03/06/2013

Emergency psychological aid in case of acute surgical pathology and injury in the conditions of the children's hospital

                                                            This text translated by a professional translator

Podkhvatilin Nikolay, medical psychologist, Children’s Clinical and Research Institute of Emergency Surgery and Trauma

E-mail: podhvatilin.nv@niindht.mosgorzdrav.ru

Arbuzov Sergey, medical psychologist, Children’s Clinical and Research Institute of Emergency Surgery and Trauma

E-mail: podhvatilin.nv@niindht.mosgorzdrav.ru

It is not only physical but also psychological trauma which determines medical condition of children admitted to the emergency department. Physical trauma usually dominates; for this reason, surgeon or traumatologist often does not notice signs of psychological trauma at all. However, it is often the psychological trauma which causes delayed recovery of the child. The very fact of the influence of physical trauma on the child's psyche causes psychological and emotional stress. After the psychological trauma caused by the event beyond the scope of ordinary human experience (life-threat, physical destruction, loss of home or loved ones, etc.) the child may develop a pathological stress, which affects personality at biological, psychological and behavioral levels. In this case, mental state of mind may have a negative effect on the mechanisms of recovery [8].

 In the emergency department the psychologist gives psychological first aid for surgery or trauma (after patient recovers consciousness)

According to ICD-10, this transient condition is classified as acute stress reaction (F43.0) and diagnosed according to the following criteria:
1) severe mental or physical stress;
2) onset of symptoms is usually within an hour following exposure;
3) Depending on presentation of symptoms of the following two groups A and B, acute stress reaction can be mild (F43/01, includes several symptoms of group A and at least two symptoms of group B) and severe (includes several symptoms of group A and at least 4 symptoms of group B or dissociative stupor F44.2).

Group A includes criteria 2, 3 and 4 of generalized anxiety disorder (F41.1.).

Group B consists of the following symptoms: a) deviations from expected patterns of social interactions, b) narrowing of attention c) disorientation, d) anger or verbal aggression, e) despair or hopelessness, f) inadequate or meaningless hyperactivity, g) uncontrolled, or extremely severe (according to the cultural standards) sadness;

4)* in cases when stress was eliminated or mitigated, the symptoms begin to decrease not earlier than 8 hours after the trauma, and if the stress continues, symptoms start to diminish not sooner than after 48 hours;

* According to our empirical data, psychological adjustment provided to the patient with trauma or surgery-related stress in the above-mentioned period (from 1 to 48 hours after recovery of consiosness) before moving into the coping stage reduces the risk of developing PTSD symptoms and adjustment disorder.

5) no signs of another mental disorder except generalized anxiety (F41.1), an episode of any previous mental disorder ended at least 3 months prior to stress onset [9; p. 196].

Without the psychological adjustment intervention, signs of adjustment disorder (F43.2) appear within a month [9; p. 198]. PTSD symptoms occur a few months after the trauma; psychological shock or acute stress usually dominates in the first few hours or days [13; p. 47].

Thus, the challenge we face is to select methods of adjustment therapy, adapt them to the current problems of emergency care and make them available for use together with the general treatment.

We select methods of psychological adjustment which are suitable for emergency care and the most effective for acute stress conditions assuming that patient is mentally competent and has objective and strong motivation to get better.

The methods that showed best results are aimed at creating positive expectations and elimination of stress on the way to recovery [3].

 International experience of stress adjustment therapy includes strategies targeted at creating an 'Image of the Recovery.

" Karl Pribram, a neuroscientist at Stanford University, coined the term "Image of the Achievement", or "Image of the Final Result". He formulated the thesis that the human mind organizes itself according to the fundumental Images of Achievements which determine the direction of human lives: "Therefore, Image of the Final Result encodes the external effects (e.g. power) rather than muscle contraction. The Image of the Final Result controls human behavior just as the thermostat regulates the temperature: the disk in the thermostate does not turn on and off the boiler, but only sets temperature limits" [10; p. 278].

Another specialist in this field is Michael Sparks, a University of California professor, Ph.D., who studies the problem of modeling behavior. Developing the theme of "Image of the Final Result", he coined the term "Image of the Achievement" as a method of recovery after severe psychological trauma. According to the empirical experience of Stephen Gilligena, Doctor of Psychology at Stanford University, who is best known for his success in working with people who have suffered severe psychological trauma, their life has not changed, until they received instructions to visualize their own "Image of the Achievement" and positive images of their future.

The internal Image of the Achievement is responsible for the organization of behavior; it should be read as differentiation of movements from a sequence, or decoding of previously created 3D configuration, rather than combination of movements in a sequence. Thus, in many respects, behavior problems are the reverse side of problems related to the Image of the Achievement. The Image the Achievement reflects the wellness of the body, and the the achievement is implemented through the sequence of behavioral acts [10; p. 248].

Generally, there are two ways to change or create "Image of the Achievement". The first way is to stay still and relax, focus your attention inside your body. The second way involves rhythmic movement [12; p. 19]. In respect to children, this could be synchronous movement together with parents.

Stress is a state of frozenness. In moments of disorganization, changes, or crisis people experience stress and become 'frozen' in some way: their attention becomes rigidly fixed, muscles tense, breathing becomes rigidly fixed as well and may even be interrupted for a moment. Brain receives less oxygen. And just then, when a person needs new images, new dreams and new goals to set a new direction for his life, the physiology itself makes all this impossible. The consciousness is desperately trying to ease the stress; again and again it is repeating new cycles around those situations and events causing pain which the person is trying to escape. In this situation, a human looks like a missile launched along the hard-coded path. He can not ask himself the most important question: "What do I want?" [12; p. 19]. Without help, the patient is not be able to escape this state with minimal disruption of the personal and emotional and volitional sphere.

One of the most striking examples to create Image of the Achievement and Image of the Recovery is given by the the Dallas Center for Cancer Research and consulting in Texas, USA. Within four years, the specialists of this center (Carl Simonton and Stephanie Simonton) have been working with terminal-stage patients using various methods of self-managing through visualization. As a result of the treatment, 63 of 159 patients survived using the skills gained. Moreover, in 22.2% of them the tumor was not visualized four years after the start of the program [11; p. 95].

In 2011, the Research and Clinical Institute of Emergency Children's Surgery and Trauma made a study involving 110 patients which helped to determine symptoms of psychological disorders in patients in the acute stress after severe trauma and surgical pathology. It showed that there is a natural mechanism of visual-kinesthetic dissociation which is used to force out physical sensations and associated feelings from the area of realizing the realities. This is one of the defensive reactions of the body. Its purpose is to lower original emotional intensity of feelings and translate negative memories of eidetic images (associated perception) into the memories of the designed images.

The literature on this subject shows strong tendency to consider the dissociation as the main pathogenetic mechanism of the origin and development of PTSD but not as defensive mechanism of the brain (e.g., refer to Braun V.G., 1988). Proponents of this point of view believe that all the mental effects of the traumatic stress have dissociative nature and propose to include PTSD into the group of dissociative disorders. This point of view did not become generally accepted, however, it still retains its weight and has its own supporters. Dissociation is an essential component of the delayed reaction to the psychological trauma and apparently plays an important role in the development of PTSD symptoms. Dissociation represents one of the main but not the only pathogenetic mechanism of PTSD [13; p.75].

Our studies of the dissociative state as a defence mechanism (and not a pathological condition) showed that the oculomotor response in PTSD patients is located in the brain areas, which are responsible for storage of visual and auditory motion information. That is, when they ask the patient about specific bodily sensations, his eyes move in the direction of auditory and visual areas of the brain. If we artificially (by leading) lower the pupils down into the area of bodily sensations, then the pain and depressive feelings occur. On the contrary, those patients who are experiencing acute period of stress strongly associate themselves with the accident which led to the acute surgery or trauma-related stress. Their key image inducing stress feelings belongs to the objects of the real world, such as blood on their hands in the accident scene, etc. Key image from the real-world experience triggers stress feelings based on the internal picture of the same image (a simple glance at his own hands).

That is why we excluded from our practice on patients in acute condition those approaches and methods which were directed at sensations feelings, and perception of the current state (activating associative condition). We mainly used methods of behavioral psychology which spare feelings of patients in acute condition. In our method of adjustment therapy, we chose "behavioral approach" as opposed to "analytical approach" which analyses reasons for getting into the given situation; behavioral approach is determined by the well-known postulate: "from the standpoint of psychology, the physical illness is seen as a consequence of the combination of somatopsychical and psychosomatic circumstances led the patient to the traumatic event" [8]. The work with Images is based on the natural state of dissociation and that's why it is acceptable.

Obviously, using dissociation, mind protects itself from the destruction; thus, it can be used to create an Image of the Recovery (arbitrary structuring this natural mental defensive mechanism).

Foreign authors give examples of motivation to a desire to live in depressive states and severe illnesses using artificially induced dissociative state as an integral part of self-generated Image of Recovery (to make it a motivator). In this case, the patient is being attracted to this image, if it is dissociated.

Associative condition allows the patient to stay inside the image and therefore gives no motivation; moreover,it can not change the vision of what's going on [1; p.64].

When creating an image of the Recovery, the parent must take into account stage of mental development of the child. Russian psychologist Lev Vygotsky emphasized that parents must not make extra demands of children which do not meet the level of their actual development and abilities [4; p.66]. At different ages, children have different psychological comfort zones which are most vulnerable and susceptible to stress. When creating a visual Image of the Achievement in infancy or early childhood, main elements of the Image are built in the mother's mind, as it is an integral part of child's mind.

Let's give an example. Mother visualizes the image of a happy and healthy child (compensated for a disability if any) and observes his or her psychological and emotional reaction. The effect will be stronger, if she transformed this image from the negative one, which she had before, where she sees her child sick and unhappy.

In infancy and early childhood, connection between mother and child is symbiotic. Baby's movements are very complex, they are associated with integrated perception and combine sensory information from different modalities. This is the synchronization of movement between mother and child which was discovered recently. Infant and mother move synchronously without realizing it with mother's speech or when looking at the picture together when. Their smooth movement is so balanced and beautiful, that psychologists associate it with waltz [6; p. 63].

As the child grows older, mother-child symbiotic relationship transforms from a state of "we-ness", as it was called by Lev Vygotsky, into the mentoring relationship, when parents guide their child's cognitive development (0-2 years of age).

The use of Image of the Recovery differs depending on age of the child; the degree of parental engagement (and their adult visualization abilities) and conditions of non verbal communication may vary.

In order to transfer the Image of the Recovery through non verbal communication most effectively, we describe the following features of parents' behavior, depending on the age of children.

0 to 2 years of age

To compensate for the trauma in children of this age period, mother should follow the next instructions: hold the baby in her arms longer than usual, carry the baby with smooth,waltzing movements, pay more attention to the child's moods and feelings. Be caring, affectionate and kind with the baby. Remember that depression or aggression of the parent negatively affects even the small child.

Starting from the age of 5 months, the best way to promote recovery is games, especially hide and seek, which makes the child to believe that, despite short acts of disappearance, mom and dad are always to come back and they are always out there somewhere. Before leaving and going somewhere, leave your child's favorite toys nearby.

2 to 5 years of age

Preschool-aged children still have a difficulty expressing their feelings in words, especially when talking to an adult. An effective way to establish a non verbal communication and understand what happens to the child is listening to how he talks to his favorite toys. Often, children are more open with toys than with their family. Another activity which may help is fast automatic painting with bright colors, or yelling. Give a child the opportunity to shout and make some noise outside (if possible). It is important to talk to your child often about this and that, hold him in your arms or give him a hug.

5 to 10 years of age

At this age, the key mental change is building up self-esteem "I am a good person." Children overestimate their abilities, what helps them to learn new activities without doubts and fears [6; p.101]. In this age period, stress particularly affects self-esteem. To help rebuild their self-confidence, we recommend parents to paint together with their children and help them to paint their fears and illnesses, paint their mood, and play games together. At the same time, it makes easier to understand what worries your child. We recommend to tell the children the truth about the divorce, death, or illness (if it accompanied the traumatic event), or at least about that part of it, which would not aggravate the trauma. Of course, the child needs to know that parents love and support him and are proud of him no matter what.
 
10 to 16 years of age

Symptoms of stress in a child in older adolescence have virtually no difference from the symptoms of an adult. Therefore, in this age group we use methods of adjustment therapy suitable four adult mind but adjusted for the major mental functions of the corresponding age group. They should be integrated into into the Images of the Achievement as a part of the future behavior present in the dissosiative image. These are: increased attention to their appearance, status in the adolescent group, relationships with the opposite sex, epistemology of knowledge of the world. The parent can use the "mini-lectures" about the sexual relationships, self-fulfilment, good and bad, mission in life.

Parents are strictly instructed that they must not make extra demands of the child. Do not say: "Buck up! Get a grip on yourself! You must be strong." All this leads to that the child feels guilty. He feels guilty because he got in this situation. It is important to break this belief and allow him to understand that he has the right to make mistakes. Of course, it is important to watch out that the victim does not have the temptation to manipulate his parents in compensation. Nevertheless, he should know that parents love him no matter what happens. It helps a lot in work, and children usually get back to normal very fast.

Say the following: "I know that you are having difficulty with friends, but I have no doubt that you are be able to arrange everything. If you need me I'll always be there for you. " Tell your child about your memories, your own ups and downs and explain how you managed the stress. Tell about your childhood and what caused you pain, and what was you confused about. It will comfort his own feelings. Show your method for controlling stress. Nothing works as well as a demonstration of your own method of self-control.

We have observed that after acute surgery or trauma-related stress, induced dissociative state works like a lifeline for the patient's mind.

When explaining to the patient what is "dissociative Image of the Recovery", we encourage using language easily understandable to patients:
 "We need a fantasy, an example of how would you handle the situation if you already had what you want. And then, if you like this fantasy when you're watching it from the outside and it looks safe, no one is abusing you, you will not fall off the cliff, etc. Use this fantasy to observe yourself... " [2; p.104].

For children, the best way to achieve this type of transient dissociation (vision of oneself in the future), as well as spatial dissociation (vision of oneself within the current situation) is by using metaphors or "hidden instructions" in the process of adjustment therapy.

An Image of Achievement or "healthy” self-imagemust be created with the obligatory notification of the patient (saying it out loud) that the algorithm (method) to achieve this condition will remain a mystery for himself (this is a way to remove possible neurotic defense). The simplest example of this technique is "to see oneself happy in the future."

More complex Images of the Achievement for patients with potential or occurred disability (prospects of living after the loss of parents, close relatives, etc.) are created as a model of compensated personality in the future. It would not be just an image but the integral model of the behavior of the individual in different situations, formed under the prevailing circumstances. The most effective strategy in the acute period is to form personal beliefs and promote recovery and adaptation (using the logic levels) [5; p. 27]. Let's give an example. If the patient is an adolescent, then the emphasis in the creation of the image should be made on the self-realization regardless of the outcome of the surgery or trauma-related stress. A child left with one hand receives the attitute that he is different and is elected to succeed a lot in writing, computing, analytics, etc. And all his logical levels which forms his personality should be adapted to the attitude promoted: from friends to the abilities, to the values and psycological identity. Recall that in the acute period a child easily accepts these instructions and recommendations. It should also be remembered that work with the beliefs reinforcing the image created implies the following condition: change in beliefs is carried out based on the higher logic level than the level at which the patient can realize what is happening to him [5; p. 55].

Results of adjustment therapy in the acute stage show that PTSD symptoms determined by SCID (Structured Clinical Interview for DSM) or CAPS (Clinician Administered PTSD Scale) do not develop in patients who received urgent care using the methods described above.
Then, at the same time, in a modified form we use it for the diagnosis of patients in late-stage recovery and when reporting on the recovery dynamics. A survey of 110 patients in NII NDHiT (Research and Clinical Institute of Emergency Children's Surgery and Trauma) taken 2011 helped to reveal features of psychological disorders in patients from 1 to 16 years years of age caused by acute surgery or trauma-related stress. The symptoms found were

- Disturbed thought process (disturbed cause-effect relationships, difficulties with generalization and separation into categories by essential features, etc.), found in 8 patients;

- changes in the emotional state and personality changes: these patients presented with symptoms of anxiety not determined by the current situation (agitation, insomnia, fear of medical procedures, stress), observed in 54 children.

Of particular interest were 9 patients who experienced the traumatic event caused by family relationships (negative role imprinting). When exposure of family to the traumatic situation is long-term, child's emotional experience is pushed into the area of uncosciousness and seeks for escape. Children's minds, finding no other way to influence the situation, selects the "sacrification" which often manifests itself in the unconscious behavior. In other words, a child with a negative imprinting psychologically is more susceptible to all kinds of traumatic situations than the child from a healthy family.

For children with distrubed thought processes, we recommended the primary physician to refer them to the psychoneurologist or a child psychiatrist for additional examination.

Our patients with emotional disorders, personality changes, or negative imprinting received several sessions of adjustment therapy. They included: Visual / kinesthetic dissociation technique, which is effective for the rapid and long-term decrease in the susceptibility of patients to the traumatic incidents and phobias; - change in personal history, allowing a patient to make a quick assessment/re-assessment of his adaptive behavioral resources and integrate himself into certain situations; reframing - which is a process by which one can perceive certain problem situations differently than before, and turn them into positive and adaptive resource for recovery; and psycho metaphorics - very mild therapy which is very effective for children and works through telling specially selected stories.

Results of therapy were evaluated by changes in the attitude of the patient to his own traumatic experience.

After adjustment therapy, we managed to cover ("laminate") traumatic experience in 58 patients, and 15 patients showed improvement in general condition and relationships with their parents during the therapy . In the course of physiological recovery after trauma, small mental deviations of identity were no longer observed in 37 children.

Our experience confirms the importance and necessity of introduction of first-aid methods of the psychological first aid to children admitted to emergency department after trauma. An integrated approach to the study of acute and chronic pathological conditions is the most important if not the only way in some cases to further improve the effectiveness of medical care. [14].

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Translated - http://www.medpsy.ru/mprj/archiv_global/2012_1_12/nomer/nomer07.php