Helping patients operated on for thyroid

cancer: the main strategies of

psychotherapeutic correction
03/09/2013 HTTP://WWW.CONSILIUM-MEDICUM.COM/ARTICLE/19548
The study of the internal picture of the disease has become one of the most important trends in
modern research in the field of psychotherapy and clinical psychology. In the course of the study, a
personal questionnaire of the Behterev Institute was used in 90 patients who underwent surgery for
thyroid cancer. The study showed that patients with thyroid cancer had a preferred block of anxiety-
type response to the disease compared with the control group. The results of the research allow
timely detection of psychological and psychopathological problems in a given cohort of patients, and
improvement of existing approaches to psychological care. Methods of short-term psychotherapy,
such as the method of desensitization and processing of traumas by eye movements,

A lot of work has been devoted to the study of the patient's emotional reaction to a physical illness
and how he treats his suffering. So, back in 1950 E.Krasnushkin [1] wrote about the "consciousness
of the disease". KA Skvortsov introduced the concept of "attitude towards illness" into scientific
usage [2]. ND Lakosin and GK Ushakov use the broader term "reaction to the disease" [3]. The
concept of the internal picture of RA Luria's disease became widely known [4, 5]. The internal picture
of the disease, characterizing the holistic attitude towards the disease, is closely linked with the
awareness of the sick of their illness. The doctor's task is to correct the model of the disease, the
"scale of experiences".
Individual reaction of a person to stress or a serious illness, which is cancer, is related to the state of
psychological defense, which determines the presence and severity of subsequent stressful mental
disorders and is reflected in the patient's emotional response to the disease [6]. Psychotherapeutic
approach is based on the fact that, despite their own fear of cancer and despite the negative
attitudes of others, they tried to change their ideas about this disease and believed that they could
still recover and lead an active and meaningful life.
The presence of a subjective component brings together the concepts of "quality of life" and "internal
picture of the disease." Deepening knowledge about the psychological side of diseases in the
domestic theory and practice of medicine led to the emergence of various conceptual schemes that
reveal the structure of the inner world of a sick person. The variety of terms used to describe the
subjective side of the disease is also characteristic of foreign researchers [7, 8].
In the majority of modern psychological studies of the internal picture of the disease, several
interconnected aspects distinguish it in its structure under different nosological forms of
diseases. The emotional side of the disease is associated with different types of emotional response
to individual symptoms, the disease as a whole and its consequences, the intellectual (rational-
information level ) - with the patient's ideas and knowledge about his illness, reflections on his
causes and consequences, volitional (motivational level) - with a certain attitude of the patient to his
disease, Parts Required behavior change and habitual way of life, the actualization of the return and
preservation of health activities. Based on these sides, the patient creates a model of the disease,
i.e. representation of its origin, clinical picture, treatment and prognosis, which also determines their
behavior in general [6]. Since, in addition to sensory reflection (pain, altered self-perception), there is
an intellectual evaluation of the disease, affecting it, the doctor influences the internal picture of the
disease, which in turn determines psychological and psychoemotional reactions, psychoemotional
state and even physical well-being. Internal picture of the disease, the formation of which begins at
the stage of clarifying the cancer and is fuzzy, consists of three components: emotional, somatic and
intellectual. In addition, it is during this period that the patients are in a crisis state, When the
capacity for objective analysis of the situation is violated. Internal picture of the disease is not only a
set of subjective models of manifestations of the symptoms of the disease, but the concept of this
disease is real or false [9].
The formation of a model of the disease, associated with it a conscious or unconscious need to get
rid of its manifestations, threats of disability or death lead to the formation of programs and goals of
the individual aimed at overcoming the disease. At the same time, a model of disease prognosis and
a model of expected treatment outcomes are formed. The model of the prognosis of this disease
appears as an emotionally charged complex of the patient's representations about its probable flow
and outcome. Depending on life experience, intelligence, emotional structure of a person, patients
differently project the course of their disease in time. At the same time, the polar parameters are full
recovery and death, between them there may be intermediate models - results with partial
recovery. The model of the expected results of treatment is an image or set of images, anticipating
such a result of treatment, which the patient counts or who was inspired by his surroundings or by a
doctor. At some stages of the disease, the model of expected treatment outcomes can largely
determine the patient's behavior. During the course of treatment, patients develop psychological
models of the results of treatment-emotionally colored representations that reflect both real and
imaginary (induced, self-induced) changes in impaired functions toward improvement or
deterioration. At the personal level, evaluation of treatment outcomes is carried out by comparing the
models of expected and obtained treatment outcomes. In this case, the coincidence of the named
models causes positive emotions (satisfaction), and a mismatch (when the model of the results
obtained is lower than the model of the expected results of treatment) - negative emotions
(dissatisfaction). Such emotions may be the reason for the curtailment of the model of expected
treatment outcomes with the rejection of treatment by this method and depression or restructuring of
the psychological zone of the information field of the disease with the underestimated models of the
disease prognosis and the model of expected treatment results [10].
A major role in the formation of the internal picture of the disease is played by the type of emotional
relationship of the patient to his disease, its manifestations, and the prognosis [11].
What makes doctors pay so much attention to measuring the individual response of patients to the
fact of a serious illness? The main reason for interest in an individual response to a disease is that
feelings largely determine bodily and mental health [7, 12].
Recognizing the right to feelings for the patient, the doctor recognizes for him and the right to
participate in the selection of medicines and other types of treatment, because only the patient
himself can know, feel and measure the values of his life, which can be endangered by treatment [6].
Completely restore health, even at the modern level of medical technology, unfortunately,
sometimes impossible. But to live better, despite the remaining "scars" or symptoms, you can. And
the improvement of a person's life, which can not be completely cured, has become one of the
legitimate goals of treatment. Very rarely after a cure for a serious illness, a person returns to the
original worldview. For some people, a disease, especially a cancer, becomes a turning point in
personal development.
In most cases, the connection between disease, treatment and discontent with life is not so obvious
and is only detected with the help of special measurements. Understanding of the internal picture of
the disease determines the construction of the interaction between the doctor and the patient, the
possibility of understanding the patients for the presence of the disease and the adequacy of the
proposed treatment [9]. The indicator of individual reaction to the disease makes it possible to
determine more precisely the directories of the psychotraumatic experience and the missing
information platform, thanks to which the transition to the adaptive level of interaction is possible,
and it is also possible to determine the most appropriate ways of psychotherapeutic correction.
The aim of the study was to study the psychological state and the assessment of the patient's
attitude toward the disease in the period between 2005 and 2008, including the assessment of the
perception of the psychocorrection course using different approaches, in patients with thyroid cancer
(thyroid cancer) rational and integrative psychotherapy with the use of the method of desensitization
and treatment of traumas with eye movements (DPDG).

Materials and methods

We examined 90 patients operated on for a thyroid cancer (3 to 10 years old prescription) who
underwent a course of radioiodine therapy receiving lifelong suppressive therapy with L-thyroxine
and having a disability group (main group or group I). This group was divided in the process of
psychotherapy into 2 subgroups of 45 patients each in accordance with the conducted
psychotherapeutic course: group IA (integrative psychotherapy using DPDG) and group IB (rational
psychotherapy).
The control group (group II) consisted of 90 people who did not have a history of thyroid gland
pathology. The age of the examined patients in both groups ranged from 19 to 40 years (mean age
31 ± 1 year). The sex distribution was as follows: 69 women, 21 men (in both groups). The socio-
demographic characteristics (the level of education and professional employment, financial position,
etc.) of both groups were similar.
The results of the research were processed using the "Statistica 6.0" software package (StatSoft,
USA). Taking into account the definition of normal distribution, comparative analysis between the
groups was carried out using Student's t-test.

Results of the study

Diagnosis of mental and behavioral disorders was carried out in accordance with the diagnostic
diagnostic criteria of ICD-10 (5th class of diseases) [13].
To investigate the patient's emotional reaction to the disease, a personal questionnaire of the
Behterev Institute (LOBI) was developed, developed by the St. Petersburg Research Institute of
Psychoneurology. VM Bekhterev for the purpose of diagnosing the types of attitude to the disease
and other related personal relationships in patients with chronic physical illnesses [2]. We took this
technique to assess the pattern of relations to the disease, its treatment developed in patients during
the course of the disease.
The test reveals 12 types of relationships to the disease:
1) harmonious (D) - sober assessment of their condition, active cooperation in all areas of
treatment. In the case of an unfavorable prognosis for life - the concentration of interests in their
business, close people;
2) ergopathic (P) - withdrawal from the disease in the work, the desire at all costs to continue
working;
3) anosognosic (3) - denial of the disease or its severity;
4) anxiety (T) - a constant concern because of a possible adverse outcome of the disease;
5) hypochondriacal (I) - concentrating on painful and other unpleasant sensations in the body,
exaggeration of the severity of the disease, seeking out the nonexistent signs of the disease;
6) neurasthenic (H) - incontinence, quick temper and irritability, followed by a subsequent
repentance;
7) melancholic (M) - depression of the disease and a pessimistic view of the future;
8) Apathy (A) - indifference to one's health and future;
9) Sensitive (C) - excessive concern about what impression on others can produce a disease,
heightened sensitivity to the attitude of other people;
10) egocentric (I) - setting at the heart of self and one's own illness;
11) paranoid (P) - excessive suspicion with regard to everything related to one's own personality or
illness;
12) dysphoric (D) - gloomily-embittered mood, constant dissatisfaction with everything and
everything.
At the first stage, the survey was aimed at identifying patterns of personal response to a deadly
disease, which is cancer. The purpose of testing in the postoperative period is to study the dynamics
of the internal picture of the disease after surgery and, based on this, to develop tactics of
psychotherapy, to evaluate the results of psychotherapeutic intervention and to outline the ways of
further psychotherapeutic correction.
Objective research with LOBI allowed us to analyze the effect of individual reactions of patients of
groups I and II on stress, which is the disease.
In a comparative analysis of the types of attitude towards the disease in patients of groups I and II, a
significant discrepancy in the nature of the response was revealed. The indicators of the types of
attitudes to the disease that characterize the state of psychological defense in both groups are
shown in Fig. 1.
In evaluating the study of the emotional response to the disease in 2005, the patients of group I
predominantly noted the following types of response: the main type was anxious (in 26 people,
29%), neurasthenic (20, 22%), neurasthenic (in 15 people, 17%) and apathetic (10 people, 11%),
and also the characteristic selected types were obsessive-phobic (6 people, 7%) and sensitive (6
people, 7%).
In 2008, these emotional types of response practically did not change and amounted to: anxious -
32% (29 people), neurasthenic - 24% (22 people), neurasthenic (17, 19%) and apathetic (11 12%),
characteristic types were obsessive-phobic (in 7 people, 8%) and paranoid (in 6 people, 7%).
In Group II patients, the emotional type of response was preferably characterized by the main type of
response: neurasthenic - in 18 (20%), anosognosic - in 9 (10%), and in addition the types chosen
were euphoric (11, 12%) and neurasthenic (in 6 people, 7%). In 2008, the types of response
changed insignificantly: neurasthenic was detected in 20 (22%) people, euphoric in 11 (12%),
additional types were the same (8 persons, 9%).
In examining the difference in response types in different age groups, it was noted that the main type
of response in group I was the alarming type of relationship to the disease found in most patients
(24% at the age from 19 to 29 and 41% at the age of 30 to 40 years ). It can be assumed that with
age, while maintaining the general tendency of individual characteristics of the attitude towards the
disease in patients operated on for thyroid cancer, an alarming type of attitude towards the disease
prevails, which indicates the urgency of the disease state. A long disturbing type of attitude causes
disorganization of mental activity, reduces the effectiveness of adaptation processes and the
assimilation of new information in the rehabilitation process. According to the data obtained, the
adaptive processes of patients with thyroid cancer decrease in the older age group,
At the same time, Group II patients in the age group of 19-29 years noted a euphoric type of
response 12 times more often (t = 3.24, p <0.05) than group I patients, anosognosic type 2 times (t =
0 , 83). The lack of these types of response in patients of group I determines their significant
integration with the disease and a pessimistic attitude to the future.
An analysis of the emotional type of response to the disease revealed that patients with a thyroid
cancer had a preferable block of anxiety-type response, which eventually manifested itself more and
had a statistically significant difference between groups I and II (p <0.05). All this indicates that
patients have a high level of internal anxiety, suspicion regarding the unfavorable course of the
disease, as well as possible complications that may arise during treatment. An alarming type of
attitude towards the disease, patients operated on for thyroid cancer, were 3.3 times more likely than
patients in the control group (t = 2.03, p <0.05).
It should also be noted that their types of responses in the aggregate - neurasthenic, apathic, phobic
and sensitive - indicate an intrapsychic response style. This indicates that, due to the peculiarities of
the internal picture of the stress response, they had low adaptive capabilities before the onset of the
disease and were more prone to developing maladaptation states, and also confirms their passive
compliance with the treatment being carried out with the persistent prompting of medical personnel.
It should be noted that neurasthenic type of response was characteristic for patients of both groups
and the tendency of exceeding this index in group I was preserved. Such an attitude towards the
disease of patients of all studied groups shows that the peculiarities of their psychological state and
internal picture of the response to stress predetermined their predisposition to the diseases under
consideration.
The available analysis of the types of emotional response makes it possible to understand the
characteristics of the internal picture of the disease in patients of groups I and II, determine its
dynamics and outline the plan for subsequent psychotherapeutic actions.
An assessment was made of the type of response to the disease with LOBI after the course of
psychotherapy.
When comparing the available data before the course of psychotherapy between groups IA and IB,
there was a difference in the choice of the preferable attitude to the disease. In group IA, the main
type of response was ergopathic (3.78 ± 0.35), anxious (3.04 ± 0.26), neurasthenic (2.69 ± 0.27), in
group IB - neurasthenic (3.78 ± 0.26), anxious (3.53 ± 0.19), and apathetic (3.51 ± 0.17). During the
course of the course of psychotherapy there was a significant change, reflected in the choice of the
type of attitude towards the disease. In group IA, after the implementation of integrative
psychotherapy by DPPH, the harmonizing (5.4 ± 0.28) and ergopatic (5.96 ± 0.22) types with
statistically significant difference (p <0.001) became the leading ones. The level of indicators for the
previously preferred types - anxiety (1.91 ± 0.2) and neurasthenic (1.91 ± 0.17) - decreased almost
2-fold. All this indicates a significant improvement in the overall well-being of patients, a change in
their assessment of their condition, and a desire to actively promote the success of
treatment. Despite the existence of a disability group, there was a shift in the interests of patients in
the field of life, which were the most resourceful.
In the IB group, after rational therapy, neurasthenic and anxious types remained the preferred types
(2.51 ± 0.29 and 2.56 ± 0.23, respectively). There was also a slight increase in the harmonious (2.53
± 0.33) type of response. This indicates a superficial level of perception of the psychotherapeutic
correction performed.
Comparative analysis of applied psychotherapeutic approaches in groups IA and IB (Fig. 2) showed
a statistically significant difference (p <0.001) for the following types of response: harmonious - 5.4 ±
0.28 and 2.53 ± 0.33, respectively (p <0.001), hypochondriacal - 0.71 ± 0.1 and 1.64 ± 0.22 (p
<0.001), apathetic - 0.07 ± 0.07 and 1.58 ± 0.2 (p <0.001), egocentric - 0,22 ± 0,09 and 1,27 ± 0,18
(p <0,001), euphoric - 3,4 ± 0,16 and 1,13 ± 0,24 (p <0,001), anosognosic - 2, 2 ± 0.23 and 0.58 ±
0.17 (p <0.001), ergopathic - 5.96 ± 0.22 and 2.04 ± 0.34 (p <0.001). With an alarming response
type (1.91 ± 0.2 and 2.56 ± 0.23, respectively), the statistically significant difference was p = 0.040,
sensitive (1.89 ± 0.13 and 1.47 ± 0.19) - p = 0.022, paranoid (0.53 ± 0.08 and 1.24 ± 0.19) - p =
0.010, which indicates the appropriateness of psychocorrectional therapy.
Analysis of the dynamics of the data obtained after the course of psychotherapy testifies to the
preferential use of integrative psychotherapy by the DPDH method, as a result of which more
qualitative changes occur in the psychoemotional state of patients operated on for the thyroid cancer
(Figure 3).
The noted changes in the attitude towards the disease in the process of psychotherapy are
important primarily for the formation in the patients with a thyroid cancer optimistic model of the
expectation of recovery, a significant improvement in well-being and well-being. The applied
combination of biological therapy with psychotherapy increases the rehabilitation potential of thyroid
cancer patients.

conclusions
1. Patients who are diagnosed with thyroid cancer need adequate psychological preparation before
surgery and complex psychotherapy at the stages of subsequent rehabilitation based on the active
partnership of the patient doctor with the aim of correcting the physical, psychological and social
functioning impaired by the disease.
2. The use of the psychocorrection program is relevant at all stages of the provision of rehabilitation
care, especially when diagnosing when the symptoms of psychological and social maladaptation are
most evident, which is confirmed by the improvement in the LOBI questionnaire after a course of
psychotherapy in practically all indicators with a statistically significant difference (p < 0,05) after the
implementation of integrative psychotherapy by DPDH and rational psychotherapy.
3. The change in the prevalent type of response to the disease from anxious and neurasthenic to
harmonious and ergopathic in group IA shows a significant improvement in overall health, a change
in the patient's assessment of his condition, and a desire to actively promote the success of
treatment.
4. Methods of short-term psychotherapy, such as DPDH, lead to persistent states of psychological
adaptation and the formation of new behavioral skills, return the patient to an active working state for
a shorter period of time in comparison with the traditional methods of rational psychotherapy.
5. The above information indicates the need to revise traditional approaches to ongoing rehabilitation
activities in patients operated on for thyroid cancer, towards highly effective methods of short-term
psychotherapy, in particular the DPDH method.
Narcologist-psychiatrist in Minsk Igumnov Sergey Alexandrovich

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Psychotherapist in Minsk Grigoryeva Inessa Viktorovna