Lecture
Chulkova V.A.
At present, numerous psychological studies of cancer patients are being conducted. These studies broaden our understanding of the mental state and personality characteristics of adult and pediatric cancer patients at different stages of the disease and treatment across various tumor localizations. They examine patients' attitudes toward their illness, the psychological defenses and coping strategies used by patients in adapting to the situation of illness, and other psychological problems in oncology. Psychological research forms the basis for the psychological care that cancer patients need, and its findings are also used in educational programs for oncologists, medical psychologists, and nurses.
At the same time, it must be taken into account that in conducting psychological research the medical psychologist enters the patient's inner world, and this in itself may give rise to a great deal of negative experiences in the patient.
While acknowledging the importance of psychological research in oncology, attention should be paid to the ethical aspect of conducting it:
Psychological research in oncology should not be conducted for the sake of research, for the sake of obtaining results. It must always have scientific justification that can subsequently bring practical benefit to patients.
Research must be conducted under specific conditions, the most important of which is psychological safety for the patient.
The patient must be informed of the purpose of the study and of what specifically will be examined.
The patient must give voluntary consent to participate in the psychological study.
The principle of confidentiality must be observed: the results of a particular patient's study must not be disclosed without their permission. Information about the patient obtained as a result of the study and cited as an example in scientific articles, etc., must not contain personal data.
The patient has the right to receive information about the results of the study in a form that is accessible and understandable to them.
In conducting the study and interpreting the results, respect for the patient must be maintained.
(based on the work of Shipovnikov N.B.)
Pestereva E.V.
To this day, unfortunately, in the majority of patients with malignant neoplasms of the gastrointestinal tract, removal of the tumor focus is achieved through mutilating surgery and other aggressive treatment methods, which lead to functional impairments and emotional disorders. Adaptation to the new aspects of altered functioning (a forced abrupt change in habitual dietary patterns, a strict diet, the need to carefully monitor physiological functions) is accompanied by profound distress in the patient and fear of losing the value of one's "self" in the eyes of others, including family members. All of this makes the study of the personality
characteristics of patients with this pathology an extremely relevant issue.
A total of 250 patients (mean age 57+1.2) undergoing treatment in the gastrointestinal tumor department of the N.N. Petrov Research Institute of Oncology were examined, of whom 67 had gastric cancer and 183 had rectal cancer. The patients were studied on admission to the oncology inpatient unit, before surgery, and on discharge from the department.
Using the clinical-psychological method (observation, clinical interview), the content of the patients' experiences was studied and the degree of the patient's psychological compensation was determined, which meant an assessment of the level of their psychological adaptation to the disease through the psychological resources of the personality (appendix 4).
The experimental-psychological method included the Spielberger-Khanin test for studying patient anxiety (state and trait anxiety) and the Minnesota Multiphasic Personality Inventory (MMPI), which determines the personality profile across ten basic scales that allow the patient's personality characteristics to be judged and their state to be assessed [1, 3] (appendix 5).
The clinical-psychological interview showed that most patients suffering from gastric and rectal cancer noted that the diagnostic stage was for them, although brief, "the most difficult period." The initial reaction upon being informed of the diagnosis and the need for surgery, in the form of anxiety, predominated in 56.4% of patients, and it was more pronounced in patients with gastric cancer. A focus on the social and everyday consequences of the disease, due to the restructuring of the dietary regimen, was noted in 23.9% of patients suffering from gastric cancer. The greatest concern of patients with rectal cancer was associated with fear about the outcome of the operation - 47.6%; they also had the highest percentage of fear of death - 4.8%.
Whereas patients with gastric cancer often, in the period preceding the onset of the oncological process, experience discomfort and various digestion-related ailments, patients with rectal cancer, as a rule, are characterized by normal well-being with moderate complaints. In this respect, patients with gastric cancer are in a psychological sense more prepared for the disease, while patients suffering from rectal cancer unexpectedly face the need to undergo surgery and subsequent chemoradiation treatment. One can speak of the suddenness and acute onset of the disease in patients with rectal cancer. The results of the clinical-psychological interview with rectal cancer patients showed that the better the patient's well-being before admission to the hospital, the more difficult the period of adaptation was for them, initially in accepting the need for abdominoperineal extirpation, and in the postoperative period - in existence with an artificial anus.
It was found that 67.2% of the examined patients, despite clear signs of the onset of the disease process, did not consult a doctor for an interval ranging from 2-3 months to 1 year. First among the reasons for the delay in consulting a doctor was the fear of "learning the worst," which accounted for 30% of the entire sample. Next in order of significance were the following arguments: insignificance of symptoms - 21.6% ("did not pay attention, although I noticed it; did not attach importance to it - thought it was a trifle, nonsense"), neglect of one's health - 17.2% of patients.
At the diagnostic stage, 39.6% of all patients were convinced of the "benign" nature of the tumor. A study of attitudes toward the diagnosis at subsequent stages of treatment showed that 28.8% of patients steadfastly believed in the benign nature of the tumor. The maximum denial of the disease was established in patients with gastric cancer (38.8%). Rather than denying it, 16.4% of all patients ignored the seriousness of the disease. Patients in this subgroup did not consider the disease especially serious and ignored clear evidence of the
true nature of the pathology - radiation treatment and courses of chemotherapy. The malignant nature of the disease was partially acknowledged by 26.8% of patients: they were characterized by a distancing from the real situation, and they often demonstrated their own version of the disease. An indefinite attitude toward the disease was found in 23.3% of patients: on the one hand, they expressed an unwillingness to receive medical information, but at the same time they would have liked to learn "their histology" and the results of laboratory tests through informal means; on the other hand, they feared their worst apprehensions. Only 4.8% of all patients had a realistic attitude toward the diagnosis: they acknowledged the malignant nature of their disease.
The clinical-psychological interview showed that 48.8% of patients did not associate the appearance of their oncological disease with anything. Others most often named as the cause of the disease themselves - 17.2%, unfavorable living conditions and circumstances - 13.2%, their social environment, i.e., other people - 10.8%.
The question of stressful, dramatic events during the 2-3 years preceding the appearance of the disease symptoms was examined. The maximum rate of distressing events was established in patients with gastric cancer - 32.8%, compared with rectal cancer - 13.7%.
A benevolent attitude during the clinical-psychological interview predominated in 46.4% of patients, and a further 8.0% of patients expressed a desire to continue communicating with the psychologist. The highest percentage of a benevolent attitude was found in patients with rectal cancer with a pull-through procedure - 56.4%. A concealed negative attitude, sometimes with suspicion and distrust, was noted in 22.4% of patients with gastric cancer and in 19% of patients with rectal cancer with a pull-through procedure. On the whole, patients with gastric cancer were characterized by conflict, manifestations of a neutral tone, and distant behavior (p<0.05). Patients with a negative attitude toward the clinical-psychological interview often
regarded psychological topics as "having nothing to do with the matter." Even in communication with the doctor, including during the period of preoperative preparation, they tended to mask psychological problems with somatic complaints: the patient spoke only of the somatic manifestations of the disease, without touching on the sphere of experiences and emotions; their speech was monotonous and little intoned. At times, only in the course of a long, in-depth conversation would the patient with difficulty acknowledge the psychological subtext of their complaints and doubts. The patient's inability to voice their experiences related to the disease and treatment contributed to an increase in their psychoemotional tension and also worsened the coordination of the joint efforts of the doctor and patient in the treatment process. At the same time, the patient's participation in the treatment process, the absence of negative components in psychological contact with the doctor, and the absence of strained relations make it possible to lay the foundations of psychological stability, equilibrium, and psychological compensation.
An analysis of the referrals made by attending physicians to the psychologist for the purpose of providing professional psychological care to patients suffering from malignant neoplasms of the gastrointestinal tract showed that the most frequent reason for referral was the patient's anxious reaction to surgery, up to and including refusal of the operation. The study showed that patients with malignant neoplasms of the gastrointestinal tract who were inclined to refuse surgery were distinguished by a peculiar orientation during the diagnostic period, manifesting itself in an anxious expectation that "everything will be clarified and turn out to be a mistake." Initially, the psychological reaction of refusal was accompanied by pronounced affective components - an inability to control emotions, chaotic behavior. After some time, the intensity of these manifestations decreased, but no restructuring occurred with respect to accepting the fact of the disease and the need to undergo surgery; on the contrary, there was an intensification of the desire to
flee from the situation, the urge to leave everything as it was, and even vexation with oneself for having consulted an oncologist. From this moment began the search for the most suitable motive, from the patient's point of view, to justify the potentially preprogrammed refusal. Patients cited the following reasons for refusing surgery: the conviction that cancer is incurable ("and therefore there is no point in being treated") and that the outcome is predetermined ("the end is the same for everyone, death will come even if one is operated on"); the mutilating nature of the operation;
the presence, even before the disease, of "oncological wariness" as a result of the psychologically traumatic experience of interacting with relatives who died of an oncological disease; reasons of an objective nature (vacation, business trip, etc.).
The psychological disposition toward surgery was determined according to three conventional gradations: positive, forced, unstable. The highest positive disposition was noted in patients with rectal cancer who were to undergo surgery with subsequent pull-through. In 46.7% of patients with rectal cancer with a colostomy, a forced attitude toward the operation was noted, which is explained by the traumatic effect of the anticipated postoperative defect in the form of an unnatural anus.
An emotional, empathic attitude on the part of family members was noted by 55.2% of all patients. A formal nature of relationships within the family was most typical of patients with gastric cancer - 38.8%; negative relationships were observed in 8.6% of patients with rectal cancer with a colostomy, and were due to a psychological barrier in the face of the functional defect.
Psychological adaptation to the disease and its consequences could not be considered complete by the time the patient was discharged from the hospital. The spectrum of social-psychological difficulties permeated the patient's entire existence, especially during the first 3-6 months up to a year, the content of which was: a decrease in interest in life, a reaction of withdrawal
into illness, difficulties in relationships within the family and the work collective, a reaction to the occurrence of disease recurrence. Patients complained of pain, to a greater degree psychalgia, of poor sleep, appetite, decreased tone, an inability to concentrate, weakened memory, and rapid fatigability. When these complaints were pronounced, in 16% of patients they could be regarded as a manifestation of an anxious-depressive state. Emotional disturbances in 73% of patients were expressed in the form of unstable and lowered mood, anxiety, and fears. Emotional disturbances were often a consequence of conflict in the patients' significant relationships. Such complaints of patients as fear of transport, of leaving home without accompanying persons, and of appearing in public had a clear psychological subtext of the fear of not coping with oneself, of "breaking down" in public. These manifestations of fear could become entrenched as such psychopathological disturbances as a sense of inferiority, a feeling of being abandoned and isolated. A significant degree of the described deviations was noted in 28% of patients.
At the time of the patient's discharge from the hospital, on the basis of the clinical-psychological study (taking into account the opinion of the attending physician), their final state was determined - the degree of psychological compensation, which meant an assessment of the level of the patient's psychological adaptation to the disease and the consequences of its treatment through the psychological resources of the personality. The most important difference between patients in terms of the level of psychological compensation was the success in developing certain compensatory mechanisms, the realization of the ability to process stressful information about the disease, reflected both in emotional-mental stability and in the patient's behavior. The distribution of patients with malignant involvement of the gastrointestinal tract was as follows: compensated patients - 25.6% (64 persons), partially compensated - 38.0% (95 persons), decompensated - 36.4% (91 persons). The group of patients
with rectal cancer with a colostomy had the highest percentage of decompensated patients - 38.4% and the lowest among compensated patients - 19%, which reflects the significant difficulties of adaptation of these patients.
In the group of decompensated patients, a delay in consulting a doctor after the appearance of the first painful symptoms was observed in 73.6%, whereas at a satisfactory level of psychological compensation - in 46.9% of patients (p<0.001). Among the motives for postponing consultation with a doctor, the greatest difference is traced by the factor "fears and apprehensions," including the presence of a fear of illnesses in the past (<0.001). People who had experienced pronounced apprehensions about serious illnesses in the anamnestic period reacted to the news of their oncological disease with a more intense reaction.
It was found that in 73.6% of patients of the decompensated group, negativism toward the psychological examination was maximally pronounced, which significantly exceeds the analogous indicator of compensated patients - 15.7% (p<0.001), allowing one to judge the qualitative difference in the psychological contact of these two groups. The group with an unsatisfactory level of psychological compensation was also characterized by the highest indicators of anxious and depressive mood (27.5% and 57.1% respectively, p<0.001).
An interrelation was found between the level of a patient's psychological compensation and their attitude toward treatment procedures: as the level of psychological compensation decreases, the forced disposition changes from 12.5% to 45.1%, and the intensity of an unstable attitude - from 6.3% to 52.7% in decompensated patients (p<0.001).
Consideration of the attitude toward psychological support showed that all patients with successful compensation had it, whereas in the group of decompensated patients such an attitude was absent in 47.2% of cases, which significantly weakens the potential of psychological resources. The family
relationships of compensated patients were defined by emotional support - sympathy, encouragement, and participation - 75%, while in the group of decompensated patients it was expressed in only 31.9% (p<0.001). The percentage of deterioration of the family climate was significantly higher in the group of patients with unsatisfactory psychological compensation (p<0.001).
Patients assessed the change in their own character since the onset of the disease as follows: 72.4% of patients indicated the invariability of their character traits, and in 12.8% - their character worsened. The highest indicators of character-trait dynamics were in the group of patients with gastric cancer - it improved in 19.4% and worsened in 20.9%. A tendency was noted toward a decrease in the number of positive responses and an increase in the percentage of negative ones as psychological compensation worsened (p<0.001). Thus, in the responses of patients who indicated an improvement in character, an explanation followed that things of secondary importance in life had lost their meaning, and that they themselves had begun to see everything more clearly, to value time and life. When noting negative changes in character, patients indicated that "life had stopped for them, had lost all meaning, and their state was such that they no longer wanted anything." Sometimes they stated directly that they had "become much worse than before."
174 patients (mean age 57+1.2) with gastric cancer and rectal cancer participated in the experimental-psychological study. All patients underwent surgery: patients with gastric cancer - extirpation and subtotal resection (38 persons), patients with rectal cancer - surgery with pull-through (sphincter-preserving) (62 persons) and surgery with the creation of a colostomy (74 persons). According to the degree of psychological compensation, patients were divided into three groups. The compensated group included 49 patients, of whom 12 had gastric cancer, 18 had rectal cancer with pull-through, and 19 had rectal cancer with a colostomy. The partially compensated group of patients included 63 patients, of whom 13 had gastric cancer, 22 had rectal cancer with pull-through, and 28 had rectal
cancer with a colostomy. The decompensated group included 62 patients, of whom 13 had gastric cancer, 22 had rectal cancer with pull-through, and 27 had rectal cancer with a colostomy.
Assessment of the state of anxiety (the Spielberger-Khanin method) revealed that the trait anxiety indicators of patients at various stages of examination lie within the zone of moderate anxiety (below 45 points). The exception was patients with rectal cancer with a colostomy, who had, on average, high anxiety.
The dynamics of state anxiety at various stages of the disease changed as follows: at the admission stage, all patients showed high anxiety (48.9 points); this indicator tended to increase at the stage before surgery (p<0.001). By the time of the patients' discharge from the hospital, the anxiety indicators decreased and anxiety shifted from the high category to the moderate one (p<0.001), except in patients with rectal cancer with a colostomy, where it remained high (more than 45.1 points).
An interrelation was revealed between anxiety indicators and the degree of a patient's psychological compensation. Thus, decompensated patients already on admission had a high level of trait and state anxiety (48.1 points and 52.8 points, respectively), which remained at this level even at discharge, in contrast to the group of compensated patients, where the indicator was high only before surgery (47.8 points, p<0.001). The most intense anxiety, affecting the personality as a whole, was experienced by patients with rectal cancer with a colostomy of the decompensated group (p<0.001). Thus, the intensity of a patient's anxious reaction depends on the stage of treatment and the success of psychological compensation.
Correlation analysis showed an interrelation between the level of anxiety and the quality of contact with the patient: an increase in anxiety affects trust, the loss of emotional contact, up to the point of withdrawal (K=-0.26).
The study using the personality profile of patients (MMPI) indicated the absence of a specific personality pattern in patients both in gastric cancer and in rectal cancer. The indicators of all scales of the personality inventory corresponded to normative values, except for the depression scale (D) or the tendency toward lowered mood (71.2+0.7). Next in magnitude was the indicator of the hypochondriasis scale (Hs)/neurotic overcontrol (65.0+0.7). The dominance of these scales is characteristic of patients in a general somatic clinic - with lowered mood and complaints about health in connection with malaise. The interpretation of the ratios of all scales of the profile testified that patients suffering from malignant tumors of the gastrointestinal tract are characterized by a tendency to avoid candor, a passive-contemplative stance, avoidance of failure, caution and indecisiveness in personally significant situations, sensitivity to external influences, intrapunitiveness, an orientation toward distant goals and avoidance of conflict; an analytical, inert type of thinking, a possible type of maladaptation - depressive, accompanied by neuroticization.
A study of the interrelation between the indicators of the personality inventory scales and the degree of a patient's psychological compensation found that the indicators on the hysteria, depression, hypochondriasis, psychasthenia, and schizophrenia scales increase (p<0.001) as psychological compensation decreases.
Thus, the success of psychological compensation is affected by a symptom complex that finds its expression in the indicators of the scales of "neurotic overcontrol" (hypochondriasis), lowered mood (depression), fixation of anxiety and restrictive behavior (psychasthenia), as well as the repression of factors causing anxiety (hysteria), and autization (schizophrenia). A third of patients with gastric and rectal cancer, at the time of discharge from the hospital after undergoing treatment,
find themselves in a psychologically decompensated state and are in need of professional psychological help.
Chulkova V.A.
Breast cancer (BC) is a socially significant disease, still leading in the structure of morbidity and mortality worldwide. Despite progress in the drug treatment of BC, surgery remains the main method of treatment. Therefore, for a woman who has fallen ill, a diagnosis of breast cancer carries a threat of psychological trauma. This is due not only to fear of the disease, the emergence of a threat to life, and the collapse of life plans, but also to the need to undergo mutilating surgery. Often a shift of emphasis occurs: the fear of losing femininity and of changes in relationships with other people acquires paramount importance for the patients. As a result, BC is accompanied by excessive emotional tension in the patients, leading to various psychological and neuropsychiatric disorders. The social-psychological adaptation of the woman who has fallen ill is disrupted and, as a consequence, frequent neuroticization of BC patients is noted. With the currently increasing life expectancy of BC patients, the absence of psychological care lowers their quality of life and hinders the achievement of a more
complete effect of treatment. A peculiar paradox arises: on the one hand, enormous material expenditures and the efforts of oncologists are directed at curing the patient, while on the other hand, an underestimation of the patient's personality and of her attitude toward the disease and treatment leads to a situation in which the superstress caused by the disease becomes insurmountable.
To identify the personality characteristics of BC patients and establish their relationship with the level and features of psychological compensation, 183 patients were studied who were initially admitted to the breast tumor department of the N.N. Petrov Research Institute of Oncology. The patients' age ranged from 26 to 74 years (mean age - 50.3±0.8 years). In 53.0% of patients, metastases were detected during treatment. 94.5% of patients underwent various types of breast surgery, radiation treatment was administered to 66.7% of patients, chemotherapy was applied in 82.0% of patients, and hormonal treatment was received by 20.2% of patients.
The study was conducted dynamically in accordance with the process of diagnosis and treatment: on admission to the department, before surgery, after surgery, and before discharge.
Clinical-psychological and experimental-psychological methods of study were used. The clinical-psychological method consisted of an unstructured interview on questions grouped into five main themes: discovery of the disease, attitude toward the disease and its causes in the patient's opinion, attitude toward treatment (including attitude toward surgery), social questions, and attitude toward the future (appendix 4). With the experimental-psychological method of study, the following psychological techniques were used: the Minnesota Multiphasic Personality Inventory (MMPI) [1, 2, 5], the Rosenzweig frustration tolerance study technique, the type of attitude toward the disease (TAD), the Spielberger scale of trait and state anxiety in Khanin's modification, and the Dembo-Rubinstein self-assessment technique (appendix 5).
The clinical-psychological study made it possible to examine the personal reaction of BC patients to the disease. More than half of the patients had experience of distress regarding BC associated with the illness of other people. This experience of distress (negative or positive) influenced the notion, formed even before the illness, of the prospects of BC patients, which was based on information obtained from a wide variety of sources. Only 7.1% of patients knew that BC can be cured, while the notion of the majority - 58.5% - regarding the prospects of BC patients was indefinite.
The reason for consulting a doctor was fear of an oncological disease, which was experienced by 81.4% of patients. However, a strong feeling of fear prevented 14.2% of patients from seeking medical help immediately after discovering the symptoms of the disease: they consulted doctors 6 or more months later. After the first visit to the oncologist, strong negative feelings of varying degrees of intensity, from fear and despair to anxiety and worry, arose in 86.3% of patients.
The cause of the disease for 26.8% of patients was, in their opinion, excessive nervous tension over the course of their life, for 21.3% of patients - physical trauma, for others - heredity, hormonal disturbances, or the loss of a loved one, but 27.3% of patients could not surmise what had caused the disease.
16.9% of patients believed that their disease was malignant; for the larger part of patients - 44.3% - a partial acknowledgment of the malignant nature of the disease was characteristic, 14.2% of patients denied that they had cancer, and 24.6% had an indefinite attitude toward the diagnosis. At the same time, 73.2% of patients did not ask the doctors about their disease, because they were afraid to hear something unpleasant ("I don't want either to talk or to think about the disease"; "to ask the doctor is only to get upset"; "it's better not to talk about the illness: it becomes frightening").
Trust in the doctor and a positive attitude toward the chosen method of treatment were demonstrated by 44.8% of patients, while 10.9% were passive, apathetic, and had a negative attitude toward all methods of treatment; an unstable attitude toward treatment, characterized by ambivalence of mood and behavior, was characteristic of 44.3% of patients. With respect to surgery (mastectomy), the patients were divided into three groups: 55.8% of patients accepted its necessity and it was precisely with it that they associated their recovery; whereas in 11% of patients the necessity of surgery provoked violent protest: some refused it, others had a negative attitude toward the operation after it was performed; 32.2% of patients could not come to terms with the necessity of surgery and agreed to it only under the pressure of circumstances. At the same time, fear of the consequences of the mutilating operation was experienced, with few exceptions, by practically all patients.
The main motive - the striving for recovery - acquired value for the patients in connection with the setting of specific life goals. This was most vividly manifested in women who had small or underage children. An active desire to adapt to the new life situation, taking into account the disease and its consequences, including possible difficulties in the family and at work, was characteristic of 30.1% of patients. 12.5% of patients believed that because of the disease their life had lost its meaning. For 57.4% of patients, the future was represented as a mass of unsolvable problems.
An analysis of the results of the clinical-psychological study of BC patients showed that, despite the seemingly identical psychological trauma that BC disease represents, the patients had different degrees of psychological compensation, which we defined as a system of psychological techniques that help the personality adapt to the superstress caused by an oncological disease. The definition of psychological compensation was based on six types of the patient's personal attitudes: attitude toward the diagnosis, attitude toward
treatment, attitude toward surgery, attitude toward the curability of the disease, relationships with loved ones, attitude toward the future.
Criteria were developed and three groups of BC were identified with varying degrees of psychological compensation:
Group I - compensated patients - 31.2%,
Group II - partially compensated - 50.8% (subsequently divided into two further subgroups: partially compensated II-A - 25.7% and II-
B - 25.1%),
Group III - decompensated patients - 18.0%.
An interrelation was revealed between the level of psychological
compensation and the features of personal reaction to the disease and treatment of BC. Thus, compensated patients (group I) significantly more often (p<0.05) than patients of other groups believed that timely medical care would contribute to curing the disease; emotional reactions upon discovering the disease and during treatment were more pronounced in less compensated patients (groups II-B and III) than in more compensated patients (groups I and II-A) (p<0.05); less compensated patients more often than others considered nervous tension over the course of life to be the cause of the disease (p<0.05); the notion of the disease in compensated patients (group I) and partially compensated patients (group II-A) was more distinct than in partially compensated patients (group II-B) and decompensated patients (group III) (p<0.05); it was more difficult for less compensated patients (groups II-B and III) to inform other people about their disease (p<0.05); more compensated patients (groups I and II-A) more often expressed confidence in their being needed both in the family and at work (p<0.05).
An analysis of the data obtained using the MMPI revealed that the dominant tendency characteristic of BC patients is not depression, but anxiety, accompanied by a depressive component. It was possible to distinguish four variants of profiles reflecting the personal tendencies
of BC patients. The name of each variant was determined on the basis of the dominant scale or scales in the profile code: depressive (D), affectively rigid (Pa in one of the first three positions), maladaptive (Sc, Pt, D, Pd), and hysterical tendencies (Hy). In studying the frequency of manifestation of various personal tendencies depending on the degree of psychological compensation, the following pattern was revealed: as the degree of psychological compensation decreases, the frequency of affectively rigid tendencies changes: the greatest frequency in group I (41.7%
±7.1%), then it continuously decreases and becomes the lowest in group III (21.8%±7.3%). The frequency of maladaptive tendencies has the opposite dependence on the degree of psychological compensation: in group I - 8.3%±4.0% - it is the lowest, and, continuously increasing, this tendency becomes the greatest in group III - 34.4%±8.4%. For depressive and hysterical tendencies, no regular statistically significant change in their frequency depending on the degree of psychological compensation was revealed. A greater magnitude of the anxiety index was found in the group of patients with less psychological compensation
(p<0.05).
According to the Rosenzweig technique, an interrelation was found between the degree of psychological compensation and the type of reaction to frustration. At the same time, no such interrelation with the direction of frustration reactions was established. In analyzing the type of reaction, it was determined that the groups with greater psychological compensation (I
and II-A groups) are characterized by a greater frequency of the persistent type (N-P) of reaction and, at the same time, a lower frequency of the obstacle-dominant type (O-D) compared with the group of less compensated patients (II-B
and III groups). No differences were revealed in the frequency of the self-defensive type of reaction (E-D). On the whole, patients with greater psychological compensation are characterized by an orientation toward overcoming frustrating circumstances and overcoming the blocking of needs, while less
compensated patients are characterized by an emotional fixation on the obstacle with a decrease in attempts to overcome it, that is, in less compensated patients a pronounced reaction is possible to such frustrating situations as are usually perceived by others as insignificant. The difference in the coefficient of social adaptation (GCR) between compensated (60.5±1.6) and decompensated (50.3±2.3) patients testifies that more compensated patients are better adapted in their social environment than decompensated ones.
A study of the attitude toward the disease using the "Type of Attitude Toward the Disease" (TAD) questionnaire showed that the most frequently encountered types in the group of BC patients are the ergopathic (25.1±2.5 points), sensitive (22.1±1.6 points), and anxious-depressive types of attitude toward the disease (17.3±1.6 points). The results of comparing the scale scores of the TAD technique between patients with greater (I and II-A groups) and lesser (II-B and III groups) psychological compensation reveal significant differences on the scale of the anxious-depressive and neurasthenic types of attitude toward the disease. Less compensated patients are characterized by a significantly pronounced anxiety and worry in connection with the disease, irritation, especially with pain and suffering, an intolerance of the slightest painful sensations, and an inability to wait for relief. With greater psychological compensation, the indicators of the scales of the harmonic, anosognosic, and ergopathic types of attitude toward the disease are higher. As the degree of patients' psychological compensation decreases from group to group, a decrease in the frequency of the ergopathic type is observed with a simultaneous increase in the sensitive and anxious-depressive types of attitude toward the disease.
In studying the dynamics of the psychological state of breast cancer patients in the hospital, it was found that for each stage of treatment in the hospital there exist characteristic problems experienced by patients
with breast cancer. During treatment in the hospital, patients experienced pronounced emotional tension, the indicators of which were high levels of trait (RX2) and state (RX1) anxiety and lowered self-assessment. Moreover, the most difficult in terms of the intensity of experiences was the stage of admission to the hospital (RX2 - 51.3±0.8 points; RX1 - 57.6±0.9); by discharge, the levels of trait (RX2 - 49.3±0.8) and
state (RX1 - 49.6±0.9) anxiety decreased (in the group of compensated patients to a moderate level RX2 - 43.6±1.1 points; RX1 - 42.7±1.1), and self-assessment increased in the "health" category in all groups, and in the "happiness" category - in compensated and partially compensated patients (p<0.05).
Thus, the personal reactions to the disease in BC patients differ according to the degree of psychological compensation. In this regard, the group of partially compensated patients deserves the special attention of the medical psychologist, since psychological care for the patients of precisely this group - the largest in number - creates for them the opportunity to overcome the psychological consequences of the disease.
With the aim of studying the attitude of BC patients toward chemotherapy and determining the emotional state of patients depending on its duration, a psychological study was conducted of patients undergoing treatment at the N.N. Petrov Research Institute of Oncology [10]. 45 patients aged 30 to 70 years were studied; all patients had had surgery (mastectomy) before chemotherapy. Depending on the duration of the chemotherapy courses, the patients were divided into three groups:
Group I (15 persons) - patients receiving their first course of chemotherapy during treatment in the hospital;
Group II (14 persons) - patients undergoing their second, third, or fourth course of chemotherapy on an outpatient basis;
Group III (16 persons) - patients completing chemotherapy: their fifth or sixth course on an outpatient basis.
The study used a clinical interview in the form of an unstructured interview (appendix 4) and psychological tests aimed at studying the levels of trait and state anxiety (the Spielberger-Khanin test), the differential diagnosis of depressive states (the W. Zung test adapted by T. Balashova at the V.M. Bekhterev St. Petersburg Research Psychoneurological Institute), and self-assessment (the Dembo-Rubinstein test) (appendix 5). The study was supplemented by observations of the patients' behavior during the interview and the performance of the tests.
Patients spoke about chemotherapy in the following ways: "It was frightening to begin," "I experience severe pain," "I want to turn to face the wall and see no one." Two women out of all of them said that after chemotherapy "you lie like a corpse" (at the time of examination they were in their fifth course of chemotherapy). The complications accompanying chemotherapy were expressed in weakness, nausea, loss of appetite (in some, on the contrary, increased appetite), tearfulness, sweating, trembling, chills, a heightened sense of smell, apathy, and lowered mood. Many women, when filling out the test scales, reacted emotionally to some of the proposed statements. The interview after the completion of the self-assessment test revealed in the majority a skeptical attitude toward their health and happiness: "My health is over," "I feel sorry for myself all the time, I am afraid," "Is this really happiness?", "What happiness can I speak of?".
The results of the conducted study showed that there is a directly proportional relationship between the duration of chemotherapy and an increase in the levels of state and trait anxiety and depression for groups I and II (p<0.05) and for groups I and III (p<0.05). In group III, the indicators of state and trait anxiety reach a high level, and the depression indicator rises above the norm. Self-assessment in the "health" and "happiness" categories is below normal in all groups, and it is the lowest in patients of group III. By the 5th-6th courses of chemotherapy, absolutely all patients know their diagnosis, and they are characterized by a positive-neutral
notion of chemotherapy, and a significant portion of them believe that chemotherapy will help in treatment. Along with this, as the number of chemotherapy courses increases, the number of patients experiencing fear of it grows, and the number of patients who tolerate chemotherapy poorly and for whom it turned out to be harder than they had anticipated increases. This may be explained by the general fatigue from treatment with chemotherapeutic drugs and from the accompanying complications, which exhaust and wear down to such an extent that some patients are ready to insist on stopping the chemotherapy courses before the prescribed time. In this state, patients most of all need the emotional support of those around them and especially of the chemotherapist. Many during the study complained of the absence of stable contact with the doctor, while those who had such contact emphasized its significance for them. As the number of chemotherapy courses increases, the number of patients who believe that they have not been prepared by the doctor for undergoing chemotherapy increases significantly. This circumstance is evidence that patients are not informed about the treatment to the extent that they would like to be informed, on the one hand, and, on the other, indicates that they are in need of the doctor's emotional support. One may put forward the assumption that with psychological preparation of the patient for undergoing chemotherapy, the fear of it may possibly decrease, and perhaps the subjective tolerability of the drugs will be better.
Thus, the conducted psychological studies of BC patients testify to the psychological traumatization of the women who have fallen ill and to the necessity of providing them with psychological care both by the oncologist and by the medical psychologist.
Pestereva E.V.
Malignant lymphomas (Hodgkin lymphoma and non-Hodgkin lymphomas) belong to the category of systemic lymphoproliferative diseases. Hodgkin lymphoma (HL) is one of the most curable malignant processes. The use of modern chemoradiotherapy makes it possible to cure up to 80-95% of patients with HL; nevertheless, in some patients a primary-refractory course of the disease is noted. Therefore, for such patients the timely identification of factors of unfavorable prognosis is extremely relevant, with the aim of early intensification of HL treatment and timely administration of high-dose chemotherapy with autologous hematopoietic stem cell transplantation. Among patients with non-Hodgkin lymphomas (NHL), distinguished by a high degree of malignancy, complete regression of the disease after standard chemotherapy is possible in only 40-60% of patients. In the rest, primary resistance of the lymphoma to chemotherapy and/or recurrence of the disease inevitably develops. Despite all of the above, malignant lymphomas, with adequate and timely treatment, have a favorable prognosis, but the changes at the psychophysiological and emotional levels that this disease causes may persist for many years after the end of treatment. All of this points to the psychological traumatization of patients with malignant lymphomas.
If oncological diseases with a clear localization - breast cancer, gastric cancer, lung cancer, etc. - are perceived both by the patients themselves and by those around them as "serious illnesses," then the absence of a specific localization in lymphoproliferative diseases creates a notion of them as some kind of "incomprehensible illness." At the same time,
society's lack of awareness of lymphoproliferative diseases, which in the initial stages of the illness are often masked as the ailments that visit people in everyday life, also affects the untimely consultation with a doctor. In addition, malignant lymphomas often affect people of young age, during the period of establishing personal and professional status and developing family relationships, and of mature age, during the period of active working life: the situation associated with the disease and the need for long-term treatment frustrates the patients' current needs.
The study was conducted at the Russian Scientific Center of Radiology and Surgical Technologies (RSCRST). 138 patients with malignant lymphomas (Hodgkin lymphoma - 77 patients, non-Hodgkin lymphoma - 61 patients) aged 18 to 55 years were examined at different stages of the course of the disease: 41 persons - before the start of chemoradiation treatment, 42 persons - during primary treatment, 36 persons - during treatment of recurrence, 19 persons - in a state of remission. The majority of patients had stage II-III of the disease. In accordance with the International Prognostic Index (IPI), patients with HL were assigned to the favorable and intermediate-favorable prognostic groups, and in NHL - to the low-intermediate and intermediate-high risk groups.
Using the clinical-psychological method (observation, clinical interview), the content of the patients' experiences was studied (appendix 4). The experimental-psychological method was aimed at studying the features of the patients' reaction to the disease (TABOL), analyzing complaints of the neurotic register in this category of patients (NDQ-SI), as well as investigating the mechanisms of coping behavior - the patient's internality in the sphere of health (LOC) and the leading coping strategies at the cognitive, emotional, and behavioral levels (appendix 5).
One of the key aspects of the attitude toward the disease in an oncological illness is the patient's opinion about the malignant nature of the disease. At the stages before treatment and during primary treatment, patients with malignant lymphomas were characterized by denial (14.6% and 9.5%, respectively) and partial acknowledgment of the malignant nature of the disease (46.3% and 45.2%, respectively). In denying the malignant nature of the pathological process, the patient did not deny the very fact of the disease (they underwent treatment), but it was perceived by them as an ordinary, non-life-threatening illness. In partially acknowledging the diagnosis, the patient simultaneously both acknowledged and denied the malignant nature of the disease, which was expressed in the ambivalence of mood and behavior. If, in denying the diagnosis, patients are dominated by the unconscious psychological defense of denial, then in partially accepting the disease the patient is characterized by rationalization, which manifested itself in their emphasizing the "peculiarity" of their disease. In this case, "peculiarity" sounded like a certain exceptionality of the patient (they are not like everyone else) and a hope for a favorable outcome ("I read that this is a rare disease, mainly affecting socially well-off people...", "I require treatment, but my situation in connection with the disease differs substantially from the patients in the neighboring department..."). In recurrence of the disease, partial acknowledgment of the malignant nature of the disease was encountered less frequently: 75% of patients acknowledged the malignant nature of the disease.
Reflections on the disease, on its role and place in a person's life, were often so traumatic for patients that, as a defense, a striving arose to repress thoughts associated with the disease. Thus, 61% of patients before the start of treatment and 50% of patients during primary treatment believed that it was "harmful to dwell" on the question "Why did this happen to me?". From stage to stage, more and more patients found a cause of the disease for themselves (59% - during treatment of recurrence, 63.2% - in a state of remission) - the loss of a loved one, nervous tension, overwork,
harmful work, ultraviolet radiation, and other, at times irrational, causes.
In the majority of patients of all groups (70.7%; 73.9%; 50%; 84.2%), the motive of recovery contained specific life goals (starting a family, raising children, obtaining an education, fulfillment in the professional sphere). During treatment of recurrence, "the fear of becoming helpless" was the meaning of recovery significantly more often than during primary treatment (p<0.02).
On the basis of their notions about the disease, patients formed an attitude toward treatment: before the start of treatment and during primary treatment, patients were dominated by a fear regarding polychemoradiation therapy in the form of apprehensions about changes in appearance and the occurrence of side complications as a result of treatment. Before the start of treatment, 53.7% of patients were frightened by the helplessness that could arise in connection with treatment, which points to the state of uncertainty, insecurity, and anxiety experienced by them. As the duration of treatment increased, patients more often noted that they were "ready to endure any hardships of treatment, the main thing is to be treated," "if they are treating me, it means there is hope for recovery." Readiness to endure any difficulties of treatment in order to get better was most characteristic of patients during treatment of recurrence (p<0.02). It should be noted that the fear associated with treatment was often suppressed by patients, while they demonstrated an "optimistic" attitude toward treatment ("Everything will be fine"). This attitude played a protective function and reflected a desire "not to think about the bad." Such an "optimistic" attitude toward treatment was observed during primary treatment in 64.3% of cases, and during treatment of recurrence in only 38.9% of cases (p<0.05). Both during primary treatment and during treatment of recurrence there were patients with a "pessimistic" attitude toward treatment: "This is an illness where it is difficult for a person to do anything themselves, and it is best to submit to the doctor." Patients with an unstable attitude toward treatment were also identified (33.3% - during primary treatment; 50% - during treatment of recurrence), who could develop an adequate
attitude toward treatment provided there was competent and accessible information for them and timely professional psychological care.
The results of the study of the types of attitude toward the disease (TABOL) showed that the intensity of the various components of the attitude toward the disease did not depend on the diagnosis (HL and NHL). At all stages of the disease, the most pronounced components in the structure of the attitude toward the disease were the ergopathic, anosognosic, and sensitive ones; however, their ratio to each other and to the other components changed, as did their content.
Patients' underestimation of the seriousness of the disease and of its malignant nature at the stages before the start of treatment and during primary treatment manifested itself in conditionally adaptive forms of reaction to the disease (65.8%, 64.3%, respectively) with a predominance of the ergopathic, anosognosic, and ergopathic-anosognosic types.
During treatment of recurrence, an attitude toward the disease without signs of social-psychological adaptation was revealed in 41.7% of patients: along with the ergopathic and anosognosic, the harmonic type of attitude predominated. At the same time, observations showed that most patients with a harmonic attitude are characterized by a position of "defensive" optimism, in which the patient, avoiding strong experiences, builds their behavior in accordance with social norms, not allowing themselves emotional outbursts, thereby being a "convenient," "good" patient for the doctor and for loved ones.
At the remission stage, conditionally adaptive forms of reaction to the disease predominated (68.3%) with a dominance of the anosognosic and ergopathic-anosognosic types. At the same time, the anosognosic component in the structure of the attitude toward the disease in patients in remission meant not so much a denial of the disease as such, as the completion of the life stage associated with the disease and treatment, since at that moment the patients
know that they are healthy (they are told this by the doctors on the basis of the analyses performed).
At each stage, patients with a maladaptive attitude toward the disease were identified; they experienced the situation of illness more acutely and, from the point of view of social norms, were less adapted to what was happening. There were the most such patients (58.3%) at the stage of treatment of recurrence, when anosognosia and "withdrawal into work" can no longer soften the psychological trauma caused by the return of the situation of illness and treatment, and the patients are in search of new ways of adaptation.
An analysis of complaints of the neurotic register (NDQ-SI) of patients with malignant lymphomas showed that at all stages of the disease no significant differences were revealed in the frequency of occurrence and intensity of complaints of the neurotic register depending on the diagnosis (HL and NHL). Among the patients' complaints at the stages before treatment, during primary treatment, and during treatment of recurrence, the leading ones in terms of frequency of occurrence were complaints of a hypochondriacal and asthenic nature, as well as affective lability and disruption of social contacts. Hypochondriacal complaints allowed patients to present their malaise and complaints outward (to doctors, to loved ones). Moreover, since lymphoproliferative diseases do not have a specific localization, patients "listened" to their inner corporeality, which is one of the sources of the formation of the attitude toward the disease. As the disease was treated, the patients' awareness of the illness and treatment increased, and in this regard hypochondriacal complaints became more concrete and specific and reflected the patient's views on the disease, their hypotheses and expectations, and could be a request to those around them for understanding, sympathy, and information about the disease. It should be noted that those around them do not always understand the patient's request, and the non-satisfaction of this request may in turn lead to the concentration of the patient's mental life on the disease.
The patients' asthenic complaints corresponded to the clinical picture of the disease. At the stages when the disease was in its active phase, the asthenic symptoms had an interrelation with the disruption of social contacts (p<0.05). At the remission stage, the number of complaints of an asthenic nature decreased, but complaints pointing to a disruption of social contacts continued to be the leading ones, which may be a reflection of the existential problems actualized in connection with the disease, one of the manifestations of which is existential isolation.
At all stages of the disease, in patients with malignant lymphomas, differences were noted in the intensity and frequency of the dominance of complaints of the neurotic register depending on the age criterion: at the stages before treatment and during primary treatment, in patients under 40 years, compared with older ones, depressive disorders occur less frequently (20% and 52.4% respectively, p<0.05), affective tension (30% and 71.4% respectively, p<0.02), with a lower intensity of the scales of depressive and derealization disorders (p<0.03). However, upon the occurrence of recurrence of the disease, they have a higher intensity of the scales of affective tension (p<0.02) and anankastic disorders (p<0.05). This may testify that younger patients began to realize the threat to their health in connection with the disease only upon recurrence.
The process of forming an attitude toward the disease is associated with a person's possibilities for psychological adaptation, which include coping behavior. Coping behavior is based on a person's assessment of their own capabilities and manifests itself in the form of various strategies at the cognitive, emotional, and behavioral levels. A study of the internality of patients with malignant lymphomas (LOC) showed that in the majority of patients, at the stages when the disease was in its active phase, a lowered level of internality in the sphere of health was revealed: these patients felt anxiety and insecurity, felt themselves unable to control the situation related to health, were not aware of their
reactions to the disease, and did not find meaning in what was happening. A lowered level of internality in the attitude toward health in patients with recurrence of the disease, despite the experience of the illness, may testify to the psychological traumatization of the patient's personality in the situation of the return of the disease. In the majority of patients at the remission stage, a moderate level of internality in the sphere of health was revealed. At the remission stage, there were more internals among patients under 40 years, compared with older patients (p<0.02), which manifested itself in curiosity about one's own life, in attention to one's personal needs, and in a responsible choice of one's behavior.
An analysis of the interrelation between patients' attitude toward the disease and their internality in the sphere of health showed that patients with malignant lymphomas before treatment and during primary treatment do not manifest clear signs of maladaptation in connection with the situation of illness when they do not take into account the state of their health: an inverse interrelation of internality in the sphere of health with the anosognosic component (r=-0.48, p<0.01) and a direct one with the maladaptive components of the attitude toward the disease (r=0.59, p<0.05) was found. At the stages before treatment and during primary treatment, the acceptance of the disease and the awareness of responsibility for one's health by patients is accompanied by maladaptation, which is congruent with the traumatic situation, but is not always understood and accepted by society.
At the remission stage, an inverse interrelation was found between the patient's internality in the sphere of health and the maladaptive components of the attitude toward the disease (r=-0.54, p<0.05): it may be assumed that patients in remission are adapted to the situation of illness through a change in their attitude toward their health.
The results of the study of coping strategies in the structure of coping behavior showed that patients with malignant lymphomas are characterized by cognitive strategies adequate to the situation, which contributed to a reduction of emotional tension, but with
their prolonged use they can block experiences. At the emotional level, "optimism" was most often used, which could be either adequate (real) or inadequate (defensive). At the behavioral level, despite the cognitive processing of the situation of illness, not always constructive stereotypes were at work. This pointed to the fact that in these patients thoughts and feelings are disconnected. For a holistic experience of the traumatic situation, an acknowledgment of negative feelings is necessary, since only in the process of experiencing them can the changed reality be accepted.
Thus, a specific feature of the attitude toward the disease in patients with malignant lymphomas is a prolonged period of denial of the malignant nature of the disease, which accounts for the delayed nature of the psychological traumatization of patients; in essence, it is observed only upon recurrence of the disease. Professional psychological care for the oncological patient, aimed at their acceptance of the malignant nature of the disease not only at the cognitive but also at the emotional level, contributes to a more adequate psychological adaptation of the patient to the disease and treatment.
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