Lecture: Perinatal psychology and psychiatry. Perinatal psychology - a new section of clinical (medical) psychology Perinatal pathopsychology

Modern ideas about the mechanisms of ADHD formation

Glossary of terms found in the article:

Etiology - (from Greek aitia - cause and...logy), the doctrine of the causes of diseases. Professional (in medicine) use of the term is as a synonym for “cause” (for example, influenza is a “disease of viral etiology”).

Anamnesis - (from Greek - anamnesis - memory), a set of information about development of the disease, living conditions, previous diseases etc., collected for the purpose of their use for diagnosis, prognosis, treatment, prevention.

Catamnesis - (catamnesis; Greek katamnemoneuo remember) - the term was proposed by the German psychiatrist W. Hagen. Denotes a set of information about the patient’s condition and the further course of the disease after diagnosis and discharge from the hospital.

Prenatal - (from Latin prae - before and natalis - relating to birth), prenatal. Typically, the term "prenatal" is applied to the later stages of embryonic development in mammals. Recognition before birth (prenatal diagnosis) of hereditary diseases in some cases makes it possible to prevent the development of severe complications in children.

Perinatal period (synonymous with the peripartum period) - the period from the 28th week of pregnancy, including the period of labor and ending 168 hours after birth. According to the WHO classification, adopted in a number of countries, P. p. begins at 22 weeks.

Catecholamines (syn.: pyrocatechinamines, phenylethylamines) - physiologically active substances related to biogenic monoamines, which are mediators (norepinephrine, dopamine) and hormones (adrenaline, norepinephrine).

Mediators , transmitters (biol.), - substances that transfer excitation from the nerve ending to the working organ and from one nerve cell to another.

Synapse - (from the Greek synapsis - connection), the area of ​​​​contact (connection) of nerve cells (neurons) with each other and with the cells of the executive organs. Interneuron synapses are usually formed by the branches of the axon of one nerve cell and the body, dendrites or axon of another. Between the cells there is a so-called. a synaptic cleft through which excitation is transmitted through mediators (chemical synapse), ions (electrical synapse) or in one and other ways (mixed synapse). Large neurons of the brain have 4-20 thousand synapses, some neurons have only one.

Despite the large number of studies conducted to date, the causes and mechanisms of development of attention deficit hyperactivity disorder remain poorly understood. It is known that the etiology of this syndrome is combined. That is, no single etiological factor has been identified for this pathology. Therefore, if it is possible to establish in the anamnesis the most probable cause violations, the influence of several factors influencing each other should always be taken into account. A motley picture of pathological manifestations, reflecting the abnormal development of mental functions, is formed due to the fact that damage occurs in the CNS (central nervous system) at different stages of development under the influence of a number of factors.

Most of the data obtained on etiological factors are interrelated in nature and do not provide direct evidence of direct and initial causation. For example, although parents of children with ADHD are more likely to smoke tobacco during pregnancy and pregnant women who smoke are more likely to have children with ADHD, this is not direct evidence that smoking causes ADHD. It is possible that parents of children with ADHD may smoke more than parents of normal children because they are more likely to have symptoms of the disorder themselves. It is the genetic relationship between parents and children that may be more significant here than smoking itself. For this reason, it is necessary to interpret with great caution the interrelated results of the many studies on the causal factors of ADHD.

Despite the fact that final clarity about the causes of the disease has not yet been achieved and it is assumed that many factors influence the development of ADHD, most modern research suggests that neurological and genetic factors are more important.

Brain damage during the prenatal and perinatal periods, according to most researchers, is important in the development of ADHD. But exactly what factors and to what extent are the cause of the development of this syndrome have not yet been established. Thus, the occurrence of ADHD is facilitated by such factors as asphyxia of newborns, maternal consumption of alcohol, certain medications, smoking, toxicosis during pregnancy, exacerbation of chronic diseases in the mother, infectious diseases, attempts to terminate pregnancy or threatened miscarriage, injuries in the abdominal area, Rh factor incompatibility, post-term pregnancy, prolonged labor, prematurity, morphofunctional immaturity and hypoxic-ischemic encephalopathy (C.S. Hartsonghetal., 1985; H.C. Lou, 1996). The risk of developing the syndrome increases if the mother's age during pregnancy is younger than 19 or older than 30 years, and the father is older than 39 years.

In recent years, an important role in the development of ADHD has been assigned to early organic damage to the central nervous system. Moreover, the predominance of this pathology in boys is associated with a higher vulnerability of the brain under the influence of pre- and perinatal pathological factors.

Causes of damage to the developing brain fall into four main types: hypoxic, toxic, infectious And mechanical. There is a dependency between timing of pregnancy, in which the impact of pathological factors on the fetus occurred, and the severity of the outcomes. Thus, adverse effects in the early stages of ontogenesis can cause developmental defects, childhood cerebral palsy and mental retardation. Pathological effects on the fetus in more than late dates Pregnancies often affect the formation of higher cortical functions and serve as a risk factor for the development of attention deficit hyperactivity disorder.

Despite the fact that not all children with ADHD can be diagnosed with organic damage to the central nervous system, pre- and perinatal damaging factors are one of the leading causes in the formation of attention deficit hyperactivity disorder.

The genetic concept of the formation of ADHD assumes the presence of a congenital inferiority of the functional systems of the brain responsible for attention and motor control.

According to the results of studies in the USA and Czechoslovakia, 10-20% of children with ADHD had a hereditary predisposition to the disease. Moreover, the more pronounced the symptoms of the disease, the more likely it is of a genetic nature.

When examining twin pairs aged 4 to 12 years from 1938 families, the diagnosis of attention hyperactivity disorder was established among monozygotic twins in 17.3% of boys and 6.1% of girls, among dizygotic twins - in 13.5% of boys and 7. 3% girls. At the same time, concordance (statistical indicator of the percentage of relatives suffering from the same disorder) for attention deficit hyperactivity disorder in monozygotic twins was equal to 82.4%, in dizygotic twins - only 37.9%. The genetic risk of developing ADHD in monozygotic twins is 81%, in dizygotic twins - 29%, a high percentage was also obtained in adopted children - 58%.

In addition, studies have shown that 57% of parents of children with ADHD experienced the same symptoms during childhood.

According to neuropsychological studies of children with ADHD, deviations in the development of higher mental functions responsible for attention, working memory, cognitive abilities, inner speech, motor control and self-regulation were noted. According to M.B.Denckla and R.A.Barkley, disruption of these executive functions, which are responsible for the purposeful organization of activity, leads to the development of the syndrome.

Adults with ADHD also show similar executive function deficits on neuropsychological tests. Moreover, recent research shows that not only do ADHD siblings of children with ADHD have similar executive function deficits, but even those siblings of children with ADHD who do not have these symptoms appear to have some deterioration of the same executive functions. These findings suggest a possible genetic risk for executive functioning deficits in families of children with ADHD, even when family members do not fully exhibit ADHD symptoms.

The impressive amount of data obtained on this issue further suggests that dysfunction of the prefrontal lobes of the brain (deficits in self-restraint and executive functioning) is a likely basis for explaining ADHD. In this case, there is no clear localization of the damage, most likely we can talk about diffuse damage, therefore such research methods as electroencephalography and CT scan violations are often not detected.

Neurophysiological and neuromorphological studies have revealed a violation of the formation of functional relationships between the midline structures of the brain, between them and various areas of the cerebral cortex in attention deficit hyperactivity disorder, as well as changes in the motor and orbitofrontal areas of the cortex, the basal ganglia (reduction in the volume of the globus pallidus, violation of the asymmetry of the caudate kernels).

Modern theories consider the frontal lobe and, above all, the prefrontal region as the area of ​​anatomical defect in ADHD. Ideas about this are based on the similarity of clinical symptoms observed in ADHD and in patients with damage to the frontal lobe. Both children and adults demonstrate marked variability and dysregulated behavior and distractibility; deficit of attention, restraint, regulation of emotions and motivation. In addition, in children with attention deficit hyperactivity disorder, a decrease in blood flow was found in the frontal lobes, subcortical nuclei and midbrain, and the changes were most pronounced at the level of the caudate nucleus.

Changes in the caudate nucleus may be the result of its hypoxic-ischemic damage during the neonatal period, since it is the most vulnerable structure under conditions of blood flow deficiency. The caudate nucleus performs an important function of modulation (mainly of an inhibitory nature) of polysensory impulses, the lack of inhibition of which may be one of the pathogenetic mechanisms of ADHD.

Apparently, the identified structural abnormalities are the morphological substrate for the occurrence of mild cerebral pathology observed in ADHD.

Currently, much attention is paid to disruption of the pathways connecting the cortex with the basal ganglia and thalamus. In accordance with the feedback principle, they form loops or cycles. At least five basal ganglion thalamocortical circuits are currently known, each of which includes different parts of the striatum, thalamus and cortex. Hyperkinetic disorders are associated with dysfunction of the “motor” cycle. However, it is unfounded to suggest that this model underlies ADHD.

No serious motor disorders, any changes in muscle tone, or impaired motor reflexes were found in children with the syndrome.

With this disease, it is more likely to assume violations of cortical relationships, because the systems of attention and working memory, according to J.T. McCracken (1991), are located in the area of ​​the orbitofrontal cortex.
Thus, neurophysiological data are not yet sufficient to support either the basal ganglionic or frontal pathophysiological model.

Neurotransmitter deficiency due to impaired metabolism of dopamine and norepinephrine, which are neurotransmitters of the central nervous system, is assumed to be one of the mechanisms for the development of ADHD. Catecholamine innervation affects the main centers of higher nervous activity: center for control and inhibition of motor and emotional activity, activity programming, attention system and RAM. It is known that catecholamines perform positive stimulation functions and are involved in the formation of the stress response. Based on this, we can assume that catecholamine systems are involved in the modulation of higher mental functions, and when catecholamine metabolism is disturbed, various neuropsychiatric disorders can occur.

Currently, the involvement of all catecholamine systems in the pathogenesis of ADHD, and not just the dopaminergic system, as previously thought, has been shown.

The catecholamine concept of the formation of ADHD is supported by the fact that symptoms of impaired attention and hyperactivity have been successfully treated for several decades with psychostimulants, which are catecholamine antagonists and change the balance of catecholamines in the body. It is assumed that these drugs increase the availability of catecholamines at the synaptic level, stimulating their synthesis and inhibiting recapture in presynaptic nerve endings. However, there is evidence of a positive, albeit lesser, response to psychostimulants in healthy children. Therefore, evidence of drug response cannot be used to support neurochemical abnormality in ADHD.

Studies of urinary excretion of catecholamines have revealed differences in their metabolism between children with ADHD and healthy children. However, due to the contradictory nature of the results obtained, there is still no clear opinion on the issue of catecholamine metabolism disorders in ADHD.

Cerebrospinal fluid findings suggest decreased dopamine in the brains of children with ADHD. At the same time, the study of blood and urinary metabolites of brain neurotransmitters showed contradictory results.

The reason for this may be not only the clinical heterogeneity of children with ADHD, but also the impermeability of the blood-brain barrier to free catecholamines.

Thus, the available evidence appears to indicate a selective deficiency in the availability of both dopamine and norepinephrine, but this cannot be considered proven at this time.

Adverse environmental factors associated with anthropogenic pollution and, above all, microelements from the group of heavy metals, can have negative consequences for the health of children. It is assumed that the intake of lead into the body of children, even in small quantities, can cause cognitive and behavioral disorders, while children 1-2 years old are most susceptible to its toxic effects. Thus, an increase in the level of lead in the blood to 5-10 mcg/dl correlates in children with the occurrence of problems with neuropsychic development and behavior, attention problems, motor disinhibition, as well as a tendency to reduce IQ.

However, even with high lead levels, less than 38% of children have hyperactive behavior. And most children with ADHD do not have elevated lead levels in their bodies, although one study suggests they may have higher lead levels than comparison subjects. Data from many studies indicate that no more than 4% of ADHD symptoms in children are due to elevated lead levels.

Thus, the toxic effects of lead on the central nervous system and mental development of children, and its possible role in the formation of the syndrome, have not yet been proven and require further study.

Dietary factors may also be risk factors and influence the development of ADHD. This primarily applies to artificial colors and natural food salicylates, which can cause cerebral irritation and cause hyperactivity. Removing these substances from food leads to significant improvements in behavior and the disappearance of learning difficulties in most hyperactive children.

Eating excess sugar increases hyperactivity and aggressive behavior. But there is also information of the opposite nature. Thus, E.N.Werder and M.V.SoIanto did not establish a significant effect of high sugar levels on the aggressive behavior of children with ADHD. There was only an increase in attention deficits.

Be that as it may, proper and balanced nutrition is important for school-age children and especially those with ADHD.

Psychosocial factors. An important role in the formation of attention deficit hyperactivity disorder is played by socio-psychological factors, including intra-family and extra-family factors. The psychological microclimate has a great influence: quarrels, conflicts; as well as alcoholism and immoral behavior of parents, upbringing in single-parent families, remarriage of parents, prolonged separation from parents, long-term serious illness and/or death of one of the parents, different approaches to raising a child among parents and grandparents living with the family . All this cannot but affect the child’s psyche. Peculiarities of upbringing also have an impact - overprotection, selfish upbringing of the “family idol” type, or vice versa, pedagogical neglect can cause a deterioration in the child’s development.

Living conditions and material security are also important. Thus, in children from socially advantaged families, the consequences of pre- and perinatal pathology generally disappear by the time they enter school, while in children from families with a low material standard of living or socially disadvantaged families, they continue to persist and create the preconditions for the formation of school maladaptation .

Therefore, psychosocial factors are controllable factors in the development of ADHD. Therefore, by changing the child’s environment and attitude towards him, it is possible to influence the course of the disease and significantly reduce the influence of medical and biological factors. Unfavorable psychosocial conditions only aggravate the influence of residual organic and genetic factors, but are not an independent cause of the formation of attention deficit hyperactivity disorder; they only provoke further development of the disease, even if it started with mild brain damage in the perinatal period or in the first years of life.

Thus, the approaches developed by various researchers to study the formation of attention deficit hyperactivity disorder mostly affect only certain aspects of this complex problem, in particular neuropsychological, neuromorphological, neurophysiological, neurochemical, unfavorable environmental factors, food, etc. But at the present stage it is possible identify only two groups of medical and biological factors that determine the development of attention deficit hyperactivity disorder: 1 - damage to the central nervous system in the pre-, peri- and early postnatal periods; 2 - genetic factors. All other identified disorders are naturally caused by early organic damage to the central nervous system, heredity, or their conjugate effect. At the same time, psychosocial conditions play an important role in the formation of ADHD, along with medical and biological factors.

Research by N.N. Zavadenko showed that in the formation of ADHD, early damage to the central nervous system during pregnancy and childbirth was important in 84% of cases, genetic mechanisms in 57%. Moreover, in 41% of cases, the formation of the syndrome was determined by the combined influence of these factors.

Dobryakov I.V. (Saint Petersburg)

Annotation. The article provides a definition of a new section of clinical (medical) psychology - perinatal psychology, describes its main features and tasks, shows the relevance of the development of perinatal psychology and the introduction of its achievements into practice.

Keywords: clinical (medical) psychology, perinatal, dyad, biopsychosocial approach.

At the beginning of the twentieth century V.M. Bekhterev, who combined the talent of an outstanding clinical psychiatrist, psychotherapist, neurologist with deep knowledge in the field of morphology, psychology, physiology, developed and introduced into practice a new scientific direction: psychoneurology. It meets modern requirements for a comprehensive interdisciplinary study of the nervous system and psyche of a healthy and sick person. In created by V.M. At the Bekhterev Research Institute, in addition to departments engaged in medical research in the field of neurology, psychiatry, and psychology, a social psychoneurology sector was formed in 1932. Thus, the concept of psychoneurology V.M. Bekhterev included biopsychosocial triad. At the institute, which bears his name after the death of its creator, treatment methods have been developed and continue to be improved, combining both biological and sociopsychological influences with a differentiated observation system. They are considered as a complex dynamic system of interconnected components (medical, psychological, social) aimed at restoring the patient’s personal and social status. Ideas by V.M. Bekhterev, despite the changing, often very difficult political situations, was successfully developed by his students and followers (E.S. Averbukh, L.I. Wasserman, R.Ya. Golant, M.M. Kabanov, B.D. Karvasarsky, A. A.F. Lazursky, A.E. Lichko, S.S. Mnukhin, V.N. Myasishchev, Y.V. Popov, T.Ya. Khvilivitsky, etc.).

Guided by his ideas, M.M. Kabanov formulated the principles of rehabilitation in psychoneurology:

The principle of unity of biological and psychosocial influences;

The principle of versatility of efforts and influences when implementing a rehabilitation program;

Partnership principle;

The principle of gradation (transition) of applied efforts, ongoing influences and activities.

Pioneering works of V.M. Bekhterev and his students made it possible to increase the efficiency of working with patients suffering from nervous and mental illnesses. The need to introduce such an approach into all areas of medicine was obvious. G. Engel played a major role in this, developing an approach called "biopsychosocial". He argued that the clinician needs to consider not only the biological, but also the psychological and social aspects of the disease. Only then will he be able to correctly understand the cause of the patient’s suffering, offer adequate treatment and win the patient’s trust. His holistic model became an alternative to the generally accepted biomedical approach that had reigned supreme in industrial societies since the mid-20th century. The speed of spread of Angel's ideas in various fields of medicine was different, which is associated with the specifics of understanding the mutual influence of psychological, biological and social factors, identifying patterns, theoretical justification and testing in practice.

The introduction of a biopsychosocial approach to obstetrics has met and continues to meet resistance from a number of doctors. Meanwhile, neglect of psychological and social factors has led and continues to lead to the currently recognized unconstructive features of providing assistance to pregnant women and women in labor. The most famous of them and previously widely practiced include a categorical ban on visits by relatives to women in maternity hospitals, separation of mother and child immediately after childbirth, etc. The urgent need to introduce a biopsychosocial approach into obstetric practice was the reason for the emergence of a new section of clinical (medical) psychology - perinatal psychology, which differs from its other sections in the features of its subject and the specifics of the range of phenomena studied.

Medical psychology- one of the main applied branches of psychological science, the purpose of which is to apply a variety of psychological knowledge in the field of medical activities (health care, disease prevention, diagnosis, treatment, rehabilitation), in medical research. In addition, the area of ​​interest of medical psychology includes the relationships that arise between all participants in the process of providing medical care. In the Russian Federation, in 2000, the Ministry of Education, by order No. 686, approved the specialty “clinical psychology” (022700). An accepted definition is that clinical psychology is a broad-based specialty that is intersectoral in nature and involved in solving a set of problems in the healthcare system, public education And social assistance to the population. Medical psychology has especially close connections with psychotherapy and psychiatry.

The branch of medical (clinical) psychology is perinatal psychology, since at all stages of the reproductive function (conception, pregnancy, childbirth, baby care) a person needs medical examination, observation, and sometimes treatment. First of all, it is closely related to obstetrics, but no less important are its relationships with psychiatry And psychotherapy. In the process of conception, during pregnancy, in feeding and caring for a child, a person experiences strong both positive and negative emotions. Pregnancy, whether desired or not, as well as the birth of a child, are accompanied by heavy loads to all systems of a woman’s body, which can affect the state of her health, the development of the child, lead to asthenia, increased anxiety, the emergence of fears, and depressive experiences. Pregnancy and childbirth certainly entail changes in a woman’s attitude towards herself, towards others, in relation to the attitude of others towards her, that is, changes in her personality. There is also a change in the social status of the spouses who become mother and father. Thus, the appearance of a new member in the family inevitably leads to a restructuring of the family system and changes marital relationships. All of the above explains why during pregnancy and the birth of a child, the risk of the emergence or exacerbation of family problems, somatic and neuropsychic disorders in both spouses, but especially in the woman, sharply increases. At conception, the two organisms of mother and child begin to live a common life, forming a dyad. A woman’s entire body is radically restructured in order to optimally ensure the two of them can function together. For this purpose, an additional common organ is formed - the placenta. Dominant states that consistently arise in connection with the reproductive function and replace each other in a woman’s body, determined by biological (primarily hormonal) changes, psychological and social factors, are called maternal dominant. Maternal dominance includes a physiological component and a psychological component. They are respectively determined by biological or mental changes that occur in a woman, aimed at bearing, and then at giving birth and nursing a child.

Gestational dominant(Latin: gestatio - pregnancy, dominans - dominant) ensures that all reactions of the body are directed towards creating optimal conditions for the development of the prenate. Psychological component of gestational dominance is a set of mental self-regulation mechanisms that are activated when pregnancy occurs and form behavioral stereotypes in a pregnant woman aimed at preserving gestation and creating conditions for the development of prenate. Features of the psychological component of gestational dominance are manifested in pregnancy-related changes in a woman’s system of relationships. We have identified five options for its formation: optimal, hypogestognosic, euphoric, anxious, depressive. The optimal option is favorable both for the course of pregnancy and childbirth, and for the formation of bonding after childbirth, for the development of the baby. Women who show signs of euphoric, hypogestognosic, anxious, euphoric variants of the psychological component of the gestational dominant need to be monitored, since they may have neuropsychic and somatic disorders, or have an increased risk of their occurrence. Options for the psychological component of the gestational dominant may change during pregnancy depending on the gestational age, the somatic state of the woman, the situation in the family, relationships with the doctor, etc. This makes it possible to correct the psychological component of the gestational dominant, sets specialists the task of conducting a screening psychological examination of pregnant women for early identification of those in need of medical and psychological help, and guides the specialist in what it should be expressed in.

Thus, pregnancy and childbirth are a critical situation for both parents, having all its characteristic features. After all, for parents, the gestation and birth of a child are events that can be dated and localized in time, accompanied by strong, persistent emotional reactions, requiring large expenses and a long time for adaptation. In this regard, professional psychoprophylactic work should be carried out with families expecting the birth of a child. Expectant parents should have access to psychological, psychotherapeutic, and sometimes psychiatric help. It is advisable for such work to be carried out by specialists in health care institutions (in perinatal centers, antenatal clinics, maternity homes, children's clinics), and not by midwives and psychologists or simply enthusiasts without special clinical training at home or “in hobby groups.” This will ensure the professionalism of the assistance provided and the interaction of specialists.

Perinatal psychology can be defined as a section of clinical psychology involved in solving the psychological problems of providing obstetric-gynecological and perinatal care to the population. The very name “perinatal psychology,” which reflects its essence, contradicts generally accepted obstetric terminology. The word “perinatal” is of mixed Greek and Latin origin: peri- - around (Greek); natus - birth (lat.). In 1973, at the YII World Congress of FIGO (International Federation of Obstetricians and Gynecologists), the definition of the “perinatal period”, according to which it begins, was adopted and included in the international classification of the 10th revision (ICD-10). from 22 completed weeks (154 days) of pregnancy and ends 7 completed days after birth. In obstetrics, perinatal is also often considered to be the period lasting from the 28th week of a person’s intrauterine life to the 7th day of his life after birth. From the point of view of perinatal psychologists, the perinatal period includes the entire prenatal period, the birth itself and the first months after birth. This, in contrast to the understanding of the term by obstetricians, is more consistent with the etymological meaning of the concept and allows us to consider the birth of a child not as a separate event represented by a point on the time axis, but as a long process starting from conception and covering the entire prenatal period, the birth itself and the first months after birth Signs of the perinatal period are:

The presence of a symbiotic relationship between mother and child;

The child’s lack of self-awareness, that is, his inability to distinguish himself from the world around him, to build clear bodily and mental boundaries;

Lack of independence of the child’s psyche, its dependence on the characteristics of the mother’s mental functions.

The activities of a perinatal psychologist are aimed at increasing the mental resources and adaptive capabilities of women and men in the process of implementing the reproductive function, harmonizing family relationships, creating optimal conditions for the development of the prenate and the baby, and protecting the health of women and children.

Object research and psychological impact in perinatal psychology are dynamically developing dyadic systems: marital holon, “pregnant-prenate”, “mother-child”. That is, a perinatal psychologist works with dyads. The essence of the dyadic approach is that the husband and wife are considered as a dyad - the marital holon, and the pregnant woman and prenate, mother and baby, as components of one mother-child system. Within the framework of these systems, their elements interact, develop and acquire a new social status of mother, father, or child. The mother-child dyad is a subsystem of the family, and it is influenced by everything that happens in the family.

The perinatal dyad is a self-developing open structure with complex dynamics regulated by presumably simple, but as yet unknown algorithms of interactions both within the dyad itself and the dyad as a whole with the environment. The result of these processes is difficult to predict: during the perinatal period, the prenate, and then the baby, lives with the mother practically one life and the dynamic structure “surrounding world-mother-prenate” is especially sensitive to any fluctuations. The fact that a woman during the perinatal period becomes part of two dyads at the same time (in one as a wife, in the other as a mother) can lead to conflict situations. Timely detection of the possibility of this and preventing the conflict, helping to resolve it constructively are the tasks of a perinatal psychologist.

Subject The professional activities of a perinatal psychologist can be:

Development of mental processes in the early stages of ontogenesis;

Social and psychological phenomena that appear in women and men in connection with their reproductive function;

Psychological characteristics of relationships in a family expecting the birth of a child or having a small child;

Psychosomatic disorders associated with reproductive processes.

A perinatal psychologist performs a variety of activities: preventive, didactic, advisory, diagnostic, correctional, expert, rehabilitation, research and others.

In addition to the dyadic nature of the object of study, the features of perinatal psychology include the family nature of the problems that it studies; sequential change of tasks related to the stages of family life, stages of implementation of the reproductive function; psychoprophylactic orientation.

The following can be distinguished sections of perinatal psychology:

Psychology of conceiving a child;

Psychology of pregnancy (mother-prenate dyad);

Psychology of the early postnatal period (mother-child dyad);

Psychology of the influence of the course of the perinatal period on mental development in general and on personality development in particular;

Crisis perinatal psychologists (if there is a threat to the health, life of the mother and/or child, death).

Basic tasks of perinatal psychology can be formulated as follows.

1. Determination of the role of psychological (including family) factors in the processes of conception, pregnancy and childbirth; formation of the mother-child dyad; child development in infancy and early childhood.

2. Study of the influence of various diseases of a woman on her attitude towards conception, pregnancy, childbirth; formation of the mother-child dyad; mental development of the prenate/child.

3. Development of psychological research methods adequate for solving problems of perinatal psychology.

4. Creation of methods of early psychological intervention aimed at optimizing the course of the perinatal period and family functioning at the stages of conception, expecting a child and in the postpartum period.

5. Development of methods of psychological and psychotherapeutic assistance in situations of perinatal loss and the birth of a sick child.

6. Solving psychological problems arising in connection with the use of modern technologies to combat infertility (in vitro fertilization, surrogacy, etc.).

Perinatal psychology develops, therefore it has both permanent specific signs and transient signs that are a sign of the present time:

Dyadic nature of the object (the “pregnant-fetus” or “mother-child” system);

The family nature of the problems it is intended to solve;

Low level of awareness of patients in need of perinatal psychological and psychotherapeutic assistance about the possibility of receiving it;

The need to actively identify those in need of perinatal psychological and psychotherapeutic help, to motivate them to receive it;

Iatrogenic, psychogenic and didactogenic nature of a number of disorders that are an indication for the use of perinatal psychocorrection and psychotherapy;

Insufficient development of the legal framework for the provision of psychological and psychotherapeutic assistance in the event of perinatal losses;

Consecutive change of tasks of perinatal psychocorrection and psychotherapy related to the stages of family life, stages of reproductive function;

The need for close cooperation between a perinatal psychologist, psychotherapist and other specialists (obstetricians-gynecologists, neonatologists, neurologists, etc.);

Preference for short-term psychocorrectional and psychotherapeutic methods;

Lack of specific psychological tools and methodological developments in the field of perinatal psychology and psychotherapy;

Insufficient number of competent perinatal psychologists and psychotherapists;

Preventive orientation of PP and psychotherapy.

A specialist in the field of perinatal psychology needs to obtain special knowledge and master special techniques. This dictates the need to train such specialists in the psychology departments of universities, in the system of postgraduate psychological and medical education. Government agency, in which, for the first time in our country, educational programs and plans for cycles of thematic improvement in the field of perinatal psychology, psychopathology and psychotherapy of psychologists, psychiatrists, psychotherapists, and neonatologists were developed was the St. Petersburg Medical Academy of Postgraduate Education (now the North-Western State Medical University. I.I. Mechnikov). The work was carried out and continues at the Department of Child Psychiatry, Psychotherapy and Medical Psychology (Head of the Department - Doctor of Medical Sciences, Prof. E.G. Eidemiller).

The development and implementation of perinatal psychological counseling and psychotherapy, aimed at improving the mental state of pregnant women and women in labor, harmonizing relationships in families expecting the birth of a child and raising a baby, is one of the urgent, priority government tasks. Their solution will reduce the number of complications during pregnancy and childbirth, the number of newborns with neuropsychiatric disorders (including by reducing the use of medications).

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UDC 159.922.7-053.31

Dobryakov I.V. Perinatal psychology - a new section of clinical (medical) psychology [Electronic resource] // Medical psychology in Russia: electronic. scientific magazine - 2012. - N 5 (16)..mm.yyyy).

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1. History of the development of perinatology.
2. Perinatal psychology.
3. Perinatal psychiatry. The concept of diathesis.
4. Diagnosis of neuropsychiatric disorders at an early age.

G. J. Craig determined perinatology(Greek peri - around, around; Lat. natus - birth). as “a branch of medicine that studies the health, diseases and methods of treating children in a time perspective, including conception, the prenatal period, childbirth and the first months of the postnatal period.” The perinatal period lasts from the 28th week of human intrauterine life to the 7th day of life after birth. Interest in new science is largely due to the need to find ways to stop the growing trend in the number of newborns with neuropsychiatric disorders. There are many reasons for this phenomenon: advances in medicine, leading to a decrease in the mortality rate of children with pathologies that in past years were incompatible with life, and unsatisfactory psychoprophylactic work with pregnant women, and errors in obstetric care, and environmental deterioration, and the growth of drug addiction. The development of perinatology in Russia and Western countries differed significantly. Widespread in the West psychoanalytically oriented research in perinatology. In the 1920s, psychoanalysis was attacked in Russia and it was banned as “propaganda of bourgeois ideology.” In 1924, the State Psychoanalytic Institute was closed, and in 1940, the director of the institute, I. D. Ermakov, was arrested and later died in the camp. In 1948, the famous psychiatrist Professor A. S. Chistovich was dismissed from the Leningrad Military Medical Academy for a lecture on dream analysis. In the Soviet Union, conception, pregnancy, and childbirth were viewed in the light of the prevailing ideas of nervism as a set of unconditioned and conditioned reflexes associated with instinctive activity. The psychology of pregnancy has been studied only from the perspective teachings of I. P. Pavlov. On its basis, I. Z. Velvovsky and his colleagues developed and implemented in 1949 “psychoprophylactic method of labor pain relief.” Mother-child relationships were studied in Soviet child psychology by L. S. Vygotsky and his students, but outside of perinatology (the mother, as a representative of the human race, as a subject of cognitive activity). The founders of perinatology in our country are deservedly considered N. L. Garmashova and N. N. Konstantinova (1985).

Research activity in this area continues to increase. In St. Petersburg, on March 20-22, 1997, a conference was held on issues of perinatology, at which it was decided to create the Association of Perinatal Psychology and Medicine of Russia. Since then, conferences have been held annually in Russia, bringing together obstetricians-gynecologists, neonatologists, neurologists, psychiatrists, psychotherapists and psychologists.

Perinatal psychology- This is an area of ​​psychological science that studies the patterns of human mental development determined by interaction with the mother at the earliest stages of his ontogenesis from conception to the first months of life after birth. The duration of the postnatal period, included in the sphere of interest of perinatologists, is assessed differently by different authors. However, if we consider the main features of the perinatal period to be the symbiotic relationship between mother and child, the child’s inability to distinguish himself from the surrounding world, that is, the absence of clear bodily and mental boundaries, the lack of independence of his psyche, then this period can be expanded as much as possible before the emergence of self-awareness, that is approximately up to three years of life. The founder of the theory of transactional analysis wrote about the influence of psychosocial factors on conception, on the formation of mental functions and the development of the personality of the unborn child. E. Bern(1972). He believed that “the situation of a person’s conception can greatly influence his fate” - this “rudimentary attitude”, i.e. the situation of childbirth can be the result of chance, passion, love, violence, deception, cunning or indifference - any of these options must be analyzed. E. Bern highlighted "generic scenarios". He considered the most common scenarios to be “origin” and “crippled mother.” The first is based on the child’s doubts that his parents are real, the second is based on the child’s knowledge of how difficult the birth was for the mother. E. Bern attaches great importance to the order of birth, given names and surnames.

Another, also widespread in Western countries, is the direction of perinatal psychology, in which the mother-child connection is interpreted as imprint form. The way mother communicated with her newborn child in the first hours of life has a great influence on their subsequent interaction.

Back in 1966, P. G. Svetlov established critical periods of ontogenesis:

· implantation period (5-6 days after conception);

· period of placenta development (4-6 weeks of pregnancy);

· The 20-24th weeks of pregnancy are also critical, since it is at this time that the rapid formation of many body systems takes place, acquiring by the end of this period the character characteristic of newborns [Anokhin P.K., 1966; Bodyazhina V.I., 1967].

The condition of a pregnant woman during critical periods can significantly influence the characteristics of the developing mental functions of the unborn child, and therefore largely determine his life scenario. The uterus represents the first ecological niche of humans. A woman experiences gestational dominant in the brain. There are physiological and psychological components of gestational dominance. The physiological and psychological components are respectively determined by biological or mental changes occurring in a woman’s body aimed at bearing, giving birth and nursing a child. The psychological component of gestational dominance is of particular interest to perinatal psychologists. 5 types of PCGD have been identified:

1. Optimal type PKGD is observed in women who treat their pregnancy responsibly, but without excessive anxiety. In these cases, as a rule, family relationships are harmonious, pregnancy is desired by both spouses. The optimal type contributes to the formation of a harmonious type of family upbringing of a child.

2. Hypogestognosic type often occurs in women who have not completed their studies and are passionate about work. Among them there are both young students and women who will soon be or have already turned 30 years old. The first ones do not want to take academic leave, they continue to take exams, attend discos, play sports, and go hiking. Their pregnancies are often unplanned. Women of the second subgroup, as a rule, already have a profession, are passionate about work, and often occupy leadership positions. They plan a pregnancy because they rightly fear that the risk of complications increases with age. The most common types of family upbringing are: hypoprotection, emotional rejection, underdeveloped parental feelings.

3. Euphoric type observed in women with hysterical personality traits, as well as in long-term infertility patients. Often pregnancy becomes a means of manipulation, a way to change relationships with a husband, and achieve mercantile goals. The euphoric type corresponds to an expansion of the sphere of parental feelings for the child, indulgent hyperprotection, and preference for children's qualities.

4. Anxious type characterized high level anxiety in pregnant women, which affects her somatic condition. Anxiety may be completely justified (the presence of acute or chronic diseases, disharmonious relationships in the family, unsatisfactory living conditions, etc.). In some cases, a pregnant woman either overestimates the existing problems or cannot explain what the anxiety is associated with, which is accompanied by hypochondriasis. With this type, a dominant hyperprotection is most often formed in family upbringing, and increased moral responsibility is often noted. The mother's educational insecurity is expressed.

5. Depressive type manifests itself, first of all, in a sharply reduced mood in pregnant women. A woman who dreamed of a child may begin to claim that now she does not want one, does not believe in her ability to bear and give birth to a healthy child, and is afraid of dying in childbirth. Dysmorphomanic ideas often arise. The woman believes that pregnancy has “disfigured her” and is afraid of being abandoned by her husband. In severe cases, overvalued and sometimes delusional hypochondriacal ideas, ideas of self-deprecation with suicidal tendencies appear. There is emotional rejection of the child and cruel treatment of him.

Childbirth is a severe physical and mental trauma for a child, accompanied by a threat to life. This echoes the statement of K. Nogpeu (1946) that the horror experienced by a person being born and the experience from the first seconds of existence of a feeling of hostility in the world form “basic anxiety,” the level of which predetermines a person’s future actions. K. Nogpeu identifies three main types of behavioral strategies associated with basal anxiety:

1. desire for people;
2. desire from people (independence);
3. desire against people (aggression).

Glad scientists agree with the existence hypothetical dynamic matrices, controlling processes related to the perinatal level of the unconscious, and name them basic perinatal matrices(BPM) on St. Grof.

1. Biological basis first perinatal matrix is the experience of the initial unity of the fetus and mother in the period of ideal intrauterine existence.
2. Empirical pattern second perinatal matrix refers to the very beginning of biological birth, to its first clinical stage. With the full development of this stage, the fetus is periodically compressed by uterine spasms, but the cervix is ​​still closed, there is no way out. The child experiences a feeling of increasing anxiety associated with the impending mortal danger, aggravated by the fact that it is impossible to determine the source of the danger.
3. Third perinatal matrix reflects the second clinical stage of biological labor. At this stage, uterine contractions continue, but the cervix is ​​already open. This allows the fetus to constantly move along the birth canal, which is accompanied by severe mechanical compression, suffocation, and often contact with biological materials (blood, urine, mucus, feces). All this happens in context desperate fight for survival. The situation does not seem hopeless.
4. Fourth Perinatal Matrix associated with the final stage of labor, with the immediate birth of a child. believes that the act of birth is liberation and, at the same time, an irrevocable rejection of the past. The joy of liberation is combined with anxiety: after intrauterine darkness, the child encounters bright light for the first time, the cutting of the umbilical cord ends the bodily connection with the mother, and the child becomes anatomically independent. The physical and mental trauma received during childbirth, associated with a threat to life, with a sharp change in living conditions, largely determines the further development of the child.

After childbirth, the process of adaptation of the child to new conditions begins. If during childbirth the child can receive and, as a rule, receives acute psychological trauma, then if the attitude towards it is incorrect in the postnatal period, the baby may end up into a chronic traumatic situation. As a result of research, it has been established that the relationship between mother and child develops during the first three months of life and determines the quality of their attachment at the end of the year and beyond.

M. Einsfort was able to identify three types of behavior in children when communicating with their mother:

Type A. Avoidant attachment - occurs in approximately 21.5% of cases. It is characterized by the fact that the child does not pay attention to the mother’s leaving the room and then to her return and does not seek contact with her. He does not make contact even when his mother begins to flirt with him.

Type IN. Secure attachment- occurs more often than others (66%). It is characterized by the fact that the child feels comfortable in the presence of the mother. If she leaves, the child begins to worry and stops research activities. When the mother returns, she seeks contact with her and, having established it, quickly calms down and continues her studies again.

Type WITH. Ambivalent attachment - occurs in approximately 12.5% ​​of cases. Even in the presence of the mother, the child remains anxious. When she leaves, anxiety increases. When she returns, the baby strives for her, but resists contact. If his mother picks him up, he breaks away.

PERINATAL PSYCHIATRY. For more than 10 years now, in our country and even earlier abroad, a new branch of psychotherapy and psychiatry has emerged, specializing in serving young children. Under early age understand

• neonatal period (from 0 to 1 month of life),
• infant period (from 1 month to 1 year of life)
• the period of early childhood itself (from 1 to 3 years of life).

Perinatal psychiatry- a section of child psychiatry devoted to the study of etiology, pathogenesis, clinical picture and prevalence, as well as the development of methods for diagnosis, treatment, rehabilitation and prevention of mental disorders of children that arise in the earliest stages of ontogenesis from conception to the first months of life after birth in the context of interaction between the child and the mother and her mental state.

In many ways, the development of micropsychiatry was predetermined by the successes of child psychoanalysis (A. Freud, M. Klein, D. Bowlby, D. Vinicott, R. A. Spitz). The most consistent studies of children at high risk for mental pathology are carried out by the American researcher V. Fish, who began observing children born to parents with schizophrenia (from the day of their birth) in 1952. Developmental disorders that she was able to establish in children in the first 2 years of life, were ration, or PDM) and the syndrome of “pathologically calm children”.

In Russia, interest in mental disorders of young children has been shown since approximately the 50s of the 20th century through individual works of such famous child psychiatrists as G. E. Sukhareva, T. P. Simeon, S. S. Mnukhin, M. Sh. Vrono, G. V. Kozlovskaya, O. V. Bazhenova. In domestic child psychiatry, recently a set of signs characterizing a predisposition to mental pathology is designated by the term "mental diathesis". These can be short-term stops in development, jumps and “pseudo-delays”. In these cases there is developmental dissociation. Epidemiological studies (1985-1992) showed that the prevalence of schizotypal diathesis in young children is 1,6 %.

Clinical manifestations of schizotypal diathesis.(mental features of schizotypal diathesis are based on observation and examination using the GNOM 1 technique of children with schizophrenic parents in infancy and children under 3 years of age). Already at the early stages of ontogenesis, mental abnormalities are detected in children in the psychobiological systems mother-child, sleep-wakefulness, and in food rituals that form the basis of the preverbal behavior of the newborn. Developmental disorders are expressed in the form of 4 groups of disorders: 1) disharmony of psychophysical development; 2) irregularity or uneven development; 3) developmental dissociation; 4) deficiency mental manifestations.

Psychopathology of early age has the following features: mosaic clinical symptoms in the form of a combination of mental disorders with manifestations of developmental disorders; “coherence” of mental disorders with neurological disorders; coexistence of positive and negative symptoms; rudimentary psychopathological phenomena (microsymptoms), transient clinical phenomena.

Children experience disorders in all areas of the body's vital functions. In the instinctive-vegetative sphere this is expressed by dissomnias, perverted reactions to hunger and microclimatic stimuli. There is an absence or decrease in the “food dominant” in eating behavior, a peak symptom, pathological cravings, a decrease and perversion of the instinct of self-preservation, with simultaneous reactions of panic, conservatism and rigidity of protective rituals, the phenomenon of identity. As a rule, the listed disorders develop against the background of various somatovegetative dysfunctions. The described disorders can be noted starting from the 2nd month of life. Emotional sphere: from the first 2 months of a child’s life, emotional disturbances are also noted. They are manifested by distortion of the maturation of the formula of the revitalization complex, emotional rigidity and the prevalence of the negative pole of mood, the absence or weakness of emotional resonance, exhaustion of emotional reactions, their inadequacy and paradoxicality. Against the background of this general characteristic of emotional response, children from infancy also experience more pronounced dysthymia, dysphoria, and less often hypomania, fears, and panic reactions (mainly nocturnal). Signs of depression are especially common: depression with phobias, masked by a somatovegetative component, with persistent weight loss and anorexia, an endogenous mood rhythm. Among the wide variety of depressive reactions, two relatively defined variants have been identified - “infantile depression” (after birth distress) and “deprivation depression”.

Cognitive disorders most often expressed in a distortion of gaming activity in the form of stereotypical rigid gaming manipulations with non-gaming objects. The structure of cognitive disorders also includes symptoms of distortion of a child’s self-awareness and sense of self. This manifests itself in the form of persistent pathological fantasizing with reincarnation and loss of self-awareness as a child, as well as violations of gender identification at an older age (3-4 years).

Also characteristic attention disorders observed from the 1st month of a child’s life. They are expressed by a frozen “doll” look or a look “to nowhere”, which is usually associated with the phenomena of “withdrawal” (without disorders of consciousness) in the form of short “disconnections” from the environment. Among attention disorders, the phenomenon of “hypermetamorphosis” (over-attention) and selectivity of attention are observed. In these cases, concentration of attention is both fleeting in a forced situation and rigid in spontaneous activity.

Social behavior disorders are manifested by a delay and distortion of neatness and self-care skills, as well as stereotypy of behavior in the form of meaningless rituals when falling asleep, eating, dressing, and playing. Communication disorders manifested by a negative attitude towards the mother or an ambivalent symbiotic relationship with her, the phenomenon of protodiacrisis and fear of people (anthropophobia) with simultaneous indifference to them in general. Quite often, autistic behavior is observed, which, traced from the first months of life, becomes more pronounced by the age of 1 year and older, reaching the degree of “pseudo-blindness” and “pseudo-deafness.” Disorders of communication function play an important role speech disorders: true and pseudo speech delays, as well as selective mutism, echolalia, speech stereotypies, neologisms, “stammers” and disorders such as “stuttering”.

Among motor disorders The most frequently observed are microcatatonic symptoms and phenomena related to specific neurological pathology.

Neurological manifestations of schizotypal diathesis. In the 1st year of life, the following phenomena are already quite clearly visible: violations of adaptive reactions in the vegetative-instinctive sphere with hypersensitivity to sensory stimuli, violation of orienting reflexes; the formation of diffuse muscle hypotonia and a decrease in motor activity in the absence of focal motor symptoms.

From the first year of life the following are determined: neurological disorders: hydrocephalus syndrome; “gaze ataxia”, instability of gaze during fixation, insufficiency of conjugate movements of the eyeballs, convergence, divergence, oculogyric crises; suprasegmental lesions of VII, IX, XII pairs of cranial nerves, expressed in disturbances in the process of development of complex complex acts of chewing, swallowing, expressive facial expressions, speech; muscle hypotonia in combination with dynamic muscular dystonia; change in general motor activity; violation of the concordance of left- and right-sided orientation of movements; hypomimia and orofacial hyperkinesis; hypotonic-hyperkinetic and hypokinetic-rigid disorders; dyspraxic disorders; motor stereotypies; ataxic syndromes of the developmental period; disturbances in tempo and general expressiveness of speech; speech development dissociation; cortical dysarthria during speech development; tactile and sensory hypo- and hypersensitivity; sleep disorders, night screams; hyperventilation disorders, heart rate arrhythmia; distal hyperhidrosis; transient miosis, anisocoria. A special neurological status is formed that does not fit into the framework of any of the known neurological syndromes. According to EEG data, in children from groups at high risk of developing schizophrenia against the background of varying degrees of immaturity of bioelectrical activity, signs of pathological electrogenesis were revealed in the form of hypersynchrony of physiological wave forms and abnormal “burst” activity.

After 3 years of age, if the schizotypal diathesis remains quite pronounced, it begins to gradually transform into schizoid personality traits from character accentuations (an extreme variant of the norm) to pronounced schizoidia, sometimes with outpost symptoms of endogenous psychosis, but without signs of manifestation of the disease. It is possible to transform schizotypal diathesis into early childhood autism and schizophrenia, as well as its full compensation before practical recovery. In this sense, the first option is naturally more favorable, although its greater severity does not always mean an unfavorable prognosis.