If in the 19th century people died mainly from infectious diseases, today diseases of civilization have come to the fore among the causes of death. They are named so because they are largely determined by the way of life of modern people, which is characterized by low physical activity, overnutrition, constant emotional overstrain.

These diseases primarily include cardiovascular: arterial hypertension, coronary heart disease, concomitant myocardial infarction and cerebral stroke. Psycho-emotional stress also underlies obesity, peptic ulcer of the stomach and duodenum, bronchial asthma, diabetes, allergies, arthritis.

Human health, therefore, largely depends on how he endures stressful situations, how optimal ways of solving life problems he chooses. It has been noted that centenarians "often have a calm character, love of life, optimism, and a desire to be useful to people.

Chronic emotional or nervous overstrain" can occur for a variety of reasons: this is job dissatisfaction, conflicts at work or in the family, and poor working and living conditions. Negative emotions leading to stress can also be the result of sad events in life, for example, death of a loved one, divorce, etc. However, it is not the circumstances themselves, sometimes beyond our control, that lead to stress, but the way we perceive them.

In many countries of the world, including ours, mass population studies were carried out using psychodiagnostic methods. It was found that people who are suspicious, insecure, prone to despondency, as well as angry, vindictive, irritable, often conflicting have a higher risk of getting angina pectoris, myocardial infarction or arterial hypertension. This is due to the fact that negative character traits reduce a person’s resistance to stress, contribute to the emergence of strong negative emotions at the slightest pretext. Such an emotional state often becomes chronic, which, in turn, causes adverse physiological reactions, leading to the development of diseases.

Even Hippocrates said: "Despondency, melancholy, fear, anger destroy the body." The scientist X. V. Hufeland, who lived in the 18th century, wrote: “Among the influences that shorten life, fear, sadness, despondency, longing, cowardice, envy, hatred occupy a predominant place.” It is curious that modern scientific research has confirmed these words.

That is why it is so important to train your emotions, try not to dramatize events, be able to switch off from depressing thoughts, establish equal relations with others, and be benevolent towards people. Learn to “extinguish” conflict situations, not attach importance to minor troubles, missteps made by others, and be critical of yourself. Try not to be the initiator of conflicts. Before giving vent to your emotions, think for a second: will you help yourself if you show incontinence, won't you heat up the atmosphere even more? Think: is it worth getting annoyed at all in this situation?

There is another way to deal with stressful situations. This is humor. It is well known that laughter helps to get rid of excessive nervous tension. Looking at the situation with humor, you can largely overestimate its dramatic nature, otherwise treat the cause of the conflict and your behavior. And, by the way, it is very important in a conflict situation to understand and feel the thoughts and mood of the “enemy”. Don't try to force your point of view on others. Listen to your opponent's point of view and try to respect it. On the contrary, try to critically perceive your point of view. Don't be ashamed to admit you're wrong and give in. Reasonable concessions are not only useful for business, but also cause the respect of others.

Know how to distract yourself from worries and troubles for a while, no matter how great they are. If something is bothering you, distract yourself with some household chores, go to the cinema, to an exhibition, listen to your favorite music or read an interesting book. Communication with nature helps many people - hiking, climbing, just a walk in the park. Talk to a close friend, girlfriend who will understand and support you.

Scientists have long proven that the best way to relieve nervous tension is physical activity. It can be physical labor, such as gardening, or physical education - walking, running, swimming, gymnastics, any other sport that you enjoy.

Try to walk as much as possible (5-8 kilometers a day). If there is not enough time for walking, walk to work and on business. By

if possible, do not use the elevator. Climbing stairs 3-5 floors is a great workout, and such physical activity helps to better endure stress and relieve nervous strain. Being in good physical shape, a person will resist a viral infection, and withstand heavy workloads. Interestingly, all this has a scientific basis. During physical activity, substances such as endorphins and enkephalins are produced in the body, which have the ability to improve mood, vitality, and make it easier to endure various kinds of stress.

It has also been noticed that those who devote at least 20 minutes to physical education a day are more restrained, correct, and smile more often. With systematic training, anxiety decreases, self-confidence increases - a person's character becomes balanced and calm.

Physical exercise also ensures good sleep. which is also important for coping with stressful situations.

An excellent remedy for stress is a bath (steam or sauna). The bath procedure enhances metabolism, activates blood circulation and thereby relieves nervous and physical fatigue, restores strength, increases vitality, improves mood. If there are no contraindications, then it is advisable to go to bath every 7-10 days.

Autogenic training has proven itself well. Of course, it is necessary to master its techniques with the help of a specialist. Auto-training gives you the opportunity to independently influence your mental and physical state. After all, relaxation of the muscles of the body also relieves nervous tension, normalizes the activity of the nervous system. With the help of such training, you can quickly restore working capacity, improve mood and sleep, and achieve many other useful results.

Perhaps, in order to fulfill all the tips given here, you will need not only to review and change your habits, lifestyle, but also your character. And this requires readiness and desire. In the early stages, this can cost you a lot of effort. But your efforts will pay off handsomely: the psychological climate in the family and at work will improve, you will become more balanced, optimistic and cheerful.

F. B. Berezin, M. P. Miroshnikov

The systematic study of the influence of emotional reactions on somatic health is an important element of the psychosomatic approach to illness. The role of emotions in the formation of psychophysiological relationships (i.e., the system of interaction between mental and biological factors) is determined by the fact that emotions, acting as a subjective experience of individually significant stimuli, include reactions from various physiological systems. Taking into account this circumstance, the mechanisms of pathophysiological effects of emotions were investigated, in particular; the relationship of varieties of emotions with the nature of the pathology; individual characteristics of emotional response and the significance of personality traits associated with them (including their ontogenesis) in susceptibility to certain somatic diseases. This article is devoted only to the most general aspects of psychosomatic relationships in emotional stress and consideration of their patterns using several characteristic nosologies as an example.

We can talk about emotional stress if the emotion acquires strength and (or) duration, in which the individual's ability to restore mental balance by resolving the stressful situation (by influencing this situation, eliminating stressful factors, or by changing one's own attitude towards it) is insufficient. relations). The ways in which an individual copes with emotional problems, and their effectiveness, are very important for his state of health. These methods are denoted by the term "coping" (overcoming, coping). The process of resolving a stressful situation is the essence of mental adaptation. If the process of mental adaptation is not effective enough, the physiological components of emotions during emotional stress acquire pathogenetic significance in the formation of psychosomatic disorders.

In the study of nonspecific adaptation syndrome in relation to psychosomatic disorders, special attention should be paid to the features of stressors of a psychological nature, which distinguish them from physical ones. The range of the latter is relatively limited, they are associated with a direct effect on the body. The set of reactions to these stressors in different people basically coincide, while the set of mental stressors and the nature of reactions to them are determined by the characteristics of individual experience and therefore are extremely diverse. The same impact can be stressful, unbearable for one person and be indifferent or even desirable for another.

Opinions are also expressed about the difference in reactions to physical and mental stressors. According to some authors, the fundamental difference in the body's response to stressors of a physical or psychosocial nature is that physical stressors, such as infections, fever, heat exposure and intoxication, as a rule, cause vasodilation and a drop in blood pressure, and sympathoadrenal activation is a secondary protective response to these physiological changes. On the contrary, psychosocial stimuli lead to direct sympathetic activation, without mediation through a drop in vascular tone and blood pressure, since the biological function of the nonspecific response to these stressors is, in particular, to bring the body into a state optimal for intense activity. However, this difference cannot be considered absolute. The reaction to the impact of mental stressors in some cases can also manifest itself mainly in vagoinsular shifts (including vasodilation and arterial hypotension), in a decrease in the production of catecholamines. However, regardless of the primary reaction, further consequences for the body are the same for both physical and emotional stress.

Since emotional stress is the mobilization of all body systems, which prepares it for physical activity (“fight-flight”), with chronic exposure to a stressful factor, the initial stage of stress is the stage of anxiety, characterized by changes in humoral regulation typical of this stage and transient autonomic reactions (more often from the side of the cardiovascular system), goes into the stage of resistance. Chronic vegetative-humoral activation in this case at the initial stage is manifested by symptoms of vegetative dystonia and can serve as the basis for the development of more pronounced psychosomatic disorders. It should be taken into account that in modern society, mental stress significantly predominates over physical stress, especially when you consider that people react not only to real, current situations, but also to imaginary dangers, to painful emotionally saturated memories, to many negatively colored messages, in particular delivered by the media. In addition, the body can respond to mental stress much stronger than physical. As a result, the possibilities of resistance are exhausted, and the stage of exhaustion occurs. Under the influence of ongoing emotional stress, various psychosomatic disorders develop, the formation and nature of which depend on genetic predisposition, on the insufficiency of certain body systems and personality traits acquired in ontogenesis.

For the development of psychosomatic disorders, it is especially important that during emotional stress, changes are noted in the entire multilevel system of regulation of psychophysiological relationships. At different levels of this system, such regulation is carried out mainly by psychological or mainly physiological mechanisms. Psychological mechanisms are realized mainly at the socio-psychological (interpersonal relations, social interaction) and psychological (personal characteristics and current mental state) levels, and physiological - at the levels of integrative cerebral systems, peripheral vegetative-humoral and motor mechanisms, the executive system or organ ( Fig. 1). For the formation of psychosomatic disorders under emotional stress, the changes observed at each of these interrelated levels are significant, and approaches to the treatment of psychosomatic disorders should be determined taking into account these changes.

Rice. one. Multilevel system of organization of psychophysiological relationships 1 - macrosocial impacts; 2 - individual characteristics of the persons with whom the interaction is carried out; 3 — nature of intragroup interaction; 4 - interpersonal relationships; 5 - personality traits and current mental state; 6 - neocortex; 7 - limbic-hypothalamic-reticular complex; 8 - peripheral mechanisms of vegetative humoral regulation; 9 - organ or executive system.

At the socio-psychological level of the system of psychophysiological regulation, the development of psychosomatic disorders is facilitated by the large massiveness, firstly, of psychosocial stressors that depend on macrosocial processes and affect large groups of people, and, secondly, individually significant stressors associated with certain areas of the social interactions: psychosomatic disorders are usually found in individuals exposed to a large number of mental (psychosocial) stressors. Comparative studies made it possible to establish that in psychosomatic disorders there is a steady tendency to an increase in the number of stressful situations, significant life events (and, in particular, events that were regarded as undesirable), not only in comparison with the control group of healthy subjects, but even in comparison with the group persons suffering from neurotic disorders, but not showing severe somatic pathology. Situations in which the realization of urgent needs was blocked (frustrating situations) could occur in any of the essential areas of the patient's life and usually affected several areas at once. Differences in the number of significant life events between the control group and the group of people suffering from psychosomatic disorders were especially large in the family sphere and in the sphere of work, i.e., where interaction with the environment is most important and is implemented intensively. At the same time, life events were recorded significantly more often than in the control, the perception of which was accompanied by negative emotions. The most characteristic in psychosomatic disorders were stressful situations related to conflicts in various areas of social interaction, exclusion from the social context (for example, migration, retirement, job loss), loss of loved ones (especially the death of a spouse or actual breakup of marriage), threats to social status and important life values.

Greater intensity and a certain specificity of negative influences that contribute to the emergence of emotional stress in persons suffering from psychosomatic disorders (compared to healthy and neurotic people) are already noted in childhood. Violations of socialization and negative emotional experience received by these individuals in childhood were determined by the characteristics of the personality and behavior of parents, causing a lack of social support and a sense of threat, preventing the adaptive expression of emotions and the assimilation of adequate sex-role stereotypes, as well as the emotional instability of parents, conflicting trends in education, generating unpredictability of the future. The lack of social support in childhood was often combined with the fact that the health of parents was perceived by children as poor.

Stereotypes of reaction and emotional experience formed in childhood, which subsequently determine the individual significance of life events, lack of a sense of basic security and inadequate behavior patterns create sensitization to mental stressors, expand their range and reduce the resources of the individual necessary to resolve stressful situations. The pathogenetic role of the factors acting in childhood is preserved in the future also because negative emotional experience is reactivated in similar conditions, no matter how far in the past it lies. Thus, although the influence of stressors in the process of social interaction is essential for the emergence of both neurotic and psychosomatic disorders, the latter are characterized by its greater intensity at various stages of the life path.

For the formation of psychosomatic disorders, it is important that violations of interaction in the family and extra-family environment, the relationship of the individual with significant persons positively correlate with physiological changes. These shifts can appear already with one expectation of such violations and even be more pronounced, especially in situations characterized by uncertainty and unpredictability.

The relationship between stressful influences caused by a violation of socio-psychological adaptation and a change in physiological parameters is indirect and is realized through psychological mechanisms involved in the formation of psychophysiological relationships (psychological level of regulation). The influence of psychosocial stressors, the violation of social interaction are associated with the blockade of certain socially significant needs, which causes a state of frustration, manifested by a more or less pronounced feeling of dissatisfaction. For the formation of mental stress, it is essential that the effects of repeated and successive frustrating influences (in which various, often unconscious needs can be blocked), accumulate, cause an increase in total frustration tension, which is closely related to an increase in anxiety and emotional stress. The severity of total frustration tension and anxiety in psychosomatic disorders is significantly higher than in the healthy group. In turn, the level of anxiety correlates with the severity of physiological changes. The significance of anxiety in the pathogenesis of psychosomatic disorders is determined by its role as the main link in the formation of emotional stress and its place in the system of organization of psychophysiological relationships. For the development of psychosomatic disorders, not only a high level of anxiety is important, but also the specific weight of physiological parameters in that complex psychophysiological reaction to a stressor, the central element of which is anxiety. The factor analysis carried out in our laboratory (F. B. Berezin, P. E. Dedik) showed that the proportion of the dispersion of this complex characteristic, which is explained by changes in physiological parameters in psychosomatic disorders, is twice as high as in the control group.

One of the reasons for the increase in the intensity of physiological reactions in psychosomatic disorders can be considered the lack of ability to adequately respond to emotions in behavior. Violation of this ability leads to a significant increase in vegetative-humoral activation in the event of anxiety and emotional stress. The insufficiency of an adequate reaction of emotions may be associated with a pronounced tendency to control one's own behavior. This tendency is most determined by the need to follow the accepted norm, not to draw the attention of others to their emotional problems, to look socially well, a conscious desire to meet social expectations. Behavior control has a dual effect: its high level improves social interaction and reduces the number of frustrating situations; at the same time, it makes it difficult to adequately respond to emotions, which leads to an increase in vegetative-humoral activation, an increase in physiological changes. A comparative study shows that in the group of people suffering from psychosomatic disorders, the level of behavior control is significantly higher than in neurotic or personality disorders.

Difficulties in reacting to emotions may also be due to insufficient ability to recognize and express them, including verbal. This feature (dubbed "alexithymia") may play an important role in the pathogenesis of psychosomatic disorders. More importantly, in psychosomatic disorders, emotional tension is usually determined not by an isolated emotion, but by the simultaneous existence of conflicting emotions, such as anxiety and aggression, anger and depression, feelings of dependence and ambition. The inconsistency of emotions largely arises due to the disharmony of the personality, since the stereotypes of emotional response are closely related to certain personal characteristics. Disharmonious personality traits include a combination of a tendency to “get stuck” in hostility, a tendency to blame others for the unfavorable development of the situation with anxiety, increased sensitivity to negative environmental signals, and sensitivity. There is also a combination of insufficient acceptance of social norms, readiness to protest with the need to control one's behavior in accordance with these norms, to maintain close positive ties with the environment.

A disharmonious combination of personality traits contributes to internal inconsistency, the simultaneous existence of comparable in strength, but incompatible needs (intrapsychic conflict). An intrapsychic conflict, on the one hand, increases frustration and anxiety, and on the other hand, it prevents the awareness of emotions and leads to a blockade of the response of each of them. In addition, as a result of an intrapsychic conflict, the forms of behavior that, with effective mental adaptation, are determined by a certain emotion or personal characteristic, are mutually inhibited, which makes it difficult (or impossible) to overcome emotional problems, since it complicates the choice of an adequate behavioral strategy aimed at resolving a traumatic situation. Decreased ability to build integrated behavior (focused on solving the problem, taking into account the needs of the individual and the requirements of the environment, immediate and long-term consequences) is one of the risk factors for the occurrence of psychosomatic pathology.

It is possible to avoid the consequences of emotional stress, including those leading to psychosomatic disorders, either by eliminating the external source of stressful influences, or by changing the attitude towards the situation. The first is achieved either by actively influencing the environment, or by leaving a frustrating situation (change of lifestyle, nature of activity, avoidance of unwanted contacts, etc.). As for changing the attitude to the situation, it is realized with the participation of psychological defenses (mechanisms of intrapsychic adaptation), due to which the perception or awareness of anxiety-causing stimuli is blocked, the circle of stressors narrows, the intensity of blocked needs decreases, their significance or ways of satisfaction change, the interpretation of what is happening changes. As a result of the action of psychological defenses, the perception, processing and use of the information received changes in such a way that the level of anxiety decreases and the likelihood of the appearance of emotions that are undesirable due to their excessive intensity or negative coloring decreases. Psychological defenses largely determine the mental activity of a person, are important factors involved in the formation of personality and play a significant role in its adaptation to the social environment. Psychological defenses can contribute to the construction of adequate and socially successful behavior. They may also provide relative or temporary alleviation of emotional distress through behavioral restriction, modest reductions in quality of life and socially useful functioning. However, with excessive severity and stability, they acquire a pathogenetic role in the development of mental and psychosomatic disorders.

Of all the variety of psychological defenses that are essential for the formation of psychosomatic disorders, one of the most important is the somatization of anxiety, as a result of which anxiety is attributed to somatic rather than psychological factors. Somatization of anxiety provides a socially acceptable way out of difficult and emotionally significant problems (usually related to interpersonal interaction), shifting the focus from these problems to bodily sensations. It may be preceded by a protective blocking of the ability to recognize the causes of a stressful situation, resulting in an indefinite (“free-floating”) anxiety, which is then fixed on somatic sensations and disorders. The psychological genesis of such disorders is often denied, even if a direct dependence of the deterioration on the stressful situation is found. It is also important that under the influence of psychological defenses, depreciation of previously significant needs and a change in the direction of emotional reactions (in particular, the displacement of aggression from an external object to oneself) can occur. This is typical for depressive states, which can contribute to the development of somatic pathology.

The influence of emotional stress on somatic functions is realized due to the fact that the inclusion of the level of integrative cerebral systems in the process of psychophysiological regulation of the level of integrative cerebral systems is associated with emotional mechanisms, frustration and anxiety. The structures of the limbic-hypothalamoreticular complex in close interaction with the frontal cortex (considered as a neocortical continuation of the limbic system) act as a neurophysiological substrate for such regulation at this level, and both clinical and experimental data indicate a special role in this complex of hypothalamic structures. This is due to the fact that the hypothalamus, while playing an important role in the formation of motivations and emotions, at the same time is the central link in the system that coordinates the vegetative-humoral and motor mechanisms of behavior. Emotional tension arising from mental stress leads to somatic changes due to the implementation of hypothalamic influences through the nerve pathways, the system of releasing factors and tropic hormones of the pituitary gland, which causes changes in the autonomic-humoral regulation. Hormones and mediators involved in this regulation, in turn, affect the mechanisms for switching on and maintaining certain emotional states. The physiological changes noted in this case are characterized by an increase in the activity of the sympathetic-adrenal and hypothalamic-pituitary-adrenal systems with increased production of catecholamines and glucocorticoids, as well as activation of thyroid function with a change in iodine binding by proteins. Norepinephrine and epinephrine increase the release of releasing factors by the hypothalamus, and under the influence of the corticotropin-releasing factor, ACTH production increases, followed by an increase in glucocorticoid production and an even greater activation of catecholamine synthesis. In parallel, insulin production may increase as a result of its activation by an increase in blood sugar, as well as due to the influence of catecholamines through β-adrenergic receptors. An increase in sympathoadrenal activity is accompanied by hemodynamic (increase in cardiac output and stroke volume, increase in peripheral vascular resistance and blood pressure) and metabolic (increase in blood sugar and lipids due to the ?-adrenergic effect of lipolysis of free fatty acids, as well as low density lipoproteins) shifts. Increases blood clotting. Due to metabolic shifts, there is a change in the intima of the vessels with the accumulation of neutrophilic fats and acidic polysaccharides. This complex of shifts, which reflects the body's readiness for action and is called the "ergotropic syndrome", is the most typical of emotional stress. At the same time, the intensity of the described changes reflects the severity of anxiety, the intensity of which determines the production and metabolism of catecholamines and corticosteroids, and, accordingly, vegetative and metabolic changes, in particular, the intensity of cardiac activity, blood pressure, blood sugar, triglycerides, cholesterol. , low density lipoproteins .

In addition to vegetative-humoral and metabolic changes, the described syndrome also includes an increase in muscle tone, diffuse or structured, that is, spreading to certain muscle groups, depending on the predominance of postures and movements that would be realized according to a stressful situation (for example, flight or aggression), if they were not consciously restrained in the conditions of life of modern man. Especially noticeable are the consequences of muscular hypertension in the lumbar and cervical regions, where they contribute to the occurrence of dislocations in the spine, as well as spondyloarthrosis and myositis.

Assessing the effect of stress on the state of autonomic-endocrine regulation, it is important to note that the concentration of glucocorticoids and catecholamines in the blood, which always increases in the anxiety stage, varies widely in the resistance phase depending on the severity of the stress state. If a stable and intense effect of a stressor continues, their concentration is constant or remains high most of the time. Such a development of the situation with emotional stress is especially likely, since, as already noted, emotional stress in modern society is characterized by significant intensity. This is due to the severity and speed of changes in social stereotypes, an increase in the sense of threat, and the frequency of negatively colored interactions. The tendency to reactivate negative emotional experience further contributes to the maintenance of a high concentration of glucocorticoids and catecholamines in the resistance phase. Against this background or after the onset of the stage of exhaustion, certain psychosomatic disorders develop, the nature of which depends on the characteristics of the psychophysiological response, which are reproduced in each individual case quite constantly.

As a result of emotional stress, in addition to the described ergotropic syndrome, vegetative-humoral changes are also observed, characterized by activation of the vagoinsular system (trophotropic syndrome). The occurrence of such changes may be the result of reciprocal relationships between the sympathoadrenal and vagoinsular systems (when vagoinsular shifts are hypercompensation of the primary sympathoadrenal reaction) or individual characteristics of psychophysiological relationships. Somatic shifts in this case are manifested in arterial hypotension, increased secretory activity and dyskinesia of the gastrointestinal tract. In real conditions, often we are not talking about an exclusively ergotropic or trophotropic orientation of changes, but only about a more or less significant predominance of these reciprocal relationships, vegetative-humoral systems. A decrease in sympathoadrenal activity and an increase in vagoinsular activity are more often observed in individuals who, due to the characteristics of individual development, are prone to addiction and are oriented to outside help, although in the case of hypercompensation of this tendency, they are oriented towards high personal achievements. A similar set of reactions can occur if a state of stress is accompanied by a feeling of hopelessness and a rejection of coping behavior.

An important role for the development of psychosomatic disorders is played by the influence of emotional stress on the immune system, which is found in the inhibition of immunological reactions by increased production of hydrocortisone, in glucocorticoid-mediated atrophy of the thymus, and in changes in the T-system of immunity. In chronic emotional stress, changes in the level of immunoglobulins, activation of antibody production, and increased autoimmune processes were also noted.

All of the above gives reason to believe that the pathogenetic patterns of the development of psychosomatic disorders are associated with a certain stereotype of the organization of psychosomatic relationships. Such a stereotype includes the presence of individually significant frustrating situations, an increase in frustration tension, an increase in anxiety, leading to an intensification of psychological defenses (the type and severity of which are associated with the characteristics of the psychological state and psychophysiological relationships), insufficient response of emotions, mainly due to disharmonious personality traits. An increase in anxiety and emotional stress leads to the inclusion in the described stereotype of the development of psychosomatic disorders of the integrative cerebral systems discussed above, including the hypothalamic structures, through which a complex of physiological changes is realized, which determines, along with the state of the mental sphere, the nature of psychosomatic disorders, general and specific features of the psychophysiological reactions. The type of this reaction depends on the characteristics of the subject, which are based on a combination of genetic prerequisites and factors affecting the individual during the life path, in particular, during the period of early socialization. When implementing the described stereotype of the development of psychosomatic disorders, two points are essential: the nature of psychological reactions associated with a certain constellation of personality traits, and the special relationship between the mental and somatic aspects of the response (Fig. 2).

Rice. 2. Stereotype of the development of psychosomatic disorders

The variety of physiological changes that occur during emotional stress suggests that emotional stress can act as a pathogenesis factor in various forms of somatic pathology. This circumstance, as well as the results of a continuous psychodiagnostic study of patients with various somatic diseases accumulated to date, indicate the inappropriateness of dividing diseases into psychosomatic and non-psychosomatic diseases, singling out psychosomatic diseases as a special class of conditions. At the same time, the proportion of mental factors in the genesis of individual somatic diseases varies significantly. The data obtained allow us to consider that somatic diseases form a certain series (“psychosomatic continuum”), in which the importance of psychological mechanisms in their occurrence and development, the frequency of mental adaptation disorders in them decreases gradually (Fig. 3).

In diseases located in the upper part of this continuum, such as, for example, neurocirculatory dystonia, coronary heart disease, hypertension, paroxysmal cardiac arrhythmias, bronchial asthma, peptic ulcer, rheumatoid arthritis, pathogenetically significant disorders of mental adaptation are found in the majority (66— 90%) examined. Disorders of mental adaptation in diseases that are in the upper part of the psychosomatic continuum are manifested not only by somatic symptoms, but also by neurotic reactions or even outlined neurotic syndromes, which in this case do not represent a “second illness”, but act as an integral component of psychosomatic disorders. In conditions of chronic emotional stress, their frequency increases even more. In diseases located in the lower part of the continuum (for example, acute pneumonia or post-traumatic disorders of the musculoskeletal system), such disorders are found much less often (in 30-40% of those examined).

The significance of psychosomatic relationships can be traced on the example of some somatic diseases characterized by various ergo- or trophotropic phenomena, or associated with immune changes.

If the somatic symptoms resulting from emotional stress are limited to polymorphic vegetative manifestations that directly reflect changes in the autonomic-humoral regulation, vegetative-vascular (neurocirculatory) dystonia is usually diagnosed. Vegetative symptoms (tachycardia, blood pressure lability, transient hyper- or hypotension, functional disorders of the gastrointestinal tract, psychogenic dyspnea, hyperhidrosis, muscle tremor, neck and shoulder syndromes due to increased muscle tone) are usually combined with fleeting pain and neurotic phenomena . The described symptoms are closely related to a high level of anxiety (largely somatized) and can be considered as its physiological correlates. At the same time, psychophysiological correlations are also characterized by a decrease in the frustration threshold and an increase in the proportion of the psychophysiological component of a single psychophysiological reaction to a frustrating situation. The tenth revision of the International Classification of Diseases (ICD-10) uses the designation “somatoform autonomic dysfunction” to characterize this common condition, although the previously proposed term “general psychovegetative syndrome” may better reflect its pathogenetic essence.

Vegetative-vascular dystonia of the hypertensive type can persist indefinitely. But in the presence of a personal and biological predisposition, with certain psychophysiological relationships, transient hypertension is replaced by a stable one in the process of developing hypertension (essential hypertension). Frustrating effects in this disease are most often associated with situations that are characterized by an unsatisfied need for achievement, with the expectation of such situations, with a blocked need for self-assertion and dominance, as a rule, observed in the field of professional activity. The family predisposition to essential hypertension is combined with a tendency to strong and prolonged emotions that are formed in these frustrating situations. An adequate response to the resulting aggressive reactions is blocked, since in parallel with the increase in aggressiveness, anxiety, sensitivity and the need to comply with accepted social norms increase. Disharmonious personal characteristics and psychological defenses that cause the blockade of aggressive reactions are of great importance in the pathogenesis of essential hypertension. It is also significant that the resulting anxiety, the level of which is significantly higher in essential hypertension than in controls, does not fade for a long time due to the rigidity of the affect, which contributes to increased emotional stress during repeated frustrations. At the same time, "stuck" hostility finds a socially acceptable way out due to the mechanism of somatization. Significant correlations between an increase in blood pressure, the severity of somatization of anxiety, rigidity of affect, blocked aggressiveness are already found at the stage of transient hypertension and persist with a stable increase in blood pressure. The results obtained in our laboratory (together with E. M. Kulikova) allow us to identify (based on factor analysis) a complex psychophysiological characteristic in which an increase in blood pressure, peripheral vascular resistance and plasma triglyceride levels are combined with such psychological indicators as the need for dominance , the tendency to fix attention on frustrating situations for a long time, the total frustration tension and anxiety. The possibility of isolating such a characteristic confirms the considered psychophysiological dependencies that are typical for hypertension.

Prolonged exposure or recurrence of frustrating situations (mostly similar to those noted in hypertension), increased emotional vulnerability, a high level of anxiety, accompanied by a change in the neurohumoral regulation of heart activity with increased sympathoadrenal influences, may underlie paroxysmal cardiac arrhythmias (in particular , paroxysmal atrial fibrillation) even with intact myocardium. The frequency, duration and severity of paroxysms in these cases correlate with the severity of neurotic phenomena, the level of anxiety, and the tendency to long-term processing of situations that cause negative emotions. The intrapsychic conflict in this group of patients is largely determined by a combination of demonstrative tendencies, the desire to attract and retain the attention of others with anxiety, alertness, which prevent the implementation of these tendencies. As a result, the ability to build integrated behavior decreases, dissatisfaction increases (with stimulation of negative emotional zones of the hypothalamus), anxiety, and the intensity of sympathoadrenal influences. As the final result of these disorders at the level of the heart in paroxysmal atrial fibrillation, there is a re-entry of excitation into the myocardium, due to its functional fragmentation and leading to atrial fibrillation. A likely intermediate link in this chain is the occurrence of functional weakness of the sinus node. A similar mechanism leading to ventricular fibrillation seems to underlie emotionally induced sudden cardiac death, the genesis of which is still poorly understood.

The mental correlates of coronary artery disease (CHD) are reflected in Rosenman and Friedman's classic description of a behavioral stereotype they labeled "type A" characterized by aggressive involvement in a relentless struggle to achieve more and more in less and less time, even in the face of resistance and with a constant readiness for competition.

The described behavioral stereotype is associated with an increase in the number of frustrating situations, an increase in emotional stress, and, at the physiological level, with chronic sympathoadrenal activation and its consequences for the cardiovascular system in general and coronary insufficiency in particular. Sympathoadrenal activation in IHD is even more increased due to the fact that adequate response of emotions is hampered by a high level of behavior control. Increasing anxiety is initially attributed to an uncertain outcome of activity and tense interpersonal relationships, but the onset of angina attacks (or a previous myocardial infarction) is accompanied by somatization of anxiety, which provides a socially acceptable exit from competitive struggle or other activity that causes emotional stress.

An increase in vascular resistance, an increase in the content of low-density lipoproteins in plasma and an increase in blood clotting correlate with an increase in emotional stress and the production of catecholamines. Factor analysis allowed us to show that anxiety, emotional instability, triglycerides and low-density lipoprotein levels are included in one complex psychophysiological characteristic with an approximately equal factor load.

Attacks of stenocardia often occur in direct connection with emotional stress. If this occurs with already existing stenosis of the coronary vessels, then the pathogenic effect of emotional arousal is indirect, mediated in nature and is the result of myocardial circulatory failure due to an emotional increase in cardiac activity. At the same time, data are given that about 1/3 of all patients with complaints typical of angina pectoris suffer from its angiospathic (vasomotor) form, i.e. coronary spasm of psychovegetative origin with organically intact vessels. Clinical studies and modeling of emotional states with simultaneous cardiography have shown that among the emotional states for the reproduction of vasospasmodic reactions in angina pectoris, the most significant is anxiety that appears in situations of threat to one's own existence, the well-being of loved ones or other persons for whose fate one feels responsible. In general, in the formation of psychophysiological relationships that play a pathogenetic role in the development of angina pectoris, psychophysiological effects that contribute to the atheromatous process and spasm of the coronary vessels are equally significant, since in most cases of the disease vasoconstrictor reactions develop against the background of more or less pronounced sclerotic changes in the coronary vessels. .

When examining the differences between patients suffering from angina pectoris and those who had myocardial infarction, it was shown that the first group of patients had more pronounced neurotic features and emotional instability. Similar results were obtained in our laboratory. Generalization of studies on the relationship between the state of the emotional sphere, angina pectoris and myocardial infarction suggests that anxiety and neuroticism have a greater prognostic value in relation to angina pectoris and cardiac death than in relation to myocardial infarction.

Peptic ulcer and bronchial asthma can be considered as typical forms of pathology in which emotional stress, frustration and anxiety are associated with trophotropic syndrome.

Regarding the psychophysiological relationships in peptic ulcer disease, it should be noted that the very fact of changes in gastric secretion and blood supply to the gastric mucosa under the influence of mental factors is not in doubt and is subject not only to indirect methods, but also to direct observation. Psychophysiological influences are more significant than the conditions of life, work, food. The incidence of peptic ulcer is similar in countries of Europe, Asia, America with completely different dietary traditions. In people with a tendency to gastric hypersecretion (determined by the level of pepsinogen in the blood), emotional overload has been shown to contribute to peptic ulcers. The stability and repeatability of emotional reactions is so great that they are associated with serious violations of secretion, motility, ischemia of the gastric mucosa and duodenum with a weakening of its cytoprotective properties (including against infectious agents and, in particular, Helicobacter pyloris, which has recently importance in the occurrence of peptic ulcer).

Features and conditions for the occurrence of emotional reactions in peptic ulcer require special consideration. In accordance with the psychosomatic hypothesis, the nature of emotional reactions is due to certain personal characteristics. Patients with duodenal ulcers are characterized by a contradictory combination of the need for dependence, support from significant people and the desire to seek rewards through their own vigorous activity and social achievements. Since the need for dependence contradicts the self-concept of such patients, their self-esteem, psychological defenses prevent its awareness, while the significance of success is usually recognized and often accompanied by ambition, emphasized independence of behavior and self-sufficiency. The role of such personality traits in the development of peptic ulcer is confirmed by the possibility of predicting the occurrence of peptic ulcer in "hypersecretors" using projective psychological tests.

The formation of the described type of personality is associated with the features of early socialization, which are characterized, in particular, by a pronounced and long-lasting dependence on parents with a feeling that their love depends on potential achievements and the fulfillment of duty. The intrapsychic conflict, generated by a combination of conflicting personal tendencies, underlies constant frustration, leads to an increase in emotional tension with an insufficient ability to recognize emotional problems and adequately respond to emotions. According to our data, the level of frustration, dissatisfaction, anxiety in the group suffering from peptic ulcer is significantly higher than in the control group of healthy people. The somatization of anxiety noted in these patients can play the role of a protective mechanism that contributes to the satisfaction of the need for dependence and allows you to periodically switch off from socially significant interactions without compromising self-esteem.

The most stressful in this form of pathology are life events in which the need for dependence or the need for achievement, or both of these needs, is frustrated. Among such events (their frequency in the group suffering from peptic ulcer is significantly higher than in the control group) are events that lead to the loss of the usual social environment (in particular, the loss of loved ones, migration, dismissal from work, the actual breakup of marriage, difficulties in marital relations) . In all these cases, social support is weakened, the need for dependence is not satisfied. On the other hand, events such as the threat of dismissal, reorganization and conflicts at work, changes in the type of activity lead to frustration of the need to achieve or to the threat of such frustration. The frequency of such situations, the features and severity of emerging emotional reactions differentiated a group of patients with different clinical course and nature of the ulcer. In particular, the large size of the ulcer was associated with a more pronounced tendency towards self-sufficiency, independence of behavior and readiness for activities with an uncertain outcome, combined with a greater frequency of life events that prevent the realization of these tendencies and do not allow the realization of the need for dependence.

A relationship was also established between an increase in the frequency of exacerbations of peptic ulcer or a transition to a continuously relapsing course and the frequency of adverse events, mainly in the family sphere, with increased emotional vulnerability and long-term preservation of negative emotions. The influence of mental factors, the level of anxiety, emotional tension on the results of treatment is also shown. Ulcer scarring slowed down in patients who noted conflicts in the family or high work intensity with an unstable work situation, and accelerated with a decrease in work intensity and a socially justified departure from responsible duties.

The significance of mental factors in the pathogenesis of bronchial asthma is evidenced by clinical observations indicating the appearance of asthmatic paroxysms and the aggravation of the course of the disease in emotionally significant situations when mental stress occurs. Changes in the parameters of external respiration, characteristic of obstructive syndrome, and attacks of expiratory suffocation can be associated with emotional stress and situational factors, and the relationship between exposure to the allergen initiating an asthmatic attack and the conditions in which this exposure occurs can be fixed by a conditioned reflex mechanism. In the event that the reproduction of these conditions in itself (sometimes even mentally) is capable of causing an asthmatic attack, the response stereotype, originally conditioned somatically, acquires a predominantly psychogenic character. Mental factors are included in a complex polyetiological pathogenetic complex, leading to a change in immunoreactivity and an increase in the reactivity of the bronchial apparatus through mediating mechanisms. Possible changes in immunoreactivity in response to aversion (negative stimulation) and the dependence of the antigen-antibody reaction on psychophysiologically determined sensitization are discussed.

In the study of the system of psychophysiological correlations, conducted in our laboratory in conjunction with the Clinic for Therapy and Occupational Diseases of the Moscow Medical Academy. I. M. Sechenov, it was shown that in the group of patients with bronchial asthma, negative stimulation associated with an increase in the number of undesirable life events (especially in the family sphere) is significantly higher than in the control group. At the same time, a high level of anxiety, frustration, emotional tension is accompanied by a decrease in the ability to organize effective purposeful behavior and overcome life's difficulties without drawing the attention of others to them. Adequate response to emotional stress is complicated by the disharmony of emotions and personality traits. The combination of latent anger, “stuck” on negative emotions with a feeling of symbiosis, the need to be involved in the problems of other people and involve them in one’s own problems, which is characteristic of this group of patients, prevents not only the manifestation, but to a large extent the awareness of aggressive tendencies. In addition, there is a combination of a tendency to view the situation as unsatisfactory, an internal rejection of social norms with disturbing, psychasthenic features that cause a high level of internal standard and the need for normative behavior. The intrapsychic conflict that arises as a result of such disharmony further intensifies anxiety, which is largely somatized and is accompanied by an increase in the severity of its physiological correlates.

Factor analysis made it possible to single out in bronchial asthma as the most significant (21.1% of the explained variance) complex psychophysiological factor, which, with the highest factor loads, includes indicators reflecting the intensity of anxiety, total frustration tension and the relationship of this tension to the level of integration of behavior. With an increase in this factor, there is a parallel increase in frustration and emotional tension, anxiety, a number of other psychological characteristics discussed above (affective rigidity, psychasthenic tendencies, insufficient integration of behavior, an unsatisfied need for dependence, a tendency to consider the situation as unsatisfactory) and the severity of the complex of somatic phenomena that occur during the predominance of trophotropic activation or with ergotropic activation in a situation of blockade of ?-adrenergic receptors. IgA and IgG are included in the same factor with a positive sign. The nature of the described factor reflects the relationship between the characteristics of the mental state, typical for patients with bronchial asthma, and changes in immunoreactivity, impaired respiratory function (RF) of the obstructive type. The analysis of correlation dependencies also allows us to trace the influence of emotional and frustration tension and related psychophysiological characteristics on the level of immunoglobulins in the blood, changes in respiratory function and indicators of the clinical course of bronchial asthma: the frequency, duration and severity of attacks. A parallel increase in anxiety and a complex of changes in respiratory function (decrease in forced vital capacity and volumetric exit rate) that contribute to hypoventilation, apparently, are specific for psychophysiological relationships in bronchial asthma, since in other cases anxiety is usually associated with hyperventilation syndrome.

Changes in psychophysiological relationships caused by emotional stress can act as one of the risk factors for diseases in the pathogenesis of which psychosomatic addictions obviously do not play a decisive role. This applies, in particular, to such severe forms of pathology as oncological diseases, in the origin of which psychoimmune ratios may play a certain role.

The relationship between emotional state and the likelihood of oncological diseases, as well as the course of the latter, was initially noted on the basis of clinical observations. With the beginning of a systematic study of this problem, a fairly clear picture began to emerge of both life events preceding the disease, which led to changes in the emotional state, and predisposing personality traits of patients. Epidemiological studies, including prospective ones, indicate that feelings of despair, helplessness and hopelessness, usually caused by the loss of a significant person, are a risk factor for cancer. For oncological patients, the presence of frustrations in childhood caused by relationships with parents, especially with the mother, was also characteristic. It is believed that the sensitization caused by this causes a particularly difficult experience of the situation of loss throughout later life. Also, specific forms of psychological defenses acquired in childhood and used by cancer patients throughout their lives, which prevent the release of emotional stress, were identified.

When studying the pathogenetic links of the chain: emotional reaction - integrative structures of the brain (on the basis of which it is formed) - oncogenic process, the main attention was paid to the hypothalamus - pituitary gland - adrenal cortex and immunosuppressive effects. Clinically and experimentally, the dependence of glucocorticoid production on the severity of negative emotions, the depth of depressive states, and the effect of glucocorticoids on the state and function of the thymus, which are associated with the T-system of immunity and, in particular, antitumor immunity, was shown. Thus, numerous studies indicate that neuroendocrine changes are associated with stressful exposure, which causes a strong affective reaction, and the inability of the individual to cope with it, which can have an immunosuppressive effect and, thereby, contribute to the oncogenic disease. Obviously, the described psychophysiological constellations are only one of the factors in the complex pathogenesis of oncological conditions.

The treatment of diseases, in the genesis and clinic of which psychosomatic addictions play an important role, requires a specialist to be trained in the field of clinical psychology, sufficient experience in assessing emotional situations, in diagnosing and treating mental disorders of the neurotic circle and personality disorders. Such training makes it possible to integrate all the information received, to form a holistic view of the patient and use it to conduct adequate therapy. The treatment of psychosomatic disorders caused by emotional stress should take into account the described stereotype of psychosomatic disorders and the expediency of influencing the system of psychophysiological regulation at all its levels to the maximum extent. This involves measures aimed at reducing the number and intensity of individually significant frustrating situations by correcting the social environment and restructuring the patient's perception of his relationship with this environment, reducing the level of anxiety, correcting neurotic disorders and personal inadequacy, restoring emotional and vegetative-humoral balance. Finally, therapeutic measures should include means and methods aimed at eliminating somatic pathology at the level of interested organs or systems. In our laboratory, such a complex treatment, including preliminary personal diagnostics, orienting psychotherapy, psychopharmacological agents (with an individual choice of drugs and doses), agents that normalize the peripheral response to autonomic stimulation, was effective in diseases such as the cardiac variant of neurocirculatory dystonia (vegetative-endocrine cardiopathy), paroxysmal cardiac arrhythmias, essential hypertension, peptic ulcer, sometimes even in cases previously resistant to therapy.

The named goals of treatment require diagnostics corresponding to them. The latter, in addition to the examination methods adopted in somatic medicine, is aimed at identifying stressful situations, emotionally significant problems, assessing the current mental state and personality characteristics of the patient. At the same time, it should be borne in mind that the information received from the patient (and his environment) should be evaluated taking into account the emotionally determined selectivity of its selection, the likelihood of underestimating or, conversely, emphasizing certain facts due to their emotional processing. A frequent effect of psychological defenses is the transformation of the patient's initial attitudes and values ​​(sometimes into the opposite ones). Familiarity with the laws of such transformations and the mechanisms of psychological defenses helps to establish the source of emotional stress, which may not be recognized by the patient himself. Accordingly, to assess the pathogenetic role of stressful situations in order to correct them (sociotherapy), it is not the objective characteristics of the external environment in themselves that matter, but the extent to which they disrupt the balance of the relationship between the patient and his environment, prevent the satisfaction of his actual needs.

To select adequate methods of treatment and determine the optimal therapeutic tactics, it is necessary, as already mentioned, to have the most complete picture of the mental state of the patient, the characteristics of his personality, the prevailing stereotypes of his personal response. The possibilities of obtaining such an idea are greatly expanded if, along with clinical research, standardized methods of psychological diagnostics are used. The high value of such methods in the study of patients with psychosomatic disorders is also confirmed by many years of experience in our laboratory.

The place of psychotherapy in the treatment of psychosomatic disorders is determined by the fact that the elimination of the state of emotional stress, the reduction of the level of frustration and anxiety, the reorientation of the patient in the environment in order to change his attitude to pathogenetically significant situations, the correction of inadequate stereotypes of behavior and personal reactions are essential goals of the pathogenetically oriented system of therapeutic events. In this case, the whole variety of psychotherapeutic methods can be used, of which only a few will be considered within the framework of this article.

An important circumstance that complicates psychotherapy for psychosomatic disorders and prevents the establishment of the necessary cooperation between the patient and the therapist (“the formation of a therapeutic alliance”) is that, although emotional disturbances, the inability to cope with emotional problems, are an important link in the occurrence and course of psychosomatic disorders, they, as a rule, are not sufficiently realized and are often denied by the patient himself, which determines his orientation towards biological methods of therapy. Usually, psychotherapeutic methods that are directly aimed at changing somatic functions are more favorably perceived by patients.

These methods include relaxation, which as a psychotherapeutic procedure is widely used in psychosomatic medicine. It is usually carried out in two ways: according to Jackobson, when the patient is taught to feel his muscle tone, and then relax the muscles, and according to Schultz, when the patient, by mobilizing the imagination, causes sensations (warmth, heaviness, etc.) that accompany muscle relaxation , as a result of which it actually occurs. The last method in the form of a specific system is called autogenic training. Meditation techniques can also be used to achieve relaxation. General relaxation is an effective anxiolytic (anti-anxiety) agent, since the anxiety syndrome always contains a component of muscle hypertension (especially in the muscles of the shoulder girdle and neck). In addition, against the background of relaxation and a decrease in the level of wakefulness in the process of psychogenic training, it is easier to teach patients to control some autonomic functions. Good results are obtained for this purpose by the use of biofeedback, i.e. visualization by means of technical means of the effects of controlling physiological functions, which makes it possible for patients to control their changes. Depending on the nature of the feedback, this control extends to heart rate and rhythm, blood pressure, smooth muscle tone, and gastric secretion. The successful application of this method in vegetative-vascular dystonia, hypertension, cardiac arrhythmias, peptic ulcer, bronchial asthma is reported.

The use of deep (psychodynamic) therapy becomes appropriate if the source of inadequate emotional response is left far in time (for example, in early childhood) or is not recognized by the patient under the influence of psychological defenses due to incompatibility with the self-concept. The removal of emotional problems into the sphere of consciousness makes it possible to adequately resolve them, which can also help eliminate somatic symptoms that have developed on the basis of emotional stress.

Awareness of one's emotional reactions in situations associated with intractable problems can be achieved with the help of non-directive psychotherapy. The principle of such therapy is that the patient is assisted in self-analysis through directed questions and paraphrasing the patient's answers in such a way that he himself can realize and formulate his attitude to the problem and find ways to resolve it.

The formation of a stable connection between mental stereotypes, emotions and somatic functions can be of pathogenic significance. This pathogenetic chain: unfounded judgment - emotion - somatic symptom - can be broken with the help of cognitive therapy, which is especially indicated for patients capable of introspection and introspection. At the same time, the patient identifies his judgments, recognizes their groundlessness, replaces inadequate judgments with realistic ones, and checks the correctness of this replacement. Correction of inadequate cognitive structures can be achieved by introducing new elements into these structures, which makes it possible to influence the hierarchy of needs and behavioral stereotypes (orienting psychotherapy) and, accordingly, cope with emotional problems reflected by somatic symptoms.

Treatment of emotiogenic disorders of interpersonal relationships is sometimes successfully carried out by discussing and (or) modeling appropriate situations in small groups of patients (group psychotherapy), which, as a means of treating emotionally conditioned somatic disorders, can be quite effective. This is also due to the fact that in the process of group interaction, socially acceptable forms of responding to emotional stress are worked out.

Hypnotherapy is sometimes successfully used to remove functionally fixed psychosomatic monosymptoms. It is also used to achieve general relaxation (especially non-directive, "soft" hypnosis according to M. Erickson).

Psychopharmacological therapy for psychosomatic disorders is used to reduce anxiety and emotional stress (including the physiological correlates of anxiety) and to transform persistent maladaptive responses associated with psychosomatic phenomena. At the same time, the basic principles of psychopharmacological therapy are observed, which involve the choice of a drug in accordance with the specifics of the mental state and personality traits, a slow and gradual increase in doses, starting from the minimum (which is associated with pronounced individual differences in the pharmacokinetics and pharmacodynamics of drugs and the presence of a "therapeutic window", in within which the psychopharmacological effect is maximum), the gradual reduction of doses at the end of therapy in order to avoid the "withdrawal syndrome".

Since the main types of psychopharmacological effects and classes of drugs have already been considered in a previous article1, it is advisable to dwell here only on some points that are essential in the treatment of psychosomatic disorders.

It should be borne in mind that in cases where anxiety and emotional stress determine the mental state, and the physiological correlates of anxiety cause the main somatic symptoms, psychopharmacological therapy may be limited to the use of psychotropic drugs, the action of which is manifested by a rapidly developing tranquilizing effect (mainly benzodiazepine tranquilizers). However, since psychosomatic disorders are usually based on fairly persistent and maladaptive stereotypes of mental response, in most cases, along with tranquilizers, drugs are used that have not only a quick tranquilizing effect, but also a slow antipsychotic (tranquilizing neuroleptics). If this stereotype is characterized by depressive forms of response, including those expressed by masked depression, drugs are used in which the tranquilizing effect is combined with an antidepressant (tranquilizing antidepressants). At the same time, it is necessary to take into account the fact that the effect of tranquilizers on vegetative-humoral regulation is realized indirectly through a decrease in the level of anxiety and emotional stress and, accordingly, helps to eliminate the shifts that have arisen in connection with emotional stress, regardless of their initial sympathoadrenal or vagoinsular orientation. In particular, the initial increase in secretion and the increase in the intensity of catecholamine synthesis under the influence of tranquilizers decrease. In the same case, if initially the secretion of catecholamines was reduced, and their metabolism is slowed down, under the influence of tranquilizers, the opposite effect is observed.

When using drugs with slow effects, their direct effect on the autonomic-humoral regulation should be taken into account, which is associated both with the main effect (with antipsychotics - mainly adrenolytic, with antidepressants - mainly adrenomimetic), and with the action usually considered as a side effect. (in particular, the anticholinergic effect of many neuroleptics and antidepressants). It is important that persons suffering from psychosomatic disorders tend to exaggerate the side effects of drugs due to increased attention to their physical sensations. The significance of such a negative attitude of the patient is confirmed by the occurrence of adverse somatic phenomena against the background of taking placebo. A positive placebo effect, or worsening placebo, reflects the patient's attitude towards treatment and can be used to assess this attitude, whether or not it is recognized by the patient.

In psychosomatic disorders, some effects of psychopharmacological agents, usually regarded as side effects, may be desirable. Thus, the muscle relaxant action of tranquilizers - derivatives of benzodiazepine and propanediol - is useful for muscle "clamps", in various spastic conditions. The anticholinergic properties of a number of neuroleptics and antidepressants may be desirable where their antispasmodic, antiemetic and antacid effects are needed.

We can note the drugs, the effect of which on the vegetative symptoms is so pronounced that it allows us to consider their action as a vegetative-stabilizing one. Such drugs among antidepressants include, in particular, opipramol (Insidon), among antipsychotics - sulpiride (Eglonil), which are purposefully used for some psychosomatic disorders, such as peptic ulcer, migraines. Vestibulo- and vegetative-stabilizing properties are also expressed in etaperazine.

Means acting on peripheral mediator processes (for example, ?-blockers) are not only effective at the level of autonomic regulation, eliminating autonomic correlates of anxiety, but, due to the feedback mechanism, often reduce emotional stress.

It is important to consider the interaction between psychotherapy and psychopharmacological treatment, since the use of psychopharmacological agents cannot be considered as a purely biological therapy. Behavior modification under the influence of these drugs can lead to a decrease in the active role of the patient in resolving his conflicts and emotional problems, without which it is impossible to achieve a stable therapeutic effect. Directed psychotherapeutic influence helps to prevent such a development of the situation. At the same time, the use of psychopharmacological drugs creates a more favorable background for psychotherapy, reducing the level of anxiety and contributing to the transformation of psychological defenses, weakening emotionally conditioned distortions in perception and assessment of the environment and one's own reactions, improving the integration of behavior and social interaction. In addition, reducing anxiety and alertness makes the interaction between the therapist and the patient more productive.

LITERATURE

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760 rub.

Introduction

Psycho-emotional stress

Fragment of the work for review

Socio-psychological block. Any person, whether he wants it or not, is influenced by his social environment and, more broadly, the social and objective environment. Under stress, the attitude to the surrounding world, including the world of people, changes, especially under the influence of physical, physiological stressors, and as a result of contacts with people whose nature of communication is changed by stress (6, p. 183).
In the process of activity, motives are "filled" emotionally, are associated with intense emotional experiences, which play a special role in the emergence and course of states of mental tension. It is no coincidence that the latter is often identified with the emotional component of activity. Hence the parallel use of such concepts as "emotional tension", "affective tension", "nervous-psychic tension", "emotional arousal", "emotional stress" and others. Common to all these concepts is that they denote the state of a person's emotional sphere, in which the subjective coloring of his experiences and activities is clearly manifested.
However, according to N. I. Naenko, these concepts are not actually differentiated from each other, the proportion of the emotional component in states of mental tension is not the same and, therefore, one can conclude that it is unlawful to reduce the latter to emotional forms. This opinion is shared by other researchers who tend to consider the concept of "mental stress" as generic in relation to the concept of "emotional stress".
A simple indication of the obligatory participation of emotions in the genesis and course of mental tension is not enough to understand their place in the structure of the corresponding states. The work of N. I. Naenko reveals their role in reflecting the conditions in which the activity is performed, and in the implementation of the regulation of this activity (22, p. 92).
G. N. Kassil, M. N. Rusalov, L. A. Kitaev-Smyk and some other researchers understand emotional stress as a wide range of changes in mental and behavioral manifestations, accompanied by pronounced non-specific changes in biochemical, electrophysiological parameters and other reactions.
Yu. L. Alexandrovsky connects the tension of the barrier of mental adaptation with emotional stress, and the pathological consequences of emotional stress - with its breakthrough. K. I. Pogodaev, taking into account the leading role of the central nervous system in the formation of the general adaptation syndrome, defines stress as a state of tension or overstrain of the processes of metabolic adaptation of the brain, leading to protection or damage to the body at different levels of its organization through common neurohumoral and intracellular regulatory mechanisms. This approach fixes attention only on the energy processes in the brain tissue itself. When analyzing the concept of "emotional stress", the question of its relationship with the concept of "emotions" is quite natural. Although emotional stress is based on emotional stress, the identification of these concepts is not legitimate. It has already been noted earlier that R. Lazarus characterizes psychological stress as an emotional experience caused by a “threat”, which affects a person’s ability to carry out their activities quite effectively. In this context, there is no significant difference between emotion (negative in its modality) and emotional stress, since the influence of emotional stress on the activity of an individual is considered as a determining factor. In psychology, this constitutes the traditional and rather detailed problem of the influence of emotions on motivational-behavioral reactions (30, p. 42).
According to V. L. Valdman et al., in the phenomenon of emotional stress one should distinguish between:
a) a complex of direct psychological reactions, which in general form can be defined as the process of perception and processing of information that is personally significant for a given individual, contained in a signal (impact, situation) and subjectively perceived as emotionally negative (a “threat” signal, a state of discomfort, awareness conflict, etc.);
b) the process of psychological adaptation to an emotionally negative subjective state;
c) the state of mental disadaptation, caused by emotional signals for a given person, due to a violation of the functional capabilities of the system of mental disadaptation, which leads to a violation of the regulation of the subject's behavioral activity.
Each of these three states (they are fundamentally close to the general phases of stress development, but are assessed by psychological rather than somatic manifestations) is accompanied, according to the authors, by a wide range of physiological changes in the body. Vegetative, symptomatic-adrenal and endocrine correlates are found with any emotion or emotional stress (both positive and negative) in the period of psychological adaptation to stress exposure and in the phase of mental maladaptation. Therefore, according to the listed complex of reactions, it is not yet possible to differentiate emotion from emotional (psychological) stress, and the latter from physiological stress (30, p. 44).
G.G. Arakelov believes that the mechanisms of stress and emotions are different, but in the human mind, stress and emotions are actualized simultaneously. Moreover, the strength of the subsequent stress reaction is realized and evaluated by the severity of the emotion, while the initial manifestation of the stress reaction manifests itself at an unconscious level. The emergence of appropriate emotions after assessing the danger is necessary for the subsequent conscious control and choice of behavioral tactics (25, p. 135).
In the activity of a human operator, the main attention is drawn to the problem of the impact of the dominant emotional (mental) state on the process of his functional activity, on the effectiveness of work. The state of emotional (mental) tension is precisely determined by the occurrence of interference in this activity, the appearance of errors, failures, etc. During the development of a direct psychological reaction to an extreme impact, most emergency situations occur. At the first stage of the stress reaction, an acutely developing emotional arousal plays the role of a disorganizer of behavior, especially if the content of the emotion contradicts the goals and objectives of the activity. The complex process of analysis and plan for the formation of activity, the choice of its most optimal strategy, is disrupted.
Chapter 3
In psychological studies, various complexes of emotional response are compared with a tendency to form one or another psychosomatic pathology. In humans, the most common superstrong stress stimulus leading to the development of cortico-visceral disorders is mental trauma, inflicted in some cases acutely, once, often suddenly, and in other cases chronically, repeatedly, often gradually, almost imperceptibly, but deeply affecting mental sphere and, as a rule, proceeding against the background of emotional accompaniment, which intensifies the impact of the traumatic factor. A frequent consequence of the impact of mental trauma are psychosomatic diseases.
About the role of unreacted emotions in the formation of somatic disorders, G. Flang wrote, in particular, in 1932: “Sadness, not crying out with tears, makes other organs cry.” The common and main cause of hypertension, as well as peptic ulcer, which also belongs to the category of psychosomatic disorders, is increased neuropsychic trauma and excessive psycho-emotional stress, - he considered, based on the experience of the Great Patriotic War, especially on the materials collected during the 900-day period. blockade of Leningrad, a prominent domestic therapist M.V. Chernorutsky. (12, p. 383)
In 92% of cases, severe mental trauma and prolonged nervous strain were noted by T.S. Istamanova in the anamnesis of patients with neurasthenia, accompanied by functional disorders of internal organs. The increase in cases of peptic ulcer and its atypical course during the Second World War was observed in almost all warring countries. During the aerial bombardment of London, Liverpool and Coventry by German aircraft, British doctors noted in these cities a sharp increase in the number of gastric perforations in patients suffering from peptic ulcer. On the material of a medical examination of 109 thousand people, Z.M. Volynsky found that hypertension was twice as common in front-line soldiers and three times more likely in people who survived the Leningrad blockade and other horrors of war than in those who were in wartime in the rear.
Each emotion is characterized primarily by the subject's intrapersonal state - experience. Experience is the expressive side of emotion. The expressive side of emotion is the characteristic objective changes in the vital activity of the organism, manifested by electrophysiological, biochemical, vegetative-vascular and motor effects. As a physiological phenomenon, emotion is the result of the activity of the whole brain, as a psychological phenomenon, it is a specific expression of the activity of the individual. Initially arising as a physiological phenomenon and without ceasing to be such at the level of complex personal relationships, emotion acts as an experience, i.e. as a mental phenomenon - in the form of a peculiar form of reflection of a person's attitude to objects and events that are significant for him. In other words, the psychic and the physiological appear in emotions as two sides of a single nervous activity. As P. Kh. (12, p. 384)
E.Gelgorn and J.Lufborrow find a certain connection between the quality (modality) of emotional experience and the specifics of changes occurring in the physiological systems of the human body. In particular, they believe that “emotions can be accompanied by sympathetic tuning of some organs and systems and parasympathetic tuning of others. In indignation and indignation, sympathetic influences predominate in the vascular system, while parasympathetic influences predominate in the gastrointestinal tract. In a state of anger, the excretion of catecholamines, especially norepinephrine, increases. When experiencing fear against the background of an increase in the level of catecholamines, a predominant increase in adrenaline is observed. The Swedish researcher M.Frankenhäuser calls adrenaline the “rabbit hormone”, in contrast to norepinephrine, the “lion hormone”.
Emotional activation of vegetative systems under normal conditions is an adaptive reaction of the body and does not lead to pathology of internal organs. Emotional states, according to Yu.M. Gubachev, B.V. Iovlev, B.D. Karvasarsky, “become factors in the pathogenesis of somatic diseases either in the presence of sharply altered structures of target organs, the adaptive capabilities of which are sharply reduced, or under the condition of extreme strength and duration of such states. This provision is based, in particular, on the results of studies by K.M. Bykov and I.T. Kurtsyn, in which it was shown that when any physiological system (organ) is weakened, it is involved in the pathological process, regardless of the specific psychological content. conflict.
The physiological response to stress does not depend on the nature of the stressor, as well as on the type of organism in which it occurs. This reaction is universal and is aimed at protecting a person or animal and maintaining the integrity of its body. The defensive reaction to the ongoing or repeated action of a stressor includes three stages, united by the concept of "general adaptation syndrome". (28, p. 141)
At the first stage - anxiety - changes in the body occur, such as muscle tension, rapid breathing, accelerated pulse, high blood pressure, anxiety. It reflects the mobilization of all resources in the body. In this case, the body's resistance decreases, and if the stressor is strong enough, then death may even occur.
In the second stage - resistance - the body begins to adapt to the ongoing effects of the stressor. During this stage, increased resistance to the stressor is established. The stability (resistance) of the organism in relation to it becomes higher than the initial level.
The third stage - exhaustion, which occurs when exposed to super-strong or super-long stimuli, is accompanied by a decrease in the body's resistance and, in severe cases, can lead to its death.
Selye divided stress into constructive and destructive, emphasizing that not all stress is harmful. Constructive stress, having passed the stage of anxiety, ends with the adaptation of the body to a new situation, increasing its stability. However, if the stress factor is of great intensity or duration, if it is incorrectly assessed, if several stress factors are combined and the body is weakened for other reasons (due to hereditary or congenital weakness of defense mechanisms), then stress can become destructive. In such cases, the reactions of adaptation reach the level of exhaustion and the processes of destruction are launched - protection through illness, maladaptation.
Disadaptation is a state of disturbed homeostasis (dynamic balance of the body and the environment), which occurs if the protective mechanisms have been exhausted, and the effect of the stress factor has not been completely neutralized. (28, p. 158)
A stress factor is any influence coming from the external environment or arising inside the body that causes a stress response.
There are two ways of causing stress: psychological and physiological. If a stress factor is not recognized by a person, but causes symptoms characteristic of stress, then such stress is regarded as physiological or systemic.
If the stress factor is refracted to a greater or lesser extent through the consciousness of a person, then the resulting changes are considered psychological stress. The impact acquires a stressful character if it is assessed by a person as threatening his social, psychological or physical well-being. Of great importance is the understanding of iatrogenic stress, which arises from receiving information from medical professionals that can cause anxiety in the patient. One of the causes of psychological stress in a person is the inability to realize one or another significant need for him, caused, for example, by illness. The psychological causes of stress are called mental trauma (psychotrauma). Currently, the concept of psychological stress is often equated with the concept of frustration.
Frustration (from Lat: frustratio - deceit, frustration, destruction of plans) is a mental state of collapse and depression, expressed in the characteristic features of experiences and behavior that are caused by the experience of failure. Difficulties that arise on the way to achieving a goal or solving problems are perceived as insurmountable. The situation in which such a mental state occurs is called frustrating. (1, p. 232)
Despite the variety of frustrating situations, they are characterized by two mandatory conditions:
the presence of an actual need as a source of activity, a motive as a specific manifestation of a need, a goal and an initial plan of action;
blocking the possibility of its implementation, the presence of resistance (an obstacle - a frustrator).
Types of obstacles.
1. Passive external resistance - the presence of an elementary physical barrier, a barrier on the way to the goal; remoteness of the object of need in time and space.
2. Active external resistance - prohibitions and threats from the environment, if the subject does or continues to do what he is forbidden.
3. Passive internal resistance - conscious or unconscious inferiority complexes; inability to implement the plan, a sharp discrepancy between the high level of claims and the possibilities of execution.
4. Active internal resistance - remorse (2, p. 11).
The main subjective psychological manifestations of a stressful state are anxiety and fear, i.e. feeling of vague threat, danger. It is due to the fact that a person cannot accurately determine the nature of the threat due to the lack or lack of information about the stimulus, its incorrect logical processing, or a combination of both. A slight degree of anxiety sometimes has a positive effect on the intellectual and physical activity of a person. Examples of this are the improvement in the ability to recall the necessary material on the exam with slight excitement; an increase in sports performance with moderate pre-start stress, etc. As anxiety increases, productive activity decreases. But in all cases, anxiety is a signal of trouble that prompts a person to take certain actions that help him get rid of this feeling. Fear arises when a person does not currently find a way out of a situation that threatens him, but singles out some specific factor (phenomenon, object) as its cause, which in fact may not be a true prerequisite for stress. Fear, like anxiety, has a protective value, it encourages a person to act in order to preserve himself. However, when overexpressed, fear can lead to disorganization of behavior.
Stress and blood cholesterol levels. Elevated cholesterol leads to the development of atherosclerotic plaques on the walls of blood vessels, which causes a violation of blood flow (usually its deterioration). This can result in strokes and heart attacks. It is generally accepted that there can be several reasons for high blood cholesterol levels. It has now been shown that one of the important causes of high cholesterol levels is increased stress levels. So, accountants had a sharply elevated cholesterol level when they had to do a large amount of work in a short time - to prepare a summary report or summaries for the tax authorities. Testing of medical students immediately before and after final exams shows that 20 out of 21 examined students have an increased level of cholesterol-s sterol in blood serum before exams, i.e., in a stressful situation. (18, p. 339)
Arterial hypertension. This is the increased and damaging pressure of the blood against the walls of the arteries. There can also be several reasons for high blood pressure. But there is no doubt that the action of stressors leads to an increase in pressure.
Emotional stressors are considered as one of the main factors in the etiology of hypertension. Therefore, educational programs for hypertensive patients provide training in methods of managing stress levels.
Stroke and coronary heart disease. A stroke occurs as a result of a blockage in blood flow or a rupture of a blood vessel in the brain, which causes a lack of oxygen and death of nerve cells. A stroke can result in paralysis, speech impairment, motor impairment, or death. It is believed that stroke is associated with high blood pressure, stressors and some other causes. (18, p. 340)
Coronary heart disease (CHD) and its association with increased levels of stress are explained by increased activation of stress mechanisms under the influence of stressors: increased heart rate, increased blood pressure, fluid retention in the body. The typical victim of a heart attack is an overworked, overworked, overweight businessman with a cigarette in his mouth, relieving stress with alcohol. Type A behavior has been identified and is most common in people who have had a heart attack. Usually these people are aggressive, vain, impatient, hostile, dependent on the evaluation of their work, doing several things at once.

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Psycho-emotional stress is a protective and adaptive reaction that mobilizes the body to overcome various obstacles that disrupt life, in the event of many conflict situations in which the subject is limited in the ability to satisfy his basic vital biological and social needs.

Reasons for development.

A constant load on the emotional sphere is a continuous repetitive action of stressors that require the elimination of their action. For example, information overload of higher medical education.

The impossibility of satisfying a need in specific conditions, especially if the need for a person is of vital importance. For example, the inability to enter a medical university for a person with a medical vocation.

Wrong decision, on the basis of which a system is formed that is not able to satisfy the dominant motivation. For example, an unloved profession.

Unfavorable forecast of satisfaction of the need due to the weakness of the system or insufficient information. For example, the lack of information about the family during the polar winter.

The inability of the central nervous system to create a functional system of adaptation due to the weakness of the nervous processes, especially the lack of inhibition. For example, low intellectual abilities with excessive ambition.

Development mechanism.

1. First, the dorsomedial part of the amygdala nucleus (one of the central formations of the limbic system) is excited.

2. From the amygdala, the flow of impulses goes to the ergotropic nuclei of the hypothalamus, from there the impulse goes to the thoracic spinal cord, and then to the adrenal medulla.

3. In response, adrenaline and noradrenaline are released, as a result, blood pressure increases, cardiac output increases, blood flow in non-working muscles and organs decreases, the level of free fatty acids (activation of lipolysis), triglycerides, cholesterol, glucose levels increase.

The adrenocortical mechanism includes the following chain of events: activation of the neocortex, the septal-hypothalamic complex (release of corticoliberin), the anterior pituitary gland (release of ACTH, stimulation of the adrenal cortex and the release of glucocorticoids and partially mineralocorticoids (aldosterone). Glucocorticoids cause an increase in energy reserves:

increases the level of glucose (due to gluconeogenesis) and free fatty acids.

However, excessive release of glucocorticoids simultaneously leads to undesirable effects (this is called the price of adaptation). There is a triad of morphological manifestations: hypertrophy of the adrenal cortex, involution of the thymic-lymphatic system and the temporary appearance of gastric and duodenal ulcers.

In the development of the general adaptation syndrome (stress reaction), there is a consistent development of the stages of anxiety, resistance and exhaustion.

I. Stage of anxiety - a short-term stage (from 6 to 48 hours), due to the restructuring of the endocrine function of the body, is associated with an increased release of adrenaline and glucocorticoids into the blood, the predominance of catabolic processes. The size of the thymus, spleen, lymph nodes, the amount of adipose tissue decrease, erosion appears in the gastrointestinal tract, the content of eosinophils in the blood and lipids in the adrenal cortex decreases.

II. A steadily increased concentration of adrenaline and glucocorticoids in the blood indicates the onset of the resistance stage. Adrenal hypertrophy occurs. This stage determines the adaptive effect of the stress response.

III. If the stressor was extremely strong or its effect did not stop for a long time, stage 3, the stage of exhaustion, may develop. It is associated with functional insufficiency of the adrenal glands. At the same time, they return

symptoms characteristic of stage I (shock phase), but now they are irreversible, which can lead to the death of the organism. In the internal environment, not only a violation of homeostasis occurs, but also multiple organ failure develops with a predominance of catabolic and necrotic changes in organs and tissues.

Prolonged emotional stress is dangerous, as conditions are created for the pathogenic effect of the content of emotions on the central nervous system - neuroses, psychoses and the autonomic nervous system - the source of various somatic diseases - hypertension, coronary heart disease and brain disease, diabetes mellitus, peptic ulcer disease.

Examples:

Mechanism of stress-induced myocardial damage: overload of Ca ++ cells and an increase in free radical forms of fatty acids leads to damage to cell membranes and disruption of the structure and function of cells.

The mechanism of stress ulcers in the gastrointestinal tract: Long-term mobilization of energy and plastic material with the redistributive nature of the blood flow creates conditions for ischemic damage to "non-functioning organs".

Long-term leads to the development of stress-induced immunodeficiency (glucocorticoids have an immunosuppressive effect), which, in combination with the expression of proto-oncogenes, may be one of the mechanisms of the oncogenic effect of stress.