Vladimir Horowitz, the youngest in the family. Shepard's Amazing Dreams

• Dontsov Alexander Ivanovich, doctor of sciences, professor, other position
• Lomonosov Moscow State University
• Dontsov Dmitry Alexandrovich, Candidate of Sciences, Associate Professor
• State Classical Academy. Maimonides
• Dontsova Margarita Valerievna, Candidate of Sciences, Associate Professor
• Moscow Psychological and Social University

• PSYCHOLOGICAL HELP
• PSYCHOSOCIAL WORK
• post-traumatic stress disorder
• PSYCHOSOCIAL APPROACH
• SUFFERING PTSD
• PSYCHOLOGICAL TRAUMA
• EXTREME PSYCHOLOGY

The article presents the main provisions of the psychosocial approach to the study of post-traumatic stress disorder (PTSD), to psychosocial work with people suffering from PTSD and to psychological assistance for PTSD.

• History and trends in the development of psychological counseling in the information network "Internet"
• The system of concepts and the general content of orientation in the world of professions
• Professional orientation of the individual as a component of the social development of a person
• Socio-psychological and pedagogical support of the professional and personal development of psychology students

Brief description of PTSD

When it is said that a person suffers from PTSD, first of all, it means that he experienced something terrible, and he has some of the specific symptoms, there are post-stress consequences. PTSD (post-traumatic stress disorder) occurs as a result of traumatic situations. Traumatic situations are such extreme critical events that have a powerful negative impact on an individual and groups of people. These are situations of a clear and strong threat that require extraordinary efforts from a person to cope with the consequences of a sharply negative impact on him and / or the people around him. Traumatic situations take the form of events that go beyond the scope of everyday experience and radically differ from typical classes of situations of socio-professional interaction between people. In a traumatic situation, a person (a group of people) is exposed to extreme, intense, extraordinary impact, which is expressed in a threat to the life or health of both the person himself and those close to him (significant to him) people. Traumatic situations are extremely powerful negative stressors for people.

According to the ICD-10 (adopted in 1995, the tenth edition of the International Classification of Diseases, the main diagnostic standard in European countries, including the Russian Federation), after traumatic events that go beyond normal human experience, post-traumatic stress disorder (PTSD) can develop. The “normal” human experience is understood to mean such events as: the loss of a loved one due to natural causes, a severe chronic illness, loss of a job, family conflicts, etc. Stressors that go beyond ordinary human experience include those events that can injure the psyche of almost any healthy person: natural disasters, man-made disasters, as well as events that are the result of targeted, often criminal activities (sabotage, terrorist acts, torture, mass violence, fighting, getting into a "hostage situation", destroying one's own home, etc.).

PTSD is a complex of a person's psychophysiological reactions to physical and / or psychological trauma, where trauma is defined as an experience, a shock that causes fear, horror, and a feeling of helplessness in most people. These are, first of all, situations when a person himself experienced a threat to his own life, the death or injury of another person (especially a loved one) that occurred in emergency circumstances. It is assumed that PTSD can manifest itself in a person immediately after being in a traumatic situation, or it can occur after several months or even years - this is the particular trickiness of PTSD (I.G. Malkina-Pykh, 2008).

Theoretical models of PTSD

The intensity of the traumatic situation is the primary risk factor for PTSD. Other risk factors include: low level of education, low social status, chronic stress, psychiatric problems preceding the traumatic event, the presence of close relatives suffering from psychiatric disorders, etc.

Other important risk factors for the occurrence of PTSD include such personal characteristics of a person as accentuation of character, sociopathic disorder, low level of intellectual development, as well as the presence of alcohol or drug addiction.

In the event that a person is prone to exteriorization (“bringing outside”) stress, then he is less susceptible to PTSD.

Genetic predisposition (having a history of psychiatric disorders) may increase the risk of developing PTSD after trauma.

A risk factor for the development of PTSD is a previous traumatic experience (for example, due to physical abuse in childhood, parental divorce, past accidents). The age factor is important: overcoming extreme situations is more difficult for very young and very old people.

The risk of developing PTSD also increases in cases of isolation of a person during the period of experiencing trauma, loss of family and close environment. The importance of the general psycho-behavioral reaction of family members is enormous, the role of timely provided professional psychological assistance is great.

Recently, more and more importance is attached to the psychological aspects of stress, in particular, the vital significance of a tragic event, including the attitude of the individual to a threatening situation, taking into account moral values, religious values ​​and ideology.

Currently, there is no single generally accepted theoretical concept that explains the etiology (“origin”) and mechanisms of the onset and development of PTSD. There are several theoretical models, among which are the psychodynamic (psychoanalytic) approach, the cognitive approach, the psychosocial approach, the psychobiological (psychophysiological) approach, and the multifactorial theory of PTSD that has been developed in recent years. Psychodynamic (psychoanalytic) models, cognitive models and psychosocial models, refer to psychological models. These models were developed during the analysis of the main patterns of the process of adaptation of victims of traumatic events to normal life.

Studies have revealed that there is a close relationship between the ways out of a crisis situation, i.e. ways to overcome PTSD (elimination and avoidance of any reminders of the trauma, immersion in work, alcohol, drugs, the desire to enter a self-help group, etc.) and the success of subsequent adaptation. It was found that the most effective (positively productive) are two cumulative (used in a complex) strategy for combating PTSD:

1. purposeful return to memories of a traumatic event (carried out by the person himself with the help of professional psychologists) in order to analyze it and fully understand all the circumstances of the trauma that occurred;
2. awareness by the bearer of traumatic experience of the reversible significance of the traumatic event for later life, readaptation of the victim and development of self-help skills, which is also carried out with the help of professional psychologists (I.G. Malkina-Pykh, 2008).

Information model of PTSD

The information model of PTSD was developed by the American psychologist M. Horowitz (Horowitz, 1998), who introduced the term “post-traumatic stress disorder” (PTSD) into scientific use in 1980. The information model of PTSD is an attempt at a scientific and empirical synthesis of three models of PTSD: cognitive, psychodynamic (psychoanalytic) and psychobiological (psychophysiological) models. According to the information model of PTSD, stress is a mass of internal and external information, the main part of which cannot be coordinated with the cognitive (intellectual) schemes (representations) of the subject. As a result, information overload occurs. Raw information is transferred from consciousness to the unconscious, but stored in an active form. Obeying the universal principle of pain avoidance, a person seeks to store information in an unconscious form. But, in accordance with the tendency towards completion (the effect of the incomplete image), at times traumatic information becomes conscious, as part of the information processing process. When the information processing is completed, the experience becomes integrated into the structure of the personality, the trauma is no longer “stored in an active state”. The biological factor, as well as the psychological one, is included in this dynamic. This kind of reaction phenomenon is a normal reaction to shocking information. Extremely intense reactions that are not adaptive and block the processing of information (in a negative way, embedding it into the cognitive schemes of the subject) are abnormal. Horowitz's information model of PTSD, for all its successful typology, is insufficiently scientifically and empirically differentiated, as a result of which it does not allow full consideration of individual differences in traumatic disorders (I.G. Malkina-Pykh, 2008).

Psychosocial approach to the study of PTSD and to psychological assistance in PTSD

The great importance of social conditions, in particular, the factor of social support of others, for the successful overcoming of PTSD is reflected in the models that have been called "psychosocial".

According to the psychosocial approach, the model of response to trauma is multifactorial, and it is necessary to take into account the weight of each factor in the development of a response to stress. The basis of the psychosocial model of PTSD is Horowitz's information model of PTSD. Along with this, the developers and supporters of the psychosocial approach also emphasize the exceptional need to take into account environmental factors (Creen, 1990; Wilson, 1993). The authors mean such factors as: social support factors, religious beliefs, demographic factors, cultural characteristics, the presence or absence of additional stresses, etc.

There are a number of conditions that affect the intensification of PTSD:

1. to what extent the situation was subjectively perceived as threatening;
2. how objectively real was the threat to life;
3. how close the subject was to the place of the tragic events (he could not be physically hurt, but he could see the consequences of the disaster, the corpses of the victims, etc.);
4. how much people close to the person were involved in the tragic event, whether they suffered, what was their reaction. This is especially significant for children. When parents perceive the events that have not been irreversible very painfully and react in panic, the child will not feel doubly psychologically safe.

The psychosocial model of PTSD has the disadvantages of an informational model, but the introduction of environmental factors reveals individual differences. The main social factors influencing the success of the adaptation of victims of mental trauma were identified. These are such factors as: absence/presence of physical consequences of an injury, strong/unstable financial position, preservation/non-preservation of the former social status, presence/absence of social support from society (surrounding people) and, especially, a group of close people.

At the same time, the factor of social support is the most significant. Regarding people who fought, the following stressful situations related to the social environment were identified: a person with military experience is not needed by society; the war and its participants are unpopular; there is no mutual understanding between those who were at war and those who were not; society forms a guilt complex among veterans, and so on.

A collision with such stressors, already secondary to extreme experience, for example, obtained in the war (the so-called secondary maladjustment), quite often led to a deterioration in the condition of war veterans (for example, veterans of the Great Patriotic War (WWII), veterans of the Vietnam War, veterans of the war in Afghanistan.

All this testifies to the objectively very significant role of social factors both in the process of helping to survive traumatic stressful conditions and in the formation of PTSD in cases where there is no support and understanding from society and surrounding people.

It should be emphasized that quite often subjects with PTSD experience secondary traumatization, which occurs, as a rule, as a result of negative reactions of relatives, surrounding people, medical personnel and social workers to the problems faced by people who have suffered trauma.

Negative reactions of people to a mentally traumatized person are manifested in the denial of the very fact of the trauma, in the denial of the connection between the trauma and the suffering of a person, in a negative attitude towards the victim and her accusation (“it is his own fault”), in the refusal to provide assistance.

In other cases, secondary traumatization may occur as a result of hyper-care (excessive care) shown by others in relation to the victims, around whom relatives create a “disabled environment”, which fences them off from the outside world and prevents rehabilitation and readaptation.

So, it is extremely important for the development and course of PTSD are the so-called. secondary factors, among which a complex of social (socio-psychological) factors, of course, occupies a leading place, since often what happens to a person after a trauma affects him even more than the trauma itself. It is possible to identify factors (conditions) that contribute to the prevention of the development of PTSD and mitigate its course. These include: immediately initiated psychosocial therapy with the victim, giving him the opportunity to actively share his experiences; early and long-term social support; socio-professional restoration of the victim's belonging to society (rehabilitation and readaptation) and resuscitation of a sense (feeling) of psychological security; participation of the victim in psychotherapeutic work together with similarly psychologically traumatized people; no re-traumatization, etc. (I.G. Malkina-Pykh, 2008).

In overcoming the weighty majority of the negative consequences of psychological trauma listed above, the most effective (productive) is the psychosocial approach.

Bibliography

1. Malkina-Pykh I.G. Extreme situations: a reference book of a practical psychologist. - M.: Eksmo, 2005.
2. Malkina-Pykh I.G. Psychological assistance in crisis situations / I.G. Malkin-Pykh. - M.: Eksmo, 2008. - 928 p. - (The newest reference book of the psychologist).
3. Malkina-Pykh I.G. Psychological assistance in crisis situations. - M.: Eksmo, 2010.

It

Materials on the book: Yu. Zilberman, “Vladimir Horowitz. Kyiv years. Kyiv. 2005.

Vladimir Horowitz was born in 1903 in Kyiv. He was the fourth and youngest child in the family. Father - Samuel Ioakhimovich Horowitz, a graduate of the Faculty of Physics and Mathematics of the University of St. Vladimir. Mother Sofia Yakovlevna Bodik. “According to biographers, according to the pianist, he, as the youngest member of the family, was very pampered. So, (...) when little V. Horowitz was sleeping, the whole family walked around the apartment in specially made slippers so as not to wake the child. The pianist's cousin, Natalya Zaitseva, also spoke about the incredible family pampering of V. Horowitz. She recalled the extremely early manifestation of musicality in her cousin, talked about how little Volodya improvised on the piano, depicting musical pictures of either thunderstorms, or storms, or pantheistic idyll. We will only note a very important fact mentioned by everyone: the pianist's childhood passed in an atmosphere unusually rich in music.”

“The surname Horowitz comes from the name of a place (Horovice) in the Czech Republic. The first documented data on the relatives of the great pianist who lived in Ukraine refer to his grandfather Joachim Horowitz. They are most directly related to the question of the birthplace of Vladimir Horowitz, which has remained debatable until now.” The possible birthplace of V. Horowitz is considered to be Berdichev, “an unremarkable small Jewish town located not far from Kyiv”. Berdichev in 1909 belonged to the 3rd class of cities in Russia. Very significant centers were assigned to this class: Arkhangelsk, Astrakhan, Vitebsk, Voronezh, Yekaterinburg, Kursk, Penza, Orenburg, etc. Kyiv was assigned the 2nd class in this list, along with Kronstadt, Ryazan, Rzhev, Tver, Serpukhov, etc. "... Of the banking houses in Berdichev, the house of the Jew Halperin, Kamyanka, the office of Manzon, Horowitz with his son, and so on are remarkable in terms of wealth and credit." (N. Chernyshev, editor of the Kyiv Provincial Gazette, reports in the Memorable Book of the Kyiv Province for 1856). Y. Zilberman: “…Unfortunately, there is no birth certificate (V. Horowitz - E.Ch.)”. According to another version, Vladimir Horowitz was born in Kyiv.

“Joachim Horowitz (grandfather) studied in Odessa. At the age of 18 he graduated from the Odessa Richelieu gymnasium with a gold medal. The exact time of his appearance in Kyiv could not be established. (...) In the birth certificate of Samuil Horowitz (1871) in the column “father” it is written: “Berdichevsky 2nd guild merchant Joachim Samoilovich Horowitz”. “With confidence, one can [talk] about the two sons of I.S. Horowitz (grandfather of Vladimir Horowitz): Alexandra and Samuil. Samuil Horowitz, father of V. Horowitz, could meet his future wife, Sophia Bodik, when she studied at the Kiev Musical College in the class of the famous musician and teacher V. Pukhalsky. Marriage with S. Bodick took place in 1894.

Alexander Horowitz (1877-1927), V. G.'s uncle, is a musician. His influence on the formation of the young pianist is enormous. Entered the Kiev Musical College in 1891 in the class of Grigory Khodorovsky immediately to the middle course, which in itself means the presence of a solid home preparation. According to G. Plaskin, the mother of Alexander Ioakhimovich (grandmother V.G.) was allegedly an excellent pianist.

V. Horowitz's father Samuil Ioakhimovich Horowitz (1871-?) was born in Kyiv, entered the Kyiv University of St. Vladimir at the Faculty of Physics and Mathematics. Immediately after graduating from the university, he left for Belgium and entered the Electrotechnical Institute of the city of Liege, from which he graduated with a degree in electrical engineering in 1896. Until 1910, Samuel Horowitz worked as the chief engineer of the General Electricity Company in Kyiv. In 1910, S. Horowitz founded a small construction and technical firm for the energy of sugar factories. In 1921, V. Horowitz's father was arrested. [Addendum 2018: Yu. Zilberman reports that, despite the five-year term specified in the Case, Samuil Horowitz managed to get out no later than next year.] To organize a concert by Vladimir Horowitz and R. Milstein (violin) with the orchestra "Persimfans" in Moscow, the father of the musician, according to the descriptions of N. Milstein, went already in 1922. Then S.I. Horowitz lived in Kyiv until Vladimir's departure abroad, and in 1926 he moved to Moscow, where he worked as head. Electrotechnical section of the State Institute for the Design of Sugar Plants "Hydrosugar" Narkompischeprom. Very little was known about the tragic fate of Father Vladimir Horowitz in the last years of his life - researchers limited themselves to ascertaining the fact of his arrest by the GUGB of the NKVD of the USSR on the charge that “being anti-Soviet, he carried out sabotage activities, releasing substandard projects for the construction of sugar factories” (cited according to Y. Zilberman). Shortly before the Great Patriotic War, Regina Horowitz visited her father in the camp and, upon arriving, told her family that she had found him in a very bad condition. A few weeks after this trip, the family received a notice of the death of S.I. Horowitz. This document has not been preserved in the family archive. According to O.M. Dolberg (granddaughter of R.S. Horowitz), her great-grandfather died in 1939 or 1940.

Moses Yakovlevich Bodik was born in 1865 and was a Kyiv merchant of the 1st guild, which is confirmed by the statement of his wife with a request to accept his son Yakov as a student at the Kyiv Musical School. The second son of Moses Bodik, Sergei, was enrolled in the school in 1912 as a violinist - in the class of the outstanding performer and teacher Mikhail Erdenko.

The daughter of Yakov Bodik and the mother of Vladimir Horowitz, Sofya (Sonya) Yakovlevna Bodik, was born on August 4, 1872. Almost nothing is known about her mother (grandmother V.G.), only her name is Ephrusinia. The name, frankly, is not at all typical for Jewish families in a provincial town - rather Christian. Perhaps the complex character of Vladimir Horowitz, described by his contemporaries, was partly inherited from his mother. A characteristic example of suspiciousness and, at the same time, strong attachment to his mother is a dramatic episode of his more than four-year break in concert activity and illness in 1935-1938. All biographers note that on the basis of the news of the death of his mother from peritonitis, as a result of an unsuccessful and belated operation for appendicitis, gloomy forebodings began to overcome him, he constantly complained of pain in the intestines. V. Horowitz showed himself to doctors and demanded the removal of the appendix, while all the doctors who examined him refused to operate on a healthy organ. In the end, Horowitz convinced the doctors to perform an operation on him, which was not very successful, he was bedridden for a long time. And the consequences of this operation tormented the pianist all his life. In 1987, V. Horowitz confessed to G. Schonberg: “Of course, they (pains - Yu. Zilberman) were definitely psychosomatic. But you never know."

So, the childhood and youth of Vladimir Horowitz passed in a large, prosperous, quite successful and cultured Jewish family, quite typical for large cities of the Russian Empire. Here it is appropriate to note two factors that contributed to the early musical development of W. Horowitz. The first is the presence of several musicians in the family at once. In accordance with the lists of students of the Kyiv Musical College and the Kyiv Conservatory, 10 members of the Horowitz-Bodik family studied at this educational institution: Sonya Bodik (V. Horowitz's mother), Alexander Horowitz (brother of Vladimir Horowitz's father - Samuil Ioakhimovich), Elizaveta Horowitz and Ernestina Bodik (aunts V. Horowitz), Yakov and Grigory Horowitz (brothers V.G.), Regina Horowitz (sister V.G.), Yakov and Sergey Bodiki (his cousins). To this it should be added that the father of the family, Samuel Horowitz, was an amateur musician and played the cello well, and his mother, V. Horowitz's grandmother, was allegedly a brilliant pianist. When Vladimir Horowitz was five years old, his mother began to teach him to play the piano.

1. THEORETICAL FOUNDATIONS FOR STUDYING STRESS DISORDERS IN FIRE FIGHTERS. 12 The history of the concept of stress disorders 12 Diagnostic criteria for stress disorders 21 Stress conditions and stress disorders in firefighters

2. EMPIRICAL STUDY OF THE REPRESENTATION OF STRESS DISORDERS IN FIRE FIGHTERS 36 Sociodemographic characteristics of the sample 36 Research methods 37 Development of a methodology for assessing traumatic professional experience (a questionnaire of stressful situations) of firefighters

Other methods used in the work

Primary results 54 Symptoms of stress disorders in firefighters and other professions 56 Analysis of the relationship of professional experience with manifestations of PTSD and other mental disorders

Brief chapter summary

3. DEVELOPMENT OF CRITERIA AND ALGORITHM FOR IDENTIFYING RISK GROUPS OF STRESS DISORDERS AMONG FIRE 67 Development of basic decision rules for determining risk groups 67

Assessment of the risk of stress disorders by indirect signs

Brief summary of chapter 3.

CRITERIA FOR ASSESSING THE RISK OF PTSD.

Approbation of an abbreviated version of the methodological complex 91 Connection of psychodiagnostic data and observation of department heads 97 Approbation of the decisive rule for indirect assessment of the risk of stress disorders

Brief summary of chapter 4.

Dissertation Introduction in psychology, on the topic "Methods for identifying the risk of stress disorders in firefighters"

The urgency of the problem.

The work of firefighters refers to those types of activities, the distinguishing feature of which is the constant encounter with danger. Emergencies and extreme operating conditions are an integral part of the professional experience of firefighters. For workers in dangerous professions, stress as a state of mental tension that occurs when a subject collides with professionally specific events and situations is caused, on the one hand, by daily intense activities leading to professional exhaustion, and on the other hand, by the so-called "critical incidents" during which they have to witness the death or serious injury of people, or the events as a whole become catastrophic. In addition, there are secondary stress factors that are due to the nature of social relations in the units and enhance the effect of primary factors. Such secondary factors include the insufficiency of material and moral incentives, the denial of the necessary medical, psychological and social assistance, unfair accusations, the rudeness and tactlessness of others - in particular, bosses.

For practical psychologists, an important task is the timely identification of persons who may find themselves in a severe neuropsychic state due to the extreme situations they have experienced. Such people need special attention from the management of departments, effective moral support, and in many cases, professional help from psychologists and doctors. Conditions of mental disadaptation that develop after experienced extreme situations can manifest themselves in the form of specific mental disorders - acute and post-traumatic stress disorder (ASD and PTSD). Research in recent decades has led to the understanding that these disorders are not mental illnesses, because represent a natural protective mental reaction that can exceed the normal level and lead to a violation of adaptation, depending on its intensity and duration /13, 53, 61, 76, 82, 84, 99, etc./. In developed countries, PTSD and ASD occur in 3% of the population, and in hazardous professions - 15-16%. According to foreign studies, among firefighters operating in conditions of large-scale disasters, these forms of mental disorders are no less common than among participants in hostilities /91, 97/.

The concept of PTSD, relatively recently officially approved /63, 64/, affirms a humanistic approach to the problem of the psychological consequences of extreme situations, since based on the notion of a non-pathological and reversible nature of these mental disorders. This distinguishes it from the concept of psychogeny, in which maladaptive states in extreme conditions are described exclusively within the framework of traditional psychiatric concepts /2, 3/. This implies differences in practical measures to overcome states of mental maladaptation: in the prevention and correction of PTSD, much more attention is paid to information and educational work, psychotherapy, and various forms of non-drug exposure /14, 45, 61, 62/.

At the same time, to date, there have been no domestic comprehensive studies of stress disorders in firefighters in accordance with internationally recognized theoretical concepts and diagnostic criteria for these disorders. The practice of diagnosing PTSD among police officers in departmental medical institutions is rare, and among firefighters it is practically absent; the number of specialists who own the method of clinical interview for diagnosing PTSD is negligible.

Thus, there is a need: - development of scientific ideas about the nature of the psychological consequences of the activities of firefighters in difficult and dangerous conditions; - timely determination of the presence and specifics of the psychological problems of firefighters; - scientifically based improvement of the system of medical and psychological support for firefighters exposed to extreme situations.

For such a branch of psychological knowledge as labor psychology, when studying PTSD, questions about the relationship between the specifics of the professional activity of the subjects and the phenomena of delayed mental reactions to events, as well as the features of the psychological consequences of extreme situations in different professional contingents, are especially important. Despite the fact that modern psychological science has accumulated rich material for the study and classification of "stressors" that can cause mental trauma, the issue of obtaining indicators that quantitatively characterize the traumatic experience of individuals remains insufficiently developed. Therefore, the main attention in the work is paid to studying the experience of workers encountering professionally specific situations that can cause mental trauma (we call it professional traumatic experience), and to analyzing the relationship of this experience with indicators of the severity of PTSD symptoms. In addition, the obtained results are compared with the results of studies that studied the symptoms of PTSD in workers of other professions (police, rescuers), whose activities are associated with an increased risk.

Specialists involved in the diagnosis and correction of PTSD sometimes face the fact that people suffering from these disorders do not want to talk about the events they have experienced and discuss their psychological problems with anyone, are reluctant to make contact in communication, although they need it /16 , 61/. In this regard, it is often necessary to assess the risk of PTSD not only by direct signs (using verbal or written questions about symptoms), but also by indirect (questions that are not related to the symptoms as such) or external (changes in behavior observed from the side). Therefore, part of our work is devoted to the question of the possibilities of studying indirect and external signs in identifying the risk of stress disorders.

The object of the study is employees of the territorial divisions of the fire department in Moscow, Irkutsk and the Irkutsk region, the city of Perm and the Perm region.

The subject of the study is the state of emotional stress, stress reactions in various types of situations that arise in the activities of firefighters; the severity of symptoms of post-traumatic stress disorder and its usual comorbidities (anxiety, depressive symptoms, obsessions, etc.).

The aim of the work is to study the nature of the impact of professionally specific extreme situations on the mental state of firefighters, both directly during the events experienced and after them, and to develop a system for diagnosing and preventing stress disorders arising from such exposure.

Research objectives:1. To analyze the current state of the problem of stress disorders in firefighters, to study foreign experience in studying the psychological consequences of critical incidents and emergency situations.

2. Conduct a comprehensive study of the prevalence of symptoms of post-traumatic stress disorder (PTSD) among employees of operational fire departments who continue their work.

3. Compare the severity of PTSD symptoms in firefighters and employees of other ATS services.

4. Determine which of the situations encountered in the work of firefighters are most likely to lead to the development of PTSD.

5. To draw up a methodological complex for the timely identification of those individuals who may show maladaptive reactions associated with experienced extreme situations.

6. Develop decision rules and diagnostic criteria for determining whether the examined firefighters belong to the risk group for developing PTSD.

7. Determine the most effective methods for both direct and indirect assessment of the risk of stress disorders in firefighters.

8. Formulate proposals on measures to prevent and correct the negative psychological consequences of extreme situations typical for the professional activities of firefighters.

Research hypotheses.

1. In terms of the severity of symptoms of stress disorders, firefighters are similar to representatives of other professions, whose work is associated with participation in events of an extreme nature.

2. There is a direct relationship between the length of service in the fire department, the experience of experiencing extreme situations and the severity of PTSD symptoms. The trend of "accumulation" of the psychological consequences of extreme situations experienced by firefighters prevails over the trend of professional adaptation.

3. It is possible to predict the risk of stress disorders in firefighters using: a) an indirect assessment of the condition; b) structured observation of behavior.

The following provisions are put forward for defense: 1. The professional traumatic experience of firefighters is a significant predictor of the development of symptoms of post-traumatic stress disorders. The questionnaire of stressful situations of firefighters, the data on which is processed in the manner proposed in the work, can serve as a tool for quantifying the severity of the first of the diagnostic criteria for PTSD - experienced events and emotional reactions during them.

2. The nature and magnitude of the psychological consequences of exposure to occupational stress are generally similar for firefighters, other services of the internal affairs bodies and rescuers.

3. It is possible to predict the risk of developing stress disorders in firefighters by indirect signs using the methodology for assessing "psychological defenses".

4. Some of the manifestations of post-stress maladaptation can be identified by observing the behavior of employees and interviewing department heads.

5. An integrated approach to assessing the traumatic experience and the nature of the mental reactions of people who have encountered extraordinary circumstances in their work activity makes it possible to most accurately identify a group of people with a high probability of developing stress disorders. Depending on the specifics of the tasks of practical psychologists, it is possible to use variants of the methodological complex of various volumes, which provides the necessary balance of its brevity and information content.

Scientific novelty. A comprehensive study of the severity of PTSD symptoms in Russian firefighters in accordance with the diagnostic criteria for this disorder was carried out for the first time. So far, only individual manifestations of stress reactions and maladaptive states of this professional contingent have been studied in our country.

A new methodology for assessing the traumatic professional experience of firefighters has been developed; for the first time, the degree of negative psychological impact on employees of various situations encountered when working on fires is quantitatively determined, which is new in comparison with both domestic and foreign studies conducted earlier. Also, together with colleagues, a method for structured observation of behavioral manifestations of symptoms of stress disorders "from outside" was developed.

The method proposed in this work for predicting the risk of stress disorders using the methodology for assessing the mechanisms of "psychological defense" (without direct questions about symptoms) has not yet been used either in Russia or in other countries.

For the first time in our country, the results of a survey of this category of persons were obtained using a number of psychometric methods used in world practice to study PTSD. The similarity of the nature and severity of delayed reactions to mental trauma in firefighters and other workers in dangerous professions - employees of various police departments and rescuers is shown.

An unparalleled set of techniques has been formed that allows conducting a survey of varying degrees of detail to identify the risk of developing PTSD among firefighters. An algorithm has been developed that decides the rules and criteria for classifying the examined firefighters into groups characterized by one or another level of risk of stress disorders.

Practical significance of the research results.

The conducted research allowed to create a scientific and practical basis for improving the system for identifying, preventing and correcting the mental maladaptation of firefighters, due to the nature of their work.

The results of the study are used in the development of guidelines for the diagnosis and prevention of stress disorders in firefighters, as well as a software product used for data processing and drawing up a conclusion based on the results of a psychodiagnostic examination /11/. The use of these recommendations and the software product by practical psychologists will contribute to the timely determination of the need for medical and psychological assistance to individuals, the implementation of targeted measures to prevent the occurrence of psychological distress conditions that cause serious problems in the professional and personal life of firefighters.

In order to assist practical psychologists and psychotherapists, the author examined the employees of some units that participated in extinguishing fires that were accompanied by human casualties (in the cities of Novokuznetsk and Samara). Based on the results of these examinations, the need for psychotherapeutic assistance was identified, and psychological consultations were conducted for personnel.

Approbation of the results The main results of the study were approved by the leadership of the State Fire Service of the Ministry of Internal Affairs of Russia and recommended for implementation in the activities of practical psychologists and employees of the personnel apparatus of the regional Fire Service Departments.

The results of the study were reported and discussed at: III scientific-practical conference “Post-traumatic and post-war stress. Problems of rehabilitation and social adaptation of participants in emergency situations: an interdisciplinary approach "(Perm, May 1998); seminar on psychological diagnosis and correction of stress disorders among employees of internal affairs bodies (Kemerovo, September 1998); scientific and practical conference "Problems of training personnel for fire protection "(Moscow Institute of Fire Safety, November 1998); XIV annual conference of the International Society for the Study of Traumatic Stress (Washington (USA), November 1998). IV scientific and practical conference "Post-traumatic and post-war stress. Problems of rehabilitation and social adaptation of participants in emergency situations "(Perm, May 1999); VI scientific and practical conference on the problems of psychological and pedagogical support for the activities of law enforcement officers (Omsk, May 1999).

The author expresses his gratitude to: psychologists of the Office of the State Fire Service of the Perm Region Gorbenko (Avdeeva) O.S., Yurchenko O.V., Burdina M.S. and Soldatova I.V. - for participation in data collection; employees of the Institute of Psychology of the Russian Academy of Sciences Tarabrina N.V. and Agarkov V.A. - for organizational and methodological assistance; employees of the All-Russian Research Institute of Fire Defense Lovchan S.I. and Bobrinev E.V. - for advisory assistance. AND THEORETICAL FOUNDATIONS FOR STUDYING STRESS DISORDERS OF FIRE FIGHTERS The history of the formation of the concept of stress disorders The problem of psychological, medical and social consequences of exposure to the human psyche of extreme situations has been studied for many centuries. So, Lucretius (1st century BC), apparently, for the first time pointed out the phenomena of traumatic nervous breakdown in soldiers, in which the main element is reminiscences /21/.

The psychological problems of the influence of a combat (extreme) situation on a person were studied by doctors of the time of the Civil War in America, Da Costa and R. Gabriel (1871). On the basis of these studies, a military psychiatric hospital and homes for providing psychotherapeutic assistance to veterans were established.

In the same years, more and more attention of psychiatrists was attracted by nervous disorders that appeared as a result of accidents. Since a large part of these disorders occurred after railroad accidents, even the terms "railway spine" and "railway brain" (literally, "railway spinal cord and brain") appeared to designate appropriately localized disorders. These concepts covered the totality of both neurological and mental symptoms, the origin of which was attributed to the predominant influence of mechanical concussion /10/.

From the mid-80s of the XIX century, the term "traumatic neurosis" began to be used, and at the beginning of this century it established itself as an independent nosological category, and the leading role of mental trauma in its etiology began to be recognized. Kraepelin (1904) proposed the name "neurosis of fright and anguish" for nervous diseases due to accidents. A peculiar clinical picture of traumatic neurosis, according to researchers, was formed from a combination of various symptoms of hysterical, neurasthenic and hypochondriacal neurosis. The psychotic symptoms noted after the trauma (amnesia, confusion, hallucinations), as well as "a kind of post-traumatic perversion of the personality" and "post-traumatic dementia, resembling a picture of progressive paralysis, but without a deep disintegration of the personality and without a progressive course" scientists did not attribute to the picture of traumatic neurosis, t .to. believed that these states differ significantly from it in terms of the mechanism of their genesis. It was proposed to distinguish between mental trauma: 1. Due to the accident itself - “primary”; 2. Chronic anxiety traumatist for his plight - "secondary". Even then, the question of disability in connection with this disorder was raised. There was a significant dependence of the percentage of recovery on social policy in relation to the victims /10/.

During the Russo-Japanese War in 1904, a department for soldiers with mental disorders received in a combat situation was created in the Harbin military hospital. The department was headed by G.E. Shumkov, who was the first in Russia to study the signs of psychogeny (dreams about combat episodes, increased irritability, weakening of the will, fatigue). In his work “The Behavior of a Fighter under Shelling”, G.E. Shumkov identified many psycho-traumatic factors of extreme conditions (1910). Further development of the problem of the consequences of people's activities in a combat situation was obtained in the works of M.I. Astvatsaturov (1912), V.M. Bekhterev (1915), and others /21, 53/.

Thanks to these studies, during the First World War, the concept of mental combat losses was introduced into scientific circulation. Delayed mental phenomena observed in fighters were considered within the framework of the concept of traumatic neurosis. The average loss due to mental disorders during this period was 6-10 cases per 1000 people.

3. Freud defined these phenomena as "war neurosis", which he interpreted as a state of ego-conflict. He called mental traumas received in extreme conditions "traces of affective experiences" (1909). In the introductory lectures on psychoanalysis (1915-1917), psychic trauma is seen as the result of a great and intense irritation from which one cannot be freed or which cannot be processed in a normal way. 3. Freud suggested that the nightmares of soldiers who took part in the war reflect the primary localization of "traumatic images", and their repetition is an infantile form of protection, when the constant unconscious recall of misfortune leads to the formation of a protective experience. Later, he expressed the idea of ​​two forms of manifestation of a reaction to a traumatic event: a negative one, which displaces trauma by suppression, avoidance, and phobias, and a positive one, which manifests traumatic experience in the form of memories, images, and fixation. These ideas are reflected in modern concepts of delayed reactions to traumatic stress /13/.

The issue of the consequences of mental traumatization associated with the experiences of wartime was also touched upon by P.B. Gannushkin (1926). He attributed the combination of physical and mental overload to the main etiological factor of "acquired mental disability" - "physical, intellectual overwork, and even more - affective, moral". The scientist drew attention to the facts proving that prolonged and intense shocks "do not pass without a result for the body and leave behind quite definite traces and flaws." He came to the conclusion that pathogenetically in these cases we are talking about a diffuse sclerotic lesion of small vessels of the brain /43/.

The French psychiatrist and psychologist, a student of Z. Freud, A. Kardiner, was the first to describe the structure of a long-term mental disorder under the influence of extreme circumstances and proposed the concept of adaptation /86/; later these ideas received a modern interpretation in the works of M. Horowitz /82, 84/.

A. Kardiner considered the basis of mental disorders to be a decrease in the body's internal resources and a weakening of the power of the "Ego". For this reason, the world begins to be perceived as hostile. Traumatic neuroses of war, as A. Kardiner believed, have both a physiological and a psychological nature. The basis for the violation of a number of personal functions that ensure successful adaptation to the outside world, in his opinion, is the "central physioneurosis", the concept of which he introduced himself, based on Freud's ideas. He singled out 5 most characteristic delayed mental reactions to psycho-traumatic events: - a decrease in the overall level of mental activity, avoiding reality; - excitability and irritability; - a tendency to unrestrained, explosive aggressive reactions; - fixation on the circumstances of the traumatic event; - typical dreams.

In studies on the mental consequences of the Great Patriotic War, V.A. Gilyarovsky (1946) found that the adverse effects of extreme (combat) conditions increase sensitivity to psycho-traumatic factors. This is facilitated by general asthenization, a decrease in tone, lethargy and apathy. V.A.Gilyarovsky developed the concept of thymogenies, investing in it the idea of ​​a pathogenic principle that affects a person’s feelings in a global sense, i.e. leading to various clinical conditions, united by a common affective genesis. The concept of thymogenesis proposed by him differed from the widespread concept of psychogenesis. For the emergence of the latter, he considered it necessary to have not an affect in general as something pointless, but an affective experience with a specific intellectual content. VA Gilyarovsky pointed out the exceptional complexity of the differentiated picture of psychogenic disorders arising from the impact of a traumatic situation /14, 21/.

In the West, research also continued on the mental states of people who survived extreme situations. After World War II, the word "stress" became popular in the United States. This term is borrowed from engineering, where it is used to denote an external force applied to a physical object and causing it to tension, i.e. temporary or permanent change in structure /8/. R.R. Grinker and J.P. Spiegel (1945) understood by "stress" some of the unusual conditions or demands of life, in particular, the dangers of war and psychological conflicts. The authors conducted clinical studies of the psychological reactions of pilots diagnosed with front-line fatigue. They attributed impatience, aggressiveness, irritability, apathy and fatigue, personality changes, depression, tremors, war fixation, nightmares, suspicion, phobic reactions, alcohol addiction to delayed reactions to combat stress. Much attention was paid to the restoration of self-esteem in the process of psychological rehabilitation of combatants / 8, 14, 15 /. e. reactions to external influences - stress. Initially, this concept in physiology denoted a non-specific reaction of the body (“general adaptation syndrome”) in response to any adverse effect, and later it began to be used to describe the states of an individual in extreme conditions at the physiological, biochemical, psychological, and behavioral levels. The relative independence of the process of adaptation of the organism from the characteristics of the influencing factors was shown. G. Selye substantiated the existence of three stages of the adaptation syndrome: 1. Stage of anxiety when a stressor appears, when some somatic and vegetative functions are disturbed and the mechanisms of regulation of protective processes are activated; 2. Stage of resistance, when, in the case of prolonged exposure to a stressor, a balanced expenditure of adaptive reserves occurs under stress adequate to external conditions; 3. The stage of exhaustion, when the mechanisms of regulation of protective and adaptive processes are violated, and the body's resistance decreases. Such conditions are also called "distress", which literally means "calamity, need." R.S. Lazarus (1966) proposed to distinguish between physiological and psychological types of stress. In his opinion, they differ from each other in terms of the characteristics of the influencing stimulus, the mechanism of occurrence and the nature of the response. The analysis of psychological stress, according to R. Lazarus, requires taking into account the significance of the situation for the subject, the features of intellectual processes, and personal characteristics. Under physiological stress, reactions are highly stereotyped, while under psychological stress they are individual and cannot always be predicted. R. Lazarus developed a cognitive theory of psychological stress, which is based on the provisions on the role of subjective cognitive assessment of the threat of adverse effects and one's ability to overcome stress / 8, 14, 15. / By the end of the 70s, a large clinical material was accumulated for examining participants in the Vietnam War . For 25% of veterans (who did not receive serious injuries and disabilities), the experience of the war was the reason for the development of adverse personality changes in them. Among the wounded and crippled, this figure reached 42% /53/. In the United States, a special system of research centers and centers for social assistance to participants in the Vietnam War was created as part of a state program. Mental disorders in veterans were highly specific, so Figley /76/ even suggested using the term "post-Vietnam syndrome".

It has also been found that, despite the difference in mental trauma, there are a number of common and recurring symptoms in victims of war and other disasters. At the same time, a feature of the condition is that it tends not only not to disappear with time, but also to become more clearly expressed, and also to appear suddenly against the background of the general well-being of a person. Since these disorders did not correspond to any of the generally accepted nosological forms, M. Horowitz proposed to single them out as an independent syndrome. He was the first to introduce the term "post-traumatic stress syndrome" /13, 21/.

The concept of M. Horowitz was formed under the influence of psychoanalysis, as well as the cognitive psychology of J. Piaget, R. Lazarus and others. The two forms of reactions in traumatic neurosis (negative and positive), singled out by Freud, in Horowitz correspond to two interconnected groups of symptoms: “denials” ( avoidance) and “re-experiencing” (invasion). He reveals the pathogenetic mechanism as follows. The response to stressful events contains 4 phases: - primary emotional reaction; - "denial" - avoidance of thoughts about trauma; - alternation of "denial" and "invasion" of these thoughts; - processing of traumatic experience.

The duration of the response process can last from several weeks to several months /81, 82, 84/.

Thus, the concept of post-traumatic stress disorder (PTSD) as a specific form of mental disorder was formed, due to which in 1980 it was singled out as an independent diagnostic category by the American Psychiatric Association. These developments have been documented in the Diagnostic Manual of Mental Disorders Revision 3 (DSM-III) /63/. Subsequently, depending on the duration of the observed symptoms, they began to distinguish between acute (OSD) and post-traumatic (PTSD) stress disorders /64/. They are classified as anxiety disorders along with phobic disorders and generalized anxiety. It has been established that PTSD should not be attributed to a special type of neurosis, because it may include clearly psychotic components of psychogenic origin /63, 64, 99/.

At present, as P.V. Kamenchenko notes /13/, the most promising are theoretical developments in pathogenesis that take into account both psychological and biological aspects of the development of PTSD. In accordance with biological models, the pathogenetic mechanism of PTSD is due to a violation of the functions of the endocrine system caused by extreme stress. It has been established that as a result of the extreme intensity and duration of the stimulating effect, changes occur in the neurons of the cerebral cortex, blockade of synaptic transmission, and even death of neurons. First of all, the areas of the brain associated with the control of aggressiveness and the sleep cycle are affected.

R. Pitman proposed a theory of pathological associative emotional "networks", based on the concept of Lang /53/, who suggested that there is a specific memory information structure organized according to an associative type - a "network". It includes 3 components: information about external events and conditions for their manifestation; information about the person's reaction to these events; information about the semantic evaluation of incentives and response acts. If such an element as imagination is included in the "network", it begins to work as a whole, producing an emotional effect. This hypothesis was supported by the fact that the inclusion in the experiment of reproducing the traumatic situation in the imagination (based on the event that took place in reality) reveals significant differences between healthy and suffering from PTSD veterans of the Vietnam War. In the latter, an intense emotional reaction was observed in the process of experiencing elements of their combat experience in the imagination, which caused an increase in recorded physiological parameters (heart rate, galvanic skin response, electromyogram of the frontal muscles) /104/. Difficulties in the processes of highly organized processing of information, voluntary attention, typical of those suffering from PTSD, are shown /98/. Some symptoms of an increase in general physiological excitability, characteristic of most PTSD sufferers, were studied by recording reactivity to the presentation of loud sounds. In the group diagnosed with PTSD, adaptation (fading of reactions) occurs much more slowly when the stimulus is repeated /101, 102, 105/. The mechanisms of operation of the neural structures of the brain and the biochemical processes occurring at this level can explain such specific manifestations of PTSD as the “flashback” phenomenon (see below), obsessive memories of the experience, dreams and nightmares about the trauma. Physiological parameters are essential as an objective criterion for the presence of a disorder. This is important, in particular, for determining sanity in some cases of judicial practice: a person suffering from PTSD is generally not mentally ill, but may experience short-term states (due to experienced events), when conscious control of behavior disappears or decreases.

In domestic psychiatry, PTSD was not recognized as an independent diagnostic category for a long time. Approaches to stress disorders, definitions and terminology remained typical of classical psychiatry. So, Yu.A. Aleksandrovsky with co-authors /2, 3/ give the following classification of the psychological consequences of the impact of catastrophic situations on a person: 1. Non-pathological psycho-emotional reactions, which are characterized by a direct dependence on the situation and a short duration, and in which a critical analysis of their behavior, working capacity and the ability to communicate with others are preserved; Pathological reactions, or psychogenies (reactive states), which are divided into two groups: with non-psychotic symptoms - neurotic reactions and psychogenic states (neurosis); with psychotic symptoms - acute affective-shock reactions and prolonged reactive psychoses.

The intensive development of reactive states is associated with the culminating moments of a natural disaster. But subsequently, a significant number of people experience disruptions in neuropsychic activity, changes in somatic health within 1-20 years after the situation. Different states pass into each other without sharp boundaries, which creates difficulties in making a diagnosis for the victims. Meanwhile, the approach to diagnosis can be of fundamental importance for determining ways to correct existing mental disorders. There have been cases when Afghan war veterans suffering from PTSD ended up in psychiatric clinics with a diagnosis of schizophrenia and received treatment with potent antipsychotic drugs (chlorpromazine, haloperidol, etc.), which cause powerful side effects.

The neurotic disorders diagnosed in the victims of the earthquake in Armenia /37/ corresponded to the International Classification of Diseases (ICD-9) used at that time, acute reactions to stress and adaptive (adaptive) reactions, and according to DSM-III - PTSD. It was suggested that the diagnostic category of PTSD more fully and accurately reflects the essence of these phenomena.

Since the beginning of the 90s, a number of research works have been carried out in our country, which were carried out on the basis of the theoretical provisions of the doctrine of PTSD using an appropriate arsenal of methods, and were devoted to the problems of the psychological consequences of various military conflicts, as well as natural and man-made disasters /12, 17-19, 54-57, 88, 109/. The severity of PTSD symptoms was also studied in representatives of some professions associated with a high degree of risk, regardless of the events in which they participated /5, 17-19, 40, 52, 60/. Many researchers note a significant similarity in the nature of psychological problems and difficulties in social adaptation in veterans of Vietnam and Afghanistan /53, 57/. The problem of diagnosing and correcting post-traumatic conditions has now become especially acute in connection with the military operations in Chechnya. To determine the correct strategy for rehabilitation work, as I.V. Soloviev /51/ emphasizes, it is necessary to understand the differences between the traumatic stress of a combat situation and additional psychotraumatization that occurs after returning to normal conditions of civilian life. “Secondary” psychotraumatic for veterans are: exclusion from the system of social ties with comrades in arms, which make it possible to receive psychological support; a situation in the family when close people themselves need psychological rehabilitation, and there is a contradiction between the need to help and receive help yourself. Among combatants who continue military service, post-traumatic phenomena are much less pronounced than among those transferred to the reserve.

Comparison of the results of a survey of two numerous categories of people who survived mentally traumatic situations - veterans of the war in Afghanistan and liquidators of the consequences of the accident at the Chernobyl nuclear power plant - prompted domestic specialists in the field of PTSD to distinguish between "event" and "invisible" types of traumatic stress, the consequences of each of which have their own specifics /54-56, 109/. It has been established that the majority of Chernobyl liquidators diagnosed with clinically significant PTSD lack the characteristic physiological reactivity to a reminder of a traumatic event /56/. It is assumed that this fact is due to the absence of a violent emotional reaction during the event.

In recent years, experience has emerged of using the diagnosis of PTSD to establish the necessary disability /43/. It is allowed / to establish the 3rd group of disability in connection with the actual manifestations of PTSD, when they are of a protracted nature and reduce activity, the ability to psycho-emotional stress. The conclusion about the definition of the 2nd group of disability is possible when psychogenic symptoms are combined with concomitant disabling somatic pathology.

Diagnostic Criteria for Stress Disorders A system of diagnostic criteria has been developed for diagnosing post-stress disorders, on the whole corresponding to the ideas substantiated by Kardiner, Horowitz and other researchers. These criteria were included in the diagnostic manual for nervous diseases (DSM) of the 3rd and 4th revision /63, 64/, and later - in the international classification of diseases /39/. The main diagnostic method is a specially organized interview with standardized recording of results, conducted in two versions: the PTSD module from the Clinical Structured Diagnostic Interview (SCID) and the PTSD Clinical Assessment Scale (CAPS) /69/. In the second variant, not only the presence or absence of each symptom is recorded, but also a numerical assessment (from 0 to 4) of its occurrence and intensity is given. A symptom is considered present if its occurrence is rated at least 1 (for most symptoms -1-2 times or 10-20% of the time during the month), and its intensity is at least 2.

Criterion A, according to DSM-IV, consists of two parts. A (1): the fact of an individual's encounter with an event that goes beyond the limits of ordinary human experience, capable of injuring the psyche of almost any healthy person, for example, a serious threat to life and health, both for oneself and for relatives or friends; sudden destruction of a dwelling or public building, etc. By “ordinary” human experience, here we mean such events as the loss of a loved one due to natural causes, chronic severe illness, loss of a job, or family conflict. The stressors that cause these disorders include natural disasters, man-made (man-made) disasters, as well as events resulting from targeted, often criminal activities. A (2): A necessary condition for the likely development of PTSD is also that the experienced event was accompanied by intense emotions of fear, horror, or a sense of helplessness of the individual in the face of dramatic circumstances, which is the main etiological factor in the occurrence of post-stress disorders.

Criterion B - Constantly recurring experience of a traumatic event ("invasion"). It is considered identified if at least one of the following symptoms is detected: 1. Recurring intrusive memories of an event that cause distress, appearing in the waking state when nothing is happening to remind of it. Intensity is measured by how difficult it is to get rid of the memories and continue the activities that the person is engaged in at the time of their occurrence.

2. Intense, difficult experiences, excitement and discomfort under circumstances that symbolize or resemble in one way or another the traumatic event, including anniversaries of the trauma. Distress occurs under the influence of "key stimuli", reminiscent of some aspect of the event, also called "triggers" (literally, a "trigger" that suddenly triggers stress reactions).

3. Feeling as if the traumatic event is happening again or corresponding sudden actions (including the feeling of revived experiences, illusions, hallucinations,) - even those that appear in a sleepy state. This is the most powerful symptom, called a “flashback” (literally means “reverse flash”, i.e. a flash in the mind of a previously experienced event. The intensity is assessed by the feeling of the realism of the situation, the perception of it with all senses, the loss of connection with the environment at the time of the symptom onset In the worst cases, a complete loss of control over oneself is possible, followed by amnesia for this episode - an "eclipse", a memory lapse.

4. Recurring dreams about the event, causing difficult experiences. The intensity is measured by whether these dreams cause awakening, whether the person falls asleep easily again.

5. Physiological reactivity (rapid heartbeat, muscle tension, trembling in the hands, sweating, etc.) when exposed to circumstances that resemble or symbolize various aspects of the traumatic event. The symptom was originally (DSM-III) a diagnostic criterion "D" (see below), and is now (DSM-IV) classified as a criterion "B" due to its strong association with symptom 2 of this group.

Criterion C - Sustained avoidance of trauma-associated stimuli or "numbing" of general responsiveness not observed prior to injury. It is considered diagnosed if at least any three of the following symptoms are present: 1. Efforts to avoid thoughts or feelings associated with trauma. Attempts to drive them away include distraction, suppression, and reduction of arousal with alcohol or drugs.

2. Efforts to avoid activities or situations that trigger memories of the trauma. For example, unwillingness to be close to certain places, refusal to participate in veteran events, etc.

3. Inability to remember important aspects of the trauma (psychogenic amnesia). It is estimated by what part (in percent) of the circumstances of the incident is difficult to remember, how impaired is the ability to reproduce the event in memory.

4. A marked loss of interest in favorite activities that were important or enjoyable to the person, such as sports or hobbies. Assessed by the number of activities in which interest has decreased, and by whether the pleasure received from them has been preserved.

5. Feeling detached or alienated from others, different from how the person felt before the event. With a low intensity of the symptom, a person periodically feels that he is “out of step” with others, and with a high intensity, he loses a sense of belonging to the world around him and the ability to interact and maintain close relationships with others.

6. Reduced level of affect, such as the inability to experience feelings such as love and happiness. It is expressed in a feeling of "insensibility", in the worst case - a complete absence of emotions. The symptom is sometimes erroneously referred to as psychotic (schizophrenia).

7. Feeling of lack of prospects for the future. For example, a person does not expect promotion, marriage, children, long life, feels that there is no need to make plans. The symptom ranges from a slight sense of a reduced life perspective to a complete conviction of premature death (without medical evidence).

Criterion D - Persistent symptoms of increased excitability (physiological hyperactivation) not observed before the injury. It is considered diagnosed if at least any two of the following symptoms are present: 1. Difficulty falling asleep or staying asleep. Includes waking up in the middle of the night or early in the morning. The intensity is estimated by the amount of sleep time lost from the duration that is desirable for the subject.

2. Irritability or fits of anger, aggressiveness in various forms. The intensity of the symptom is rated based on how the person expresses their anger, from raising their voice to episodes of physical abuse.

3. Difficulty concentrating. The amount of effort required to focus on some activity or something that surrounds a person is estimated.

4. Increased alertness, vigilance, even when there is no obvious need for this. At low intensity - slightly increased curiosity about what is happening around, at moderate - alertness and choosing a safe place in public places, at high - a significant investment of time and energy in efforts to ensure safety.

5. An exaggerated startle response (the "starting" response) to sudden stimuli, such as loud unexpected noises (e.g., car exhausts, pyrotechnic effects, door slamming, etc.) or something the person suddenly saw (e.g. , movement seen at the periphery of the visual field - "the corner of the eye"). Includes flinching, "jumping", etc. The intensity varies from a minimal startle response to overt defensive behavior, and also depends on the duration of arousal during such a response. This is sometimes referred to as the "fight or flight" response.

Criterion F - distress and maladjustment. The presence of the described groups of symptoms is a necessary but not sufficient condition for making a diagnosis. Another criterion that complements the picture of the post-stress state is that the disorders cause clinical distress or disrupt social, professional, or other significant activities. This criterion can be called functional: it is associated with a violation of psychological adaptation, a violation (or decrease) of professional performance, a deterioration in the quality of life in general due to a mental trauma.

The structure of acute stress disorders includes a subgroup of the so-called "dissociative" symptoms (the term "dissociation" was first used in his works in 1889 by P. Janet), observed either during the period of trauma or subsequently (criterion b). It is considered present if at least three of the following symptoms are present: 1. subjective feeling of emotional dependence, 2. "dulling" or lack of emotional response; 3. narrowing of consciousness about the surrounding world (“confusion”); 4. derealization (a feeling of unreality of surrounding things, phenomena and ongoing events); 5. depersonalization (violation of a person's perception of himself, his body, thoughts and feelings); 6. dissociative amnesia (inability to remember any important aspect of the traumatic event).

Diagnostic criterion A is common for PTSD and ASD. In addition, for the diagnosis of ASD, criteria are applied that correspond to the described criteria for PTSD. So, criterion c completely coincides with "B" for PTSD; criterion d includes only the first two symptoms of group "C" for PTSD, and is considered present when both are present; criterion e for OSR includes all the symptoms of criterion "D" for PTSD, and one more symptom - the absence of physical fatigue, the need for rest. Criterion f corresponds to "F" for PTSD, but differs slightly from the latter: it is that the disorder causes clinically significant distress or impairs the individual's ability to receive the necessary help, to communicate to family members about the trauma experienced. In addition, there is a criterion h for OSR; the disorder is not associated with the direct action of physiologically active substances (narcotic, medicinal) or the general somatic state of the body, does not fit the definition of a brief psychotic disorder and is not an exacerbation (exacerbation) of an existing mental illness.

There is an additional list of symptoms that are not included in the main diagnostic criteria. Experts refer to them: a feeling of "survivor's guilt" in front of those who died, or guilt for the actions that had to be committed; a sharp division of the retrospective of the life path into "before" and "after" a certain event or period of time, and the social environment - into "we" (participants in certain events) and "they" (not participating); feeling of loneliness; problems in the sexual sphere and in family life; substance abuse.

Stress conditions and stress disorders in firefighters.

Extreme conditions that often accompany the professional activities of firefighters are characterized by a strong traumatic effect of events, incidents and circumstances on the psyche of an employee. This impact can be powerful and single in case of a threat to life and health, explosions, building collapses, etc., or multiple, requiring adaptation to permanent sources of stress. It is characterized by varying degrees of suddenness, scale, and can serve as a source of both objectively and subjectively conditioned stress. The most powerful objective stressors include: a threat to one's own life, the lives of fellow workers, some categories of citizens (women, children, the elderly) /18, 19/. A specific stress factor for the professional activity of firefighters is the mode of anxious waiting during daily combat duty /41/. The subjective causes of stress include: lack of experience, psychological unpreparedness, low emotional stability.

A document published by the US Fire Defense Association describes 5 types of "everyday" stressors inherent in the fire department /79/: 1. High level of surprise, unpredictability of events; 2. Sudden alarms; 3. Tension in interpersonal relationships; 4. Confrontation with human suffering; 5. Fear for one's life and health, as well as for possible mistakes in work. In foreign publications, “critical incidents” are named that are most likely to cause mental trauma in firefighters: death or injury to a firefighter during work; death or injury of a child; a situation in a fire where access to the victim is impossible (especially when the victim is a child); a situation where a firefighter is personally acquainted with the victims; the situation during rescue, when the victim received severe burns, excluding the possibility of recovery /68/. According to Hildebrand "a / 80 /, tragic events in which there are no survivors cause a particularly strong state of frustration among firefighters. At the same time, stress can arise due to communication with survivors, who often turn their negative emotions on firefighters. For additional stressors for fire extinguishing managers are: the need to communicate with officials, great responsibility with a lack of experience.

It should be noted that firefighters are at increased risk of experiencing both "event" and "invisible" stress, as not only face tragic situations, but often experience the impact of factors that can lead to unpredictable and irreversible changes in health - primarily radiation and complexes of toxic substances, the consequences of which appear after a long time (several years) with increasing intensity. The vagueness of the prospects for changing one's physical condition and the possibility of negative consequences for the health of children born after the event are an additional powerful psychotraumatic factor /22, 33, 34, 44/.

To prevent the development of long-term consequences of mental trauma in the West, support groups are being created that provide psychological assistance in the coming days after emergencies using the “debriefing” method. The method was proposed by J. Mitchel "oM, who in his youth was a volunteer fire brigade / 72 /. Debriefing is a specially organized discussion and is used in groups of people who have jointly experienced a stressful or tragic event / 61 /. Its name implies as much as possible a detailed description by each of the participants of what happened to him, as opposed to the word "briefing", which means the exchange of brief messages. The method has become especially widespread in the fire department and other services that eliminate the consequences of natural and man-made disasters. Both professional psychologists and specially trained employees of departments /65/.

In early domestic research on the psychology of firefighting, almost no attention was paid to the possibility of a traumatic neurosis in firefighters. However, there were sharp nervous reactions of employees during non-working hours at sounds reminiscent of a combat departure signal /41/. It was substantiated that nervous diseases should be considered professional for firefighters /42/.

In recent decades, the problems of stress conditions in firefighters have been discussed in domestic psychological studies devoted to: 1. Prevention of unfavorable functional conditions in the activity of firefighters /29, 30, 32, 33, 36, 46/; 2. Assessing the severity of the work of firefighters and justifying changes in the system of benefits /31, 32, 34/; 3. Psychological training of firefighters /33, 48/.

I.O. Kotenev /17/ studied a group of firefighters as a control sample, comparing the dynamics of situational anxiety in people working in stressful (fire department) and extreme (armed conflict zone) conditions of activity.

The impact of extreme situations that arise when extinguishing a fire, as well as the mechanisms of development of post-traumatic conditions in firefighters, are not well understood, although many works contain statements that firefighters are at increased risk of stress disorders. It was found that when training combat alarm signals are given in fire departments guarding especially dangerous facilities, the neuropsychic reactions of employees significantly exceed the normal level. As a result of the research, it was found that some of the personnel experience low mood, anxiety, unmotivated aggressiveness, indiscipline, evasion of professional duties, deterioration in performance, alcohol abuse, interpersonal conflicts in the family and at work, suicidal tendencies /33 , 34/. Until now, there have been no domestic psychological studies that would allow: a) to correlate these maladaptive forms of behavior with a wide range of phenomena of post-traumatic states, b) to reveal the relationship between the frequency and intensity of experienced psychotraumatic situations with the characteristics of delayed reactions to mental trauma.

In the Norwegian work /85/ we are talking about stress reactions and phenomena of acute stress disorder in volunteer firefighters who extinguished a fire in a multi-storey hotel and rescued its guests (at that time 14 out of 128 people in the building died). According to the survey, the greatest stress was caused by such circumstances as finding the dead and injured, working in conditions of time pressure and the need to wait in inactivity. Particular difficulties arose during rescue operations in smoky rooms. Among the acute stress reactions are: anxiety, anxiety, over-activity, fear, agitation, irritability. All of them were noted to a moderate or high degree in about half of the extinguishing participants. It was found that the severity of symptoms of "invasion" and "avoidance" after the event significantly correlates with the presence of states of anxiety, uncertainty, over-activity and anxiety during work. According to the self-assessment of the state, the level of symptoms of stress disorder is significantly higher in those who had no experience of actions in smoke conditions before this case, but these differences are small in absolute values. In general, reactions regarded as clinically significant were observed in 10% of the examined patients. Pike et al. /103/ report somatic comorbidities of PTSD that are characteristic of firefighters. Groups of firefighters who have been diagnosed with PTSD have a significantly higher incidence of complaints of cardiovascular, respiratory, musculoskeletal, neurological and gastrointestinal ailments.

Misha & Jenkins /100/ investigated the impact of emotional support from the social environment on firefighters working during and immediately after the devastating 1992 Florida hurricane. Emotional support is divided into two types: 1. "Received", which consists in the fact that other people (family members, friends, colleagues and others) allow a person to talk about problems and express their feelings, show a caring attitude; 2. "Felt" (empathy), which consists in the subjective feeling that other people (both experienced and not experienced the same event) understand what the person experienced and do not reject his feelings and thoughts associated with the event. It was found that the indicator of the first type of emotional support, determined by a special questionnaire, is positively associated with the level of PTSD symptoms, while the second is negative. It remains a controversial question whether the feeling of empathy is a cause or a consequence of successfully overcoming maladaptive states.

An analysis of the literature data allows us to draw some conclusions regarding the features of the occurrence and course of post-traumatic stress disorders in firefighters: 1. Psychic trauma can often be the result of a combination of emotional stress that occurs during tragic events and exposure to harmful occupational factors that cause “invisible” stress.

3. Firefighters often experience re-experiencing of past events in the form of images and thoughts, but this is not always combined with other symptoms of PTSD.

4. A comparison of data from different studies shows that, in percentage terms, clinically significant stress disorders in firefighters who have experienced particularly severe and large-scale disasters occur as often as in people who participated in the war (respectively 18 and 16-21%). As for the indicators of psychometric methods that assess the severity of symptoms, firefighters were not compared with other categories of people.

5. The diagnosis in most cases is multiple, i.e. PTSD in firefighters is found along with other mental disorders.

6. There are indications that the nature of the traumatic experience of firefighters (both experienced events and individual reactions to them) significantly affects the severity and characteristics of the course of stress disorders. However, since there is no definitive approach to quantifying traumatic experience (more on this in Chapter 2), different researchers measure slightly different phenomena. Therefore, it is not possible to draw general conclusions about the connection between the professional traumatic experience of firefighters and the phenomena of post-traumatic mental disorders.

7. The lack of development of the problem of PTSD in firefighters in domestic psychology necessitates the conduct of complex psychodiagnostic studies and the creation of a system of preventive and rehabilitation measures.

EMPIRICAL STUDY OF THE REPRESENTATION OF STRESS DISORDERS IN FIRE FIGHTERS At the first stage of the work, a pilot sample was examined, which consisted of 138 firefighters from Moscow and Irkutsk. Then, after a statistical analysis of the data obtained and the development of an algorithm for identifying the risk of stress disorders and other forms of maladaptive conditions (see Chapter 3), 145 firefighters from Perm and the Perm region were examined to test the reliability of the methodological complex. The socio-demographic characteristics of the sample are presented in Appendix 2. The sample of employees of the fire service in Moscow, Perm and the Perm region was made up of practically healthy people working mainly in the positions of firefighters and chiefs of guards. In addition, 6 people of the inspector and preventive staff were examined in the Perm region. A significant part of the surveyed Muscovites was employed in the fire department during 1993-94. in connection with the replacement of conscripts with contract servicemen, which explains the relatively large percentage of them with less than 5 years of service. However, due to the tense situation with the fires in Moscow, their experience of dealing with difficult and dangerous situations was quite significant.

The sample of employees of the fire service of Irkutsk and the Irkutsk region consisted of persons who were poisoned by a complex of toxic substances as a result of a fire at the cable plant in the city of Shelekhov in December 1992 / 22, 44 /. During the combustion of cable insulation during this fire, dioxin was released, which, acting on the human body, leads to damage to the skin, and later to the liver, kidneys and hematopoietic system. Until now, the firefighters who took part in the extinguishing continue to experience the progressive consequences of this fire. The individuals who participated in the survey continued to work in the fire department or were about to retire. They are, on average, older than the rest of the surveyed, have a longer service record in the fire department and experience in dealing with critical situations, and also differ in the scale and nature of the medical and psychological consequences of these situations.

It is obvious that Irkutsk firefighters are a very specific part of the sample, and therefore their data were analyzed both together with the data of Moscow firefighters and separately.

Research methods.

A comprehensive study of stress disorders in Russian firefighters was carried out for the first time. Therefore, one of the most important tasks was to determine the complex of the most diagnostically significant psychological techniques. Diagnosis of PTSD among police officers in departmental medical institutions is not yet widely used, and among the psychologists of the fire service there are no specialists who know the method of clinical interview for diagnosing PTSD. At the same time, the clinical interview is the main and most reliable method used by foreign experts to study PTSD. The lack of the possibility of wide application of this method was compensated by a large number of psychometric tests used. This made it possible to carry out mass surveys, which is difficult when conducting a clinical interview, which requires a face-to-face conversation with each subject. A number of techniques were used that are traditionally used to study post-traumatic stress disorders and associated symptoms of mental ill-being, primarily anxiety and affective disorders. In addition, methods were developed to assess the experience of encountering extreme situations, taking into account the specifics of this professional contingent, and at the next stage of work, also to assess the external manifestations of stress disorders according to observations from outside (see Appendix 1).

Development of a methodology for assessing traumatic professional experience (a questionnaire of stressful situations) for firefighters.

However, there is currently no single approach to assessing the traumatic experience of firefighters in the world practice of PTSD research. Methods have not been developed to study the experience of firefighters encountering extreme situations throughout their professional life. Also, a detailed comparative analysis of various situations specific to the professional activity of firefighters was not carried out, with a quantitative assessment of the degree of their negative psychological impact. In general, the question of the quantitative measure of professional and life traumatic experience is highly debatable. Even when reasoning within the framework of everyday concepts, it is often difficult to determine who has “experienced more” and who has experienced “less”. The approach we proposed to the assessment of traumatic experience and the developed methodology seem to allow solving a similar issue for firefighters; in the future, subject to the creation of methods of a single sample, it will be possible to compare the severity of the traumatic experience of representatives of various professions.

For our study, a special questionnaire of events (situations) encountered by firefighters was developed, called the questionnaire of firefighters' stressful situations (FSFS). /25/. It consists of 57 items. It describes situations that are specific to the professional experience of firefighters and that cause stress reactions (Appendix 1). In addition to questions about situations that occur directly when extinguishing fires, questions are included about cases that can be regarded as "moral pressure", usually occurring after combat work during the analysis and discussion of what happened and causing "secondary" stress (the last 4 lines of the questionnaire). The questionnaire was compiled with the participation of 11 experts - employees of fire extinguishing services on duty and teachers of the fire tactics department of the Moscow Institute of Fire Safety, who have served in the fire department for at least 10 years. The subjects - firefighters and chiefs of guards - noted how often each of the described situations occurred to them, and how strong emotional experiences were accompanied. Three types of such experiences are considered: fear, anxiety and helplessness, the presence of which during events that occur to a person is a significant factor influencing the development of stress disorders in the future. Thus, the questionnaire is built in accordance with the first diagnostic criterion (criterion A) of post-traumatic stress disorder according to DSM or ICD-10 /39, 63, 64/, which includes two subcriteria: 1. The individual has experienced an event associated with a serious threat to life and health of people, or beyond the ordinary human experience; 2. The event was accompanied by an intense experience of fear, horror, helplessness.

Since the word “horror” was regarded by almost all experts as an actual synonym for the word “fear”, it was replaced by the word “anxiety” in the questionnaire, because. the experience of anxiety was considered by experts to be very characteristic of the situations under consideration. Both the occurrence of events and the intensity of experiences are evaluated on a 5-point scale. In assessing the occurrence, it is important to record both the very fact of a person's encounter with a situation, even if it is a single one, and the frequency of a collision with a situation if it occurs repeatedly. Therefore, the frequency of occurrence is estimated at 1 point if the event (situation) occurred only once, and the frequency of a person’s collision with an event (situation) that occurred repeatedly is measured by an assessment of occurrence of 2, 3, 4, and 5 points, and formulations are used that allow one to navigate for generally accepted or understandable units of time for the examined (year, month, duty every 4 days).

ROS SII s * A * "ffccyA ^ cTSEHj ^ - lisKVSOT" si "Did you lose consciousness during work? - Not. - Then we mark nothing in this line, we move on. Did you have to learn about the death of the closest employees - from your guard, link? - It happened once. I note the occurrence - one? - Yes. ”, etc., until it is clear that the subject has fully understood the instructions. The questionnaire can serve as a kind of tool for conducting a conversation that precedes the main examination. As experience shows, in some cases, when filling out the questionnaire form, traces of mental trauma can clearly make themselves felt (see Appendix 4): nervous reactions occur, there are also attacks against the experimenter, for example: “Why are you reminding us of all this again, it's hard without you." It can be difficult for people with pronounced symptoms of PTSD to fill out the right side of the form (to assess their experiences). In these cases, we sometimes suggested filling in only the "Occurrence" column at first, and returning to the evaluation of experiences later - after working with other methods, talking and a short break.

As practice shows, the use of an event questionnaire can be effective when a psychotherapist provides firefighters with assistance /24/. Referring to the questionnaire form filled out by the patient contributes to the actualization of emotional states associated with mentally traumatic situations, which is often necessary for “working through” and correcting these conditions. Self-assessment of the emotions that accompanied the experienced events, in numerical form, performed while working with the technique, is one of the necessary elements of many psychotherapy techniques.

Based on the data obtained, for each item of the questionnaire (each situation), an indicator was determined, which we called the “stress index” (hereinafter referred to as SI), calculated as a weighted average of the estimates of emotional experiences characteristic of a given situation, by the subjects and experts, according to the formula: SI = (1PEREVexp +1PEREVshzh * SG2exp / SG2Pozh) / (n + m * SG2.zhsp / SG2 [South), n mwhere n - respectively, the number of experts and the number of examinees (firefighters) who assessed this situation, EFEREVexp and 2d1EREVExp - the total sum of the assessments of severity three types of experiences (“fear” + “anxiety” + “helplessness”), respectively, by all experts and all firefighters who assessed this 2 2 situation, s exp and<Т пож - дисперсия оценок переживаний, характерных для данной ситуации, соответственно экспертами и пожарными. Вычисление средневзвешенного значения мы сочли необходимым потому, что группы экспертов и пожарных являются достаточно разнородными: эксперты на момент опроса не занимались тушением пожаров, однако были хорошо знакомы практически со всеми рассматриваемыми ситуациями по собственному опыту или по опыту людей, с которыми непосредственно взаимодействовали, т.е. обладали более отстраненно-аналитическим взглядом; пожарные же обладали большей «свежестью» эмоциональных впечатлений от событий, но многие из них имели еще недостаточно опыта для их оценки. Также для всех пунктов опросника были вычислены коэффициенты корреляции между показателями левой и правой части строки ответов (встречаемостью события и суммой оценок трех видов переживаний, связанных с ним). При отрицательных значениях этой корреляции для какой-либо из рассматриваемых ситуаций можно предположить, что люди к ней «привыкают», т.к. при большей встречаемости ситуации уменьшается её субъективная стрессогенность. При положительных же значениях корреляции дело обстоит противоположным образом: с ростом встречаемости ситуации её воздействие «усугубляется», т.к. субъективная стрессогенность увеличивается. Поэтому эти корреляции были названы «индексами привыкания» (ИП); строго говоря, их следовало бы назвать индексами «не-привыкания». Описания ситуаций по тексту опросника, расчет ИС, а также значения ИП представлены в табл. 1.

2 "switching on" is called putting on a gas mask and bringing it into working condition.

Other methods used in the work.

1. The Horowitz Impact of Event Scale (IOES) /83, 110, 111/ allows you to determine the presence of PTSD in the subject according to the severity of one of two tendencies: the desire for obsessive experiences about the trauma (constant return to thoughts and feelings about the event that occurred regardless of the will of the person) or avoiding everything related to it (the desire to reduce the impact of memories of the event on the emotional state and behavior, up to the complete denial of this influence and the desire to forget the event itself), as well as the presence of increased nervous excitability. In the modern version /110/ the scale contains 22 statements, allowing to determine the severity of these trends over the past seven days. The indicators calculated according to the method measure 3 main areas of responses to traumatic stress: the phenomenon of obsessive experiences, or “intrusions” (“Intrusion”, IN), the phenomenon of avoiding any reminders of trauma (“Avoidance”, AV) and the phenomenon of physiological excitability ( Arousal, AR). Inviting the subject to fill out this questionnaire, he should be reminded that the questions relate to the event that he considers the most difficult and terrible of what he had to deal with at work and in life, or that left the most difficult memory mark today. Before answering, he can optionally write in the line specially designated for this, what kind of event it was, or not to do so.

2. The Mississippi Scale (Mississippi Scale for Combat Related PTSD) /87/ is used in the practice of studying PTSD - a syndrome associated with participation in hostilities or with mentally traumatic events in civilian life. It consists of 39 statements reflecting the internal state of people who have experienced a particular traumatic situation. The behavioral reactions and emotional experiences described in the questionnaire are combined into several groups and include: obsessive memories, depression, communication difficulties, affective lability, memory problems, sleep disturbances, and various personality problems. Each of the statements is evaluated on a 5-point scale. As a result, a total score is calculated, which makes it possible to identify the measure of the impact of traumatic experience and assess the degree of general psychological distress of the subject. According to foreign data, the Mississippi scale score allows you to determine the presence of PTSD in 93% of cases, and in 89% of cases - its absence. The criterion value of PTSD on a scale is 107 points.

3. Questionnaire of traumatic stress (OTS) IO Koteneva /18, 19/ is designed to assess the severity of symptoms of post-stress disorders based on the criteria contained in the DSM-4. The wording of most of the items in the questionnaire is based on the results of many years of research into the consequences of mental trauma among police officers. At the same time, proceeding from the concept of PTSD as a normal human reaction to extreme circumstances, items with obvious psychopathological overtones and negatively perceived by the subjects were excluded from the set of statements, if possible.

The questionnaire consists of instructions, 110 statements and an answer sheet. A 5-point Likert scale is used, allowing the subject to rank each of the statements (from “absolutely true” to “absolutely false”) depending on its relevance to their own state. 56 points are “key” for assessing the severity of symptoms of post-stress disorders, 9 points make up 3 rating scales - “lies”, “aggravations” and “dissimulations”, which allow you to control the degree of sincerity of the subject, his tendency to emphasize the severity of his condition or deny the presence of psychological problems. In addition, the Questionnaire includes reserve and so-called. “masking” statements that prevent the subjects from involuntarily understanding the main focus of the test. First, the values ​​of the control and main subscales of PTSD and RSD are calculated:

Dissertation conclusion scientific article on the topic "Psychology of work. Engineering psychology, ergonomics."

1. It has been established that about 26% of the employees of the territorial divisions of the fire service are at risk of developing acute and post-traumatic stress disorder, while 6.5% experience conditions that can cause a significant violation of adaptation, cause inappropriate behavior and reduce the effectiveness of the professional activities of personnel fire department. Data have been obtained that the level of severity of symptoms of stress disorders in firefighters is not lower, and for a number of symptoms even higher than in employees of other ATS services.

2. The prognostic significance of such a factor as professional traumatic experience was determined, i.e. experience of encountering events that cause professional stress, regarding the risk of developing PTSD and other forms of mental maladaptation in firefighters. The importance of professional experience in the emergence and development of adverse mental states of the fire service personnel is manifested in the fact that firefighters with more service experience and more likely to encounter emergency situations are more likely to suffer from post-traumatic stress disorders.

3. For the first time, a methodological complex was compiled to determine the risk of negative psychological consequences of firefighters' activities in extreme conditions. It includes methods for determining the experience of encountering extreme situations, specific symptoms of PTSD and general psychopathological symptoms. When conducting surveys in the field, taking into account the brevity and informativeness of diagnostic methods, it is recommended to use 4 different survey options in terms of the degree of detail.

4. The developed methodological complex and decision rules make it possible to divide the examined people into four groups according to the degree of risk of developing PTSD. Methods and methods of medical and psychological support and correction of maladaptive conditions differ depending on whether the subjects belong to risk groups for developing PTSD.

5. An assessment of the risk of occurrence of stress disorders was carried out according to indirect signs, which are the severity of certain psychological defense mechanisms inherent in the subjects.

6. For a more accurate identification of risk groups for the development of PTSD, it is advisable to use the data of structured observation of manifestations of disadaptation at the behavioral level as an external criterion, which makes it possible to establish the facts of dissimulation and stimulate the psychological observation of commanders, their attention to the psycho-emotional state of subordinates.

7. It has been found that firefighters exposed to extreme effects of hazardous and harmful factors of working conditions that cause irreversible damage to health (radiation, toxic substances, etc.), later endure emotional trauma from a collision with tragic events more difficult. This is due to the depletion of the protective resources of the psyche as a result of the combined impact of the "critical incident" and "invisible" stress, which is typical for the profession of a firefighter.

CONCLUSION

The study made it possible to analyze in detail the possibilities of using a complex of psychodiagnostic methods to study the phenomena of post-stress mental disorders in firefighters. We are talking about identifying the risk of stress disorders, and not about their diagnosis as such, since the diagnosis can only be made by the result of a clinical interview. This is justified for the reason that the psychological fire service is mainly faced with the need to conduct mass examinations of persons, the vast majority of which are practically healthy physically and mentally; in these cases, survey methods are significantly more effective than interviews.

The complex of methods considered in the work covers the following areas of research:

1. Self-assessment of traumatic experience, which is a necessary part of the study of the risk of stress disorders, and is carried out taking into account the professional specificity of the situations experienced by the subjects. For this, the author's questionnaire of stressful situations of firefighters, developed in full and abbreviated versions, is used.

2. Self-reported symptoms of post-traumatic and acute stress disorder, as well as other psychopathological phenomena. This is especially important because, as foreign studies have shown, clinically significant PTSD in firefighters is usually accompanied by other mental disorders. The methods used make it possible to obtain sufficiently complete information about the psychological consequences of extreme situations.

3. Evaluation of the risk of stress disorders on indirect grounds, which allows, as shown in the work, the use of the methodology for studying "psychological defenses".

4. Evaluation of external manifestations of maladaptive states by fixing observations "from the side" of human behavior. This purpose is served by a specially developed questionnaire for department heads.

Groups of the surveyed, characterized by varying degrees of risk of maladaptive conditions, were identified on the basis of a significant array of psychodiagnostic data. Further statistical analysis showed the possibility of establishing the subjects' belonging to each of these groups with high accuracy using a significantly smaller number of indicators.

The paper proposes a new method for assessing the experience of a person experiencing stressful situations, both for domestic and foreign psychology: the stressfulness of various events and circumstances, which are classified both as “critical incidents” and simply as stressful conditions, and typical for professional activities, is calculated by expert means. subjects (averaging the estimates of emotional reactions to each type of event reported by several people allows us to obtain, to some extent, “objective” indicators of their stressfulness); this makes it possible then to evaluate the individual traumatic experience, taking into account how often and what type of situation the person encountered, and what were the characteristics of his state during them. Stable correlations of indicators calculated according to the author's methodology "questionnaire of stressful situations of firefighters" with the degree of severity of symptoms of post-stress disorders give reason to consider this method effective.

An in-depth examination is currently underway aimed at identifying PTSD in firefighters, using a clinical interview and psychophysiological methods (one of the cases of such an examination is described in Appendix 3). In the future, a longitudinal study of the dynamics of post-stress syndromes is planned, as well as a study of the relationship between the likelihood of stress disorders in firefighters and basic personality traits and characteristics of professional motivation. The introduction of the developed set of methods into the activities of the psychological fire service provides an opportunity to create an extensive database on stress disorders among firefighters in our country.

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Family behavioral therapy sees reinforcement of behavior by consequences as its main principle, which implies that the pattern of behavior resists change in all cases, except when there are more favorable consequences. Representatives of this direction are interested in the analysis of the sequence of actions. It is based on the position that satisfaction in marriage is to a much greater extent due to the absence of mutual frustrations than to the volume of pleasures delivered to each other.

One of the most commonly used techniques is behavioral parenting training. The process of psychotherapy begins with the fact that the therapist reformulates the client's ideas about the essence of the problem and possible ways to solve it. Behavioral psychotherapists are one of the few who do not invite the whole family for treatment, but only the child and one of the parents. Behavioral training of parents aims to increase their competence in raising children, recognizing and modifying patterns of emotional and behavioral response.

The following techniques are the most popular:

shaping - achieving the desired behavior in small portions through sequential reinforcement;

token system - uses money or points to reward children for successful behavior;

contract system - includes an agreement with parents to change their behavior in sync with the change in the behavior of the child;

exchange of changes for a fee;

· interruption (timeout) - punishment in the form of isolation.

Family behavioral therapy is one of the most popular methods due to its simplicity and economy, although often therapeutic changes are one-sided or short-lived.

The following techniques are also used: concluding marital contracts, communication trainings, constructive argument, problem solving techniques, etc. Currently, many specialists use an integrative approach, most often combining the methods of cognitive behavioral therapy and systemic psychotherapy.

At the heart of the contract is an agreement in which the spouses clearly define their requirements in terms of behavior and circumstances assumed. When formulating requirements, it is recommended to use the following order: general complaints, then their concretization, then positive proposals, and finally, an agreement listing the responsibilities of each of the spouses.

Family Communication Therapy

Family communication therapy has evolved from the Palo Alto trend. Its leading representatives are P. Vaclavik, D. Jackson and others. The goal of family communication therapy is to change modes of communication, or "conscious action to change poorly functioning patterns of interaction." At first, representatives of this direction, for example, Virginia Satir, set the goal simply to improve communication in the family, then this idea narrowed down to changing exactly those modes of communication that support the symptom. The main groups of family communication therapy techniques are: teaching family members the rules of clear communication; analysis and interpretation of communication methods in the family; manipulation of communication in the family with the help of different techniques and rules. This type of family therapy failed to establish itself as a highly effective method.

Experiential Family Therapy

Experiential family therapy is rooted in existential-humanistic philosophy. Like the structural and strategic approaches, it focuses on the present rather than the past. But, unlike them, and like psychoanalysis, it deals primarily with individual family members who are trained to share personal experiences with each other. Although the focus is on individuals, experiential family therapy is considered systemic.

Carl Whitaker, Virginia Satir and others were prominent representatives of this trend. They focused on personal growth rather than changing dysfunctional interactions or eliminating symptoms. Personal growth implies autonomy and freedom of choice. Growth occurs when each member of the family is able to experience the present and, moreover, to share their experiences with others. The task of the psychotherapist is to help family members express their experiences as honestly and openly as possible. They are taught not so much to discuss each other's problems or symptoms as to share their personal experiences.

4. Post-traumatic stress

4.1. Phenomenology of post-traumatic stress

The phenomenology of post-traumatic stress is described in the work of N.V. Tarabrina. According to the author, situations that are characterized by super-extreme impact on the human psyche, causing him traumatic stress, psychological consequences of which, in its extreme manifestation, are expressed in post-traumatic stress disorder(PTSD) occur as a protracted or delayed reaction to situations involving a serious threat to life or health.

Some of the famous researchers of stress, such as Lazarus, who are followers of G. Selye, mostly ignore PTSD, like other disorders, as possible consequences of stress, limiting the field of attention to research on the characteristics of emotional stress.

The concepts of Linderman's (1944) traumatic grief and Horowitz's (1986) stress response syndrome are often cited as examples of extensions of the concept of classical stress theory. However, these models include concepts of a recovery or assimilation phase, the essence of which is a prolonged struggle with the consequences of extreme or traumatic stress. The authors of these concepts point out that the survivors of mental trauma are characterized by experiences of mental discomfort, distress, anxiety and grief during this period.

Attempts to view these concepts as a variation of the classical theory of stress, apparently, stem from the authors' designation of the reactions described above as stress and chronic stress.

Chronic stress is not limited to the situation of exposure to the stressor. Reactions can take place both before the effect of the stressor disappears, and in later life. From a theoretical point of view, it would be more correct to use the terms stress to denote an immediate response to a stressor and post-traumatic mental disorders for the delayed consequences of traumatic stress.

The differences between research on stress and traumatic stress are methodological. Thus, most studies of traumatic stress are focused on assessing the relationship between trauma and the disorders caused by it, as well as assessing the degree of traumatogenicity of an event to a greater extent than its stressfulness.

Research in the field of stress is mainly experimental in nature, using special experimental designs under controlled conditions. In contrast, research on traumatic stress is naturalistic, retrospective, and largely observational.

Hobfall (1988) has offered a point of view that can serve as a bridge between the concepts of stress and traumatic stress. This point of view is expressed in the idea of ​​a total stressor that provokes a qualitatively different type of reaction, which consists in the conservation of adaptive resources. A similar point of view is expressed by Crystal (1978), who, while remaining within the framework of psychoanalytic theory, suggested that mental collapse, affect freezing, and subsequent disturbances in the ability to modulate affect and alexithymia are the main features of the traumatic reaction to extreme conditions.

Other terms that describe an extreme reaction to total stress are dissociation and disorganization. Metaphorically speaking, two approaches, stress and traumatic stress, include ideas of homeostasis, adaptation and normality on the one hand, and separation, discontinuity (discontinuity) and psychopathology on the other.

Traumatic stress is a special form of the general stress response. When stress overloads the psychological, physiological, adaptive capabilities of a person and destroys the defense, it becomes traumatic, i.e. causes psychological anxiety. Not every event can cause traumatic stress.

Psychological trauma is possible if:

- the event that happened is conscious, i.e. the person knows what happened to him and because of what his psychological state worsened;

- the experience destroys the habitual way of life.

Post Traumatic Stress Disorders

Post-traumatic stress disorders are described in the work of E.M. Cherepanova. According to the author in the International Classification of Mental Disorders, traumatic stress is defined as a set of reactions when:

1. The traumatic event is persistently relived over and over again. This can take various forms:

Repetitive and forcibly erupting, invading consciousness memories of the event, including images, thoughts or ideas;

Recurring nightmares about the event;

Actions or feelings consistent with those experienced during the trauma;

Intense negative experiences when confronted with something that resembles (symbolizes) a traumatic event;

sleep problems (insomnia or interrupted sleep);

Irritability or outburst of anger;

Violation of memory and concentration of attention;

Hypervigilance;

Exaggerated response (at the slightest noise, knock, etc., a person starts, rushes to run, screams loudly, etc.).

So, a person has experienced one or more traumatic events that deeply affected his psyche. These events differed sharply from all previous experience and caused such severe suffering that the person responded to them with a violent negative reaction. A normal psyche in such a situation, naturally, seeks to alleviate discomfort: a person radically changes his attitude to the world around him, trying to make his life at least a little easier, and this, in turn, causes mental stress.

When a person does not have the opportunity to defuse the internal tension that has arisen, his body, his psyche find a way to "get used" to it, adapt to it. In the same way, a person adapts to his illness - he takes care of his sore hand, does not step on his sore leg. His gait becomes not quite natural, lameness appears. Just as lameness is a symptom that a person has adapted to his bad leg, so the symptoms of traumatic stress, which sometimes look like a mental disorder, are actually nothing more than behaviors associated with experienced events.

4.2. Psychological models and theories of post-traumatic stress

Psychological models and theories of post-traumatic stress are described in the works of N.V. Tarabrina. According to the author, there is currently no single generally accepted theoretical concept that explains the etiology and mechanisms of the onset and development of PTSD. However, as a result of many years of research, several theoretical models have been developed, among which we can distinguish: psychodynamic, cognitive, psychosocial and psychobiological approaches and the multifactorial theory of PTSD developed in recent years.

Psychodynamic models include psychodynamic, cognitive and psychosocial models. They were developed during the analysis of the main patterns of the process of adaptation of victims of traumatic events to normal life. Studies have shown that there is a close relationship between ways to get out of a crisis situation, ways to overcome a state of post-traumatic stress (elimination and avoidance of any reminders of trauma, immersion in work, alcohol, drugs, the desire to enter a self-help group, etc.) and success subsequent adaptation.

It has been found that perhaps the most effective are two strategies: 1) purposeful recall of the traumatic event in order to analyze it and fully understand all the circumstances of the trauma; 2) awareness by the bearer of traumatic experience of the significance of the traumatic event.

The first of these strategies was used in the development of psychodynamic models that describe the process of PTSD development and exit from it as a search for the optimal balance between pathological fixation on a traumatic situation and its complete displacement from consciousness. At the same time, it is taken into account that the strategy of avoiding mentioning the trauma, its displacement from consciousness (“trauma encapsulation”) is, of course, the most appropriate for the acute period, helping to overcome the consequences of a sudden trauma.

With the development of post-stress conditions, awareness of all aspects of trauma becomes an indispensable condition for the integration of the inner world of a person, the transformation of a traumatic situation into a part of the subject's own being.

Another aspect of the individual characteristics of overcoming PTSD - cognitive assessment and reassessment of traumatic experience - is reflected in cognitive psychotherapeutic models. The authors of these models believe that a cognitive assessment of a traumatic situation, being the main factor in adaptation after a trauma, will be the most conducive to overcoming its consequences if the cause of the trauma in the mind of its victim acquires an external character and lies outside the personality characteristics of a person (a well-known principle: not “I am bad”, but “I did a bad deed”).

In this case, according to researchers, faith in the reality of being, in the existing rationality of the world, and also in the possibility of maintaining one's own control over the situation is preserved and increased.

The main task in this case is to restore the harmony of the existing world in the mind, the integrity of its cognitive model: justice, the value of one's own personality, the kindness of others, since it is these assessments that are most distorted in victims of traumatic stress suffering from PTSD.

Finally, the importance of social conditions, in particular the factor of social support of others, for the successful overcoming of PTSD is reflected in models that have been called psychosocial.

The main social factors influencing the success of the adaptation of victims of mental trauma were identified: the absence of physical consequences of trauma, a strong financial position, the preservation of the former social status, the presence of social support from society and especially a group of close people. At the same time, the last factor affects the success of overcoming the consequences of traumatic stress to the greatest extent.

In a number of domestic publications related to the problems of adaptation of Afghan veterans after returning home, it was emphasized how much situations of misunderstanding, alienation, and rejection by others hinder the return of Afghan veterans to civilian life.

The following stressors associated with the social environment have been identified: the uselessness of a person with combat experience in society; the unpopularity of the war and its participants; mutual misunderstanding between those who were at war and those who were not; a guilt complex formed by society.

Encounter with these stressors, already secondary to the extreme experience gained in the war, quite often led to a deterioration in the condition of veterans of the wars of both Vietnam and Afghanistan. This indicates the enormous role of social factors both in helping to overcome traumatic stress conditions and in the formation of PTSD in the absence of support and understanding of people around.

Until recently, the main theoretical concept explaining the mechanism of the occurrence of post-traumatic stress disorders was the “two-factor theory”. It was based as the first factor on the classical principle of conditioned reflex conditioning of PTSD (according to I.P. Pavlov).

The main role in the formation of the syndrome is given to the actual traumatic event, which acts as an intense unconditioned stimulus that causes an unconditioned reflex stress reaction in a person. Therefore, according to this theory, other events or circumstances, in themselves neutral, but somehow related to the traumatic stimulus-event, can serve as conditioned reflex stimuli. They seem to “awaken” the primary trauma and cause the corresponding emotional reaction (fear, anger) according to the conditioned reflex type.

The second component of the two-factor theory of PTSD was the theory of behavioral, operant conditioning of the development of the syndrome. According to this concept, if the impact of events that have a similarity (explicit or by association) with the main traumatic stimulus leads to the development of emotional distress, then the person will constantly strive to avoid such exposure, which, in fact, underlies the psychodynamic models of PTSD.

However, with the help of the two-factor theory, it was difficult to understand the nature of a number of symptoms inherent only in PTSD, in particular, those related to the second criterion group of the diagnostic technique, the constant return to experiences associated with a traumatic event. These are symptoms of obsessive memories of the experience, dreams and nightmares about the trauma, and, finally, a “flashback” effect, i.e. a sudden, for no apparent reason, resurrection in memory with pathological certainty and a complete sense of the reality of the traumatic event or its episodes. In this case, it turned out to be practically impossible to establish which "conditioned" stimuli provoke the manifestation of these symptoms, so often their apparent connection with the event that caused the trauma turns out to be weak.

To explain such manifestations of PTSD, R. Pitman proposed the theory of pathological associative emotional networks, which is based on the Lange theory. The specific information structure in memory that ensures the development of emotional states - the "network" - includes three components:

1) information about external events, as well as the conditions for their occurrence;

2) information about the reaction to these events, including speech components,

motor acts, visceral and somatic reactions;

3) information about the semantic evaluation of incentives and response acts.

This associative network, under certain conditions, begins to work as a whole, producing an emotional effect. The basis of the post-traumatic syndrome is the formation of similarly constructed pathological associative structures. This hypothesis was confirmed by Pitman, who found that the inclusion of an element of imagining the traumatic situation in the design of the experiment leads to significant differences between healthy and suffering from PTSD Vietnam veterans. In the latter, an intense emotional reaction was observed in the process of experiencing in the imagination the elements of their combat experience, while in healthy subjects such a reaction was not noted.

Thus, with the help of the theory of associative networks, the mechanism for the development of the “flashback” phenomenon was described, however, such symptoms of PTSD as obsessive memories and nightmares were difficult to explain in this case. Therefore, it was suggested that the pathological emotional networks of the PTSD syndrome should have the property of spontaneous activation, the mechanism of which should be sought in the neuronal structures of the brain and the biochemical processes occurring at this level.

The results of neurophysiological and biochemical studies in recent years have become the basis for biological models of PTSD. In accordance with them, the pathogenetic mechanism of PTSD is due to a violation of the functions of the endocrine system caused by extreme stress.

Complex models of pathogenesis include theoretical developments that take into account both biological and mental aspects of the development of PTSD. These conditions are most consistent with the neuropsychological hypothesis of L. Kolb, who, summarizing the data of psychophysiological and biochemical studies of veterans of the Vietnam War, indicates that as a result of the extreme intensity and duration of the stimulating effect, changes occur in the neurons of the cerebral cortex, blockade of synaptic transmission and even death of neurons. First of all, the areas of the brain associated with the control of aggressiveness and the sleep cycle are affected.

Symptoms of PTSD appear, as already mentioned, within a few months from the moment of traumatization; in the first days and hours after an injury, psychological shock or a state of acute stress often predominate. In a significant number of cases, then spontaneous recovery occurs: within 12 months after the injury, one third of the victims get rid of the symptoms of stress and post-stress disorder, and 4 years after the injury, half of the victims have a complete absence of complaints.

These data raise the question: how inevitable is the development of PTSD, what are the factors that determine its occurrence?

The learning theory and cognitive approach, being psychological concepts, do not explain the symptoms of hyperarousal and other psychophysiological changes in PTSD, while biological views on the nature of post-traumatic stress are designed to fill this gap. To answer the question why only a part of people who have been traumatized show psychological symptoms of post-traumatic stress, an etiological multifactorial concept developed by A. Marker is also proposed.

He proposes an etiological multifactorial concept, with the help of which he attempts to explain why some people, after experiencing traumatic stress, begin to suffer from PTSD, while others do not. This concept identifies three groups of factors, the combination of which leads to the onset of PTSD:

Factors associated with a traumatic event: the severity of the injury, its uncontrollability, unexpectedness;

Protective factors: the ability to comprehend what happened, the presence of social support, coping mechanisms; for example, it has been shown that those who have the opportunity to talk about trauma feel better and are less likely to go to doctors (of whatever profile);

Risk factors: age at the time of trauma, negative past experience, history of mental disorders, low intelligence and socioeconomic level.

4.3. Psychodiagnostics of post-traumatic stress

Psychodiagnostics of post-traumatic stress can be carried out using various methods, each of which has its own tasks. A large number of methods are presented in the work of V.N. Tarabrina.

Clinical Diagnosis Scale CAPS developed in two versions (Weathers F. W. et al., 1992; Weathers F. W, 1993). The first is designed to diagnose the severity of current PTSD both during the past month and in the post-traumatic period as a whole. Second option CAPS is intended for a differentiated assessment of symptoms over the past two weeks. The application of the technique not only makes it possible to evaluate each symptom on a five-point scale in terms of frequency and intensity of manifestation, but also to determine the reliability of the information received.

Scale CAPS applied, as a rule, in addition to the Structured Clinical Interview (SCID) (Structured Clinical Interview for DSM-III-R) for clinical diagnosis of the level of severity of PTSD symptoms and the frequency of its manifestation. It is used if during the interview the presence of any symptoms of PTSD or the entire disorder as a whole is diagnosed (Weathers F. W., Litz V. T., 1994; Blake D. D., 1995).

CAPS-1 allows you to assess the frequency of occurrence and intensity of manifestation of individual symptoms of the disorder, as well as the degree of their influence on the social activity and production activities of the patient. Using this scale, you can determine the degree of improvement in the condition at a second examination compared to the previous one, the validity of the results and the overall intensity of symptoms. If possible, it is advisable to use a scale CAPS-1 in combination with other diagnostic methods (self-assessment, behavioral, physiological). It must be remembered that the time for considering the manifestations of each symptom is 1 month. Using the questions of the scale, the frequency of occurrence of the studied symptom during the previous month is determined, and then the intensity of the symptom is assessed.

Scale for assessing the impact of a traumatic event (TSOVTS). The first version of SHOVTS (Impact of Event Scale - IES) was published in 1979 by Horowitz et al. (Horowitz M. J., Wilner N. et. al., 1979). The creation of this scale was preceded by empirical research by Horowitz. The first was devoted to the study of the relationship between imagination and stress disorders, which showed that intrusive images accompany traumatic experiences. His second study was aimed at analyzing symptoms and behavioral characteristics in order to find strategies for individual treatment depending on various stressors, such as illness, accident, loss of a loved one. This work led to the creation of a questionnaire IES (Impact of Event Scale). The questionnaire consists of 15 items, is based on a self-report and reveals the predominance of a tendency to avoid or invade (compulsive reproduction) of a traumatic event.

The next stage of research was to identify, clinically describe and test the opposition of these two tendencies in the process of brief therapy. The results of the research led Horowitz to theoretical ideas about the existence of the two most commonly accepted specific categories of experiences that arise in response to the impact of traumatic events.

The first category includes the symptoms of invasion - the term "invasion" (intrusion- English) is sometimes translated as "imposition" - including nightmares, obsessive feelings, images or thoughts. The second category includes symptoms of avoidance, including attempts to mitigate or avoid experiences associated with a traumatic event, a decrease in reactivity. Based on his views on the response to traumatic stressors, Horowitz (Horowitz M. J., 1976) identified reactions that fall within the scope of invasion and avoidance. These symptoms were the original measurement area IES. Analyzing the associations between traumatic life events and subsequent psychological symptoms that could manifest themselves over time, Horowitz et al noted that often the study of these reactions was confused either with experimental physiological measurements or with self-reporting on more general indicators of anxiety, defined, for example, with using the Taylor anxiety scale (Taylor Manifest Anxiety Scale)(Taylor J.A., 1953).

Mississippi scale(MS) was developed to assess the severity of post-traumatic stress reactions in combat veterans (Keap T. M., et al., 1987, 1988). It is currently one of the widely used tools for measuring the signs of PTSD. The scale consists of 35 statements, each of which is evaluated on a five-point Likert scale. The evaluation of the results is made by summing up the points, the final indicator allows you to identify the degree of impact of the traumatic experience transferred by the individual. The items contained in the questionnaire fall into 4 categories, three of them correspond to the criteria DSM: 11 items are aimed at identifying the symptoms of invasion, 11 - avoidance and 8 questions are related to the criterion of physiological excitability. Five other questions are aimed at identifying feelings of guilt and suicidality. Studies have shown that MS has the necessary psychometric properties, and a high final score on the scale correlates well with the diagnosis of post-traumatic stress disorder, which prompted researchers to develop a “civilian” version of MS that can be used for counseling and correctional purposes.

Beck Depression Inventory (Beck Depression Inventory - BDI)

In world psychological practice, when examining people who have experienced extreme, stressful situations, a large psychometric methodological complex is used, the results of which can be used to judge the features of the psychological state of the subjects being examined. The Beck Depressiveness Inventory is an important component of this complex, which has shown its diagnostic significance when working with people who have experienced traumatic stress. BDI is designed to assess the presence of depressive symptoms in the subject for the current period. The questionnaire is based on clinical observations and descriptions of symptoms that are common in depressed psychiatric patients as opposed to non-depressed psychiatric patients.

The systematization of these observations made it possible to identify 21 statements, each of which represents a separate type of psychopathological symptoms and includes the following items: 1) sadness; 2) pessimism; 3) a feeling of bad luck; 4) dissatisfaction with oneself; 5) feeling of guilt; 6) feeling of punishment; 7) self-denial; 8) self-accusation; 9) the presence of suicidal thoughts; 10) tearfulness; 11 irritability; 12) feeling of social alienation; 13) indecision; 14) dysmorphophobia; 15) difficulties in work; 16) insomnia; 17) fatigue; 18) loss of appetite; 19) weight loss; 20) health concerns; 21) loss of sexual desire.

Currently, the Beck Depressiveness Inventory is widely used in clinical psychological research and in psychiatric practice to assess the intensity of depression.

Semi-structured interview to assess children's traumatic experiences. The use of the semi-structured interview method has a number of advantages and, in comparison with questionnaires filled out in writing, increases the accuracy of the measurement, since it is direct communication between the psychologist and the subject during the interview that provides the prerequisites for the emergence of mutual trust, security and emotional acceptance. In general, children tend to respond more accurately when the psychologist asks relevant research questions and when they can ask him questions if there is any ambiguity in understanding a point.

Interviewing children is more effective than analyzing data from parents (guardians), teachers, educators and other adults, since these data often concern only visible manifestations of a traumatic reaction. Moreover, adults themselves may be complicit in the traumatic situation and therefore often conceal or downplay traumatic symptomatology. In addition, it should be noted that, according to some researchers, individual interviews with child survivors of traumatic events may have a therapeutic effect.

Parental questionnaire for assessing traumatic experiences of children. The use of self-filled questionnaires makes it possible to cover a larger number of families than the interview method, since it does not require the direct presence of a psychologist when filling it out. In addition, this method makes it possible to cover those categories of parents who do not show sufficient social activity (do not come to school or do not visit a psychologist themselves), since the questionnaire can be transmitted in this case through the child.

The questionnaire has the following scales: 1) immediate response); 2) obsessive reproduction; 3) avoidance; 4) increased excitability; 5) dysfunction.

4.4. Ways to correct post-traumatic stress

According to N.V. Tarabrina currently does not have a well-established point of view on the outcome of treatment. The author notes that some researchers believe that PTSD is a treatable disorder, while others believe that its symptoms cannot be completely eliminated.

In this process, psychotherapeutic, psychopharmacological and rehabilitation aspects can be distinguished.

Psychopharmacological therapy is determined by the characteristics of the clinical picture, the leading psychopathological symptoms at the moment. Eliminating the most acute of them, psychopharmacotherapy facilitates psychotherapy and rehabilitation measures.

Psychotherapy for PTSD. is an integral part of general rehabilitation measures, since it is necessary to reintegrate mental activity disturbed due to trauma. At the same time, psychotherapy is aimed at creating a new cognitive model of life, an affective reassessment of traumatic experience, restoring a sense of the value of one's own personality and the ability to continue to exist in the world.

The goal of psychotherapeutic treatment of patients with PTSD is to help release haunting memories of the past and interpret subsequent emotional experiences as reminders of trauma, and to enable the patient to actively and responsibly engage in the present. To do this, he needs to regain control of his emotional reactions and find the proper place for the traumatic event that occurred in the overall time perspective of his life and personal history.

Group therapy is the most commonly used type of therapy for trauma survivors. It is often carried out in combination with different types of individual therapy. There are no specific recommendations as to which type of group therapy is preferable. Directions differing from each other are offered: 1) open-type groups focused on solving educational problems or structuring traumatic memories; 2) groups with a given structure, aimed at performing a specific task, at developing the skills of coping with trauma, at working with interpersonal dynamics.

An overview of the many areas of group therapy, which covers cognitive-behavioral, psycho-educational, psychoanalytic, psychodramatic groups, self-help groups, dream analysis, art therapy and many others, is presented in Allen A. and Bloom S. L. (1994).

Whatever the group format, group therapy aims to achieve certain therapeutic goals:

Sharing with the therapist (and group) re-experiencing the trauma in a safe space (while the therapist needs to follow the patient without forcing the process);

Reducing feelings of isolation and providing a sense of belonging, relevance, common purpose, comfort and support; creating a supportive atmosphere of acceptance and safety from shame;

Working in the same group with those who have similar experiences, which makes it possible to feel the universality of their own experience;

Getting rid of feelings of isolation, alienation, despite the uniqueness of the traumatic experience of each member of the group;

Providing social support and opportunities to share emotional experiences with others;

Clarifying common problems, teaching methods of coping with the consequences of trauma and achieving an understanding that personal trauma requires resolution;

Observing how others experience flashes of intense affect, which has a supportive and encouraging effect;

The ability to be in the role of someone who helps (provides support, inspires confidence, is able to regain a sense of self

dignity);

The development of "elbow feeling", when common problems are shared by group members with each other; overcoming the feeling of one's worthlessness - "I have nothing to offer another";

Opportunity to learn about the lives of other members of the group and displacement, so

way, focusing on feelings of isolation and negative self-deprecating thoughts;

Reducing guilt and shame, developing trust, the ability to share

grief and loss;

The ability to work with the "secret" - to share with someone other than the therapist, information about yourself (for example, for victims of incest);

Strengthening confidence that progress in therapy is possible; an important basis for such optimism is the protective atmosphere in the group, which gives the experience of new relationships;

The adoption of a group ideology, a language that enables group members to perceive a stressful event in a different, more optimistic way;

Getting the opportunity to form their own idea of ​​the reality of the changes that occur with each member of the group.

Cognitive-behavioral (behavioral) psychotherapy for PTSD. Central to this form of PTSD psychotherapy is the patient's confrontation with traumatic memory images in order to progressively reduce PTSD symptoms. It is especially effective for overcoming avoidance behaviors, as well as reducing the intensity of flashbacks and overarousal.

There are several options for using behavioral therapy to treat PTSD. The most famous today are the techniques of "opening interventions" (Exposure-Based Interventions, EVG) and desensitization and processing of traumatic experiences through eye movements (Eye Movement Desensitization and Reprocessing, EMDR), designed to help the patient cope with situations that cause fear; as well as anxiety management training (Anxiety Management Training, AMT), during which he learns to control his feelings of anxiety with the help of special skills.

Opening technique (EBI).

It is based on the premise that PTSD is affected not only by fear of trauma-relevant stimuli, but also by memories of trauma. It follows that the patient's access to fearful memories (whether in the imagination or directly) must be therapeutic. Thus, the method is to help the patient relive traumatic memories and integrate them.

Various authors, for example A. Allen, B. Litz et al., R. Pitman et al., S. Solomon (Allen A., 1994; Litz W. T. et al., 1990; Pitman et al., 1991; Solomon S. D. et al, 1992) note that this therapy is contraindicated for clients with the following features:

No flashbacks;

Abuse of drugs and alcohol;

Crisis conditions (for example, at the risk of suicide);

Existing ineffective experience with this therapy;

Benefit from disease;

Inability to "turn on" one's imagination;

No recurring symptoms;

Inability to withstand a strong arousal reaction;

Psychotic disorders.

When conducting this therapy, the importance of motivation for treatment is emphasized. The patient should be given intensive assistance to the psychotherapist, and the therapist should be sure that the treatment is safe for the patient and that he has sufficient resources to successfully "immerse" in therapeutic work.

A technique for desensitizing and processing traumatic experiences through eye movements (EMDR.)

The method proposed by F. Shapiro in 1987 (Shapiro F., 1998) currently causes the most controversy. There are cases when, in the treatment of a twenty-year-old injury, improvement was achieved within one session. It is believed that the method is suitable mainly for the treatment of cases of single trauma, such as, for example, an injury resulting from a car accident, but there is experience in the use of therapy for the treatment of agoraphobia and depression, panic symptoms.

Shapiro herself warns against overestimating the effectiveness of the method. EMDR- this is a variant of the technique of "opening interventions" (EVG), supplemented by the movements of the patient's eyes. The therapy consists of the following procedures: presentation by the patient of a traumatic scene, experiencing feelings of anxiety, cognitive restructuring (common to EMDR and EVG) and saccadic movements directed by the therapist (saccades are fast, strictly coordinated eye movements that occur simultaneously and in one direction. On the recording they look like vertical straight thin lines ).

The patient is asked to focus on the traumatic memory and try to reproduce all the thoughts that this trauma causes in him (for example: “helpless” or “I have no control over anything”, etc.). The patient is then asked to visualize the traumatic scene in a more “condensed” way, to formulate negative thoughts about the traumatic memory, to concentrate on the physical sensations associated with these thoughts, and to follow the therapist's finger rhythmically moving at a distance of 30-35 cm from his face with his eyes. After 24 saccadic movements, the patient is asked to take a deep breath and distract from the experience.

The therapist evaluates the patient's condition on a subjective ten-point distress scale (Subjective Units of Distress scale, SUD), then decides whether to make any changes to the scene. The procedure is repeated until the SUD score drops to 1 or 2.

Despite reports of successful cases of PTSD treatment EMDR, these results are considered rather subjective, since many authors do not find any changes in the condition of patients that could be measured using psychometric or psychophysiological procedures (Acierno R. et al., 1994; Boudewyns P. A. et al., 1993; Jensen J. A., 1994 ; Lohr J. M. et al., 1993).

Anxiety Coping (AMT.)

Includes a wide variety of procedures, including the "biofeedback" technique (biofeedback), relaxation methods, cognitive restructuring, etc. The latter serves, among other things, to recognize and correct distorted perceptions and beliefs; these include: 1) training to suspend thoughts in the case of persistently emerging memories; 2) recognition of irrational thoughts; 3) memorization of an adequate model of behavior; 4) cognitive restructuring through the "Socratic" method of asking questions.

Psychodynamic psychotherapy for PTSD.

In its theoretical foundations, it goes back to the concept of mental trauma 3. Freud, which is presented in his relatively late works. According to this concept, in addition to unbearable traumatic external influences, one should single out unacceptable and unbearably intense impulses and desires, i.e., internal traumatic factors. In this case, the trauma becomes an integral part of the history of life as a history of the development of motives and life goals. Freud proposed to distinguish between two cases: the traumatic situation is a provoking factor that reveals the neurotic structure that existed in the premorbid; trauma determines the occurrence and content of the symptom. At the same time, the repetition of traumatic experiences, constantly recurring nightmares, sleep disturbance, etc. can be understood as attempts to "link" the trauma, to respond to it.

In the following decades, the psychoanalytic concept of trauma

undergoes a number of changes. Thus, in the works of A. Freud (1989, 1995), D. Winnicott (1998) and others, the role of the relationship between mother and child is emphasized and the nature and meaning of the concept of psychic trauma are radically revised.

These views were further developed in the works of the English psychoanalyst M. Khan (1974), who proposed the concept of “cumulative trauma”. He considered the role of the mother in the mental development of the child from the point of view of her protective function - the "shield" - and argued that cumulative trauma arises from minor injuries as a result of the mother's misses in the implementation of this function. This statement, he believes, is true throughout the entire development of the child - from his birth to adolescence in those areas of life where he needs this "shield" to maintain his still unstable and immature "I". Such minor injuries at the time of their occurrence may not yet have a traumatic character, however, accumulating, they turn into a mental trauma. In the optimal case, the inevitable failings of the mother are corrected or overcome in a complex process of maturation and development; if they occur too often, then a gradual formation of a psychosomatic disorder in a child is possible, which then becomes the core of subsequent pathogenic behavior.

Thus, in line with the psychodynamic understanding of trauma, three different interpretations of the term itself can be distinguished: 1) mental trauma as an extreme event limited in time (i.e., having a beginning and an end), which had an adverse effect on the subject's psyche; 2) "cumulative trauma" arising in ontogenesis from a multitude of minor psychotraumatic events; 3) developmental psychic trauma as a result of the inevitable frustrations of the subject's needs and drives. Within the framework of this work, we will keep in mind the first meaning of the term and refer only to those works that operate with the concept of trauma in this meaning.

Currently, Freud's "energetic" ideas about trauma are being reinterpreted in line with the psychodynamic approach: modern authors propose to replace the concept of "energy" with the concept of "information". The latter denotes both cognitive and emotional experiences and perceptions that have an external and / or internal nature (Horowitz M. J., 1998; Lazarus R. S., 1966). Due to this, there is a convergence of the cognitive-informational and psychodynamic views on trauma.

This approach assumes that information overload plunges a person into a state of constant stress until this information undergoes appropriate processing. Information, being exposed to psychological defense mechanisms, is compulsively reproduced in memory (flashbacks); emotions, which play an important role in the post-stress syndrome, are essentially a reaction to a cognitive conflict and, at the same time, motives for protective, controlling, and coping behavior.

As a result of a traumatic experience, a conflict between the old and new images of the “I” is actualized in a person, which gives rise to strong negative emotions; to get rid of them, he tries not to think about the trauma and its real and possible consequences, as a result, traumatic perceptions are not processed enough.

Nevertheless, all information is stored in memory, and in a sufficiently active state, causing involuntary memories. However, as soon as the processing of this information is completed, the idea of ​​a traumatic event is erased from active memory (Horowitz M. J., 1986).

This theory focuses on symptoms of PTSD such as alienation

and a sense of a "shortened" future. In addition, this approach offers an explanation for flashbacks and avoidance symptoms. A cognitive schema is understood here as an information pattern stored in memory that regulates and organizes perception and behavior.

In clinical psychology, such a pattern is denoted by the term "self-scheme", which breaks down into various components (schemes, images of "I", roles); this also includes schemas of a significant other/significant others and the world as a whole (worldview).

Altered cognitive schemas are associated with so-called dysfunctional cognitions, i.e., altered attitudes or "thinking errors" leading to distorted processing of information. Under the influence of trauma, these schemas can change, first of all, the schemas of the “I” and the schemas of roles (Horowitz M. J., 1986;).

After the trauma, the image of the “I” and the images of significant others change; these altered schemas remain in the memory until the perception and processing of further information leads to the integration of the altered schemas into the composition of the old ones that remained unaffected by the trauma.

For example, a previously self-confident active person suddenly feels weak and helpless as a result of a trauma. His idea of ​​himself after the injury can be formulated as follows: "I am weak and vulnerable." This idea comes into conflict with his former image of "I": "I am competent and stable."

Traumatically altered circuits will remain active until the person is able to accept the fact that they can also be weak and vulnerable at times. Until the activated altered schemas are integrated into the self-image, they generate flashbacks and intense emotional tension. To reduce it, according to Horowitz, the processes of protection and cognitive control are included in the action, for example in the form of avoidance, denial or emotional deafness. Whenever cognitive control fails to fully function, the trauma is re-experienced as an intrusion (flashback), which in turn leads to emotional stress and further avoidance or denial. Recovery after trauma, according to Horowitz, occurs only as a result of intensive processing of traumatically altered cognitive schemas.

Empirical studies quite convincingly testify in favor of the theory of M. Horowitz. Thus, the content analysis of the categories found in the statements of patients - victims of traffic accidents and criminal acts - revealed the most frequent topics: frustration about one's own vulnerability, self-accusation, fear of a future loss of control over feelings (Krupnick J. L., Horowitz M. J ., 1981).

A group of women who had been raped was examined - their statements were grouped as follows: an altered image of another; altered self-image; changed close relationships; a changed sense of confidence; self-blame (Resick R. A., Schnicke M. K., 1991).

The intensity of the post-stress syndrome, according to Horowitz, is determined by how strongly expressed, firstly, the tendency to invade involuntary memories, and secondly, the tendency to avoid and deny. The main task of psychotherapy is to reduce the excessive intensity of both of these processes.

First, it is necessary to control the extreme mental state that has arisen after traumatization, and then the task is to integrate the traumatic experience into an integral system of ideas about oneself and the world, thereby reducing the sharpness of the conflict between old and new ideas. The overall goal of therapy is not the implementation of a comprehensive change in the personality of a patient with PTSD, but the achievement of cognitive and emotional integration of the images of "I" and the world, which allows reducing the post-stress state.

Patients with PTSD are also characterized by certain difficulties associated with their taking on the role of a recipient of psychotherapeutic assistance. Here are the reasons for these difficulties:

1) Patients often believe that they must "get the experience out of their heads" on their own. This desire is also stimulated by the expectations of others, who believe that patients should finally stop thinking about what happened. However, this assumption of patients, of course, is not justified;

2) their own suffering, at least partially, is externalized: patients remain convinced that there is an external cause of the injury (the rapist, the perpetrator of the accident, etc.), and the mental disorders that followed are also beyond their control;

3) post-traumatic symptoms (nightmares, phobias, fears) cause sufficient suffering, but the patient does not know that they constitute a picture of a treatable disease (like depression or anxiety);

4) some patients struggle to obtain legal and/or financial compensation and turn to a doctor or psychologist only for confirmation of this right to it.

Based on this, the psychotherapist, already at the very first contact with a patient suffering from PTSD, should strive to achieve the following goals: creating a trusting and reliable contact; informing the patient about the nature of his disorder and the possibilities of therapeutic intervention; preparing the patient for further therapeutic experience, in particular for the need to return again to painful traumatic experiences.

D. Hammond (Hammond D. C, 1990) suggests using the metaphor "correction of a fracture" or "disinfection of a wound" to prepare the patient for a painful encounter with a traumatic experience. Here is what he says: “The work that we have to do in the next sessions is similar to what happens when a child breaks a leg or an adult receives a painful, infected wound that requires antiseptic treatment. The doctor does not want to hurt the patient. However, he knows that unless he fixes the fracture or disinfects the wound, the patient will end up in more pain, becoming disabled, and never able to move normally again. The doctor also experiences pain, inflicting suffering on the patient when he fixes a broken bone or cleans a wound. But these necessary actions of the doctor are a manifestation of care for the patient, without which a cure is impossible. Similarly, replaying the trauma experience can be very painful, like disinfecting a wound. But after that, the pain will become less and recovery may come ”(Maercker A., ​​1998).

The main prerequisites for successful work with patients suffering from PTSD can be formulated as follows. The patient's ability to talk about trauma is directly proportional to the therapist's ability to listen empathically to the story. Any sign of rejection or devaluation is perceived by the patient as a failure of the therapist to help him and may lead to a cessation of the patient's efforts to fight for his recovery.

The empathic therapist encourages the patient to recount the horrific events without digressing or slipping into side topics or showing him his own shock reaction. The therapist does not downplay spontaneous topics or divert the conversation into areas that are not directly related to the traumatic fear.

Otherwise, the patient feels that the existential gravity of the experience is unbearable for the therapist, and he will feel misunderstood.

The therapeutic relationship with a patient who has PTSD has characteristics that can be summarized as follows:

Gradual gaining of the patient's trust, given that he has a pronounced loss of trust in the world.

Hypersensitivity to "therapy formalities" (rejection of standard diagnostic procedures

before talking about traumatic events).

· Creation of a safe environment for the patient during therapy.

Adequate performance of rituals that contribute to the satisfaction of the patient's need for safety.

Before starting therapy, reduce the dose of drug treatment or cancel it to demonstrate the success of the psychotherapeutic effect.

Discussion and elimination of possible sources of danger in real life