Psychogenic disorders at various stages of an emergency. Neuropsychiatric disorders in extreme situations In conditions of disasters and natural disasters, the nerve
Severe natural disasters and catastrophes, not to mention the possible massive sanitary losses during war, are a difficult experience for many people. A mental reaction to extreme conditions, especially in cases of significant material losses and loss of life, can permanently deprive a person of the ability to act rationally and effectively, despite the “psychological protection” that helps prevent disorganization mental activity and behavior. Many researchers conclude that preventive health care will be the most effective means to prevent the impact of injury on mental health person. A group of American researchers (Fullerton S., Ursano R. et al., 1997), based on a generalization of their own data, came to the conclusion that preventive medical care in anticipating mental trauma, during an emergency event and during overcoming its consequences can be considered in the following three directions.
I. Primary prevention
Informing you of what to expect.
Training in control and mastery skills.
Limit exposure.
Sleep hygiene.
Filling the psychological need for support and rest.
Informing and training loved ones to enhance “natural support.”
II. Secondary prevention
Restore security and public services.
Primary care training.
Sorting the sick and wounded.
Early diagnosis of the wounded.
Diagnosis of somatization as a possible mental distress.
Training teachers for early decontamination of distress.
Collection of information.
III. Tertiary prevention
Treatment of comorbid disorders.
Increased attention to family distress, loss and demoralization, violence against loved ones or children in the family.
Compensation.
Deactivation of the processes of “withdrawal” and social avoidance.
Psychotherapy and necessary drug treatment.
Practical measures aimed at preventing psychiatric and medical-psychological consequences of emergency situations can be divided into those carried out in the period before the occurrence, during the action of psychotraumatic extreme factors and after the cessation of their influence.
Before an emergency occurs, medical services need to be prepared Civil Defense(GO) and rescuers to work in extreme conditions. It is worth noting that it should include:
Training of personnel of sanitary posts and squads to provide medical assistance to victims with psychogenic disorders;
Formation and development of high psychological qualities, the ability to behave correctly in extreme situations, the ability to overcome fear, determine priorities and act purposefully; development of organizational skills for psychoprophylactic work with the population;
Informing medical workers and the population about the possibilities of using psychotherapeutic and medications for psychoprophylaxis.
The list of the indicated ways to prevent states of mental maladjustment in extreme conditions, directly addressed primarily to various units of the civil defense medical service, should be supplemented by a wide range of educational and organizational activities aimed at overcoming carelessness and neglect of certain life-threatening effects on a person, both in those cases when “harmfulness” is clearly tangible, so also when it is, until a certain time, hidden from the sight and understanding of ignorant people. It is important to know that mental hardening is of great importance, i.e. development by a person of courage, will, composure, endurance and the ability to overcome feelings of fear.
The need for this kind of preventive work follows from the analysis of many emergency situations, incl. and the Chernobyl disaster.
“...From Minsk in this car, I (an engineer, a nuclear power plant worker) was driving towards the city of Pripyat... I was approaching the city somewhere around two hours and thirty minutes at night... I saw a fire above the fourth power unit. A flame-lit ventilation pipe with transverse red stripes was clearly visible. I remember well that the flame was higher than the chimney. That is, it reached a height of about one hundred and seventy meters above the ground. I didn’t turn home, but decided to drive closer to fourth power unit, it would be better to take a closer look... stopped about a hundred meters from the end of the emergency block (in this place, as will be calculated later, during that period the radiation background reached 800-1500 roentgens per hour, mainly from graphite scattered by the explosion, fuel and a flying radioactive cloud ) I saw in the near light of the fire that the building was dilapidated, there was no central hall, no separator rooms, the separator drums, moved from their places, gleamed reddishly. Such a picture really hurt my heart... I stood there for a minute, there was an oppressive feeling of incomprehensible anxiety, numbness, my eyes absorbed everything and remembered it forever. But anxiety kept creeping into my soul, and involuntary fear appeared. Feeling of an invisible threat nearby. It smelled like after a strong lightning strike, still astringent smoke, it began to burn my eyes and dry my throat. I was coughing. And to get a better look, I lowered the glass. It was such a spring night. I turned the car around and drove to my home. When I entered the house, mine were asleep. It was about three o'clock in the morning. It is worth noting that they woke up and said that they heard explosions, but did not know what they were. Soon an excited neighbor came running, whose husband was already on the block. It is worth noting that she informed us about the accident and suggested drinking a bottle of vodka to decontaminate the body...”
“At the time of the explosion, two hundred and forty meters from the fourth block, just opposite the turbine room, two fishermen were sitting on the bank of the supply canal and catching fry. It is worth noting that they heard explosions, saw a blinding burst of flame and pieces of hot fuel, graphite, reinforced concrete and steel beams flying like fireworks. Both fishermen continued their fishing, not realizing what had happened. They thought that a barrel of gasoline had probably exploded. Literally before their eyes, fire crews deployed, they felt the heat of the flames, but blithely continued fishing. The fishermen received 400 roentgens each. Closer to the morning, they developed uncontrollable vomiting; according to them, it was as if the chest was burning with heat, like fire, the eyelids were cutting, the head was bad, as if after a wild hangover. Realizing that something was wrong, they barely made it to the medical unit...”
“Resident of Pripyat X., senior engineer of the production and administrative department of the Chernobyl NPP construction department, testifies: “On Saturday, April 26, 1986, everyone was already preparing for the May 1st holiday. Note that it is a warm, fine day. Spring. The gardens are blooming... Among the majority of builders and installers, no one knew anything yet. Then something leaked about an accident and fire at the fourth power unit. But no one really knew what exactly happened. The children went to school, the kids played outside in sandboxes and rode bicycles. By the evening of April 26, all of them already had high activity in their hair and clothes, but we didn’t know that then. Not far from us on the street they were selling delicious donuts. An ordinary day off... A group of neighboring kids rode bicycles to the overpass (bridge), from where the emergency block from the Yanov station was clearly visible. This, as we later learned, was the most radioactive place in the city, because a cloud of nuclear release passed through there. But it became clear later, and then, on the morning of April 26, the guys were simply interested in watching the reactor burn. These children later developed severe radiation sickness."
Both in the above and in many similar examples, belief in a miracle, in “maybe”, in the fact that everything can be easily fixed, paralyzes, makes a person’s thinking inflexible, deprives him of the opportunity to objectively and competently analyze what is happening, even in the case when there is the necessary theoretical knowledge and some practical experience. Amazing carelessness! In the case of the Chernobyl accident, it turned out to be criminal.
During the period of exposure to psychotraumatic extreme factors, the most important psychoprophylactic measures will be:
Organization of clear work to provide medical care to victims with psychogenic disorders;
Objective information from the population about the medical aspects of a natural disaster (catastrophe);
Assistance to civil society leaders in suppressing panic, statements and actions;
Involving lightly injured people in rescue and emergency recovery operations.
After the end of a life-threatening catastrophic situation [It should be emphasized that psychotraumatic factors quite often continue to operate after the culmination of a natural disaster or catastrophe, although less intensely. This includes the anxious anticipation of aftershocks during an earthquake, and the ever-increasing fear of “dose accumulation” when being in an area with increased level radiation, etc.] psychoprophylaxis should include the following measures:
Complete information to the population about the consequences of a natural disaster (catastrophe) and other impacts and their impact on human health;
Making the most of all opportunities for engagement large groups victims for the purpose of making generalized collective decisions on organizing rescue operations and medical care;
Prevention of relapses or repeated mental disorders (so-called secondary prevention), as well as the development of psychogenically caused somatic disorders;
Drug prevention of delayed psychogenic reactions;
Involving the easily injured in participation in rescue and emergency recovery operations and in providing medical care to victims.
Experience shows that the main causes of “man-made” tragedies are quite similar in different countries in case of all kinds of disasters: technical imperfection of machines and mechanisms, violation technical requirements on their operation. At the same time, behind this there are human flaws - incompetence, superficial knowledge, irresponsibility, cowardice, which prevents the timely detection of detected errors, inability to take into account the capabilities of the body, calculate forces, etc. Such phenomena should be condemned not only by various control bodies, but first of all by the conscience of every person brought up in the spirit of high morality.
One of the most important socio-psychological preventive tasks is information to the population about the situation, carried out permanently. Information must be complete, objective, truthful, but also, within reasonable limits, reassuring. The clarity and brevity of the information makes it especially effective and understandable. The absence or delay of information necessary for making rational decisions during or after a natural disaster or catastrophe gives rise to unpredictable consequences. For example, untimely and half-true information from the population about the radiation situation in the zone of the Chernobyl accident led to many tragic results both directly for public health and for making organizational decisions to eliminate the accident and its consequences.
This contributed to the development of neuroticism in wide circles of the population and the formation of psychogenic mental disorders at the remote stages of the Chernobyl tragedy. For this reason, in the territories where the population lives, to one degree or another affected by the accident (contamination zones, places of residence of displaced persons), Psychological Rehabilitation Centers were created, combining socio-psychological and informational assistance and focused on the prevention of preclinical forms of mental maladaptation .
We should not forget that an important place in the implementation of primary prevention of psychogenic disorders is given to the understanding that modern man must be able to behave correctly in any, even the most difficult, situations.
Along with cultivating the ability not to get lost in difficult life situations that develop in extreme conditions, competence, professional knowledge and skills, moral qualities of people managing complex mechanisms and technological processes, and the ability to give clear and constructive instructions are of the most important preventive importance.
Especially dire consequences cause incompetent decisions and the choice of the wrong course of action during the initial stages of an extreme pre-catastrophic situation or during an already developed disaster. Consequently, during the professional selection and training of managers and performers of the most critical areas of work in many areas economic activity it is extremely important to consider psychological characteristics, professional competence of a particular candidate. Anticipation of his behavior in extreme conditions should occupy an important place in the system of general prevention of the development of life-threatening situations and the psychogenic disorders caused by them.
It is not without reason that they believe that uncontrollable fear indicates a lack of self-confidence, knowledge, and skills. It is worth noting that it can also lead to panic reactions, to prevent which it is necessary to stop the spread of false rumors, be firm with the “leaders” of alarmists, direct people’s energy to rescue work, etc. It is known that the spread of panic is facilitated by many factors caused by a person’s psychological passivity in extreme situations and lack of readiness to fight the elements.
Special mention should be made of the possibilities of primary drug prevention of psychogenic disorders. In recent decades, significant attention has been paid to such prevention. It is extremely important to keep in mind that the use of psychopharmacological drugs for prevention is limited. Such remedies can be recommended exclusively for small groups of people. In this case, one should take into account the possibility of development muscle weakness, drowsiness, decreased attention (tranquilizers, antipsychotics), hyperstimulation (psychoactivators), etc. Preliminary consideration of the doses of the recommended drug, as well as the nature of the intended activity, is required. The material was published on http://site
It can be used much more widely to prevent mental disorders among people who survived a natural disaster or catastrophe.
Extreme situation we will call a suddenly arising situation that is threatening or subjectively perceived by a person as life threatening, health, personal integrity, well-being.
The main features of extreme situations are the following:
– the usual way of life is destroyed, a person is forced to adapt to new conditions;
– life is divided into “life before the event” and “life after the event.” You can often hear “this was before the accident” (illness, move, etc.);
- a person who finds himself in such a situation is in special condition and needs psychological help and support;
– Most of the reactions that occur in a person can be characterized as normal reactions to an abnormal situation.
We can say that when faced with an extreme situation, a person is in a special psychological state. This condition in medicine and psychology is usually called an acute reaction to stress.
Acute stress disorder is a short-term disorder that occurs in response to psychological or physiological stress of exceptional magnitude. That is, this normal reaction person to an abnormal situation.
Psychological assistance techniques can significantly alleviate a person’s condition and, to a certain extent, prevent delayed consequences. psychological trauma. Probably everyone has found themselves in a situation where the person next to them feels bad, but we don’t know how to help them. The most faithful and most old way To help a person experiencing this condition is participation, compassion, empathy, the techniques described below may also be useful.
Experts talk about an acute reaction to stress when the following symptoms are observed:
– a person may be in a state of stupor, anxiety, anger, fear, despair, hyperactivity (motor agitation), apathy, etc. may also be observed, but none of the symptoms prevails for a long time;
– symptoms pass quickly (from several hours to several days);
– there is a clear temporal connection (several minutes) between the stressful event and the onset of symptoms.
Techniques for helping with conditions such as fear, anxiety, crying, hysteria, apathy, guilt, anger, anger, uncontrollable trembling, motor agitation will be discussed.
When providing psychological assistance, it is important to follow following rules:
You need to take care of your own safety. When experiencing grief, a person often does not understand what he is doing, and therefore can be dangerous. Do not try to help a person if you are not sure of your absolute physical safety (there are examples when, when attempting suicide, a person not only throws himself from the roof, but also pulls along the one who is trying to help him; or, for example, people often attack with their fists on the one who reports the death of a loved one, even if it is a random stranger).
Get medical attention. Make sure the person has no physical injuries or heart problems. If necessary, call a doctor, call ambulance. The only exception is a situation when, for some reason, medical assistance cannot be provided immediately (for example, you have to wait for doctors to arrive, or the victim is isolated, for example, blocked in the rubble of a building collapse, etc.).
In this case, your actions should be as follows:
– inform the victim that help is already on the way;
– tell him how to behave: save energy as much as possible; breathe shallowly, slowly, through the nose - this will save oxygen in the body and the surrounding space;
– prohibit the victim from doing anything for self-evacuation or self-liberation.
When you are near a person who has suffered mental trauma as a result of exposure to extreme factors (terrorist attack, accident, loss of loved ones, tragic news, physical or sexual violence, etc.), do not lose your composure. The victim's behavior should not frighten, irritate or surprise you. His condition, actions, emotions are a normal reaction to abnormal circumstances.
If you feel that you are not ready to help a person, you are scared, it is unpleasant to talk to a person, do not do it. Know that this is a normal reaction and you have the right to it. A person always senses insincerity from his posture, gestures, and intonations, and an attempt to help through force will still be ineffective. Find someone who can do it.
The basic principle of providing assistance in psychology is the same as in medicine: “Do no harm.” It is better to refuse unreasonable, thoughtless actions than to harm a person. Therefore, if you are not sure of the correctness of what you are going to do, it is better to refrain.
Now let’s look at emergency psychological assistance techniques for others in each of the conditions listed above.
Help with fear
Don't leave the person alone. Fear is hard to bear alone.
Talk about what the person is afraid of. There is an opinion that such conversations only increase fear, but scientists have long proven that when a person speaks out his fear, it becomes less strong. Therefore, if a person talks about what he is afraid of, support him, talk about this topic.
Don’t try to distract a person with phrases: “Don’t think about it,” “This is nonsense,” “This is nonsense,” etc.
Invite the person to do some breathing exercises, such as these:
1. Place your hand on your stomach; inhale slowly, feel how first your chest fills with air, then your stomach. Hold your breath for 1-2 seconds. Exhale. First the stomach goes down, then the chest. Repeat this exercise slowly 3-4 times;
2. Take a deep breath. Hold your breath for 1-2 seconds. Start exhaling. Exhale slowly and pause for 1-2 seconds about halfway through the exhalation. Try to exhale as much as possible. Slowly repeat this exercise 3-4 times. If it is difficult for a person to breathe at this rhythm, join him - breathe together. This will help him calm down and feel that you are nearby.
If a child is afraid, talk to him about his fears, after that you can play, draw, sculpt. These activities will help your child express his feelings.
Try to keep the person busy with something. This will distract him from his worries.
Remember - fear can be useful (if it helps you avoid dangerous situations), so you need to fight it when it interferes with living a normal life.
Help with anxiety
It is very important to try to get the person to talk and understand what exactly is bothering him. In this case, perhaps the person will become aware of the source of the anxiety and will be able to calm down.
Often a person becomes anxious when he lacks information about current events. In this case, you can try to make a plan for when, where and what information can be obtained.
Try to keep the person busy with mental work: counting, writing, etc. If he is passionate about this, then the anxiety will subside.
Physical work, household chores can also be in a good way calm down. If possible, you can do exercises or go for a run.
Help with crying
Crying is a way to let out your feelings, and you shouldn't immediately try to calm someone down if they're crying. But, on the other hand, being next to a crying person and not trying to help him is also wrong. What should the help consist of? It’s good if you can express your support and sympathy to the person. You don't have to do it with words. You can simply sit next to him, hug the person, stroking his head and back, let him feel that you are next to him, that you sympathize and empathize with him. Remember the expressions “cry on your shoulder”, “cry on your vest” - this is exactly what it’s about. You can hold a person's hand. Sometimes an outstretched helping hand means much more than hundreds of spoken words.
Help with hysteria
Unlike tears, hysteria is a condition that you need to try to stop. In this state, a person loses a lot of physical and psychological strength. You can help a person by doing the following:
Remove spectators, create a calm environment. Stay alone with the person if it is not dangerous for you.
Unexpectedly perform an action that may greatly surprise (for example, you can slap the person in the face, pour water on him, drop an object with a crash, or sharply shout at the victim). If you cannot perform such an action, then sit next to the person, hold his hand, stroke his back, but do not engage in conversation with him or, especially, in an argument. Any words you say in this situation will only add fuel to the fire.
After the hysteria has subsided, speak to the victim in short phrases, in a confident but friendly tone (“drink water,” “wash your face”).
After the hysteria comes a breakdown. Give the person a chance to rest.
Help with apathy
In a state of apathy, in addition to a loss of strength, indifference sets in and a feeling of emptiness appears. If a person is left without support and attention, then apathy can develop into depression. In this case, you can do the following:
Talk to the person. Ask him a few simple questions based on whether he is familiar to you or not: “What is your name?”, “How are you feeling?”, “Are you hungry?”
Take the victim to a place of rest, help him get comfortable (you must take off your shoes).
Take the person's hand or place your hand on their forehead.
Give him the opportunity to sleep or just lie down.
If there is no opportunity to rest (an incident on the street, in public transport, waiting for the end of the operation in the hospital), then talk more with the victim, involve him in any joint activity (you can take a walk, go for tea or coffee, help others who need help).
Extreme is a situation that has arisen, characterized by significant socio-ecological and economic damage, the need to carry out evacuation and rescue operations and liquidation negative consequences what happened.
Psychological stress resulting from a threat to life and health can serve as a source of maladjustment with its various manifestations in the form of mental disorders and disorders of the psychotic register.
In extreme conditions, victims turn on psychological defense mechanisms - various types of response to the situation. The primary forms of mental disorders are abnormal (inadequate to the stimulus) reactions.
In addition, most people, although not consistently, have a constitutional predisposition to the development of certain diseases. Their manifestation is most likely in persons with psychopathy and with accentuated (latent forms of psychopathy) character traits.
Frequency knowledge mental structure and clinical dynamics of mental disorders arising in extreme conditions make it possible to organize adequate therapeutic and preventive care.
At the initial stage, when an accident is detected, it is important to have a primary awareness of its danger, timely reporting of the accident in accordance with accepted schemes; assessing the situation and making a decision on the use of existing plans, the necessary forces and resources, and the involvement of consultants and specialists.
Among psychoprophylactic measures, clear management occupies an important place. If, when moral shocks arise, people do not establish constant notification of specific information, do not ensure clear management, timely delivery of signals and procedures for acting on them, and weaken the leadership of the masses, panic and other negative phenomena are inevitable.
Along with developing the ability not to get lost in complex life situations developing in extreme conditions, the competence, professional knowledge and skills, and moral qualities of people managing complex mechanisms and technological processes are of major preventive importance.
Training of personnel of sanitary posts, sanitary squads, and first aid units should be carried out in compliance with the basic rule of didactics: first, training programs are developed and the acquisition of theoretical knowledge is planned, then practical skills are formed and the ability to provide assistance is practiced, brought to automaticity. In particular, the personnel of sanitary posts and sanitary squads, first aid units must know the main syndromes of mental disorders in extreme situations and be able to use modern means providing assistance with motor agitation.
It is not without reason that they believe that uncontrollable fear indicates a lack of confidence in oneself, one’s knowledge, and skills. It can also lead to panic reactions, to prevent which it is necessary to stop the spread of false rumors, be firm with the “leaders” of alarmists, and direct people’s energy to rescue work.
IN modern conditions There is every reason to more widely use data from psychology, psychotherapy, mental hygiene and other disciplines in order to optimize people’s activities in extreme situations, necessary to overcome increased psychological and physical stress.
Krzhechkovsky A.Yu. (Stavropol)
Krzhechkovsky Alexander Yurievich
Doctor of Medical Sciences, Professor, Head of the Department of Psychiatry, Narcology and medical psychology State Educational Institution of Higher Professional Education St. State Medical Academy of the Ministry of Health and Social Development of Russia.
Email: [email protected]
Email: [email protected]
Annotation. The increasingly frequent occurrence of extreme situations in our time and definite change relationships with them require systematization of data on this issue. The report describes the characteristics of mental disorders during natural disasters and catastrophes, during environmental disasters, among refugees and migrants. The issues of the emergence of mental disorders both in military service and in “unusual living conditions”, as factors of extreme influences, are also discussed. The information may be useful to physicians caring for victims in these conditions.
Keywords: mental disorders, extreme influences, correction.
INTRODUCTION
In our age of civilization, urbanization and scientific and technological progress, people, as before, are faced with extremely strong influences from the external environment. In some cases, they are on the verge of tolerance and can cause adaptation disorders. The term “extreme conditions” is commonly used to refer to these impacts. The latter are understood as extreme natural conditions of existence that put the body on the brink of tolerance. Habitats with such conditions are usually called extreme zones. The latter can be natural - natural (for example: the Arctic, Antarctica, deserts, etc.) and anthropogenic - resulting from human activity (for example: areas of the Chernobyl nuclear power plant, an explosion at the crossing of the Arzamas station, large-scale terrorist attacks, etc.). Extreme zones can form over a long period of time (significant changes in climatic conditions, intense pollution environment industrial waste, etc.) and occur suddenly, which is observed during natural disasters or disasters caused by people (catastrophes).
Extreme conditions are a powerful factor influencing the human body as a whole, including its psyche. These conditions can easily lead to stressful conditions and general maladaptation phenomena. The clinical manifestations of the disorders are diverse. However, they have common features and mechanisms of occurrence and development, which to a certain extent depend on the nature and rate of formation of extreme conditions.
This report will discuss mainly acute and prolonged psychogenic mental disorders in various extreme conditions, as well as some clinical manifestations of mental adaptation disorders. It (the message) is intended for persons who have initial training in general and private psychiatry within the scope of the medical university program in this discipline.
MENTAL DISORDERS
IN NATURAL DISASTERS AND DISASTERS
Mental disorders during natural disasters and mass disasters occupy a special place due to the fact that they can simultaneously occur in a large number of people. In these cases, extreme conditions mean situations that are dangerous to the life, health and well-being of large groups of the population, caused by floods, fires, earthquakes, various accidents, and the use of various weapons by the enemy during war. The World Health Organization defines natural disasters as situations characterized by unforeseen, serious and immediate threats to public health. A multifactorial assessment of such situations allows us to distinguish three periods of their development, during which various psychogenic disorders are observed.
The first period is characterized by a sudden threat to one’s own life and the death of loved ones. It continues from the onset of a disaster to the organization of rescue efforts. Powerful extreme exposure during this period mainly affects the instincts of self-preservation and leads to the development of nonspecific psychogenic reactions, the basis of which is fear of varying intensity. At this time, psychogenic reactions of psychotic and non-psychotic levels are predominantly observed; in some cases, panic may develop.
In the second period, which occurs during the deployment of rescue operations, the personality traits of the victims play a large role in the formation of states of maladjustment and mental disorders. It is also important for the victims to realize that in some cases the life-threatening situation continues in combination with new stressful influences, such as the loss of relatives, separation of families, loss of home and property. An important element of prolonged stress during this period is the expectation of repeated impacts, the discrepancy between expectations and the results of rescue operations, and the need to identify dead relatives. At first of this period psycho-emotional stress is observed, which is usually subsequently replaced by increased fatigue and asthenodepressive manifestations.
In the third period, which begins for victims after their evacuation to safe areas, many experience complex emotional and cognitive processing of the situation, assessment of their own experiences and sensations, and assessment of losses incurred. During this period, psychotraumatic factors associated with changes in life stereotypes (living in a destroyed area or in a place of evacuation, the need for close communication with strangers and etc.). Becoming chronic, these factors contribute to the formation of relatively persistent psychogenic disorders.
As studies by Yu.A. Aleksandrovsky and his colleagues, psychopathological disorders in extreme situations have much in common with clinical disorders that develop under normal conditions, but there are also significant differences. Firstly, during natural disasters and catastrophes, mental disorders occur simultaneously in a large number of people. Secondly, the clinical picture in these cases is not strictly individual, as in ordinary psychotraumatic situations, in nature and is reduced to a small number of fairly typical manifestations. Thirdly, despite the development of psychogenic disorders and the ongoing life-threatening situation, the affected person is forced to continue to actively fight the consequences of a natural disaster (catastrophe) for the sake of his survival and the preservation of the lives of loved ones and everyone around him.
Schematically, all psychogenic disorders that arise in life-threatening situations during and after natural disasters and catastrophes can be divided as follows: 1. Non-pathological (physiological) reactions, 2. Psychogenic pathological reactions, 3. Psychogenic neurotic conditions, 4. Acute reactive psychoses and 5. Protracted reactive psychoses.
Non-pathological (physiological) reactions. They are characterized by a predominance of emotional tension with fear or depressed mood, increased (or decreased) motor activity, and vegetative-vascular lability. Fear arises immediately after the appearance of signs of danger and is combined with confusion and misunderstanding of what is happening. After this short period, with a simple reaction of fear, a slight increase in activity is noted: movements become clear, economical, muscle strength increases, people move to safer places. Speech becomes faster, voice becomes louder; mobilization of will, attention, and thinking is noted. Memory impairments can be represented by a decrease in fixation of the environment, unclear recollection of what is happening around with a full volume of memories of one’s own actions and experiences. Characteristic is a change in the perception of time, the flow of which seems to slow down and the duration of events seems to be increased several times. Often there is a sharpening of characterological characteristics and decompensation of personal accentuations. However, in any case, it is typical to retain the ability to critically assess what is happening and purposeful activities of the victims. Approximately non-pathological psychogenic reactions are observed within several days.
Psychogenic pathological reactions. They are characterized by a deeper level of disorder, assessed as neurotic. They are also based on a fear reaction, in which quite pronounced movement disorders are noted. With their hyperdynamic variant, aimless throwing and many inappropriate movements are observed, making it difficult quick acceptance right decisions, a panic flight is possible. The hypodynamic variant is manifested by the fact that a person seems to freeze in place, squat down, and clasp his head in his hands. When assistance is provided, he either passively submits or begins to resist. In the future in clinical picture Asthenic, depressive and hysteroid states begin to predominate. These reactions arise under the influence of circumstances that are specifically significant for a person, and their clinical manifestations largely depend on the personal characteristics of the victims. However, the most common are depressive and astheno-depressive disorders, which have a wide range of severity. The ability to critically assess the situation and purposeful activity is reduced. The course of psychogenic pathological reactions depends on the real ways of development of the emergency situation and the prospects for its resolution for each individual person; their duration is up to 6 months.
Psychogenic neurotic states. In this case, there is a stabilization and complication of the existing reactive reactions. neurotic disorders, which leads to the formation of various neuroses: neurasthenia (exhaustion neurosis, asthenic neurosis), hysterical neurosis, depressive neurosis, obsessive-compulsive neurosis. In terms of their duration, neurotic conditions can last for 3-5 years. Due to their chronic nature and socially determined circumstances becoming more complex over time, neurotic states are transformed into various variants pathological development personality. The latter are accompanied not only by sharpening, but also by the appearance of new characterological traits, as well as a complex of psychosomatic disorders. In these cases, the formation of alcoholism, substance abuse, and drug addiction is often observed. The process of pathological personality development usually begins 3-5 years after the onset of neurotic disorders and leads, figuratively speaking, to the formation of socially determined psychopathy.
Acute reactive psychoses. This pathology occurs immediately after a disaster and is characterized primarily by the development of affective-shock reactions in the form of reactive stupor or psychomotor agitation and twilight states of consciousness. Affective-shock reactions develop instantly and occur in the form of either a fugiform reaction or a stuporous form. The fugiform reaction is characterized by a disorder of consciousness with meaningless, erratic movements, and uncontrollable flight, often towards danger. The victim does not recognize those around him, there is no adequate contact, speech production is incoherent, often limited to an inarticulate scream. Hyperpathy is noted, in which an extraneous sound or light touch further intensifies fear; possible unmotivated aggression. Memories of the experience are partial; Usually the beginning of the event is remembered. In the stuporous form, general immobility, numbness, mutism, and sometimes catatonic-like symptoms are observed. Patients do not react to their surroundings, often assume a fetal position, and there are memory impairments in the form of fixation amnesia. Psychomotor agitation, as a rule, short-term and lasts up to several hours. Stuporous reactions last longer - up to 15-20 days. Full recovery observed in almost all cases. Twilight states of consciousness are characterized by a narrowing of the volume of consciousness, predominantly automated forms of behavior, motor restlessness (less often retardation), and sometimes fragmentary hallucinatory and delusional experiences. Their duration is short and in almost half of patients the psychosis ends within one day. As a rule, all persons who have experienced psychogenic twilight disorders experience full recovery health and adapted activities.
Acute reactive psychoses end with a sharp drop in mental tone, “paralysis of emotions,” states of prostration, severe asthenia and apathy, when a threatening situation does not cause anxiety. Residual effects are most often represented by an asthenic symptom complex.
Protracted reactive psychoses. These psychoses usually form within a few days. The most common depressive form of psychosis with the classic triad clinical manifestations(decreased mood, motor retardation, slow thinking). Patients are “immersed” in the current situation, which determines all their experiences. Usually there is a deterioration in appetite, weight loss, bad dream, constipation, tachycardia, dry mucous membranes, cessation of menstruation in women. The duration of psychosis is 2-3 months; the prognosis is relatively favorable. More long course has psychogenic paranoid. Delusional ideas relationships and persecution with it develop against the background of pronounced affective disorders: anxiety, fear, depression. A pseudodementia form of prolonged psychosis is also possible, the duration of which in this case reaches a month or more. The condition of the patients is characterized by gross “impairments” of the intellect (the inability to name age, date, list anamnestic data, names of relatives, or perform basic calculations). The behavior is of the nature of foolishness (inappropriate facial expressions, stretching of lips, lisping speech, etc.).
When diagnosing psychogenic disorders that arise in an extreme situation, it is always necessary to take into account the possibility of the presence of other lesions (including traumatic brain injuries) that aggravate and prolong mental disorders in victims.
Thus, mental disorders during natural disasters and catastrophes are diverse and range from non-pathological forms of reaction to their psychotic variants. Very important role in the genesis of these disorders occupy personal characteristics victims, who (under almost equal conditions of influence) determine the nature and duration of mental maladjustment.
MENTAL DISORDERS
IN ECOLOGICAL DISASTER
Extreme situations that arise as a result of changes in the environment can be called environmental disasters. Environmental disasters can be either natural or man-made and affect both large and small regions. Unlike rapidly developing natural disasters, an environmental disaster can be not only sudden, but also the result of slowly developing (tens of years), disastrous in its consequences, ordinary environmental processes (radiation and industrial pollution of the natural environment, contamination of food with toxic substances, cumulation of “genetic harmfulness" of generations in certain regions of the world, etc.). Sudden environmental disasters (the accident at the Chernobyl nuclear power plant, an explosion on an overpass in Bashkiria, etc.) in their pathogenic significance can be equated to natural disasters, and therefore the victims will also experience a corresponding structure of psychogenic disorders (see the previous section). A different picture arises with the slow accumulation of environmental hazards. In this case, they can be divided into three main groups: 1. Direct effects of toxic substances mainly on the central nervous system; 2. Somatic diseases resulting from exposure to toxic substances; 3. Awareness of the possibility of occurrence various diseases due to exposure to environmental hazards. As a rule, all these factors act in combination, significantly complicating the picture of the manifestation of mental disorders. However, when carrying out the diagnostic process, it is advisable to take into account the possibility of various pathogenetic mechanisms, since this can determine the tactics of providing medical care.
The direct effects of toxic substances are directly related to toxicology and are covered in sufficient detail in the relevant literature. Depending on the chemical class of the acting agent and its concentration, various mental disorders can occur, from minor neurosis-like disorders to psychotic states with disturbances of consciousness according to the exogenous type of response, as well as in the form of the formation of an organic symptom complex.
Somatic diseases that arise in people living in areas of environmental disasters are often not recognized by them as a consequence of exposure to an unfavorable living environment. In this case, the clinical picture is represented by typical disorders characteristic of somatogenic mental illnesses. The range of observed disorders is quite wide and extends from borderline mental disorders (asthenia, depression, hysterical and obsessive states, hypochondria) to somatically caused psychoorganic pathology (encephalopathic syndrome) and psychoses (affective, exogenous, schizoform).
Psychogenic mental illness arise in an environmentally unfavorable environment due to a person’s awareness of a constant threat to his life and health (fears for the life and health of loved ones). The high significance and extreme relevance of these experiences is often provoked and supported by sensations arising as a result of autonomic hyperactivity (for example, a person who, for objective reasons, feels a rapid heartbeat can associate it with the onset of a serious heart disease). The leading manifestation of these conditions is anxiety, which is directly related to the possibility of the onset of a particular disease. Along with this, irritability, difficulty concentrating, hyperesthesia, and general anxiety are noted; Complaints of memory loss are common. The latter should be differentiated from a true decrease in memory in a somatically caused psychoorganic disorder. A depressive disorder is often detected, characterized by low mood, an inability to experience feelings of joy, a pessimistic way of thinking and decreased energy, and a significant deterioration in performance. These conditions are often difficult to distinguish from each other, since anxiety is a typical symptom of the syndrome depressive disorder; and vice versa - anxiety syndrome often includes some depressive symptoms. These syndromes can therefore be differentiated by the relative severity of their symptoms and the order in which they occur. Based on anxiety and depressive disorders, a hypochondriacal state is often formed. In this case we're talking about not about a person’s painful conviction that he has a serious somatic disease, but about the reorientation of the victim’s personal attitudes with a predominant fixation of attention on the state of his health, a significant overestimation of the severity of the disorders and a change on this basis in his entire lifestyle, according to the victim’s ideas about inner picture his illness. Other forms of mental disorders are possible, but they are not common and rarely reach psychotic levels. This is probably due to the slow increase in situational influence, which, with this type of development, causes predominantly borderline mental disorders. The personal characteristics of the victims are of enormous importance in the occurrence of mental disorders. People with anxious-suspicious, anankastic and paranoid character traits are most susceptible to them (disorders).
MENTAL STATE OF REFUGEES AND MIGRANTS
Migrants are a population that moves from one area to another. The term “migrant” unites people of different cultures, nationalities, religions, and different socio-demographic characteristics. By type, migration is distinguished between planned (students, people changing jobs, migrants from agricultural to industrial areas and vice versa, etc.) and unplanned - spontaneous migration caused by various disasters, war, oppression, violence, etc. IN the latter case Migrants are usually called refugees. Based on the direction of movement, internal migration (within the country) and external migration (outside the country) are distinguished. The relevance of the problem of refugees and migrants (including the problem of their mental health) is growing from year to year due to the steady increase in their number. According to statistics, today there are about 20 million refugees in the world and twice as many more people, forcibly displaced within their own countries. People with unplanned external migration are at greatest risk of developing mental illness. The problems they face upon arrival in a new country are, first of all, a new society, a new language, a new culture. A person’s adaptation to a place of migration is also influenced by nationality and belonging to one or another ethnic group. Stress reactions arising from various levels before migration and during resettlement, they intensify as a person adapts to new conditions. In these conditions, migrants especially feel the suppression of their culture in the process of adopting new customs; They realize that many of them will no longer be able to return to their homeland, they experience nostalgia, and feel isolation. In addition, migrants face the following difficulties: certain forms of their behavior and their speech are often not accepted by the new society; people are unable to express themselves due to language barriers, which can cause mental trauma amounting to deafness and dumbness. A particularly significant stress factor for a person is cultural change, since, regardless of other factors, a conflict arises between old and new cultural values. As for refugees, the occurrence of mental disorders in them is associated with the situation of violence in their home country, the process of expulsion, with the environment of the move, with impressions of the first refuge, and then with the peculiarities of the new country of culture and the first period of adaptation, during which refugees most acutely feel their uselessness, isolation from their homes, isolation, loss of work, and in some cases, family. Such psychological problems allocated to the group of post-traumatic stress disorders.
The multiplicity of active psychogenic factors complicates the clinical picture of mental disorders and can lead to an incorrect assessment of the patient by the doctor. Without taking into account cultural and national characteristics, as well as without proper knowledge of the language, the patient can be ascribed to non-existent confusion, anxiety, delirium, disorientation, etc. In this regard, the diagnosis of mental disorders must be based on very specific and easily identifiable signs. A guide published by the World Health Organization (1996) and translated into Russian in 1998 (Kyiv - Sfera Publishing House) entitled “Mental Health of Refugees” makes the following recommendations for identifying people with various mental disorders:
Symptoms and signs of stress - Mental symptoms: irritability or anger over minor issues; sadness, crying, or feeling helpless; rapid mood changes; poor ability to concentrate, the need for repeated repetitions to learn simple things; obsessive return to the same thoughts. Physical symptoms: fatigue, headaches, muscle tension, irregular heartbeat, feeling short of breath, nausea or abdominal pain, poor appetite, vague pain in the arms, legs or chest, menstrual irregularities in women. Behavioral symptoms: decreased activity, lack of energy; increased activity, "restlessness"; difficulties associated with the need to concentrate on one thing; using alcohol or drugs to reduce tension; sleep disorders; lack of emotionality; disputes and disagreements; too much dependence on others in decision making, the need for constant external support.
Symptoms and signs of depression- all-consuming grief and deep sadness; lack of hope for the best; thoughts of harming yourself; tearfulness; constant worry; anxiety, tension; lack of joy in life; lack of energy, fatigue; physical complaints such as persistent headaches; poor sleep; weight loss; lack of interest in sex; problems with concentration and memory; feeling “bad,” worthless, or less respected than other people.
These symptoms must be actively identified, since in an extreme situation, a refugee can assess his condition as the norm corresponding to his status, and therefore will not make complaints.
Symptoms and signs acute psychosis , occurring with impaired consciousness, do not have any special manifestations compared to ordinary painful conditions. However, one should take into account the fact that in conditions of migration, acute psychotic states can be not only of psychogenic origin, but also caused by other reasons; acute infectious diseases, vitamin deficiency, head injury, abrupt cessation of alcohol or drug intake. Differential diagnosis of the causes of psychotic disorders usually does not present any particular difficulties.
The mental health of refugee children poses a rather complex problem. Mass movements of people inevitably lead to cases of family breakdown and separation. The risk is particularly high in unstable refugee camps. There are two general problems that require special attention. First, some children belong to vulnerable and dysfunctional families (single-parent families, large families, families caring for other people's children in addition to their own). Secondly, many children may be neglected due to the loss of family and home. In the latter case, children exhibit relatively similar signs of suffering. The development of such children sometimes stops or even goes backwards.
Children younger age separated from their families often exhibit the following disorders: short attacks crying a lot; teacher's rejection; refusal of food; digestive disorders; sleep disorders.
Children aged 4-5 years may have the same reactions and often behave like younger children. At this age, the following disorders may occur: the child sucks his thumb; bed-wetting; Difficulties in controlling impulses (the child easily loses self-control or shows inappropriate emotions); signs characteristic of a younger age appear in speech. Street children aged 4-5 years often have nightmares and night terrors. They may also experience fear of specific objects and phenomena ( loud voices, animals, etc.) or imaginary creatures (ghosts, witches, etc.).
School-age children may exhibit the following symptoms: withdrawal towards teachers; depression; irritability; anxiety; inability to concentrate; bad behavior at school; isolation towards children of their own age.
Adolescents separated from their families often experience the following reactions: depression, moodiness, isolation, aggressiveness, frequent headaches, stomach cramps and other functional disorders.
Another problem for doctors working among refugees is the problem of alcoholism and drug addiction. Some refugees turn to alcohol and drugs as a means of distracting them from real life problems. Others have excess time not engaged in any useful activity. A refugee may reason like this: “I don’t care about the future and what happens to me and others...” When family and society cease to control the normal behavior of their members, young people are especially quick to turn to alcohol and drugs. If refugees regularly resort to alcohol or drug use, they quickly lose interest in improving their living conditions, stop thinking about the future, and do not worry about the well-being of their loved ones. Even if just a few people begin to abuse alcohol or drugs, it affects the entire community, undermining discipline and its confidence in the future.
MILITARY SERVICE
AS A FACTOR OF EXTREME IMPACTS
The conscription of young people for active service in the Army can be assessed as a kind of extreme impact, since it significantly changes the usual way of life and places increased demands on the physical and mental capabilities of the individual, especially during the period of adaptation to military service. Special studies have shown that difficulties military service, especially against the background of psychological unpreparedness for it, cause a decrease in mood, emotional instability, isolation and isolation, passivity and apathy, self-doubt, and a feeling of hopelessness in a number of people. This is often accompanied by a deterioration in relationships with others and behavioral deviations - suicidal attempts, demonstrative and blackmailing auto-aggressive actions, unauthorized abandonment of the unit, conflicts with commanders. Behavioral disorders in this case should be considered in terms of the impact on a person of a complex of interrelated and interdependent external pathogenic causes and internal predisposing conditions, which depend on a combination of psychopathological, personal and situational factors. Based on their target orientation and motives, they can be divided into two groups: 1) passive-defensive type, which includes unauthorized abandonment of a unit, auto-aggressive actions and addictive behavior, which are a form of escape from traumatic experiences with refusal to solve personal and social problems; 2) aggressive type, which consists in the dominance of negativistic, hostile, defiant behavior, accompanied by rudeness, outbursts of anger, rage with destructive actions, physical violence, cruelty towards others, caused by motives of hostility, enmity, anger, revenge against the background of insecurity social status, anxiety, feelings of threat, alienation.
In peacetime, in military personnel with psychogenic behavioral disorders that developed during the first half of the year from the moment of conscription into the Army, in the vast majority of cases (84%) character accentuations were identified, among which epileptoid, unstable, asthenoneurotic and hysteroid were more often identified. Poor tolerance of a regulated regime, a poorly developed sense of duty, the need to stay in a closed group, incompatibility in a microsocial environment, a negative attitude towards military service among some people with character accentuations lead to a rapid increase in personality disharmony against the background of emotional tension and the secondary emergence of microsocial conflicts.
In the second half of military service, contrary to what was expected, the number of behavioral violations not only does not decrease, but even increases. Highest specific gravity behavioral disorders falls during this period on persons with character accentuations of predominantly sensitive, asthenoneurotic, schizoid and psychasthenic types. They are characterized by self-doubt, indecision, vulnerability, emotional lability under conditions of increased physical and psycho-emotional stress, they contribute to an increase in asthenic manifestations, a sharpening of characterological characteristics with the appearance of increased irritability, rapid mental and physical exhaustion, and a decrease in resistance to negative situational influences. Against this background, the impact of additional psychological trauma associated with family and legal problems, emotional rejection from colleagues, etc., as a rule, was a trigger point in the development of psychogenic reactions. Their structure during this period is dominated by neurotic reactions, the characteristic feature of which is the high prevalence of behavioral disorders and the weak severity of vegetative and motor symptoms, which is due to age characteristics, as well as limited resolution capabilities conflict situations in the army environment. The internal orientation of experiences, fixation on traumatic events are accompanied by detachment from the environment, the desire for loneliness, the experience of despair, hopelessness, the insurmountability of the situation, a feeling of dissatisfaction with oneself, as well as outbursts of irritation, which culminated in auto-aggressive actions and unauthorized abandonment of the part. In the second year of service, the number of psychogenic disorders decreases, probably due to the completion of the adaptation process.
Thus, in the conditions of military service, the leading role in the occurrence of psychogenic reactions and associated behavioral disorders belongs to the personal factors formed in the pre-conscription period that determine increased vulnerability to various types of psychotraumatic situations. The sharpening of characterological characteristics, the decrease in moral criteria and moral attitudes during the period of destabilizing socio-political processes affecting the Army, contribute to the development of behavioral disorders of a predominantly passive-defensive type.
The physical and psychological stressors of war, in contrast to peacetime, significantly reduce the role of premorbid soil in the development of psychogenic reactions. In military personnel with psychogenic behavioral disorders developing in the first six months of being in a combat situation, a sharpening of personality characteristics was predominantly observed in conditions of pronounced psycho-emotional stress and in most cases reflected the usual ways of responding within the framework of pathocharacterological reactions. A longer stay in a combat situation contributes not only to the sharpening of inherent characterological traits, but also to the appearance of new, acquired, previously uncharacteristic traits in some individuals against the background of long-term anxious fears and asthenia. It should be noted that the formation of accentuations is accompanied by the development of preferential ways of responding, reflecting the presence of a certain personality structure. In military personnel with epileptoid traits, they manifest themselves in outbursts of passion with a tendency toward aggression; in persons with hysterical traits, the same affective reactions acquire a demonstrative coloring; in the presence of asthenic features, irritable weakness with an auto-aggressive orientation is typical. Becoming more and more differentiated for each type of accentuation, these habitual ways of responding largely determine the specificity of behavioral disorders. The appearance of nonspecific (not characteristic of this type of accentuation) psychogenic behavioral disorders indicates the unfavorable nature of the dynamics of accentuation, reflecting the increase in personal disharmony due to the addition of new traits. Thus, in a combat situation, military personnel with epileptoid accentuation often exhibit increased vulnerability in the sphere of interpersonal relationships, an increased sense of duty and responsibility for the lives of colleagues; in persons with unstable, asthenoneurotic, schizoid and sensitive character accentuations, alertness, suspicion, hostility appeared, combined with increased irritability, explosiveness.
The impact of powerful psycho-traumatic factors in a combat situation contributes to the formation of psychogenic reactions and associated behavioral disorders in a large number of individuals, regardless of the presence of character accentuations. Survival in war is associated with the development of new ways of responding in the form of constant vigilance, hostile perception of the environment, immediate response (usually aggressive) in relation to the source of the threat. At the same time, growing threat and fear are accompanied by a feeling of helplessness, self-doubt, powerlessness in front of the external environment and lead to a change in the form of affects, actions, and thinking. The affective embrace of experiences determines a one-sided assessment of reality, an exaggeration of its threatening nature, and significantly distorts emotional connections with others. Contributing to survival in a complex and contradictory combat environment, aggressiveness skills take the form of a pathological behavioral stereotype acquired under conditions of chronic stress, leading to persistent socio-psychological disadaptation.
Thus, in contrast to peacetime, in a combat situation the role of environmental stress factors in the development of psychogenic behavioral disorders increases significantly. Adaptation in conditions of constant threat to life, affecting the vital instincts of a person, is accompanied by the development of methods of response necessary for survival in the form of alertness, suspicion, hostile perception of the situation, aggression towards the source of the threat. Existing for a long time, they are constantly strengthened by the personality and increase its disharmony, which is expressed in behavioral disorders, mainly of the aggressive type.
EXTREME IMPACTS
“UNUSUAL CONDITIONS OF EXISTENCE”
A radical break in the habitual, long-established conditions of existence puts the “unusuality of existence” on a par with psychogenics and psychotraumatization. The emergence and actualization of the problem of “unusual conditions of existence” is predetermined by mankind’s intensive exploration of air, sea and outer space in the 20th century, as well as the penetration of civilization into hard-to-reach regions of the earth (long-term autonomous expeditions to the Far North, Antarctica, etc.). The psychophysiological organization of a person sometimes turns out to be unprepared to reflect these conditions either in the process of phylogenesis (development of the genus) or in the process of ontogenesis (individual development), which creates a serious problem: to what extent and how can the psychophysiological organization of a person ensure adequate adaptation and adequate perception of reality? reality in conditions to which it was not adapted in the process of its development.
“Unusual conditions of existence” have features that differ from “usual” conditions, which primarily include the presence of a threat to life, monotony of life (monotony), desynchronosis of sleep and wakefulness rhythms, limitation of information (personal, special and mass), and in certain conditions - a feeling of loneliness. The identified psychological features of “unusual conditions of existence” do not act in isolation, but in combination, ultimately leading to maladaptation of the individual in new conditions. It should be remembered that mental re-adaptation to unusual conditions, disadaptation and readaptation to ordinary living conditions are subject to the natural alternation of stages described by V.I. Lebedev (1989):
1. Preparatory stage - the stage of starting mental stress - the stage of acute mental reactions of “entry”.
2. Mental re-adaptation - unstable mental activity - deep mental changes.
3. Readaptation - the stage of acute mental reactions of “exit” - the stage of final mental stress.
On preparatory stage , regardless of the specifics of unusual conditions, a person collects the necessary information and understands the tasks that he has to solve in these conditions, masters the necessary professional skills and establishes a system of personal relationships with other group members. As we approach the conventional barrier that separates ordinary living conditions from unusual ones (the stage of initial mental stress) and the similar barrier that separates the time spent in unusual conditions from ordinary ones (the stage of final mental stress), mental tension increases, which is expressed in unpleasant experiences, in subjective slowing down the passage of time, sleep disturbances and autonomic disorders. The reasons for the increase in mental stress also include information uncertainty, anticipation of possible emergency situations and mental “playing out” of the corresponding operations to resolve them.
When overcoming the psychological barrier separating ordinary living conditions from unusual (changed) ones, positive emotional experiences arise, states of “emotional resolution”, which are largely associated with the elimination of information uncertainty. Acute mental reactions of “entrance” manifest themselves in the form of spatial illusions, impaired self-awareness (derealization-depersonalization disorders), acute affective reactions and disharmonies in the motor sphere.
Stage mental re-adaptation has a lot in common with the stage readaptation, at which the processes of reflection, the system of reflection and coordination of motor activity are restored to a level adequate for normal living conditions. The longer the period of stay in unusual, changed conditions, the longer and more difficult the readaptation to normal living conditions occurs. During this period, mental re-adaptation may be replaced by a stage of unstable mental activity.
At all of the above stages, one often has to deal with a number of mental phenomena that can be designated as “unusual mental states (pseudopsychopathological). During periods of re-adaptation and readaptation, these include the phenomena of eidetism, exteriorization reactions (the phenomenon of “creating an interlocutor”), as well as psychological openness. At the stage of unstable mental activity - emotional lability, disturbance of the rhythm of sleep and wakefulness. Unusual mental states (pseudopsychopathological) are distinguished from mental pathology by a clear psychologically understandable connection with reality, the motivation of these phenomena, as well as the short duration and preservation of a critical attitude towards them. normal living conditions and doubts about the reality of experienced mental disorders quickly dissipate under the influence of rational explanations from others.
The stage of final mental stress is caused by anticipation of a return to normal life, and, sometimes, by anxious expectations of possible extreme situations during the final period of being in unusual conditions. In this situation, nervousness, painful emotional experiences, a slowdown in the passage of time and other disturbances appear. Among acute mental “exit” reactions, it is necessary to take into account the possibility of developing pronounced shifts in the emotional state (euphoria, hypomanic states), disturbance of motor automatisms, disorders of perception of the depth of objects and violation of the constancy of their sizes, decreased sensitivity thresholds of the visual and auditory analyzers. At the long stage of readaptation, in addition to “pseudopsychopathological” conditions, psychopathic, schizoid and hypochondriacal personality disorders are possible. This personal pathology, being a consequence of individual or group isolation in extreme conditions, affects readaptation to the usual social environment, reduces the overall “level of civilization” and sometimes forms an attitude to return to the experienced situation of unusual conditions.
Thus, a person’s personality develops, mastering unusual conditions of existence. The need to form an individual’s relationship to them determines the difficulties of adaptation that arise. The breakdown of relationships towards their inadequacy and self-centeredness leads to the formation of ideas of relation, overvalued and obsessive ideas, manifesting themselves either at the level of pre-pathology or at the level of psychosis. Information insufficiency covers not only the assessment of the external conditions of the situation, but also self-esteem in fundamentally new operating conditions. Psychogenies of unusual conditions of existence are clinically manifested in both sthenic (with overvalued ideas) and asthenic (with obsessions) options. At the same time, the asthenic variant, recognized by the individual as a disease, predominantly leads to neurotic dynamics, and the unconscious supervalue leads to psychopathic and psychotic dynamics.
ISSUES OF PROVIDING PSYCHIATRIC CARE
IN EXTREME SITUATIONS
As already noted, the largest share of mental disorders in extreme situations falls on psychogenic disorders of the borderline level. In this regard, when providing medical care to victims, leading importance must be given to psychotherapeutic methods of treatment. Considering that psychotherapeutic influence in these conditions is forced to be provided not only by psychiatrists, but also by doctors of other profiles, it is advisable, within the framework of this manual, to highlight some general issues of psychotherapy.
In all forms of psychotherapy aimed at helping the patient overcome emotional problems, two methodological techniques are combined - listening And statement. In this process, the former is usually more important than the latter, since the main goal of treatment is to help the patient better understand himself. For the patient, part of this process is thinking aloud, which is good for clarifying ideas that have not previously been formulated in verbal form, as well as allowing one to become aware of previously unrecognized connections between certain aspects of feelings and behavior. The next important part of psychotherapy is restoration of morale, since most of the victims experienced stressful situations, was demoralized and lost confidence that they could help themselves. It should also be remembered that all types of psychotherapy include rationalization, which makes it possible to make the patient's disorders more understandable. A reasonable explanation for the condition can be given either by the victim himself as a result of a conversation with a doctor, or by a doctor. Whatever the method of presenting a reasonable explanation, the problem as a result becomes more understandable, and this gives the patient confidence that it can be resolved. The psychotherapeutic effect also contains an element suggestions however, its effects are short-lived (excluding hypnotherapy) and wear off over time.
Based on the above general provisions The goal of psychotherapeutic influence on victims in extreme situations is to cause significant positive changes in the patient in a short time mental state. In the first stages, immediately after exposure to stress, it is most advisable to use the so-called “discussion therapy”. In its use, the physician primarily plays a passive role, mostly limiting his intervention to comments regarding the emotional significance of the patient's statements. In this case, it is necessary to take into account that not all victims are able to verbally define their feelings. In this regard, in the process of work it is necessary to teach the patient to name his sensations and shades of experiences. Partial “translation” of the patient’s emotional feelings to the level of abstraction contributes to a certain rationalization of his experiences and opens up access to further psychotherapeutic work with him. Next, you need to invite the patient to tell the story of his mental trauma (catastrophe), and allow him to talk about it as many times as he wants. During this period, you need to listen to patients with emotional support, occasionally assessing their behavior style and, if necessary, offering new options. You need to be prepared for the fact that symptoms of emotional disturbances may intensify during the first stories. However, this process is necessary, since the untold story of the disaster “keeps the victim in place” and he cannot begin his new story, new life. In other words, the story of the disaster separates the past from the present and allows us to build the future on the basis of the present. The doctor’s comments during the conversation should emphasize human resilience and virtue, eliminate feelings of guilt, try to reduce suffering from losses, and open perspectives.
Subsequently (or with other types of exposure to extreme conditions on the psyche), it is advisable to use “supportive” psychotherapy. During this procedure, the patient is also encouraged to talk about his problems. Doctor listens his patient with sympathy, gives advice and can use suggestion to help the patient during a period of short-term worsening of symptoms. In case of insoluble problems, the patient is helped to come to terms with the inevitable and, despite everything, lead as normal a life as possible. It is necessary to be able to listen to the patient; this is an important part of maintenance therapy. The patient should feel the doctor's focused attention and interest and see that their concerns are taken seriously. Play a big role explanation and advice, but it must be borne in mind that a patient in a state of distress will subsequently be able to remember, most likely, only a little of what the doctor said. In addition, doctors often give their advice in overly complicated language. The main provisions should be formulated simply and clearly; It is advisable to repeat them more often, and sometimes it is useful to put these points in writing so that the patient can study them outside of a conversation with the doctor. Has great value reassurance However, it should not be premature, as this may destroy confidence in the doctor. This technique can only be used when the patient's problems are fully understood. The reassurance must be truthful, but if the patient asks about the prognosis, then the most optimistic one should be spoken. possible outcomes. If the patient discovers that he has been deceived, he will lose the trust on which the entire treatment depends. Even in the most difficult cases, a positive approach can be maintained, encouraging the patient to rely on the positive qualities he has, albeit few. In supportive care, patients must be encouraged to take responsibility for their actions and solve their problems independently. However, there are times when the doctor needs to use his authority as a specialist to convince the patient to take the necessary first step. Thus, a patient in a state of anxiety can be confidently told that he is able to cope with the social difficulties that frighten him. This type of belief is called instilling prestige. It is important to discuss the achieved results in such a way that the patient gets the impression that the problem was solved in to a greater extent himself than the doctor. During maintenance therapy, the regulation of the relationship between the patient and the doctor is very important. The doctor should behave in such a way as not to make the patient dependent on him. The patient should not rely on the doctor in everything and should always know the boundary between him and himself.
Along with psychotherapy, tranquilizers, antipsychotics and other psychotropic drugs are used when treating victims in extreme situations. Recommendations for their use are given in any prescription reference book. A peculiarity of the use of these drugs in these conditions is that they are prescribed in small doses. This especially applies to tranquilizers, the use of which can quickly lead to addiction. In this regard, there are recommendations in the literature to sharply limit the use of these drugs and prescribe small doses of antipsychotics instead. When treating victims in extreme situations (especially refugees), one should also take into account their need to take large doses of alcohol or drugs. In this regard, work with this contingent should also have a drug treatment focus.
If mental disorders of a psychotic level occur, conventional treatment with antipsychotic drugs is carried out, according to the existing recommendations of psychopharmacotherapy.
CONCLUSION
This report highlighted the most important manifestations of mental disorders in people who find themselves in extreme situations. On the one hand, these disorders are very diverse, but on the other hand, they have much in common. The main point uniting the mental pathology developing in this case is the formation of psychogenies of various levels. Their range is very wide: from acute stress disorders and adaptation reactions to protracted neuroses and psychotic states. This fact also determines the nature of assistance to victims, which, along with psychotropic drugs, should mandatory be also psychotherapeutic. An increase in the number of disasters in the world, the introduction of a person into areas that are unusual for him, the imposition of increasingly higher demands on the human psyche as a result of the acceleration of the rhythm of life, urbanization, etc. makes the problem of living in extreme situations relevant not only for psychiatrists, but also for doctors of other profiles. The author hopes that the information presented on this issue, will provide some assistance to doctors who are forced to work with a contingent of people who have survived certain extreme situations.
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Literature
Krzhechkovsky A.Yu. Mental disorders in extreme conditions and their medical and psychological correction. [Electronic resource] // Medical psychology in Russia: electronic. scientific magazine 2011. N 3..mm.yyyy).
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Severe natural disasters and catastrophes, not to mention the possible massive sanitary losses during war, are a difficult experience for many people. A person’s mental reaction to extreme conditions, especially in cases of significant material losses and loss of life, can deprive a person of the ability to act rationally and act for a long time, despite " psychological protection", helping to prevent disorganization of mental activity and behavior.
Practical activities can be divided into those that are carried out in the period before the occurrence of an extreme situation, during the period of exposure to psychotraumatic extreme factors and after the cessation of their influence.
Before an emergency occurs, the following measures are necessary:
Preparing the civil defense medical service to work in extreme conditions; training personnel of sanitary posts and squads to provide medical care to victims with psychogenic disorders;
Formation and development of high psychological qualities among the personnel of the civil defense medical service, the ability to behave correctly in extreme situations, and the ability to overcome fear;
Developing organizational skills in psychoprophylactic work with the population among the personnel of the civil defense medical service;
Informing medical workers and the population about the possibilities of using psychotherapeutic and medications for psychoprophylaxis.
The list of the indicated ways to prevent states of mental maladjustment in extreme conditions, directly addressed primarily to various units of the civil defense medical service, should be supplemented by a wide range of educational and organizational activities aimed at overcoming carelessness and neglect of certain life-threatening effects on a person, both in those cases when “harmfulness” is clearly tangible, so also when it is, until a certain time, hidden from the sight and understanding of ignorant people. Mental hardening is of great importance, i.e. development by a person of courage, will, composure, endurance and the ability to overcome feelings of fear.
The need for this kind of preventive work follows from the analysis of many emergency situations, including the Chernobyl disaster.
“From Minsk in my car I (an engineer, a nuclear power plant worker. - Author) was driving towards the city of Pripyat... I approached the city somewhere around two hours and thirty minutes at night... I saw a fire above the fourth power unit. It was clearly visible a ventilation pipe illuminated by flames with transverse red stripes. I remember well that the flame was higher than the pipe. That is, it reached a height of about one hundred and seventy meters above the ground. I did not turn home, but decided to drive closer to the fourth power unit to get a better look... I stopped. about a hundred meters from the end of the emergency block. (In this place, as will be calculated later, the radiation background at that time reached 800-1500 roentgens per hour, mainly from the graphite scattered by the explosion and the flying radioactive cloud. I saw it in the low beam of the fire.) that the building was dilapidated, there was no central hall, no separator rooms, the separator drums, moved from their places, shone reddishly, my heart hurt from such a picture... I stood there for a minute, there was an oppressive feeling of incomprehensible anxiety, numbness, my eyes absorbed everything and remembered it forever. . But anxiety kept creeping into my soul, and involuntary fear appeared. Feeling of an invisible threat nearby. It smelled like after a strong lightning strike, still astringent smoke, it began to burn my eyes and dry my throat. I was coughing. And I lowered the glass to get a better look. It was such a spring night. I turned the car around and drove to my home. When I entered the house, mine were asleep. It was about three o'clock in the morning. They woke up and said they heard explosions but didn't know what they were. Soon an excited neighbor came running, whose husband was already on the block. She informed us about the accident and offered to drink a bottle of vodka to decontaminate the body...” At the time of the explosion, two hundred and forty meters from the fourth block, just opposite the turbine room, two fishermen were sitting on the bank of the supply canal and catching fry. They heard explosions , they saw a blinding burst of flame and pieces of hot fuel, graphite, reinforced concrete and steel beams flying like fireworks. Both fishermen continued their fishing, not realizing what had happened. They thought that a barrel of gasoline had probably exploded. Literally before their eyes, fire crews deployed. they felt the heat of the flame, but carelessly continued fishing. The fishermen received 400 roentgens each. Towards the morning, they developed uncontrollable vomiting; according to them, it was as if the heat was burning inside their chests, their eyelids were burning, their heads were bad, as if after a wild hangover. Realizing that something was wrong, they barely made it to the medical unit. ..
Resident of Pripyat Kh., senior engineer of the production and administrative department of the Chernobyl NPP construction management, testifies: “On Saturday, April 26, 1986, everyone was already preparing for the May 1st holiday. Warm, fine day. Spring. Gardens are blooming... Among the majority of builders and no one knew anything about the installers. Then something leaked about the accident and fire at the fourth power unit. But no one really knew what happened. The children went to school, the kids played outside in the sandboxes, rode their bicycles. by the evening of April 26, there was already a lot of activity in the hair and clothes, but we didn’t know it then. Not far from us, delicious donuts were being sold on the street. It was a normal day off... A group of neighborhood kids rode their bicycles to the overpass (bridge), and it was good from there. the emergency block was visible from the side of the Yanov station. This, as we later learned, was the most radioactive place in the city, because a cloud of nuclear release passed there. But this became clear later, and then, on the morning of April 26, the guys were just interested in watching. how the reactor burns. These children later developed severe radiation sickness."
Both in the above and in many similar examples, belief in a miracle, in “maybe”, in the fact that everything can be easily fixed, paralyzes, makes a person’s thinking inflexible, deprives him of the opportunity to objectively and competently analyze what is happening, even in the case when There is the necessary theoretical knowledge and some practical experience. Amazing carelessness! In the case of the Chernobyl accident, it turned out to be criminal.
During the period of exposure to psychotraumatic extreme factors, the most important psychoprophylactic measures are:
Organization of clear work to provide medical care to victims with psychogenic disorders;
Objective information from the population about the medical aspects of a natural disaster (catastrophe);
Assistance to civil society leaders in suppressing panic, statements and actions;
Involving lightly injured people in rescue and emergency recovery operations.
After the effect of psychotraumatic factors ends, psychoprophylaxis includes the following measures:
Objective information from the population about the consequences of a natural disaster, catastrophe, nuclear and other strikes and their impact on the neuropsychic health of people;
Bringing to the attention of the population data on the possibilities of science in relation to the provision of medical care at the modern level;
Prevention of relapses or repeated mental disorders (so-called secondary prevention), as well as the development of somatic disorders as a result of neuropsychic disorders;
Drug prevention of delayed psychogenic reactions;
Involving the easily injured in participation in rescue and emergency recovery operations and in providing medical care to victims.
It should be emphasized that psychotraumatic factors quite often continue to operate even after the culmination of a natural disaster or catastrophe, although less intensely. This includes the anxious anticipation of aftershocks during an earthquake, and the ever-increasing fear of “dose accumulation” when being in an area with an increased level of radiation.
Experience shows that the main causes of “man-made” tragedies are quite similar in different countries in all kinds of disasters: technical imperfection of machines and mechanisms, violation of technical requirements for their operation. However, behind this there are human flaws - incompetence, superficial knowledge, irresponsibility, cowardice, which prevents the timely detection of detected errors, inability to take into account the capabilities of the body, calculate forces, etc. Such phenomena should be condemned not only by various control bodies, but first of all by the conscience of every person, brought up in the spirit of high morality.
One of the most important socio-psychological preventive tasks is information to the population about the situation, carried out permanently. Information must be complete, objective, truthful, but also reasonably reassuring. The clarity and brevity of the information makes it especially effective and understandable. The absence or delay of information necessary for making rational decisions during or after a natural disaster or catastrophe gives rise to unpredictable consequences. For example, untimely and half-truthful information from the population about the radiation situation in the zone of the Chernobyl accident led to many tragic results both directly for public health and for making organizational decisions to eliminate the accident and its consequences.
This contributed to the development of neuroticism in wide circles of the population and the formation of psychogenic mental disorders at the remote stages of the Chernobyl tragedy.
An important place in the implementation of primary prevention of psychogenic disorders is given to the understanding that a modern person must be able to behave correctly in any, even the most difficult, situations.
Along with cultivating the ability not to get lost in difficult life situations that develop in extreme conditions, the competence, professional knowledge and skills, and moral qualities of people managing complex mechanisms and technological processes are of the most important preventive importance.
Particularly terrible consequences are caused by incompetent decisions and the choice of the wrong course of action during the initial stages of an extreme pre-catastrophic situation or during an already developed disaster. Consequently, during the professional selection and training of managers and performers of the most critical areas of work in many areas of economic activity, it is necessary to take into account the psychological characteristics and professional competence of a particular candidate. Anticipation of his behavior in extreme conditions should occupy an important place in the system of general prevention of the development of life-threatening situations and the psychogenic disorders caused by them.
Correct and enough full information informing the population about possible human reactions to an extreme situation is the first necessary preventive measure. Familiarizing people with such information in advance (not after the occurrence of an extreme situation!) is the second preventive measure. Promptness and activity in implementing protective measures is the third preventive measure.
Training of personnel of sanitary posts, sanitary squads, and first aid units should be carried out in compliance with the basic rule of didactics: first, training programs are developed and the acquisition of theoretical knowledge is planned, then practical skills are formed and the ability to provide assistance is practiced, brought to automaticity. In particular, the personnel of sanitary posts and sanitary squads, first aid units must know the main syndromes of mental disorders in extreme situations and be able to use modern means of providing assistance with motor agitation. It is extremely important that the development of practical skills is carried out at special tactical and complex civil defense exercises in complicated, as close as possible to real conditions, at night, in any weather, etc. At the same time, it is necessary to cultivate in people high moral, political and psychological qualities, a willingness to show courage, endurance and self-control, initiative and resourcefulness, confidence and endurance when providing medical care to victims.
It is not without reason that they believe that uncontrollable fear indicates a lack of confidence in oneself, one’s knowledge, and skills. It can also lead to panic reactions, to prevent which it is necessary to stop the spread of false rumors, show firmness with the “leaders” of alarmists, direct people’s energy to rescue work, etc. It is known that the spread of panic is facilitated by many factors caused by a person’s psychological passivity in extreme situations and lack of readiness to fight the elements.
Special mention should be made of the possibilities of primary drug prevention of psychogenic disorders. In recent decades, significant attention has been paid to such prevention. However, it must be borne in mind that the use of psychopharmacological drugs for prevention is limited. Such remedies can be recommended only to small groups of people. In this case, one should take into account the possibility of developing muscle weakness, drowsiness, decreased attention (tranquilizers, antipsychotics), hyperstimulation (psychoactivators), etc. A preliminary consideration of the doses of the recommended drug, as well as the nature of the intended activity, is required. It can be used much more widely to prevent mental disorders in people surviving after a natural disaster or catastrophe.
Medical and social preventive actions play an important role during remote stages of natural disasters and disasters. Thus, just a year after the Chernobyl tragedy, in many of the affected areas and surrounding areas, not so much radiation problems as psychological and psychiatric problems became the most pressing, which in some cases gave rise to the widespread prevalence of so-called radiophobias. As a rule, such conditions are widespread, although they are most pronounced in hysterical and anxious-suspicious individuals. It is they who experience the development of pathocharacterological personality changes. In these cases, it is quite often possible to observe the mechanisms of inducing painful disorders. Anticipating the possibility of the occurrence of these psychogenic disorders at remote stages of natural disasters and catastrophes, it is necessary, while developing and implementing the entire range of recovery measures, to provide active socio-psychological support to victims and conduct tactical explanatory work.
An analysis of many severe natural disasters and catastrophes shows that the number of psychogenies during them is large, and the population and medical staff are practically unprepared for the possibility of their development.
In modern conditions, there is every reason to more widely use data from psychology, psychotherapy, mental hygiene and other disciplines in order to optimize people’s activities in extreme situations, necessary to overcome increased psychological and physical stress.