Psychosocial rehabilitation of pneumoconiosis patients at the outpatient stage of treatment

General requirements for the organization of psychosocial rehabilitation of patients with pneumoconiosis at the outpatient stage have been formulated. An integrative therapeutic complex has been developed, including modern methods of psychotherapy in combination 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 for stable remissions of the disease in 46.3% of patients after 6-12 months.

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

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

The disease situation dramatically changes the nature of a person's relationship with the surrounding world. Therefore, a comprehensive examination of the relationship between the disease and personality allows us to talk about a change not in the physical and/or mental status of the patient, but in the entire system of his relationships with the world and to the world.

The theoretical basis of this direction in domestic clinical psychology is the concept of personality by V. M. Myasishchev, in which a person is understood as a single biopsychosocial system, and personality as a system of emotionally charged relationships with the social environment and oneself. In this system, illness 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 usual 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 in studying 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 biological and social problem of modern health care.

At the present stage of development of medicine it is becoming increasingly obvious that scientifically based and effective implementation of psychoprophylactic and psychocorrectional work with patients is possible only on the basis of knowledge of internal psychological patterns of changes in the psyche. Obtaining full scientific data on the influence of chronic disease on the psyche can contribute to more effective therapeutic interventions, an individual approach to the choice of strategy and tactics of treatment on the part of doctors, as well as, if necessary, psychological support. This fully applies to severe chronic diseases accompanied by significant psychological shifts 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 an outpatient setting and to confirm its effectiveness by studying the quality of life of patients with pneumoconiosis.

The studies were conducted at the 3rd therapeutic department of the Regional Clinical Hospital for Occupational Diseases in Donetsk in the period from 2008 to 2011. The group of subjects included 146 patients with pneumoconiosis aged 40 to 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 conducted, which included a clinical examination (collection of complaints, study of the anamnesis of the disease and life). To study the quality of life, the generally accepted international general questionnaire of quality of life WHO100 was used. To assess the effectiveness of the proposed rehabilitation programs, dynamic observation of 112 patients with pneumoconiosis was carried out with control of the effectiveness of the measures taken for 3 months. 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 observation, but they did not undergo a set of rehabilitation measures.

The rehabilitation program consisted of three stages: inpatient, outpatient, and readaptation. 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 selection of the dose of therapeutic drugs, physiotherapy procedures, breathing exercises and massage, educational programs, and psychotherapeutic intervention. Outpatient observation was carried out for 6 months with monitoring of the effectiveness of treatment after 8, 16, and 24 weeks and repeated monitoring in dynamics after a year.

The main stage of rehabilitation consisted of medical-psychological rehabilitation therapy. The goal of the medical-psychological rehabilitation program is to improve the patient's subjective well-being and restore full social functioning, and the main task is to change the patient's attitude to the disease and correct, on this basis, inadequate reactions and behavior patterns.

The analysis of literature data and the results of our own research obtained at the first stage served as the basis for long-term outpatient observation 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, dispensary or specialized center. The main objective of this stage was to maintain the patient's social status that he had before the disease, or to adapt him to life and possible work in outpatient conditions. At this stage, biological therapy retains its leading role. However, the patient's transition from the first stage to the second, from hospital conditions to home conditions, 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 is continued to optimize the therapy.

Psychotherapeutic, information therapy and educational work with patients and relatives is of great importance and consists of developing ways to reduce the changes that arise in the patient's system of attitudes to illness, work, social environment, and treatment. Emphasis must be placed on the possibility of a positive treatment perspective, the so-called model of expected treatment results, and other topics can be discussed individually. Labor reorientation is the main characteristic of the second stage of rehabilitation.

Biological therapy, its adequacy and optimization occupy the main place at both the 2nd and 3rd stages of rehabilitation. The patient and his family are responsible for ensuring that the drug treatment regimen is followed correctly. To understand the complexity of following the doctor's recommendations for treatment, it should be recalled that most patients currently receive more than one drug. As a negative factor at this stage of rehabilitation, it should be noted that there are various drug treatment regimens for clinically related syndromes. All this leads to the fact that the obtained 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 with the patient was the doses of drugs that provided a high therapeutic effect. Secondly, we determined the volume and nature of the pathogenetic therapy; thirdly, the biologically justified duration of drug treatment.

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

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

The meaning of targeted psychological pathogenetic correction is that the sick person must realize the contradictory nature of his attitude to the disease, formed by the intrapersonal conflict, which will allow to resolve it constructively. This can be achieved by forming a new, adequate attitude to the disease and a clear understanding of its causes, consequences, reasons for the occurrence of exacerbations and complications. Elimination of inadequate, contradictory attitude to the disease interrupts the further development of all secondary disorders. By eliminating concerns related to an existentially significant event in life - chronic pulmonary disease with ventilation disorder, self-regulation can be restored. It is necessary to rebuild the patient's attitude, which is the source of psychogenic decompensation.

The patient must trace the history of the origin and development of his disease, the reasons for the occurrence of exacerbations and complications, his own mistakes, consisting in ignoring the planned basic therapy. When analyzing the causes of the disease and symptoms together with the doctor, the sick person clearly understands the causes of the disease, changes in his own behavior.

The condition for conducting systematic basic therapy, disciplined implementation of medical prescriptions is the establishment of convincing reasons for the emergence and development of the disease for the patient, as well as the principles of treatment. A clear understanding of the reasons becomes a deep conviction of the patient and is a necessary condition for demonstrating the possibility of eliminating these reasons in one way or another.

The main principles of our outpatient training program were simple, clear 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, the use of elements of "operationalization", i.e. demonstration of the means to achieve them along with the goals; acquisition of skills for coping with the disease at home. The criterion for successful work was also the assessment of the patient's readiness for treatment.

The main stage of the program of medical and psychological rehabilitation of patients with pneumoconiosis included 10 classes on a specific topic and psychocorrection. The duration of one class is 1 hour, including 40 minutes of information block and 20 minutes of psychocorrection. Classes were held with a group of patients of 8-10 people. The information block was the same for men and women, and psychological correction was different, therefore patients should be of the same sex, age can be different. Issues related to employment, retraining (patients are familiarized with the procedure for issuing sick leave, a list of decreed professions is given, if it is necessary to change profession, individual recommendations are given) and social security in case of unfavorable prognosis and disability (patients are familiarized with the rights of disabled people, told about the possibilities of receiving social assistance, about social security centers, legal support) were necessarily considered.

The therapeutic strategy was also maximally individualized, a mandatory component of training was partnership and the creation of an atmosphere of mutual understanding and trust, which is directly related to the need to personalize patient training. To improve the quality of treatment of patients with pneumoconiosis, family members were also involved in the training process, who have the opportunity to determine the lifestyle of patients.

The program included advice on preventive measures during the conversation. The patient was given the opportunity to express his concerns and discuss them. Based on this, the doctor and the patient came to an agreement on the goals of treatment.

During the psychocorrection at the second stage, special attention was paid to patients with inadequate personal reaction to the disease, unfavorable internal picture of the disease. Psychocorrection work was carried out according to the program developed by us, influencing the emotional sphere of the patient, suggestion was carried out in a state of wakefulness, relaxation, self-confidence, training in self-suggestion of a state of peace and relaxation using the method of autogenic training in expressing negative emotions of anger and irritation, in changing emotional reactions when recalling psychotraumatic situations.

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

Correction of personality changes was carried out in cases where the patient at the first stage of treatment was prepared for psychocorrectional work, when he himself, in the process of conversation with the doctor and psychologist, to some extent realized the undesirability of certain forms of his behavior for himself, partially or completely understood that they were the cause of disorganization of his work activity and caused tension in interpersonal relationships in the family.

The choice of arguments, reasons, examples, and the level of emotional contact were related to the individual typological characteristics of patients. In patients with preserved verbal-logical functions of intelligence, it was advisable to use verbal training and various forms of verbal therapy. With a decrease in the level of abstract-logical thinking, a limited amount of knowledge, and weakening of the communicative properties of the individual, the best are motor-practical, non-verbal forms of training. The principle of psychocorrectional work consisted in the selection of the most benevolent, calming effects.

The results of the psychological examination, along with the results of the clinical study of patients, were the pathogenetic basis for the construction of psychotherapeutic work, which not only provided for an impact on individual symptoms of the disease, but was also aimed at eliminating changes in the patient’s system of relationships to his illness.

The issues of correcting the patient's attitudes in connection with the change in his social and labor status were considered much more broadly. At the same time, the program included issues of a positive treatment perspective, labor adaptation, and the possibility of restoring work skills lost during the illness.

Outpatient observation was continued for 83 patients with pneumoconiosis and was conducted for a year. It consisted of examining patients once a month for the first three months, then once every two to three months during the first year of observation and at least four times a year thereafter. The results of long-term treatment were also assessed based on clinical data, electrophysiological, psychological indicators of social functioning and quality of life.

The quality of life indicators in all areas were significantly higher in the patients of the main group than in the comparison group. At the same time, the integral assessment of the quality of life indicators "normalization" correlated with a high degree of significance with the achieved clinical effect. This idea corresponds to the results of the study of the quality of life of patients at the final stages of rehabilitation during a period of stable long-term remission. For most parameters, patients of the main group assessed the quality of life as "good", and in some cases, for individual indicators, the assessment was "very good". As clinical experience shows, patients with a controlled course of the disease, especially long-term remission, are very scrupulous in following the doctor's recommendations. They largely associate the success of treatment, which allows them to significantly expand their social opportunities, with correctly selected drug and information therapy, as well as psychotherapy.

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

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

One of the main factors influencing the timing of remissions was timely and adequate therapy. It was established that adequate systematic treatment with optimal doses of drugs allows for stable remissions of the disease in 46.3% of patients after 6-12 months. In patients who were treated irregularly, the timing of remissions was extended 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 emergence 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 significantly expands the possibilities of professional and family rehabilitation of patients.

Thus, timely clinical-psychopathological, psychodiagnostic, social-psychological diagnostics, the use of step-by-step biological therapy, psychotherapy and information technologies allow to significantly increase the percentage of patients with both stable remission of the disease and remission of the disease, which contributes to the improvement of social functioning and quality of life of patients with pneumoconiosis.

PhD L. A. Vasyakina. // International Medical Journal No. 4 2012

[ 1 ], [ 2 ], [ 3 ]