Psychosocial rehabilitation of patients with pneumoconiosis at an outpatient stage of treatment

General requirements for the organization of psychosocial rehabilitation of patients with pneumoconiosis at the stage of outpatient treatment are formulated. An integrative therapeutic complex has been developed, which includes modern methods of psychotherapy combined with information and biological therapy, which contribute to the development of a socially acceptable life stereotype of patients and the correction of mental disorders. It has been established that adequate systematic treatment with optimal doses of drugs at the outpatient stage allows obtaining persistent remission of the disease in 46.3% of patients after 6-12 months.

Key words: pneumoconiosis, quality of life, psychosocial rehabilitation, outpatient stage, psychocorrection, basic treatment, remission.

In recent decades, psychological research in the field of physical medicine has been actively conducted. This is due to the recognition of the role of psychological factors in the occurrence, flow and treatment of various somatic disorders, with increased attention to the mental and physical qualities of a person in conditions of illness.

The situation of the disease dramatically changes the nature of the relationship between a person and the world around him. Therefore, a comprehensive examination of the relationship between illness and personality allows us to talk about changing not the physical and / or mental status of the patient, but the whole system of his relations with the world and the world.

The theoretical basis of this trend in the domestic clinical psychology is the concept of the personality of VM Myasyshchev, in which a person is understood as a single biopsychosocial system, and the personality as a system of emotionally saturated relationships with the social environment and himself. In this system, the disease as a situation of uncertainty and an unpredictable result can act as an independent psychotraumatic factor, destabilizing the picture of the world, destroying self-esteem, the habitual order of events, the nature of interpersonal interaction and, in general, the social functioning of the individual.

Recently, a significant number of studies have been devoted to the study of psychological characteristics and quality of life (QOL), associated with the health of patients with pulmonary pathology. In particular, interest to the study of the quality of life of patients with pneumoconiosis (PnC) has increased significantly. The increase in the number of pneumoconiosis, both in our country and abroad, has determined the attitude to this disease as an important medical and social problem of modern health.

At the present stage of the development of medicine, it becomes increasingly obvious that the scientifically based and effective management of psycho-prophylactic and psychocorrectional work with patients is possible only on the basis of knowledge of the internal psychological patterns of changes in the psyche. Getting full-fledged scientific data on the impact of chronic illness on the psyche can contribute to more effective therapeutic interventions, an individual approach to choosing the strategy and tactics of treatment on the part of doctors, and also if necessary psychological support. This fully applies to severe chronic diseases, accompanied by significant psychological changes and changes in the quality of life, including pneumoconiosis.

The aim of our study was to develop a program of psychosocial rehabilitation of patients with pneumoconiosis in outpatient monitoring and to confirm its effectiveness by studying the quality of life of patients with pneumoconiosis.

The research was carried out on the basis of the 3rd therapeutic department of the Regional Clinical Hospital of Occupational Diseases in Donetsk, from 2008 to 2011. The group included 146 patients with pneumoconiosis aged 40-60 years (1.41 (95.13%) men and 5 (4.87%) women).

Clinical-epidemiological, clinical-psychopathological, psycho-diagnostic and statistical methods were used.

A comprehensive examination of each patient was carried out, which included a clinical examination (collection of complaints, examination of an anamnesis of the disease and life). To study the quality of life, a generally accepted international general questionnaire on the quality of life of WHO was used. To evaluate the effectiveness of the proposed rehabilitation programs, 112 patients with pneumoconiosis with dynamic monitoring of the efficacy of the measures performed within 3 months were monitored dynamically. They formed the main group of dynamic observation. To compare the effectiveness of the proposed program, a comparison group was formed - 34 patients with pneumoconiosis, who were under outpatient supervision, but did not undergo a complex of rehabilitation measures.

The rehabilitation program consisted of three stages: inpatient, outpatient and readaptation phase. During the stay in the clinic, a set of optimal rehabilitation measures for each patient was determined according to the severity of the disease: individual dose selection of therapeutic drugs, physiotherapy procedures, respiratory gymnastics and massage, educational programs and psychotherapeutic effects. Outpatient monitoring was carried out for 6 months with control of the effectiveness of treatment at 8, 16 and 24 weeks and repeated monitoring in dynamics after a year.

The main stage of rehabilitation consisted in carrying out medical-psychological rehabilitation therapy. The goal of the program of medico-psychological rehabilitation is to improve the subjective well-being of the patient and restore full-fledged social functioning, and the main task is to change the patient's attitude to the disease and correct in this way inadequate reactions and behaviors.

Analysis of literature data and the results of our own studies, obtained at the first stage, served as the basis for long-term outpatient monitoring and anti-relapse treatment of patients with pneumoconiosis using information therapy, psychotherapy and psychocorrection.

The second stage of rehabilitation was carried out on an outpatient basis under the supervision of specialists from a polyclinic, a dispensary or a specialized center. The main task of this stage was to preserve the patient's social status, which he had before the illness, or adaptation (adaptation) to life and possible work activities in out-of-hospital settings. At this stage, biological therapy continues to play a leading role. However, the transition of the patient from the first stage to the second, from the stationary to the home, is accompanied by an increase in the number and quality of exogenous factors that have a harmful effect on the disease. Therefore, at this stage, further work on optimizing therapy continues.

Psychotherapeutic, information therapy and educational work with patients and relatives is of great importance and consists of developing ways to reduce the emerging changes in the patient's relationship to illness, work, social environment, and treatment. There must necessarily be an emphasis on the possibility of a positive therapeutic perspective, the so-called model of expected treatment outcomes, and other topics can be individually discussed. Labor reorientation is the main characteristic of the second stage of rehabilitation.

Biological therapy, its adequacy and optimization occupy the main place in both the 2nd and the third stages of rehabilitation. On the shoulders of the patient and his family, care is taken to ensure the correctness of the drug treatment regimen. To understand the complexity of the implementation of the doctor's recommendations for treatment, it can be recalled that at present most patients get more than one drug. As a negative factor at this stage of rehabilitation, it should be noted the existence of various schemes of drug treatment in clinically related syndromes. All this leads to the fact that the remission of the underlying disease is disrupted, as soon as the patient is transferred to long-term outpatient treatment. Therefore, the first thing we paid attention to when meeting a patient is doses of drugs that provided a high therapeutic effect. Secondly, the volume and nature of the pathogenetic therapy was determined; in the third - biologically justified duration of drug treatment.

The main principles of maintenance therapy conducted in outpatient settings are: individual approach, consistency, duration and continuity of treatment. The peculiarity of the treatment of pneumoconiosis is the complex implementation of the principle of partnership "doctor-patient".

The main stage of rehabilitation involves targeted psychological correction, information support, ways to increase internal reserves. Psycho-correction includes the general (trainings of conflict-free behavior, assertiveness, emotional self-regulation and adequate emotional self-expression) and pathogenetic. Purposeful psychocorrection of personal reactions to the disease prevents distress, leading to decompensation.

The meaning of the purposeful psychological pathogenetic correction is that the sick person should realize the inconsistency of his attitude towards the illness, formed by an intrapersonal conflict, which will allow to solve it constructively. This can be achieved by forming a new, adequate attitude to the disease and a clear understanding of its causes, consequences, causes of exacerbations and complications. Elimination of an inadequate, contradictory attitude towards the disease interrupts the further development of all secondary disorders. If you eliminate the concern associated with an existentially significant event in life - a chronic lung disease with a violation of ventilation, it is possible to restore self-regulation. It is necessary to rebuild the attitude of the patient, which is the source of psychogenic decompensation.

The patient himself must trace the history of the onset and development of his disease, the causes of the emergence of exacerbations and complications, his own mistakes, consisting in ignoring the planned base therapy. With a joint analysis with the doctor of the causes of the illness and symptoms, the sick person clearly understands the causes of the disease, changes in one's own behavior.

The prerequisite for systematic baseline therapy, disciplined performance of medical appointments is the establishment of convincing for the sick person the causes of the onset and development of the disease, as well as the principles of treatment. A clear understanding of the causes becomes a deep conviction of the patient and is a prerequisite for demonstrating the possibility of eliminating these causes in one way or another.

The basic principles of our out-of-school curriculum were simple, lucid formulations that did not contain medical terms, maximum individualization of the patient's capabilities, the degree of his motivation for learning and personal experience, the content of practical actions to achieve the greatest normalization of health status, the use of elements of "operationalization", t e. Demonstration along with the objectives of the means to achieve them; obtaining coping skills with the disease at home. Criterion of successful work was also an assessment of the patient's readiness for treatment.

The main stage of the program of medical-psychological rehabilitation of patients with pneumoconioses included 10 sessions on a certain topic and psycho-correction. The duration of one lesson is 1 hour, including 40 minutes of the information block and 20 minutes of psychocorrection. Classes were conducted with a group of patients for 8-10 people. The information block was similar for men and women, and psychological correction was different, so patients should be of the same sex, the age can be different. The issues related to employment, retraining were considered (the patients were introduced to the procedure for issuing sick leave lists, the list of the decreed professions was listed, personal recommendations were given if necessary) and social security in case of poor prognosis and disability (patients are introduced to the rights of disabled people, social assistance, social welfare centers, legal support).

The therapeutic strategy was also maximally individualized, the compulsory component of the training was partnership and the creation of an atmosphere of mutual understanding and trust, which is directly related to the need for personalization of patient education. To improve the quality of treatment for patients with pneumoconiosis, family members who were able to determine the patients' lifestyle were also involved in the learning process.

The program provided advice on preventive measures during the conversation. The patient was given the opportunity to express his fears and discuss them. Based on this, the doctor and the patient agreed on the goals of the treatment.

When carrying out psychocorrection in the second stage, special attention was paid to patients with an inadequate personal response to the disease, an unfavorable internal picture of the disease. Psychocorrectional work was carried out according to the program developed by us, affecting the emotional sphere of the patient, suggestion was made in the state of wakefulness, relaxation, self-confidence, training self-suggestion of rest and relaxation with the help of autogenic training in expressing negative emotions of anger and irritation, memories of traumatic situations.

Rational psychotherapy at this stage in the complex of therapeutic measures was used more widely than other methods of psychotherapeutic work. The application of this method is based on the logic and appeal to the mind of the patient, assumes a good knowledge of the individual, as well as a detailed study of the nature and mechanisms of the development of the disease.

Correction of personal changes was carried out in those cases when the patient at the first stage of treatment was prepared for psychocorrectional work, when he himself in the course of a conversation with a doctor and a psychologist was somewhat aware of the undesirability of certain forms of his behavior, partially or fully understood that they are the cause of the disorganization of his work activity and cause tension in interpersonal relations in the family.

The choice of arguments, arguments, examples, the level of emotional contact was correlated with the individual typological characteristics of patients. In patients with the preservation of verbal and logical functions of intelligence, it was expedient to use verbal training, various forms of verbal therapy. With a decrease in the level of abstract-logical thinking, a limited amount of knowledge, weakening of the communicative properties of the person, motor-practical, nonverbal forms of instruction are the best. The principle of psychocorrectional work was to select the most benevolent, soothing effects.

The results of the psychological examination were, along with the results of the clinical study of patients, a pathogenetic justification for the construction of a psychotherapeutic work that not only provided for the impact on individual symptoms of the disease but was also aimed at eliminating changes in the system of patients' relations to their disease.

The issues of correction of the patient's relations in connection with the change in his social and labor status were considered much broader. At the same time, the program included questions of a positive medical perspective, labor adaptation and the possibility of restoring the lost labor skills lost in the process of illness.

Clinical follow-up was continued for 83 patients with pneumoconioses and was performed during the year. It consisted of examining patients once a month for the first three months, and then once every two to three months during the first year of observation and at least four times a year after. The results of long-term treatment were also assessed by clinical data, electrophysiological, psychological indicators of social functioning and quality of life.

The indicators of the quality of life in all areas of patients in the main group were significantly higher than in the comparison group. At the same time, the integral evaluation of the quality of life indicators "normalization" with a high degree of significance correlated with the clinical effect achieved. This presentation corresponds to the results of a study of the quality of life of patients at the final stages of rehabilitation in the period of stable long-term remission. For most of the parameters, the patients in the main group rated the quality of life as "good", and in some cases the score was "very good" for some indicators. Clinical experience shows that patients with a controlled course of the disease, especially long-term remission, are very scrupulous in implementing the doctor's recommendations. The successes of treatment, allowing to significantly expand their social opportunities, they are largely associated with properly selected drug and information therapy, as well as psychotherapy.

The study of the aspects of medical rehabilitation conducted at the second stage made it possible to distinguish three categories of patients: with complete remission of all clinical manifestations of pneumoconiosis, with partial remission and torpid forms of pneumoconiosis.

Full remission means persistent (within a year) cessation of all clinical manifestations of the disease. Speaking of incomplete or clinical remission of pneumoconiosis, we mean a stable (for several months) absence of any clinical manifestations of the disease while preserving instrumental signs of its progression.

One of the main factors affecting the timing of the onset of remission was timely and adequate therapy. It has been established that adequate systematic treatment with the optimal doses of the drugs makes it possible to obtain persistent remission of the disease in 46.3% of patients after 6-12 months. In patients treated irregularly, the timing of the onset of remission was prolonged to 34 years.

The conducted studies of the second stage of rehabilitation show that adequate, systematically conducted therapy of patients with pneumoconiosis contributes to the appearance of a large percentage of patients with stable remission, more pronounced when using information therapy and psychotherapy. There is an increase in social functioning and quality of life. This greatly expands opportunities for professional and family rehabilitation of patients.

Thus, timely clinico-psychopathological, psychodiagnostic, socio-psychological diagnostics, the use of step-by-step biological therapy, psychotherapy and information technologies make it possible to significantly increase the percentage of patients with both stable remission of the disease and remission of the disease, which improves social functioning and quality of life patients with pneumoconiosis.

Cand. Honey. Sciences LA Vasyakina. // International Medical Journal №4 2012

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