Home Gums Affective disorders history of studying the main theoretical models. Theoretical models and empirical studies of hostility in depressive and anxiety disorders.

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Affective disorders history of studying the main theoretical models. Theoretical models and empirical studies of hostility in depressive and anxiety disorders.

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Introduction of the dissertation (part of the abstract) on the topic “Theoretical and empirical foundations of integrative psychotherapy for affective spectrum disorder”

Relevance. The relevance of the topic is associated with a significant increase in the number of affective spectrum disorders in the general population, among which depressive, anxiety and somatoform disorders are the most epidemiologically significant. In terms of prevalence, they are the undisputed leaders among other mental disorders. According to various sources, they affect up to 30% of people visiting clinics and from 10 to 20% of people in the general population (J.M.Chignon, 1991, W.Rief, W.Hiller, 1998; P.S.Kessler, 1994; B.T.Ustun, N. Sartorius, 1995; H.W. Wittchen, 2005; A.B. Smulevich, 2003). The economic burden associated with their treatment and disability constitutes a significant part of the budget in the health care system of different countries (R. Carson, J. Butcher, S. Mineka, 2000; E.B. Lyubov, G.B. Sargsyan, 2006; H.W. Wittchen, 2005). Depressive, anxiety and somatoform disorders are important risk factors for the emergence of various forms of chemical dependence (H.W. Wittchen, 1988; A.G. Goffman, 2003) and, to a large extent, complicate the course of concomitant somatic diseases (O.P. Vertogradova, 1988; Yu.A.Vasyuk, T.V.Dovzhenko, E.N.Yushchuk, E.L.Shkolnik, 2004; V.N.Krasnov, 2000; E.T.Sokolova, V.V.Nikolaeva, 1995) Finally, Depressive and anxiety disorders are the main risk factor for suicide, in terms of the number of which our country ranks among the first (V.V. Voitsekh, 2006; Starshenbaum, 2005). Against the backdrop of socio-economic instability in recent decades in Russia, there has been a significant increase in the number of affective disorders and suicides among young people, elderly people, and able-bodied males (V.V. Voitsekh, 2006; Yu.I. Polishchuk, 2006). There is also an increase in subclinical emotional disorders, which are included within the boundaries of affective spectrum disorders (H.S.Akiskal et al., 1980, 1983; J.Angst et al, 1988, 1997) and have a pronounced negative impact on the quality of life and social adaptation.

The criteria for identifying different variants of affective spectrum disorders, the boundaries between them, the factors of their occurrence and chronicity, targets and methods of assistance are still debatable (G. Winokur, 1973; W. Rief, W. Hiller, 1998; A. E. Bobrov, 1990; O.P.Vertogradova, 1980, 1985; N.A.Kornetov, 2000; V.N.Krasnov, 2003; S.N.Mosolov, 2002; G.P.Panteleeva, 1998; A.B.Smulevich, 2003). Most researchers point to the importance of an integrated approach and the effectiveness of a combination of drug therapy and psychotherapy in the treatment of these disorders (O.P. Vertogradova, 1985; A.E. Bobrov, 1998; A.Sh. Tkhostov, 1997; M. Perrez, U. Baumann , 2005; W. Senf, M. Broda, 1996, etc.). At the same time, in different areas of psychotherapy and clinical psychology, various factors of the mentioned disorders are analyzed and specific targets and tasks of psychotherapeutic work are identified (B.D. Karvasarsky, 2000; M. Perret, U. Bauman, 2002; F.E. Vasilyuk, 2003, etc. ).

Within the framework of attachment theory, system-oriented family and dynamic psychotherapy, disruption of family relationships is indicated as an important factor in the emergence and course of affective spectrum disorders (S. Arietti, J. Bemporad, 1983; D. Bowlby, 1980, 1980; M. Bowen, 2005 ; E.G. Eidemiller, Yustitskis, 2000; E.T. Sokolova, 2002, etc.). The cognitive-behavioral approach emphasizes skill deficits, disturbances in information processing processes and dysfunctional personal attitudes (A.T. Vesk, 1976; N.G. Garanyan, 1996; A.B. Kholmogorova, 2001). Within the framework of social psychoanalysis and dynamically oriented interpersonal psychotherapy, the importance of disrupting interpersonal contacts is emphasized (K. Horney, 1993; G. Klerman et al., 1997). Representatives of the existential-humanistic tradition highlight the violation of contact with one’s internal emotional experience, the difficulties of its awareness and expression (K. Rogers, 1997). All the mentioned factors of occurrence and the resulting targets of psychotherapy for affective spectrum disorders do not exclude, but complement each other, which necessitates the integration of various approaches when solving practical problems of providing psychological assistance. Although the task of integration is increasingly coming to the fore in modern psychotherapy, its solution is hampered by significant differences in theoretical approaches (M. Perrez, U. Baumann, 2005; B. A. AIford, A. T. Beck, 1997; K. Crave, 1998; A. J. Rush, M. Thase, 2001; W. Senf, M. Broda, 1996; A. Lazarus, 2001; E. T. Sokolova, 2002), which makes it relevant to develop theoretical foundations for the synthesis of accumulated knowledge. It should also be noted that there is a lack of comprehensive objective empirical research confirming the importance of various factors and the resulting targets of assistance (S.J.Blatt, 1995; K.S.Kendler, R.S.Kessler, 1995; R.Kellner, 1990; T.S.Brugha, 1995, etc.). Finding ways to overcome these obstacles is an important independent scientific task, the solution of which involves the development of methodological means of integration, conducting comprehensive empirical studies of the psychological factors of affective spectrum disorders and the development of scientifically based integrative methods of psychotherapy for these disorders.

Purpose of the study. Development of theoretical and methodological foundations for the synthesis of knowledge accumulated in different traditions of clinical psychology and psychotherapy, a comprehensive empirical study of the system of psychological factors of affective spectrum disorders with the identification of targets and the development of principles of integrative psychotherapy and psychoprevention of depressive, anxiety and somatoform disorders. Research objectives.

1. Theoretical and methodological analysis of models of occurrence and methods of treatment of affective spectrum disorders in the main psychological traditions; justification of the need and possibility of their integration.

2. Development of methodological foundations for the synthesis of knowledge and integration of methods of psychotherapy for affective spectrum disorders.

3. Analysis and systematization of existing empirical studies of psychological factors of depressive, anxiety and somatoform disorders based on the multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of the family system.

4. Development of a methodological complex aimed at the systematic study of macrosocial, family, personal and interpersonal factors of emotional disorders and affective spectrum disorders.

5. Conducting an empirical study of patients with depressive, anxiety and somatoform disorders and a control group of healthy subjects based on a multifactorial psycho-social model of affective spectrum disorders.

6. Conducting a population-based empirical study aimed at studying macrosocial factors of emotional disorders and identifying high-risk groups among children and youth.

7. Comparative analysis of the results of studies of various population and clinical groups, as well as healthy subjects, analysis of connections between macrosocial, family, personal and interpersonal factors.

8. Identification and description of the system of targets for psychotherapy for affective spectrum disorders, based on data from theoretical and methodological analysis and empirical research.

9. Formulation of the basic principles, objectives and stages of integrative psychotherapy for affective spectrum disorders.

10. Determination of the main tasks of psychoprophylaxis of emotional disorders in children at risk.

Theoretical and methodological foundations of the work. The methodological basis of the study is the systemic and activity-based approaches in psychology (B.F. Lomov, A.N. Leontiev, A.V. Petrovsky, M.G. Yaroshevsky), the bio-psycho-social model of mental disorders, according to which the emergence and in the course of mental disorders, biological, psychological and social factors are involved (G. Engel, H. S. Akiskal, G. Gabbard, Z. Lipowsky, M. Perrez, Yu. A. Aleksandrovsky, I. Ya. Gurovich, B. D. Karvasarsky, V. N. Krasnov), ideas about non-classical science as focused on solving practical problems and integrating knowledge from the point of view of these problems (L.S. Vygotsky, V.G. Gorokhov, V.S. Stepin, E.G. Yudin, N. L.G. Alekseev, V.K. Zaretsky), cultural and historical concept of mental development by L.S. Vygotsky, concept of mediation by B.V. Zeigarnik, ideas about the mechanisms of reflexive regulation in normal and pathological conditions (N.G. Alekseev, V. K. Zaretsky, B.V. Zeigarnik, V.V. Nikolaeva, A.B. Kholmogorova), a two-level model of cognitive processes developed in cognitive psychotherapy by A. Beck. Object of study. Models and factors of mental norm and pathology and methods of psychological assistance for affective spectrum disorders.

Subject of study. Theoretical and empirical foundations of integration various models occurrence and methods of psychotherapy of affective spectrum disorders. Research hypotheses.

1. Various models of the occurrence and methods of psychotherapy for affective spectrum disorders are focused on different factors; the importance of their comprehensive consideration in psychotherapeutic practice necessitates the development of integrative models of psychotherapy.

2. The developed multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of the family system allow us to consider and study macrosocial, family, personal and interpersonal factors as a system and can serve as a means of integrating various theoretical models and empirical studies of affective spectrum disorders.

3. Macrosocial factors such as social norms and values (the cult of restraint, success and perfection, gender role stereotypes) affect the emotional well-being of people and can contribute to the occurrence of emotional disorders.

4. There are general and specific psychological factors of depressive, anxiety and somatoform disorders associated with various levels (family, personal, interpersonal).

5. The developed model of integrative psychotherapy for affective spectrum disorders is an effective means of psychological assistance for these disorders.

Research methods.

1. Theoretical and methodological analysis - reconstruction of conceptual schemes for studying affective spectrum disorders in various psychological traditions.

2. Clinical-psychological - study of clinical groups using psychological techniques.

3. Population - study of groups from the general population using psychological techniques.

4. Hermeneutic - qualitative analysis of interview data and essays.

5. Statistical - the use of mathematical statistics methods (when comparing groups, the Mann-Whitney test was used for independent samples and the Wilcoxon T-test for dependent samples; to establish correlations, the Spearman correlation coefficient was used; to validate methods - factor analysis, test-retest, coefficient a - Cronbach's, Guttman Split-half coefficient; multiple regression analysis was used to analyze the influence of variables). For statistical analysis, the software package SPSS for Windows, Standard Version 11.5, Copyright © SPSS Inc., 2002, was used.

6. Method of expert assessments - independent expert assessments interview data and essays; expert assessments of the characteristics of the family system by psychotherapists.

7. Follow-up method - collecting information about patients after treatment.

The developed methodological complex includes the following blocks of techniques in accordance with the levels of research:

1) family level - the questionnaire “Family Emotional Communications” (FEC, developed by A.B. Kholmogorova together with S.V. Volikova); structured interviews “Scale of stressful events in family history” (developed by A.B. Kholmogorova together with N.G. Garanyan) and “Parental criticism and expectations” (RKO, developed by A.B. Kholmogorova together with S.V. Volikova), test family system (FAST, developed by T.M.Gehring); essay for parents “My Child”;

2) personal level - questionnaire of prohibition of expressing feelings (ZVCh, developed by V.K. Zaretsky together with A.B. Kholmogorova and N.G. Garanyan), Toronto Alexithymia Scale (TAS, developed by G.J. Taylor, adaptation by D.B. Eresko , G.L. Isurina et al.), emotional vocabulary test for children (developed by J.H. Krystal), emotion recognition test (developed by A.I. Toom, modified by N.S. Kurek), emotional vocabulary test for adults ( developed by N.G. Garanyan), perfectionism questionnaire (developed by N.G. Garanyan together with A.B. Kholmogorova and T.Yu. Yudeeva); physical perfectionism scale (developed by A.B. Kholmogorova together with A.A. Dadeko); hostility questionnaire (developed by N.G. Garanyan together with A.B. Kholmogorova);

3) interpersonal level - social support questionnaire (F-SOZU-22, developed by G.Sommer, T.Fydrich); structured interview “Moscow Integrative Social Network Questionnaire” (developed by A.B. Kholmogorova together with N.G. Garanyan and G.A. Petrova); test for the type of attachment in interpersonal relationships (developed by C. Hazan, P. Shaver).

To study psychopathological symptoms, we used the severity of psychopathological symptoms questionnaire SCL-90-R (developed by L.R. Derogatis, adapted by N.V. Tarabrina), the depression questionnaire (BDI, developed by A.T. Vesk et al., adapted by N.V. Tarabrina), anxiety questionnaire (BAI, developed by A.T. Vesk and R.A. Steer), childhood depression questionnaire (CDI, developed by M. Kovacs), personal anxiety scale (developed by A.M. Prikhozhan). To analyze factors at the macrosocial level when studying risk groups from the general population, the above methods were selectively used. Some of the methods were developed specifically for this study and were validated in the laboratory of clinical psychology and psychotherapy of the Moscow Research Institute of Psychiatry of the Russian Health Service. Characteristics of the examined groups.

The clinical sample consisted of three experimental groups of patients: 97 patients with depressive disorders, 90 patients with anxiety disorders, 52 patients with somatoform disorders; two control groups of healthy subjects included 90 people; groups of parents of patients with affective spectrum disorders and healthy subjects included 85 people; samples of subjects from the general population included 684 school-age children, 66 parents of schoolchildren and 650 adult subjects; The additional groups included in the study to validate the questionnaires included 115 people. A total of 1929 subjects were examined.

The study involved employees of the laboratory of clinical psychology and psychotherapy of the Moscow Research Institute of Psychiatry of the Russian Health Service: Ph.D. leading researcher N.G. Garanyan, researchers S.V. Volikova, G.A. Petrova, T.Yu. Yudeeva, as well as students of the department of the same name of the Faculty of Psychological Counseling of the Moscow City Psychological and Pedagogical University A.M. Galkina, A. A. Dadeko, D. Yu. Kuznetsova. A clinical assessment of the patients’ condition in accordance with ICD-10 criteria was carried out by a leading researcher at the Moscow Research Institute of Psychiatry of the Russian Health Service, Ph.D. T.V.Dovzhenko. A course of psychotherapy was prescribed to patients according to indications in combination with drug treatment. Statistical processing of the data was carried out with the participation of Doctor of Pedagogical Sciences, Ph.D. M.G. Sorokova and Candidate of Chemical Sciences O.G. Kalina. The reliability of the results is ensured by the large volume of survey samples; using a set of methods, including questionnaires, interviews and tests, which made it possible to verify the results obtained using individual methods; using methods that have undergone validation and standardization procedures; processing the obtained data using methods of mathematical statistics.

Main provisions submitted for defense

I. In existing areas of psychotherapy and clinical psychology, emphasis is placed on various factors and different targets for working with affective spectrum disorders are identified. The current stage of development of psychotherapy is characterized by trends towards more complex models of mental pathology and the integration of accumulated knowledge based on a systematic approach. The theoretical basis for integrating existing approaches and research and identifying on this basis a system of targets and principles of psychotherapy are the multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of family system analysis.

1.1. The multifactorial model of affective spectrum disorders includes macrosocial, family, personal and interpersonal levels. At the macrosocial level, factors such as pathogenic cultural values and social stress are highlighted; at the family level - dysfunction of the structure, microdynamics, macrodynamics and ideology of the family system; at the personal level - disorders of the affective-cognitive sphere, dysfunctional beliefs and behavioral strategies; at the interpersonal level - the size of the social network, the presence of close trusting relationships, the degree of social integration, emotional and instrumental support.

1.2. The four-aspect model of family system analysis includes the structure of the family system (degree of closeness, hierarchy between members, intergenerational boundaries, boundaries with the outside world); microdynamics of the family system (daily functioning of the family, primarily communication processes); macrodynamics (family history in three generations); ideology (family norms, rules, values).

2. The empirical basis for psychotherapy of affective spectrum disorders is a complex of psychological factors of these disorders, substantiated by the results of a multi-level study of three clinical, two control and ten population groups.

2.1. In the modern cultural situation, there are a number of macrosocial factors of affective spectrum disorders: 1) increased stress on a person’s emotional sphere as a result of a high level of stress in life (pace, competition, difficulties in choosing and planning); 2) the cult of restraint, strength, success and perfection, leading to negative attitudes towards emotions, difficulties in processing emotional stress and receiving social support; 3) a wave of social orphanhood against the background of alcoholism and family breakdown.

2.2. In accordance with the levels of research, the following psychological factors of depressive, anxiety and somatoform disorders have been identified: 1) at the family level - disturbances in structure (symbioses, coalitions, disunity, closed borders), microdynamics (high level of parental criticism and violence in the family), macrodynamics (accumulation stressful events and reproduction of family dysfunctions in three generations) ideology (perfectionistic standards, distrust of others, suppression of initiative) of the family system; 2) at the personal level - dysfunctional beliefs and disorders of the cognitive-affective sphere; 3) at the interpersonal level - a pronounced deficit of trusting interpersonal relationships and emotional support. The most pronounced dysfunctions at the family and interpersonal level are observed in patients with depressive disorders. Patients with somatoform disorders have severe impairments in the ability to verbalize and recognize emotions.

3. The theoretical and empirical research conducted are the basis for the integration of psychotherapeutic approaches and the identification of a system of targets for psychotherapy for affective spectrum disorders. The model of integrative psychotherapy developed on these grounds synthesizes the tasks and principles of cognitive-behavioral and psychodynamic approaches, as well as a number of developments in Russian psychology (concepts of internalization, reflection, mediation) and systemic family psychotherapy.

3.1. The objectives of integrative psychotherapy and prevention of affective spectrum disorders are: 1) at the macrosocial level: debunking pathogenic cultural values (the cult of restraint, success and perfection); 2) at the personal level: development of emotional self-regulation skills through the gradual formation of reflexive ability in the form of stopping, fixing, objectifying (analysis) and modifying dysfunctional automatic thoughts; transformation of dysfunctional personal attitudes and beliefs (hostile picture of the world, unrealistic perfectionist standards, prohibition on expressing feelings); 3) at the family level: working through (comprehension and response) traumatic life experiences and events in family history; work with current dysfunctions of the structure, microdynamics, macrodynamics and ideology of the family system; 4) at the interpersonal level: practicing deficient social skills, developing the ability to form close, trusting relationships, expanding the system of interpersonal connections.

3.2. Somatoform disorders are characterized by fixation on the physiological manifestations of emotions, a pronounced narrowing of the emotional vocabulary and difficulties in recognizing and verbalizing feelings, which determines a certain specificity of integrative psychotherapy for disorders with pronounced somatization in the form of an additional task of developing mental hygiene skills of emotional life. Novelty and theoretical significance of the study. For the first time, theoretical foundations have been developed for the synthesis of knowledge about affective spectrum disorders obtained in different traditions of clinical psychology and psychotherapy - a multifactorial psycho-social model of affective spectrum disorders and a four-aspect model of family system analysis.

For the first time, based on these models, a theoretical and methodological analysis of various traditions was carried out, existing theoretical and empirical studies of affective spectrum disorders were systematized, and the need for their integration was substantiated.

For the first time, based on the developed models, a comprehensive experimental psychological study of the psychological factors of affective spectrum disorders was carried out, as a result of which macrosocial, family, and interpersonal factors of affective spectrum disorders were studied and described.

For the first time, based on a comprehensive study of the psychological factors of affective spectrum disorders and theoretical and methodological analysis of various traditions, a system of targets for psychotherapy has been identified and described and an original model of integrative psychotherapy for affective spectrum disorders has been developed.

Original questionnaires have been developed to study family emotional communications (FEC), prohibition on the expression of feelings (TE), and physical perfectionism. Structured interviews have been developed: a scale of stressful events in family history and the Moscow Integrative Social Network Questionnaire, which tests the main parameters of a social network. For the first time, a tool for studying social support - the Sommer, Fudrik Social Support Questionnaire (SOZU-22) - has been adapted and validated in Russian. Practical significance of the study. The main psychological factors of affective spectrum disorders and scientifically based targets of psychological assistance are identified, which must be taken into account by specialists working with patients suffering from these disorders. Developed, validated and adapted diagnostic techniques, allowing specialists to identify factors of emotional disorders and identify targets for psychological assistance. A model of psychotherapy for affective spectrum disorders has been developed that integrates knowledge accumulated in various traditions of psychotherapy and empirical research. The objectives of psychoprophylaxis of affective spectrum disorders for children at risk, their families and specialists from educational and educational institutions are formulated. The results of the study are implemented:

In the practice of the clinics of the Moscow Research Institute of Psychiatry of the Russian Health Service, the Scientific Center for Mental health RAMS, GKPB No. 4 named after. Gannushkina and City Clinical Hospital No. 13 of Moscow, into the practice of the Regional Psychotherapeutic Center at OKPB No. 2 of Orenburg and the Consultative and Diagnostic Center for the Mental Health of Children and Adolescents of Novgorod.

The results of the study are used in the educational process of the Faculty of Psychological Counseling and the Faculty of Advanced Training of the Moscow City Psychological and Pedagogical University, the Faculty of Psychology of Moscow State University. M.V. Lomonosov, Faculty of Clinical Psychology

Siberian State Medical University, Department of Pedagogy and Psychology of Chechen State University. Approbation of the study. The main provisions and results of the work were presented by the author at the international conference “Synthesis of Psychopharmacology and Psychotherapy” (Jerusalem, 1997); at the Russian national symposiums “Man and Medicine” (1998, 1999, 2000); at the First Russian-American Conference on Cognitive Behavioral Psychotherapy (St. Petersburg, 1998); at international educational seminars “Depression in the primary medical network” (Novosibirsk, 1999; Tomsk, 1999); at sectional sessions of the XIII and XIV Congresses of the Russian Society of Psychiatrists (2000, 2005); at the Russian-American symposium “Identification and treatment of depression in the primary medical network” (2000); at the First International Conference in Memory of B.V. Zeigarnik (Moscow, 2001); at the plenum of the board of the Russian Society of Psychiatrists within the framework of the Russian conference “Affective and schizoaffective disorders” (Moscow, 2003); at the conference “Psychology: modern directions of interdisciplinary research”, dedicated to the memory of corresponding member. RAS A.V.Brushlinsky (Moscow, 2002); at the Russian conference " Modern tendencies organizations of psychiatric care: clinical and social aspects” (Moscow, 2004); at the conference with international participation “Psychotherapy in the system of medical sciences during the formation of evidence-based medicine” (St. Petersburg, 2006).

The dissertation was discussed at meetings of the Academic Council of the Moscow Research Institute of Psychiatry (2006), the Problem Commission of the Academic Council of the Moscow Research Institute of Psychiatry (2006) and the Academic Council of the Faculty of Psychological Counseling of the Moscow State University of Psychology and Education (2006).

Structure of the dissertation. The text of the dissertation is presented in 465 units, consists of an introduction, three parts, ten chapters, a conclusion, conclusions, a list of references (450 titles), an appendix, includes 74 tables, 7 figures.

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Conclusion of the dissertation on the topic “Medical Psychology”, Kholmogorova, Alla Borisovna

1. In various traditions of clinical psychology and psychotherapy, theoretical concepts have been developed and empirical data have been accumulated on the factors of mental pathology, including affective spectrum disorders, which complement each other, which necessitates the synthesis of knowledge and the tendency towards their integration at the present stage.

2. The methodological basis for the synthesis of knowledge in modern psychotherapy is a systematic approach and ideas about non-classical scientific disciplines, which involve the organization of various factors into blocks and levels, as well as the integration of knowledge based on the practical tasks of providing psychological assistance. Effective means of synthesizing knowledge about the psychological factors of affective spectrum disorders are a multifactorial psycho-social model of affective spectrum disorders, including macrosocial, family, personal and interpersonal levels and a four-aspect model of the family system, including structure, microdynamics, macrodynamics and ideology.

3. At the macrosocial level, there are two differently directed trends in the life of a modern person: an increase in the stressfulness of life and stress on the emotional sphere of a person, on the one hand, maladaptive values in the form of the cult of success, strength, well-being and perfection, which make it difficult to process negative emotions, on the other. These trends are expressed in a number of macrosocial processes leading to a significant prevalence of affective spectrum disorders and the emergence of risk groups in the general population.

3.1. The wave of social orphanhood against the background of alcoholism and family breakdown leads to pronounced emotional disturbances in children from dysfunctional families and social orphans, and the level of disturbances is higher in the latter;

3.2. Growing number educational institutions with increased study loads and perfectionistic educational standards leads to an increase in the number of emotional disorders in students (in these institutions their frequency is higher than in regular schools)

3.3. Perfectionistic standards of appearance promoted in the media (low weight and specific standards of proportions and body shapes) lead to physical perfectionism and emotional disorders in young people.

3.4. Gender-role stereotypes of emotional behavior in the form of a ban on the expression of asthenic emotions (anxiety and sadness) in men lead to difficulties in seeking help and receiving social support, which may be one of the reasons for secondary alcoholism and high rates of completed suicide in males.

4. General and specific psychological factors of depressive, anxiety and somatoform disorders can be systematized on the basis of a multifactorial model of affective spectrum disorders and a four-aspect model of the family system.

4.1. Family level. 1) structure: all groups are characterized by dysfunctions of the parental subsystem and the peripheral position of the father; for depressed people - disunity, for anxious ones - symbiotic relationships with the mother, for somatoforms - symbiotic relationships and coalitions; 2) microdynamics: all groups are characterized by a high level of conflicts, parental criticism and other forms of inducing negative emotions; for the depressed - the predominance of criticism over praise from both parents and communication paradoxes from the mother; for the anxious - less criticism and more support from the mother; for families of patients with somatoform disorders - elimination of emotions; 3) macrodynamics: all groups are characterized by the accumulation of stressful events in family history in the form of severe hardships in the lives of parents, alcoholism and serious illnesses of close relatives, presence at their illness or death, abuse and fights; in patients with somatoform disorders, early deaths of relatives are added to the increased frequency of these events. 4) ideology: all groups are characterized by the family value of external well-being and a hostile picture of the world; for depressed and anxious groups - a cult of achievements and perfectionistic standards. The most pronounced family dysfunctions are observed in patients with depressive disorders.

4.2. Personal level. Patients with affective spectrum disorders have high rates of prohibition on expressing feelings. Patients with somatoform disorders are characterized by a high level of alexithymia, a narrowed emotional vocabulary, and difficulties in recognizing emotions. For patients with anxiety and depressive disorders, there is a high level of perfectionism and hostility.

4.3. Interpersonal level. Interpersonal relationships of patients with affective spectrum disorders are characterized by a narrowing of the social network, a lack of close trusting ties, a low level of emotional support and social integration in the form of self-assignment to a certain reference group. In patients with somatoform disorders, in contrast to anxiety and depressive disorders, there is no significant decrease in the level of instrumental support; the lowest rates of social support are in patients with depressive disorders.

4.4. Data from correlation and regression analysis indicate the mutual influence and systemic relationships of dysfunctions at the family, personal and interpersonal levels, as well as the severity of psychopathological symptoms, which indicates the need for their comprehensive consideration in the process of psychotherapy. The most destructive influence on the interpersonal relationships of adults is exerted by the pattern of eliminating emotions in the parental family, combined with the induction of anxiety and distrust of people.

5. Tested foreign methods: social support questionnaire (F-SOZU-22 G.Sommer, T.Fydrich), family system test (FAST, T.Ghering) and developed original questionnaires “Family Emotional Communications” (FEC), “Prohibition of Expression” feelings" (SHF), structured interviews "Stressful Events in Family History Scale", "Parental Criticism and Expectation" (RKO) and "Moscow Integrative Social Network Questionnaire" are effective tools for diagnosing dysfunctions at the family, personal and interpersonal levels, as well as identifying targets for psychotherapy .

6. The objectives of providing psychological assistance to patients with affective spectrum disorders, substantiated by theoretical analysis and empirical research, involve work at different levels - macrosocial, family, personal, interpersonal. In accordance with the means accumulated to solve these problems in different approaches, integration is carried out based on cognitive-behavioral and psychodynamic approaches, as well as a number of developments in domestic psychology (concepts of internalization, reflection, mediation) and systemic family psychotherapy. The basis for the integration of cognitive-behavioral and psychodynamic approaches is a two-level cognitive model developed in cognitive therapy by A. Beck.

6.1. In accordance with different tasks, two stages of integrative psychotherapy are distinguished: 1) development of emotional self-regulation skills; 2) work with the family context and interpersonal relationships. At the first stage, cognitive tasks dominate, at the second - dynamic ones. The transition from one stage to another involves the development of reflexive regulation in the form of the ability to stop, fix and objectify one’s automatic thoughts. Thus, a new organization of thinking is formed, which significantly facilitates and speeds up the work at the second stage.

6.2. The objectives of integrative psychotherapy and prevention of affective spectrum disorders are: 1) at the macrosocial level, debunking pathogenic cultural values (the cult of restraint, success and perfection); 2) at the personal level, developing emotional self-regulation skills through the gradual formation of reflexive ability; transformation of dysfunctional personal attitudes and beliefs - a hostile picture of the world, unrealistic perfectionist standards, a ban on the expression of feelings; 3) at the family level: working through (comprehension and response) traumatic life experiences and events in family history; work with current dysfunctions of the structure, microdynamics, macrodynamics and ideology of the family system; 4) at the interpersonal level", training of deficient social skills, development of the ability for close, trusting relationships, expansion of interpersonal connections.

6.3. Somatoform disorders are characterized by fixation on the physiological manifestations of emotions, a pronounced narrowing of the emotional vocabulary and difficulties in recognizing and verbalizing feelings, which determines the specificity of integrative psychotherapy for disorders with pronounced somatization in the form of an additional task of developing mental hygiene skills of emotional life.

6.4. Analysis of follow-up data of patients with affective spectrum disorders proves the effectiveness of the developed model of integrative psychotherapy (a significant improvement in social functioning and the absence of repeated visits to the doctor is noted in 76% of patients who completed a course of integrative psychotherapy in combination with drug treatment).

7. Risk groups for the occurrence of affective spectrum disorders in the child population include children from socially disadvantaged families, orphans and children studying in educational institutions with an increased academic load. Psychoprophylaxis in these groups involves solving a number of problems.

7.1. For children from disadvantaged families - social and psychological work on family rehabilitation and the development of emotional mental hygiene skills.

7.2. For orphans - social and psychological work on organizing family life with mandatory psychological support for the family and the child in order to process his traumatic experience in his birth family and successfully integrate into the new family system;

7.3. For children from educational institutions with an increased academic load - educational and advisory work with parents, teachers and children, aimed at correcting perfectionist beliefs, inflated demands and competitive attitudes, freeing up time for communication and establishing friendly relationships of support and cooperation with peers.

Conclusion

The data obtained contribute to clarifying the nature and status of affective spectrum disorders, which are the subject of heated debate among specialists. The high figures for comorbidity of depressive, anxiety and somatoform disorders presented in the first chapter indicate their common roots. Currently, an increasing number of studies confirm the complex multifactorial nature of these disorders and most leading experts adhere to systemic bio-psycho-social models, according to which, along with genetic and other biological factors, psychological and social factors play an important role.

The data obtained confirm the observations of specialists and empirical research data on the common psychological factors of these disorders: the important role of family traumatic experience, various family dysfunctions in the form of a high level of parental criticism and other types of induction of negative emotions. Based on the data from the study, we can talk not only about the traumatization of the patients themselves, but about the accumulation of stressful events in their family history. Many of the patients' parents had to endure severe hardships, there were alcoholic family scenarios, and psychological and physical violence was practiced in families.

The study of family factors in affective spectrum disorders also revealed many similarities in the structure, communication, family history, norms and values of the three clinical groups studied. Communication in such families is characterized by the induction of negative emotions through fixation on negative experiences and a high level of criticism. Accumulated negative emotions cannot be effectively processed, since another characteristic feature of communication between family members is the elimination of emotions - a ban on open expression of feelings. It can be assumed that families develop certain compensatory strategies to process traumatic experiences. Closed boundaries, distrust of people, the cult of strength and restraint in the family form perfectionistic standards and high levels of hostility in children, which lead to various cognitive distortions that make an important contribution to the induction of negative affect.

These studies indicate the important role of traumatic experiences in family relationships in the genesis of affective spectrum disorders and their reproduction in subsequent generations. From this follows two most important goals of psychological work - processing this traumatic experience, on the one hand, and assistance in building a new system of relationships both in the family and with other people. The main defect of these relationships is the inability to have close, confidential contact. Such contact requires a culture of emotional self-expression and the ability to understand the emotions and experiences of other people. According to regression analysis data, it is the elimination of emotions in the parental family that makes the greatest contribution to violations of interpersonal relationships in adulthood. This leads to another important goal of working with these patients - the development of emotional psychohygiene skills, the ability to self-understanding, emotional self-regulation and trusting, close relationships. The identified targets determined the need to integrate different approaches.

I would like to especially emphasize the data concerning the peripheral role of the father in the modern family. Almost half of healthy people and the same percentage of patients rated their fathers as taking virtually no part in upbringing. In patients, these data are supplemented by a fairly high percentage of families where the father is aggressive and critical of the children. These data relate to another problem area of modern culture - the role of the father figure in raising children. Families of patients with affective disorders are characterized by profound violations of the parental subsystem - the relationship between parents.

So, the data obtained point to common psychological roots and testify in favor of a unitary approach to the status of depressive, anxiety and somatoform disorders, which is followed by many domestic specialists (Vertogradova, 1985; Krasnov, 2003; Smulevich, 2003). However, they also make it possible to identify certain specifics of these disorders and outline differentiated targets for psychotherapy.

The tendency to somatization and fixation on anxiety about health was associated with traumas related to damage to health - being present at the death or illness of loved ones, early deaths and serious illnesses. Somatization can be considered as a strategy for obtaining help - the level of instrumental support in these patients does not differ from healthy subjects. This may be an important reinforcer of somatization due to certain benefits associated with it. Disorders with severe somatization, including anxiety and depression, require a special psychotherapeutic approach aimed at overcoming the alexithymic barrier and developing emotional mental hygiene skills.

The most severe traumatic experience associated with a particularly high level of criticism and a ban on the expression of feelings, which often came from both parents, a large number of various stresses in the family history turned out to be characteristic of patients prone to depressive reactions. Depressed patients also suffer from deficits in social support and emotional intimacy more than patients in the other two groups. Patients with anxiety disorders were more likely to have symbiotic relationships and report more support from their mother.

Considering the ongoing wave of social orphanhood in Russia and the significant number of children deprived of parental care and experiencing violence and abuse, one can expect a rapid increase in the number of patients with severe depressive and personality disorders.

However, material security and external well-being of the family are not a guarantee of mental well-being. The percentage of children at risk with emotional disorders in elite gymnasiums is equal to that among social orphans. Perfectionistic standards and competition lead to the development of perfectionism as a personality trait and prevent the establishment of trusting relationships.

All identified macrosocial, family, personal and interpersonal factors represent a complex system of targets that require consideration in practical work. It is precisely the practical tasks of assistance that the integration of approaches should be subordinated to. The integration of psychotherapy methods, subordinated to practical tasks and built on theoretically and empirically substantiated targets of assistance, is evidence-based psychotherapy in accordance with the modern understanding of the status of non-classical scientific disciplines (Yudin, 1997; Shvyrev, 2004; Zaretsky, 1989). The integration of cognitive and dynamic approaches with the developments of Russian psychology on the role of reflection in the development of emotional self-regulation seems constructive for psychotherapy of affective spectrum disorders (Alekseev, 2002, Zaretsky, 1984, Zeigarnik, Kholmogorova, Mazur, 1989; Sokolova, Nikolaeva, 1995).

An important task for further research is to study the influence of the identified factors on the course of the disease and the process of treatment, both medicinal and psychotherapeutic. Particularly important is the need for further research into personality factors of affective spectrum disorders and further search for their specificity for anxiety, depressive and somatoform disorders.

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431. Kholmogorova Alla Borisovna

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In terms of prevalence, they are the undisputed leaders among other mental disorders. According to various sources, they affect up to 30% of people visiting clinics and from 10 to 20% of people in the general population (J.M.Chignon, 1991, W.Rief, W.Hiller, 1998; P.S.Kessler, 1994; B.T.Ustun, N. Sartorius, 1995; H.W. Wittchen, 2005; A.B. Smulevich, 2003). The economic burden associated with their treatment and disability constitutes a significant part of the budget in the health care system of different countries (R. Carson, J. Butcher, S. Mineka, 2000; E.B. Lyubov, G.B. Sargsyan, 2006; H.W. Wittchen, 2005). Depressive, anxiety and somatoform disorders are important risk factors for the emergence of various forms of chemical dependence (H.W. Wittchen, 1988; A.G. Goffman, 2003) and, to a large extent, complicate the course of concomitant somatic diseases (O.P. Vertogradova, 1988; Yu.A.Vasyuk, T.V.Dovzhenko, E.N.Yushchuk, E.L.Shkolnik, 2004; V.N.Krasnov, 2000; E.T.Sokolova, V.V.Nikolaeva, 1995)

Finally, depressive and anxiety disorders are the main risk factor for suicide, in terms of the number of which our country ranks among the first (V.V. Voitsekh, 2006; Starshenbaum, 2005). Against the backdrop of socio-economic instability in recent decades in Russia, there has been a significant increase in the number of affective disorders and suicides among young people, elderly people, and able-bodied males (V.V. Voitsekh, 2006; Yu.I. Polishchuk, 2006). There is also an increase in subclinical emotional disorders, which are included within the boundaries of affective spectrum disorders (H.S. Akiskal et al., 1980, 1983; J. Angst et al, 1988, 1997) and have a pronounced negative impact on quality of life and social adaptation.

All the mentioned factors of occurrence and the resulting targets of psychotherapy for affective spectrum disorders do not exclude, but complement each other, which necessitates the integration of various approaches when solving practical problems of providing psychological assistance. Although the task of integration is increasingly coming to the fore in modern psychotherapy, its solution is hampered by significant differences in theoretical approaches (M. Perrez, U. Baumann, 2005; B. A. Alford, A. T. Beck, 1997; K. Crave, 1998; A. J. Rush, M. Thase, 2001; W. Senf, M. Broda, 1996; A. Lazarus, 2001; E. T. Sokolova, 2002), which makes it relevant to develop theoretical foundations for the synthesis of accumulated knowledge. It should also be noted that there is a lack of comprehensive objective empirical research confirming the importance of various factors and the resulting targets of assistance (S.J.Blatt, 1995; K.S.Kendler, R.S.Kessler, 1995; R.Kellner, 1990; T.S.Brugha, 1995, etc.). Finding ways to overcome these obstacles is an important independent scientific task, the solution of which involves the development of methodological means of integration, conducting comprehensive empirical studies of the psychological factors of affective spectrum disorders and the development of scientifically based integrative methods of psychotherapy for these disorders.

Purpose of the study. Development of theoretical and methodological foundations for the synthesis of knowledge accumulated in different traditions of clinical psychology and psychotherapy, a comprehensive empirical study of the system of psychological factors of affective spectrum disorders with the identification of targets and the development of principles of integrative psychotherapy and psychoprevention of depressive, anxiety and somatoform disorders.

Research objectives.

Theoretical and methodological analysis of models of occurrence and methods of treatment of affective spectrum disorders in the main psychological traditions; justification of the need and possibility of their integration.
Development of methodological foundations for the synthesis of knowledge and integration of methods of psychotherapy for affective spectrum disorders.
Analysis and systematization of existing empirical studies of psychological factors of depressive, anxiety and somatoform disorders based on the multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of the family system.
Development of a methodological complex aimed at the systematic study of macrosocial, family, personal and interpersonal factors of emotional disorders and affective spectrum disorders.
Conducting an empirical study of patients with depressive, anxiety and somatoform disorders and a control group of healthy subjects based on a multifactorial psycho-social model of affective spectrum disorders.
Conducting a population-based empirical study aimed at studying macrosocial factors of emotional disorders and identifying high-risk groups among children and youth.
Comparative analysis of the results of studies of various population and clinical groups, as well as healthy subjects, analysis of connections between macrosocial, family, personal and interpersonal factors.
Identification and description of the system of targets for psychotherapy for affective spectrum disorders, based on data from theoretical and methodological analysis and empirical research.
Formulation of the basic principles, objectives and stages of integrative psychotherapy for affective spectrum disorders.
Determination of the main tasks of psychoprophylaxis of emotional disorders in children at risk.

Theoretical and methodological foundations of the work. The methodological basis of the study is the systemic and activity-based approaches in psychology (B.F. Lomov, A.N. Leontiev, A.V. Petrovsky, M.G. Yaroshevsky), the bio-psycho-social model of mental disorders, according to which the emergence and in the course of mental disorders, biological, psychological and social factors are involved (G. Engel, H. S. Akiskal, G. Gabbard, Z. Lipowsky, M. Perrez, Yu. A. Aleksandrovsky, I. Ya. Gurovich, B. D. Karvasarsky, V. N. Krasnov), ideas about non-classical science as focused on solving practical problems and integrating knowledge from the point of view of these problems (L.S. Vygotsky, V.G. Gorokhov, V.S. Stepin, E.G. Yudin, N. L.G. Alekseev, V.K. Zaretsky), cultural and historical concept of mental development by L.S. Vygotsky, concept of mediation by B.V. Zeigarnik, ideas about the mechanisms of reflexive regulation in normal and pathological conditions (N.G. Alekseev, V. K. Zaretsky, B.V. Zeigarnik, V.V. Nikolaeva, A.B. Kholmogorova), a two-level model of cognitive processes developed in cognitive psychotherapy by A. Beck.

Object of study. Models and factors of mental norm and pathology and methods of psychological assistance for affective spectrum disorders.

Subject of study. Theoretical and empirical foundations for the integration of various models of the occurrence and methods of psychotherapy for affective spectrum disorders.

Research hypotheses.

Different models of the emergence and methods of psychotherapy for affective spectrum disorders focus on different factors; the importance of their comprehensive consideration in psychotherapeutic practice necessitates the development of integrative models of psychotherapy.
The developed multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of the family system allow us to consider and study macrosocial, family, personal and interpersonal factors as a system and can serve as a means of integrating various theoretical models and empirical studies of affective spectrum disorders.
Macrosocial factors such as social norms and values (the cult of restraint, success and perfection, gender role stereotypes) affect the emotional well-being of people and can contribute to the occurrence of emotional disorders.
There are general and specific psychological factors of depressive, anxiety and somatoform disorders associated with different levels (family, personal, interpersonal).
The developed model of integrative psychotherapy for affective spectrum disorders is an effective means of psychological assistance for these disorders.

Research methods.

Theoretical and methodological analysis – reconstruction of conceptual schemes for studying affective spectrum disorders in various psychological traditions.
Clinical-psychological – study of clinical groups using psychological techniques.
Population - study of groups from the general population using psychological techniques.
Hermeneutic – qualitative analysis of interview and essay data.
Statistical - the use of mathematical statistics methods (when comparing groups, the Mann-Whitney test was used for independent samples and the Wilcoxon T-test for dependent samples; to establish correlations, the Spearman correlation coefficient was used; to validate methods - factor analysis, test-retest, coefficient α - Cronbach's, Guttman Split-half coefficient; multiple regression analysis was used to analyze the influence of variables). For statistical analysis, the software package SPSS for Windows, Standard Version 11.5, Copyright © SPSS Inc., 2002, was used.
Method of expert assessments – independent expert assessments of interview data and essays; expert assessments of the characteristics of the family system by psychotherapists.
The follow-up method is the collection of information about patients after treatment.

The developed methodological complex includes the following blocks of techniques in accordance with the levels of research:

1) family level – family emotional communications questionnaire (FEC, developed by A.B. Kholmogorova together with S.V. Volikova); structured interviews “Scale of stressful events in family history” (developed by A.B. Kholmogorova together with N.G. Garanyan) and “Parental criticism and expectations” (RKO, developed by A.B. Kholmogorova together with S.V. Volikova), test family system (FAST, developed by T.M.Gehring); essay for parents “My Child”;

2) personal level – questionnaire of prohibition of expressing feelings (ZVCh, developed by V.K. Zaretsky together with A.B. Kholmogorova and N.G. Garanyan), Toronto Alexithymia Scale (TAS, developed by G.J. Taylor, adaptation by D.B. Eresko , G.L. Isurina et al.), emotional vocabulary test for children (developed by J.H. Krystal), emotion recognition test (developed by A.I. Toom, modified by N.S. Kurek), emotional vocabulary test for adults ( developed by N.G. Garanyan), perfectionism questionnaire (developed by N.G. Garanyan together with A.B. Kholmogorova and T.Yu. Yudeeva); physical perfectionism scale (developed by A.B. Kholmogorova together with A.A. Dadeko); hostility questionnaire (developed by N.G. Garanyan together with A.B. Kholmogorova);

interpersonal level – social support questionnaire (F-SOZU-22, developed by G.Sommer, T.Fydrich); structured interview “Moscow Integrative Social Network Questionnaire” (developed by A.B. Kholmogorova together with N.G. Garanyan and G.A. Petrova); test for the type of attachment in interpersonal relationships (developed by C. Hazan, P. Shaver).

To study psychopathological symptoms, we used the severity of psychopathological symptoms questionnaire SCL-90-R (developed by L.R. Derogatis, adapted by N.V. Tarabrina), the depression questionnaire (BDI, developed by A.T. Beck et al., adapted by N.V. Tarabrina), the anxiety questionnaire ( BAI, developed by A.T.Beck and R.A.Steer), Childhood Depression Inventory (CDI, developed by M.Kovacs), Personal Anxiety Scale (developed by A.M. Prikhozhan). To analyze factors at the macrosocial level when studying risk groups from the general population, the above methods were selectively used. Some of the methods were developed specifically for this study and were validated in the laboratory of clinical psychology and psychotherapy of the Moscow Research Institute of Psychiatry of the Russian Health Service.

Characteristics of the examined groups.

The clinical sample consisted of three experimental groups of patients: 97 patients with depressive disorders , 90 patients with anxiety disorders, 52 patients with somatoform disorders; two control groups of healthy subjects included 90 people; groups of parents of patients with affective spectrum disorders and healthy subjects included 85 people; samples of subjects from the general population included 684 school-age children, 66 parents of schoolchildren and 650 adult subjects; The additional groups included in the study to validate the questionnaires included 115 people. A total of 1929 subjects were examined.

Reliability of results is ensured by a large volume of survey samples; using a set of methods, including questionnaires, interviews and tests, which made it possible to verify the results obtained using individual methods; using methods that have undergone validation and standardization procedures; processing the obtained data using methods of mathematical statistics.

Main provisions submitted for defense

1. In existing areas of psychotherapy and clinical psychology, different factors are emphasized and different targets for working with affective spectrum disorders are identified. The current stage of development of psychotherapy is characterized by trends towards more complex models of mental pathology and the integration of accumulated knowledge based on a systematic approach. The theoretical basis for integrating existing approaches and research and identifying on this basis a system of targets and principles of psychotherapy are the multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of family system analysis.

1.1. The multifactorial model of affective spectrum disorders includes macrosocial, family, personal and interpersonal levels. At the macrosocial level, factors such as pathogenic cultural values and social stress are highlighted; at the family level - dysfunction of the structure, microdynamics, macrodynamics and ideology of the family system; at the personal level – disorders of the affective-cognitive sphere, dysfunctional beliefs and behavioral strategies; at the interpersonal level - the size of the social network, the presence of close trusting relationships, the degree of social integration, emotional and instrumental support.

2.2. In accordance with the levels of research, the following psychological factors of depressive, anxiety and somatoform disorders have been identified: 1) at the family level - disturbances in structure (symbioses, coalitions, disunity, closed borders), microdynamics (high level of parental criticism and violence in the family), macrodynamics (accumulation stressful events and reproduction of family dysfunctions in three generations) ideology (perfectionistic standards, distrust of others, suppression of initiative) of the family system; 2) at the personal level – dysfunctional beliefs and disorders of the cognitive-affective sphere; 3) at the interpersonal level – a pronounced deficit of trusting interpersonal relationships and emotional support. The most pronounced dysfunctions at the family and interpersonal level are observed in patients with depressive disorders. Patients with somatoform disorders have severe impairments in the ability to verbalize and recognize emotions.

Novelty and theoretical significance of the study. For the first time, theoretical foundations have been developed for the synthesis of knowledge about affective spectrum disorders obtained in different traditions of clinical psychology and psychotherapy - a multifactorial psycho-social model of affective spectrum disorders and a four-aspect model of family system analysis.

For the first time, based on the developed models, a comprehensive experimental psychological study of the psychological factors of affective spectrum disorders was carried out, as a result of which macrosocial, family interpersonal factors of affective spectrum disorders were studied and described.

Practical significance of the study. The main psychological factors of affective spectrum disorders and scientifically based targets of psychological assistance are identified, which must be taken into account by specialists working with patients suffering from these disorders. Diagnostic methods have been developed, standardized and adapted, allowing specialists to identify factors of emotional disorders and identify targets for psychological help. A model of psychotherapy for affective spectrum disorders has been developed that integrates knowledge accumulated in various traditions of psychotherapy and empirical research. The objectives of psychoprophylaxis of affective spectrum disorders for children at risk, their families and specialists from educational and educational institutions are formulated.

The results of the study are implemented:

In the practice of the clinics of the Moscow Research Institute of Psychiatry of the Russian Health Service, the Scientific Center for Mental Health of the Russian Academy of Medical Sciences, State Clinical Hospital No. 4 named after. Gannushkina and City Clinical Hospital No. 13 of Moscow, into the practice of the Regional Psychotherapeutic Center at OKPB No. 2 of Orenburg and the Consultative and Diagnostic Center for the Mental Health of Children and Adolescents of Novgorod.

Approbation of the study. The main provisions and results of the work were presented by the author at the international conference “Synthesis of Psychopharmacology and Psychotherapy” (Jerusalem, 1997); at the Russian national symposiums “Man and Medicine” (1998, 1999, 2000); at the First Russian-American Conference on Cognitive Behavioral Psychotherapy (St. Petersburg, 1998); at international educational seminars “Depression in the primary medical network” (Novosibirsk, 1999; Tomsk, 1999); at sectional sessions of the XIII and XIV Congresses of the Russian Society of Psychiatrists (2000, 2005); at the Russian-American symposium “Identification and treatment of depression in the primary medical network” (2000); at the First International Conference in Memory of B.V. Zeigarnik (Moscow, 2001); at the plenum of the board of the Russian Society of Psychiatrists within the framework of the Russian conference “Affective and schizoaffective disorders” (Moscow, 2003); at the conference “Psychology: modern directions of interdisciplinary research”, dedicated to the memory of corresponding member. RAS A.V.Brushlinsky (Moscow, 2002); at the Russian conference “Modern trends in the organization of psychiatric care: clinical and social aspects” (Moscow, 2004); at the conference with international participation “Psychotherapy in the system of medical sciences during the formation of evidence-based medicine” (St. Petersburg, 2006).

Structure of the dissertation. The text of the dissertation is presented on 465 pp., consists of an introduction, three parts, ten chapters, a conclusion, conclusions, a list of references (450 titles, of which 191 are in Russian and 259 in foreign languages), appendices, includes 74 tables, 7 figures.

MAIN CONTENT OF THE WORK

In administered the relevance of the work is substantiated, the subject, purpose, objectives and hypotheses of the study are formulated, the methodological basis of the study is revealed, the characteristics of the surveyed group and the methods used are given, scientific novelty, theoretical and practical significance, the main provisions submitted for defense are presented.

First part consists of four chapters and is devoted to the development of theoretical foundations for the integration of models of the occurrence and methods of psychotherapy of affective spectrum disorders. IN first chapter the concept of affective spectrum disorders is introduced as an area of mental pathology with the dominance of emotional disorders and a pronounced psycho-vegetative component (J. Angst, 1988, 1997; H. S. Akiskal et al., 1980, 1983; O. P. Vertogradova, 1992; V. N. Krasnov, 2003, etc.). Information is presented on the epidemiology, phenomenology and modern classification of depressive, anxiety and somatoform disorders, as the most epidemiologically significant. A high level of comorbidity of these disorders is recorded, discussions regarding their status and common etiology are analyzed.

In second chapter analyzed theoretical models of affective spectrum disorders in the main psychotherapeutic traditions - psychodynamic, cognitive-behavioral, existential-humanistic, and considered integrative approaches centered on the family and interpersonal relationships (system-oriented family psychotherapy, D. Bowlby's attachment theory, G. Klerman's interpersonal psychotherapy, theory of relations by V.N. Myasishchev). Particular attention is paid to the theoretical developments of domestic psychology devoted to reflection, its role for emotional self-regulation is revealed.

It is shown that the traditional confrontation between the classical models of psychoanalysis, behaviorism and existential psychology is currently being replaced by integrative trends in ideas about the structural and dynamic characteristics of the psyche in normal and pathological conditions: 1) increasing importance is attached to the analysis of dysfunctions of the parental family and the traumatic experience of early interpersonal relationships as a factor creating vulnerability to affective spectrum disorders; 2) mechanistic cause-and-effect relationships (trauma - a symptom; inadequate learning - a symptom) or a complete denial of the principle of determinism are replaced by complex systemic ideas about internal negative representations of oneself and the world and a system of negative distortions of external and inner reality as factors of personal vulnerability to affective spectrum disorders.

As a result of the analysis, the complementarity of existing approaches is proved and the need for a synthesis of knowledge to solve practical problems is substantiated. Cognitive behavioral therapy has accumulated the most effective means of working with cognitive distortions and dysfunctional beliefs (A. Beck et al., 2003; Alford, Beck, 1997); in the psychodynamic approach - with traumatic experience and current interpersonal relationships (S. Freud, 1983; S. Heim, M. G. Owens, 1979; G. Klerman et al., 1997, etc.); in systemic family psychotherapy - with current family dysfunctions and family history (E.G. Eidemiller, V. Justitskis, 2000; M. Bowen, 2005); in the domestic tradition, which developed the principle of subject activity, ideas about the mechanisms of mediation and emotional self-regulation were developed (B.V. Zeigarnik, A.B. Kholmogorova, 1986; B.V. Zeigarnik, A.B. Kholmogorova, E.P. Mazur, 1989; E.T.Sokolova, V.V.Nikolaeva, 1995; F.S.Safuanov, 1985; Tkhostov, 2002). A row is highlighted general trends development of areas of psychotherapy: from mechanistic models to systemic ones within traditions; from opposition to integration in relations between traditions; from influence to cooperation in relationships with patients.

Table 1. Ideas about the structural and dynamic characteristics of the psyche in the main directions of modern psychotherapy: tendencies towards convergence.

Directions psychotherapy Character ristika psyche	Psychodynamic tradition Object theory Relationships	Cognitive-behavioral tradition Beck's cognitive psychotherapy	Existential-humanistic tradition Client-centered Rogers psychotherapy
Structure	System of ideas about oneself and the world (object representations)	System of ideas about oneself and the world (cognitive schemes: beliefs and beliefs)	System of ideas about oneself and the world (I concept)
Microdynamics	Reflection of reality (protective mechanisms)	Reflection of reality (cognitive distortion)	Reflection of reality (distortions of internal experience)
Macrodynamics	Early experience, nature of attachment (stages of development of object relations)	Early experience, nature of attachment (formation of cognitive schemes)	Early experience, nature of attachment (formation of the concept of “I”)

As one of the grounds allowing for a synthesis of approaches, a two-level cognitive model developed in cognitive psychotherapy by A. Beck is proposed, and its high integrative potential is proven (B.A.Alford, A.T.Beck, 1997; A.B. Kholmogorova, 2001).

Chapter Three is dedicated to the development of methodological means for synthesizing theoretical and empirical knowledge about affective spectrum disorders and methods of their treatment. It sets out the concept of non-classical science, in which the need to synthesize knowledge is determined by the focus on solving practical problems and the complexity of the latter.

This concept, dating back to the works of L.S. Vygotsky in the field of defectology, was actively developed by domestic methodologists based on the material of engineering sciences and ergonomics (E.G. Yudin, 1997; V.G. Gorokhov, 1987; N.G. Alekseev, V. K. Zaretsky, 1989). Based on these developments, the methodological status of modern psychotherapy as a non-classical science aimed at developing scientifically based methods of psychological assistance is substantiated.

The constant growth in the amount of research and knowledge in the sciences of mental health and pathology requires the development of tools for their synthesis. In modern science, a systematic approach acts as a general methodology for the synthesis of knowledge (L. von Bertalanffy, 1973; E.G. Yudin, 1997; V.G. Gorokhov, 1987, 2003; B.F. Lomov, 1996; A.V. Petrovsky, M.G. Yaroshevsky, 1994).

In the sciences of mental health, it is refracted into systemic bio-psycho-social models, reflecting the complex multifactorial nature of mental pathology, clarified by more and more new research (I.Ya. Gurovich, Ya.A. Storozhakova, A.B. Shmukler, 2004; V.N.Krasnov, 1990; B.D.Karvasarsky, 2000, A.B.Kholmogorova, N.G.Garanyan, 1998; H.Akiskal, G.McKinney, 1975; G.Engel, 1980; J.Lipowsky, 1981; G. Gabbard, 2001, etc.).

As a means of synthesizing psychological knowledge about affective spectrum disorders, a multifactorial psychosocial model of these disorders is proposed, on the basis of which factors are organized into interconnected blocks belonging to one of the following levels: macrosocial, family, personal and interpersonal. Table 2 shows which factors are emphasized by different schools of psychotherapy and clinical psychology.

Table 2. Multilevel psycho-social model of affective spectrum disorders as a means of knowledge synthesis

Levels	Factors in affective spectrum disorders	Traditions psychotherapy and clinical psychology
Macrosocial	Pathogenic and conflicting values of modern culture	Social psychoanalysis
Family	Traumatic experience Insecure attachment Family system dysfunctions	Psychodynamic (S. Freud) D. Bowlby's attachment theory System-oriented family (S. Minukhin, M. Bowen)
Personal	Negative thinking, dysfunctional beliefs Negative self-concept, disclaimer Repressed aggression, negative self-esteem, alexithymia Disorders of reflexive regulation of thinking and behavior	Cognitive-behavioral (A. Beck, A. Ellis) Existential-humanistic (K. Rogers, R. May) Psychodynamic (K. Abraham, Z. Freud, D. Jacobson, P. Sifneos) Research on thinking at the Moscow school (N.G. Alekseev, V.K. Zaretsky, B.V. Zeigarnik, A.B. Kholmogorova)
Interpersonal	Inability to cooperate Destructive strategies for interpersonal relationships Communication dysfunctions, social skills deficits Lack of awareness, activity and selectivity in relationships	Individual psychology by A. Adler Social psychoanalysis (G. Sullivan, K. Horney) Interpersonal psychotherapy by G. Klerman Psychology of relationships by V.N. Myasishchev, personal reconstructive psychotherapy by B.D. Karvasarsky, G.L. Isurina, V.A. Tashlykov.

Table 3 presents a four-aspect model of the family system as a means of systematizing the conceptual apparatus developed in different schools of system-oriented family psychotherapy. Based on this model, a synthesis of knowledge about family factors of affective spectrum disorders and their comprehensive empirical study are carried out.

Table 3. Four-aspect model of the family system as a means of synthesizing knowledge about family factors

Family structure

Family microdynamics

Family Macrodynamics

Family ideology

1.Communication

over-involvement, disunity.

autonomy, differentiation

coalition

2. Hierarchy

low, high, moderate.

Hierarchy inversion

3. Subsystems.

parental, childish, grandparental.

4.Borders:

internal – between generations, external – with the outside world

1.Family roles –

Mixing roles.

Role flexibility.

2. Stereotypes of interaction

Frequency of conflicts. Degree of control.

3.Circulation of information in the system.

Family secrets.

4. Style of emotional communication in the family. level of criticism, negative emotions, expression of feelings, paradoxical communications

5. Metacommunication

communication about communication

6. Triangulation

the use of the third in resolving conflicts between the other two

1.Family history or evolution

relationships and events in 3 generations

2.Family scenario

patterns repeating from generation to generation

3. Family development cycle.

Turning points

4. Resistance to change

difficulties of perestroika

5. Resources for change

positive aspects of relationships

6. Transmission

accumulation of negative patterns over three generations

7. Traumatic events in family history

early deaths, serious illnesses, victims of wars and repressions, etc.

1. Family

rules, norms.

Constructive - dysfunctional

2. Delegation of requirements and expectations.

Agreed, uncoordinated.

destructive, supportive

4. Family

values, beliefs and convictions

constructive - dysfunctional

5.Traditions, rituals

stable patterns that unite family members

6. General cultural context of the family system

cultural values, stereotypes, norms

IN fourth chapter The first part presents the results of systematization of empirical studies of psychological factors of affective spectrum disorders based on the developed tools.

Macrosocial level. The role of various social stresses (poverty, socio-economic cataclysms) in the growth of emotional disorders has been shown (WHO materials, 2001, 2003, V.M. Voloshin, N.V. Vostroknutov, I.A. Kozlova et al., 2001). At the same time, there has been an unprecedented increase in social orphanhood in Russia, which ranks first in the world in terms of the number of orphans: according to official statistics alone, there are more than 700 thousand of them. According to research, orphans represent one of the main risk groups for deviant behavior and various mental disorders, including affective spectrum disorders (D. Bowlby, 1951, 1980; I.A. Korobeinikov, 1997; J. Langmeyer, Z. Matejczyk , 1984; V.N.Oslon, 2002; V.N.Oslon, A.B.Kholmogorova, 2001; A.M.Prikhozhan, N.N.Tolstykh, 2005; Yu.A.Pishchulina, V.A.Ruzhenkov , O.V.Rychkova 2004; Dozortseva, 2006, etc.). It has been proven that the risk of depression in women who lose their mother before the age of 11 increases threefold (G.W.Brown, T.W.Harris, 1978). However, approximately 90% of orphans in Russia are orphans with living parents, living in orphanages and boarding schools. The main reason for family breakdown is alcoholism. Family forms of living arrangements for orphans in Russia are not sufficiently developed, although the need for substitute family care for the mental health of children has been proven by foreign and domestic studies (V.K. Zaretsky et al., 2002, V.N. Oslon, A.B. Kholmogorova, 2001, B N. Oslon, 2002, I. I. Osipova, 2005, A. Kadushin, 1978, D. Tobis, 1999, etc.).

Macrosocial factors lead to stratification of society. This is expressed, on the one hand, in the impoverishment and degradation of part of the population, and on the other, in the growing number of wealthy families with a request for the organization of elite educational institutions with perfectionist educational standards. A pronounced focus on success and achievement, intensive educational loads in these institutions also create a threat to the emotional well-being of children (S.V. Volikova, A.B. Kholmogorova, A.M. Galkina, 2006).

Another manifestation of the cult of success and perfection in society is the widespread propaganda in the media of unrealistic perfectionist standards of appearance (weight and body proportions), and the large-scale growth of fitness and bodybuilding clubs. For some of the visitors to these clubs, figure correction activities become extremely valuable. As Western studies show, the cult of physical perfection leads to emotional disorders and eating disorders, which also belong to the spectrum of affective disorders (T.F. Cash, 1997; F. Skärderud, 2003).

Such a macrosocial factor as gender stereotypes also has a significant impact on mental health and emotional well-being, although it remains insufficiently studied (J. Angst, C. Ernst, 1990; A. M. Möller-Leimküller, 2004). Epidemiological data indicate a higher prevalence of depressive and anxiety disorders in women, who are significantly more likely to seek help for these conditions. At the same time, it is known that the male population is clearly ahead of the female population in the number of completed suicides, alcoholism, and premature mortality (K. Hawton, 2000; V.V. Voitsekh, 2006; A.V. Nemtsov, 2001). Since affective disorders are important factors in suicide and alcoholism, there is a need to explain these data. Features of gender stereotypes of behavior - the cult of strength and masculinity in men - can shed light on this problem. Difficulties in making complaints, seeking help, receiving treatment and support increase the risk of undetected emotional disorders in men and are expressed in secondary alcoholism and anti-vital behavior (A.M. Meller-Leimküller, 2004).

Family level. In recent decades, there has been increased attention from researchers to family factors in affective spectrum disorders. Beginning with the pioneering works of D. Bowlby and M. Ainsworth (Bowlby, 1972, 1980), the problem of insecure attachment in childhood as a factor in depressive and anxiety disorders in adults has been studied. The most fundamental research in this area belongs to J. Parker (Parker, 1981, 1993), who proposed the well-known questionnaire for studying parental bonding (PBI). He described the style of parent-child relationships of depressed patients as “cold control” and of anxious patients as “emotional vice.” J. Engel studied family dysfunctions in disorders with severe somatization (G. Engel, 1959). Further research made it possible to identify a whole series of family dysfunctions characteristic of affective spectrum disorders, which are systematized on the basis of a four-aspect model of the family system: 1) structure - symbioses and disunity, closed borders (A.E. Bobrov, M.A. Belyanchikova, 1999; N.V. Samoukina, 2000, E.G. Eidemiller, V. Yustitskis, 2000); 2) microdynamics - a high level of criticism, pressure and control (G.Parker, 1981, 1993; M.Hudges, 1984, etc.); 3) macrodynamics: serious illnesses and deaths of relatives, physical and sexual violence in family history (B.M.Payne, Norfleet, 1986; Sh.Declan, 1998; J.Hill, A.Pickles et all, 2001; J.Scott, W.A.Barker, D. Eccleston, 1998); 4) ideology - perfectionist standards, the value of obedience and success (L.V. Kim, 1997; N.G. Garanyan, A.B. Kholmogorova, T.Yu. Yudeeva, 2001; S.J. Blatt., E. Homann, 1992) . Recently, there has been a growing number of comprehensive studies proving the important contribution of psychological family factors to childhood depression along with biological ones (A. Pike, R. Plomin, 1996), systemic studies of family factors are being conducted (E. G. Eidemiller, V. Justitskis, 2000; A.B. Kholmogorova, S.V. Volikova, E.V. Polkunova, 2005; S.V. Volikova, 2006).

Personal level. If the work of psychiatrists is dominated by studies of various personality types (typological approach), as a factor of vulnerability to affective spectrum disorders (G.S. Bannikov, 1998; D.Yu. Veltishchev, Yu.M. Gurevich, 1984; Akiskal et al., 1980 , 1983; H.Thellenbach, 1975; M.Shimoda, 1941 etc.), then in modern studies clinical psychologists The parametric approach predominates - the study of individual personality traits, attitudes and beliefs, as well as the study of the affective-cognitive style of the individual (A.T.Beck, et al., 1979; M.W.Enns, B.J.Cox, 1997; J.Lipowsky, 1989). In studies of depressive and anxiety disorders, the role of such personality traits as perfectionism is especially emphasized (R. Frost et al., 1993; P. Hewitt, G. Fleet, 1990; N. G. Garanyan, A. B. Kholmogorova, T. Yu Yudeeva, 2001, N.G. Garanyan, 2006) and hostility (A.A. Abramova, N.V. Dvoryanchikov, S.N. Enikolopov et al., 2001; N.G. Garanyan, A.B. Kholmogorova , T.Yu.Yudeeva, 2003; M.Fava, 1993). Since the introduction of the concept of alexithymia (G.S.Nemiah, P.E.Sifneos, 1970), research into this affective-cognitive personality style as a factor of somatization and discussions regarding its role have not stopped (J.Lipowsky, 1988, 1989; R.Kellner, 1990; V. V. Nikolaeva, 1991; A. Sh. Tkhostov, 2002; N. G. Garanyan, A. B. Kholmogorova, 2002).

Interpersonal level. The main body of research at this level concerns the role of social support in the emergence and course of affective spectrum disorders (M.Greenblatt, M.R.Becerra, E.A.Serafetinides, 1982; T.S.Brugha, 1995; A.B. Kholmogorova, N.G. Garanyan, G.A. Petrova, 2003). As these studies show, a lack of close, supportive interpersonal relationships, formal, superficial contacts are closely associated with the risk of depressive, anxiety and somatoform disorders.

PartII consists of four chapters and is devoted to presenting the results of a comprehensive empirical study of the psychological factors of affective spectrum disorders based on a multifactorial psycho-social model and a four-aspect model of the family system. IN first chapter the general design of the study is revealed, a brief description of the groups surveyed and the methods used is given.

Chapter two is devoted to the study of the macrosocial level - identifying risk groups for affective spectrum disorders in the general population. To avoid stigmatization, the term “emotional disorders” was used to refer to the manifestations of affective spectrum disorders in the form of symptoms of depression and anxiety in the general population. Data from a survey of 609 schoolchildren and 270 university students are presented, demonstrating the prevalence of emotional disorders in children and youth (about 20% of adolescents and 15% of students fall into the group with high rates of depressive symptoms). Table 5 indicates the studied macrosocial factors of affective spectrum disorders.

Table 5. General organization of the study of factors at the macrosocial level

Factors at the macrosocial level	Groups surveyed	Techniques
Factor 1. The breakdown and alcoholization of families, a wave of social orphanhood, an increase in the number of children with traumatic family experiences of violence and loss	Group 1 - social orphans Group 2 - children from socially disadvantaged families Gr.3 – children from ordinary families Total – 141 people	Kovak Childhood Depression Inventory, Parishioner Anxiety Questionnaire, Crystal Emotional Vocabulary Test for Children
Factor 2. Growth of educational institutions (EI) with increased teaching load, perfectionistic training standards	Group 1 – children from educational institutions with increased workload Gr..2 – children from regular classes Group 3 – parents of children from educational institutions with increased workload Group 4 – parents of children from regular classes Total – 197 people	Kovak Childhood Depression Inventory, Church Anxiety Inventory, Perfectionism Inventory
Factor 3. The cult of physical perfection in the form of perfectionistic standards of weight and body proportions, their propaganda in the media	Group 1 - girls. those involved in figure correction Gr.2 – girls not involved in this activity Group 1 - young men engaged in figure correction Gr.4 – young men not involved in this activity Total – 170 people	Beck Anxiety and Depression Inventory, Physical Perfectionism Scale, Perfectionism Inventory
Factor 4. Gender-role stereotypes of emotional behavior	Gr.1 – male Floor Gr. 2 – female floor Total – 210 people	Inhibited Expression of Feelings Questionnaire (TEQ)

Impact Study factor 1(breakup and alcoholization of families, a wave of social orphanhood) for the emotional well-being of children showed that social orphans represent the most disadvantaged group of the three studied.

They demonstrate the highest scores on scales of depression and anxiety, as well as a narrowed emotional vocabulary. Children living in socially disadvantaged families occupy an intermediate position between social orphans who have lost their families and schoolchildren from ordinary families.

Study factor 2(an increase in the number of educational institutions with an increased academic load) showed that among students in classes with an increased workload there is a higher percentage of adolescents with emotional disorders compared to students from regular classes.

Parents of children with symptoms of depression and anxiety that exceeded the norm showed significantly higher rates of perfectionism compared to parents of emotionally well children; significant correlations were identified between indicators of parental perfectionism and symptoms of childhood depression and anxiety.

Study factor 3(cult of physical perfection) showed that among young people involved in figure correction activities in fitness and bodybuilding clubs, rates of depressive and anxiety symptoms are significantly higher compared to groups not involved in this activity.

Table 6. Rates of depression, anxiety, general and physical perfectionism in the fitness, bodybuilding and control groups.

Groups Questionnaires	Women		Men
Groups Questionnaires	FitnessN=60 M (SD)	Counter. N=60 M (SD)	Bodybuilding. N=25 M (SD)	Counter. N=25 M (SD)
Beck's depression	15** (9)	8 (7)	21* (12)	13 (12)
Beck's anxiety	14* (8)	10 (6)	19** (11)	10 (8)
Overall Perfectionism Questionnaire Score	43* (10)	41 (12)	50** (9)	44 (14)
Physical Perfectionism Scale	26,5 **(6)	17 (8)	23** (7)	19 (5)

*at p<0,05 (Критерий Манна-Уитни) M – среднее значение

**at p<0,01 (Критерий Манна-Уитни) SD – стандартное отклонение

As can be seen from the table, groups of boys and girls involved in figure correction activities are distinguished from control groups by significantly higher rates of general and physical perfectionism. Indicators of the level of physical perfectionism are associated with indicators of emotional distress through direct significant correlations.

Study factor 4(gender-role stereotypes of emotional behavior) showed that men have a higher rate of prohibition on the expression of asthenic emotions of sadness and fear compared to women. This result helps clarify some of the important inconsistencies in the epidemiological data discussed above. The results obtained indicate significant difficulties in making complaints and seeking help in males, which hinders the identification of affective spectrum disorders and increases the level of suicidal risk in the male population. These difficulties are associated with such gender-role stereotypes of male behavior as the cult of masculinity, strength and restraint.

Chapters three and four The second part is devoted to a study of clinical groups conducted on the basis of a multifactorial psycho-social model of affective spectrum disorders. Three clinical groups were examined: patients with depressive, anxiety and somatoform disorders. Among the patients of all three groups, women predominated (87.6%; 76.7%; 87.2%, respectively). The main age range in the groups of patients with depressive and anxiety disorders is 21-40 years old (67% and 68.8%, respectively), more than half have higher education (54.6 and 52.2%, respectively). Among patients with somatoform disorders, patients in the age range 31-40 (42.3%) and with secondary education (57%) predominated. In the presence of comorbid affective spectrum disorders, the main diagnosis was made by a psychiatrist based on the symptoms that were dominant at the time of examination. In some patients with depressive, anxiety and somatoform disorders, comorbid disorders of mature personality were identified (14.4%; 27.8%; 13.5%, respectively). A course of psychotherapy was prescribed according to indications in combination with drug treatment carried out by a psychiatrist.

Table 7. Diagnostic characteristics of patients with depression disorders

ICD-10 code		Diagnosis	Patients with depressive disorders N=97
ICD-10 code		Diagnosis	N	%
	F32	Depressive episode	29	29,9
	F32+F34.1	Combination of depressive episode and dysthymia	16	16,5
	F32+F45	Combination of a depressive episode and somatoform disorder	4	4,1
F33	F33	Recurrent depression	34	35,1
F34.0	F34.0	Cyclothymia	3	3,1
F34.1	F34.1	Dysthymia	11	11,3
Total:			97	100

The table shows that the predominant diagnoses in the group of depressive disorders are recurrent depressive disorder and depressive episode.

Table 8. Diagnostic characteristics of patients with anxiety disorders

ICD-10 code		Diagnosis	Patients with anxiety disorders N=90
ICD-10 code		Diagnosis	N	%
	F40.01	Agoraphobia with panic disorder	7	7,8
	F40.01+ F32	Combination of agoraphobia with panic r-vom and depressive episode	5	5,6
	F40.1	Social phobias	9	10
	F40.1+F32	Combination of social phobia and depressive episode	4	4,4
	F41.0	Panic disorder	6	6,7
	F41.0+F32	Combination of panic disorder and depressive episode	8	8,8
	F41.1	Generalized anxiety level	4	4,4
	F41.1+F32	Combination of generalized anxiety disorder and depressive episode	7	7,8
	F41.2	Mixed anxiety and depression	24	26,7
	F41.2+F41.0	Combination of mixed anxiety and depression and panic disorder	7	7,8
F42	F42	Obsessive-compulsive disorder	9	10
Total:			90	100

The table shows that the predominant diagnoses in the group of anxiety disorders are panic disorder with various combinations and mixed anxiety and depressive disorder.

Table 9.Diagnostic characteristics of patients with somatoform disorders

ICD-10 code		Diagnosis	Patients with somatoform disorders N=52
ICD-10 code		Diagnosis	n	%
	F 45.0	Somatization disorder	24	46,2
	F 45.3	Somatoform autonomic dysfunction	28	53,8
Total			52	100

As can be seen from the table, the group of somatoform disorders included two main ICD-10 diagnoses. Patients diagnosed with somatization disorder complained of diverse, recurring and often changing localization of somatic symptoms. Complaints of patients diagnosed with somatoform autonomic dysfunction related to a separate organ or system of the body, most often cardiovascular, gastrointestinal or respiratory.

As can be seen from the graph, in the depressed group there is a clear peak on the depression scale, in the anxious group - on the anxiety scale, and in the somatoform group - the highest values on the somatization scale, which is consistent with their diagnoses according to ICD-10 criteria. Depressed patients have significantly higher scores on most scales of the symptomatic questionnaire.

In accordance with the multifactorial psycho-social model, the psychological factors of somatoform, depressive and anxiety disorders were studied at the family, personal and interpersonal levels. Based on theoretical and empirical research data, as well as our own work experience, a number of hypotheses are put forward. At the family level, based on a four-aspect model, hypotheses were put forward about the dysfunctions of the family system: 1) structure (disruption of connections in the form of symbioses, disunity and coalitions, closed external boundaries); 2) microdynamics (high level of criticism, inducing distrust of people); 3) macrodynamics (high level of stress in family history); 4) ideologies (perfectionistic standards, hostility and distrust of people). At the personal level, the following hypotheses were put forward: 1) about a high level of alexithymia and poorly developed skills of expressing and recognizing emotions in patients with somatoform disorders; 2) about a high level of perfectionism and hostility in patients with depressive and anxiety disorders. At the interpersonal level, hypotheses were put forward regarding a narrowed social network and low levels of emotional support and social integration.

In accordance with the hypotheses, the blocks of techniques were slightly different for patients with somatoform disorders from the other two clinical groups; different control groups were also selected for them, taking into account differences in sociodemographic characteristics.

Depressive and anxious patients were examined using a general set of techniques; in addition, in order to verify the family-level research data, two additional groups were examined: parents of patients with depressive and anxiety disorders, as well as parents of healthy subjects.

Table 10 presents the surveyed groups and blocks of techniques in accordance with the levels of the study.

Table 10. Surveyed groups and blocks of techniques in accordance with the levels of research

Groups Levels	Patients with somatoform r-you, healthy subjects Total 82 people	Patients with depression anxious r-you, healthy subjects Total 247 people	Parents of patients depressed, anxious r-you, healthy Spanish. Total 85 people
Family	Family Emotional Communication Questionnaire (FEC), Family History Stressful Life Events Scale, FAST Family System Test	SEC questionnaire, scale of stressful life events in family history, method of expert assessments, interview “Parental criticism and expectations”	Questionnaires of SEC, HHF, hostility, perfectionism, interview “Rod. criticism and expectations" essay "My Child"
Personal	EHF Questionnaire, Alexithymia Scale, Emotion Recognition Test, Emotional Vocabulary Test	Inhibited Expression of Feelings (IFE), Perfectionism, and Hostility Questionnaires
Interpersonal	Social support questionnaire, Moscow integrative social network questionnaire.	Social support questionnaire, Moscow integrative social network questionnaire, attachment type test

The results of a study of patients with anxiety and depressive disorders revealed a number of dysfunctions at the family, personal and interpersonal levels.

Table 11. General indicators of dysfunction at the family, personal and interpersonal levels in patients with depressive and anxiety disorders (questionnaires)

Groups Questionnaires	Depressed M (SD)	Alarming M (SD)	Healthy M (SD)
Family level Family Emotional Communications (FEC)	49,9** (9,5)	47,7** (10,7)	40,3 (7,3)
Personal level Prohibition on Expression of Feelings (BFA) Perfectionism Questionnaire Hostility Questionnaire
Interpersonal level Social Support Questionnaire

*at p<0,05 (Критерий Манна-Уитни) M – среднее значение

**at p<0,01 (Критерий Манна-Уитни) SD – стандартное отклонение

***at p<0,001 (Критерий Манна-Уитни)

As can be seen from the table, patients are distinguished from healthy subjects by more pronounced family communicative dysfunctions, higher rates of inhibition of the expression of feelings, perfectionism and hostility, as well as a lower level of social support.

Analysis of individual indicators on the subscales of the SEC questionnaire shows that the greatest number of dysfunctions occurs in the parental families of patients with depressive disorders; They are significantly different from healthy subjects in terms of high levels of parental criticism, inducing anxiety, eliminating emotions, the importance of external well-being, inducing distrust of people, and family perfectionism. Anxious patients differed significantly from healthy subjects on three subscales: parental criticism, anxiety induction, and distrust of people.

Both groups differed significantly from the group of healthy subjects in terms of all subscales of the perfectionism and hostility questionnaires. They are characterized by a tendency to see other people as malicious, indifferent and despising weakness, high standards of performance, inflated demands on themselves and others, fear of not meeting the expectations of others, fixation on failures, polarized thinking according to the “all or nothing” principle.

All indicators of the social support questionnaire scales differ in patients with depressive and anxiety disorders from the indicators of healthy subjects at a high level of significance. They experience deep dissatisfaction with their social contacts, a lack of instrumental and emotional support, trusting connections with other people, and they lack a sense of belonging to any reference group.

Correlation analysis shows that family, personal and interpersonal dysfunctions are related to each other and to indicators of psychopathological symptoms.

Table 12. Significant correlations of general indicators of questionnaires testing dysfunctions at the family, personal, interpersonal levels and the severity of psychopathological symptoms

** – at p<0,01 (коэффициент корреляции Спирмена)

As can be seen from the table, general indicators of family dysfunction, perfectionism and the index of overall severity of psychopathological symptoms are interconnected by direct correlations at a high level of significance. The general indicator of social support has inverse correlations with all other questionnaires, i.e. Broken relationships in the parental family and high levels of perfectionism are associated with a decreased ability to establish constructive and trusting relationships with other people.

A regression analysis was carried out, which showed (p<0,01) влияние выраженности дисфункций родительской семьи на уровень перфекционизма, социальной поддержки и выраженность психопатологической симптоматики у взрослых. Полученная модель позволила объяснить 21% дисперсии зависимой переменной «общий показатель социальной поддержки» и 15% зависимой переменной «общий показатель перфекционизма», а также 7% дисперсии зависимой переменной «общий индекс тяжести психопатологической симптоматики». Из семейных дисфункций наиболее влиятельной оказалась независимая переменная «элиминирование эмоций».

A study of family-level factors using the structured interview “Family History Stressful Events Scale” revealed a significant accumulation of stressful life events in three generations of relatives of patients with depressive and anxiety disorders. Their relatives, significantly more often than relatives of healthy people, suffered serious illnesses and hardships of life; in their families, violence in the form of fights and abuse, cases of alcoholism, even family scenarios where, for example, father, brother and other relatives drank. The patients themselves more often witnessed serious illness or death of relatives, alcoholism of close family members, abuse and fights.

According to structured interviews “Parental criticism and expectations” (conducted with both patients and their parents), patients with depressive disorders more often note the predominance of criticism over praise from the mother (54%), while the majority of patients with anxiety disorders – the predominance praise over criticism from her (52%). The majority of patients in both groups rated their father as critical (24 and 26%) or not involved in upbringing at all (44% in both groups). Patients with depressive disorders faced contradictory demands and communicative paradoxes from their mother (she scolded them for being stubborn, but demanded initiative, toughness, and assertiveness; she claimed that she praised a lot, but listed mainly negative characteristics); They could deserve praise from her for obedience, and patients with anxiety - for achievements. In general, patients with anxiety disorders received more support from their mother. Parents of patients in both groups are distinguished from healthy subjects by a higher level of perfectionism and hostility. According to expert assessments of the structure of the family system by psychotherapists, disunity is equally represented in the families of patients in both groups (33%); symbiotic relationships predominated among anxious people (40%), but also occurred quite often among depressed people (30%). A third of families in both groups had chronic conflicts.

The study of interpersonal level factors using a structured interview, the Moscow Integrative Social Network Questionnaire, in both groups revealed a narrowing of social connections - a significantly smaller number of people in the social network and its core (the main source of emotional support) compared to healthy people. The Hesen and Shaver attachment type test in interpersonal relationships revealed a predominance of anxious-ambivalent attachment in depressed people (47%), avoidant in anxious ones (55%), and secure in healthy ones (85%). The test data are in good agreement with the data from a study of parental families - disunity and communication paradoxes in depressed parental families are consistent with constant doubts about the sincerity of the partner (ambivalent attachment), symbiotic relationships in patients with anxiety disorders are consistent with a pronounced desire to distance themselves from people (avoidant attachment).

A study of a group of patients with somatoform disorders also revealed a number of dysfunctions at the family, personal and interpersonal levels.

Table 13. General indicators of dysfunction at the family, personal and interpersonal levels in patients with somatoform disorders (questionnaire methods)

*at p<0,05 (Критерий Манна-Уитни) M – среднее значение

**at p<0,01 (Критерий Манна-Уитни) SD – стандартное отклонение

***at P<0,001 (Критерий Манна-Уитни)

As can be seen from the table, patients with somatoform disorders, compared with healthy subjects, have more pronounced communicative dysfunctions in the parental family, higher rates of prohibition on the expression of feelings, they have a narrowed emotional vocabulary, a reduced ability to recognize emotions by facial expressions, a higher level of alexithymia and a lower level of social support.

A more detailed analysis of individual subscales of the questionnaires shows that patients with somatoform disorders, compared to healthy subjects, have increased levels of parental criticism, induction of negative experiences and distrust of people, and decreased indicators of emotional support and social integration. At the same time, they have a lower number of parental family dysfunctions compared to depressed patients, and indicators of instrumental support do not differ significantly from those of healthy subjects, which indicates their ability to receive sufficient technical assistance from others, unlike patients with depression and anxiety disorders. It can be assumed that the various somatic symptoms characteristic of these patients serve as an important reason for receiving it.

Significant correlations were identified between a number of general indicators of the questionnaires and the somatization and alexithymia scales, the high values of which distinguish these patients.

Table 14. Correlations of general indicators of questionnaires and tests with the somatization scale of the SCL-90-R questionnaire and the Toronto Alexithymia Scale

* – at p<0,05 (коэффициент корреляции Спирмена)

** – at p<0,01 (коэффициент корреляции Спирмена)

As can be seen from the table, the somatization scale indicator correlates at a high level of significance with the alexithymia indicator; both of these indicators, in turn, have direct significant connections with the general index of severity of psychopathological symptoms and the prohibition on expressing feelings, as well as an inverse relationship with the richness of the emotional vocabulary. This means that somatization, high levels of which distinguish the somatoform group from depressed and anxious patients, is associated with a reduced ability to focus on the inner world, openly express feelings, and a narrow vocabulary for expressing emotions.

A study using a structured interview, the Family History Stressful Events Scale, revealed the accumulation of stressful life events in three generations of relatives of patients with somatoform disorders. In the parental families of patients, compared to healthy subjects, early deaths, as well as violence in the form of abuse and fights, occurred more often, in addition, they were more likely to be present at the serious illness or death of a family member. When studying somatoform patients at the family level, the Hering Family System Test (FAST) was also used. Structural dysfunctions in the form of coalitions and inversion of hierarchy, as well as chronic conflicts, were found significantly more often in the families of patients compared to healthy subjects.

A study using a structured interview “Moscow Integrative Social Network Test” revealed a narrowing of the social network compared to healthy subjects and a deficit of close trusting connections, the source of which is the core of the social network.

PartIII is devoted to a description of the model of integrative psychotherapy, as well as a discussion of some organizational issues of psychotherapy and psychoprevention of affective spectrum disorders.

In the first chapter Based on a generalization of the results of empirical research of population and clinical groups, as well as their correlation with existing theoretical models and empirical data, an empirically and theoretically grounded system of targets for integrative psychotherapy for affective spectrum disorders is formulated.

Table 15. Multifactorial psycho-social model of affective spectrum disorders as a means of synthesizing data and identifying a system of targets for psychotherapy

Target factors Traditions Levels Research	Factors of depressive, anxiety and somatoform disorders and targets of psychotherapy	Traditions Psychotherapy and clinical psychology
Macrosocial	Social stress, social orphanhood, pathogenic cultural values (cult of strength, restraint, success, perfection)	Social psychoanalysis Research by D. Bowlby et al.
Family	1. structure (symbioses, disunity, coalitions, violations of hierarchy, closed boundaries, weak parental subsystem, peripheral father) 2. microdynamics (high level of criticism, low level of warmth and support, conflicting demands and communications, double bind, high control) 3. macrodynamics (accumulation of acute and chronic stress, family dysfunctional scenarios) 4. ideology (cult of success and external well-being, perfectionism, distrust of people, prohibition on open expression of feelings, suppression of initiative)	D. Bowlby's attachment theory System-oriented family Psychodynamic
Personal	Perfectionistic standards, hostile worldview, prohibition on expressing feelings, lack of emotional self-regulation skills	Cognitive-behavioral Existential-humanistic Psychodynamic Ideas about reflection as the basis of self-regulation (Moscow school)
Interpersonal	Narrow social connections, low level of social integration, emotional support, insecure attachment in relationships with a partner	Social psychoanalysis, The theory of relations by V.N. Myasishchev Interpersonal psychotherapy by G. Klerman, Psychodynamic group

In second chapter the stages and tasks of psychotherapy for affective spectrum disorders are presented . Integrative psychotherapy for depressive and anxiety disorders begins with the psychodiagnostic stage, at which, based on a multifactorial model, specific targets for work and resources for change are identified using specially designed interviews and diagnostic tools. Groups of patients are identified that require different management tactics. In patients with high levels of perfectionism and hostility, these countertherapeutic factors should first be addressed, as they interfere with the establishment of a working alliance and may cause premature withdrawal from psychotherapy. With the remaining patients, the work is divided into two large stages: 1) development of emotional self-regulation skills and the formation of reflexive ability based on the techniques of cognitive psychotherapy by A. Beck and ideas about reflexive regulation in Russian psychology; 2) work with the family context and interpersonal relationships based on the techniques of psychodynamic and system-oriented family psychotherapy, as well as ideas about reflection as the basis of self-regulation and an active life position. A model of psychotherapy for patients with severe somatization is described separately, in connection with specific tasks, for the solution of which an original training for the development of emotional psychohygiene skills has been developed.

Table 16. Conceptual diagram of the stages of integrative psychotherapy for affective spectrum disorders with severe somatization.

Tasks Stages	COGNITIVE	PSYCHODYNAMIC
I STAGE	DEVELOPMENT OF EMOTIONAL SELF-REGULATION SKILLS
Stage 1 Informational and motivating Neoplasms Finding the meaning of psychological work, self-determination - a conscious choice of position in relation to the disease and treatment	1. Informing about the connection between emotions and physiological states; general “laws” of emotional life; consequences of violation of emotional psychohygiene for mental and physical health. 2. Problematization and presentation of the method of group psychotherapy.	1. Creating an atmosphere of trust and openness.
Stage 2 Training of awareness and expressions of feelings Neoplasms Ability to focus on the inner world Means of symbolizing emotional experience	1. Changing the negative attitude towards emotions. 2. Awareness of the difficulties of understanding one’s own and others’ emotional life: 3. Development of skills of self-observation and emotional self-expression: 4. Development of skills to differentiate individual emotions in the range of feelings.	1. Creating an atmosphere trust and openness. 2. Establishing a working alliance. 3. Feedback training. 4. Diagnosis of modes of resistance, transference reactions and group themes.
Stage 3 Emotion management training Neoplasms Reflexive ability to stop, fix and objectify automatic thoughts	1. Presentation of cognitive and psychodynamic coping methods: 2. Practicing cognitive coping skills 3. Preparing to work with beliefs	1. Labeling resistance, transference reactions and group themes. 2. Encouraging the expression and response of negative emotions.
II STAGE	WORKING WITH FAMILY CONTEXT AND INTERPERSONAL RELATIONSHIPS
Stage 4 Reflexive-positional analysis Neoplasms The ability to analyze one’s own position, correlate it with the position of others, self-determination - conscious choice of position in a group, gaining experience of trusting relationships	1. Formulation of beliefs associated with position in the group 2. Working with mental distortions	1. Determination of the position of each participant 2.Comparing your own position with the positions of other group members 3.Working with resistance, discussing the “conditional benefit” of the disease. 4. Analysis of the consequences of the position and associated beliefs for life and the process of psychotherapy 5. Compiling “piggy banks” of individual and group problems and topics 6. Changing the leading position to a more passive one
Stage 5 Elaboration of the family context Neoplasms liberation from accumulated negative feelings, self-determination - a conscious choice of position in life	Exploring the sources of beliefs and their more complete formulation	1. Analysis of the family context (roles, rules, norms) in three generations. 2.Identification of parental programming (requirements and expectations, family myths and values). 3.Identification, response and elaboration of childhood traumatic experiences and transference reactions
Stage 6 Analysis and working out personal problems and identifying resources. Neoplasms New means of solving problems, an active position in relation to them, liberation from the power of the past	Developing new beliefs and practicing new behavioral strategies and skills	Establishing relationships between current issues and family context

In accordance with the norms of non-classical science, one of the grounds for integrating approaches is the idea of the sequence of tasks solved during the treatment of affective spectrum disorders and those neoplasms that are the necessary basis for the transition from one task to another (Table 16).

Information is provided on the effectiveness of psychotherapy based on follow-up data. 76% of patients who completed a course of integrative psychotherapy in combination with drug treatment experienced stable remissions. Patients note increased resistance to stress, improved family relationships and social functioning, and the majority attribute this effect to undergoing a course of psychotherapy.

Particular attention is paid to organizational issues of psychotherapy and psychoprevention of affective spectrum disorders. The place of psychotherapy in the complex treatment of affective spectrum disorders by specialists from a multiprofessional team is discussed, the significant possibilities of psychotherapy in increasing compliance in drug treatment are considered and justified.

The last paragraph formulates the objectives of psychoprophylaxis for affective spectrum disorders when working with risk groups - orphans and children from schools with increased academic loads. The necessity of their family life arrangement with subsequent psychological support for the child and family is substantiated as important tasks of psychoprevention of affective spectrum disorders in social orphans. For the successful integration of an orphan child into a new family system, professional work is required to select an effective professional family, work with the traumatic experience of the child in the birth family, as well as help the new family in the complex structural and dynamic restructuring associated with the arrival of a new member. It should be remembered that the rejection of a child and his return to an orphanage is a severe repeated trauma, increases the risk of developing affective spectrum disorders and may negatively affect his ability to develop attachment relationships in the future.

For children studying in educational institutions with increased workload, the tasks of psychoprophylaxis are psychological work in the following areas: 1) with parents - educational work, clarification of the psychological factors of affective spectrum disorders, lowering perfectionistic standards, changing requirements for the child, a more relaxed attitude towards grades , freeing up time for rest and communication with other children, using praise instead of criticism as a stimulus; 2) with teachers - educational work, clarification of the psychological factors of affective spectrum disorders, reducing the competitive environment in the classroom, abandoning ratings and humiliating comparisons of children with each other, help in experiencing failure, positive mistakes as an inevitable component of activity when mastering new things, praise for any success in a child with symptoms of emotional disturbances, encouraging mutual assistance and support between children; 3) with children - educational work, development of mental hygiene skills in emotional life, a culture of experiencing failure, a calmer attitude towards assessments and mistakes, the ability to cooperate, friendship and help others.

IN conclusion the problem of the contribution of psychological and social factors to the complex multifactorial bio-psycho-social determination of affective spectrum disorders is discussed; prospects for further research are considered, in particular, the task is set to study the influence of the identified psychological factors on the nature of the course and process of treatment of affective spectrum disorders and their contribution to the problem of resistance.

CONCLUSIONS

3.2. The increase in the number of educational institutions with increased academic loads and perfectionistic educational standards leads to an increase in the number of emotional disorders in students (in these institutions their frequency is higher than in regular schools)

4.1. Family level. 1) structure: all groups are characterized by dysfunctions of the parental subsystem and the peripheral position of the father; for depressed people - disunity, for anxious ones - symbiotic relationships with the mother, for somatoforms - symbiotic relationships and coalitions; 2) microdynamics: all groups are characterized by a high level of conflicts, parental criticism and other forms of inducing negative emotions; for depressed people - the predominance of criticism over praise from both parents and communication paradoxes from the mother; for anxious ones - less criticism and more support from the mother; for families of patients with somatoform disorders – elimination of emotions; 3) macrodynamics: all groups are characterized by the accumulation of stressful events in family history in the form of severe hardships in the lives of parents, alcoholism and serious illnesses of close relatives, presence at their illness or death, abuse and fights; in patients with somatoform disorders, early deaths of relatives are added to the increased frequency of these events. 4) ideology: all groups are characterized by the family value of external well-being and a hostile picture of the world; for depressed and anxious groups - a cult of achievements and perfectionistic standards. The most pronounced family dysfunctions are observed in patients with depressive disorders.

6.2. The objectives of integrative psychotherapy and prevention of affective spectrum disorders are: 1) at the macrosocial level: debunking pathogenic cultural values (the cult of restraint, success and perfection); 2) at the personal level: development of emotional self-regulation skills through the gradual formation of reflexive ability; transformation of dysfunctional personal attitudes and beliefs - a hostile picture of the world, unrealistic perfectionistic standards, a ban on the expression of feelings; 3) at the family level: working through (comprehension and response) traumatic life experiences and events in family history; work with current dysfunctions of the structure, microdynamics, macrodynamics and ideology of the family system; 4) at the interpersonal level: training of deficient social skills, development of the ability for close, trusting relationships, expansion of interpersonal connections.

7.1. For children from disadvantaged families – social and psychological work on family rehabilitation and the development of emotional mental hygiene skills.

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Abstract on the topic “Theoretical and empirical foundations of integrative psychotherapy for affective spectrum disorders” updated: March 13, 2018 by: Scientific Articles.Ru

research	Emotional disorders
research	depressive	alarming	somatoform
Macrosocial	Social values and stereotypes that contribute to the growth of negative emotions and make it difficult to process them
	The cult of success and achievement	Cult of strength and competitiveness	Cult of ratio and restraint
Family	Features of the family system that contribute to the induction, fixation and difficulties in processing negative emotions
	Closed family systems with symbiotic relationships
	High parental demands and expectations, high level of criticism	Distrust of other people (outside the family), isolation, overcontrol	Ignoring emotions in family relationships and prohibiting their expression
Interpersonal	Difficulty building close relationships with people and receiving emotional support
	High demands and expectations from other people	Negative expectations from other people	Difficulty expressing yourself and understanding others
Personal	Personal attitudes that contribute to a negative perception of life, oneself, others and complicate self-understanding
Personal	Perfectionism	Hidden Hostility	“Life outside” (alexithymia)
Cognitive	Cognitive processes that stimulate negative emotions and impede self-understanding
	Depressive triad	Anxious triad	"It's dangerous to feel"
	Absolutization	Exaggeration	Negation
	Negative selection, polarization, overgeneralization, etc.		Operator thinking
Behavioral and symptomatic	Severe emotional states, unpleasant physical sensations and pain, social maladjustment
	Passivity, melancholy and dissatisfaction with oneself, a feeling of disappointment in others	Avoidance behavior, feelings of helplessness, anxiety, fear of being critical of oneself	Emotions are gumized and experienced at a physiological level without psychological complaints

Affective disorders history of studying the main theoretical models. Theoretical models and empirical studies of hostility in depressive and anxiety disorders.

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