Factors of the therapeutic effect of psychotherapy. The effectiveness of psychotherapy

How does psychotherapy help, through what mechanisms does the psychotherapist achieve the desired changes in the patient’s thinking and behavior? Several factors are described in the literature therapeutic effect, called differently by different authors. We will consider a combined classification compiled on the basis of those described by R.Corsini and B.Rosenberg (1964), I.Yalom (1970), S.Kratochvil (1978). Some of the factors under consideration are characteristic of both individual and group psychotherapy, others - only for group psychotherapy.

1. VERSATILITY. Other designations for this mechanism - “sense of community” and “participation in a group” - indicate that this factor is observed in group psychotherapy and is absent in individual psychotherapy.

Universality means that the patient’s problems are universal, to one degree or another they manifest themselves in all people, the patient is not alone in his suffering.

2. ACCEPTANCE (ACCEPTATION). S. Kratochvil calls this factor “emotional support”. This last term has become entrenched in our psychotherapy.

With emotional support great value has climate creation psychological safety. Unconditional acceptance of the patient, along with the therapist's empathy and congruence, is one of the components of the positive relationship that the therapist strives to build. This “Roger triad”, which has already been mentioned, is of great importance in individual therapy and no less in group therapy. In its simplest form, emotional support for an individual occurs when the therapist (in individual therapy) or group members (in group psychotherapy) listen to him and try to understand him. Next comes acceptance and compassion. If the patient is a member of the group, then he is accepted without regard to his situation, his disorders, his characteristics of behavior and his past. He is accepted as he is, with his own thoughts and feelings. The group allows him to be different from other members of the group, from the norms of society, no one condemns him.

To a certain extent, the mechanism of “emotional support” corresponds to the factor of “cohesion” according to I. Yalom (1975). “Cohesion” can be considered as a mechanism of group psychotherapy, identical to “emotional support” as a mechanism of individual psychotherapy. Indeed, only a cohesive group can provide a group member with emotional support and create conditions for psychological safety.

Another mechanism close to emotional support is “instilling hope” (I. Yalom, 1975). The patient hears from other patients that they feel better, he sees the changes that are happening to them, this gives him hope that he too can change.

3. ALTRUISM. Positive therapeutic effect can be provided not only by the fact that the patient receives support and is helped by others, but also by the fact that he himself helps others, sympathizes with them, and discusses their problems with them. The patient who comes to the group demoralized, unsure of himself, with the feeling that he himself has nothing to offer in return, suddenly begins to group work to feel necessary and useful to others. This factor - altruism - helps to overcome a painful focus on oneself, increases the feeling of belonging to others, a sense of confidence and adequate self-esteem.

This mechanism is specific to group psychotherapy. It is absent in individual psychotherapy, because there the patient is exclusively in the position of a person being helped. In group therapy, all patients play psychotherapeutic roles in relation to other group members.

4. RESPONSE (CATHARISS). Strong expression of affect is an important part of the psychotherapeutic process. However, it is believed that response in itself does not lead to any changes, but creates a certain basis or prerequisites for change. This mechanism is universal - it works in both individual and group psychotherapy. Emotional response brings significant relief to patients and is supported in every possible way by both the psychotherapist and members of the psychotherapeutic group.

According to I. Yalom, responding to sadness, traumatic experiences and expressing strong, important emotions for the individual stimulates the development of group cohesion. Emotional response is reinforced by special techniques in psychodrama in “meeting groups” (“encounter groups”). In "meeting groups" anger and its response are often stimulated by strong blows on a pillow symbolizing the enemy.

5. SELF-DISCOVERY (SELF-EXPLORATION). This mechanism is more present in group psychotherapy. Group psychotherapy stimulates frankness, the manifestation of hidden thoughts, desires and experiences. In the process of psychotherapy, the patient reveals himself.

In order to better understand the mechanism of self-exploration and the mechanism of confrontation described below in group psychotherapy, let us turn to the scheme of J. Luft and H. Ingham (1970), known in the literature as the “Jogari window” (from the names of the authors - Joser and Harry), which clearly conveys the relationship between the conscious and unconscious areas of the psyche in interpersonal relationships.

1. The open area ("arena") includes behavior, feelings and prayers that are known both to the patient himself, there and to everyone else.
2. The blind spot area is something that is known to others but not known to the patient.
3. Hidden area - something that is known only to the patient.
4. The unknown, or unconscious - that which is not known to anyone.

With self-exploration, a group member assumes responsibility because he takes the risk of realizing feelings, motives and behavior from his hidden or secret area. Some psychotherapists talk about “self-stripping,” which they consider the primary mechanism of growth in a group (O. Mowrer, 1964 and S. Jourard, 1964 - cited in S. Kratochvil, 1978). The man takes off his mask and begins to speak frankly about ulterior motives that the group could hardly guess about. It's about about deeply intimate information that the patient would not trust to everyone. In addition to various experiences and relationships associated with guilt, this includes events and actions that the patient is simply ashamed of. Things can only come to the point of “self-undressing” if all other members of the group react with mutual understanding and support. There is, however, a risk that if the patient opens up and does not receive support, then such “self-undressing” will be painful for him and cause mental trauma.

6. FEEDBACK OR CONFRONTATION. R. Corsini calls this mechanism “interaction”. Feedback means that the patient learns from other group members how they perceive his behavior and how it affects them. This mechanism, of course, also occurs in individual psychotherapy, but in group psychotherapy its importance increases many times over. This is perhaps the main healing factor of group psychotherapy. Other people can be a source of information about ourselves that is not entirely accessible to us and is located in the blind spot of our consciousness.

For greater clarity, let's use the Jogari window again. If during self-exploration the patient reveals something to others from his secret, hidden area, then during feedback others reveal to him something new about himself from the area of ​​his blind spot. Thanks to the action of these two mechanisms - self-exploration and confrontation - the hidden area and the blind spot area are reduced, due to which the open area ("arena") increases.

IN everyday life We often come across people whose problems are written directly on their faces. And everyone who comes into contact with such a person does not want to point out his shortcomings, because... they are afraid of seeming tactless or offending him. But it is this information that is unpleasant for a person that provides him with material with which he could change. There are many such delicate situations in interpersonal relationships.

For example, a person who tends to talk a lot and does not understand why people avoid talking to him is told in a therapy group that his way verbal communication very boring. A person who does not understand why many people are unfriendly to him learns that his unconscious ironic tone irritates people.

However, not all information about a person received from others is feedback. Feedback must be distinguished from interpretation. Interpretation is an interpretation, an explanation; these are our thoughts, reasoning about what we saw or heard. Interpretation is characterized by statements such as: “I think that you are doing such and such,” and feedback is: “When you do such and such, I feel like this...” Interpretations may be erroneous or may represent the interpreter's own projections. Feedback, in essence, cannot be wrong: it is an expression of how one person reacts to another. Feedback can be non-verbal, manifested in gestures or facial expressions.

The presence of differentiated feedback is also of significant value to patients. Not all behavior can be assessed unambiguously - negatively or positively - it affects different people differently. Based on differentiated feedback, the patient can learn to differentiate his behavior.

The term confrontation is often used for negative feedback. G. L. Isurina and V. A. Murzenko (1976) consider confrontation in the form of constructive criticism to be a very useful psychotherapeutic factor. At the same time, they point out that when confrontation alone predominates, criticism is no longer perceived as friendly and constructive, which leads to increased psychological protection. Confrontation must be combined with emotional support, which creates an atmosphere of mutual interest, understanding and trust.

7. INSIGHT (AWARENESS). Insight means understanding and awareness by the patient of previously unconscious connections between the characteristics of his personality and maladaptive modes of behavior. Insight refers to cognitive learning and, together with emotional corrective experience (see below) and experience of new behavior, is combined by I. Yalom (1970) into the category of interpersonal learning.

S. Kratochvil (1978) distinguishes three types, or levels, of insight:
Insight N1: Understanding the connection between emotional disorders and intrapersonal conflicts and problems.
Insight N2: awareness of one’s own contribution to the emergence of a conflict situation. This is what is called “interpersonal awareness.”
Insight N3: Awareness underlying reasons present relationships, states, feelings and behavior patterns rooted in the distant past. This is "genetic awareness".

From a psychotherapeutic point of view, insight N1 is an elementary form of awareness, which in itself has no therapeutic value: its achievement is only a prerequisite for the patient's effective cooperation in psychotherapy. The most therapeutically significant insights are N2 and N3.

The subject of constant debate among various psychotherapeutic schools is the question of whether genetic awareness alone is sufficient or, conversely, only interpersonal awareness. S. Kratochvil (1978), for example, is of the opinion that only interpersonal awareness is sufficient. From this you can go straight to learning new ways of behavior. Genetic awareness, from his point of view, can be useful in that it leads the patient to abandon childhood forms of response and replace them with the reactions and attitudes of an adult.

Genetic awareness is an exploration of one's own life history that leads the patient to understand his or her present ways of behaving. In other words, it is an attempt to understand why a person became the way he is. I. Yalom (1975) believes that genetic awareness has limited psychotherapeutic value, which strongly disagrees with the position of psychoanalysts.

From a certain point of view, insight can be considered as a consequence of psychotherapy, but it can be spoken of as a therapeutic factor or mechanism, since it is primarily a means of changing maladaptive forms of behavior and eliminating neurotic symptoms. In achieving these goals, it is, as a rule, always a very effective, but not necessarily necessary, factor. IN ideally based on deep awareness, symptoms can disappear and behavior can change. However, the relationships between awareness, symptoms, and behavior are actually much more complex and less clear-cut.

8. CORRECTIVE EMOTIONAL EXPERIENCE. Corrective emotional experience is an intense experience of current relationships or situations, due to which the incorrect generalization made on the basis of past difficult experiences is corrected.

This concept was introduced by psychoanalyst F. Alexander in 1932. Alexander believed that since many patients suffered psychological trauma in childhood due to bad attitude parents to them, then the therapist needs to create a “corrective emotional experience” to neutralize the effects of the primary trauma. The therapist reacts to the patient differently than his parents reacted to him in childhood. The patient experiences emotions, compares relationships, corrects his positions. Psychotherapy takes place as a process of emotional re-education.

Most vivid examples can be taken from fiction: the story of Jean Valjean from “Les Miserables” by V. Hugo and a number of stories from the works of A.S. Makarenko, for example, the episode when Makarenko entrusts all the money of the colony to one guy, a former thief. Unexpected trust, which comes into contrast with earlier justified hostility and mistrust, corrects existing relationships through strong emotional experience and changes the guy's behavior.

During emotional adjustment, people around them behave differently than a patient with inappropriate forms of behavior might expect based on his false generalization (generalization). This new reality makes it possible to redifferentiate, that is, distinguish between situations in which a given response is appropriate or not. Thanks to this, the preconditions are created for breaking the vicious circle.

So, the essence of this mechanism is that the patient, in a psychotherapeutic situation (whether individual or group psychotherapy), re-experiences an emotional conflict that he has not been able to resolve until now, but the reaction to his behavior (the psychotherapist or group members) different from the one he usually provokes in others.

For example, a female patient with strong feelings of mistrust and aggressiveness toward men, resulting from her experiences and disappointments in the past, might be expected to bring this mistrust and aggressiveness toward male patients in the psychotherapy group. Unexpected manifestations on the part of men can have an effective impact here: they do not distance themselves from the patient, do not show irritation and dissatisfaction, but, on the contrary, are patient, courteous, and affectionate. The patient, who behaves in accordance with her previous experience, gradually begins to realize that her primary generalized reactions are unacceptable in the new situation, and she will try to change them.

A type of corrective experience in a group is the so-called “corrective repetition of the primary family” proposed by I. Yalom (1975) - a repetition of the patient’s family relationships in the group. A group resembles a family: its members are to a large extent depend on the leader; group members may compete with each other to gain the "parental" favor. The therapeutic situation can evoke a number of other analogies with patients' families, provide corrective experiences, and work through unresolved relationships and conflicts in childhood. Sometimes the group is deliberately led by a man and a woman so that the group situation imitates the family situation as closely as possible. Low-adaptive relationships in a group are not allowed to “frozen” into rigid stereotypes, as happens in families: they are compared, reevaluated, the patient is encouraged to test new, more mature way behavior.

9. TESTING NEW BEHAVIOR (“REALITY CHECK”) AND TEACHING NEW WAYS OF BEHAVIOR.

In accordance with the awareness of old non-adaptive behavioral stereotypes, a transition to the acquisition of old ones is gradually taking place. The psychotherapeutic group provides for this a whole series opportunities. Progress depends on the patient’s readiness for change, on the degree of his identification with the group, on the persistence of his previous principles and positions, on individual character traits.

The impulse from the group plays a big role in consolidating new reactions. The socially insecure patient, who is trying to gain acceptance by passive waiting, begins to become active and express his own opinion. Moreover, by this he not only does not lose the sympathy of his comrades, but they begin to appreciate and recognize him more. As a result of this positive feedback, the new behavior is reinforced and the patient becomes convinced of its benefits.

If change occurs, it triggers a new cycle of interpersonal learning based on ongoing feedback. I. Yalom (1975) speaks of the first turn of the “adaptation spiral”, which originates within the group and then goes beyond its boundaries. As inappropriate behavior changes, the patient's ability to improve relationships increases. Thanks to this, his sadness and depression decrease, self-confidence and frankness increase. Other people like this behavior significantly more than the previous behavior and express more positive feelings, which in turn reinforces and stimulates further positive changes. At the end of this adaptive spiral, the patient achieves independence and no longer requires treatment.

In group psychotherapy, systematically planned training can also be used - training based on the principles of learning. For example, an insecure patient is offered “affirmative behavior training”, during which he must learn to insist on his own, assert his opinion, and make independent decisions. The rest of the group members resist him, but he must convince everyone of the correctness of his opinion and win. Successful completion of this exercise earns approval and praise from the group. Having experienced satisfaction, the patient will try to transfer the new experience of behavior to a real life situation.

Similarly, in a group you can learn to resolve conflict situations in the form of a “constructive dispute”, disagreement with the established rules.

When learning new ways of behavior, modeling and imitation of the behavior of other group members and the therapist play an important role. I. Yalom (1975) calls this mechanism of therapeutic action “imitating behavior,” and R. Corsini (1989) calls it “modeling.” People learn to behave by observing the behavior of others. Patients imitate their peers, observing which forms of their behavior the group approves and which they reject. If the patient notices that other group members are being open, taking certain risks associated with self-disclosure, and the group approves of this behavior, then this helps him behave in the same way.

10. PRESENTATION OF INFORMATION (LEARNING BY OBSERVATION).
In the group, the patient gains new knowledge about how people behave, information about interpersonal relationships, and adaptive and maladaptive interpersonal strategies. What is meant here is not feedback and the interpretations that the patient receives regarding his own behavior, and the information that he acquires as a result of his observations of the behavior of others.

The patient makes an analogy, generalizes, and draws conclusions. He learns by observing. In this way he learns some of the laws of human relationships. He can now look at the same things with different sides, get to know different opinions on the same issue. He will learn a lot even if he does not actively participate.

Many researchers especially emphasize the importance of observation for positive change. Patients who simply observed the behavior of other group members used their observations as a source of awareness, understanding, and resolution of their own problems.

R. Corsini (1989), when studying the factors of the therapeutic effect of psychotherapy, divides them into three spheres - cognitive, emotional and behavioral. The author considers “universality”, “sense”, “modeling” to be cognitive factors; to emotional factors - “acceptance”, “altruism” and “transfer” (a factor based on emotional connections between the therapist and the patient or between patients of the psychotherapeutic group); to behavioral ones - “reality check”, “emotional response” and “interaction” (confrontation). R. Corsini believes that these nine factors underlie therapeutic change. Cognitive factors, writes R. Corsini, boil down to the commandment “know yourself”; emotional - to “love your neighbor” and behavioral - to “do good”. There is nothing new under the sun: philosophers have been teaching us these commandments for thousands of years.

EFFECTIVENESS OF PSYCHOTHERAPY

In 1952, the English psychologist Hans Aysenck compared the effectiveness of traditional psychodynamic therapy with the effectiveness of conventional medical methods treatment of neuroses or with no treatment in several thousand patients. The results obtained by the psychologist surprised and frightened many therapists: the use of psychodynamic therapy does not increase patients' chances of recovery; In fact, more untreated patients recovered than those who received psychotherapeutic treatment (72% versus approximately 66%). In subsequent years, Aysenck supported his conclusions with additional evidence (1961, 1966) as critics continued to argue that he was wrong. They accused him of excluding from his analysis several studies that supported the effectiveness of psychotherapy. They offered the following counterarguments: perhaps patients who did not receive therapy suffered less severe disorders than those who received it; non-medical patients may actually have received therapy from frequent psychotherapists; therapists assessing untreated patients may have used different, less stringent criteria than psychotherapists assessing their own patients. There has been much debate about how to interpret the results of H.Aysench, and this debate has shown that more reliable methods for assessing effectiveness need to be developed.

Unfortunately, performance evaluation work still varies widely in quality. In addition, as D. Bernstein, E. Roy et al. point out. (1988), it is difficult to define exactly what is meant by successful therapy. Because some therapists seek change in the areas of unconscious conflicts or ego strength, while others are interested in changes in overt behavior, different effectiveness researchers have different judgments about whether therapy was effective for a given patient. These points must be kept in mind when considering studies on the overall effectiveness of psychotherapy.

Recent reviews are more optimistic than H. Aysenck's studies. A number of works have refuted the “null hypothesis” of H. Aysench, and now the real percentage of spontaneous recovery ranges from 30 to 45.

Using a special mathematical procedure called meta-analysis (“analysis of analyses”), Smith M. L., Glass G. V., Miller T. J. (1980) compared the results of 475 studies that reported on the conditions of patients who received psychotherapy and those who did not receive treatment. The main conclusion was this: the average patient who received psychotherapy felt better than 80% of those patients who did not receive therapy. Other meta-analyses confirmed this conclusion. These reviews have shown that when the results of all forms of psychological treatment are considered together, the view that psychotherapy is effective is supported.

However, critics of meta-analysis argue that even such a complex combination of results, representing a “hodgepodge” of good and mediocre studies of the effectiveness of treatment various methods, may be misleading. According to critics, these studies do not answer more important question: which methods are most effective in treating certain patients.

Which of the main psychotherapeutic approaches is most effective in general, or which approach is preferable when treating specific problems of patients? Most reviews are not found significant differences in the overall effectiveness of the three main areas of psychotherapy. Critics have pointed out that these reviews and meta-analyses are not sensitive enough to detect differences between individual methods, but even studies that have carefully compared psychodynamic, phenomenological, and behavioral treatments have not found significant differences between these approaches, although they have noted their advantage over no treatment. When differences between methods are identified, there is a tendency to find behavioral methods to be more effective, especially in the treatment of anxiety. The favorable results of behavioral therapy and the attractiveness of phenomenological therapy to many psychotherapists have led to these two approaches becoming increasingly popular, while the use of psychodynamic therapy as the dominant method of treatment has become less and less popular.

Evaluating research on the effectiveness of psychotherapy can be approached from a completely different perspective and formulate the question as follows: Are attempts to measure the effectiveness of psychotherapy correct?

On the issue of the effectiveness of psychotherapy, many share the opinion expressed back in 1969 by H.H.Strupp, Bergin A.E. (quoted by R. Corsini): The problem of psychotherapy research should be formulated as a standard scientific question: what specific therapeutic interventions produce specific changes in specific patients under specific conditions?

R. Corsini, with his characteristic humor, writes that he finds the “best and most complete” answer to this question in C. Patterson (1987): before any model subject to research can be applied, we need: 1) taxonomy problems or psychological disorders of the patient, 2) taxonomy of patients' personalities, 3) taxonomy of therapeutic techniques, 4) taxonomy of therapists, 5) taxonomy of circumstances. If we were to create such classification systems, the practical problems would be insurmountable. Let us assume that the five listed classes of variables each contain ten classifications, then research project will require 10x10x10x10x10, or 100,000 elements. From this C. Petterson concludes that we do not need complex analyzes of many variables and should give up trying precise study psychotherapy, because this is simply not possible.

Psychotherapy is an art based on science, and just like art, simple measures of such a complex activity are not applicable.

Many people wonder what psychotherapy is the most effective. And the answer would seem obvious. We go to courses on psychoanalysis and they tell us: “Psychoanalysis is the most effective direction, only it treats the causes, and any other methods are aimed only at correcting symptoms.” In courses on behavioral therapy they will tell us: “Behavioral therapy is the most effective direction, because we have a strict theoretical and empirical justification,” and when we come to the humanistic direction, they will tell us: “The main thing is the self-realization of the individual, and not the symptom,” and they will also be right. How things really are. In fact, everything is very ambiguous, and it is not so easy to check the effectiveness of this or that therapy, if only because of the following problems:

1. Different health criteria in different areas of psychotherapy (accordingly, it is not clear whether it is even possible to evaluate behavioral therapy by the same yardstick as psychoanalysis).
2. Long-term and short-term orientation - different directions can be effective to varying degrees depending on the time focus. One method brings only a temporary effect, but quickly, which affects the results of research, although then we encounter a relapse, and, conversely, another method may not have an effect on the patient for years, until it eventually leads to a complete cure.
3. The difficulty of conducting research due to its scale.
4. Difficulty in comparing therapy results due to extraneous factors (for example, we cannot say that the therapist we evaluate in Gestalt therapy is as competent in his field as the therapist we evaluate in cognitive therapy research).

There are other difficulties. However, a number of studies have still been carried out. What did we get as a result? The earliest studies were carried out by G. Eysenck. Eysenck always had a negative attitude towards psychotherapy, believing that it had no scientific basis. To prove his opinion, he reviewed nineteen publications regarding the results of psychotherapy, and came to a shocking conclusion: according to various data, “improvement” took place in 39-77% of cases, and such a wide range cannot but arouse suspicion; Clearly something was wrong here. Moreover: combining the data considered, Eysenck received an average figure of 66% - and then cited evidence from other studies, according to which improvement was noted in 66-72% of neurotics who were in hospital treatment, but did not receive psychotherapy.

Eysenck's conclusion was that there is no evidence that psychotherapy is responsible for its purported effects; the radical consequence of this was the conclusion that all training of psychotherapists must henceforth cease.

However, since then there have been many other, more differentiated studies that still indicate that psychotherapy is generally effective, at least compared to placebo.

Since then, many hundreds of publications have appeared on the results of psychotherapy; these studies vary enormously in scientific quality, sample sizes examined, improvement measures used, and the presence or absence of comparison groups; Accordingly, the scatter of the obtained data is very large.

However, a meta-analysis - a careful review of materials based on scientific quality and methodological differences - still shows that the evidence for psychotherapy is stronger. In 1975, Lester Luborsky of the University of Pennsylvania published a detailed meta-analysis of nearly a hundred controlled studies; he concluded that most studies indicate high proportion patients who have benefited from psychotherapy. Contrary to Eysenck's claims, two-thirds of the studies showed significant improvement in treated patients compared to those who did not. (If we exclude cases of minimal intervention from consideration, the superiority of psychotherapy over no therapy becomes even more pronounced.)

An even larger 1980 meta-analysis of 475 studies by a different group of researchers, using a wide range of outcome measures to compare patients receiving psychotherapy with members of control groups, led to the unequivocal conclusion that therapy was beneficial in the majority (though not the majority). in all) cases.

However, one thing the meta-analysis revealed was disconcerting: Regardless of the form of psychotherapy, approximately two-thirds of patients benefit from it. However, if each type of psychotherapy works for certain reasons - determined by the theory on which the type is based - then how can they all work equally well?

The explanation for this phenomenon comes down to the fact that different types of psychotherapy have common components, primarily the helping relationship between the therapist and the patient. Other researchers point to other common factors: the opportunity to evaluate reality in a protected environment, the hope of relief generated by therapy, which motivates the patient to change.

IN recent years However, more nuanced analyzes are beginning to provide evidence that some types of psychotherapies are more effective than others in treating certain disorders.

In addition, the superiority of behavioral and cognitive-behavioral therapy for panic syndrome and other manifestations of anxiety has been revealed; cognitive therapy - treatment of social phobias; group psychotherapy - in the treatment of personality disorders; Cognitive-behavioral and interpersonal therapy, or both, in combination with the prescription of antidepressants - in the treatment of depression.

Although many hundreds of outcome studies have been conducted, scientists have only recently begun to isolate causal relationships within treatments. The overall numbers provided by the meta-analysis do not reveal them. Among other things, they average the results obtained by individual psychotherapists. Recent studies, in contrast, have begun to link the findings to the therapists themselves. Luborsky and colleagues' study of three different treatment approaches drug addiction showed that the choice of approach is less important than the personal characteristics of the therapist.

You can find other studies via the links, but we will try to convey the general idea.

1. We can definitely say that behavioral therapy shows the best results, and psychoanalysis shows the worst results, since psychoanalysts in some cases also manage to worsen the patient’s condition.
2. In general, the gap between behavioral therapy and other areas is not large, and it is quite possible that it is connected with the study of the treatment of those problems, the treatment of which is most effective with the help of behavioral therapy. For example, in the treatment of schizophrenia, cognitive behavioral therapy does not show greater effectiveness than other areas.
3. Different types of psychotherapy are differently effective in working with different disorders and types of clients (different types of psychotherapy are suitable for different clients).
4. Most studies devoted to studying the effectiveness of psychotherapy have already lost their relevance.
5. The effectiveness of psychotherapy is influenced more by general therapeutic factors than by the method itself. These include: the personality of the therapist, the personality of the patient, the characteristics of their interaction, and other variables.
6. The effectiveness of psychotherapy is influenced by extratherapeutic factors and sometimes even more than the therapy process itself. This includes the placebo effect and various cognitive distortions.

It is worth noting that the modern position on the effectiveness of psychotherapy is clear - the most effective therapy is the one that is the most comprehensive. For example, many authors agree that combining pharmacotherapy and cognitive behavioral therapy is more effective than using them separately (although, of course, there are cases when the use of medications is a contraindication for psychotherapy). Also, complex environmental influence, when the client is placed in a certain environment that changes him, is more effective than periodic individual meetings. Thus, more effective will be the direction of psychotherapy, which is aimed at the systematic study of the personality, all its spheres: emotional, cognitive, behavioral.

Let us note another point that all modern directions of psychotherapy gradually come to this concept, i.e. they include various elements of work aimed at different areas of the individual. For example, behavioral therapy originally included a cognitive component. Psychoanalysts began to use humanistic methods of interaction with clients. Instead of direct suggestions, hypnosis began to use regression and the search for the causes of the problem.

Initially, it is possible to designate only one direction, which included the study of almost all components of the personality - Gestalt therapy (hence, in fact, the name of the direction, Gestalt - the whole). However, in the early version, Gestalt was closer to psychoanalysis, which is why the effectiveness was low. Now Gestalt therapy is something different, combining work with thinking, emotions, and behavior. Work in Gestalt is aimed both at the current moment and at finding the cause of the problem. In its modern version, it also includes coaching work.

The main reason for the lower effectiveness of Gestalt compared to the same cognitive behavioral therapy and hypnosis in a number of ways. Gestalt actively uses the trance state to find the causes of illness, however, therapists themselves usually do not recognize this. Thus, there is no targeted guidance this state as in hypnotherapy, and, consequently, the work in it is less effective. There are also a number of problems with cognitive behavioral therapy. This is primarily the lack of formalization of therapeutic procedures, and hence the low level of training of specialists. Well, another reason is the lack of a clear theoretical and empirical basis. For some reason, Gestatists believe that the best choice as a theoretical basis is the Gestalt theory and the philosophical concepts of the existentialists. While the therapy itself is completely based on rational principles and includes a fairly strong behavioral component. It should also be noted that it is from Gestalt that cognitive behavioral therapy has taken most of its techniques. Also, the most modern direction of cognitive therapy (mindfulness - fullness of consciousness) has precisely come to the same concept that was originally proposed by Gestalt therapy - this is non-judgmental awareness.

The most important conclusion is that psychotherapy in general is not as effective when working with mental disorders. As a rule, a fairly limited range of problems can be solved with the help of psychotherapy. Specific behavioral problems (for example, specific phobias) are solved most quickly and effectively. Some areas are aimed at forming and changing character, but such work most often lasts for years and rarely leads to results. Speaking about psychotic diseases (when disorders lie in the functioning of the brain), here psychotherapy is in principle ineffective (it can only be effective if psychotic symptom caused by psychological reasons). In such cases, psychotherapy is simply a method of increasing the patient’s social adaptation.

A universal drug possessing several important pharmacological effects:
- anxiolytic (sedative and vegetotropic)
- nootropic
- stress-protective

Effective therapy vegetative-vascular dystonia in young patients

E. N. Dyakonova, doctor medical sciences, professor
V. V. Makerova
State Budgetary Educational Institution of Higher Professional Education IvSMA Ministry of Health of the Russian Federation, Ivanovo Resume. Approaches to the treatment of vegetative-vascular dystonia in young patients in combination with anxiety and depressive disorders are considered. The study included 50 patients aged 18 to 35 years with vegetative-vascular dystonia syndrome; the effectiveness and safety of therapy were assessed during treatment and after discontinuation.
Keywords: vegetative-vascular dystonia, anxiety-depressive disorders, asthenia.

Abstract. The treatment of vegetative-vascular dystonia in young patients in combination with anxiety and depressive disorders was discussed. The study included 50 patients aged 18 to 35 years with a syndrome of vegetative-vascular dystonia. In the course of the treatment and after its cancellation, the efficacy and safety of the therapy were evaluated.
Keywords: vegetative-vascular dystonia, anxiety and depressive disorders, asthenia.

The term “vegetative-vascular dystonia” (VSD) is often understood as psychogenically caused multisystem autonomic disorders, which can be an independent nosology, and also act as secondary manifestations of somatic or neurological diseases. At the same time, the severity of vegetative pathology aggravates the course of the underlying disease. Vegetative-vascular dystonia syndrome significantly affects the physical and emotional state of patients, determining the direction of their seeking medical help. In the structure of general morbidity, disorders of the autonomic nervous system occupy one of the leading places (category G90.8 according to ICD-10). Thus, the prevalence of vegetative-vascular dystonia in the general population, according to various authors, ranges from 29.1% to 82.0%.

One of the most important features VSD is a polysystemic clinical manifestation. Vegetative-vascular dystonia includes three generalized syndromes. The first is psychovegetative syndrome (PVS), which is manifested by permanent paroxysmal disorders caused by dysfunction of nonspecific brain systems (suprasegmental autonomic systems). The second is the syndrome of progressive autonomic failure and the third is the vegetative-vascular-trophic syndrome.

Anxiety spectrum disorders are observed in more than half of patients with VSD. They acquire particular clinical significance in patients with a somatic profile, including functional pathology, since in these cases there are always anxious experiences of varying degrees of severity: from psychologically understandable to panic or to generalized anxiety disorder (GAD). As everyday practice demonstrates, all patients with this type of disorder are prescribed anxiolytic or sedative therapy. In particular, various tranquilizers are used: benzodiazepines, non-benzodiazepines, antidepressants. Anxiolytic therapy significantly improves the quality of life of these patients and contributes to their better compensation during the treatment process. However, not all patients tolerate these drugs well due to the rapid development side effects in the form of lethargy, muscle weakness, disturbances in attention, coordination, and sometimes symptoms of addiction. Taking into account the noted problems, in recent years there has been an increasing need for drugs with an anxiolytic effect of a non-benzodiazepine structure. These may include the drug Tenoten, which contains antibodies to the brain-specific protein S-100, which have undergone technological processing during the production process. As a result, Tenoten contains release-active antibodies to the brain-specific protein S-100 (PA-AT S-100). It has been shown that release-active drugs have a number of typical characteristics that allow them to be integrated into modern pharmacology (specificity, non-addiction, safety, high efficiency).

The properties and effects of release-active antibodies to the brain-specific protein S-100 have been studied in many experimental studies. Drugs created on their basis are used in clinical practice as anxiolytic, vegetostabilizing, stress-protective agents for the treatment of anxiety and autonomic disorders. Molecular target PA-AT S-100 is a calcium-binding neurospecific protein S-100, which is involved in the coupling of information and metabolic processes in the nervous system, signal transmission by secondary messengers (“messengers”), processes of growth, differentiation, apoptosis of neurons and glial cells. In studies on the Jurkat and MCF-7 cell lines, it was shown that PA-AT S-100 exerts its action, in particular, through the sigma1 receptor and the glycine site of the NMDA glutamate receptor. The presence of such an interaction may indicate the influence of the drug Tenoten on various mediator systems, including GABAergic and serotonergic transmission.

It should be noted that, unlike traditional benzodiazepine anxiolytics, PA-AT S-100 does not cause sedation and muscle relaxation. In addition, PA-AT S-100 contributes to the restoration of neuronal plasticity processes.

S. B. Shvarkov et al. found that the use of RA-AT S-100 for 4 weeks in patients with psychovegetative disorders, including those caused chronic ischemia brain, led not only to a significant decrease in the severity of anxiety disorders, but also noticeable decrease vegetative disorders. This gave the authors the opportunity to consider Tenoten not only as a mood corrector, but also as a vegetative stabilizer.

M. L. Amosov et al. when observing a group of 60 patients with transient ischemic attacks in various vascular territories and accompanying emotional disorders, they found that the use of RA-AT S-100 can reduce anxiety. The anxiolytic effect was practically no different from the anti-anxiety effect of phenazepam, while the tolerability of the drug containing PA-AT S-100 turned out to be significantly better and, unlike the use of benzodiazepine derivatives, there were no side effects.

However, there is not enough work demonstrating the effectiveness of Tenoten in the correction of autonomic disorders in young people.

The purpose of this work was to evaluate the effectiveness and safety of the drug Tenoten in the treatment of vegetative-vascular dystonia in young patients (18–35 years).

Materials and research methods

A total of 50 patients (8 males and 42 females) aged 18 to 35 years (average age 25.6 ± 4.1 years) with autonomic dystonia syndrome, emotional disorders, and decreased performance were included in the study.

The study did not include patients taking psychotropic and vegetotropic drugs during the previous month; pregnant women during lactation; with signs of severe somatic diseases according to anamnesis, physical examination and/or laboratory and instrumental tests, which could interfere with participation in the program and affect the results.

All patients received Tenoten orally, according to the instructions for medical use of the drug, 1 tablet 3 times a day for 4 weeks (28–30 days) without food intake, sublingually. During the study, the use of vegetotropic, hypnotic, sedative drugs, as well as tranquilizers and antidepressants was prohibited.

All patients were identified for autonomic disorders according to the Wein table (more than 25 points indicate the presence of vegetative-vascular dystonia); assessment of the level of anxiety - according to the HADS anxiety scale (8–10 points - subclinically expressed anxiety; 11 or more points - clinically expressed anxiety); depression - according to the HADS depression scale (8–10 points - subclinically expressed depression; 11 or more points - clinically expressed depression). During the study period, the patients' condition was assessed 4 times: 1st visit - before starting the drug, 2nd visit - after 7 days of therapy, 3rd visit - after 28–30 days of treatment, 4th visit - after 7 days from the end of therapy (37th day from the start of therapy). At each stage we assessed neurological status, heart rate variability (HRV) and state on the scales: A. M. Vein’s autonomic dysfunction, HADS anxiety/depression, as well as the SF-36 questionnaire (Russian version created and recommended by the ICCI), which allows to determine the level of physical functioning (PF) and psychological health (MH). After the 30th day of taking Tenoten, the effectiveness of the therapy was additionally assessed on the CGI-I scale.

HRV analysis was carried out for all subjects initially in the supine position and under conditions of an active orthostatic test (AOP) in accordance with the “Recommendations working group European Society of Cardiology and North American Society of Stimulation and Electrophysiology" (1996) on the VNSspectr device. The study was carried out no earlier than 1.5 hours after eating, with the obligatory cancellation of physical procedures and drug treatment taking into account the timing of drug removal from the body after a 5-10 minute rest. Vegetative status was studied by analyzing HRV using 5-minute recordings of a cardiointervalogram (CIG) in a state of relaxed wakefulness in a supine position after 15 minutes of adaptation and during an orthostatic test. Only stationary sections of the rhythmograms were taken into account, i.e., recordings were allowed for analysis after eliminating all possible artifacts and if the patient was in sinus rhythm. The spectral characteristics of the heart rhythm were studied, which make it possible to identify periodic components in heart rate fluctuations and quantify their contribution to the overall dynamics of the rhythm. Spectra of variability of R-R intervals were obtained using the Fourier transform. When conducting spectral analysis, the following characteristics were assessed:

• TP “total power” - total spectrum power neurohumoral regulation, characterizing the total effect of all spectral components on sinus rhythm;
• HF “high frequency” - high-frequency oscillations reflecting the activity of the parasympathetic department of the autonomic nervous system;
• LF “low frequency” - low-frequency oscillations reflecting the activity of the sympathetic part of the autonomic nervous system;
• VLF “very low frequency” - very low frequency oscillations, which are part of the spectrum of neurohumoral regulation, which includes the complex various factors, affecting heart rate(cerebral ergotropic, humoral-metabolic influences, etc.);
• LF/HF - an indicator reflecting the balance of sympathetic and parasympathetic influences, measured in normalized units;
• VLF%, LF%, HF% are relative indicators that reflect the contribution of each spectral component to the spectrum of neurohumoral regulation.

All of the above parameters were recorded both at rest and during an active orthostatic test.

Statistical analysis of the study results was carried out using Statistics 6.0 using parametric and non-parametric methods (Student's, Mann-Whitney tests). As a threshold level statistical significance a value of p = 0.05 was accepted.

Results and discussion

All patients complained of decreased performance, general weakness, fatigue, hesitation blood pressure(in 72% it was reduced and amounted to 90–100/55–65 mm Hg; in 10%, blood pressure periodically increased to 130–140/90–95 mm Hg). Headaches in 72% of patients were not constant and were associated with increased mental or emotional stress. 24% periodically experienced pain in the scalp and upon palpation of the pericranial muscles. 72% of patients had sleep disturbances, 18% had cardialgia and a feeling of interruptions in heart function. Hyperhidrosis of the palms and feet, persistent red dermographism, and acrocyanosis were noted by half of the patients. Clinical manifestations functional disorders of the gastrointestinal tract (GIT) (constipation, flatulence, abdominal pain) were recorded in 10% of the total number of patients examined.

Analysis of anamnestic data showed that about 80% of the subjects had a stress factor. When surveyed, 30% of patients associated stress with professional activity, 25% - with studies, 10% - with family and children, 35% - with personal relationships.

Analysis of the Hospital Anxiety and Depression Scale (HADS) revealed subclinically expressed anxiety in 26% of patients, and clinically significant anxiety in 46% of patients. Half of the patients (50%) often experienced tension and fear; 6% of patients constantly felt a feeling of internal tension and anxiety. Panic attacks occurred in 16% of respondents. 10% of patients had subclinical and clinically significant depression.

Violations in the psychological component of health (MH) were significant according to the SF-36 questionnaire, and they were associated with an increased level of anxiety. At the same time, physical functioning (PF) did not affect the daily activities of the subjects.

Evaluation of the effectiveness and safety of treatment showed a clear prevalence of positive results when using the drug Tenoten.

Subsequently, based on the results of a dynamic study of heart rate variability, all patients were retrospectively divided into two groups.

The first group consisted of 45 people (90%), initially having autonomic disorders with clear positive dynamics according to HRV results after the 30th day of taking Tenoten. They were patients without signs of clinically significant depression. The initial data for this group of patients were: the number of points on the Wein scale - 25–64 (average 41.05 ± 12.50); on the HADS anxiety scale - 4–16 (9.05 ± 3.43); on the HADS depression scale - 1–9 (5.14 ± 2.32). When assessing the quality of life on the SF-36 scale, the level physical health(PF) was 45.85 ± 7.31 and mental health (MH) level was 33.48 ± 12.

After seven days of taking Tenoten, all patients subjectively noted an improvement in their well-being, however, the average numerical values ​​revealed significant differences in this group only on the HADS anxiety scale (p
Rice. 1. Dynamics of scores on the HADS anxiety scale in patients of the first group (*p). Further analysis of the dynamics of indicators within the scales in the first group showed that the greatest and most significant changes in the state occurred after 30 days from the start of taking Tenoten. Positive dynamics were observed in the form of a decrease in the number and severity of symptoms of vegetative-vascular dystonia: on the Wayne scale, the number of points significantly decreased to 8–38 (average 20.61 ± 9.52) (p
Rice. 2. Dynamics of scores on the A. M. Wein scale in patients of the first group (*p The mental health indicator (MH) increased significantly to 54.6 ± 4.45 points (p

Rice. 3. Dynamics of physical (PF) and mental (MH) health indicators in patients of the first group (*p Analysis of the HADS anxiety scale showed that 68% did not experience tension at all versus 100% who experienced tension before treatment; in 6%, the number of points remained unchanged; in the remaining 26%, the number of points decreased (patients no longer felt a sense of fear). During the observation period, patients in the first group did not have any active complaints of pain in the pericranial muscles, but after focusing attention on this area. rare headaches. Dermographism remained unchanged. Rare interruptions in heart function were noted by 4% of patients. Sleep returned to normal in 26 people.

A study conducted on the 37th day (seven days after discontinuation of the drug) did not reveal significant differences from the indicators on the 30th day of taking Tenoten, i.e., the resulting effect from taking the drug persisted.

The second group included 5 people with weak positive dynamics in heart rate variability study indicators. They were patients who initially had signs of clinically significant anxiety and depression.

Data before the start of therapy for this group of patients were: the number of points on the Wein scale 41–63 (average 51.80 ± 8.70); HADS anxiety scale 9–18 (13.40 ± 3.36); HADS depression scale 7–16 (10.60 ± 3.78). When assessing the quality of life on the SF-36 scale, these patients had a significantly reduced level of physical health, which was 39.04 ± 7.88, as well as a level of mental health - 24.72 ± 14.57. Analysis of the dynamics of indicators in the second group after 30 days of taking Tenoten revealed a trend towards a decrease in autonomic dysfunction on the Wein scale - from 51.8 to 43.4 points; anxiety-depressive symptoms on the HADS anxiety/depression scale - from 13.4 to 10.4 points and from 10.6 to 8.6 points, respectively; according to SF-36, the mental health (MH) score increased from 24.72 to 33.16, and the physical health (PF) score increased from 39.04 to 43.29. However, these values ​​did not reach statistically significant differences, which indicates the need for individual selection of the duration and regimen of therapy in patients with clinically significant anxiety and depression.

Thus, a retrospective division of patients into two groups during an in-depth examination made it possible to identify signs of clinically significant anxiety and depression in one of the groups, which initially did not differ significantly from the majority of respondents. Analysis of the dynamics of indicators on the main scales after a month of taking Tenoten, 1 tablet 3 times a day, did not reveal significant differences in this group. The anxiolytic and vegetostabilizing effects of Tenoten in the group of clinically severe anxiety and depression with the usual (1 tablet 3 times a day) treatment regimen appeared only in the long term, which can serve as a justification for correcting the treatment regimen and prescribing 2 tablets 3 times a day. Consequently, the data obtained indicate the need to select different regimens for the use of Tenoten depending on the severity of anxiety and depressive symptoms, which provides an individual approach for each patient, forming a high adherence to treatment.

Analysis of heart rate variability in patients of the first group showed significantly significant changes after 30 days of taking Tenoten, which persisted 7 days after discontinuation of the drug. During spectral analysis at the end of a month of therapy absolute values the powers of the LF and HF components, and due to this, the total power of the spectrum (TP) were significantly higher than in the study before taking the drug (from 1112.02 ± 549.20 to 1380.18 ± 653.80 and from 689. 16 ± 485.23 to 1219.16 ± 615.75, respectively, p

Rice. 4. Spectral indicators of HRV at rest in patients of the first group (* significance of differences: compared with the initial indicator, p During spectral analysis during an active orthostatic test after therapy, a lower reactivity of the sympathetic division of the autonomic nervous system (ANS) was noted compared with the initial data , this is evidenced by the values ​​of the LF/HF and %LF indicators, namely LF/HF - 5.89 (1.90–11.2) and 6.2 (2.1–15.1), respectively, %LF - 51 .6 (27–60) and 52.5 (28–69) (p

Rice. 5. Spectral indicators of HRV during an orthostatic test in patients of the first group (* significance of differences: compared with the initial indicator, p Thus, in the first group, when performing HRV after 30 days of taking Tenoten, there is an increase in the total power of the spectrum due to the increased influence of HF- component, as well as the normalization of sympathetic-parasympathetic influences during the background test, the same trends remain in the active orthostatic test, but less pronounced. Analysis of the dynamics of the 30/15 coefficient suggests an increased reactivity of the parasympathetic division of the ANS and, therefore, an increase in the adaptive one. potential as a result of therapy in patients of the first group (Table 1).

Table 1
Spectral indicators of HRV at rest and during an orthostatic test in patients of the first group

Parameter	1st visit (screening)	2nd visit (7 ± 3 days)	3rd visit (30 ± 3 days)	4-visit (36 ± 5 days)
Background recording
TP, ms²	2940.82 ± 1236.48	3096.25 ± 1235.26	4103.11 ± 1901.41*	3932.59 ± 1697.19*
VLF, ms²	1139.67 ± 729.00	1147.18 ± 689.00	1503.68 ± 1064.69*	1402.43 ± 857.31*
LF, ms²	1112.02 ± 549.20	1186.14 ± 600.97	1380.18 ± 653.80*	1329.98 ± 628.81*
HF, ms²	689.16 ± 485.23	764.34 ± 477.75	1219.16 ± 615.75*	1183.57 ± 618.93*
LF/HF	2.08 ± 1.33	1.88 ± 1.12	1.28 ± 0.63*	1.27 ± 0.62*
VLF, %	36.93 ± 16.59	35.77 ± 15.45	35.27 ± 11.44	35.14 ± 11.55
LF, %	38.84 ± 11.62	38.61 ± 11.54	34.25 ± 8.40	34.39 ± 8.51
HF, %	24.16 ± 11.90	25.50 ± 11.69	30.45 ± 10.63*	30.43 ± 10.49*
Orthostatic test
TP, ms²	1996.98 ± 995.85	2118.59 ± 931.04	3238.68 ± 1222.61*	3151.52 ± 1146.54*
VLF, ms²	717.18 ± 391.58	730.91 ± 366.16	1149.43 ± 507.10*	1131.77 ± 504.30*
LF, ms²	1031.82 ± 584.41	1101.43 ± 540.25	1738.68 ± 857.52*	1683.89 ± 812.51*
HF, ms²	248.00 ± 350.36	269.93 ± 249.64	350.59 ± 201.57*	336.05 ± 182.36*
LF/HF	6.21 ± 3.69	5.27 ± 2.68	5.93 ± 3.37	5.59 ± 2.68
VLF, %	36.82 ± 10.69	34.64 ± 9.80	36.93 ± 13.33	36.93 ± 12.72
LF, %	51.64 ± 12.20	52.34 ± 11.23	52.48 ± 12.16	52.27 ± 11.72
HF, %	11.51 ± 9.71	12.69 ± 7.60	10.50 ± 4.09	10.75 ± 3.671
K 30/15	1.26 ± 0.18	1.32 ± 0.16	1.44 ± 0.11	1.44 ± 0.11

Note. *Significance of differences: compared with the original indicator, p

In patients of the second group, spectral analysis of heart rate variability indicators (background recording and active orthostatic test) at the end of a month of therapy did not reveal any significantly significant dynamics in the numerical values ​​of the power indicators of the LF and HF components, and due to this, the total power of the spectrum (TP) . All patients had hypersympathicotonia and high sympathetic reactivity before the start of therapy and a slight decrease in numerical values ​​at the end of therapy, however, the percentage contribution of the sympathetic division of the ANS “before”, “during therapy” and “after its end” remained unchanged (Fig. 6, 7 ).

Rice. 6. Spectral indicators of HRV at rest in patients of the second group

Rice. 7. Spectral indicators of HRV during an orthostatic test in patients of the second group

Analysis of the dynamics of the coefficient 30/15 suggests low parasympathetic reactivity and reduced adaptive potential before the start of therapy with Tenoten and increased reactivity and, therefore, an increase in adaptive potential as a result of treatment in patients of the second group by the end of therapy (Table 2).

Table 2
Spectral indicators of HRV at rest and during an orthostatic test in patients of the second group

Background recording	1st visit (screening)	2nd visit (7 ± 3 days)	3rd visit (30 ± 3 days)	4-visit (36 ± 5 days)
TP, ms²	2573.00 ± 1487.89	2612.80 ± 1453.45	2739.60 ± 1461.93	2589.80 ± 1441.07
VLF, ms²	1479.40 ± 1198.51	1467.80 ± 1153.00	1466.60 ± 1110.23	1438.00 ± 1121.11
LF, ms²	828.80 ± 359.71	862.60 ± 369.07	917.60 ± 374.35	851.60 ± 354.72
HF, ms²	264.60 ± 153.49	282.40 ± 150.67	355.40 ± 155.11	300.20 ± 132.73
LF/HF	4.06 ± 3.02	3.86 ± 2.76	3.10 ± 2.21	3.36 ± 2.37
VLF, %	50.80 ± 15.01	50.00 ± 14.40	48.00 ± 13.29	49.60 ± 14.42
LF, %	35.00 ± 5.79	35.40 ± 5.94	35.80 ± 5.81	35.40 ± 6.15
HF, %	14.20 ± 9.55	14.60 ± 9.50	16.20 ± 9.01	15.00 ± 8.92
K 30/15	1.16 ± 0.12	1.22 ± 0.08	1.31 ± 0.08	1.35 ± 0.04
Orthostatic test
TP, ms²	1718.80 ± 549.13	1864.00 ± 575.61	1857.00 ± 519.17	1793.40 ± 538.21
VLF, ms²	733.80 ± 360.43	769.60 ± 370.09	759.40 ± 336.32	737.40 ± 338.08
LF, ms²	799.00 ± 341.97	881.20 ± 359.51	860.60 ± 307.34	826.20 ± 326.22
HF, ms²	186.20 ± 143.25	213.20 ± 119.58	237.00 ± 117.84	229.80 ± 123.20
LF/HF	6.00 ± 3.56	5.36 ± 3.32	4.60 ± 2.92	4.64 ± 2.98
VLF, %	42.00 ± 11.00	40.40 ± 9.45	40.00 ± 9.38	40.20 ± 9.28
LF, %	45.60 ± 12.46	46.60 ± 12.22	46.20 ± 11.54	45.80 ± 12.24
HF, %	12.40 ± 11.33	13.20 ± 10.28	14.00 ± 9.08	14.20 ± 9.98

Thus, the drug Tenoten had positive influence on the state of the autonomic nervous system in patients with VSD in combination with clinically significant depression. However, a treatment duration of 30 days is insufficient for this group of patients, which serves as a basis for continuing treatment or using an alternative regimen of 2 tablets 3 times a day.

Conclusion

Tenoten is a sedative and vegetative stabilizing drug with a proven high level of safety. The use of Tenoten seems extremely promising in young patients with vegetative-vascular dystonia.

• The study recorded that Tenoten leads to normalization (stabilization) of the autonomic balance in any type of vegetative-vascular dystonia (sympathetic-tonic, parasympathetic-tonic), increased autonomic support for the regulatory functions of the body and increased adaptive potential.
• Tenoten has a pronounced anti-anxiety and vegetative-stabilizing effect.
• During Tenoten therapy, the level of mental and physical health (according to the SF-36 questionnaire) became significantly higher, indicating an improvement in the quality of life of patients.
• Reception of Tenoten by patients with clinical pronounced signs anxiety and depression requires differentiated approach to the treatment regimen and its duration.
• The study noted that Tenoten does not cause side effects and is well tolerated by patients.
• Tenoten can be used as monotherapy for vegetative-vascular dystonia in young patients (18–35 years).

Literature

1. Amosov M. L., Saleev R. A., Zarubina E. V., Makarova T. V. Use of the drug tenoten in the treatment of emotional disorders in patients with transient cerebrovascular accidents // Russian Psychiatric Journal. 2008; 3:86–91.
2. Neurology. National leadership/ Ed. E. I. Guseva, A. N. Konovalova, V. I. Skvortsova, etc. M.: GEOTAR-Media, 2010.
3. Wayne A. M. et al. Autonomic disorders. Clinic, treatment, diagnosis. M.: Medical Information Agency, 1998. 752 p.
4. Vorobyova O. V. Autonomic dystonia- what is hidden behind the diagnosis? // Difficult patient. 2011; 10.
5. Mikhailov V. M. Heart rate variability. Ivanovo, 2000. 200 p.
6. Shvarkov S. B., Shirshova E. V., Kuzmina V. Yu. Ultra-low doses of antibodies to protein S100 in the treatment of autonomic disorders and anxiety in patients with organic and functional diseases CNS // Attending Physician. 2008; 8:18–23.
7. Epshtein O. I., Beregovoi N. A., Sorokina N. S. et al. The influence of various dilutions of potentiated antibodies to the brain-specific protein S-100 on the dynamics of post-tetanic potentiation in surviving slices of the hippocampus // Bulletin of Experimental Biology and Medicine. 1999; 127(3):317–320.
8. Epshtein O. I., Shtark M. B., Dygai A. M. et al. Pharmacology of ultra-low doses of antibodies to endogenous function regulators: monograph. M.: Publishing house RAMS, 2005.
9. Epshtein O.I. Ultra-low doses (the story of one study). Experimental study of ultra-low doses of antibodies to protein S-100: monograph. M.: Publishing house of the Russian Academy of Medical Sciences, 2005. pp. 126–172.
10. Kheifets I. L., Dugina Yu. L., Voronina T. A. et al. Participation of the serotonergic system in the mechanism of action of antibodies to protein S-100 in ultra-low doses // Bulletin of Experimental Biology and Medicine. 2007; 143(5):535–537.
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Effective therapy for post-traumatic stress disorder
disorders
Edited by
Edna B. Foa Terence M. Keane Matthew J. Friedman
Moscow
"Cogito-Center"
2005

UDC 159.9.07 BBK88 E 94
All rights reserved. Any use of materials from this book in whole or in part
without permission of the copyright holder it is prohibited
Edited by E
BOTTOM
Foa. Terence M. Keane, Matthew Friedman
Translation from English under general editing N. V. Tarabrina
Translators: V.A. Agarkov, SA. Pitt- chapters 5, 7, 10, 17, 19, 22, 27 O.A. Crow - chapter 1,
2,11,12,14,15,16, 23, 24, 26 E.S. Kalmykova- chapters 9, 21 EL. Misko- chapters 6, 8, 18, 20 ML.
Padun- chapters 3, 4, 13, 25
E 94 Effective treatment of post-traumatic stress disorder/ Ed. Edna Foa,
Terence M. Keane, Matthew Friedman. - M.: “Cogito-Center”, 2005. - 467 p. (Clinical Psychology)
UDC 159.9.07 BBK88
This guide is based on an analysis of research into the effectiveness of psychotherapy for adults, adolescents, and children with post-traumatic stress disorder (PTSD). The purpose of the manual is to assist the clinician in the treatment of such patients.
Since PTSD therapy is carried out by specialists with different vocational training, the authors of the manual chapters took an interdisciplinary approach to the problem. The book as a whole brings together the efforts of psychologists, psychiatrists, social workers, art therapists, family consultants etc. The chapters of the manual are addressed to a wide range of specialists involved in the treatment of PTSD.
The book consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. The second part contains brief description using different therapeutic approaches to treat PTSD.
© Translation into Russian by Cogito Center, 2005 © The Guilford Press, 2000
ISBN 1-57230-584-3 (English) ISBN 5-89353-155-8 (Russian)

Contents i. Introduction.............................................................................................................7
2. Diagnosis and assessment...........................................................................................28
Terence M. Keane, Frank W. Wethers, and Edna B. Foa
I. Approaches to the treatment of PTSD: a review of the literature
3. Psychological debriefing...................................................................51
Jonathan E. Bisson, Alexander S. McFarlane, Suzanne Ros
4. ...............................................75
5. Psychopharmacotherapy......................................................................... 103
6. Treatment of children and adolescents................................................................ 130
7. Desensitization and reprocessing using eye movements.... 169
8. Group therapy...................................................................................189
David W. Foy, Shirley M. Glynn, Paula P. Schnurr, Mary K. Jankowski, Melissa S. Wattenberg,
Daniel S. Weiss, Charles R. Marmar, Fred D. Guzman
9. Psychodynamic therapy..............................................................212
10. Treatment in hospital.............................................................................239
AND. Psychosocial rehabilitation.......................................................270
12. Hypnosis.............................................................................................................298
Etzel Cardena, Jose Maldonado, Otto van der Hart, David Spiegel
13. ....................................................336
David S. Riggs
^.Art therapy..............................................................................................360
David Reed Johnson

II. Therapy Guide
15. Psychological debriefing................................................................377
Jonathan E. Bisson, Alexander Macfarlane, Suzanne Ros
16. Cognitive behavioral therapy............................................381
Barbara Olasov Rothbaum, Elizabeth A. Meadows, Patricia Resick, David W. Foy
17. Psychopharmacotherapy.........................................................................389
Matthew J. Friedman, Jonathan R.T. Davidson, Thomas A. Mellman, Stephen M. Southwick
18. Treatment of children and adolescents...............................................................394
Judith A. Cohen, Lucy Berliner, John S. March
19. Desensitization and processing
using eye movements......................................................................398
Cloud M. Chemtob, David F. Tolin, Bessel A. van der Kolk, Roger C. Pitman
20. Group therapy...................................................................................402
David W. Foy, Shirley M. Glynn, Paula P. Schnurr, Mary K. Jankowski, Melissa S. Wattenberg,
Daniel S. Weiss, Charles R. Marmar, Fred D. Guzman
21. Psychodynamic therapy..............................................................405
Harold S. Kadler, Arthur S. Blank Jr., Janice L. Krapnick
22. Treatment in hospital.............................................................................408
Christine A. Kurti, Sandra L. Blum
23. Psychosocial rehabilitation.......................................................414
Walter Penk, Raymond B. Flannery Jr.
24. Hypnosis.............................................................................................................418
Etzel Cardena, Jose Maldonado, Otto van der Hart, David Spiegel
25. Marriage and family therapy....................................................423
David S. Riggs
26. Art therapy..............................................................................................426
David Reed Johnson
27. Conclusion and conclusions.............................................................................429
Aryeh W. Shalev, Matthew J. Friedman, Edna B. Foa, Terence M. Keene
Subject index
457

1
Introduction
Edna B. Foa, Terence M. Keane, Matthew J. Friedman
Members of a special commission created to develop guidelines for treatment methods for PTSD were directly involved in the preparation of the materials presented in this book. This commission is organized by the Board of Directors of the International Society for Research traumatic stress(International Society for Traumatic Stress Studies, ISTSS) in November 1997.
Our goal was to describe various ways therapy, based on a review of extensive clinical and research literature prepared by experts in each specific field. The book consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. The second part provides a brief description of the use of different therapeutic approaches in the treatment of PTSD. This guideline aims to inform clinicians of the developments we have identified as best for the treatment of patients diagnosed with post-traumatic stress disorder (PTSD). PTSD is a complex mental condition that develops as a result of experiencing a traumatic event. Symptoms that characterize PTSD include repeated replays of the traumatic event or episodes; avoidance of thoughts, memories, people or places associated with the event; emotional numbness; increased arousal. PTSD is often comorbid with other mental disorders and is a complex illness that can be associated with significant morbidity, disability, and impairment of life. important functions.

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In developing this practice guide, the Select Committee acknowledged that traumatic experiences can lead to the development various violations, such as general depression, specific phobias; disorders of extreme stress not otherwise specified (DESNOS), personality disorders such as borderline anxiety disorder and panic disorder. However, the main focus of this book is the treatment of PTSD and its symptoms, which are listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, 1994)
American Psychiatric Association.
The guideline authors acknowledge that the diagnostic scope of PTSD is limited and that these limitations may be particularly evident in patients who have experienced childhood sexual or physical abuse. Often, patients diagnosed with DESNOS have a wide range of problems in relationships with other people, which contribute to impairments in personal and social functioning. Relatively little is known about the successful treatment of these patients. The consensus among clinicians, supported by empirical data, is that patients with this diagnosis need long-term and complex treatment.
The Task Force also recognized that PTSD is often comorbid with other mental disorders and that these concomitant diseases require sensitivity, attention from medical personnel, as well as clarification of the diagnosis throughout the entire treatment process.
Disorders requiring special attention are abuse chemicals and general depression as the most common comorbid conditions.
Practitioners may refer to guidelines for these disorders to develop treatment plans for individuals demonstrating multiple disorders and to the comments in Chapter 27.
This guide is based on cases of adults, adolescents and children suffering from PTSD. The purpose of the guide is to assist the clinician in treating these individuals. Because PTSD is treated by clinicians with a variety of backgrounds, these chapters were developed using an interdisciplinary approach. Psychologists, psychiatrists, social workers, art therapists, family counselors and other specialists actively participated in the development process. Accordingly, these chapters address a wide range of professionals involved in the treatment of PTSD.
The Special Commission excluded from consideration those individuals who are currently being subjected to violence or insults. These individuals (children who live with an abusive person, men

9 and women who experience abuse and violence in their home), as well as those living in war zones, may also meet the criteria for diagnosis
PTSD. However, their treatment, and the associated legal and ethical issues, differ significantly from the treatment and problems of patients who have experienced traumatic events in the past. Patients directly in a traumatic situation require special attention from clinicians. These circumstances require the development of additional practical guidelines.
Very little is known about the treatment of PTSD in industrialized regions. Research and development on these topics is carried out mainly in Western industrialized countries.
The Special Commission is keenly aware of these cultural limitations. There is a growing belief that PTSD is a universal response to traumatic events that is found across many cultures and societies. However, there is a need for systematic research to determine the extent to which treatments, both psychotherapeutic and psychopharmacological, that have proven effective in Western societies will be effective in other cultures.
In general, practitioners should not limit themselves to only the approaches and techniques outlined in this manual. The creative integration of new approaches that have demonstrated effectiveness in the treatment of other disorders and have a sufficient theoretical basis is encouraged in order to improve treatment outcomes.
PROCESS OF WORK ON THE GUIDE
The development process for this guide was as follows. Co-Chairs
A special commission identified specialists in the main therapeutic schools and methods of therapy that are currently used in working with patients suffering from
PTSD. As new effective methods of therapy were found, the composition of the Special Commission expanded. Thus, the Special Commission included specialists from various approaches, theoretical orientations, therapeutic schools, and professional training. The focus of the Guide and its format were determined by the Special Commission over a series of meetings.
The co-chairs instructed the members of the Special Commission to prepare an article on each area of ​​therapy. Each article had to be written by a recognized expert with the support of an assistant, whom he independently selected from among other panel members or clinicians.

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Articles were required to review the literature on research in the field and clinical practice.
Literature reviews for each topic are compiled using online search engines such as Published International Literature on Traumatic Stress
International Literature on Traumatic Stress, PILOTS), MEDLINE and PsycLIT In the final version, articles were reduced to a standard format and limited in length. The authors cited literature on the topic, presented clinical developments, provided a critical review of the scientific basis for a particular approach, and presented the articles to the chair. The completed articles were then distributed to all members of the Special Commission for comments and active discussion. The results of the reviews with modifications turned into articles and subsequently became chapters of this book.
Based on articles and careful study of the literature, a set of brief practical recommendations for each therapeutic approach. It can be found in Part II.
Each therapeutic approach or modality in the guideline was rated according to its therapeutic effectiveness. These ratings were standardized according to a coding system adapted by the Agency for Health Care Policy and Research (AHCPR).
The rating system below is an attempt to formulate recommendations for practitioners based on available scientific advances.
The Guide was reviewed by all members of the Special Committee, agreed upon and then presented to the ISTSS Board of Directors, submitted to a number of professional associations for review, presented at the ISTSS Annual Convention Public Forum, and posted on the website
ISTSS for comments from lay members of the scientific community. Materials resulting from this work were also included in the manual.
Published research on PTSD, as with other mental disorders, contains certain limitations. In particular, most studies use inclusion and exclusion criteria to determine whether the diagnosis is appropriate for a particular case; therefore, each study may not fully represent the spectrum of patients seeking treatment. PTSD studies, for example, often do not include patients with substance abuse disorders, suicidal risk, neuropsychological impairment, developmental delays, or cardiovascular diseases. This guideline covers studies that do not involve these patient populations.

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CLINICAL PROBLEMS Type of injury
Most randomized clinical trials conducted on veterans of wars (mostly Vietnam) found that treatment was less effective for this population compared with non-combat veterans whose PTSD was associated with other traumatic experiences (eg, rape, accidents). accidents, natural disasters). This is why some experts believe that war veterans suffering from PTSD are less responsive to treatment than those who have experienced other types of trauma. This conclusion is premature. The difference between veterans and other patients with PTSD may be due to the greater severity and chronicity of their PTSD rather than to characteristics specific to military trauma. In addition, low rates of treatment effectiveness for veterans may be associated with the characteristics of the sample, since groups are sometimes formed from volunteer veterans, chronic patients with multiple impairments. In general, at this time it is not possible to draw a clear conclusion that PTSD after certain traumas may be more resistant to treatment.
Single and multiple injuries
No studies have been conducted among patients with PTSD. clinical trials to answer the question of whether the number of previous traumas may influence the course of treatment for PTSD. Because most studies have been conducted on either military veterans or sexually abused women, most of whom have experienced multiple traumas, it has been found that much of what is known about the effectiveness of treatment applies to people who have had multiple traumatic experiences. Studies of individuals with single and multiple traumatization would be of great interest to determine whether the former are expected to respond better to treatment. However, conducting such studies can be quite complex, since it would be necessary to control for factors such as concomitant diagnoses, severity and chronic nature PTSD, and each of these factors may be a more significant predictor of treatment outcome than the amount of trauma experienced.

Year of manufacture: 2005

Genre: Psychology

Format: PDF

Quality: OCR

Description: Members of a special commission created to develop guidelines for treatment methods for PTSD were directly involved in the preparation of materials presented in the book “Effective Therapy for Post-Traumatic Stress Disorder.” This panel was organized by the Board of Directors of the International Society for Traumatic Stress Studies (ISTSS) in November 1997. Our goal was to describe the various treatments based on a review of the extensive clinical and research literature prepared by experts in each specific field. The book “Effective Therapy for Post-Traumatic Stress Disorder” consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. The second part provides a brief description of the use of different therapeutic approaches in the treatment of PTSD. This guideline aims to inform clinicians of the developments we have identified as best for the treatment of patients diagnosed with post-traumatic stress disorder (PTSD). PTSD is a complex mental condition that develops as a result of experiencing a traumatic event. Symptoms that characterize PTSD include repeated replays of the traumatic event or episodes; avoidance of thoughts, memories, people or places associated with the event; emotional numbness; increased arousal. PTSD is often comorbid with other mental disorders and is a complex illness that can be associated with significant morbidity, disability, and impairment of vital functions.

When developing this practical guide, a special commission confirmed that traumatic experiences can lead to the development of various disorders, such as general depression, specific phobias; disorders of extreme stress not otherwise specified (DESNOS), personality disorders such as borderline anxiety disorder and panic disorder. However, the main focus of this book is the treatment of PTSD and its symptoms, which are listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) of the American Psychiatric Association.
The authors of the Effective Treatments for Post-Traumatic Stress Disorder manual acknowledge that the diagnostic scope of PTSD is limited and that these limitations may be particularly evident in patients who have experienced childhood sexual or physical abuse. Often, patients diagnosed with DESNOS have a wide range of problems in relationships with other people, which contribute to impairments in personal and social functioning. Relatively little is known about the successful treatment of these patients. The consensus among clinicians, supported by empirical data, is that patients with this diagnosis require long-term and complex treatment. The Special Commission also recognized that PTSD is often accompanied by other mental disorders, and these comorbidities require sensitivity, attention, and clarification of the diagnosis by medical personnel throughout the treatment process. Disorders requiring special attention are substance abuse and general depression as the most common comorbid conditions. Practitioners may refer to guidelines for these disorders to develop treatment plans for individuals demonstrating multiple disorders and to the comments in Chapter 27.
The Effective Treatment for Post-Traumatic Stress Disorder guideline is based on cases of adults, adolescents, and children suffering from PTSD. The purpose of the guide is to assist the clinician in treating these individuals. Because PTSD is treated by clinicians with a variety of backgrounds, these chapters were developed using an interdisciplinary approach. Psychologists, psychiatrists, social workers, art therapists, family counselors and other specialists actively participated in the development process. Accordingly, these chapters address a wide range of professionals involved in the treatment of PTSD.
The Special Commission excluded from consideration those individuals who are currently being subjected to violence or insults. These individuals (children who live with an abusive person, men and women who are abused and abused in their home), and those living in war zones may also meet criteria for a diagnosis of PTSD. However, their treatment, and the associated legal and ethical issues, differ significantly from the treatment and problems of patients who have experienced traumatic events in the past. Patients directly in a traumatic situation require special attention from clinicians. These circumstances require the development of additional practical guidelines.
Very little is known about the treatment of PTSD in industrialized regions. Research and development on these topics is carried out mainly in Western industrialized countries. The Special Commission is keenly aware of these cultural limitations. There is a growing belief that PTSD is a universal response to traumatic events that is found across many cultures and societies. However, there is a need for systematic research to determine the extent to which treatments, both psychotherapeutic and psychopharmacological, that have proven effective in Western societies will be effective in other cultures. In general, practitioners should not limit themselves to only the approaches and techniques outlined in this manual. The creative integration of new approaches that have demonstrated effectiveness in the treatment of other disorders and have a sufficient theoretical basis is encouraged in order to improve treatment outcomes.

The book “Effective Therapy for Post-Traumatic Stress Disorder” is based on an analysis of the results of research on the effectiveness of psychotherapy for adults, adolescents and children suffering from post-traumatic stress disorder (PTSD). The purpose of the manual is to assist the clinician in the treatment of such patients. Since PTSD treatment is carried out by specialists with various professional training, the authors of the chapters of the manual took an interdisciplinary approach to the problem. The book as a whole brings together the efforts of psychologists, psychiatrists, social workers, art therapists, family counselors, etc. The chapters of the manual are addressed to a wide range of specialists involved in the treatment of PTSD.
The book “Effective Therapy for Post-Traumatic Stress Disorder” consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. Part 2 provides a brief description of the use of different therapeutic approaches to treat PTSD.

"Effective Therapy for Post-Traumatic Stress Disorder"

1. Diagnosis and evaluation

Treatment approaches for PTSD: a review of the literature

1. Psychological debriefing
2. Psychopharmacotherapy
3. Treatment of children and adolescents
4. Group therapy
5. Psychodynamic therapy
6. Treatment in hospital

Psychosocial rehabilitation

1. Hypnosis
2. Art therapy

Therapy Guide

1. Psychological debriefing
2. Cognitive behavioral therapy
3. Psychopharmacotherapy
4. Treatment of children and adolescents
5. Desensitization and reprocessing using eye movements
6. Group therapy
7. Psychodynamic therapy
8. Treatment in hospital
9. Psychosocial rehabilitation
10. Hypnosis
11. Marriage and family therapy
12. Art therapy

Conclusion and conclusions