CORTIC-VISCERAL THEORY

Thanks to fundamental research I.M. Sechenov, I.P. Pavlov, N.E. Vvedensky, the cortico-visceral theory was developed, the basic principles of which were developed by K. M. Bykov and I. T. Kurtsin in the 1960s. This theory made its own adjustments to the theory of the pathogenesis of internal diseases and changed the attitude towards psychosomatics in general.

The basic principles of the cortico-visceral theory can be summarized as follows:

1. Participation of the mechanisms of the cerebral cortex in the reproduction of pathological reactions of the body according to the type of conditioned reflex.

2. The role of the neurotic state in the pathogenesis of cortico-visceral diseases. The neurotic state is due to the processes of excitation, inhibition and mobility of the processes of the cerebral cortex.

IP Pavlov discovered the functional interaction between the internal organs and the cerebral cortex. In general, the basic principles of the cortico-visceral theory have significantly changed the view of psychogeny and their impact on the etiology and pathogenesis of a number of diseases. Mediators between the cerebral cortex and internal organs are the limbic-reticular, autonomic and endocrine systems. And the main transmitters are cortisol, thyroxine and adrenaline. It follows that the emotional background of a person, influencing the nervous and hormonal systems, triggers biochemical processes which are reflected at the bodily level.

The developments in the field of reflexology by I.M. Sechenov, which were developed in the teachings of I.P. Pavlov on higher nervous activity, allow us to assert that through conditioned reflex mechanisms any of the autonomic functions can arise and be changed, incl. and in the department of endocrine glands, in the activity of the blood system, metabolism, etc. Thus, thanks to the cortico-visceral theory, today we can talk about the somatoform nature of the following diseases: secretory disorders of the gastrointestinal tract, stomach, liver, intestines, pancreas, endocrine disorders such as diabetes, thyrotoxicosis, impotence, etc. Diseases with organic manifestations: duodenal ulcer, atherosclerosis, hypertension and hypotension, angina pectoris, bronchial asthma, myocardial infarction.

From the point of view of the formation of a symptom, the following should be noted - the formation of conditioned reflexes in a person can be formed at two levels, on the conscious and unconscious. Moreover, the reflex process at the unconscious (subcortical) level can be formed independently of the conscious (cortical). And since fewer “instances” are required for the formation of a reflex at the unconscious level, it is formed faster than at the conscious level. Here (in the unconscious) a mechanism for the formation of emotions is formed, which are recognized by a person as the last instance of this mechanism. According to the theory of James Lange: initially, a reaction occurs at the level of the cortex of the right hemisphere of the GM and the limbic-reticular system, then the autonomic system is connected, which manifests itself in muscle reactions, as a rule, the heartbeat and breathing become more frequent, which leads to awareness of emotions. As soon as physiological changes are recognized by the cerebral cortex, emotion arises.

The cortico-visceral theory has been repeatedly criticized for its lack of specificity. The main doubt was that this theory substantiated the etiopathogenesis of diseases of various nature and organs with different functionality within the same mental mechanisms. Another stumbling block is the neglect of complex biochemical and hormonal processes.

the cerebral hemispheres and internal organs. Extension of the ideas of the cortico-visceral theory to region pathology made it possible to understand role mental influences in the occurrence and course of certain diseases.

CORTIC-VISCERAL PATHOLOGY - a theoretical direction in medicine of the 20th century; postulates the possibility of reproducing pathological visceral reactions by a conditioned reflex. The formulation of the concept of K.-v. n. is historically associated with that stage of ideas about the structural and functional organization of conditioned reflexes, when the input and output links of their arc were usually localized within the cerebral cortex. The cortico-visceral theory of pathology developed by K. M. Bykov and other students of IP Pavlov, vulgarizing the teachings of the great physiologist, asserted the decisive role of the cerebral cortex in the development of almost all diseases; at the beginning of the 2nd half of the 20th century. this theory, which received the support of the party-state. leadership of the country, was declared the banner of owls. medicine, both theoretical and clinical, - a comprehensive theory of medicine, a guide to diagnosis (encephalographic study of higher nervous activity in each disease, etc.), treatment (for example, the unbridled expansion of electrosleep therapy) and prevention (so-called. protective regime in medical institutions, etc.). Like any attempt to universalize private patterns and create a single honey. "systems", this concept proved to be fruitless and was rejected by clinical practice. In modern science, higher nervous activity is considered as a complex multi-level multi-channel afferent-efferent organization. Conditioned visceral reflexes in their manifestations are much less connected with the functions of the cerebral cortex than skeletal-motor ones. Therefore, the impulses from the internal organs under normal conditions for the most part remain outside consciousness. The term "cortico-visceral pathology" has lost its original meaning. It became clear that any forms of pathology of the internal organs are primarily mediated through the excitation of the corresponding subcortical structures of the brain and, due to the activation of emotional excitations, spread to the cerebral cortex. Some theoretical concepts of K.-v.p. were used by the founders of psychosomatic medicine.

3 .Successful/Unsuccessful:

3.1. Successful coping - constructive strategies are used that ultimately lead to overcoming a difficult situation that caused stress.

3.2. Unsuccessful coping - non-constructive strategies are used that prevent overcoming a difficult situation.

It seems that each coping strategy used by a person can be evaluated according to all of the above criteria, if only because a person who finds himself in a difficult situation can use one or several coping strategies. Thus, it can be assumed that there is a relationship between those personal constructs, with the help of which a person forms his attitude to life's difficulties, and what strategy of behavior under stress (coping with the situation) he chooses.

As many authors note, there are significant difficulties in distinguishing between defense and coping mechanisms (Libina, Libin, 1998). The most common point of view is that psychological defense is characterized by the individual's refusal to solve the problem and the specific actions associated with it in order to maintain a comfortable state. At the same time, the ways of coping imply the need to show constructive activity, to go through the situation, to survive the event without shying away from trouble. We can say that the subject of coping psychology, as a special area of ​​research, is the study of the mechanisms of emotional and rational regulation by a person of his behavior in order to optimally interact with life circumstances or transform them in accordance with their intentions (Libin, Libina, 1996).

The modern approach to the study of the mechanisms of formation of coping behavior takes into account the following provisions.

The instinct to overcome is inherent in a person (Fromm, 1992), one of the forms of manifestation of which is search activity (Arshavsky, Rotenberg, 1976), which ensures the participation of evolutionary-program strategies in the interaction of the subject with various situations. The preference for ways of coping is influenced by individual psychological characteristics: temperament, level of anxiety, type of thinking, features of the locus of control, orientation of character. The severity of certain ways of responding to difficult life situations is made dependent on the degree of self-actualization of the individual - the higher the level of development of a person's personality, the more successfully he copes with the difficulties that have arisen. According to this provision, the obstacles encountered in a person's life have their source not only in external (the specifics of the environment), but also in internal (individual prerequisites) conditions. Both protective and coping response styles are associated with attitudes and feelings, attitudes towards oneself and others, with the structure of life experience, that is, with cognitive, emotional and behavioral levels of the hierarchical structure of the psyche.

AT domestic psychology the actual problem of personality behavior in stress was studied mainly in the context of overcoming extreme situations. The exception is a few works devoted to the study of personality and life path (Antsyferova, 1995; Libina, 1995 a, b), as well as the treatment of marital conflicts (Kocharyan, Kocharyan, 1994).

In foreign psychology, the study of behavior in difficult situations is carried out in several directions. Lazarus and Folkman (Lasarus, Folkman, 1984) emphasize the role of cognitive constructs that determine ways of responding to life's difficulties. Costa and McCrae (Costa, McCrae, 1992) focus on the influence of personality variables that determine an individual's preference for certain behavioral strategies in difficult circumstances. Lehr and Thomae (1993) pay great attention to the analysis of difficult situations themselves, rightly assuming a strong influence of the context on the choice of response style. The interpretation of the phenomena of protection and coping is also associated with the study of the nature of individual behavior in the context of the problem of stress (Selye, 1991).

Depending on the chosen starting point, the authors define the goals of studying protective and coping behavior in different ways. This is an analysis of the problems of adaptation of an individual in the surrounding society, and the problems of spiritual self-determination, which allows making a choice taking into account personal potential. According to a leading specialist in the field of study copy styles(“coping methods”) of Lazarus (Lazarus, 1966; 1991), despite the significant individual diversity of behavior in stress, there are two global types of response style.

Problem-oriented style, aimed at a rational analysis of the problem, is associated with the creation and implementation of a plan for resolving a difficult situation and manifests itself in such forms of behavior as an independent analysis of what happened, seeking help from others, searching for additional information.

Subject-oriented style is the result of an emotional response to a situation that is not accompanied by specific actions, and manifests itself in the form of attempts not to think about the problem at all, involving others in one’s experiences, a desire to forget oneself in a dream, dissolve one’s hardships in alcohol or compensate for negative emotions with food. These forms of behavior are characterized by a naive, infantile assessment of what is happening.

English psychologist D. Roger (Roger et al., 1993) in his measurement questionnaire copy styles identifies four factors - rational and emotional response, detachment and avoidance. At the same time, emotional response also means only negative experiences.

Behavioral strategies are revealed in various forms adaptation. Adaptation, in contrast to simple adaptation, is understood today as an active interaction of a person with the social environment in order to achieve its optimal levels according to the principle of homeostasis and is characterized by relative stability. The problem of adaptation is closely related to the problem of health/illness. This continuum is integral to the individual's life path. The multifunctionality and multidirectionality of the life path determine the interconnection and interdependence of the processes of somatic, personal and social functioning. Thus, the adaptation process includes various levels of human activity.

A kind of "cut" of the adaptation process, covering the entire life path from birth to death, is an internal picture of the life path, which characterizes the quality of human life and its adaptive capabilities on different levels. The inner picture of the life path is a holistic image of human existence. This is a feeling, perception, experience and evaluation of one's own life and, ultimately, an attitude towards it. The internal picture of the life path includes a number of components:

1. somatic (bodily) - attitude towards one's physicality (to one's health, changes in it, including illness, to age-related and various somatic changes);

2. personal (individual-psychological) - attitude towards oneself as a person, attitude towards one's behavior, mood, thoughts, defense mechanisms;

3. situational (socio-psychological) - attitude to situations in which a person is included throughout his life path.

Behavioral strategies are different variants of the adaptation process and are divided into somatically-, personality- and socially-oriented depending on the primary participation in the adaptation process of one or another level of life activity of the personal-semantic sphere. If the life path, consisting of many situations, is considered in the continuum of health / illness, then it turns out that completely different personalities will be at the poles of this continuum, i.e., first of all, we mean different value systems, different priority of life values. For a sick person, the most significant situations are those related to his disease, its occurrence, course and outcome. With illness, the circle of other significant experiences is sharply narrowed. At the “health” pole, completely different situations are important for a person, primarily related to social and professional status.

Successful resolution of the situation depends not least on the degree of adequacy of the assessment of what is happening. Often, the severe consequences of stress are the result of a mismatch between the real complexity of an unpleasant event and the subjective assessment of its significance. Therefore, the success of the chosen response style is also related to whether or not the event is perceived as threatening (Libina, Libin, 1998).

The shift on the scale of the assessment made by the person from left to right when analyzing the significance of a particular situation indicates the need to move from emotional experiences to decisive action. If the stage of negative experiences is prolonged, especially when the stressful event receives a subjectively high assessment, then a nervous breakdown is inevitable, provoking an uncontrollable and inadequate reaction. In this case, stress threatens to turn into distress.

Response styles are an intermediate link between the stressful events that have occurred and their consequences in the form of, for example, anxiety, psychological discomfort, somatic disorders associated with protective behavior, or emotional uplift and joy from a successful solution of a problem that are characteristic of a coping style of behavior.

Finding the positive in a tragic event makes it easier for people to get over it. Five ways to mitigate the situation were identified (using the example of the attitude to the consequences of a fire) (Thompson, 1986):

Detection of unexpected side positive moments (“But now we live with children”);

A conscious comparison with other victims of the fire (“In our country, at least the cost of the house was not fully paid, but with the neighbors ...”);

Presentation of the more tragic consequences of the situation (“We are still alive, but we could have died!”);

Attempts to forget about what happened (“What are you talking about? About the fire? Yes, we have long forgotten about this”).

The response style of even one person can change depending on the area of ​​life in which it manifests itself: in family relationships, work or career, taking care of one's own health.

The work (Libina, Libin, 1998) proposes a typology of protective and coping response styles based on a structural-functional model of behavior (Table 1). The table shows some examples of items (1a – 4c) of the Behavior Style questionnaire (Lazarus, 2000).

Table 1

Structural-functional model of human behavior in difficult situations

visceral psychosomatic neurosis

Bykov constantly combined scientific activity with medical practice. This was the reason for the scientist's close interest in the problems of human pathologies. Jointly I.T. Kurtsin, he developed a special theory of cortico-visceral pathology, which in the 60s was considered as the theoretical foundation of Soviet medicine.

According to this theory, the emergence and development of a number of diseases of the internal organs are associated with a primary violation of higher nervous activity, which can occur as a result of a violation of extero- and interoreceptive signaling. The basis of this disorder is the functional weakening of the cortical cells due to overexertion of the strength and mobility of the nervous processes, especially the process of internal inhibition. As a result, there is a breakdown in the functional relationship between the cerebral cortex and subcortical formations, which involves the entire complex of vegetative and somatic functions in the sphere of the pathological process.

According to Bykov and Kuritsin, in cortico-visceral pathology, a cyclic process occurs: on the one hand, impulses are sent from the brain centers to the organ, changing its function, trophism, blood supply, and on the other hand, impulses go to the brain centers, increasing their pathological activity. Such a violation of the body's work can be fixed and maintained with the help of the mechanisms of a conditioned reflex. Within the framework of the concept of cortico-visceral pathology, disturbances in the functioning of the body are considered as having a psychotropic nature, i.e., new ideas about visceral pathogenesis are being formed. If earlier it was believed that aggressive environmental agents always directly affect the organ and lead to its destruction, now the representatives of the Pavlovian school proposed the idea that the pathogenic effect of the environment can be mediated by the cortex, i.e. direct cause disease is impaired brain activity. However, cortical activity itself is traditionally presented as conditioned by the external environment and dependent on the environment in which a person lives.

Within the framework of the concept of cortico-visceral pathology, for the first time in the history of Russian psychophysiology, a kind of “reversal” of the psychophysiological problem is observed. If earlier it was posed as the question of the dependence of consciousness on physiological processes, now it is as the question of the dependence of physiological processes on consciousness. This is due to the fact that within the framework of this concept, the mechanisms of the occurrence of visceral disorders caused by mental shifts are discussed. In the works of Bykov and Kurtsin, the pathogenic effects of neuroses and stress are constantly being investigated. Therefore, we can talk about the emergence of a special psychosomatic problem, which is the reverse formulation of the psychophysiological problem.

The original opinion on the theory of cortico-visceral interaction was expressed by V.N. Chernigov. As a student of Bykov, he accepted most of the provisions put forward by his teacher, but some of them proposed to be revised. According to Chernigovsky, the thesis about the absolute dependence of the work of visceral organs on the cortex cannot be considered true. He believed that it does not follow from the possibility of influence of the cortex on the functioning of organs revealed by Bykov that such an influence is carried out constantly. From the point of view of Chernigovsky, the influence of the cortex is not absolute, because, firstly, there are intracellular processes in the body that are not controlled by the cortex in principle, and secondly, all visceral organs are capable of self-regulation (automation), which ensures the functioning of the organ at a constant external load. Thus, the essence of Chernigovskii's objections boiled down to the fact that at rest the visceral organs are not subject to the influences of the cortex, but he recognized the existence of cortical control during changes in the external load.

Despite some peculiarity of the position, Chernigovsky is considered one of the main followers of Bykov. The team of scientists led by him did a great job of studying the cortical-visceral interaction. Particular attention was paid to the problem of perception by the cortex of impulses coming from the internal organs. At the same time, in accordance with the principle of the pyramidal hierarchy of organs, the signal perception system was divided into several parts: the receptor, the afferent pathway, subcortical structures, and the cortical analyzer. It is interesting to note that Chernigovskii analyzed the process of afferentation as one-sided, i.e. did not consider the inverse effect of cortical activity on receptors.

In the experimental works of Chernigovsky, the structure and physiological characteristics of the receptors and afferent pathways responsible for the occurrence of visceral reflexes were studied. The main method of research was the observation of changes in electrical potentials arising in receptors and afferent pathways as a result of exposure to various stimuli. The purpose of these works was to establish the relationship between the characteristics of the external stimulus and the change in the activity of the sensitive link of the reflex. Then the physiological mechanisms of reflexes at the level of subcortical structures of the brain were elucidated, with much attention paid to the problem of the interaction of various reflexes. To study the cortical analyzers of visceral reflexes, Chernigovskii used the technique of evoked potentials. The essence of this method consists in repeatedly presenting identical external stimuli to the subject and fixing electrical responses to them. The responses recorded on a set of presentations are averaged, and due to this, a stereotypical repetitive component of the brain response is revealed. It can be noted that this technique is used to study the brain by all psychophysiological schools both in our country and abroad, however, the goals and objectives that researchers set for themselves can vary significantly. In Chernigovskii's studies, the analysis of evoked potentials was carried out to establish the exact cortical representation of visceral reflexes and to establish the pathways for the propagation of excitation through the cortex. In these experiments, Bykov's earlier conclusion about the multiple cortical representation of such reflexes was confirmed; the principle of duplication of both analyzer and effector structures was confirmed.

According to Zakharzhevsky, the absolutization of the cortical control of visceral functions naturally affected the attitude of the authors of the cortico-visceral concept to the problem of psychosomatic relationships. The genesis of a wide variety of diseases of internal organs and systems began to be directly linked to the primary disruption of the activity of the cerebral cortex. Such an interpretation of the nature of psychosomatic relationships could not but lead to the idea of ​​the actual defenselessness of visceral systems from psychogenic influences. At the same time, many studies have shown that parietal digestion, basal vascular tone and autoregulation of vascular tone, regulation of the pumping function of the heart are not controlled by nervous mechanisms. High degree their self-regulation is provided by intraorganic nervous structures (metasympathetic nervous system).

The founders of the cortico-visceral theory also sought to consider the issue of the specificity of diseases of the internal organs, believing that the main thing here is the conditional interoceptive connection formed with the internal organ as a result of its repeated “traumatization”. Became an important stage in the formation physiological foundations psychosomatic addictions, the cortico-visceral theory at the same time was not without flaws. It did not fully take into account that there are a number of intermediate links between the cerebral cortex and the internal organ regulated by it (in particular, the hypothalamic and endocrine), without taking into account which it is impossible to explain the mechanism of psychosomatic disorders. She excluded from the circle of her consideration the actual psychological aspect of the study of psychosomatic relationships, the role of personality as the highest form of regulation of human activity in the formation of this pathology, any attempts at a meaningful understanding of psychogenic factors in their etiological role in psychosomatic disorders. The requirements to extend the concepts of higher nervous activity to personal functioning, the system of significant personality relationships and their violations, of course, could not be realized either theoretically or methodically.

The cortico-visceral theory in the works of a number of its successors was enriched with new information regarding the concept of the reticular formation as a morphological substrate of powerful influences on the cerebral cortex from its subcortical-stem sections, data from modern neurochemistry and neuroendocrinology, which made it possible to better understand the mechanisms of interaction of disorders of higher nervous activity. and vegetative-endocrine-metabolic disorders. In essence, these studies reflected a broader understanding of cortico-visceral pathology with the desire to take into account the entire complex of biological, psychological and social factors in genesis.

In a complex hierarchy of a vertically organized regulatory system, each "floor" has an important place. However, it was the central nervous system that subjugated other links, heading the entire regulatory apparatus. Its effect on internal organs, including the heart and blood vessels, is mediated in two ways (Fig. 1).

Functional visceral pathology (etiopathogenetic formation).

The first pathway is transhypophyseal, first through the releasing (realizing) factors of the hypothalamus, then the tropic hormones of the pituitary gland, and finally the corresponding hormones of the peripheral endocrine glands. The second way is parahypophyseal: through the channels of the neuro-vegetative connections of the center with the periphery.

If the mechanisms of humoral-hormonal regulation, according to A.F. Samoilov (1960), act in accordance with the slogan "everyone - everyone - everyone!", then the influence of the autonomic nervous system is carried out according to the principle of "letter with an address", i.e. more substantive, and therefore illustrative.

G. Bergman (1936), the most prominent representative of the functional trend in medicine in the 1930s, also wrote about this: “... a functional disorder covers the humoral and neural together”, but “the neural is clinically more visible”.

The formation of visceral functional disorders is largely due to a defect in the neurovegetative pathway of regulation and is topographically associated with dysfunction of suprasegmental (subcortical-cortical) autonomic formations.

As emphasized by A.M. Vein et al. (1981), "feature modern stage is the approach to vegetative-visceral disorders as psycho-vegetative. We are talking about a combination of emotional and vegetative disorders that occur either simultaneously or in a certain sequence ”(our discharge - A.M.).

Accordingly, the formation of functional visceral pathology can be expressed by the following construction: psychogenic (emotional) disorders -» vegetative dysfunction -> somatic disorders. Thus, functional diseases of the internal organs in general and the heart in particular are the result of integral part neurosis, i.e. represent his "somatic response".

According to I.P. Pavlov, a neurosis or breakdown of higher nervous activity develops as a result of a collision (“mistake”) and overstrain of the cortical processes of excitation and inhibition. Such an interpretation of neurosis has become a textbook, although, according to I.P. Pavlov himself, it had a significant gap. If all the paths of the process of excitation as one of the "struggling" parties were traced with accuracy, it remained unclear how inhibition arises and what it is.

On this occasion, I.P. Pavlov wrote: “No matter how significant our experimental material is, it is clearly insufficient to form a general definite idea of ​​inhibition and its relation to stimulation.” At the end of 1934, i.e. shortly before his death, at one of his famous clinical environments, he spoke even more categorically: "... it is significant that at present we do not know at all what internal inhibition is."

And he continued: "This is a damned question - the relationship between excitation and inhibition ... its solution does not come." A quarter of a century later, P.K. Anokhin tried to answer it. In 1958, his monograph "Internal Inhibition as a Problem of Physiology" was published, which contained a number of provisions that differed significantly from the generally accepted ones.

Some orthodox physiologists perceived them almost as an infringement on the teachings of I.P. Pavlov. The author himself did not think so, believing that he was following the precept of his teacher, who had repeatedly called for a "decisive attack" on the "damned question" mentioned above.

According to P.K. Anokhin, internal inhibition never acts as an independent nervous process, but arises only as a result of a collision of two excitation systems and is a means by which a stronger (dominant) excitation suppresses a weaker one, thereby eliminating, “ activity that is unnecessary or harmful at the moment.

Thus, he countered the classical formula of "the struggle between excitation and inhibition" as the main cortical processes, "having their own individuality and, to some extent, independence of course," another - "the struggle of two systems of excitation" with the help of "universal weapon - inhibition".

“Excitation,” writes P.K. Anokhin, “can never fight inhibition, because the latter is the result of excitation and immediately disappears as soon as the excitation that gave rise to it has disappeared.”

The concept of P.K. Anokhin captivates with its “tangibility”, vitality, proximity to clinical reality. It transfers the question of internal inhibition from a number of theoretical, concerning only physiological laboratories, to a practical plane.

In fact, if you think about it, the collision of differently directed excitations (urges) and the conflict-free inhibition of one of them by another, stronger system of motivations is a universal pattern of our daily life. Only thanks to this, orderly human behavior and purposeful actions that meet the "relevance of the moment" become possible.

How can one disagree with A.A. Ukhtomsky, who stated that “in general, it is difficult to imagine a non-dominant state of the central nervous system, since at any given moment the body performs some kind of activity.” An overstrain of higher nervous activity, according to P.K. Anokhin, occurs when competing excitations, for some reason, cannot slow each other down and, alternately gaining “victories”, mutually potentiate and stabilize at a new, higher energy level of excitability . A conflict situation arises that persists for a long time - a state of "explosiveness" or readiness for an emotional breakdown.

Although I.P. Pavlov never considered the genesis of inhibition, as well as neurosis, from the standpoint of the “struggle” of two excitations, he was close to this when he said: “I am occupied with a strong irritable process, and circumstances urgently demand to slow it down. Then it becomes difficult for me ... ".

Personal conflicts leading to neurosis most often develop precisely according to this type: in one or another life collision, some kind of human motivation comes into conflict with another system of excitations, i.e. with the very "circumstances" that for some reason do not allow its implementation.

A practical conclusion follows from this: if in a particular case of neurosis it is possible to hide the content of conflicting excitations, then by strengthening one and weakening the second, one can reduce nervous tension - reverse side conflict. Strictly speaking, this is the essence and ultimate goal of psychotherapy, or, in the words of PK Anokhin, "education of inhibition."

It is no coincidence that the definitions of neurosis have acquired etiopathogenetic and clinical overtones. Here is one of them (Raisky V.A., 1982) in a slightly edited form. Neurosis is a psychogenic (usually of a conflict nature) functional neuropsychic disorder that occurs under the influence of psychotraumatic stimuli and manifests itself as a pathology in the sphere of emotions in the absence of psychotic disorders, i.e. a critical attitude to the disease is maintained and the ability to control one's behavior is not lost.

There are three clinical forms of neurosis: neurasthenia, hysteria and obsessive-compulsive disorder. 90% of all cases of neuroses are due to neurasthenia (Votchal B.E., 1965; Svyadoshch A.M., 1982), which serves as the pathogenetic basis of NCA. Neurasthenia as an independent nosological unit was singled out by W. Beard in 1880.

Its main distinguishing feature is "irritable weakness" - mild excitability and rapid exhaustion of patients. VN Myasishchev Reveals the essence of the disease as follows: “In neurasthenia, the source of the disease is that the person is not able to cope with the task facing her, even with the most active desire to solve it.

The contradiction lies in the relative discrepancy between the capabilities or means of the individual and the requirements of reality. Unable to find the right solution with maximum effort, a person ceases to cope with work, a painful condition develops.

It is impossible not to notice that this definition clearly shows the same "struggle" between two systems of excitations: "an active desire to solve the problem", on the one hand, and "requirements of reality", on the other. A. Paunescu-Podyanu, deviating from dry formulations, calls neurasthenia “a disease of a tortured, exhausted brain”, qualifies it as “a neurosis of tense people, overwhelmed with worries and anxiety, whipped by a lack of time”, i.e. "neurosis of squeezed time".

In this he sees its fundamental difference from hysteria - "the neurosis of well-to-do people who can waste time and are not involved in the struggle with life", i.e. neurosis of free, empty time. Neurasthenia in general and NCA in particular are caused by psycho-emotional stimuli (psychogeny) that cause negative emotions.

Emotions are called mental processes, the content of which is the attitude of a person to the world around him, his own health, behavior and occupation.

They are characterized by such polar states as pleasure or disgust, fear or peace, anger or joy, excitement or discharge, acceptance or rejection of the situation as a whole. Consequently, the emotional stimulus is directed towards consciousness with its tip. It requires reflection and an adequate response, and therefore "emotion is an integral part of understanding."

J. Hassett's phrase contains a lot of meaning: "Emotions give flavor to life and serve as the source of all life dramas." The scale of psychogenies leading to neurosis is extensive and unequal in terms of value: from overstrain due to persistent intellectual activity, prompted by lofty thoughts, to the so-called primitive emotions.

These include household, family and other troubles, love troubles, all sorts of frustrations (dissatisfaction), for example, sexual ones. Of great importance are the “silent conflicts” smoldering in the depths of consciousness, caused by a clash between needs and opportunities, desire and decorum, motives and rules of the hostel, etc., in a word, everything that I.P. Pavlov aptly called “deceptions of life” .

Particularly pathogenic are situations that are characterized by relative insolubility, putting a person in front of the need to make an alternative decision: “either-or”. From the standpoint of physiology, we are talking about a “mistake” of two highly competitive excitations, when the strengthening of one (inhibitory excitation) induces the other (inhibitory excitation) - a struggle of arguments and counter-arguments.

Unsuccessfully trying to slow each other down, they stabilize, maintaining a high degree of psycho-emotional stress. One cannot but agree with R. Dubos that “the need to make a choice is perhaps the most characteristic feature of conscious human life. This is its greatest advantage, but also its greatest burden.

Not only external (exteroceptive), but also internal (interoceptive) stimuli can become a source of psychogeny. We are talking about secondary psycho-emotional disorders associated with the peculiarities of perception, experience and self-esteem of organic pathology, i.e. about the so-called somatogenic neurosis.

It is clear that a person cannot but be depressed by the deterioration in the quality of life caused by any disease, whether it is a myocardial infarction, recurring attacks of bronchospasm, skin diseases, problems with the gastrointestinal tract, etc.

Someone's expression that "the rectum determines the state of mind of a person" does not sound caricature at all. Even the outstanding French thinker Francois Voltaire (1694-1778) did not ignore this. With his usual brilliance, he wrote: “How blessed by nature are those people who empty their intestines daily with the same ease as they expectorate sputum in the morning.

"No" in their mouth sounds much more kind and helpful than "yes" - in the mouth of a person suffering from constipation. It is appropriate to recall the “hemorrhoidal character” described by Hippocrates and the common literary type of the “bilious person”. It is no coincidence that the term "hypochondria", which refers to a painful fixation on one's health, comes from the Latin word "hypochondricus" - hypochondria.

As B.E. Votchal wrote, every person who constantly suffers from his illness, “involuntarily acquires neurotic features.” In turn, somatogenically caused psycho-emotional disorders boomerang affect visceral symptoms, aggravating old ones or giving rise to new ones.

A "vicious circle" or the well-known image of the "snake biting its own tail" is created. The formation of emotions is associated with the activity of the limbic system of the brain (limbic-reticular complex), which includes a large group of subcortical formations centered around the brain stem (Vane A.M. et al., 1981; Magun G., 1960; Lindsley D., 1960; Cellhorn E., 1961).

On the one hand, the limbic system has neuronal connections with the "new" cortex, in particular the "orbital cortex", and takes an active part in the organization of behavioral and other conscious acts. This is well illustrated by the words of I.P. Pavlov: “The main impulse to the activity of the cortex comes from the subcortex. If these emotions are excluded, the core loses its main source of strength.

The function of the limbic system is also associated with I.P. Pavlov’s idea of ​​the “bright spot of consciousness”. Explaining this, P.V. Simonov writes: “A bright spot of consciousness”, like a searchlight beam, “highlights” precisely those phenomena in the surrounding world that currently represent highest value for the body." On the other hand, the higher autonomic centers are concentrated in the limbic system, mainly in the hypothalamus.

Consequently, it is closely connected with the internal organs and is endowed with the functions of regulation and control over their activities. Thus, using the terminology of A. Clod (1960), the limbic system is a "somato-psychic crossroads."

Its functional originality is also emphasized by other names: "emotional brain" (Konorsky M., 1954), "neurovegetative brain" (Fulton 1943), "visceral brain" (McLean, 1949). Schematically, the formation of emotional (psychogenic) visceral disorders is shown in fig. 2. In any emotional reaction, two parallel effects can be distinguished.

Functional visceral pathology (etiopathogenetic formation).

The first effect is ascending, or cortical, controlled by consciousness. It determines the sensual coloring of the stimulus and the adequacy of the mental and behavioral response to it, including facial expressions, gestures, words.

It can be suppressed by an effort of will (external calm) and artificially reproduced (acting). The second effect is descending, or neurohumoral, eluding cortical control. He owns the function of vegetative maintenance of holistic behavior.

On this occasion, P.K. Anokhin wrote: “A person who has subordinated all types of external expression of his emotional state to cortical control ... with fatal inevitability “turns pale” and “blushes” due to his visceral organs, and also makes a “mimic reaction” due to smooth muscles of their viscera"

So, in the clinical sense, emotion is a psychovegetative reaction of the body, where the autonomic nervous system acts as an intermediary between the cerebral cortex and visceral organs (Topoliansky V.D., Strukovskaya M.V., 1986). In the language of metaphors used by E.K. Krasnushkin, one of the most famous psychiatrists of the past, “the autonomic nervous system is the “mouthpiece of emotions”, and the “inner speech” of emotions is a function of the organs.”

Such, in summary, is the physiology of emotions, which, under the circumstances discussed above, develops into their pathology. It manifests in the same two directions: ascending (psychoneurosis) and descending (vegetative dystonia). To understand the psychogenesis of neurosis, it is important to keep in mind that the pathogenicity of a psycho-traumatic effect is determined not by the “physical strength” of the stimulus, but by its high individual significance, i.e. emergency for this individual.

Indifferent or insignificant for one, qualitatively the same stimulus is highly relevant for another. Moreover, the main significance is not so much acute severe shocks, which at once age a person for several years, but long-term mental stress, acquiring the features of chronic emotional stress with the formation of a stagnant-dominant focus of excitation, crowding out all the others - an idea fix.

At the same time, “in cases of prolonged and repeated exits of emotional excitations to the vegetative organs, all conditions are created for the emergence of so-called autonomic neuroses” or, in other words, dysregulatory visceropathies. In their formation, the role of unreacted emotions is especially great. As P.K. Anokhin emphasized, “when the cortical component of emotion is suppressed, the reaction of the body does not cease to be holistic, but the entire force of central excitations is directed along well-defined centrifugal vegetative pathways” (Fig. 3).

Moreover, “excitations with emphasized intensity rush to the internal organs through the centers of emotional discharge” (our discharge - A.M.). The same meaning is contained in the aphorism of H. Mandsley: "sadness that does not pour out in tears makes other organs cry."

Functional visceral pathology (etiopathogenetic formation).

Thus, vegetative disorders in neurosis are obligate (Vane A.M. et al., 1981; Svyadoshch A.M., 1982), but the form of their clinical expression is different. In some, they are limited to peripheral (nonspecific) stigmas, in others, certain viscero-organ, including cardiac syndromes are formed. This is the subject of a separate discussion (see Chapter 5).

Let's finish with another quote from P. Kanokhin (p. 420): “Which particular effector path will be prevailing for reaching the periphery of emotional excitations depends on the characteristics of the emotion, the nervous constitution this person and from the whole history of his life. As a result of these determining factors, we will have in each individual case various kinds of visceral neurotic disorders.

They can affect smooth muscles (pylorospasm, cardiospasm, spastic constipation), have a predominant expression on the vessels (hypertensive conditions), have an outlet to the heart, etc.” . As clinical practice shows, it is the heart that is the main visceral target of psycho-emotional disorders and associated autonomic dystonia.

Home > Document

« Psychosomatic medicine» in domestic science, the cortico-visceral theory of the pathogenesis of diseases of internal organs was opposed, which was a specific application of Pavlov's teaching on higher nervous activity to the clinic of internal diseases. Its creators Bykov and Kurtsin attributed diseases of the internal organs to cortico-visceral pathology that occur when "the presence of a neurotic state of the cerebral cortex, with all its characteristic features and characteristics." This, they write, is the dividing line between diseases related to cortico-visceral pathology and diseases of other etiologies (infection, trauma, etc.), which can also be accompanied by impaired functions of the cerebral cortex.

As Zakharzhevsky points out, such an absolutization of the cortical control of visceral functions naturally affected the attitude of the authors of the cortico-visceral concept to the problem of psychosomatic relationships. The genesis of a wide variety of diseases of internal organs and systems began to be directly linked to the primary disruption of the activity of the cerebral cortex. Such an interpretation of the nature of psychosomatic relationships could not but lead to the idea of ​​the actual defenselessness of visceral systems from psychogenic influences. Indeed, many studies have shown that parietal digestion, basal vascular tone and autoregulation of vascular tone, regulation of the pumping function of the heart are not controlled by nervous mechanisms (Ugolev, Konradi, etc.). A high degree of their self-regulation is provided by intraorganic nervous structures (metasimpathetic nervous system).

The thesis of cortico-visceral pathology about neurosis as the main and most common form of psychosomatic diseases did not receive confirmation either on experimental material (Zakharzhevsky and others) or on clinical material (Karvasarsky, Ababkov). Clinical forms of neuroses retain their nosological independence for decades.

The founders of the cortico-visceral theory, from the standpoint of their concept, also sought to consider the issue of the specificity of diseases of the internal organs, believing that the main thing here is the conditional interoceptive connection formed with the internal organ as a result of its repeated “traumatization”. Having become an important stage in the formation of the physiological foundations of psychosomatic addictions, the cortico-visceral theory, at the same time, was not without its shortcomings. It did not fully take into account that there are a number of intermediate links between the cerebral cortex and the internal organ regulated by it (in particular, the hypothalamic and endocrine), without taking into account which it is impossible to explain the mechanism of psychosomatic disorders. She excluded from the circle of her consideration the actual psychological aspect of the study of psychosomatic relationships, the role of personality as the highest form of regulation of human activity in the formation of this pathology, any attempts at a meaningful understanding of psychogenic factors in their etiological role in psychosomatic disorders. The requirements to extend the concepts of higher nervous activity to personal functioning, the system of significant relationships of the personality and their violations, of course, could not be realized either in theory or in methodological plans.

In the recent period, the cortico-visceral theory in the works of a number of its successors has been enriched with new information regarding the concept of the reticular formation as a morphological substrate of powerful influences on the cerebral cortex from its subcortical-stem sections, data from modern neurochemistry and neuroendocrinology, which made it possible to better understand the mechanisms of interaction of disorders higher nervous activity and autonomic-endocrine-metabolic disorders, etc. In essence, these studies are already talking about a broader understanding of cortico-visceral pathology with the desire to take into account the whole complex of biological, psychological and social factors in their genesis.

Medico-psychological aspects of psychosomatic relationships in the studies of domestic authors of the last period. The clinical and psychological characteristics of somatic disorders in neurosis within the framework of a broader clinical and functional study are covered in detail by us (Karvasarsky), as well as in studies carried out by Gubachev and Stabrovsky. In these studies, it was shown that somatic disorders in neuroses have a different origin. Often (especially defiantly it appears in cardiovascular reactions) they represent a psychophysiological accompaniment of emotional disorders in patients with the presence in many cases of a meaningful relationship between disorders of the function of one or another somatic system and psychogeny. In other patients, these are paroxysmal disturbances in the activity of visceral systems, which are an expression of the disintegration of the autonomic regulation characteristic of neurosis (Vayne, Rodshtat). Dominant in clinical picture neurosis, disturbances in the activity of individual anatomical and physiological systems can be a manifestation of previously latent somatic diseases or an expression of decompensation of a particular function that has a deficiency of a different nature; the development of such decompensation occurs either in conditions of excessive functioning of the system, or in connection with a violation of the rhythm of adaptive processes in conditions of psychogenic (neurotic) disintegration. Finally, cases of neurotic processing of obvious somatic diseases can be considered separately.

Medico-psychological studies of psychosomatic relationships in "major" psychosomatic diseases are presented in many works. In a significant part of them, we are talking about the continuation of the search (albeit at a new clinical and psychological and methodological level) of personality profiles characteristic of individual diseases. The value of these works is different. The personality profile is established either by the clinical and anamnestic method - retrospectively, or with the help of various psychological methods, including personality tests. As regards the first path, let us refer to Alexander: “The clinic is able to provide good starting points, which, however, must be checked by other methods. It is not difficult to select certain configurations from the abundance of psychological events and find in each patient exactly the picture that one wants to see in him. When examining patients with the help of personality tests, the question arises whether the characteristics of a premorbid personality or personality, the system of its relations, and attitudes that have changed under the influence of the disease itself are determined.

These shifts, caused by the "internal picture of the disease", were revealed in a vivid form, in particular, in the results of studies carried out as early as the mid-1960s. Then a large group of patients suffering from a malignant tumor was studied, and the patients knew their diagnosis or guessed about it. It turned out that according to a number of test studies based on self-assessment, premorbid patients (in response to questions, the patient characterized himself before the onset of the disease) were distinguished by high rates of emotional stability, frustration tolerance, and were devoid of any neurotic features and manifestations. This personality profile of the studied patients could be correctly understood only by additional study of them. It turned out that the realization of oneself as a patient, doomed to a slow death (and this is exactly what most cancer patients still believe), led to a pronounced correction of the scale of experiences of events and their behavior in the past. The period “before the tumor”, from the point of view of the “incurable” patient, was devoid of any life problems and difficulties worthy of attention, especially those that could not be resolved objectively or subjectively. This determined the results of studies of this group of patients with the help of the so-called personality questionnaires.

The issue is further complicated by the fact that, with rare exceptions, each scientist studies only one group of diseases. Often, with further clarification of supposedly specific personality types and conflict situations, it turned out that they are in many respects similar to the indicators obtained for other diseases.

Taking into account the possibility of distorting the personality profile, determined retrospectively, already in the course of the disease, one should, at the same time, positively evaluate these data for a better understanding of the clinical manifestations of the disease, the characteristics of its course, the nature of neuropsychiatric disorders associated with somatic suffering, establishing a prognosis, building a therapeutic -rehabilitation programs.

The data obtained in prospective studies cannot be considered impeccable either. In addition to the difficulties of performing purely technical research here, for many years of observing the subjects, their personality does not remain unchanged - the system of its relations, attitudes, needs, motives change, which should be borne in mind when analyzing the results of observations.

In addition, in a prospective study of the role of such a risk factor for the development of cardiovascular diseases as a behavioral "type A", it cannot be ruled out that over the years of the study other risk factors have appeared, for example, smoking, weight gain, etc.

Among the numerous studies of psychosomatic relationships, several more topical areas in psychosomatics should be singled out.

Thus, the works of Gubachev, Karvasarsky, Ababkov and others are important for understanding the mechanisms of the development of functional disorders into organic changes in the internal organs. on examination and treatment in the clinic of neuroses and psychotherapy of the Institute. V. M. Bekhtereva showed that, as a rule, there is no transformation of neurotic disorders of internal organs into the corresponding "large" psychosomatic diseases- ischemic heart disease, hypertension, bronchial asthma and gastric ulcer. These data again raise the question of the need for a clear distinction between the concepts of functional (non-psychogenic) as a stage of an organic disease and functional psychogenic (neurotic), which most often is not. Moreover, the presence of neurotic systemic disorders can be considered as a prognostically favorable sign in relation to "major" psychosomatic diseases. Today there is no convincing answer to the question why this is happening. Does neurosis act as “life insurance” due to frequent visits by patients with neurotic disorders to a doctor already at an early stage of the disease and timely (to some extent, preventive) treatment, or do specific psychological compensatory mechanisms acquire a warning value in neuroses, leading to a decrease in pathogenic emotional and affective tension.

The understanding of these facts can be facilitated by Solozhenkin's research aimed at studying the typology of psychological defense mechanisms in patients with initial forms of hypertension, coronary heart disease and neuroses in the system of their multilateral (somatic, biochemical, psychophysiological and psychological) studies.

We have indicated only some of the trends in the field of psychosomatic relationships that have been realized in recent research. It can be confidently stated that the psychosomatic approach is promising for a better understanding of the etiology, pathogenesis, clinic and the development of the most adequate treatment and rehabilitation programs for diseases in the development mechanisms of which the mental factor plays a significant role. The implementation of these programs is no longer conceivable without considering the psychological links of the studied pathology.

It is now obvious that one of the causes of various somatic diseases can be mental factors. An important group of such factors are negative emotions. In some diseases, they play a major role. It is known what mechanisms are responsible for the fact that emotions cause somatic disorders. Three important mechanisms may be that emotions influence 1) immune system, 2) hormonal status, 3) peripheral physiological activation (eg, heart rate and blood pressure). In this case, the role is played, first of all, by the following emotions:

A. Important for the occurrence of ulcers (gastric or duodenal ulcers), in addition to infections, obviously, are emotions that arise in insufficiently controlled situations: anxiety and feelings of helplessness and overload.

B. Coping anger, on the other hand, seems to be the main cause of essential hypertension (high blood pressure) and thus angina pectoris and myocardial infarction. Anger and hostility are among those "type A" personality components that make a clear distinction between those with and without cardiovascular disease.

B. For other disorders (such as asthma, skin diseases etc.), on the contrary, it is less clear which emotions are the causes of their occurrence (Perret, Baumann).

From the standpoint of the psychology of relations, experience is a consequence of a violation of human relations; it acquires a painful pathogenic character in disorders of personality relations, which occupy a central place in common system human relationship to reality. Their significance is the main condition for emotional-affective stress, the neuro-vegetative-endocrine correlate of which is the central link in the mechanisms of development of psychosomatic disorders.

The hypothesis of search activity remains promising, presented in the studies of Rotenberg and Arshavsky, who showed that it is not the nature of emotions in itself, but the degree of severity of search activity (as opposed to passive-defensive behavior) that determines the response to stress and the degree of resistance of the organism to pathogenic influences.

In this regard, a study of 60 men at high risk of heart disease is of interest. Contrary to theory, just the majority of men with "type A" behavior, i.e. those who, when there is a shortage of time, grabs at once for several things, experience the burden of competition, act quickly, behave rather aggressively towards others, i.e. strong, expressive, charismatic faces, did not fall ill with heart disease. Persons with “type A” also fell ill, but others were inhibited, slow, tense.

Changes in mental activity in chronic somatic diseases. Modern ideas about the essence of the disease concept involve taking into account the entire set of changes affecting both the biological level of disorders (somatic symptoms and syndromes) and the social level of the patient's functioning with a change in role positions, values, interests, social circle, with the transition to a fundamentally new social situation with with its own specific prohibitions, prescriptions and restrictions.

The influence of the somatic state on the psyche can be both sanogenic and pathogenic. The latter refers to violations of mental activity in conditions of somatic illness.

There are two types of pathogenic influence of a somatic disease on the human psyche: somatogenic (due to intoxication, hypoxia, and other effects on the central nervous system) and psychogenic , associated with the psychological reaction of the individual to the disease and its possible consequences. Somatogenic and psychogenic components are represented in the influence on the mental sphere in various proportions depending on the nosology of the disease. So, for example, somatogenic influences play a particularly important role in the genesis of mental disorders in kidney diseases and in congenital heart defects.

In patients with chronic renal failure, intoxication phenomena are observed. Against the background of intoxication, asthenia develops. As a result of growing asthenia, changes are observed primarily in the structure of such cognitive processes as memory and attention - the prerequisites for intelligence: there is a narrowing of the amount of attention, a violation of the processes of imprinting and storing information. As asthenia increases, other changes in the intellectual sphere join the disturbances in the processes of attention and memory: the level of analytical and synthetic activity of thinking decreases with the predominance of visual-figurative thinking over abstract-logical. Cogitative activity begins to bear the features of concreteness and situationality. Intellectual insufficiency is gradually formed, the productivity of thinking decreases. Changes in the cognitive sphere of patients with chronic renal failure are inextricably linked with changes in emotionality. In the structure of asthenia, irritability is observed with a decrease in control over emotional reactions. The psychological reaction to the patient's awareness and experience of emerging intellectual failure (especially in the later stages of the disease) is depression. Anxiety and hypochondriacal traits may develop.

Forced abandonment of habitual professional activity, the need to change profession due to illness or transition to disability, becoming an object of family care, isolation from the usual social environment (due to long-term inpatient treatment) - all this greatly affects the personality of the patient, who has features of egocentrism, increased demands , resentment.

Severe chronic somatic disease significantly changes the entire social situation of human development. It changes his ability to carry out various activities, leads to a limitation of the circle of contacts with other people, leads to a change in the place he occupies in life. In this regard, there is a decrease in volitional activity, a limitation of the circle of interests, lethargy, apathy, violations of purposeful activity with a drop in working capacity, impoverishment and impoverishment of the entire mental appearance.

Nikolaeva notes another important mechanism of the relationship between the mental and somatic levels of human functioning - the mechanism of the "vicious circle". It lies in the fact that a violation that occurs initially in the somatic sphere causes psychopathological reactions that disorganize the personality, and they, in turn, are the cause of further somatic disorders. Thus, a holistic picture of the disease unfolds in a “vicious circle”.

The most striking example of the mechanism of "vicious circle" is the reaction to pain, often encountered in the clinic of internal medicine. Under the influence of pain and chronic physical discomfort, patients with severe somatic disorders develop a variety of emotional disorders. Prolonged affective states change the parameters of physiological processes, transferring the body to a different mode of functioning, associated with the stress of adaptive systems. Chronic tension of adaptive and compensatory mechanisms can eventually lead to the formation of secondary somatic disorders.

Korkina proposes the concept of a "psychosomatic cycle", when periodic updating psychological problems and related prolonged or intense emotional experiences leads to somatic decompensation, exacerbation of chronic somatic disease or the formation of new somatic symptoms.

In contrast to acute pathology, in which successful treatment leads to a complete restoration of the state of health that preceded the disease, chronic diseases are characterized by long-term pathological processes without clearly defined boundaries. The patient never becomes completely healthy again, he is constantly, that is, chronically ill. The patient must be prepared for a further deterioration in his well-being, a continuing decline in performance, to come to terms with the fact that he will never be able to do everything he wants, as before.

Because of these limitations, a person often finds himself in conflict with what he expects of himself, and with what others expect of him. A chronic patient, due to the psychosocial consequences of his functional limitations (the reaction of the family, a decrease in the social sphere of activity, damage to professional performance, etc.), is threatened with turning into an "inferior", into a disabled person.

In counteracting a chronic disease, there are two strategies of behavior - passive and active. The patient must be aware of the general change in the life situation and try to actively overcome obstacles with the help of a new way of life adapted to the disease. The requirement to “live with the disease” is easier, however, to declare than to comply, and this leads to the fact that many people react to changes in their functioning caused by the disease, such psychopathological disorders as fear, apathy, depression, etc. passive behavior includes protective mechanisms: reactions of downplaying the severity of the disease such as ignoring, self-deception, rationalization or overcontrol. However, the value of these passive attempts to overcome the psychological and social consequences of long-term illness is often questionable. More significant are the active efforts of the patient to solve the problems that have arisen before him associated with the disease. According to Kallinka, the patient should strive to: mitigate the harmful effects environment and increase the chances of improving the condition, adequately assess and adapt to unpleasant events and facts, maintain a positive self-image, maintain emotional balance, maintain calm, normal relationships with others.

This is possible if the patient: receives and assimilates the necessary information about the disease; seeks and finds advice and emotional support from specialists, acquaintances or comrades in misfortune (self-help groups); acquires self-service skills at certain moments of the disease and thereby avoids excessive dependence, sets new goals related to the presence of the disease and tries to achieve them step by step. Despite the complexity of managing such patients, the doctor must carefully notice and support even the slightest attempts to solve their problems on their own. This is necessary both for cooperation in therapy and for the premise of rebuilding family and professional relationships, as well as in a new way free time. The doctor must be able to explain to the patient the possible failures of treatment or clarify the conditions of life that affect the course of the disease, when, for example, the patient successfully copes with the new situation with the help of relatives, or when, on the contrary, the family prevents the patient from concentrating efforts on the fight against the disease. Support and supervision from therapeutic teams specializing in the treatment of chronically ill or patients in need of long-term treatment (teams for the treatment of tumor patients, patients who have undergone organ transplantation, etc.) may be necessary and valuable.

Psychosomatic aspects of pain. The doctrine of pain is one of central issues biology, medicine and psychology. Anokhin defines pain as a peculiar mental state of a person, due to the totality of the physiological processes of the central nervous system, brought to life by some super-strong or destructive irritation. In the works of domestic scientists Astvatsaturov and Orbeli, ideas about the general biological significance of pain are especially clearly formulated. Unlike other types of sensitivity, pain sensation arises under the influence of such external stimuli that lead to the destruction of the body or threaten this destruction. Pain warns of a danger threatening a person, it is a signal, a symptom of painful processes that are played out in various parts of the body. For medical practice, in connection with the "signal" value of pain, an objective characteristic of the severity of pain is very important. The difficulty and complexity of this assessment is due to the fact that, by its nature, pain is a subjective sensation, depending not only on the magnitude of the stimulus that causes it, but also on the mental, emotional reaction of the individual to pain. “Being a borderline problem of general neurophysiology and science that studies the primary forms of sensations, i.e., states of a subjective nature,” Anokhin wrote, “pain can have a huge cognitive meaning, representing a milestone on the long and difficult road of materialistic analysis mental states". “We are not equal before pain” (Lerish). This dual nature of pain explains why, not only in wide medical practice, but also in the works of a number of prominent representatives of medicine, there is an underestimation to a certain extent of the significance for diagnosing the degree of subjective experience of pain. So, Pirogov wrote that “at dressing stations, where so many sufferers of various kinds accumulate, the doctor must be able to distinguish between true suffering and apparent. He must know that those wounded who scream and yell more than others are not always the most difficult and not always the first to receive immediate relief.

Numerous studies have been devoted to the study of the conditions that determine the intensity of pain sensation. They convincingly showed that the experience of pain by an individual depends both on the magnitude of the stimulus (primarily on its strength, duration and quality), and on the individual reactivity of the organism, the functional state of its nervous system, which in turn depends on a number of factors, including and psychological to a large extent. Emphasizing the non-absolute significance of each of these components that determine the subjective experience of pain, Danielopoulu rightly points out that pain can be caused not only by “abnormally intense irritation of the normal sensory pathway, but also by normal irritation of the hyperreactive sensory pathway.” Let us briefly consider the main factors affecting the intensity of pain. The experience of pain under normal conditions undoubtedly depends on the strength and duration of the pain stimulus. This dependence is especially evident in cases of sufficiently intense and prolonged flow of pain impulses. At the same time, a state arises in the nerve centers (in the subcortical formations and in the cortex), which Pavlov characterized as an inert process of excitation, and Ukhtomsky called the dominant. The pain syndrome, which has become dominant, is overgrown with diverse conditional connections, which are formed not only on the basis of primary and secondary signal stimuli, but also in connection with representations and more complex mental experiences. A classic example of a pain dominant is a pain syndrome with severe causalgia. The idea of ​​adaptation to pain is associated with the strength and duration of a painful stimulus. There is no consensus on this issue in the literature. Apparently, in cases where the stimuli that cause pain are not intense and act for a long time, a decrease in pain due to adaptation can be observed. The quality of the stimulus can also affect the intensity of the pain sensation. One of the factors determining individual reactivity is undoubtedly the type of the nervous system. The role of the type of the nervous system in the experience of pain is indirectly indicated by the studies of Pavlov's students Petrova, Blokhin and others. In experiments on animals, it was shown that changes in the general behavior of dogs and their conditioned reflex activity under the influence of pain depended on the type of nervous system of the animal. In dogs of a strong type, pain stimulation had an exciting effect on conditioned reflexes, in dogs of a weak type, this effect was depressing. Biochemical changes in the brain of animals were studied under pain and conditioned pain stimuli. It turned out that in dogs with a strong type of nervous system, the biochemical processes in the brain changed under the influence of pain and conditioned pain stimuli returned to baseline much faster than in dogs of a weak type. The intensity of pain is also affected by disturbances in the activity of the endocrine glands, in particular, the gonads. Clinical practice indicates the occurrence of numerous pain complaints in women in menopause. This, apparently, is explained primarily by the influence of the endocrine glands on the functional state of the nervous system, including the conditioned reflex activity of the brain. Among the psychological factors that have great importance in the experience of pain, one should first of all point out the following: distraction and focus on pain, expectation of pain, various emotional states - grief, joy, anger; personality traits - resistance and endurance to pain, effeminacy and intolerance; social and moral attitudes, the content and direction of a person's life relations, which determine his attitude to pain. An important role in the experience of pain is played by the expectation of pain and attitude towards it, on which the “limits of endurance” to pain and the possibility of overcoming it largely depend. Expectation, "fear of pain" according to Astvatsaturov is a primitive form of the emotion of fear in general. “Pain and emotion,” he points out, “seem to be extremely closely related by the commonality of their biogenetic roots and the identity of their biological essence.” Substantiating this position, he writes that the functional purpose of pain is not the discriminative function of distinguishing the quality of external influences, but the affective experience of an unpleasant feeling, which is an incentive to move away from the corresponding object. The identification of pain sensitivity with emotion caused objections from a number of researchers. So, Ananiev points out that the alternative formulation of the question: pain - emotion, or pain - sensation, is metaphysical in nature; it breaks the sensory-affective unity of pain. Pain is an integral reaction of the personality, expressed both in subjective experiences and in objective activity. In the studies of Berkenblit, it was found that even with a very emotional experience of pain, the gnostic components characteristic of any other kind of sensations are quite clearly expressed in it. Despite the tense expectation of pain, colored by the emotion of fear, the subjects quite correctly determined the strength of the irritation, and despite the experimenter's conscious disorientation of the subject, the sensation was fully adequate. She also showed that under the influence of ideas about this type of pain and the intense expectation of pain that arose on its basis, strongly emotionally (negatively) colored, sensitivity increased significantly, which corresponded to a decrease in the value of pain sensitivity thresholds. But along with this, the endurance to pain also increased, which was expressed in an increase in the size of the upper thresholds of pain sensitivity. This was due to the inclusion of volitional mechanisms in the experience of pain: the desire of the subjects to implement the intentions that they formed in the course of the experiment (testing their own endurance, comparing themselves with other subjects, etc.). These data show the importance of pain perceptions and the resulting reduction in pain in individual variation in pain sensitivity. The sensitivity to pain in the subjects was the higher, the stronger was the expectation of pain and the emotional and affective tension associated with it. Myasishchev, Ananiev, Beecher, and others point to the significance of a person’s life attitude in experiencing pain, which is determined by his relationships. More than a hundred years ago, the famous French surgeon Dupuytren wrote: “What is the moral difference between those we treat in civilian hospitals receiving gunshot wounds? The military man is accustomed to the fact that he must forget about himself and his family and that he will face the prospect of being crippled. He considers himself lucky if he saves his life by losing a limb, and since he is sure of safety, he courageously, even joyfully, meets the surgeon's scalpel. But look at the unfortunate worker, farmer, craftsman who is the only breadwinner for a large family. He is overwhelmed by fear, poverty awaits him, he is in deep despair, he has lost hope. He regretfully agrees to the surgeon's insistence. We shouldn't be surprised at the difference in the results." Beecher examined the relationship between the severity of injury and the intensity of pain in 150 civilians and 150 soldiers admitted to the hospital for surgical treatment. There was no relationship between the size of the wound and the sensation of pain. The determining factor in the experience of pain was the patient's attitude towards it. For the 150 soldiers who arrived at the hospital from a war zone where they had been under almost continuous bombardment for several days, admission to the hospital and operation meant relative safety. Liberation from the desperate fear of death and subsequent transfer to the rear. Only 32% of them experienced severe pain and asked for morphine. In civilians, less surgical intervention was accompanied by a significantly more pronounced pain sensation. The use of morphine due to severe pain was required in 88% of these patients. Beecher comes to a conclusion. That in the experience of pain, the size of the wound matters less, if at all, than the emotional component of suffering, determined by the relationship of the patient. Davydova, on the basis of psychological studies of pain, concludes that the relationship of a person to it is of decisive importance in the experience of pain. "Pain. - she writes - in itself does not have a self-sufficient force, since the emotions that accompany pain sensations are mediated by a certain life content. The observation cited by the author shows the different experience of pain by two wounded. In the first case, the operation was aimed at restoring the activity of the hand (withdrawal of the bullet). The patient said: "I was looking forward to this operation, it was a way out again in life." Another was the installation of the second wounded man, waiting for the prompt removal of his arm due to the onset of gangrene: “It seemed to me that I would not survive this day, everything faded in my life.” These two attitudes differed sharply from each other, and hence the attitude towards pain was different, the emotional experience of it was different. In the first case: "I don't remember if there was severe pain, I don't think so." In the second case: "Everything was excruciating and painful, from beginning to end, and before, and after." Both in functional pains and in pains based on organic changes, personal relationships (not in the occurrence, but in the degree of pain experience) play an important role. Pain often reaches its greatest severity in patients with personal disorder, lack of purpose and other unresolved conflicts. Focusing the attention of patients on themselves, pain sensations in such cases are used as a means of getting out of a traumatic situation, helping patients to get away from resolving real life difficulties. Ananiev also points out the significance in mastering pain, in changing the “limits of endurance” to pain of a person’s conscious attitude. It is in this change in the "limits of endurance", and not in absolute pain sensitivity, in his opinion, that a person's personality manifests itself in its relation to pain. In close connection with the above is one of the least studied sections of the doctrine of pain - the problem psychalgia, or mental pain . In foreign psychosomatic literature, purely psychological interpretations of psychalgia are common, in which the denial of the neurophysiological mechanisms of pain is most often combined with an analysis of their psychogenesis from psychoanalytic positions. The most systematic exposition of the psychosomatic concept of pain is found in Engel's work. He substantiates the proposition that the existence of pain "as a purely mental phenomenon" is possible, pain without pain impulses from the periphery. The author's proofs boil down to the following basic propositions. 1) Pain has a signal protective value, it warns of the threat of damage or loss of a body part. In terms of development, pain always occurs in the presence of pain impulses from the periphery. The mental mechanism of pain develops in the process of phylogenesis and ontogenesis on the basis of a reflex mechanism. But as soon as the psychic mechanism of pain has arisen, peripheral stimulation is no longer required for the sensation of pain. And this is determined by the enormous significance that pain has in the life history of the individual. 2) Pain - crying - consolation by a loved one - elimination of pain - this whole chain plays an important role in the development of tender love relationships and allows you to explain the "sweet pleasure" of pain. Pain allows you to get closer to your loved one. Some individuals act as if the pain is worth the price. 3) Pain is punishment. Pain is inflicted if "I am bad." In this case, it is a signal of guilt, and hence an important mediator for atonement for guilt. Some children, as well as adults, are happy with pain if it leads to forgiveness and connection with a loved one. If pain is a mediator for the relief of guilt, then to some extent the pleasure of pain also comes into play. 4) Pain is early combined with aggressive aspirations and the desire for power. In this sense, pain is a good way to control your aggressive tendencies. 5) There is a certain connection between pain and the true or imagined loss of loved ones, especially if there is guilt in aggressive feelings towards these persons. Pain is in these cases a means of psychic redemption. The person reduces the sense of loss by experiencing pain in their own body. He can replace a lost face with pain. 6) Pain can be combined with sexual feeling. At the height of sexual arousal, pain can not only be inflicted, but also be a source of pleasure. When this becomes dominant, one speaks of masochism. Some people are more inclined than others to use pain as a mental phenomenon, whether or not it has a peripheral component. These people are distinguished by a number of features, which, taking into account what has already been said above, can be reduced to the following: a) the predominance of guilt, in which pain is a satisfactory way of calming, b) masochistic tendencies, a tendency to endure pain, as evidenced by big number operations, injuries - a tendency to "beg for pain", c) strong aggressive tendencies that are rebuffed, and therefore pain occurs, d) the development of pain when some connection is lost or threatened, when pain is a "substitution", e) the localization of pain is determined by unconscious identification with the object of love; one of two things: the pain was in the patient when he was in conflict with the object of love, or this pain, which suffered an actual or imagined object of love. The author denies the two-component concept of pain, which recognizes pain sensation (sensory component) and reaction to it (emotional component), since "this concept leads to the incorrect conclusion that pain is impossible without pain impulses from receptors." From a clinical point of view, the problem of psychalgia includes the following main questions: 1) are there pathological processes that irritate nerve endings and cause pain; 2) if so, are they partially, completely or not at all responsible for the pain; 3) what are the psychological mechanisms that determine the final nature of the pain experienced and the way in which the patient will report this to the doctor. The peripheral factor may or may not be important, and even if it is, it does not always determine the pain experienced - this is Engel's main conclusion. From the point of view of the above concept, pain plays an extremely important role in psychological life individual. In the course of human development, pain and relief from pain influence the formation of interpersonal relationships and the formulation of the concept of good and evil, reward and punishment, success and failure. As a means of eliminating guilt, pain thus plays an active role in influencing interactions between people. However, while denying purely psychological interpretations of psychalgia, it should be noted at the same time that this problem, especially in its clinical and therapeutic aspects, can hardly be resolved today in a purely physiological plane. From the standpoint of neurophysiology and clinical psychology, it is more correct to consider psychalgia as a special case of pain in general. And with psychalgia, the position that there is no pain devoid of a material basis, outside the "pain system" retains its significance. At the same time, clinical experience shows that often the experience of pain is determined not only, and often not so much by the sensory as by the emotional component, the reaction of the individual to pain. In this regard, the correct clinical assessment of the ratio of the two main components of the experience of pain: sensory and emotional, the establishment of a kind of coefficient of "psychogenicity of pain" is of particular importance. On fig. 21 shows a possible schematic representation of the correlation of physiological and psychological factors that determine the experience of pain by an individual, and the place in this system of psychalgia. On the next fig. 22 shows the psychosomatic relationships in the occurrence and elimination of headaches from Wolf's classic works. Rice. 21. The ratio of physiological and psychological factors in physiogenic pain and psychalgia.

Rice. 22. Headache attack caused by excitement and stopped with the help of placebo (according to Wolf).

In the described pains of the "psychalgia" type, there are a number of features that must be taken into account in view of their diagnostic value. Patients have difficulty in describing the nature of pain, often they cannot clearly localize it, there are no external signs of experiencing pain. There is also no significant dynamics and progression in the course of pain, although the situational conditionality of the symptom is not excluded. The intensity of pain does not change when taking various analgesics, even the most powerful of them. The phenomenon of psychalgia reflects the unity of the physiological and psychological, objective and subjective, sensations and emotions. The main thing in characterizing psychalgia is not the absence of a sensory component (its objectification in each case depends only on our technical capabilities), but the decisive importance in their experience of the mental component of pain, the individual's reaction to pain. A meaningful analysis of this reaction requires the study of a specific life history of a person, the characteristics of his personality, the formed relationship to the surrounding reality, and especially his attitude to pain.

In conclusion, we note that the analysis of the psychosomatic problem already today makes it possible to abandon a number of studies that are methodologically and methodically obviously untenable, to carry out more adequate, taking into account their complexity and real technical capabilities, planning and conducting specific studies. It remains promising to study the biological, psychological and social aspects of the problem with the implementation of the growing trends of system analysis and a systematic approach to its solution. Training and metodology complex

Social medicine occupies one of the main places in the training of a modern social worker. This independent discipline, both in the structure of medical knowledge and in the system of social practice, is at the intersection of health care.

Fundamentals of deep psychological symbolism

Document

“We understand that man at all times has lived and lives in the world of symbols. And it was the symbols that became for him the reality that determines his existence.