The study of the conjugation of mental and hematological pathologies, at the clinical, psychological and biological levels
There is a much higher proportion of psychoses of the schizophrenic spectrum (endogenomorfic psychosis and schizophrenia attack) with lymphoproliferative diseases, especially with lymphosarcomas and Hodgkin's lymphoma. And in the case of Hodgkin's lymphoma, these forms of somatogenic psychoses occur much more often than delirium, in contrast to other diseases of the blood system, in which the opposite tendencies are revealed. In addition, lHodgkin's lymphoma is the only blood system disease in the sample studied, in which somatogenically provoked schizophrenic attacks are identified. These data correlate with the indications of a number of authors, mainly hematologists, that among patients with lymphoproliferative diseases, especially with lymphogranulomatosis, the proportion of patients with peculiarities of behavior characteristic of persons with disorders of the schizophrenic spectrum ("strangeness of character", "inadequacy of behavior" ).
In-depth study of regularities, features of manifestation and course of mental pathology and personality disorders in certain forms of hematological malignancies
Somatogenic psychoses in hematological malignancies are clinically heterogeneous and differentiate into three types: delirious obscuration of consciousness (61.9%), endogenomorphic psychoses (32.2%) (of which hallucinatory-paranoid - 50%, depressive-delirious - 42.1% , onyroid - 7.9%) and somatogenically provoked attacks of schizophrenia (5.9%).
Adjustment disorders in hematological malignancies are also clinically heterogeneous and include 6 types with different frequency of occurrence. Nosogenes in patients without signs of endogenous-procedural pathology include anxiety-dissociative (34.9%), anxiety-phobic (21.9%), anxiety-depressive (26.6%) and hypomanic (1.6%) reactions. Adjustment disorders in patients with schizophrenia include dissociative (9.9%) and anxiety - coenostopathic (5.2%) reactions.
Hematological malignancies are differentiated according to the frequency of manifestation of psychiatric disorders. The occurrence of somatogenic psychoses and adjustment disorders is maximal in acute leukemia and severe lymphoproliferative diseases: somatogenic psychoses in acute leukemia - 36.5%, somatogenic psychoses with lymphoproliferative diseases - 33%, nosogenic reactions in acute leukemia - 23.4%, nosogenic reactions with lymphoproliferative diseases - 55.2% against 30.5% of somatogenic psychoses and 21.4% of adjustment disorders in the remaining six diseases of the blood system.
Adjustment disordersare more likely to occur with accompanying therapy (61.95%), polychemotherapy (18.75%) and bone marrow transplantation (10.4%).
Somatogenic psychoses are more often formed on the background of polychemotherapy (68.6%) and accompanying therapy (28.7%). The frequency of somatogenic psychoses is higher with the combination of cytotoxic drugs with glucocorticoids (57.6%) than in the absence of the latter (29.7%).
The probability of development of somatogenic psychoses of each type is differentiated depending on the type of disease of the blood system.
Reduced delirium with the same frequency develops with all diseases of the blood system. The incidence of developed delirium is higher for acute myeloblastic leukemia, chronic myeloblastic leukemia, and lymphosarcoma 5.61%, 3.74%, and 3.74%, respectively, versus 7.47% (in total) for the remaining forms of studied blood system diseases.
The incidence of endogenomorphic psychoses is higher for lymphosarcomas, multiple myeloma and acute myeloblastic leukemia - 9.35%, 6.54% and 5.61%, respectively, vs. 9.43% for the remaining forms of studied blood system diseases.
Somatogenously provoked attacks of schizophrenia occur only with lymphogranulomatosis (4.67%).
Investigation of the features of the course of mental pathology in bone marrow transplantation and personality changes occurring in early and remote post-transplant stages
J.M. Prieto et al. (2002) concluded that the development of any affective or anxiety disorder or adjuatment disorder is associated with a significant increase in the duration of hospitalization (p = 0.022) in bone marrow transplantation, and the diagnosis of delirium is close to a significant predictor of an increase in the length of stay in the oncohematological hospital ( p = 0.05). R.Illescas-Rico et al. (2002) note that soon after the first organ transplantation in the 1950s, reports of a deterioration in the clinical prognosis of transplantation in patients with depression and / or anxiety in the pre-transplant period began to be published. Depression, as the factor of unfavorable prognosis for bone marrow transplantation, is indicated by many authors. So, K.L.Syrjala with co-workers. (2004) note that a high level of depression before transplantation of blood stem cells leads to a slowdown in physical and psychological recovery after transplantation. J.M.Prieto et al. (2005) investigated the effect of depression on the survival of patients with hematological diseases for 1, 3 and 5 years after transplantation of blood stem cells. In 18 (9.0%) and 17 patients (8.5%), the condition met the criteria for major and minor depression, respectively. It was found that major depression is a predictor of higher annual and three-year mortality, but does not affect the five-year mortality rate. N. Grulke et al. (2007) found that depression in blood stem cell transplantation is an independent predictor of decreased survival, along with indicators such as age of patients at the time of blood stem cell transplantation, re-transplantation, risk of treatment failure. E.A. Colon et al. (1991) revealed depressive symptoms of different structures were found in 13% of patients who underwent allogeneic bone marrow transplantation in various forms of acute leukemia and attempted to identify a possible association of psychopathological symptoms and psychosocial factors with the duration of survival after transplantation. It was shown that the presence of depression significantly influences the outcome of transplantation - in patients with depression, regardless of their nosological affiliation, the least favorable prognosis was found (of these 13 patients 12 (92%) died), the average survival time for these 12 patients was 60 days. Survival for the remaining patients averaged 173 days after transplantation. Thus, the data of numerous studies indicate a significant adverse effect of comorbid psychiatric pathology on the prognosis of blood system diseases in patients undergoing bone marrow transplantation. The most recognized factor of an unfavorable prognosis in the considered clinical situation is the violation of compliance with the treatment of the disease of the blood system caused by mental pathology.
Investigation of psychopathological and psychological mechanisms of symptom formation of dissociative disorders in patients with hematological malignancies
Patients with diseases of the blood system showed 2 types of nosogenic reactions, in the structure of which dissociative disorders - anxiety-dissociative (n = 67 (77.9%) and dissociative schizophrenic (n = 19, (22.1%)) reactions are revealed.
- Flows with phenomena of alienation of a real disease of the blood system and signs of latent somatized anxiety, accompanied by abnormal behavior in the disease (Barsky A.J., Klerman G.L., 1983). The fragmentation of self-consciousness (dissociative identity disorder by DSM-IV-R) is at the forefront. Alienation of manifestations of the disease of the blood system is associated with pronounced depersonalization and derealization disorders. Events occurring in the hospital, associated with the diagnosis and treatment of diseases of the blood system, are perceived as if from the outside. Patients categorically deny any concerns about the outcome of the disease. At the same time, dissociation covers, in the main, the cognitive aspect of the reaction ("cognitive dissociation"). There are doubts about the presence of the disease of the blood system, the correctness of the diagnosis, the declaration of complete recovery, the disregard of the symptoms of worsening of the somatic status, or the interpretation of them as a manifestation of less severe disease.
- persons with schizoid (expansive schizoid) and anancastic personal radicals predominate.
Dissociative schizophrenic adjustment disorders:
- the phenomenon of alienating the disease of the blood system dominates, reaching a degree of complete denial of the very fact of the disease, patients completely refuse further monitoring, as well as a number of important medical measures, motivating that they are practically healthy and do not need specialized assistance. As a rule, such patients reapply for help only in the event of complications that directly threaten life.
- persons with schizotypal personality disorder according to DSM-IV, or personality changes in juvenile one-schizophrenic
Investigation of the psychopathological and psychological structure and dynamics of posttraumatic stress disorder in patients with hematological malignancies
Ehlers A, Clark DM. (2000), who proposed a cognitive model of post-traumatic stress disorder (PTSD), suggested that PTSD becomes chronic when patients perceive trauma as a sensation of a serious, ongoing threat. The feeling of the threat arises as a consequence of: (1) an excessively negative evaluation of the trauma and / or its complications; and (2) a violation of autobiographical memory characterized by poor elaboration and contextualization, strong associative memory, and strong perceptual actualization. Substitution of negative evaluations and disactualization of memory of trauma is carried out by a series of behavioral and cognitive problems-oriented strategies. The model is compatible with the main clinical symptoms of PTSD, helps explain some clearly complex phenomena and serves as a basis for treatment, identifying the three main goals of therapy.
Wettergren L, Langius A, Bjorkholm M, Bjorvell H. (1999), who assessed the presence of posttraumatic stress symptoms (PTCS) in patients with oncohematological diseases who underwent blood stem cell transplantation, reported high enough levels of PTCS in this category of patients. Although the level of PTSD decreased over time, it was still high compared to patients with cancer of other locations. The symptoms of obsessions and avoidance were significantly correlated with anxiety and depression, but not with a sense of connectedness and somatic state. High levels of PTSD and their relationship to emotional distress emphasize the importance of psychosocial care in this group of patients schizophrenia predominate.
The study of neurocognitive function in patients with hematological malignancies
Cognitive impairment is an important component of the patient's psychoneurological status and carries important information about the state of the brain. Diagnosis of the severity and qualitative characteristics of such disorders is important for determining the exact syndromic, topical and nosological diagnosis, as well as clarifying the most appropriate therapy for patients. Cognitive impairments have a negative impact on the quality of life of the patient and his immediate environment. Recent advances in neuroscience have greatly advanced the possibilities of providing effective care for patients with cognitive disorders. Cognitive impairments develop not only in lesions of the central nervous system, but also in somatic and endocrine diseases, which cause the dismetabolic nature of the encephalopathies under consideration:
Somatic pathology: liver failure; kidney failure; respiratory insufficiency (hypoxemia); dehydration.
Pathology of the endocrine system: hypothyroidism, pituitary insufficiency, hypercortisy; diabetes mellitus with high rates of glycemia.
Exogenous intoxication with heavy metals (thallium, mercury, lead); alcoholism; drug intoxication (central anticholinergics, typical neuroleptics, tricyclic antidepressants, benzodiazepines, barbiturates).
The clinical features of cognitive impairments, which are a consequence of somatic diseases, depend on the underlying diagnosis and the specific type of dismetabolic disorders. However, with cognitive impairment, directly related to the disturbances of systemic metabolism, there are a number of common features. The leading mechanism in these cases is a decrease in the activating effects on the cerebral cortex from the side of the stem-subcortical structures (the so-called neurodynamic cognitive impairments). This leads to an increase in reaction time, delayed thinking, difficulty concentrating, increased fatigue and distractibility, a violation of the memorization of new information. Characteristic significant fluctuations in the severity of cognitive impairment. Often they depend on the time of day: the severity of cognitive disorders usually increases in the evening and night. As a rule, cognitive dysmetabolic disorders are combined with a disturbance of the "sleep-wake" cycle. There is increased drowsiness, sometimes agitation and confusion at night. EEG fixes an increase in the representation in the bioelectrical spectrum of the brain of slow-wave activity.
A special group of cognitive disorders can be identified with a deficiency of vitamin B12, folic acid and thiamine. The latter is most often observed with chronic alcoholism. So, with a deficiency of vitamin B12, memory disorders, abstract thinking, episodes of agitation, confusion, hallucinations can be noted. With a deficiency of folic acid (which is rich in fruits and greens), there are disorders characteristic of disorders of the emotional spectrum, depression. With a lack of thiamine (characteristic for alcoholism), cognitive impairments can be severe up to dementia and are characterized by a predominance of disorders in the regulatory link of the intellect due to dysfunction of the anterior parts of the brain.
With the timely correction of the pathological process, cognitive impairments completely or partially regress. With non-curable somatic diseases, the progression of dismetabolic disorders is accompanied by the progression of violations of cognitive functions and consciousness down to coma.
Development of psychopharmacological and psychotherapeutic techniques in the treatment of mental and personal pathology in patients with hematological malignancies
The effectiveness and safety of pharmacotherapy of mental disorders in hematological malignancies determine the adequacy of the choice of medications taking into account the clinical indications, possible ways of their administration, the spectrum of side effects and the risk of drug interactions: the proportion of respondents is 95.6% with somatogenic psychoses (typical neuroleptics - haloperidol and atypical antipsychotics ) and 81.3% - with nosogenic reactions (anxiolytics, antidepressants of new generations, atypical antipsychotics). The best results of psychopharmacotherapy are recorded with anxious-phobic, anxiety-depressive and hypomaniacal nosogenes. The most resistant to psychopharmacotherapy are schizophrenic adjustment disorders (dissociative and anxiety-coenostatic).
Timely diagnosis and therapy of mental disorders in patients with blood system diseases contribute to the optimization of treatment and rehabilitation activities in this contingent of patients, facilitate the prevention of adverse consequences of the disease, its complications and therapy as a medical (malignant course of the disease, adverse outcome), and social order quality of life and adaptive capabilities of the patient, disability).