only a few hours to live», deserve censure. However, both straightforward and peremptory optimistic statements are of a questionable value even in the case when the doctor believes that using them he will suggestively produce a positive effect on the patient. Such statements as «In a week you will be sound as a bell, uponmy word!» may become false and will shake the patient’s confidence in his doctor in future.
Besides the above situations and circumstances, sources of iatrogeny may be also found in the medical worker’s (first of all, the doctor’s) personality; e.g. in his unwarrantedly peremptory statements, excessive self-conceit: an omniscient doctor. Such a personality easily suggests the patient his opinions and viewpoints. Personalities of the peremptory type easily substitute absolute confidence for a good possibility in their statements. But the opinion once formed does not enable them also to watch other potential features in the process of the development of the disease; the above features may become predominant, e.g. during the transition of the disease from the syndrome of bronchitis initially diagnosed as a common disease to a malignant process.
The diffident and doubting doctor, as a type of personality, is at the opposite pole. The patient often explains himself the way of the doctor’s behaviour conformably to his disease, e.g. the doctor’s hesitations are regarded as proof of the severity or even incurability of his state. The doctor increases this impression by the fact that he «thinks aloud», tells the patient about all possibilities of the differential diagnosis, does not complete a long line of auxiliary methods of examination and leaves the patient without any treatment for this time or gives him the initiative with respect to the kind of treatment, e.g. with such words as «If only I knew what to do with you!» The doctor should always be an artist in the correct under standing of the meaning of this word; he should be able to conceal from the patient a possible difficulty and, in the majority of cases, some temporary uncertainty about his diagnostic and therapeutic approach. The doctor’s subjective uncertainty should not affect his objective behaviour.
The patient’s personality may be another source of iatrogeny. A timorous, frightened, diffident, emotionally vulnerable and mentally inflexible patient is recognized by his tense facial expression, an increased sweating of his palms when shaking hands, often also by some fine motor tremor. He is inclined to timorously interpret our wordy or other manifestations, frequently even those ones that are not of any significance for us. We may be additionally surprised how such a patient understands our silence or a tired gesture of a hand that are regarded by him more important than words. The nurse may observe how such a patient restlessly walks at the waiting-room before his turn comes, how he lively participates in talks of other patients about diseases or quietly and with strained attention listens to them. Other patients would try to get insignificant details from the nurse before going to the doctor. It is necessary to tell the nurse that she should inform the doctor about such patients.
Sometimes the role of the patient’s personality in the «iatrogenic impairment» can be so pronounced and decisive that the question is not of iatrogeny proper, but pseudoiatrogeny which is through no fault of the doctor. Pseudoiatrogeny develops in the cases when the patient cites such statements of the doctor which he has never made or isolates only separate parts from the doctor’s explanation,
At present much attention is paid to training general practitioners, i.e. family doctors.
The general practitioner (family doctor) works following the principle of the district doctor, hereby attending to adults, teenagers and children and performing the following functional duties:
— organization of and carrying out a complex of measures for general prophylactic medical examination of the population in his district, elaboration of individual complexes of prophylactic, medical and health-improving measures for each resident of the district, prophylactic inoculations and dehelminthization of the population, popularizes principles of the healthy mode of life;
— rendering of the opportune medical aid to the adults and children of the district in charge.
The general practitioner (family doctor) must know:
♦ fundamentals of medical psychology, social hygiene, organization of public health and economics in compliance with the tasks of health control for the population of the district in charge;
♦ fundamentals of general theoretical subjects within the scope required for solving professional tasks;
♦ anatomical-physiological and psychological peculiarities of the adults, children and aged people, peculiarities in the development of healthy children and teenagers, contemporary classifications of internal diseases in children and adults; health groups and risk factors in the development of diseases;
♦ causes of appearance of pathological processes in the organism, mechanisms of their development, the course of diseases depending upon the sex and age, their clinical manifestations and main syndromes;
♦ clinical picture, diagnosis and prevention of mental diseases and narcomanias (disturbances of perception, memory, thinking, mentality, the sphere of emotions, attention, drives, unrestricted activity and consciousness, the above aspects of psychoses related to somatic diseases, as well as those of schizophrenia and the manic-depressive syndrome, epilepsy, psychoses of the involutional period, neurasthenia, obsessive-compulsive neuroses, hysteria, psychopathies, mental retardation, alcoholism and alcoholic psychoses, narcomaniae and toxomaniae);
♦ fundamentals of examination in mental diseases;
♦ fundamentals of resuscitation, clinical picture, diagnosis and principles of treating main emergencies;
♦ pharmacotherapy of the most common diseases, the mechanism of effect and doses of the main drug preparations.
The general practitioner must know the aspects of psychohygiene and psychology of the family, attitude of the members of the family to their health, responses of the family to stresses, psychological problems of the family, attitude of the members of the family to sick persons (alcoholism, narcomanias, psychosexual disturbances).
The family doctor must be able:
♦ to take case history of sick and healthy persons using psychodeontological regularities of communication, to determine the mental state of the patient (stress, anger, fear, joy, etc.), streaks of his character, temperament, the level of mental development, anxiety and alarm;
♦ to observe the mental activity of people, to use the method of rational psychotherapy;
♦ to diagnose nervous system disturbances (craniocerebral symptoms, autonomic dystoniae, polyneurititides, plexititides, radiculopathies, autonomic-endocrine disturbance of the hypo-thalamic localization, brain concussion and contusion);
♦ to determine the state of the processes of perception, memory, thinking, attention and purposeful activity, consciousness and mentality, to diagnose affective disturbances, neuroses, psychopathies, alcoholism and narcomanias.
Successful performance of his professional functions by the family doctor is possible if only he has such most important personal streaks and skills as:
♦ humanism and justice, mercy and sincerity, tactfulness and affability in relations with other people; modesty and delicacy;
♦ possession of high culture, a regular execution of instructive and educational work among the population, the work for strengthening the healthy mode of life;
♦ initiative, discipline, careful fulfillment of his obligations, loyalty to Hippocratic oath, honesty and self-discipline in his work, a principled and exacting attitude to himself and other members of the staff; a systematic increase of his professional knowledge and skills;
♦ an ability to be an attentive interlocutor and communicable in contacts with the patients and their relatives, an ability to memorize and effectively use the general and specific information (obtained in the process of intercourse with them) for prophylaxis and treatment;
an aspiration to a collegiate solution of professional problems in the staff of the polyclinic (out-patient department); efficient performance of his functions as an organizer of the work and an educator of the junior medical and paramedical personnel; preparedness for business contacts with trade unions and administration (management) of enterprises in the populated area or settlement where the patients attended to the general practitioner live or work;
♦ neatness, tidiness, an immaculate appearance which attracts the patient to communication with his family doctor.
Each disease, except its typical clinical manifestations, is always accompanied by larger or smaller changes in patient’s mentality. Any disease, even if it is not accompanied by organic disturbances in the brain, influences the patient’s mentality.
On the one hand, the clinical picture of mental changes is determined by disease and on the other hand, by peculiarities of psychological characteristics of the patient.
Psychological peculiarities of patients with internal diseases
At acute onset of the disease a sense of confusion, fear of death appear in patients. At lingering illness the mood is reduced, irritability and excitability appear.
There is fear, anxiety, confusion in acute period of disease in patients with rheumatism. In future the mood is reduced and in severe cases flaccidity and apathy are changed by the appearance of locomotive and speech activities with underestimation of severity of disease and its consequences. The patients with progressive polyarthritis are suppressed and depressive, such patients get on with each other badly. As opposed to this the patients with Bechterew’s disease are amicable, as a rule, optimistic, they accept their fate with a smile even at immovable spinal column.
During the initial period of forming valvular heart diseases there are unpleasant sensations, the patients fix their attention on the heart work, fear of death from cardiac arrest appears.
In hypertension during the first stage the majority of patients estimate their health condition adequately, they fulfill all doctor’s prescriptions. People with anxious hypochondriac character perceive increased arterial pressure as a catastrophe. They fix their attention on unhealthy sensations, range of their interests is limited by the disease. In hypertension some patients ignore the possibility of sever consequences and refuse from treatment and they do not give up harmful habits.
In cerebral atherosclerosis the patients become groundlessly susceptible, hesitation of mood, lacrimation, diminution of efficiency and irritability are noticed.
During the period preceding to development of myocardial infarction a sensation of vagueness in the head, difficulties in concentration of attention, presentiment of approaching danger, anxiety, melancholy, in some cases euphoria appears. In acute period of myocardial infarction the painful syndrome is accompanied by fear of death; during the recovery the attention of patients is fixed on their sensations, they are hypochondriac.
In bronchial asthma the emotional tension promotes the origin of asphyxia attacks, moreover, the reaction at this to a considerable extent depends on peculiarities of the person. Such patients often feel fear connected with waiting for another attack. In chronic course of bronchial asthma the change of patient’s character occurs. In pneumonia, when the temperature is rising, consciousness of patients can be disturbed.
In acute pneumonia in some patients reduction of activity, hypodynamia, unsociability unhealthy attitude to investigation and treatment are observed. When the temperature is rising, the consciousness of the patients can be disturbed.
In chronic lung diseases many patients feel reduction of mood, irritability, their attention is fixed on unpleasant sensations, and a thought of incurability appears.
In pathology of organs of digestion psychological peculiarities of patients are formed under the influence of such symptoms as meteorism, frequent urges to defecate, which cause a sense of shyness, discomfort. The patients with chronic gastritis complain of weakness, reveal the activity in investigation and treatment, some of them are afraid of carcinoma of stomach.
In peptic and duodenum ulcer patients often «go into disease», fixing their attention on unpleasant sensations, they feel fear of pains. The loss of weight, gastric hemorrhage, diminution of efficiency cause anxiety for life, sensation of irreparability.
Nonspecific ulcerative colitis is often accompanied by sense of melancholy dissatisfaction with the fear of death.
In chronic liver diseases such characteristics as dissatisfaction, «irritable» grumbling appear in patients’ nature.
The patients with groundless persistent fear of malignant neoplasm, which they think they have found, require a great psychotherapeutic work. The doctor must patiently and persuasively prove insolvency of patient’s suspicions. Such patients must not be ignored oo account, because a scornful doctor’s attitude can finally persuade them in their truth and it can lead to suicide.
Gerontology: in some therapeutic departments there are more than 60 per cent of people over 60. There is no doubt that the improvement of vital conditions and medical aid prolong the life. But somatic preservation of life is not always connected with its positive mental filling. Old people caot adapt to rapid changes of life and they are not able to understand much that is difficult for young people too. In spite of that they live with young people in the family, they are still relatively isolated as far as they do not always understand new conditions of work and life. But in those cases when the people live in total solitude, their condition is the most complicated. In old solitary people such paradoxical phenomenon may be occurred that their disease will become the last opportunity of establishing the contact with people: the doctor comes to the patient, the patient can be hospitalized, where in the group of patients he would feel sympathy and interest to him.
The border between the health and disease is more pronounced in old people than in a young age. German people say about everyday usual malaise – «Alltagsbeschwerden». In frequently repeated malaise in old people attitude to it plays an important role: whether this malaise will be felt more intensively, cause fear and diffidence or whether a person on the border between health and disease will be able to abstract from unpleasant sensations, to live more by impressions of events, happening in the world and the contacts with surrounding people than by own body and fear of it. At deficiency of other stimuli, aged solitary people concentrate their attention on somatic processes, intensively feel their sensations, conditioned by organic and neurotic causes, and do the only, which, to their opinion, makes sense: they go to the doctor and ask for help.
Psychological peculiarities of patients in surgical clinics
In this speciality the technique has achieved more perfection both in sense of interventions and in equipment. Surgeons’ concentration of attention on surgical technique and its facilities sometimes leads to underestimation of patient’s psychological state. In a number of cases there is cold, featureless atmosphere, where the patient does not feel well. When the patients change frequently and the personnel is in a hurry, which is caused by emergency, it is not always possible to develop psychological relations between the medical personnel and the patient. Moreover, the patients often consider the surgeon an ideal doctor who brings help by means of rapid energetic intervention, which is taken by the patients passively. In surgery, in surgeon’s conduct, in popularization of prominent achievements of modern surgery those are definite magic features, that is why today we can speak about one of the magic forms. In surgery the patient more than in other speciality is given to doctor’s power, especially when he is under narcosis during the operation, Mental shocks, felt by the patient in such circumstances, often lead to that, the patient before the operation informs his doctor about vital problems frequently kept from the other.
Crippling interventions such as amputation of limbs, mastectomy in breast cancer, providing intestinal patency in intestinal carcinoma, partial gastrectomy in relapses of ulcer cause a considerable psychial trauma to the patient. Subjective feelings and patient’s attitude to his own physical state often play the most important part in the future life than the size of organic lesion.
Sometimes patients refuse from operation. The causes of refusal are:
♦ The patient has frightened by other patients, who had undergone such intervention, and telling about unpleasant impressions, which they had felt «heroically», they want to be in the centre of attention and to call the astonishment.
♦ Similar operation has led to severe consequences, deformation or even death of the patient’s relative or friend.
♦ The patient underestimates or denies his disease on light-mindedness or to avoid misgivings or cares.
♦ For everything the patient reacts by fear or misgiving. The question is often about psychopathic and neurotic persons.
♦ Unpleasant own impressions of the previous operations, for example, fear of narcosis, when many patients feel expressed fear «of a sense of falling into a bottomless precipice».
One of the most important stages is preparation to the operation. The surgeon should reveal interest and affability, to estimate the role of the disease and operation in the patient’s life and his future; it is important to listen to his misgivings and wishes. Some patients are afraid of unconsciousness and helplessness, caused by narcosis, they feel fear of not waking up, suffocating, disclosing their secrets, «telling nonsenses», becoming funny. Such mood is sometimes strengthened by other people who tell about their impressions, which they had felt. Some patients unwarrantably say that «narcosis had not produced any effect» and they were operated being «in clear consciousness». Sometimes because of ignorance they take local or lumbal anesthesia for general one.
At the first stage of narcosis the patients are not notable for increased receptivity to personnel expressions which retained in their memory, but sometimes, these words are perceived illusory or remembered distortly after recovering from anesthesia, and mental iatrogenia can develop without the fault of personnel. That is why it is necessary to bring to minimum speech contact between the medical personnel during the operation. At recovery from anesthesia patients demonstrate increased sensitivity to sensory irritations, such as noise, strong light, smell, which can cause nausea and vomiting. It is necessary to take this into consideration at preparation of the room where the patient will be kept after recovery from anesthesia.
The operation is a source of tension, as it is connected with waiting of result, sometimes the patients are injured by the delay in the terms of the operation. Although after the operation the majority of patients do not know about its consequences, they have a sense of alleviation, because of «becoming a thing of the past», «their returning to life», or «avoiding of death». It can favourably influence the action of a surgical placebo, especially in patients with inoperable tumours. However, in the majority of cases a sense of alleviation is brief or it is changed by strengthening of symptoms, resulting from both the disease and the postoperative weakening of the organism. If the disease becomes worst, the patients unwarrantably attribute it to the operation: «The operation is guilty», «I should not have agreed to the operation». The postoperative course becomes difficult due to such circumstances as: a bad contact of patient with the personnel, the patient’s incapacity to express his condition by means of words unfavourable vital and family situations which can complicate the operation’s results, bad adaptability; his emotional immaturity, a weak or unbalanced type of temper, neurotic features of the character.
Elderly people adapt worse to the changes, they are more afraid of death. Their wounds heal slowly, the postoperative complications develop frequently and last for a long time. (Twenty five per cent of elderly people have postoperative complications). They also have brain disorders with disturbance of blood supply and metabolism. They long for visitors who must be admitted to the patients, as they get accustomed to their belonging, the nurse should arrange with patient’s relatives which things are necessary for the patient, for instance, spectacles or hearing apparatus.
In spite of strict demands of a hygienic regimen in surgical department these requirements can be satisfied.
Plastic surgery: According to this speciality two fields of psychological problems can be described, which are various to some degree, but equally labour-intensive and complicated. Objectively, there are those conditions when the surgeon improves the results of severe injuries or burns, and during the team-work with the personnel or a psychologist he should prepare the patient to a sudden psychic trauma, for example, the first look in a mirror after the operation. The face looks aesthetically better when compared with what it was after the trauma or burn, the patient compares his appearance with that he had before the trauma or burn, and he can be disappointed or shocked.
Another field of problems deals with cosmetic operations, with the dissatisfaction with appearance and it has exclusively subjective character. For instance, the patient does not wish to have a «potato» nose or a «very turned-up nose», and he persistently demands improvement of this defect. Satisfaction of this requirement, if it has very subjective reasons, and moreover, if it is accompanied by striking, exalt, a hysterical conduct is somewhat dangerous. Such patient may be dissatisfied with improving the defect, and he or she will insist on one more operation.
In such patients their «defect» is a subjective internal justification of their vital failure, for example, in private life. Then they accuse the surgeons of their problems and try to punish them. In this case the question is about an expressed type of extrapunitic reaction of frustration.
Traumatology. Traumatologists should take into account that the attitude to trauma and rendering help change according to that fact whether the trauma prevents some interests and demands of the injured patient or relieves them. As a rule, sportsmen do not visit a doctor with small traumas. Injured people, who want to hide their traumas, for example, children, who had come to blow and had been afraid of punishment, or adults, who are in conflict with police, avoid the registration. At injury the motivation influences trophic processes and healing of wounds. «The wounds are healed better in soldiers of attacking army than in soldiers of retreating army».
The most impotent psychological task of medical personnel is attraction of the injured patient to an active rehabilitation for prognosis of favourable results.
Orthopedics. Marked body deformations influence the development of the person. The inferiority complex, malice, sarcasm, hostile prejudice with respect to healthy people are observed. Such development is noticed in persons with scoliosis; they are reserved, gloomy, avoid the society, they do not go to disco or to bathe, especially girls. Sometimes some very tall young people insist on shortening their extremities in order to find a partner more easily. The attitude to orthopedic defects is often disharmonic: some people try to hide their defect and avoid such kinds of activity which may be useful for them, for example, swimming. On the contrary, others incline to hypercompensation, try to compare with healthy people or even to leave them behind in sport, tourism, or dances. Some people try to derive benefit, for example, to get retired. Possible malingering is not diagnosed easily as in such cases the organic functional psychogenic symptomatology is interlaced indistinctly. Sometimes, according to their imagination about «the right on health», the patients insist on complicated operations which require the fulfillment of unreal demands.
Psychological peculiarities of patients in gynecological clinics
In girls the appearance of first menstruation sometimes causes fear and neurotic reactions, that is why they should be psychologically prepared. But, even in that case when the girl is informed she can feel painful menstruation. The girl who little by little becomes a woman feels her feet and looks for the corresponding examples. Most often her mother becomes such an example. If the mother’s marriage is unhappy, the daughter takes the part of the woman dually or even with misgiving and aversion. But even in healthy women, during the menstruation there are pains in sacral region and abdomen, pressure in genital organs, mental irritability and inclination to depression.
At negative mental feeling of menses these symptoms may be strengthened, and dysmenorrhea appears. In dysmenorrhea it is difficult to establish the role of hormonal and mental factors, and all the peculiarities should be bom in mind. At premenstrual period in many women the similar manifestations are present: irritability, fatigue, and headaches. Premenstrual complaints may be relieved by means of placebo in 60 per cent that shows the considerable influence of mental factors in their origin. Expectation of menstruation is often tense, connected with fear of pregnancy. Amenorrhea (e.g. the full absence of menstruation) may be caused by suggestion and hypnosis. It also develops in depression and fear of unwanted pregnancy. In that case there is a positive reverse connection, «vicious circle»: misgivings lead to amenorrhea which strengthens the fear. The influence of these disturbances was described: at earthquakes, air raids, in concentration camps, at death of the closest people or relatives and even at removals. Sometimes it is said about amenorrhea as «tendentious» purposeful symptom; living in a hostel, the girls are ashamed, try to avoid the attention, that is why they suppress the menstruation psychogenically. On the contrary, menstruation as a tendentious sign can appear prematurely, for instance, before the operation which causes fear in women, so that the menstruation «saves» the patient from unpleasantness for some time.
At gynecological examination in is necessary to remember about the feeling of shyness. The women are often admitted to a gynecological clinic for intervention, that is why it is necessary to keep similar recommendations as in surgical departments. Obstetric divisions deserve a special attention. The physician should know about the feelings of an expectant mother, especially of primipara: anxiety for pregnancy termination, fear of labor pains, trouble for the infant’s health. The unbalance, emotional instability, shame of parturient women demands benevolentness, affability, cordiality from the personnel. If possible delivery room should be situated not closely to admitting unit and prenatal wards. It is very important to watch for puerperant women as various mental reactions may occur during postpartum period.
Climacteric is one of the most important stages in a woman’s life, when the hormonal changes sometimes cause flushes to the head, tachycardia and other symptoms. But all these disturbances, appearing in climacteric, are not only hormonal ones. For a number of women menopause is a stimulus for summing up the life, for thoughts of whether they are glad of their life and what they can expect from the future. Many women do not know that sexual life may be continued after menopause and it may be more harmonic, especially in women who were afraid of pregnancy. Doctor’s assertions that disorders in climacteric have exceptionally hormonal origin can cause iatrogenia.
Psychological peculiarities of patients with infectious diseases
The fact of discovering the infectious disease and necessity of hospitalization cause senses of shame, fear in patients, they are afraid that they can become a source of contamination of their nearest.
At prodromal stage of the infectious disease the patient’s estimation of his condition depends on psychological traumatic situation. Signs of general toxic character predominate, sometimes there is disorder of consciousness. At recovery stage various asthenic manifestations prevail. In patients with dangerous infections, severity of the disease, high contagiousness, a doubtful prognosis often cause acute psychological reactions, reminding the conduct of people in situations of mass natural calamity.
Psychological peculiarities of patients infected by HIV
The reaction on the diagnosis of AIDS (the most terrible disease, «the plague of the 20 th century») is manifestation of psychological stress with reduction of the mood, ideas of self-accusation, suicide thoughts or trends. Obsessive fear of death, ideas about the process of death appear in the patients, some are afraid of a thought about a possibility of infection of the relatives. In future the symptom of intellect reduction appears. In patients from the risk group, including the infected persons and the most exposed to contamination people, alarm, irritability, anxiety are observed, capacity to work is reduced. They are fixed on their health, read a lot of literature about this disease, look for the symptoms of this disease. Many people break their sexual contacts. Some of them reveal the frank antisocial tendencies, trying to pass the virus to other people.
Psychological peculiarities of patients with tuberculosis
Diagnosis of tuberculosis, necessity of prolonged hospital treatment are taken by some patients as a tragedy, a catastrophe. Anxiety, fear that the nearest and colleagues will avoid contacts with them develop. However, the majority of people receives the fact of disease and necessity of treatment correctly.
Psychological condition of the patients with tuberculosis is characterized by special sensitivity, sentimentality, emotional lability, exhaustion. The patients are asthenic, and on this background there are situationally conditioned affective manifestations and hysteric reactions. The doctor must take into account these peculiarities and consider conflict situations with surrounding people and personnel to be a manifestation of the disease. In these cases it is necessary to prescribe sedatives and not to reprimand the patients.
In asthenia there is an increased mood with garrulity, motor activity, which rapidly change into irascibility, tension or indifference.
A number of psychological problems are also caused by the treatment. The cooperation of the patients and their responsibility have great significance. The condition of undisciplined and irresponsible patients is often worsened because they do not keep prescribed regimen and method of treatment. This circumstance increases the demands to the organization of the regimen and to individual psychotherapeutic approach to the patients.
Psychological peculiarities of patients with skin and venereal diseases
The skin is the organ which the person shows to the surrounding people, as well as his figure. It has a significant psychological meaning. Mental reactions in skin disorders include a wider range of disorders, conditioned by negative aesthetic ideas, squeamishness on the hand of surrounding people and by shame, a sense of own inferiority complex and uncertainty of future in the patient. The appearance of the patient is distorted considerably by psoriasis, eczema, acne, scars after chronic granuloma and burns, colloids, hypertrichosis. Especially in the pubertal period the patients fall into depression, ofteot corresponding to the character of the disease on the objective point of view, for example, in imperceptible acne or moderate loss of hair. In some skin disorders a special problem is pruritus, which may lead to irritability, insonmia and depression. The patient is often thankful for elimination of the signs of the disease.
Venereology. Some patients dissimulate their sexual or veneral disorders in order to avoid investigation of the circumstances, which caused the disease. They look for prohibited methods of treatment: uncertainty in the effectiveness of treatment may suggest misgivings and doubts, whether they have recovered or complications have not appeared. The result of dissimulation may be infection of other people. According to the patient’s conduct, opinions, partly to the appearance and hygiene, a skilled venereologist decides whether he can rely upon the patient’s information and his cooperation in the process of treatment. In contrast to socially doubtful persons, who are vulgar, toady, sly and insincere, some accidentally infected patients are shy or they suffer from shame and feel pangs of conscience, sense of own inferiority complex, and they need an approval and definite reduction of the disease significance. Gonorrhea and trichomoniasis are the examples of that somatically «banal» and easily cured disease which may be very severe from psychological point of view.
At recovery some patients underestimate the role of the doctor’s observation for the consolidation of treatment successes. Other patients reveal suspiciousness, overestimate the significance of separate symptoms.
Psychological peculiarities of relations mother – child – doctor
The work with children, care for them, sick or healthy, correct estimation of their conduct, reactions require a special knowledge. In pediatrics, the demand of appropriate and differential approach to children of various age groups is a psychologically difficult question. A good pediatrician possesses the entire range of verbal and mimic expressions which help him approach each sick child individually. A pediatrician, who has his own children, is in more favourable condition, as he can use his own experience. The age of the child is not a reliable indicator, showing to the personnel the level of communication with him. There is a certain percent of feebleminded children, a great number of narrow-minded and retarded children, who can make up this lag in future, and children with accelerated development, which is retarded afterwards and none the less they caught up with other children.
The child’s disease is a very difficult situation for all family. The child’s reaction on the disease depends on the parents’ conduct and ways of upbringing. The child of a pre-school age is afraid of the fact of hospitalization, isolation of parents. If in the family the children were spoilt «idols», they would be helpless in hospital. The parents’ conduct at severe conditions often influences unfavourably their children.
In case when the urgent hospitalization is needed the pathologic reaction may arise when the child weeps, cries or does not leave his mother. Such reactions may last from some hours to some days.
Great psychological problems arise in the parents, when they learn about a severe, incurable, chronic disease of the child. At first, reactions of distrust are observed, and the parents consult various specialists, they hope for a misdiagnosis. The results of the investigations are often discussed in the presence of the child that influences him negatively.
In children with a lingering illness, when the parents create them special conditions, inclination to hysteric reactions, features of mental infantilism appear, which makes adaptation to outer environment difficult.
In children’s medical establishments the doctors and personnel must be able to devote themselves to the children, to play with them, as in the play a child is calmed down. During the process of plays the doctor studies the personal peculiarities of the child, his wishes and needs. The play diverts children from unpleasant feelings.
It is recommended to gather children with the same level of development in the same ward. It is necessary to remember that children, even little ones, always listen to doctors’ and students’ talks in the ward and then they speak about their misgivings to the parents.
Sometimes in teenagers the cases of simulation malingering in order to attract the attention or as the protests against any troubles are observed.
Parents suffer most of all when their child is ill with sarcoma or leukemia. The personnel receives the death of a child more heavily than the death of an adult.
Psychological peculiarities of the work of dentists
In dentistry the first place is occupied by a pain, which leads the patient to the doctor. There is the vicious circle: fear of pain makes the patient neglect small carious processes and processes causing pain, as a rule, demand more extensive and painful interventions. When rendering help a dentist usually takes into consideration the fact that the sensitivity to pain is various in different age categories; it is also due to refraction of the pulp with the age.
It is necessary to take into account individual differences in sensitivity to pain caused by either innate or acquired reasons. Super-sensitive patients whose pains are not managed by ordinary methods of treatment should be cured gradually, dentists have to receive them repeatedly and use the all accessible means for reduction of pain. If the doctor has to hurt the patients, he must act quickly, without hesitation because uncertainty slows down manipulation, reduces the quality and none the less, harms the patient. It is appropriately to show the patient that the doctor understands and fully estimates his pain, but it is not necessary to express an excessive sympathy when the dentist rendering aid hurts the patients. The patient’s anxiety before the treatment and his fear of pain complicate the work of the dentist considerably. That is why in some cases it is necessary to carry out the joint work of a dentist, psychotherapist and psychiatrist. Both psychotherapy and some psychopharmacologic facilities can reduce the fear and pain.
Tooth extraction and preparation to it cause the most considerable tension in many persons. Skilled dentists sometimes can do extraction so dexterously that the patients prepared for a great torture can be very astonished. It is not necessary to show the patient the bloody extracted tooth pressed in pincers as negative associations are created for future. Before extraction or during it some patients reveal an abnormal reaction of a fear or fear attack of a hysteric type. It is necessary to distinguish confidently depressed hysteric attack from a collapse and an epileptic attack. At rendering a help to the patient it is possible to recommend the dentist to signal the nurse his demands by means of gestures to avoid the use of technical terms, for example, «lower jaw (mandibula) pincers!»
The patients insist on making dentures on different reasons: improvement of jaw functions is the most frequent, sometimes there is an aesthetic reason, especially in women. There are great psychic problems with removable dentures which uninterruptedly remind the patient about his age, association of his condition with the age and about other circumstances. Total denture changes the face, that is why the patient is not always satisfied with the denture even if it functions well. The term «mental incorporation of a denture» is used for definition of patient’s adaptation to it. Persons feeling shy of their dentures sometimes isolate themselves from the society, avoid acquaintances and friends. Symbolically teeth have a meaning of aggressiveness, success in society and erotics; thus, depression and sense of inferiority complex develop in people with teeth defects.
Children with teeth anomalies suffer from speech disturbances and can differ from others by appearance and face, they look «stupid». They suffer from mockeries of surrounding people and react to them differently; inferiority complex and aggressiveness appear, sometimes they play the part of «a clown in the class». In order to compensate these difficulties in children’s group the parents sometimes praise to excess and overestimate the abilities and talents of their child so that it may lead to disappointment.
Psychological factor is also connected with caries and its complications. Caries is often observed in the countries where there is the highest consumption of sugar and sweets. Considerable role belongs to the way of children’s nutrition which mainly depends on whether the parents allow their children to eat sweets especially before sleep. Parents, grandparents caot be of principle in this question, even if they know a lot about correct nutrition of the child. There is a reason of «giving a child all that they could not afford to themselves», a striving to like to their children, sometimes they try to suppress the pangs of conscience in that they do not pay enough attention to the children. In some children and adults sweets become the means of calming at personal unpleasantnesses, failure and shortage of aim and sense of life.
In gingivitis depressions and apathy are always noticed when the patient is told carelessly about the prognosis of the disease. Bad breathing makes the contacts difficult. In inflammation of the oral mucosa and tongue, cancerophobia sometimes develops.
The place where dental aid is rendered, must correspond to the demands of deontology and psychoprophylaxis. The reception room must be very comfortable with many magazines, it should not remind a hospital. The sanitary posters are not an object of attention of the patients who feel fear and tension in the reception room. In dentists’s surgery it is appropriately to limit as much as possible specific dental elements, such as a white colour, «exhibition of instruments» with which the patient connects a number of his misgivings. A row of chairs standing next to each other acts negatively on the patient because it reminds them a conveyor.
Psychological peculiarities of blind people
In childhood the parents of blind children try to guard them excessively, to create sparing conditions, to protect them from difficulties to forge the initiative. It leads to development of shyness, indecision, a striving to cry, inclination to fantasy, the departure from children’s group.
The beginning of school studies is often accompanied by neurotic reactions, suspiciousness, offence, helplessness.
In blind people the overvalued ideals of decline form, they feel badly among sighted people, a forced stay in such group causes autic tendencies.
Young people up to 20 – 30 years of age manage with suddenly arised blindness, for example, after injury, better than middle-aged and elderly people. The last constant hope is for any change or any scientific discovery. Difficult mental problems appear in a married couple where blindness of both spouses is caused genetically. They doubt if they can have children, expecting that their children will be blind and all the consequences of this, for example, difficult upbringing of blind children, help of healthy children to blind parents and as a result there is parents’ dependence on children.
Psychological peculiarities of hard on hearing and deaf people
Personal reactions on declining or loss of hearing are various. Hearing apparatus plays an important part in the life of the patients. Increasing deafness causes painful feelings as regards of inferiority complex, there are irritability, offence, difficulty in contacts, suspiciousness, mistrust.
Because of difficulty in contacts with surrounding people the ideas of reference may develop, patients think that the surrounding people condemn or laugh at them. The treatment of such people at in-patient departments has a lot of difficulties. The patient tries to listen attentively to the doctor’s words and «hears something terrible about his disease». The people with hearing loss usually hide their defect from other patients in a ward and feel too shy to say that they do not hear everything.
The doctor must give a special talk to patients with hearing loss to dispel their doubts and misgivings.
Psychological peculiarities of patients with injures of face
The face of a person defines the impression which it makes on other people and helps to give an idea about himself. Mimicry defines the emotional state of a person. Aesthetic criterion with regard to the body is inherent in every man, but it plays an important role with regard to his face. People with disfigured faces notice the curious and sometimes mocking looks of surrounding people, that is why they become supersensitive, suspicious and touchy. They are often afraid to go to the street, to meet people, who knew them before. Some people leave their places and begin in a new life in those places where they have never been before.
A correct psychotherapeutic approach may relieve the sufferings of such a patient and it helps to create a positive attitude to life.
Psychological peculiarities of patients with organic cerebral affections
A neurologist meets fear of brain tumor and severe encepha-lopathy in minor diseases, for example, in headaches of other ethiology. Psychological examination may help in determining the level of disorders of higher nervous activity and mentality at organic cerebral affections.
Psychogenic factors sometimes provoke extrapyramid symptoms of organic affections, for instance, in Parkinson’s disease, in some patients they also provoke a big spastic fit and attack of migraine. Diseases connected with limitation of mobility cause depression and suppression. More attention should be paid to development of consequences of cerebral hemorrhages. The question is about individual school for adults, who need renovation of disturbed knowledge and abilities, such as speech, reading, writing and calculation.
Peculiarities of contact with mentally ill patients
The attitude to mentally ill people must be the same as to other patients: correct, polite, benevolent, merciful, affable.
Speaking to such patients it is necessary to listen attentively to the patient’s complaints even if they seem absurd as to manifestations of the disease. It is impossible to show rudeness, contempt, mockery to the patients. The doctor should get out existed in society prejudices with regards to mentally ill. It is necessary to remember that in some patients there is absence of understanding of disease and to carry out the urgent hospitalization to the psychiatric department and to treat them without agreement or, sometimes, in spite of their demands. It requires tact and patience. It is recommended to talk with the relatives calmly, softly, to convince them in necessity of treatment in out-patient or in-patient departments. In psychiatric clinic it is necessary to keep vigilance, to see that the patients do not make any actions, threatening to health and life of the patient and surrounding people. In contacts with mentally ill it is necessary to convince, but not to deceive them.
Psychological peculiarities of care for dying patients
The human being is the only living being who knows about inevitability of death. However, the man caot realize it himself.
According to psychological investigations the man usually dies like he lived. All the strength, senses, ideas about his life, are also inherent to his death. The man is not always afraid of death. Worn out by unbearable pains, exhausted by chronic disease, the patient, to whom analgesics do not help, thinks about the death as deliverance.
The majority of doctors and nurses, meeting with death day after day, try to defend themselves from its negative influence.
However, the doctor has not only to help but also to try to understand his patient’s feelings. Helpless, dependence of a dying person on surrounding people, his isolation must be taken into account at organization of care. One should regard the wishes of a dying patient with respect. Measures are dictated by his needs and possibilities of their fulfillment. The care of relatives and attention of friends are required for such a patient.
The question is often discussed whether it is advisable to tell the patient about «approaching» death. It is not always possible to persuade the patient that he can stand any «verdict». It is necessary to keep up the hope on recovery. There are a lot of cases in medicine when the condition of hopeless patients was improved.
In hospitals the doctors should pay great attention to proper placing dying people. The neighbour’s death may cause a shock in other patients, that is why it is very important to isolate a dying person. The care for such patient in a small ward is more intensive and does not disturb others.
Relatives of a dying person also require care, sympathy and attention. Doctors sometimes listen to unjust accusations to their address. And they must regard this patiently, try to help those who feels misfortune keenly.
Young doctors sometimes say, that to help a patient to die means to fulfill a humane action, to save him from sufferings. However, the doctor, possessing professional psychological qualities, such as humanism, sympathy, honesty, selflessness, never agrees with justification of euthanasia. A doctor must try to prolong the life of his patient to the last minute and to relieve his sufferings by pharmacological and psychotherapeutic means.
Neither patient’s requests nor wishes of his relatives, even registered officially (statements, video records, etc.) caot excuse euthanasia made by the doctor.
Mechanisms of psychosomatic relations. Psychosomatic reactions and psychosomatic disorders.
When studying the relation between somatic and mental states it is reasonable to distinguish the following types:
1.Psychological factors as a cause of somatic disease (proper psychosomatic diseases).
2.Mental disorders which manifest with somatic symptoms and signs (somatization disorders).
3.Mental consequences of somatic diseases (including psychic reactions to the fact of somatic disease).
4.Incidentally simultaneous mental disorders and somatic diseases.
5.Somatic complications of mental disorders.
At present there is a system of somatopsychic and psychosomatic relations which are necessary to distinguish and consider during the treatment.
Among the changes in the somatic health caused by emotional impact, we can distinguish non-pathological psychosomatic reactions, psychosomatic diseases, influence of the emotional state on the development and course of somatization disorders.
There is no common idea about the origin of psychosomatic diseases, their pathogenesis and treatment.
Psychosomatic medicine began to develop quickly at the beginning of the 20th century. Millions of cases of so-called “functional patients” were registered at that time. Their somatic complaints were not confirmed by objective studies, treatment with traditional drugs was ineffective. At first correction of the affective states and disorders in the interpersonal relations of the patients, that is psychotherapy, mental consultations were necessary.
The representatives of psychoanalysis explain psychosomatic pathology emphasizing the prevail of forcing out emotional experience (protective mental mechanism which manifests with subconscious exclusion of the undesirable thought or emotion from the conscience) which later manifests with somatic symptoms and signs in the patients with psychosomatic signs. But they neglect the organic pathology, though in practice the physician should remember that the patients may develop organic diseases, psychotherapy is not sufficient right from the beginning of the disease, the treatment of the respective disease with the use of modern Pharmaceuticals, sometimes surgery are necessary.
Scientific validation of psychosomatic relations can be found in I.P. Pavlov’s theory of conditional reflexes. P.K. Anokhin, a Russiaeurophysiologist, worked out a biological theory of functional systems. It is the concept about organization of the processes in the whole organism which interacts with the environment. This theory regards the functions as achievement of an adaptation state by the organism at its interactions with the environment.
According to this theory, any emotional reaction is viewed as a holistic functional system which combines the brain cortex, subcortical structures and the respective regions of the body.
From the point of view of neurophysiology, emotional processes involve both central (hypothalamus, limbic system, structures of activation and rewarding) and peripheral structures (catecholamines, adrenal hormones, vegetative nervous system). Extreme in its force and duration irritants change the functional state of the central and peripheral nervous system. With this functional disturbances locus minoris resistentiae (sites of minor resistance) may develop. There is a system of constant feedback which determines the possibility of therapeutic action on the emotional factor.
In response to psychoemotional stimuli various non-pathological psychosomatic reactions (visceral, sensor) may develop. Psychosomatic reactions may appear not only in response to psychic, emotional influences but also to direct action of the irritants (e.g., a view of a lemon). Representations may influence the somatic health of the person. Psychoemotional factors may cause the following physiological disturbances in various organs and systems of the organism:
a)in the cardiovascular system – increased heartbeat, changes in the blood pressure, vascular spasms;
b)in the respiratory system – delay, increased or decreased respiratory rate;
c) in the digestive system – vomiting, diarrhea, constipation, increased salivation, dryness in the mouth;
d) in the sexual sphere – increased erection, weak erection, clitoris swelling, lubrication of the sex organs, anorgasmia;
e) in the muscles – involuntary reactions: muscular strain, tremor;
f) in the vegetative system – perspiration, hyperemia.
Psychosomatics (from Greek psyche – soul and soma – body)
is a branch of medical psychology dealing with the study of psychical factors and development of functional and organic somatic disorders.
Psychosomatic disorders are those the origin and course of which are chiefly determined by psychological factors. The cause of psychosomatic diseases is affective (emotional) overstrain (conflicts, rage, fear) when definite personality features are present. Psychological factors play a role in other diseases: migraines, endocrine disorders, malignant tumors. Nevertheless, it is important to distinguish true psychosomatic diseases, the development of which is determined by psychic factors and prevention should be aimed at elimination and correction of emotional overstrain (psychotherapy and psychopharmacology), and the diseases, the development of which is also influenced by mental and behavioral factors because they change nonspecific organism resistance but they are not the primary cause of their occurrence. For example, it is known that influence of psychoemotional stress can decrease the immune reactivity which increases the probability of diseases (including infectious).
Psychogenic component plays an active role in various organic disorders, e.g. hypertesion, gastric and duodenal ulcer, myocardial infarction, migraine, bronchial asthma, ulcerative colitis, neuro-dermitis. These diseases are frequently termed “major” psychosomatic diseases, emphasizing the severity of the disease and a leading role of the psychogenic factor in their development.
True psychosomatic disorders are characterized by the following:
1.Psychic stress plays a key role in the origin.
2.After its manifestation the disease becomes chronic or relapsing.
3.The first manifestations can be noted at any age, but chiefly in teen-agers.
Classical clinical pictures of seven diseases, namely essential hypertension, ulcer, bronchial asthma, neurodermitis, thyrotoxicosis, ulcerative colitis, rheumatoid arthritis, are psychosomatic disorders.
Psychosomatic disorders are the consequence of stress caused by prolonged mental traumas, inner conflicts between similar in the intensity but different in direction motives. Some types of motivation conflicts are believed to be specific for definite diseases. Thus, hypertension is associated with the conflict between strict social control of the behaviour and an unrealized need of power. The unrealized need causes aggression, which cannot be manifested because of social restrictions. In contrast to neuroses based on intrapsychic conflicts, psychosomatic disorders are characterized by dual forcing out of an unacceptable motive and neurotic anxiety and neurotic behaviour.
As it is important to understand the essence of protective psychological mechanisms, therefore it is necessary to characterize them. The protective mechanisms are divided into primitive, or immature (splitting, projection, idealization, identification), and more mature (sublimation, rationalization). But neither the number of variants of protection (several dozens have been described) nor their taxonomy are generally accepted.
One group combines the types of protection which decrease the level of anxiety but do not change the character of inducements. They are inhibition or forcing out from the conscience of unacceptable inducements or feelings; denial of the source or feeling of anxiety; projection of transfer of the desires and feelings to the other; identification – mimicking the other person with ascribing his qualities; inhibition – blocking in the behaviour and conscience all manifestations associated with the anxiety. The other group unites the forms of protection in which the mechanisms reducing the anxiety and changing the direction of the motives work: autoaggression – direction of the hostility to himself; reversion – polar changes in the motives and feelings to opposite; regression – decrease, or turning to earlier childish forms of reaction; sublimation – transformation of the unacceptable forms of satisfaction of the needs to other forms, e.g. creative work in art or science.
The maiine forms of mental protection are the following.
1. Forcing out. This is inhibition or exclusion of unpleasant or unacceptable events or phenomena from the conscience, that is removal of the moments, information which cause anxiety. For example, ieurosis main causative event is frequently forced out.
The following psychological experiments are interesting. The subjects were given the photos of specific conflict situations close to their experience. The subjects were expected to describe them, but they seemed to forget the photos and put them aside. When the photos were given in the state of hypnosis, the protection was taken away and the photos caused the effect adequate to their content. Similar mechanism of protection is in the basis of a well known phenomena when the persootices somebody’s errors and faults and forces out his own. In other experiments the subjects were given tests on achieving success at doing some task. They recollected only those tasks which they had done correctly and “forgot” those which they had failed.
2.Substitution is switching from an unpleasant, causing anxiety experience (subject) to another. This variety of psychological defense can be illustrated by the following examples. After a conflict with the chief or a quarrel with a date the person directs his anger to the members of the family (rationalization can frequently take place). The person during an exiting talk crumples a sheet of paper. A girl when hearing a phrase “your boyfriend is always letting you down” throws away the cat sitting on her knees.
3.Rationalization. This is an attempt to substantiate the desires and acts if recognition of their couse could threaten with loss of self-respect. The examples are numerous. If a greedy person is asked to lend some money, he can always find a reason why he cannot do it (to teach a lesson, etc). If a person is unpleasant to you, you can always find a lot of shortcomings, though your dislike may not be associated with them. The patient can explain his interest to medical literature with the necessity to broaden his outlook.
4.Projection. Protection in the form of projection is unconscious transfer of unacceptable feelings to another person, ascribing somebody’s own socially inappropriate desires, motives, acts and qualities to the surrounding persons. An example of it can be the behaviour of a young well-to-do man who placed his mother to the house for aged persons and is indignant with the bad attitude of the personnel to her.
To a certain degree, projection simplifies the behaviour, excluding the necessity to evaluate the acts constantly. We frequently transfer our behaviour to other people, projecting out emotions to them. If a person is quiet, sure of himself, well-disposed, he thinks that the rest are also well-disposed. A strained frustrated persons, unsatisfied in his wishes is hostile and projects this hostility to the other.
5.Somatization. This form of protection is expressed in exit from a difficult situation with fixation on the state of health (illness before tests is the simplest example). In this case benefit of the illness is significant – increased attention and decreased demands of the relatives. In more severe cases this form of protection becomes chronic, as a rule, exaggerated attention to the health and overestimation of the severity of the disease including creating the own concepts of the disease are present. Hypochondriacal syndrome may develop.
6.Reactive formation. In this case unacceptable tendencies are changed to the opposite ones. Thus, turned down love is often expressed in hatred to the former object of love, boys try to hurt the girls they love, the people who are secretly envious frequently sincerely believe that they are true admirers of the person they are envious of.
7. Sublimation. This form of psychological protection is characterized by transformation of unacceptable impulses to socially acceptable forms of instinctive requirements which cannot be realized in an acceptable way out and the means of expression (e.g., people who do not have children frequently have pets). For some people, hobbies are a way of realizing the most unbelievable motives. Egoistic and even “forbidden” purposes can be sublimated with an activity in arts, literature, religion, science. Aggressive impulses, for example, can be sublimated in sports or policy. But proper psychological protection is meant when the person does not realize that his activity is determined by hidden impulses with biological and egoistic basis.
8. Regression. This is turning back to primitive forms of reaction and behaviour. Especially frequently this form of psychological protection is observed in children. For example, children without parents demonstrate the behaviour characteristic of development retardation: the child who began to walk suddenly stops to walk, enuresis, which was present in infancy, recurs. We can mention a habit to suck the finger in difficult situations (this feature can be seeot only in children but also in adults). Elements of psychological protection in the form of regression can be observed in some mental diseases.
9. Negation. This is a protective mechanism, which does not recognize but rejects impracticable desires, intentions, facts and actions by unconscious negation of their existence, that is real phenomena are believed to be not existing. It is necessary to emphasize that negation is not a conscious attempt to renounce, like in mimicking or lie.
In the majority of real situations several forms of psychological protection are usually used together. This should be taken into account by the doctors working both with healthy and sick persons.
An unresolvable conflict of motives (as well as uncontrolled stress) causes capitulation, refusal from the search, which creates the background for development of psychosomatic disorders in the form of masked depression. The lesion to the organs and systems is due to genetic factors or peculiarities of ontogenetic development.
Characteristics of psychosomatic disorders
Revealing psychological features which are responsible for development of psychosomatic diseases resulted in description of the features which are present in the patients with different diseases. These are reserve, anxiety, sensitivity. Below you can find descriptions of the patients with definite psychosomatic disorders.
Essential hypertension. Main properties of the personality, prone to development of essential hypertension, are intrapersonal conflict, interpersonal strain between aggressive impulses, on the one hand, and feeling of dependence, on the other hand. Development of hypertension is due to the wish to manifest hostility at a simultaneous need of passive and adaptive behaviour. This conflict can be characterized as a conflict between contradictory personal rushes (desire of frankness, honesty and sincerity in communication and politeness, avoidance of conflicts). At stress such person can restrain his irritation and inhibit the desire to answer the offender. Suppression of negative emotions in the person during stress which is accompanied by a natural increase in the blood pressure can aggravate the condition and promote stroke development.
We examined the mental state in patients with arterial hypertension and performed daily monitoring of the arterial pressure. Our study demonstrated that at the early stage of arterial hypertension after increase of the arterial pressure the patients reduce the level of anxiety. Thus, compensatory role of pressure elevation due to prolonged psychoemotional strain was confirmed.
At the beginning of hypertension disease the majority of patients can adequately evaluate their state, perceive the administrations adequately. Some suspicious patients think that increase in the blood pressure is a tragedy, catastrophe. Their mood is decreased, the attention is fixed on the sensations, the sphere of interests diminishes and is limited to the disease.
In some patients the diagnosis of the disease does not produce any reaction, they neglect the disease, refuse from treatment. This attitude to the disease is observed chiefly in alcohol abuse.
It is necessary to admit that there is no direct association between the level of the arterial pressure and probability of mental disorders development. When examining the mental state in hypertensive subjects with daily monitoring of the arterial pressure we determined the indices of the arterial pressure which can play a role in prognosis of mental disorders in this disease. These are high variability of the arterial pressure during the day and disturbances in the circadian rhythm of the pressure fluctuations: increase or absence of night reduction in the blood pressure level.
The patients with hypertension should be explained the causes of their state. They should know that the disorders of the nervous system are functional, temporary and with the proper treatment the function will be restored.
Coronary artery disease. It has long been considered that emotional stress can result in coronary artery disease.
“Coronary personality” has been described in the literature. This idea is difficult to prove because only perspective studies can distinguish psychic factors present before the heart disease and the consequences of the disease. In the studies performed in the 80th the attention was paid to several groups of possible risk factors which include chronic emotional disorders, social economic difficulties, fatigue, constant aggressors as well as behavioural pattern A. The most probable is pattern A which is characterized by hostility, excessive aspiration to competition, ambition, constant feeling of lack of time and concentration on limitations and prohibitions. When performing the studies devoted to primary and secondary prevention, main approach consisted in elimination of such risk factors as smoking, irregular diet, insufficient physical load.
Angina. Attacks of angina can frequently be induced by anger, anxiety, excitation. The sensations survived during the attack can be horrified, sometimes the patient becomes too careful in spite of the doctor’s efforts to make him get back to his ordinary lifestyle. Angina can be accompanied by atypical pain in the chest, edema due to anxiety and hyperventilation. In many cases there is discrepancy between the real capability of the patients to withstand the physical load determined objectively and their complaints on the pain in the chest and limitation of the activity.
A good effect is produced by conservative treatment together with the adequate exercise. Some patients benefit form behaviour therapy administered according to an individual scheme.
Cardiophobia. One of psychovegetative syndromes which is frequently observed in medical practice is cardiophobia. Discomfort and unusual sensations in the left side of the chest, which first occur in the situation injuriing the mental state, determine the increasing anxiety of the patients and fixation on the activity of the heart, which increases the belief in the presence of a serious heart disease and fear of death. At first increasing affective strain, anxiety and suspicion, fears as well as constitutional and developed peculiarities of the personality are the basis for development of acute cardiophobic attack. Vital unbearable fear experienced by the patients with cardiovascular disorders cannot be compared with the ordinary sensations in their intensity and character. Feeling of a close death is the only reality for the patient. The obvious fact that dozens of attacks did not cause infarction or cardiac failure does not mean anything. As it has long been known that it is dreadful to be dying not to die, the life of the patients which “died” several times is tragic. Especially important in this case is rational psychotherapy and suggestion. The life of the patient depends on their correct use and administration.
Apnea. This is caused by numerous respiratory and cardiac disorders and can increase due to mental factors. In some cases apnea is of purely psychological origin: a typical example is hyperventilation due to anxiety.
Asthma. This is thought to be caused by unsolved emotional conflicts associated with the relations of subordination, but the proofs for this are not satisfactory. In bronchial asthma contradiction between “desire of tenderness” and ” fear of tenderness” are noted. This conflict is described as a conflict “posess-give”. Patients with bronchial asthma are frequently hysteric or hypochondriacal, they cannot “release their anger to the air” and provoke attacks of suffocation. Besides, asthmatics are hypersensitive, especially to odors.
It is known that emotions (anger, fear, excitement) can produce and increase the attacks in asthma. It was reported that in children who had died of severe form of asthma, chronic mental and family problems had been noted more often than in the other asthma patients.
Mental disorders are not more frequent in children with asthma than in the whole children population but when these children have mental problems they are more difficult to treat.
There were several attempts to treat asthma using psychotherapy and behavioral therapy but there are no convincing data suggesting the efficacy of these methods when compared with ordinary advice and support. Individual and family psychotherapy can benefit in treatment children with asthma in case when psychological factors are important.
Gastritis. In patients with gastritis and ulcer a specific character is formed in the childhood, these adult patients constantly need protection, support and guardianship. They respect force, independence and strive for them. As a result two opposite mutually exclusive needs (guardianship and independence) collude which causes unresolvable conflicts.
Ulcer. The patients with gastric and duodenal ulcer have specific features. They are often persons with explosive emotions, their thinking is categorical, frank. The other group of the patients is not prone to external manifestations of the emotions. They are frequently gloomy, distrustful people. Some authors associate ulcer with inappropriate self-perception, need in protection.
Strong prolonged affects, negative emotions such as constant fear, grief, fright at strained cortical activity can cause prolonged spasm of the blood vessels in the stomach walls, if the resistance of the mucous membrane to the action of hyperacid gastric juice is low, it can result in ulcer appearance. Further development of ulcer depends on both the above factors and appearance of pain impulses from interoreceptors of the involved organ. Psychotherapy influences the course of the disease and the efficacy of treatment.
Colitis. Ulcerative colitis was noted to begin after experiencing “loss of the object” and “catastrophe of experience”. Decreased self-estimation, excessive sensitivity to the failures and strong desire of protection and dependence are characteristic to these patients. The disease is often regarded as the equivalent of grief.
Diabetes mellitus. Feeling of chronic dissatisfaction is characteristic for the personality of the patients with diabetes mellitus. But it is believed that in contrast to the patients with the other psychosomatic disorders there is no definite diabetic type of personality.
Neurodermitis. Eczema and psoriasis are considered to be neurodermitis of psychosomatic origin. The patients are passive, they experience difficulties with self-confirmation.
Diseases of the locomotor system. The patients with rheumatoid arthritis are characterized by “stiffed and exaggerated position”, they demonstrate high level of self-control. Characteristic is the tendency to self-sacrifice and exaggerated readiness to help the people. Their help has an aggressive character.
The leading role in treatment of psychosomatic disorders is played by general physician. But psychotherapy is also important for prevention of these diseases and at all stages of treatment and rehabilitation. Important is revealing personal predisposition and prolonged personality-oriented psychotherapy. General physicians should train the patients the skills of psychic self-regulation, autogenic training for mobilizing and relaxation in stress situations.
The approach to treatment of neurotic and somatoform disorders, when the complaints of the patients are associated with functional somatic diseases caused by mental disorders, is different. In this case the treatment is administered by a psychiatrist with the use of psychotherapy and psychopharmacotherapy.
Concept psychotherapy psychosomatic illnesses
At the dawn of medicine to cure disease of any approach from the perspective of the unity of the soul (psychological) and body (“Catfish,”).Even Hippocrates considered the disease as a breach of relations between the subject and the world. Actually it is a deep and wise tenet that you should not treat the disease, but the patient and the doctor must know to explore and take into account the individual characteristics of the patient (his behavior, language and even silence). To put it in modern language, we can say that medicine at that time was “psycho-socio-somatic.
Development and natural claims positivistic outlook contributed to the “somatic” component of medicine. First of all, by the work Louis Pasteur and Robert Koch became increasingly spread the idea that in future all somatic and mental diseases can be treated and explain with the help of biochemistry and physiology. Even Freud hold back the positivist views, expressing belief that his psychological model of mental illness only temporary theory that sooner or later replaces the biochemical and physiological model.
However, through the microscope eyepiece Pasteur saw the world as if one eye, closing the second eye, “responsible” for understanding mental laws. Today is not enough. To understand the nature of the disease need to look at the phenomenoot only somatic, but also the “psychological” view, and connect with this and “third eye” – “responsible” in this context for understanding social interactions. The first application of psychoanalysis to psychosomatic diseases associated with prompting Paul Federnom at the Vienna psychoanalytic psychotherapy Society case a patient who suffered from asthma. Later psychoanalyst Georg Hroddek consistently applied psychoanalysis in its proper private sanatorium in Baden-Baden in the treatment of mainly somatic diseases. He is owned by the term “psychosomatic medicine.
What can be considered a psychosomatic disease?
Precisely speaking, the origin and flow in all the diseases involved psychogenic components. Emotional experiences show the influence of morphological structure through hormonal and immune systems, as well as by autonomic nervous system. In turn, the somatic changes affect the mental state. Thus, if the disease has a somatic, ie, physical, physiological or organic nature, secondary causes abnormal mental reactions, it can be called, “somato-mental” disorder. If the first re-mental reasons leading to physical disorders, such diseases are called “psychosomatic”.
Psychosomatic illness can be divided into:- Somatoform violation;- Psychosomatic diseases and physiological violation;- Behavioral disorders with somatic consequences.
Somatoform violation – a psychogenic functional disorders of the organs in which there is not any morphological or structural violations of these bodies. For example, tachycardia at kardionevrozi nevynosymi can bring suffering and cause great fear, especially when the “heart ready to break out of the chest, although noticeable changes in heart work happens. However, if such condition persists for a long time, you can show the morphological changes in secondary organs. For example, psychogenic lowering activity of certain muscle groups can then be wasting them.
About psychosomatic diseases and physiological disturbances in the body can speak, appear as organic changes in the patient body. Mental factor mainly determines only part of the reasons that led to these diseases. Other factors are also important genetic, somatic and social reasons. In this regard we can speak of multifactor etiology of disease.
Among the many psychosomatic diseases traditionally produce the most studied group of so-called “seven sacred cows” Psychosomatics, which include:
1) gastric ulcer and duodenal ulcer;
2) ulcerative colitis;
3) bronchial asthma;
4) thyrotoxicosis (Grave’s disease);
5) essential hypertension;
6) rheumatoid arthritis;
7) neurodermatitis.
1. Stomach ulcer and duodenal ulcer may cause a variety of reasons: stress, night work and bezsvidomi internal conflicts. Today ulcer treated successfully and efficiently with the help of drug therapy. It also used drugs that have strong psychotropic action (eg ehlonil). Important role in causing leakage and disease also play a psychological impact, with ulcer dvanadtsypaloyi intestine they are more expressive than gastric ulcer. Holding accompanying psychotherapy simplifies treatment of the disease.
2. Ulcerative colitis is a heavy inflammatory lesions of the colon with abdominal pains, diarrhea, often with strong sanies. This disease, striking mainly small intestine, called Crohn’s disease (terminal ileyit). Along with loss of blood which can lead to anemia, these serious diseases are other problems. Ulcers can affect bowel wall until the breakthrough. Great chance of rebirth in malignant ulcers. Although ulcerative colitis and Crohn’s disease occur only if the available relevant somatic tendency, while they include sometimes minor and sometimes significant psychogenic components. Paroxysmal disease progression. Aggravation may be called mental stress, such as separation from a loved one. Psychotherapy, in combination with medication, can detect a positive effect on the flow of disease. In some cases, despite the psychotherapeutic treatment, surgery is needed in the intestine.
3.Bronhialna asthma – is difficult and, unfortunately, very common disease. It is characterized by attacks of breathlessness and typical asthma, arising as a result of spasm at the level of small bronchi. In this connection it is a kind of valve effect: the breath is relatively free and exhalation difficult. Asthma runs paroxysmal but separate asthmatic attack may continue for many days. The clinical picture of disease clearly present allergic, genetic, climate and infectious components. Allergic factor in the genesis of asthma becomes more and more importance, in addition to this, of susceptibility to asthma and asthma attacks show some influence psychotic components. Often difficult to predict in advance whether psychotherapy successful in each case. Yet by experience, when it can help achieve significant improvement. Basically, psychotherapy combined with medication. In reviewing the Indications and Contraindications of psychotherapy should be considered dangerous asthma attacks increase in the mobilization of blind carbon copy bezsvidomyh conflicts. If these conflicts are conscious, they may even initially increase susceptibility to the occurrence of asthma attacks. Carried out in physiological experiments, in which bronchial muscle spasticity amplified under the influence of experimental mental stimuli. In other experiments studied the mental impact on the appearance of allergic reactions. For example, in patients allergic to hay typical asthma symptoms when there Poverty in the doctor image bevelled summer meadows, though the real allergen in the room was not. Therefore, in chronic asthma, a result which has already taken place and the heart lung lesion, intensive form of psychotherapy is usually not recommended. Here more appropriate relaxation exercises and advice psychohygiene.
4.Hiperfunktsiya thyroid reflected in the changes in basal metabolism, the nervousness and decreasing body weight, to increase the rhythm of heartbeats. This disease can be treated successfully with the help of medications. Previously it was thought that mental factors are a cause of thyroid hyperfunction. Is it really quite clear.
5. The emergence of some forms of hypertension also affected by psychological factors. High blood pressure over time leads to severe vascular disorders with risk of stroke, myocardial infarction and kidney disease, in which occurs secondary to high blood pressure, which further stabilizes, it is important to note that renal function may thus dangerously porushytys . Some patients with hypertension could achieve a reduction of its level with the help of psychotherapy. However, its use is often very late, if high blood pressure got strong character to the violation of the kidney. In this situation, psychotherapy can positively affect how patients live and cope with existing disease (that is called “pereboryuvannya disease” or “coping”). The therapist may also help convince a patient ieed regular intake of drugs.
6. Even for such serious diseases as chronic rheumatoid inflammation of joints (arthritis), reveal the impact of mental tensions, such as the crisis in mizhosobystistnyh respects. Pathogenetic, rheumatoid arthritis – autoimmune disease. Today can be considered proven that mental factors show influence on the immune system. It pains are amplified when the general mood is worsening. By contrast, overall mental condition may improve if pain subside.
7.Hronichna eczema (neurodermatitis) – a hereditary disease in the form of so-called milk Strupiv already common in infants. However, the question of whether involved in causing mental factors, Sumy, still considered controversial. More likely that changes to baby’s skin affect how the mother behaves with this child. This is the second leads to mental changes, which in turn may affect the course of the disease. However, there are also cases of chronic eczema, in which the disease first manifests much later in adulthood. Psychotherapy, as a rule, though, and can detect a positive effect on the flow of disease, but as the disease while not completely cure. Sometimes the disease can transfer back to hidden (latent) state in which the patient skin manifestations disappear. However, later they may appear again. The method of treatment of chronic eczema, which would prevent the return of symptoms, so far not found.
Behavioral disorders can cause somatic disease in which the late stages can also be organic changes. For example, capture of weight loss – abnormalities of the digestive behavior that is most common in girls in adolescence when puberty (adolescent Anorexia Nervosa) – severe weight loss leads to life-threatening condition, especially due to the loss of protein, the destruction of internal organs, and because of violation of mineral metabolism that affect the activity of cardiovascular system. Sufferers passion weight loss patients feel basically good and very active, even when they have lost much weight. If the disease is not treated, then often there are cases even death result.
In the case of the disease a large role psychogenic factor. Motives behavioral disorders understand the numerous and complex theories, but the motives which exist in each case can be said only through a serious test. Sometimes they are distinct only in their healing process. Many patients suffering seizure weight loss, if resist is to assume the role of adult women. By means of hunger and weight loss they are achieving even the disappearance of secondary sexual characteristics, monthly interrupted. Male patients suffering seizure diet to a much lesser extent, also fear in order to assume the role of adult males.
The same can be said about obesity and the overwhelming desire to eat. Many people are overweight know that they eat in order to weaken the sense of fear or grief, although not all are aware of it. In the first year of life of mother and child relationship defined in many respects eating. Later, when the child is already beginning to eat their own, as my mother prepare food and presents on the table. Food creates, so basically bezsvidomu fantasy of unity with the mother. This may have symbolically replaced later if grocery stores or home refrigerators. For many people, be satiated means be safe and not be abandoned mother. Excessive food for obesity, which is self-destruction of the body, sometimes may also have the character samonakazuvannya. Major role for obesity often plays a sense of shame. Obese people often eat secretly. And not only because of concerns that may prevent them eating, but also because they feel ashamed to overeat. They also shy of its completeness. That is why they often recognize the loneliness.
The process of eating is determined not only by internal causes, but any kind of social pressure. Children are often forced to leave an empty plate after eating. Later it becomes a habit. Some people are tormented conscience of that released products they do not doyily. One patient told that the parents of a child forced to eat up his piece of bread, threatening that otherwise this piece would be for him to run. Many people remember while on hunger strikers, whom often told as a child when the child refused to eat. Plays an important role as the fact that many parents express their love by offering food or sweets. With the aid of sweets they desire to comfort children when they are in a bad mood.
Psychotherapy behavioral disorders is based on the principle of analysis and study of mental cause of behavioral disorders.
The genesis of psychosomatic diseases
To date there is no such one universally accepted theory that could explain the occurrence of all possible psychosomatic disorders. However, depth psychology offers a number of models and theories that explain certain phenomena genesis of psychosomatic diseases and may be useful in conducting psychotherapy. It is important to note that modern psychotherapy is more inclined to need simultaneous combination of different models in the understanding and treatment of psychosomatic disorders.
In this regard, can draw an analogy with “the principle of subsidiarity” (“Somplementarity) Niels Bohr, first formulated September 16, 1927 at the International Congress of Physicists in Kamo on the 100-year anniversary of the death of Volta:” If two concepts are more , then an experiment that clearly illustrates one concept will obscure other concepts. Various, sometimes even contradictory models like covering different aspects and projection of the same complex phenomenon. Therefore, its understanding should include several models simultaneously is not limited to any particular one of them.
Among the various models describing the origin of psychosomatic diseases, the most important today is behavioral (bihevioristskym) and psychoanalytic concepts.
Behavioral psychotherapy considers mental disorders as acquired in the process of learning, adaptation and improper attempts to reconstruct with the help of so-called behavior analysis history of symptoms. Affective behavior includes, in turn, somatic reactions (through autonomic, nervous, endocrine and immune system). If the irritant effects of pathogenic organism is exposed to conflict or prolonged stress, in accordance with the processes of learning, having psychosomatic disorders. Behavioral psychotherapy caot, however, answer the question why some conflicts lead to disturbances, and others as neurotic.
Psychoanalytic methods try to discover lying by observing symptoms surfaced internal psychological conflicts, problems and fixes, walking, usually from early childhood the patient. Modern psychosomatic medicine used eight major deep psychological models of psychosomatic diseases, and it would be a problem limited to any particular one of them to work with the patient.
Freud’s model conversion
For the first time the idea of converting Freud postulated in the works “psychoneurosis protection” (1894) and “Investigation of hysteria” (1895). When conversion is understood shift mental conflict and attempt to resolve it through different symptoms within the body – somatic, motor (eg, various kinds of paralysis) or sensitive (eg, loss of sensation or localized
Hospitalizm and psychic deprivation.
Hospitalizm and mental deprivation is a psychological phenomena that develop in adults and children due to long stay outside sim”yu – namely, hospitals, homes of baby nursery week.
Hospitalizm develops in adults, but usually the elderly, and mental phenomena of deprivation in children.
Factors that contribute to their occurrence: poor mental climate in the environment, lack of human attention to the child or patient, lack of emotional display of party staff. These factors cause in children, the so-called psychic deprivation, which manifested passivity lingering of their agility skills and mental abilities. What happens – the manifestations of mental regression. Child if returned to the last stage of their development: lost some already acquired skills such as hygiene, such as maintaining cleanliness of the body, independent of urination and defecation, lose the ability to dress themselves, do not develop language skills, speak less and worse, caot play with in games. Reversal of children with the emotional reaction:
A) depression, boredom and sore;
B) noisy, vicious protest bihotneyu, search for the mother;
B) autism, insularity, not “know” her mother that her visit. This is an unconscious displacement – the child bezsvidomo “punish” her mother because she left it;
C) utilitarian attitude to the fact hospitalization. The child begins to require a lot of attention because she was “sick”, or unwilling to check out of hospital to go to school;
D) otupilist, which in most cases have features of motor manifestations of regression: monotonous, stereotyped movements kyvalni, sucking fingers, neartykulyarni sounds and other signs of inadequate motor activity, which do not meet the child’s age.
Hospitalizm often develops in the elderly who are in hospital inpatient treatment for a long time (such as tuberculosis or mental) and have lost contact with their families. After discharge from the hospital to whom they have nothing to return, or family circumstances are unfavorable. Prolonged hospitalization can lead to social maladjustment, man loses business communication skills, ability to sharply lower self. Treated patient is afraid of loneliness, loss of the minimum contacts that are in the hospital (with doctors, nurses and other patients – especially young).
Hospitalizm a factor increasing suyitsydnosti. Dezadaktovani patients after discharge from hospital often make a suicide attempt.
Hospitalizm and mental deprivation is a phenomenon of medical and social problem. Without solving the social aspect of this problem rozrishyty impossible. The doctor must psychologically prepare the patient for discharge, and to take all measures for prevention of psychological deprivation in children (together with psychologists and teachers).
Psychology of Medical Workers
The main reasons for choosing the medical profession.
1. Some young people choose medicine as a result of conscious interest in this profession based on the previous drive to the biological sciences.
2. Significant role played by tradition of the family (family dynasty). This group of future health care workers most deeply and comprehensively understand the responsibility and difficulty of the chosen profession.
3. A small number of young people choose this profession because they themselves suffered serious illness, or watched it in their loved ones and concluded to devote his life to helping patients by vocation. It is this contingent of the most committed to their profession.
4. Some young people choose the medical profession that has the appropriate conditions for learning (good skills, a sufficient level of intelligence), but has a talent in another field (artist, musician, architect, mathematical abilities, etc.).
5. A small number of young people decide to get medical education in order to have any professional training and “take time” after school. Will they work in the future by education, these young people especially not zadumuyutsya. Most of these students are taught indirectly, the natural need for thorough learning of professional knowledge and practical skills they have.
Choosing the medical profession, the young person must realize the importance of their choices and future consequences for themselves and sick people to whom it should help. You must self-critically evaluate the motives that led to go into medicine and their psychological quality. If a young persoo internal drive to medical activities, or her mental structure does not meet appropriate needs such a person in medicine to do anything. It will spoil your life (or part thereof – then will have perekvalifikovuvatys) and, most importantly, patients can harm people and tarnish medicine, and thus other doctors.
Requirements for the individual nurse.
1. A young man who decided to devote himself to medicine, should realize that the medical profession holds her duty become a spiritual director, teacher and healer sick and disabled people and their relatives and friends. Nurse, who during their professional duties is the closest to the patient and his relatives should be able to professionally and delicately maintain proper state of mind of the patient and his family. Nurse should own words, instructions, and, most importantly, their actions and personal example constantly teach patients and their relatives to fight illnesses, comply with the regime to carry out the principles of rehabilitation, reintegration and prevention. Finally, the nurse should be a healer of patients, rather than a mechanical contractor doctor appointments. Nurse must always remember that the cure is not medicine and manipulation, but it is, doctors as individuals using medications, manipulation, surgery and primary role in the medical process belongs to individual physicians.
2. One of the most important components of individual nurse has an internal need to help the sick, infirm, disabled people and their relatives and friends. Without the availability of the internal needs of the nurse becomes the spiritual director, teacher and healer, and at best will be the “man in the case,” living robot “that automatically performs the assignment and instructions doctor.
3. Qualitative and meaningful for their professional duties nurse necessarily professionalism, which are components of knowledge, skills and knowledge of practical skills. While studying at college or university nursing faculty of the future nurses receive only a basic education. Upon receipt of nursing education to improve their knowledge and skills throughout their professional activities. Medicine as science and practice, constantly evolving and complicated, there are always new methods of diagnosis and treatment, so the nurse must keep pace with the times and new requirements. Medic who does not care about the constant improvement of the professional level, must pace of life.
4. High professionalism of nurses in mandatory organically includes discipline and orderliness. At the nurse falls high load. Should be timely and properly perform numerous doctor appointments, sick pay due attention. It is such a personality as discipline and organization helps nurses cope with their responsibilities.
5. Professionalism coupled with discipline and organization to seamlessly combined with sincerity, empathy, compassion and courtesy. Appropriate mental makings of these qualities must be congenital, imitation them sooner or later must be known. However, the nurse should not only expect to deposit these innate qualities, they must constantly develop and improve. Nurse must remember that between emotions that arise to the object and the actions of this object is always a correlation. Psychologists have found that we like that, who do good and hate him who do evil. So sincerity, empathy, politeness and other virtues need to constantly develop and actively use them.
6. Professionalism “omertvytsya, unless combined with appropriate business skills and at the same time, spiritual communication with patients and their relatives. Ability to engage in language and nonverbal communication, listen to the patient, encourage him and strengthen hope blahopryyemnyy a solution is an integral part professiogram nurse. The same pill that you give to the nurse encouraging smile will work much better than when it tytsnut patient with a “cold” or, worse, fleer. Nurse must always remember that warm, encouraging words there is less and, often, and more than this medication.
7. Nurse is a member of the medical team and works with patients. All people are different iature, and nervous system of patients still exhausted disease. Therefore, when performing their professional duties nurse and sometimes there can be conflicts with patients. Ability to successfully defuse the situation, prevent and settle conflicts in a timely manner is an integral part professiogram nurse. In these circumstances, the nurse must demonstrate on the one hand, delicacy and sincerity, on the other – and principled resolve. In any setting nurse should demonstrate knowledge, patience, respect for opponents and self esteem. Nurse should not overly react to minor quirks and patient observations that indicate astenizatsiyu the nervous system, but at the same time, the nurse must be able to defend their dignity, remembering that she, as a doctor, is a spiritual director, teacher and healer, not silent and rightless popyhachem.
8. An important part professiogram nurse is the possession of the principles of medical ethics, deontology, and psychohygiene psychoprophylaxis.
9. Trust is of great importance to the patient medical psychological side of relationships. Medical qualification is only a tool used as, with greater or lesser effect depending on other parties personal physician.
10. For display of confidence is important first impression. The first impression must be supported. This value is not only verbal communication, but mostly non-verbal (the corresponding facial expression, gestures, tone of voice). He plays his role and appearance: if the patient sees doctor sloppy or nevyspanoho etc., the belief in the medical decreases. The patient unconsciously understands that if a person takes care of itself, it caot be oblivious of the other.
11. The internal culture, medical ethics and tact. For example, there are situations when you can show a sense of humor, but without a shadow of irony and cynicism by the principle: “to laugh along with the patient, but sometimes the sick.” You must remember that there are patients who do not tolerate humor even with good intentions and understand it as disrespect and humiliation.
12. Sense of responsibility. Taking a serious decision every physician should introduce and critically assess the results of his health and life of the patient.
13. Harmony of the individual physician. Poise and self-control. Medic must bring their personality characteristics,
First, watching the reaction to their behavior directly (in conversation, assessing facial expressions, gestures patients) and, secondly, indirectly, to assess their behavior when he learns from colleagues (from the more visible).
14. Taking care of your good name. Health worker loses credibility when it seems that he is the one called “bad or difficult person.” For example, arrogant behavior, inappropriate irony, subservience to superiors nespryymannya criticism pustosliv’ya, zloradstvo, ignoring the advice of experienced colleagues.
Illusions and deilusions
Young people are often prone to illusions and through their means. Like most people novice physicians tend to believe medicine is strong. Such people, when meeting the practical experience of medicine deilyuziyu – disappointment. Modern medicine can successfully treat only acute pathological conditions, not cure all people at all stages of disease. However, hypertrophy deilyuziyi is harmful. Medic stop seeing patients, but only fixes the “cases from practice. Physicians with excessive self-leaders are beginning to worry that they caot make a decisive personal contribution to a collective work (team resuscitation, care by myocardial infarction, etc.). Some young doctors fall at the hands of failures. Some of zvykayetsya that they are “no gods” and then stop or critically samootsinyuvaty best they have done to help the patient. Part of developing young physicians increased frustration and nervousness towards patients and colleagues and they make other aversion, spoil yourself and other life.
Professional mental strain
Every profession can contribute to human development and improve their personal qualities for the benefit of society. But trade may also distort and mental qualities.
The propensity to professional deformation is frequently observed especially in certain professions, representatives of which have little controlled and limited hard power. From the making and will depend on these people’s dignity and livelihood, health and even lives of others, as it happens in teachers, judges, law enforcement officers, as well as doctors and medical workers.
Medic has some power over patients, thus it is also a high risk for the development and mental strain. Power must be used only with good purpose.
Each profession must adapt. Future physicians must adapt to new unusual conditions that others were not able to (work with the corpses of dead men and material, the appearance of blood, severe injuries, traumatic operations, surveillance, suffering and death of patients, animal experiments, etc.). It is important not to lose mental abilities. It develops professional deformation, usually gradually and imperceptibly it under professional adaptation.
First, students are going through enough emotional osculation the above-mentioned factors that are inseparable from a medical education. Then they get addicted and gradually developing emotional hipesteziya and even indifference. You caot show disrespect for the dead men and dead material caot support experiments on animals without anesthesia and deep for just a curiosity.
The manifestation is a professional deformation behavior and the expressions and medical staff, if under the influence of habit shown callousness towards patients to such an extent that physicians do not have the impression bezdushnosti and even cynicism. For example the fact that a doctor and nurse did not consider it necessary to protect at least screen the dying patient in a Multi-Chamber. Nurses and doctors do not interfere with the Grand Chamber. They sometimes easier to cope with the work, the patients themselves watching each other and help each other more than small houses. But this condition can traumatize the psyche of patients. Vondrechek describes as aphoristic: “It is terrible to be in the House, where one eats, the other moans, the third produces a bowel movement, and the fourth died. Some patients get used to this quickly. But Dostoevsky’s expression that “man – a creature who gets used to the whole” caot be applied to life without life and when is the least possibility to remove the psycho situation.
Everything that is related to professional deformation, has psychological importance. The reason it is no bad intention or desire to harm a patient. It is not sadism, and bad unconscious habit, which worked out over time. It manifests itself in the professional jargon. For example, the conversation, when one physician who goes to work, “sends his patients to another:” What do you have here? “Four gastric, three gallbladder and a stone in the kidney.
Sometimes the strain shows in the form of professional admiration pathology. For example, the expression of the professor, “Look, colleagues, syphilitic ulcer is wonderful!” Or radiologist, I have long not seen such a great cavern. ”
Inertia professional deformation due largely maintained historically the medical profession and its status in society. In the past the doctor was not only a healer, teacher, chaplain, but also a magician, a magician and a ruler. This provision in this day and age something vydozminylos, but its essence remains. Previously, people literally fascinated healers, Witcher-healers, visionaries fate. Now people also admired features of modern progress in medical equipment, technology, new “fashion” products, especially effective in television commercials and print. However, the smaller the viewer or reader to understand the factual side of this process, the more its external shaking “magical” side. Magical duration, subconscious feeling of power over man who was looking to date looking at the last medical defense left in the psychology of medical workers remnants that are sometimes even caste character. After all, psychologists found that most people are unconscious yearning for power over others. Such doctors relate to patients dismissive, and sometimes not eveotice the patient, or refer to it as to things. In behavior and gestures such physicians seen defiantly clear lack of interest in the patient, especially as a person to person. Sometimes he even ignores the patient is rude towards him. Some physicians want to create stobi authority and pretend that they emphasize or terribly busy: “You lot, and I am one. Notably, however, that such strict and nadminnyy behaviors may sometimes cause mobilizing and even therapeutic effects on simple and primitive patients who see the doctor about the person of God. This method is consciously or unconsciously use many charlatans. But such behavior is medical in most patients immediately and distrust.
That’s why you need to follow to ensure that professional subconscious mental strain, which develops uncontrolled, did not become a factor in a negative psychological impact on patients.Stop at the most important features of personal medical.
First physician must be observant. People differ significantly on the direction of observation. Some good notice anything that refers to inanimate objects, others see the best features of man’s inner world, his mental state, feelings, needs, hopes, fears and so on. For the medical professional to develop the two types of observation, he should ignore what happens in the human soul to understand its internal state, vidhaduvaty her thoughts. Principles of medical ethics require that patients under observation had become deeply meaningful and convincing. Thus, an important psychological principle of medical ethics is the unity of professional observation, understanding the essence of the phenomenon and belief in its rightness.
Significant psychological aspects of medical ethics is the emotional “Tint” and meaningful information received sympathy and empathy. Medical officer must feel pain and experience of another person as their own. It helps to understand the patient’s condition and to share his experiences, which is very important for the patient. After all, for any human is very important to understand it.
An important feature of the medical profession is humanism. It follows from the very essence of the profession, because you caot love the medical profession without loving person.
One of the moral qualities is a medical charity. The patient sees the physician assistant nurses and makes special requirements specific to individual nurses, it seeks above all traits of kindness, compassion, mercy.
Psychology of Medical Workers
The main reasons for choosing the medical profession.
1. Some young people choose medicine as a result of conscious interest in this profession based on the previous drive to the biological sciences.
2. Significant role played by tradition of the family (family dynasty). This group of future health care workers most deeply and comprehensively understand the responsibility and difficulty of the chosen profession.
3. A small number of young people choose this profession because they themselves suffered serious illness, or watched it in their loved ones and concluded to devote his life to helping patients by vocation. It is this contingent of the most committed to their profession.
4. Some young people choose the medical profession that has the appropriate conditions for learning (good skills, a sufficient level of intelligence), but has a talent in another field (artist, musician, architect, mathematical abilities, etc.).
5. A small number of young people decide to get medical education in order to have any professional training and “take time” after school. Will they work in the future by education, these young people especially not zadumuyutsya. Most of these students are taught indirectly, the natural need for thorough learning of professional knowledge and practical skills they have.
Choosing the medical profession, the young person must realize the importance of their choices and future consequences for themselves and sick people to whom it should help. You must self-critically evaluate the motives that led to go into medicine and their psychological quality. If a young persoo internal drive to medical activities, or her mental structure does not meet appropriate needs such a person in medicine to do anything. It will spoil your life (or part thereof – then will have perekvalifikovuvatys) and, most importantly, patients can harm people and tarnish medicine, and thus other doctors.
Requirements for the individual nurse.
1. A young man who decided to devote himself to medicine, should realize that the medical profession holds her duty become a spiritual director, teacher and healer sick and disabled people and their relatives and friends. Nurse, who during their professional duties is the closest to the patient and his relatives should be able to professionally and delicately maintain proper state of mind of the patient and his family. Nurse should own words, instructions, and, most importantly, their actions and personal example constantly teach patients and their relatives to fight illnesses, comply with the regime to carry out the principles of rehabilitation, reintegration and prevention. Finally, the nurse should be a healer of patients, rather than a mechanical contractor doctor appointments. Nurse must always remember that the cure is not medicine and manipulation, but it is, doctors as individuals using medications, manipulation, surgery and primary role in the medical process belongs to individual physicians.
2. One of the most important components of individual nurse has an internal need to help the sick, infirm, disabled people and their relatives and friends. Without the availability of the internal needs of the nurse becomes the spiritual director, teacher and healer, and at best will be the “man in the case,” living robot “that automatically performs the assignment and instructions doctor.
3. Qualitative and meaningful for their professional duties nurse necessarily professionalism, which are components of knowledge, skills and knowledge of practical skills. While studying at college or university nursing faculty of the future nurses receive only a basic education. Upon receipt of nursing education to improve their knowledge and skills throughout their professional activities. Medicine as science and practice, constantly evolving and complicated, there are always new methods of diagnosis and treatment, so the nurse must keep pace with the times and new requirements. Medic who does not care about the constant improvement of the professional level, must pace of life.
4. High professionalism of nurses in mandatory organically includes discipline and orderliness. At the nurse falls high load. Should be timely and properly perform numerous doctor appointments, sick pay due attention. It is such a personality as discipline and organization helps nurses cope with their responsibilities.
5. Professionalism coupled with discipline and organization to seamlessly combined with sincerity, empathy, compassion and courtesy. Appropriate mental makings of these qualities must be congenital, imitation them sooner or later must be known. However, the nurse should not only expect to deposit these innate qualities, they must constantly develop and improve. Nurse must remember that between emotions that arise to the object and the actions of this object is always a correlation. Psychologists have found that we like that, who do good and hate him who do evil. So sincerity, empathy, politeness and other virtues need to constantly develop and actively use them.
6. Professionalism “omertvytsya, unless combined with appropriate business skills and at the same time, spiritual communication with patients and their relatives. Ability to engage in language and nonverbal communication, listen to the patient, encourage him and strengthen hope blahopryyemnyy a solution is an integral part professiogram nurse. The same pill that you give to the nurse encouraging smile will work much better than when it tytsnut patient with a “cold” or, worse, fleer. Nurse must always remember that warm, encouraging words there is less and, often, and more than this medication.
7. Nurse is a member of the medical team and works with patients. All people are different iature, and nervous system of patients still exhausted disease. Therefore, when performing their professional duties nurse and sometimes there can be conflicts with patients. Ability to successfully defuse the situation, prevent and settle conflicts in a timely manner is an integral part professiogram nurse. In these circumstances, the nurse must demonstrate on the one hand, delicacy and sincerity, on the other – and principled resolve. In any setting nurse should demonstrate knowledge, patience, respect for opponents and self esteem. Nurse should not overly react to minor quirks and patient observations that indicate astenizatsiyu the nervous system, but at the same time, the nurse must be able to defend their dignity, remembering that she, as a doctor, is a spiritual director, teacher and healer, not silent and rightless popyhachem.
8. An important part professiogram nurse is the possession of the principles of medical ethics, deontology, and psychohygiene psychoprophylaxis.
9. Trust is of great importance to the patient medical psychological side of relationships. Medical qualification is only a tool used as, with greater or lesser effect depending on other parties personal physician.
10. For display of confidence is important first impression. The first impression must be supported. This value is not only verbal communication, but mostly non-verbal (the corresponding facial expression, gestures, tone of voice). He plays his role and appearance: if the patient sees doctor sloppy or nevyspanoho etc., the belief in the medical decreases. The patient unconsciously understands that if a person takes care of itself, it caot be oblivious of the other.
11. The internal culture, medical ethics and tact. For example, there are situations when you can show a sense of humor, but without a shadow of irony and cynicism by the principle: “to laugh along with the patient, but sometimes the sick.” You must remember that there are patients who do not tolerate humor even with good intentions and understand it as disrespect and humiliation.
12. Sense of responsibility. Taking a serious decision every physician should introduce and critically assess the results of his health and life of the patient.
13. Harmony of the individual physician. Poise and self-control. Medic must bring their personality characteristics. First, watching the reaction to their behavior directly (in conversation, assessing facial expressions, gestures patients) and, secondly, indirectly, to assess their behavior when he learns from colleagues (from the more visible).
14. Taking care of your good name. Health worker loses credibility when it seems that he is the one called “bad or difficult person.” For example, arrogant behavior, inappropriate irony, subservience to superiors nespryymannya criticism pustosliv’ya, zloradstvo, ignoring the advice of experienced colleagues.
Illusions and deilusions
Young people are often prone to illusions and through their means. Like most people novice physicians tend to believe medicine is strong. Such people, when meeting the practical experience of medicine deilyuziyu – disappointment. Modern medicine can successfully treat only acute pathological conditions, not cure all people at all stages of disease. However, hypertrophy deilyuziyi is harmful. Medic stop seeing patients, but only fixes the “cases from practice. Physicians with excessive self-leaders are beginning to worry that they caot make a decisive personal contribution to a collective work (team resuscitation, care by myocardial infarction, etc.). Some young doctors fall at the hands of failures.Some of zvykayetsya that they are “no gods” and then stop or critically samootsinyuvaty best they have done to help the patient. Part of developing young physicians increased frustration and nervousness towards patients and colleagues and they make other aversion, spoil yourself and other life.
Professional mental strain
Every profession can contribute to human development and improve their personal qualities for the benefit of society. But trade may also distort and mental qualities.
The propensity to professional deformation is frequently observed especially in certain professions, representatives of which have little controlled and limited hard power. From the making and will depend on these people’s dignity and livelihood, health and even lives of others, as it happens in teachers, judges, law enforcement officers, as well as doctors and medical workers. Medic has some power over patients, thus it is also a high risk for the development and mental strain. Power must be used only with good purpose. Each profession must adapt. Future physicians must adapt to new unusual conditions that others were not able to (work with the corpses of dead men and material, the appearance of blood, severe injuries, traumatic operations, surveillance, suffering and death of patients, animal experiments, etc.). It is important not to lose mental abilities. It develops professional deformation, usually gradually and imperceptibly it under professional adaptation.
First, students are going through enough emotional osculation the above-mentioned factors that are inseparable from a medical education. Then they get addicted and gradually developing emotional hipesteziya and even indifference. You caot show disrespect for the dead men and dead material caot support experiments on animals without anesthesia and deep for just a curiosity.
The manifestation is a professional deformation behavior and the expressions and medical staff, if under the influence of habit shown callousness towards patients to such an extent that physicians do not have the impression bezdushnosti and even cynicism. For example the fact that a doctor and nurse did not consider it necessary to protect at least screen the dying patient in a Multi-Chamber. Nurses and doctors do not interfere with the Grand Chamber. They sometimes easier to cope with the work, the patients themselves watching each other and help each other more than small houses. But this condition can traumatize the psyche of patients. Vondrechek describes as aphoristic: “It is terrible to be in the House, where one eats, the other moans, the third produces a bowel movement, and the fourth died. Some patients get used to this quickly. But Dostoevsky’s expression that “man – a creature who gets used to the whole” caot be applied to life without life and when is the least possibility to remove the psycho situation.
Everything that is related to professional deformation, has psychological importance. The reason it is no bad intention or desire to harm a patient. It is not sadism, and bad unconscious habit, which worked out over time. It manifests itself in the professional jargon. For example, the conversation, when one physician who goes to work, “sends his patients to another:” What do you have here? “Four gastric, three gallbladder and a stone in the kidney. Sometimes the strain shows in the form of professional admiration pathology. For example, the expression of the professor, “Look, colleagues, syphilitic ulcer is wonderful!” Or radiologist, I have long not seen such a great cavern.” Inertia professional deformation due largely maintained historically the medical profession and its status in society. In the past the doctor was not only a healer, teacher, chaplain, but also a magician, a magician and a ruler. This provision in this day and age something vydozminylos, but its essence remains. Previously, people literally fascinated healers, Witcher-healers, visionaries fate. Now people also admired features of modern progress in medical equipment, technology, new “fashion” products, especially effective in television commercials and print. However, the smaller the viewer or reader to understand the factual side of this process, the more its external shaking “magical” side. Magical duration, subconscious feeling of power over man who was looking to date looking at the last medical defense left in the psychology of medical workers remnants that are sometimes even caste character. After all, psychologists found that most people are unconscious yearning for power over others. Such doctors relate to patients dismissive, and sometimes not even notice the patient, or refer to it as to things. In behavior and gestures such physicians seen defiantly clear lack of interest in the patient, especially as a person to person. Sometimes he even ignores the patient is rude towards him. Some physicians want to create to themselves an authority and pretend that they emphasize or terribly busy: “You lot, and I am one. Notably, however, that such strict and nadminnyy behaviors may sometimes cause mobilizing and even therapeutic effects on simple and primitive patients who see the doctor about the person of God. This method is consciously or unconsciously use many charlatans. But such behavior is medical in most patients immediately and distrust. That’s why you need to follow to ensure that professional subconscious mental strain, which develops uncontrolled, did not become a factor in a negative psychological impact on patients. Stop at the most important features of personal medical. First physician must be observant. People differ significantly on the direction of observation. Some good notice anything that refers to inanimate objects, others see the best features of man’s inner world, his mental state, feelings, needs, hopes, fears and so on. For the medical professional to develop the two types of observation, he should ignore what happens in the human soul to understand its internal state, to know her thoughts. Principles of medical ethics require that patients under observation had become deeply meaningful and convincing.
Thus, an important psychological principle of medical ethics is the unity of professional observation, understanding the essence of the phenomenon and belief in its rightness. Significant psychological aspects of medical ethics is the emotional “Tint” and meaningful information received sympathy and empathy. Medical officer must feel pain and experience of another person as their own. It helps to understand the patient’s condition and to share his experiences, which is very important for the patient. After all, for any human is very important to understand it.
An important feature of the medical profession is humanism. It follows from the very essence of the profession, because you caot love the medical profession without loving person. One of the moral qualities is a medical charity. The patient sees the physician assistant nurses and makes special requirements specific to individual nurses, it seeks above all traits of kindness, compassion, mercy.
