MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Published from
the year 2017
Publication frequency
1-2 issue/year
Issue status
National/International
Founder
NDSAN Network (MFC – Coordinator of the NDSAN)
Issue language
English
Media environment
International
Abbreviation key title
MHGCJ
Target audience
Scientists/researchers (medical, social, educational fields and etc.), mental health (MH)
practitioners, policy-makers, researchers, lawyers.
Mental Health: Global Challenges Journal is an open access peer-reviewed journal,
whose main aim is to promote dialogue and debate on topics such as Mental Health,
Mental Health Care Systems and etc.
Mental Health: Global Challenges Journal is a journal dedicated to international studies
on MHC systems in the context of global social challenges, Mental health and migration,
Mental health in times of military conflicts, Mental health and community, Specific issues
of MHC, Higher Education and MHC, Interdisciplinary and transdisciplinary approaches in
MHC, and related topics, therefore we will encourage those papers which focus on the
specific particularities from these topics, and /or authors coming from these areas.
The journal considers with a special attention the manuscripts which can be of interest for
policy makers and/or practitioners.
The journal accepts manuscripts such as theoretical articles, research articles, case
studies, reviews, abstracts
Fields of study and special focus
Medicine, Social Sciences, Education, Economics, Law, Inter- and Transdisciplinary
studies
DOI: http://doi.org/10.32437/mhgcj.v3i1
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Borderline personality disorder and nursing
approach
Marindela Pergjini
1
, Evangelos C. Fradelos
2
, Ioanna V. Papathanasiou
1,3
1
Nursing Department, University of Thessaly, Larissa, Greece
2
General Department, University of Thessaly, Larissa, Greece
3
Community Nursing Lab, Nursing Department, University of Thessaly, Greece
Abstract
Introduction: Borderline Personality Disorder, is one of the ten Personality Disorders. These
Disorders are split into three categories, with the Borderline being part of the second one where
elements of dramatization and emotional instability are frequently evident.
Purpose: The purpose of the present study is to investigate and highlight the characteristics, the
treatment and nursing approach for people with this disorder.
Methodology: The study material consisted of articles on the topic found in Greek and
international databases such as: PubMed, Cochrane, Hellenic Academic Libraries Association
(HEAL-Link), Scopus and PsycINFO, using keywords as: “Borderline Personality Disorder”,
“Diagnosis”, “Therapy”, “Treatment”, “Holistic Care”, “Nursing Care”.
Results and Discussion: Bordeline Personality Disorder is characterized as a condition in which
a person differs significantly from the average of people, about how he thinks, perceives, feels
or relates to others. Treatment for this Disorder does not exist, however medication is used to
remission the symptoms. Nurses are part of the treatment team. They’re going to help the
patient learn to live with the symptoms of his disorder. As these people are special patients,
nurses must learn from their training not to focus on the patient's problem, but on the patient
himself.
Conclusions: The key characteristics of Borderline are impulsivity and instability in interpersonal
relationships, self-image and emotions. As there is no treatment, nurses as members of the
treatment team must develop a relationship of trust with the patient in order to be able to help
him in his recovery. It is important for nurses to be able to properly approach the person with
Borderline Personality Disorder to learn to adapt according to his personality
Keywords
Borderline Personality Disorder, Diagnosis, Medication, Holistic Care, Nursing Care.
Address for correspondence:
Marindela Pergjini, RN, Nursing Department, University of Thessaly, Larissa, Greece. e-mail:
marindela96@gmail.com
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Pergjini, Fradelos, Papathanasiou, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI: http://doi.org/10.32437/mhgcj.v3i1.81
Submitted for publication: 18
June 2020
Received: 18 June 2020
Accepted for publication: 14
September 2020
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Introduction
Borderline Personality Disorder, according to
the American Psychiatric Association and the
DSM is one of the ten Personality Disorders. These
Disorders are split into three categories, with the
Borderline being part of the second one where
elements of dramatization and emotional
instability are frequently evident. (APA, 2013). The
key characteristics of BPD are impulsivity and
instability in interpersonal relationships, self-image
and emotions. These symptoms tend to start in
the early years of adulthood and affect various
circumstances of the patient’s life. This Disorder is
usually found in the 1% - 3% of the general
population while clinical patients cover
approximately 10% of the cases. Individuals with
Borderline Personality Disorder can also have an
intense tendency of suicidal ideation and self-
harm. The suicide rate is 8%-10% (Stroud &
Parsons, 2012) but there are few epidemiological
data for BPD patients in Greece. In order for the
diagnosis of the Personality Disorder to be
accurate, the individual needs to be over the
age of 18 because its personality is still being
shaped under this age. What is more, the
patient’s behavior should be persistent over time
and not transient.
Purpose
The purpose of the present study is to
investigate and highlight the characteristics of
Bordeline Disorder as defined by the World Health
Organization and the American Psychiatric
Association, the treatment consisting, and the
nursing approach for people with this disorder.
Methodology
The study material consisted of articles on the
topic found in Greek and international databases
such as: PubMed, Cochrane, Hellenic Academic
Libraries Association (HEAL-Link), Scopus and
PsycINFO, using keywords as: “Borderline
Personality Disorder”, “Diagnosis”, “Therapy”,
“Treatment”, “Holistic Care”, “Nursing Care”.
Results and Discussion
Historical background
In older times, scientists of the psychodynamic
direction used the terms
"Ambulatory schizophrenia" and "Pseudo-
neurotic schizophrenia" in order to describe a
group of people that is in-between neurosis and
psychosis, with the main characteristics of
instability (emotional, interpersonal relationships
and self-image) and impulsivity. In 1938 the term
“Borderline” was suggested for the first time by the
psychoanalyst Stern, in an effort to describe a
patient who was in-between neurosis and
psychosis and was mentally unstable and difficult
to manage (Eby & Brown 2010). The Borderline
Personality Disorder as an official term, was finally
institutionalized in the early 1980’s at DSM-III and
constitutes one of the ten Personality Disorders
since then (Lenzenweger & Clarkin, 2005).
Clinical Characteristics
Individuals that have been diagnosed with
Borderline Personality Disorder are usually
impulsive and unstable in their interpersonal
relationships, self-image and emotions. These
symptoms appear in the early adult life of the
individual. They may appear as responses to
personal and social situations and they differ,
fundamentally, from the way the average person
understands, thinks, feels and relates with others
(Χριστοδούλουκαισυν., 2000).
The intense and unstable relationships are
these people’s main characteristic. They tend to
be extremely sensitive to the idea of rejection
and the fear of abandonment. When it comes to
their interpersonal relationships, they usually have
non-realistic expectations and show increased
emotional instability in the case of unexpected
disappointment and obvious rejection (Dubovsky
& Kiefer, 2014; Andrew et al., 2011). Borderline
Personality Disorder is, also, characterized by an
unstable self-image and self-worth. The life goals,
plans, values, sexual identity and friends of the
BPD patient may change in an abrupt way and
that is why these people respond better to a
predictable and structured environment (Eby &
Brown, 2010).
Moreover, impulsivity is one more key element
of the BPD. The diagnosis requires impulsivity in at
least two sections that could be proven self-
destructive, such as gambling, irresponsible
waste of money, reckless driving, bulimic eating,
unprotected sex, substance abuse or self-
harming behavior (Giannouli et al., 2009; Nehls,
2000). This type of impulsivity differs from the
impulsive behavior that appears during the
manic episodes where it is prolonged and
accompanied by other symptoms of mania such
as grandeur, stressful speech and lack of need
for sleep.
Self-harming is, also, frequent in this Disorder.
More specifically, 75% of the individuals that
have been diagnosed with Personality Disorder
and an even higher percentage of the clinical
patients have attempted self-harm (Geoffrey et
al., 2016). An 8 – 10% of the patients have
successfully attempted suicide (Tomko et al.,
2014) but there are numerous cases of self-harm
without suicide, such as self-cutting, scratches or
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
burns on themselves which are much more
common.
The aforementioned behavior, often, occurs
when the person is worried about possible
abandonment or rejection. It can also be seen
during episodes of de-realization or
depersonalization (Bach & Sellbom, 2016).
Depersonalization consists of a detachment
within the self, in which the individual feels like he
is placed outside of his body and looks at himself
from a distance. He doesn’t feel pain if he is
injured. Some patients claim that the pain from
cutting and burning reminds them that they’re
alive (Eby & Brown, 2010).
Diagnosis
The immense need for a “common
language” in clinical psychiatry, not only on an
international level but also on a national, brought
to the foreground the formation of the two
taxonomic systems:
1) the Diagnostic and Statistical Manual of
Mental Disorders (DSM), the American Psychiatric
Association and
2) the International Classification of Diseases
(ICD) of the World Health Organization.
These two systems are the tools for the
classification and the diagnosis of mental
illnesses and use specific diagnostic criteria in
order for those illnesses to be diagnosed,
including the Borderline Personality Disorder.
The fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5)
includes nine diagnostic criteria. The individuals
with Borderline Personality Disorder should have at
least five of these criteria which should be evident
in various circumstances of the person’s life (APA,
2013).
Borderline Disorder patients make excessive
efforts to prevent either an existing or an
imaginary rejection. When they get the feeling of
abandonment, they may intentionally change
their self-image and behavior. They, also,
experience intense anger even when separation
is inevitable. They, often, associate
abandonment with the belief that they are “bad”
themselves. The intense efforts to avoid
abandonment may lead to impulsive actions, like
this of self-harm (Bach & Sellbom, 2016).
Furthermore, the unstable and intense
interpersonal relationships are a behavioral
characteristic of Borderline Disorder patients
(Sellbom et al., 2014). They tend to idealize a
friend, partner or mental assistant from their very
first contact, to spend time together and share
details of their personal life. However, they can
easily change this sympathy into devaluation. The
feel that this person does not give them time or
listen to them, and mainly does not show his
support.
The main feature of this Disorder, is impulsive
behavior in at least two sections that could be
proven catastrophic, such as excessive food or
alcohol consumption, substance abuse,
dangerous sexual intercourse and reckless driving
(APA, 2013).
There may be an identity crisis with an intense
and unstable self-image (Trull et al., 2011). The
individual feels the need to drastically and
dramatically change its self-image which is
characterized by a shift in goals, values and
professional aspirations. There may be a sudden
change in his views and plans about his career,
sexual identity and values (Tomko et al., 2014).
Such behaviors, occur in situations in which the
individual feels the lack of a meaningful
relationship, progress and support.
Borderline Disorder patients adopt a
continuous suicidal behavior or the habit of self-
harm (APA, 2013). The repeated suicide attempts
are often the reason why these people seek for
help. These acts are overshadowed by threats of
separation or rejection. Self-harm can occur
during fun experiences and often brings relief to
the individual.
Another criterion is the emotional instability
which is caused by intense episodic discomfort or
anxiety and lasts for a couple of hours or, very
rarely, for a few days (Trull et al., 2011).The
discomfort of people with Borderline Disorder is
often disturbed during periods of anger, panic or
despair and rarely by periods of calmness or
satisfaction.
These patients are, also, characterized by a
chronic feeling of emptiness (APA, 2013). They
can easily get bored of anything and are
constantly looking for something to do. They have
a difficulty in controlling their anger which is
usually inappropriate. This anger takes place
when they feel neglected, embarrassed or
abandoned.
In periods of intense stress, individuals with
Borderline Disorder experience transient paranoid
ideationor severe detachment symptoms [APA,
2013]. These episodes tend to be transient and
they usually last a few minutes, hours and, very
rarely, days. They occur during periods of realistic
or imaginary abandonment and usually go away
when another person’s stay is perceived (Trull et
al., 2011).
On the other hand, the World Health
Organization, through the International
Classification of Diseases (ICD-10), suggests that
there should be a separate description of five
areas – characteristics for the recognition of
Personality Disorder. According to ICD-10, the
individual should exhibit three of the general
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Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
characteristics of Personality Disorders and at
least two of the characteristics of Borderline
Disorder (Στεφανήςκαισυν., 1997).
According to the basic criteria of the ICD-10,
at first, there should be an indication of the
patient’s characteristics and the permanent
patterns of the mental experience and behavior,
as a whole, should be significantly deviant from
the culturally expected and accepted rules. Such
a deviation must be manifested in more than
one area, like cognitive function, emotionality,
control over impulses and satisfaction of needs,
and how the individual relates to others and
handles interpersonal situations. This deviation
should be present extensively as a behavior that
is inelastic, maladaptive or dysfunctional across a
wide range of personal and social situations.
What is more, there should be mental stress or an
unpleasant impact on the social environment, or
both. There must be an indication that the
deviation is stable and long-lasting and has
begun in late childhood or adolescence.
Deviation cannot be interpreted as a
manifestation or consequence of other mental
disorders, and at the same time an organic brain
disease, trauma or dysfunction must be excluded
as possible causes of the deviation (Μαδιανός,
2006).
Provided that there will be a recognition of at
least three criteria of the general diagnostic
criteria, the ICD-10 suggests the following
diagnostic criteria for Borderline Disorder. It is
mainly characterized by disturbances and
uncertainty about oneself, goals and inner
preferences. Patients usually have a
predisposition to engage in intense and unstable
relationships that often lead to emotional crises
(Whewell et al., 2000). They are filled with a sense
of grandeur and become very manipulative with
people around them. As soon as they realize that
those around them do not embrace their
grandeur, they will become quite hostile. These
people go to great lengths to avoid
abandonment. In this endeavor, they display
repeated threats or acts of self-harm. Chronic
feelings of emptiness, as well as negative
emotions and bad mood are distinctive
characteristics of theirs (Στεφανήςκαισυν., 1997).
Individuals with Borderline Disorder show severe
emotional instability, and they are also very
anxious and usually depressed. They are, also,
detached andcarry a pattern of indifference.
Apart from that, they do not feel the need to
develop intimacy with others and are mostly
indifferent to their feelings (Μαδιανός, 2006).
The symptoms should be intense to make the
diagnosis and associated with weakened
psychosocial function. Once the diagnosis of
Borderline Personality Disorder is made, the
proposed ICD-10 model includes the assessment
of the condition of individuals with BPD as mild,
moderate or severe (Στεφανήςκαισυν., 1997).
Looking at the two taxonomic systems DSM-5
and ICD-10, there do not seem to be major
differences in the recognition of Borderline
Disorder, however some differences are
noticeable. One of them is the way of diagnosing
Borderline Disorder, in DSM-5 there are nine
diagnostic criteria for the recognition of Borderline
Disorder, while in ICD-10 the diagnosis of
Personality Disorder comes first and then the
recognition of Borderline Disorder. Also, the
absence of psychosis is observed as a diagnostic
criterion in ICD-10. The element of psychosis,
according to ICD-10, seems to be a diagnostic
criterion of schizophrenia and schizotypal
personality disorder and not of Borderline
Disorder.
Despite the already existing diagnostic criteria,
further research seems to be needed to
determine whether some criteria should be more
important than others. For instance, self-harm
and suicide attempts along with unstable
interpersonal relationships may be more
important signs in the diagnosis of Borderline
Personality Disorder.
Therapy/Treatment
Ensuring the right treatment for people with
Borderline Personality Disorder is especially
important. The initial priority in the psychosocial
treatment of Borderline Disorder is to avoid self-
harm. Other issues that need attention are mood
problems and the impulsive behavior. The
treatment of this Disorder is long lasting. It requires
the individual to work with a team of health
professionals.
Dialectical Behavioral Therapy is a cognitive
and behavioral psychotherapy used specifically
for Borderline Personality Disorder. Dialectical
Behavioral Therapy has been shown to reduce
suicidal behavior and the need for
hospitalization, while increasing interpersonal
functionality and anger control (Beck et al.,
2015).
Equally important is psychopharmacology,
which should be taken as complementary
therapy and not as the main. Polypharmacy is a
common problem faced by people with
Borderline Disorder. Research shows that 80% of
people diagnosed with Borderline Disorder are on
medication, while 40% of them seem to be
receiving more than 3 medications (Gunderson &
Berkowitz, 2003). Serotonin reuptake inhibitors are
the most widely used class of drugs in people
with Borderline Disorder that help with the
symptoms of depression (Zanarini et al., 2001).
Another class of drugs used is that of
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Mental Health: Global Challenges Journal
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benzodiazepines. Although there is no research
data to support their use in people with Borderline
Disorder, they are used to treat anxiety and
emotional instability. However, they should be
prescribed, if necessary, very carefully and in
small doses (Stoffers & Lieb, 2015; Zanarini et al.,
2001). Anticonvulsants seem to have positive
effects on reducing depression and interpersonal
problems.Another widely used class of drugs are
antipsychotics, which are used both for psychotic
symptoms and to manage mood instability (Lieb
et al., 2010).
All classes of drugs should be prescribed with
great caution as there are individuals with
Borderline Disorder who are prone to suicide
attempts, with the result that the medication can
be fatal in case of overdose. Due to the different
classes of medications available, medication
should be adjusted according to the symptoms
of the person with Borderline Disorder and
unnecessary medication should be avoided.
Nursing Approach
The nurse is an integral part of the team of
health professionals in which he comes in
contact with people with Borderline Disorder.
Peplau is the one who stressed the importance of
the relationship that is being developed between
the nurse and the patient. She, also, pointed out
how important it is for the patient (as a human) to
be the focal point of nursing care and not his
problem.
Peplau's model, which is based on
psychodynamic and psychodramatic theories,
seems to be the most appropriate for the nurses'
proper treatment of people with Borderline
Disorder. Peplau described 4 interrelated and
overlapping phases in the nurse-patient
relationship [Peplau, 1997]. The orientation phase
in which the nurse understands and evaluates
why the person is at the point of receiving help.
Then, follow the phases of identification and
exploitation, which are phases of work, patient
support in recognizing internal dissonance as well
as developing and testing strategies that reduce
internal dissonance. Finally, there is the analysis
phase, where the patient uses these strategies to
reduce and resolve internal dissonance and
psychological pain [Peplau, 1992].
The role of the nurse in the treatment of
people with Borderline Disorder is mainly
supportive. The nurse, is the one who will help
these people learn to cope with the demands of
daily life and to meet their basic needs
[O’Connell & Dowling, 2013]. This procedure
should be done in collaboration with the patient,
so it is especially important to develop a trust
relationship. The nurse should encourage the
person to make small gradual decisions about his
daily life, so the person takes on a role in the
treatment team by helping in his smoother and
faster recovery and well-being.
People with Borderline Disorder are people
who have difficulty in developing interpersonal
relationships so they need to be given more time
to develop a proper therapeutic relationship. This
proper relationship, allows the nurse to determine
the roles he will adopt as well as the nursing
interventions he will follow and the roles the
person must adopt in order to proceed with the
recovery (Papathanasiou et al., 2013;
Stockmann, 2005).
The nurse is responsible for a big part of the
patient’s care. In order to be able to provide
proper nursing care and for his patients to have
the right healing process it would be right to try to
see the person and not the problem.
Unfortunately, the nurse during his training is
detuned in his attempt to learn the practical part
correctly, forgetting that he must also understand
the psychosynthesis of his patient (Henderson,
2002).
Conclusions
People with Borderline Personality Disorder are
characterized by a rather peculiar behavior, with
impulsivity, tendencies of self-injury and unstable
interpersonal relationships being key features. The
diagnosis of the Disorder cannot be made before
the age of 18, as until then the personality is still
being formed. However, it is important to
diagnose Borderline Disorder early so that people
can learn how to control their impulsivity and
reduce the tendency for self-harm. Nurses have
an important role in this process, as they are next
to these people teaching them how to cope with
meeting their basic needs. In order to do this, a
therapeutic relationship must be developed
between nurses and patients, but individuals with
Borderline Disorder find it difficult to develop and
maintain a relationship. Knowledge of the salient
features is essential to create a favorable
therapeutic alliance, to increase the patient's self-
awareness, to plan realistic therapeutic goals and
to match the treatment with the individual's
personality. Nursing has a human-centered
character so nurses should not forget that behind
the problem they face, there is a person who is
the center of attention.
Conflict of interest
Authors declare that they have no conflict of
interests.
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
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Disorders of social functioning and quality of life in
patients with gastroesophageal reflux disease while
combined with undifferentiated connective tissue
dysplasia
Iryna Romash
Ivano-Frankivsk National Medical University, Ukraine
Abstract
Introduction. It has been scientifically confirmed that the risk of developing gastroesophageal
reflux disease (GERD) increases especially with generalized or regional disruption of connective
tissue structure, which is widespread among the population. Patients with such comorbid
pathology may have a wide range of symptoms that may go beyond the general symptoms of
heartburn and regurgitation. The symptoms and complications of GERD affect general health,
daily and social functioning, physical and emotional activity. It also affects the quality of life
(QoL) associated with health through frequent breaks during sleep, work and social activities.
Purpose. study the dynamics of the level of quality of life and social functioning in patients with
gastroesophageal reflux disease in combination with the syndrome of undifferentiated
connective tissue dysplasia.
Methodology. A total of 120 patients were included in the study: 65 men and 55 women: in 75
of them (Group II) GERD occurred on the background of UCTD, in 45 (Group I) as an
independent disease. The control group consisted of 12 healthy individuals. The study was
comprehensive. The Medical Outcomes Study 36-Item Short-Form Health Status (SF-36),the
Gastrointestinal Symptom Rating Scale (GSRS) and the scale of "Personal and social
performance" (PSP) - were used to study patients in detail.
Results and Discussion. Analyzing the results obtained on the basis of the GSRS questionnaire
(Table 1), in patients with GERD on the background of UCTD, compared with patients of group I
and the control group, there is a significant increase in three and four from the five scales. QoL
in patients of Group II on the scale "Abdominal pain" were 14.3 ± 0.4 points, in Group I - 5.6 ±
1.3 points, in the Control Group - 2.4 ± 0.8 points, on the scale "Reflux syndrome": 13.7 ± 0.9,
10.5 ± 1.3 and 3.1 ± 0.9, respectively. "Dyspeptic syndrome" - 15.3 ± 0.4 points in Group II,
12.2 ± 0.6- in Group I and 6.1 ± 0.3- in the control group. "Constipation syndrome" 9.5 ± 0.8,
5.6 ± 1.03 and 5.7 ± 0.4, respectively (p <0,05).
Conclusions: In this research we investigated the effect of comorbid pathology on QoL in
patients with GERD, which developed against the background of UCTD. The results confirm that
patients with such combined pathology have a lower level of quality of life and social
functioning, and the tactics of treatment of such patients should take into account these
changes.
Keywords
Gastroesophageal reflux disease, undifferentiated connective tissue dysplasia, quality of life,
social functioning.
Address for correspondence:
Iryna Romash, Department Propaedeutics of Internal Medicine, Ivano-Frankivsk National
Medical University, Ukraine. e-mail: iromash@ifnmu.edu.ua
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Romash, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI http://doi.org/10.32437/mhgcj.v3i1.100
Submitted for publication: 21
July 2020
Received: 21 July 2020
Accepted for publication: 06
November 2020
MHGCJ – 2020
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https://mhgcj.org ISSN 2612-2138
Introduction
The number of patients suffering from
undifferentiated connective tissue dysplasia
(UCTD) has been steadily increasing in recent
decades and ranges from 9 to 85%, depending
on the population. As a premorbid background
for the development of many pathological
conditions and chronic diseases, the syndrome of
UCTD requires more attention from clinicians.
Especially often, against the background of this
syndrome, there are disorders of the digestive
system, in particular - the esophagus. The reason
is the mesenchymal nature of its origin. Against
the background of inflammatory diseases of the
upper gastrointestinal tract more often than in
patients without signs of dysplasia, motor
dysfunction, in particular, gastro-oesophageal
and duodeno-gastric reflux .
It has been scientifically confirmed that the risk
of developing gastroesophageal reflux disease
(GERD) increases especially with generalized or
regional disruption of connective tissue structure,
which is widespread among the population.
Patients with such comorbid pathology may have
a wide range of symptoms that may go beyond
the general symptoms of heartburn and
regurgitation (Kumar, A. et.al., 2020). The
prevalence of GERD ranges from 5.2-8.5% in East
Asia to 6.3-18.3% in Iran. And Arshad Kamal Butt
et.al. in their study among Pakistanis note a much
higher prevalence - 22.2% - 24.0%. There is a
worldwide increase in the incidence of GERD and
its complications, including Barrett's esophagus
and esophageal adenocarcinoma. Back in
2008, GERD was classified as one of the 5
diseases, which significantly impairs the quality of
life of patients. Recent studies by Michele Ludici
on the quality of life (QoL) of patients with UCTD
once again drew our attention to the comorbidity
of these two conditions. This is because
according to J. B. Marshall, most often in
diseases of the connective tissue affect the
esophagus. And V. Kondoh et. al. diagnosed with
pathological reflux in 29.0% of patients with UCTD,
while in its absence it was registered in 2.0% of
those examined with GERD. Even more often
manifestations of the gastroesophageal system
were detected against the background of
connective tissue pathology, which included its
undifferentiated dysplasia, among which
gastroesophageal reflux (GER) was observed in
68.0%, regurgitation - in 43.0%, dysphagia - in
33.0% of patients. Also, in UCTD, the balance
between the factors of aggression and protection
of the esophageal mucosa is disturbed by
weakening the latter. According to the results of
lower esophageal manometry, in 55% of patients
with connective tissue pathology, there was a
decrease in the tone of the lower esophageal
sphincter, a symptom of which may be reflux
(Denaxas et.al., 2018).
The symptoms and complications of GERD
affect general health, such as daily and social
functioning, physical and emotional activity. It
also affects the quality of life associated with
health through frequent breaks during sleep, work
and social activities (Iudici, M. et.al., 2017;
Kumar, A. et.al., 2020).
These data are comparable with our previous
data, according to which in adults with
developed GERD on the background of UCTD,
arthralgia, Raynaud's phenomenon, low body
weight, bone, joint and skin phenotypic traits that
correlate with the frequency and duration of GER.
(Romash I.B et.al.,2020).
QoL research is a highly informative tool that
determines the effectiveness of the health care
system and allows to give an objective
assessment of the quality of health care at the
level of its main consumer - the patient. From the
point of view of the principles of evidence-based
medicine, the patient's QoL is the only noteworthy
criterion and the main goal of the effectiveness
of treatment of long-term, chronic diseases.
(Romash I.R et. al., 2019; Moskalenko V. F et.al.,
2014).
Purpose
The aim of the study was to study the
dynamics of the level of quality of life and social
functioning in patients with gastroesophageal
reflux disease in combination with the syndrome
of undifferentiated connective tissue dysplasia.
Methodology
From June 2017 to December 2019, 378
patients with GERD were examined in the
University Clinic of Ivano-Frankivsk National
Medical University and in the therapeutic
department № 2 of the municipal enterprise
"Central City Clinical Hospital" of Ivano-Frankivsk.
The study included 134 patients. All of them
provided written informed consent. During the
study, 9 patients were lost for follow-up (at one
stage or another expressed a desire not to
continue to participate in the study).
During follow-up, 5 patients were diagnosed
with certain differentiated connective tissue
disease (1-scleroderma, 3-systemic lupus
erythematosus and 1 Sjogren's syndrome), which
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were excluded from the study. 120 patients were
included in the study: 65 men and 55 women: in
75 of them (group II) GERD occurred on the
background of UCTD, in 45 (group I) as an
independent disease. The control group
consisted of 12 healthy individuals, without signs
of UCTD, randomized by age and sex. The mean
age of the subjects was 42.0 ± 6.5 years. The
majority of patients (62%) received higher and
secondary special education, 75% of those
surveyed were employed, and 7.3% retired.
When entering the study, the most common
clinical manifestations were arthralgia / arthritis
(45.6%), Raynaud's phenomenon (45.6%), dry
eyes and/or mouth (32.6%), frequent
gastroesophageal reflux disease (32.6%),
myalgia (26.0%) and asthenia (26.0%).
The study was comprehensive. The Medical
Outcomes Study 36-Item Short-Form Health Status
(SF-36) (Ware et al., 1993), the Gastrointestinal
Symptom Rating Scale and PSP - the scale of
"Personal and social performance " (Morosini P. L.,
Magliano L., Brambilla L., Ugolini S., Pioli R., 2000)
were used to study patients in detail.
Each patient was asked to complete a
questionnaire SF-36.10, consisting of 36 questions
grouped into 8 domains: physical functioning
(PF), social functioning (SF), role limitations related
to physical problems (RP), role limitations
associated with emotional problems (RE), mental
health (MH), vitality (VT), body pain (VP) and
perception of general health (GH). The indicators
of each scale are compiled in such a way that
the higher the value of the indicator (from 0 to
100), the better the score on the selected scale.
From them form two parameters that estimate
eight concepts of health: psychological and
physical components. The physical component
includes: GH - the general perception of health,
PF - limitations in physical activity due to health
problems, RP - limitations in normal role activities
due to physical health problems, BP - physical
pain. The mental component includes: SF -
limitations in social activities due to physical or
emotional problems, MH - general mental health,
psychological distress and well-being, RE -
limitations in normal role activities due to
emotional problems, VT - viability (energy and
fatigue). The scores of each scale vary between
0 and 100, where 100 represents complete
health, and the results are presented as scores
compiled in such a way that the higher score
indicates a higher QoL level. This questionnaire is
general, can be used for patients with various
pathologies, as well as for population studies. It
has proven itself in many clinical studies, easy to
use.The questionnaire SF-36 is multidimensional,
fairly simple, short, reliable, valid and sensitive.
Peculiarities of social dysfunction were
assessed on the basis of the Personal and social
performance (PSP) scale, which assesses the
degree of impairment in four main areas: (a)
socially useful activities, including work and study;
(b) personal and social relationships; (c) self-
service; (d) restless and anxious behavior. The
level of dysfunction was assessed by the severity
of these areas from 0 to 5 (absent, weakly
expressed, markedly expressed, significantly
expressed, strongly expressed).
GSRS is a specific questionnaire consisting of
15 questions grouped into five clusters for a
detailed study of symptoms reflecting reflux,
abdominal pain, indigestion, diarrhea and
constipation. GSRS has a seven-point Likert-type
scale, where 1 means no problem symptoms
and 7 means very problematic symptoms.
The reliability and validity of GSRS are well
documented (Dimenäs, E et.al., 2008), and the
values of the norms are available for the general
population. In working with patients, we adhered
to the ethical principles of the Declaration of
Helsinki of the World Medical Association (Helsinki
1964, 2000 ed.). The study was approved by the
Bioethics Committee of Ivano-Frankivsk National
Medical University. Before inclusion in the study, all
patients signed voluntary informed consent. All
patients agreed to participate in the study and
provided written informed consent
Statistical analysis of the results was performed
using software packages STATISTICA 7.0., And a
package of statistical functions of the program
"Microsoft Excel, 2016". The reliability of the
obtained indicators was confirmed by calculating
errors for relative values, and the probability of
data difference in the compared groups was
proved based on calculating the coefficient t
(Student) and determining the accuracy of the
error forecast. The arithmetic mean (M), standard
error (± m) were used to describe quantitative
features.
Results and Discussion
In the study and comparison groups, the
analysis of QoL parameters was performed. The
comparative analysis revealed a probable
decrease in QoL in patients with GERD, which
occurred against the background of connective
tissue dysplasia. compared with the control group
who did not have concomitant pathology.
When assessing the social functioning of
patients with GERD comorbid with UCTD on the
PSP scale, the most pronounced violations were
found in the module "restless, anxious behavior"
on average in Group I - 4.8 ± 0.18 points (95% CI
4.6-4.9); Group II - 4.1 ± 0.37 (95% CI 3.73-4.47);
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Control Group - 4.9 ± 0.1 (95% CI 4.79-5.0). The
cluster "personal and social relations" is presented
as follows: 4.2 ± 0.46 points (95% CI from 4.2 to
4.78); 3.2 ± 0.18 (95% CI 3.15-3.92), 4.8 ± 0.16
(95% CI 4.53-5.0), respectively. The module
“socially useful activity” and “self-service” was less
affected, where group differences were not
statistically significant.
Analyzing the results obtained based on the
GSRS questionnaire (Table 1), in patients with
GERD on the background of UCTD, compared
with patients of group I and the control group,
there is a significant increase in three and four of
the five scales. QoL in patients of group II on the
scale "Abdominal pain" was 14.3 ± 0.4 points, in
group I - 5.6 ± 1.3 points, in the control group -
2.4 ± 0.8 points, on the scale "Reflux syndrome":
13.7 ± 0.9, 10.5 ± 1.3 and 3.1 ± 0.9,
respectively; "Dyspeptic syndrome" - 15.3 ± 0.4
points in the main (II) group 12.2 ± 0.6- in the
comparison group and 6.1 ± 0.3- in the control
group;"Constipation syndrome" 9.5 ± 0.8, 5.6 ±
1.03 and 5.7 ± 0.4, respectively (p <0,05).
In the study and comparison groups, the
analysis of quality of life indicators was
performed. The comparative analysis revealed a
probable decrease in QOL, both among its
physical and mental components, in patients of
group II in comparison with group I who did not
have concomitant pathology and control group.
A comparative assessment of the dynamics of
the physical components of the quality of life of
patients with GERD against the background of
NDST is presented in Figures 1a) and 1b).
Table 1. Assessment of the quality of life in patients with GERD in combination with UCTD and as an
independent disease.
Clinical group
n
Quality of life according to the GSRS questionnaire, points
abdominal
pain
reflux
syndrome
diarrhea
syndrome
dyspeptic
syndrome
constipatio
n
syndrome
I Group (GERD)
45
5.6±1.3*
10.5±1.3*
4.8±0.7
12.2±0.6*
5.6±1.03
II Group
(GERD+UCTD)
75
14.3±0.4*^
13.7±0.9*^
5.1±1.08
15.3±0.4*^
9.5±0.8*^
Control Group
12
2.8±0.4
3.1±0.9
3.4±1.07
6.1±0.3
5.7±0.4
p1 (ІI Gr / I Gr.)
<0.01
<0.01
0.81
<0.01
<0.01
p2 (ІI Gr./Contr. Gr)
<0.05
<0.05
0.26
<0.01
<0.01
Notes:
1. ^ - (p <0,05) data are reliable between the study groups.
2. *- (p <0,05) data are reliable relative to the control group.
MHGCJ – 2020
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Fig. 1a) Dynamics of quality of life indicators
(physical component of health) in patients with
GERD.
Notes:
1. ^ - (p <0,05) data are reliable between the study groups.
2. *- (p <0,05) data are reliable relative to the control group.
Fig 1b) Dynamics of quality of life indicators
(mental component of health) in patients with
GERD.
Notes:
1. ^ - (p <0,05) data are reliable between the study groups.
2. *- (p <0,05) data are reliable relative to the control group.
Conclusions
In this research we investigated the effect of
comorbid pathology on QOL in patients with
GERD, which developed against the background
of UCTD. The results confirm that patients with
such combined pathology have a lower level of
quality of life and social functioning, and the
tactics of treatment of such patients should take
into account these changes.
Conflict of interest
The author declares that she has no conflict of
interests.
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Vettori, S., & Valentini, G. (2017). Longitudinal
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Rizwan, A. (2020). Quality of Life in
Gastroesophageal Reflux Disease Three
Months After Laparoscopic Nissen’s
Fundoplication. Cureus. Cureus.
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(2014). Metodolohiia dokazovoi medytsyny:
pidruchnyk . Kyiv: «Medytsyna», 200 s.
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frequency of visceral and phenotypic markers
in patients with the combination of
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Romash I.R., Vynnyk M.I. (2019) Dynamics of
Quality of Life Indices in Case of Metabolic
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16
Syndrome in Patients with Paranoid
Schizophrenia on the Background of Atypical
Neuroleptic Agents Application and
Improvement of Comorbidity. Ukrains’kyi visnyk
psykhonevrolohii. 27,4 (101):62-67. DOI:
https://doi.org/10.36927/2079-0325-V27-is4-
2019-11
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Implementation of the DIR Model and the
DIR/Floortime Approach in the System of Palliative
Care for Children
Elena Akulova
Expert & Training Leader, Interdisciplinary Council on Development and Learning (ICDL), Minsk, Belarus
Abstract
Introduction. One of the systems that can be used in the system of palliative care for children is
the Developmental Individual Relationship (DIR)/Floortime concept, which can be flexibly
adapted to individual features of a child, and at the same time it has intelligible and clearly-
defined tools for work and interaction, that take into consideration not only individual
peculiarities of a patient, but also their parents and specialists.
Purpose. The purpose of the paper was to review the possibilities and prospects of using
DIR/Floortime model in the system of palliative care for children.
Methodology. The paper was prepared on the basis of input from Belarusian Children's Hospice
and also took into account experience of implementation of the DIR/Floortime Model (report
information of ICDL’ specialists).
Results and Discussion. In the course of the work the main tasks for providing palliative care to
sick children were outlined and 6 points of introduction of the DIR /Floortime concept into this
system were singled out.
Conclusions. The main postulates of the DIR concept fully coincide with the modern principles
of palliative support. Using DIR/Floortime Model also can solve urgent tasks of the system of
palliative care for children: build a team-based, positive, supportive and safe relationship
around a child and family; help to prevent conflicts; improve the emotional background of the
child in care.
Keywords
Child psychology, mental health, education, palliative care, DIR Model, DIR/Floortime
Approach.
Address for correspondence:
Elena Akulova, Expert & Training Leader, Interdisciplinary Council on Development and
Learning (ICDL), Minsk, Belarus. e-mail: akulova.al@gmail.com
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Akulova, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI https://doi.org/10.32437/mhgcj.v3i1.75
Submitted for publication: 06
March 2020
Received: 06 March 2020
Accepted for publication: 07
June 2020
MHGCJ – 2020
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https://mhgcj.org ISSN 2612-2138
Introduction
Palliative care for sick children involves
providing assistance to a wide category of
patients that includes not only oncology patients
but also children with congenital or/and acquired
diseases and (multiple) complex developmental
disorders. Thus, we cannot talk about a narrow
range of diagnoses: every child has his own
individual aspect of a disease. A team of
specialists, who provide palliative care for a
family and a child, are tasked not only with
medical, but also psychological and
pedagogical support of a child and his parents.
One of the standards of high-level palliative care
is to provide assistance not singularly to a child,
but to the entire family of a patient. In addition,
the extensive experience of palliative support of
patients in different countries shows that the
emotional background of a palliative patient has
a direct impact on the somatic and mental
condition of the child and even on the nature of
the course of his\her disease (Itskovich, G.,2018;
2019).
The system of palliative care in many countries
is currently being created and established or
improved. The model of care for terminally-ill
children undergoes changes for humanism and
personalized approach, which takes into account
not only a patient’s interests, but also peculiarities
of their stay in the family. However, even in a
personalized system of care specialists of
different profiles who work in a team need a
common frame of orienting points. It will make
the teamwork focused, well-coordinated and
consistent (Gomozova, E. S., & Gomozova, M. A.,
2019). One of the systems that can be used in
the system of palliative care for children is the
Developmental Individual Relationship
(DIR)/Floortime concept, which can be flexibly
adapted to individual features of a child, and at
the same time it has intelligible and clearly-
defined tools for work and interaction, that take
into consideration not only individual peculiarities
of a patient, but also their parents and specialists
(Pajareya, K., Sutchritpongsa, S., Kongkasuwan,
R., 2019; Boshoff, K., Bowen, H., Paton, H. et all.,
2020; Hess, E., 2020).
Purpose
The purpose of the paper was to review the
possibilities and prospects of using DIR/Floortime
Model in the system of palliative care for children.
Methodology
The paper was prepared on the basis of input
from Belarusian Children's Hospice and also took
into account experience of implementation of
the DIR/Floortime Model (report information of
Interdisciplinary Council on Development and
Learning’ specialists).
Results and Discussion
Therefore, providing of palliative care for sick
children has the following tasks:
- To organize effective teamwork of specialists
of different profiles within a single framework of
the palliative system for a particular client; it
implies using single terminology and following the
common assistance concept, which experts can
rely on for their work to be consistent and
coordinated.
- A child's family must be included into the
system of assistance: family members need to
be trained specific methods of care and
medical manipulations, but also it is crucial to
teach them the correct interaction with the child
and to provide them with psychological
counselling and spiritual support if necessary.
- Children with complex diseases are often
subjected to chronic stress associated with
frequent hospitalizations, surgical treatment, as
well as stress caused by instrumental and/or
psychological trauma. These problems also need
to be systematically addressed.
- Professionals who work in the field of palliative
care often face intense severe experiences,
which puts them at risk of emotional burnout. In
this regard, it is necessary to focus on burnout
prevention and psychological well-being of
specialists.
Implementation of the DIR/Floortime concept
into the system:
1) The DIR concept is both multidimensional
and flexible. The first aspect of the DIR is the
development component which shows us the
current state of the child and his actual level of
development. Personalized approach
presupposes that we take into account not only a
child’s level of development, but also all his/her
individual characteristics: history of illness, his
sensory-motor profile, specifics of the family
system where the child resides (resources and
"weak" areas, history of the disease as seen by
family members, psychological state of close
relatives of the child, etc.). Component "D" shows
us how to build interaction with each specific
child and their family based on the previous two
points. Besides, there are several other
"dimensions" – these are the characteristics of
each involved specialist, their individual profile,
experience, skills and current emotional state.
Basing on this data we can personalize
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interaction of all specialists with a patient and/or
their family and fully adapt it to the child's needs.
2) The crucial role of affect in the
DIR/Floortime model needs to be emphasized.
The DIR/Floortime teaches us to establish and
develop emotionally healthy and positive
relationships. Besides, special attention is paid to
compliance with ethical principles, as well as to
respect for each patient, their family members,
and specialists involved. The DIR/Floortime gives
us specific tools for building emotionally warm
relationships, with a full range of acceptance of
all emotions experienced by all participants of
the process. Such practice and attitude has a
therapeutic role in itself – it helps to prevent
emotional burnout of everyone involved and
helps to regulate the emotional background of a
patient, which, as we have already indicated,
directly affects his/her condition as a whole.
3) Reflection. The DIR/Floortime concept
increases the level of awareness in the specialist-
child or specialist-parent interaction. It implies
self-improvement of each specialist,
development of their self-awareness, which leads
to the more conscious and careful usage of their
skills and abilities in work.
4) Team. The DIR / Floortime suggests
teamwork of different specialists – of medical,
psychological and pedagogical profiles,
rehabilitation specialists, etc. However, these
specialists, provided they have the necessary
training, have an opportunity to coordinate their
work according to the common DIR parameters,
and form a single joint vision of the dynamics and
prospects of a child in their care.
5) Family. The DIR/Floortime concept
emphasizes a huge role of the family system and
of cooperation with family members – those who
take care of the child. They become the main
"players" in the team. The advantages of such an
approach are undeniable: it allows parents to
cope with the trauma of the disease, they feel
the support from outside and realize their
important role within the team, also it facilitates
the work of specialists, since some part of the
work can be taken over by trained parents.
6) Child. For many years in post-soviet
countries the role of a seriously ill patient was
"inanimate" and impersonal. These people were
treated as objects that needed to be
manipulated and cared for. Only recently they
have raised a question of the quality of life of
such people and humane attitude to them. The
DIR/Floortime approach helps us to avoid
excessive stress while dealing with seriously ill
children. As practice shows, the atmosphere of
the medical institution changes dramatically for
the better and stress levels of patients and their
relatives reduce significantly when the staff know
and successfully use the tools to establish
emotionally warm and safe relationships.
Moreover, it increases work motivation and
improves the emotional state of employees of
the institution.
Limitations of the study
Potential challenges in the implementation of
the DIR/Floortime approach in the system of
palliative care
1) The first difficulty we might encounter is
the delay of important results. It is not enough just
to train the staff and give them "tools" of the
approach to get some persistent changes in the
work of the team. Each team member will have
to go through a stage of internal changes, and
work on self-reflection, empathy, increasing
awareness of their experiences and interactions,
both in the team and with patients. However, in
the long run, this very approach helps to get a
better result in terms of team cohesion, improving
motivation and emotional state of employees.
2) The use of the DIR/Floortime requires a
very subtle adjustment of the connection
specialist-child, and there might appear
situations when a child and a specialist will not
coincide in some parameters (individual
characteristics, emotional state, etc.). This will
require "replacing the player" or taking some
other action to deal with the problem.
3) In very rare cases, some team members
might consider the DIR/Floortime concept
unsuitable due to their personal characteristics.
They might find it difficult to use non-directive
methods, as well as to work with their emotions.
Each such case requires an individual approach
and search for solutions.
4) Staff training will take a certain amount of
time, and then, after training, regular supervisions
need to be provided. Professionals who provide
assistance have to complete not only the
introductory 101 course, but also 201 and/or 202
DIR/Floortime courses. Parents and attending
personnel (nurses, junior nurses) can complete
only the introductory 101 DIR/Floortime course,
but they need to receive the support of a more
qualified specialist on a regular basis.
5) The work of such a team requires regular
supervisions by an independent external expert of
the appropriate qualification for high efficiency
maintenance.
Conclusions
Due to its flexibility, adaptability, and inclusion
of the emotional aspect, the DIR/Floortime model
can be widely and successfully used in the
system of palliative care. The main postulates of
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the DIR concept fully coincide with the modern
principles of palliative support. In addition, the
use of this model not only increases the
competence of employees, but also solves other
tasks: team cohesion, prevention of emotional
burnout, development of emotional intelligence,
awareness and empathy of everyone involved.
Building a team-based, positive, supportive and
safe relationship around a child and family helps
to prevent conflicts, and to improve the
emotional background of the child in care.
Acknowledgments
Thanks to my supervisor Galina Itskovich,
LCSW-R, DIRFloortime Expert; Special thanks to
Anna Garchakova, Director of the Belarusian
Children's Hospice end staff of the Belarusian
Children's Hospice.
Conflict of interest
The author declares that she has no conflict of
interests.
References
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S., Graetz, S., Young, A., & Lane, K. (2020).
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DIRFloortime Approach in Speech Therapy for
Speech Development in Children with ADs
and Other Disorders. Recommendations for
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Hess, E. (2020). DIR®/Floortime™. Infant Play
Therapy: Foundations, Models, Programs, and
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MHGCJ – 2020
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Mithridatism for dementia? Hypoxic - Hyperoxic
training in dementia
Christos Tsagkaris
1
, Rehab Α. Rayan
2
, Eleni Konstantara
3
, Lolita Matiashova
4
Valeriia Danilchenko
5
1
University of Crete, Heraklion, Greece
2
Alexandria University, Alexandria, Egypt
3
Medical University of Sofia, Sofia, Bulgaria
4
GI “L.T.Malaya Therapy National Institute of the NAMS of Ukraine, Kyiv, Ukraine
5
Kharkiv Regional Perinatal Center, Department of Post-Intensive Care, Rehabilitation and Nursing of Premature Newborns, Kharkiv,
Ukraine
Abstract
Introduction: Intense research on dementia has been conducted during the last years. As
advances in the field have started changing the landscape of dementia treatment, it is
necessary to assess the impact of novel therapeutic modalities.
Purpose: The current evidence about hypoxic – hyperoxic treatment for dementia is reviewed in
this article.
Methods: We conducted a thorough PubMed/MEDLINE and Google Scholar search.
Results: Preclinical and clinical data are available. Hypoxic – hyperoxic treatment is
encouraged in the context of the multimodal treatment of dementia. There are concerns
about the recovery of memory with regard to specific modalities of this treatment. Future
perspectives are highlighted in the light of potentially useful biomarkers and health policy.
Conclusion: While constant updates and further research is critical to understand the impact of
hypoxic – hyperoxic treatment in dementia, the available studies are limited and, hence,
research that is more extensive is necessary. Currently, it is important to assess the current state
of knowledge highlighting the success but also the stalemates of this treatment.
Keywords
Intermittent hypoxia, Hypoxic – hyperoxic training, Cognitive performance, Dementia.
Address for correspondence:
Christos Tsagkaris, University of Crete, Faculty of Medicine, Heraklion, Greece, e-mail:
chriss20x@gmail.com
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Tsagkaris, Rayan, Konstantara, Matiashova, Danilchenko, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI: http://doi.org/10.32437/mhgcj.v3i1.82
Submitted for publication: 15
June 2020
Received: 15 June 2020
Accepted for publication: 19
September 2020
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Introduction
The concept of Mithridatism dates back to
Mithridates the 6th, king of Pontos during the 1st
century BC. Mithridates would consume non-
lethal amounts of poison to protect himself from
poisoning in the future. By taking the poison in
gradually increased doses, the king made
himself “immune” enough to the poison to make
it ineffective when he would attempt to take his
life some years later after a defeat in battle.
Mithridates would have to order one of his
bodyguards to take his head eventually. In a
vague sense, he managed to create tolerance
against a toxic factor. (Valle et al., 2017)
The pattern of Mithridatism has been classic in
toxicology and pharmacology throughout the
years. Interestingly, hypoxic - hyperoxic treatment
seems to abide by this concept. Essentially,
hypoxic - hyperoxic treatment consists of the use
of hypoxia, a genuinely toxic factor for neuronal
integrity and memory, as a training stimulus to
create tolerance against ischemia and
safeguard human memory. Scientists have come
to investigating such treatment modalities due to
the prevalence and morbidity of neurocognitive
disorders.
Neurocognitive disorders, especially major
neurocognitive disorders (dementias), have
serious effects on patients, families, the health
system, and the economy (Hugo & Ganguli,
2014). Alzheimer’s disease (AD) is a major risk for
mortality (Murphy et al., 2013), admission to
hospitals and nursing facilities, and home
healthcare in the United States (US). The expanses
of health services and the informal expanses of
non-paid caregiving of dementia patients’ are
high and escalating. Caregivers from the family
suffer high affective pressure, depression among
other health issues (“2020 Alzheimer’s Disease
Facts and Figures,” 2020). Globally, In 2010,
almost 35.6 million individuals were assumed to
be surviving with dementia, a number
anticipated to grow to about 115.4 million
individuals by 2050 (Prince et al., 2013).
Pathophysiology of dementia
Amyloid plaques and neurofibrillary tangles
are featured abnormalities, which determine AD.
Amyloid plaques comprise mainly a 40-42 amino
acid peptide called amyloid-β (Aβ), which is
accumulated in fibrils including a high β-sheet
structure. Plaques turn insoluble and sediment in
the brain’s outside cell spaces. Amyloid plaques
are usually linked to distended, dystrophic
neurites, astrogliosis, and activated microglia that
make a neuritic plaque. However, amyloid
plaques and neurofibrillary tangles aggregate
inside the cell in neurons. (Prince et al., 2013). A-β
is naturally created by neurons inside the brain
and released in the brain’s outside cell spaces
where during the pathogenicity of AD it shifts
configuration, turns insoluble, and sediment as
plaques. A-β does not have an identified,
physiologic role, yet an increasing evidence has
shown that under specific testing circumstances,
A-β could regulate synaptic transmission. Yet, the
function of A-β in natural synaptic role or in the
disease's context is unknown (Chavez et al.,
2000).
The role of hypoxia in neurodegeneration
and dementia
Hypoxia regulates metapolyzing amyloid
plaque protein (APP), causing a growing
production of Aβ through the amyloidogenic
mechanism. Time-reliant hypoxic upregulation of
APP has been further proven at the mRNA and
protein levels, following 10–180 mins of ischemia,
which might function as a guarding pathway to
raise the levels of neuroprotective soluble APPα
(Serebrovska et al., 2019). Yet, most times the
growing APP leads to more levels of Aβ, not
soluble APPα since hypoxia prefers metapolizing
APP through the amyloidogenic mechanism
(Urike Bayer et al., 2017)
Purpose
To review the current evidence about Hypoxia
– Hyperoxia treatment for dementia.
Methodology
This is a literature review study. We searched
Pubmed and Google Scholar with the following
strategy: ((prospective[Title/Abstract] OR
cohort[Title/Abstract] OR follow-up[Title/Abstract]
OR review[Title/Abstract] OR
longitudinal[Title/Abstract] OR meta-
analysis[Title/Abstract] OR systematic
review[Title/Abstract]) AND (hypoxia – hyperoxia
treatment[Title/Abstract] OR
dementia[Title/Abstract])) AND (hypoxia OR
hyperoxia OR dementia) AND
"humans"[MeSH Terms], up until
August 30 2020. This search strategy aims to
identify: 1) Clinical trials involving hypoxia –
hyperoxia treatment; 2) Other original studies or
metanalyses related to the use of this treatment.
Original, peer-reviewed studies in English and
Russian were included.
Results
There has been encouraging evidence from
the field of basic research that supported the
methods that led to their studying in clinical
context. There are studies, both clinical and basic
researches that show that intermittent hypoxic-
hyperoxic treatment can reduce dementia and
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more specifically Alzheimer’s disease (AD) or mild
cognitive impairment which is a precursor of AD.
It is known that in AD the pathological
evidence is the presence of amyloid plagues.
Clinical data has showed that is AD patients the
reduction of cerebral perfusion happens before
memory and cognitive impairment. Hypoxia is
the direct consequence of hypoperfusion.
Improving oxygen supply in the brain might have
a positive impact on AD pathology. Normobaric
hyperoxia (NBO), not only provides more oxygen
but was also found to be protective in recent
experimental and clinical pilot studies. Morris
water maze tests showed that NBO treatment
improved the spatial learning and memory
problems in AβPP/PS1 transgenic mice.
Immunohistochemical and thioflavin S staining
showed that NBO treatment significantly
decreased Aβ deposition and neuritic plaques
formation in the cortex and hippocampus of
AβPP/PS1 transgenic mice. Immunoblotting and
ELISA assay revealed that NBO treatment
reduced Aβ production by inhibiting γ-secretase
cleavage of AβPP. From the above it is suggested
that NBO may have a potential therapeutic
effect at the early stages of AD. (Gao et al.,
2011)
A study conducted by Malle et al. focused on
the effects of normobaric hypoxia (NH) exposure
has on memory and physiology of the human
body as well as the physiological and cognitive
effects of oxygen breathing before and after the
NH exposure.
For this study 86 healthy men divided randomly
into 4 groups, were used. The groups were: the
Normoxia-Air group (N = 23), where subjects were
breathing air, the Hypoxia-Air group (N = 22), NH
exposure was preceded and followed by air
breathing, the Normoxia-O₂ group (N = 21),
similar to the Normoxia-Air group, except with the
addition of 100% O₂ breathing periods and the
Hypoxia-O₂ group (N = 20), whose participants
were exposed to 100% O₂ before and after NH
exposure. The Paced Auditory Serial Addition Test
was performed to test their memory. Moreover,
peripheral oxygen saturation (Spo₂), heart rate
(HR), and electroencephalogram (EEG) were
recorded. (Malle et al., 2016)
The results from this study showed that acute
NH exposure caused a typical physiological
response like decreased Spo₂ and increased HR,
but not the same as the physiological response
to acute hypobaric hypoxia. Impairment in
working memory was also caused by the acute
NH. Oxygen breathing after NH exposure caused
a slowing in the EEG which is associated with
making working memory ability worse. For this
reason, NH is suggested to be surrounded by air
breathing. (Malle et al., 2016)
In another study, researchers used quantitative
proton magnetic resonance spectroscopy to
evaluate the regional metabolic alterations, after
a 24-hour hypoxic or hyperoxic exposure on the
background of ischemic brain insult, in a total of
60 female Wistar rats which were divided in two
age-groups of rats of equal number: young - 3
months old and aged - 24 months old. Each age
group was further subdivided into three subgroups
of 10 rats each. Two of these subgroups were
anesthetized with Nembutal (30 mg·kg-1), after
overnight fast, and by ligation of the right
common carotid artery, cerebral ischemia was
induced to them. After taking extracts from three
different brain regions (fronto-parietal and
occipital cortices and the hippocampus) from
both hemispheres concentrations of eight
metabolites (alanine, choline-containing
compounds, total creatine, γ-aminobutyric acid,
glutamate, lactate, myo-inositol and N-
acetylaspartate) were measured. This showed
that in the control normoxic condition, there were
significant increases in lactate and myo-inositol
concentrations in the hippocampus of the aged
rats, in comparison with the young ones. In the
ischemia-hypoxia condition, the most
predominant changes in the brain metabolites
were found in the hippocampal regions of both
young and aged rats, but the effects were more
evident in the aged animals. The ischemia-
hyperoxia procedure caused less changes in the
brain metabolites, which may indicate more
limited tissue damage. (Watanabe et al. 2019)
As it is already well-known, chronic hypoxia
stimulates angiogenesis in brain and other tissues.
Therapeutic IHT (intermittent hypoxic training)
then, can improve the vascularity of the brain
and prevent AD. When in hypoxia, cerebral
angiogenesis starts by the transcription factor,
hypoxia-inducible factor-1 (HIF-1) when genes
with promoter regions containing hypoxic
response elements, including the vascular
endothelial growth factor (VEGF) gene, are
activated. (Takashi et al. 2019)
There are also clinical studies that support
these findings. More specifically, Urike Bayer et al.
in a clinical study in 2017 studied thirty-four
patients from the Geriatric Day Clinic aged
between 64 and 92 years old who participated in
a controlled trial. These patients received
randomly MTP and IHHT (experimental group-EG)
or MTP and placebo-breathing with machine
face mask (experimental group-CG) in a double-
blind fashion. Before and after the 5- to 7-week
intervention period (MTI + IHHT vs. MTI + ambient
air), cognitive function was evaluated by the
Dementia-Detection Test (DemTect), the
Sunderland Clock-Drawing Test (CDT), and
functional exercise capacity by the total distance
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of the 6-Minute Walk Test (6MWT). (Bayer et al.,
2017)
Results from other studies showed that after
MTI + IHHT was administered, DemTect showed
important improvement (+16.7% vs. -0.39%, P <
0,001) as well as the 6MWT with a larger increase
in EG than CG (+24.1% vs. +10.8%, P = .021).
Furthermore, the CDT showed similar results with
DemTect with an increase in EG but decrease in
CG (+10.7% vs. -8%, P = 0,031). Also, there was
found to be a relation between the changes of
the 6MWT, the DemTect and the CDT. The studies
concluded that, IHHT is easy in application and
well tolerated by geriatric patients up to 92 years
and, helped in the improvement in cognitive
function and exercise capacity in geriatric
patients after MTI (CIRRITO & HOLTZMAN, 2008)
(Lall et al., 2019).
Bayer et al. in 2019 updated the previous
study by performing some additional tests and
including new results. Like before, she studied
thirty-four patients (64-92 years old) who
participated in the double-blind clinical trial. The
patients took part in a 5–7 weeks lasting MTI
(strength, endurance, balance, reaction,
flexibility, coordination, and cognitive exercises)
and performed IHHT (breathing 10–14% oxygen
for 4–7 min followed by 2–4 min 30–40% oxygen)
in the Hypoxic Group (HG) or placebo treatment
with ambient air in the Normoxic Group (NG).
Before and after all treatments, mobility was
assessed by the Tinetti Mobility Test (TMT), the
Timed-Up-and-Go Test (TUG) and Barthel-Index,
while perceived health was evaluated by one
part of the EQ-5D Test, the EQ visual analogue
scale (EQ VAS).
These tests showed that after the MTI plus IHHT
or normoxia sessions, results of the TMT, TUG,
Barthel Index and EQ-VAS revealed no significant
difference between HG and NG (Bayet et al.,
2019)
Another study indicated that, IHHT added to
MTI did not cause any additional improvements
in patient’s health and mobility compared to MTI
alone (Pichiule & Lamanna, 2002).
Serebrovska et al. also conducted a study in
2019 which examined the effects of intermittent
hypoxic-hyperoxic training (IHHT) on elderly
patients with mild cognitive impairment (MCI)
which is a precursor of AD. The study used twenty-
one participants between 51 and 74 years of
age which were divided into three groups:
Healthy Control (n = 7), MCI+Sham (n = 6), and
MCI+IHHT (n = 8). IHHT was performed five times
per week for three weeks which means a total of
15 sessions. Each IHHT session had four cycles of
5-min hypoxia (12% FIO2) and 3-min hyperoxia
(33% FIO2). Cognitive parameters, Aβ and
amyloid precursor protein (APP) expression,
microRNA 29, and long non-coding RNA in
isolated platelets as well as NETs in peripheral
blood were investigated. (Serebrovska et al.,
2019)
The study found an initial decline in cognitive
function indices in both MCI+Sham and
MCI+IHHT groups and important connections
between cognitive test scores and the levels of
circulating biomarkers of AD. IHHT resulted in the
improvement in cognitive test scores, along with
significant increase in APP ratio and decrease in
Aβ expression and NETs formation one day after
the end of three-week IHHT. These effects on Aβ
expression and NETs formation remained more
pronounced one month after IHHT. In conclusion,
the results from this pilot study suggested a
potential usage of IHHT as a new therapy to
improve cognitive function in pre-AD patients and
slow down the development of AD (Serebrovska
et al., 2019).
Discussion
In this review, we elaborated on hypoxic -
hyperoxic treatment in the context of dementia.
We retrieved information from original studies
spanning from preclinical to clinical research. The
existing evidence seems to back the use of
hypoxic - hyperoxic treatment, however there are
few preclinical and clinical studies. With regard to
mechanisms, the effects of hypoxia on the
nervous system and the prevention or progression
of dementia vary from study to study, indicating
that the results also depend on the design of the
studies.
A previous review study of Lall et al,
concluded that hypoxia can prevent and treat
AD (Lall et al., 2019). Our review has reached the
same conclusion with regard to improving the
status of patients with AD but we cannot reach
the conclusion that hypoxic - hyperoxic treatment
can prevent AD among healthy individuals.
Another review has indicated that intermittent
hypoxia has not always beneficial effects on
patients with AD. Genetic traits might have
contributed in the variability of the results
(Manukhina et al., 2016). We have also reached
the same conclusion.
The interplay between preclinical and clinical
studies is also notable. Preclinical studies were
conducted first encouraging the design of
clinical interventions. With clinical studies initiated,
basic research kept proceeding unraveling key
information for the personalization of hypoxic -
hyperoxic treatment. Interestingly, in a study on
40 male mice where 40% oxygen with normal
atmospheric pressure was utilized in the early
stage of Alzheimer disease, there was a notable
improvement in AβPP/PS1 transgenic mice after
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1-2 months of treatment. The same treatment
had no effect in wild-type mice. Such findings
support the hypothesis of genetic interference
that was suspected in clinical studies.
Translational clinical studies may detect
biomarkers determining the individuals who will
benefit more from hypoxic - hyperoxic treatment.
In another study, normobaric hypoxia (NH)
appeared to decrease γ-secretase cleavage of
AβPP and Aβ in mice (Gao et al., 2011). Taking
into account the involvement of these factors in
the pathogenesis of dementia, and particularly
AD, this finding indicates that IHHT can hinder the
further progression of the disease. Provided that
large clinical studies verify these outcomes,
hypoxic - hyperoxic treatment can be used as a
dementia stabilizer, while cognitive training can
improve the functionality and the quality of life of
the patients.
The interplay of clinical and preclinical
research is highlighted in the study of Marci et al.
Their data indicated that hypoxia leads to
cerebral ischemia resulting in the damage of the
hippocampus-controlled functions (Macri et al.,
2010) and then a study on healthy young men
verified that NH and hypobaric hypoxia (HH) can
have adverse effects on memory. In both cases,
the damage was attributed to physiological
response to acute NH and HH. These modalities
are different and using oxygen after acute NH
can slow cerebral activity down harming the
recovery of memory (Malle et al., 2016). This
finding, a synergy between preclinical and
clinical research, suggests a serious adverse
effect of this treatment. Participants of future
studies should be properly warned and
monitored.
Other studies have identified further
biomarkers in patients with AD. Exercise capacity,
cognitive performance and safety in geriatric
patients have been correlated with an increase in
APP130 and APP110 fractions in platelets,
decrease in Aβ expression and downregulation of
lncRNA BACE-AS and NETs formation (Serebrovska
et al., 2019) (U. Bayer et al., 2017).
Hypoxic - hyperoxic treatment and
contemporary healthcare
The early diagnosis of dementia spectrum
diseases is a challenge for modern biomedicine.
When it comes to hypoxic - hyperoxic treatment,
the necessary assessment and monitoring of
patients or healthy individuals undergoing such
interventions will require improved imaging
techniques. Watanabe et al. have suggested the
visualization of A2 noradrenergic neurons with MRI
based on the detection of noradrenaline groups
of cells in the brain by T1-weighted MRI with
magnetization transfer (Watanabe et al., 2019).
Hypoxic - hyperoxic treatment would face cost
and implementation issues. With small studies,
absence of long-term results and a need for
expensive additional genetic testing, Hypoxic -
hyperoxic treatment can be expensive and
inaccessible to patients in the future. Regulatory
and legal parameters are also implicated.
University hospitals and centers of excellence can
offer this treatment to large number of patients to
verify its efficacy and define the eligible
population. If this intervention proves to be cost
effective, the necessary regulatory steps can be
taken. Licensing procedures ought to take into
account the multimodal approach of providing
this treatment.
Limitations of the study
Currently it seems that preclinical and clinical
evidence regarding hypoxic - hyperoxic
treatment is encouraging but limited. Systematic
approaches on studies with small populations or
short follow up time would not lead to credible
conclusions. Future studies will need to study the
effect of hypoxic - hyperoxic treatment in larger
population sets. On the other hand, the
indication that hereditary traits might affect the
efficacy of hypoxic - hyperoxic treatment
represents an opportunity of tracking genetic
biomarkers. In this context hypoxic - hyperoxic
treatment could be reserved as a precision
medicine modality in the future.
Conclusions
In the existing studies, hypoxic - hyperoxic
treatment appears as a beneficial additional
treatment for dementia. It may contribute in
preventing dementia in healthy individuals. It
seems that genetic factors are involved in the
efficacy of the treatment. Normobaric and
hyperbaric hypoxia modalities can be used in
patients with damage of the nervous system,
which leads to benefits in cognitive function,
however depending on the administration of
hypoxic - hyperoxic treatment memory recovery
may be impaired especially in healthy individuals
(Serebrovska et al., 2019) (Malle et al., 2016).
Mithridates has managed to determine the
optimal way of self-poisoning to avoid adverse
effects. Nowadays, the same challenge falls
upon contemporary scientists with regard to the
use of hypoxic – hyperoxic treatment in
dementia.
Conflict of interest
The authors declare no conflict of interest with
regard to this study.
MHGCJ – 2020
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MHGCJ – 2020
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Stigma and mental health: The curious case of
COVID-19
Connie J. Snider
1
Maureen P. Flaherty
2
Alzheimer Society of Saskatchewan, Saskatoon Resource Centre, Saskatoon, Saskatchewan, Canada
1
University of Manitoba,
Winnipeg, Canada
2
Abstract
Introduction: This article considers the impact of COVID-19 on stigma and mental health across
the life spectrum and the ways that people access services.
Purpose: To explore the ways that a pandemic (COVID-19) has changed/shifted the relationship
between mental illness or mental ill health and stigma across the life spectrum and call to re-
focus resources on sustainable healthy societies, building cultures of peace.
Methodology: A literature search was employed, combined with informal interviews and
observation.
Results and Discussion: On the one hand, the pandemic has opened public discussion of
mental health challenges such as anxiety and depression, reducing some of the stigma
attached as the experience is more common amongst people who have not previously
declared mental health challenges. On the other hand, people previously experiencing mental
ill health have mostly had that health challenge exacerbated by the pandemic. With fewer
resources available, and changes in service delivery to largely on-line resources, the reduction
in stigma has not meant better mental health care and services, but rather further marginalized
some of the population. Cultures of peace are inclusive and provide space for full growth of all
citizens, in contrast to reactive approaches now more readily applied. Mental health services
are a basic right for all people and should be considered as such in all planned health
strategies.
Limitations: The article focuses on literature review, anecdotal and observation and is focused
over a short term, in North America. It is a preliminary study.
Strengths: As a preliminary study, the article highlights an emergent and present dilemma. It
also highlights the need for a much more holistic, global approach to mental health and
wellbeing across the lifespan.
Conclusion: While there are calls for national strategies for mental health services and services
for people with dementia, in particular, there is still a need to take a more holistic approach to
mental health as part of a whole health strategy to support human dignity and inclusion across
the lifespan
Keywords
mental health, mental illness, dementia, stigma, COVID-19, peacebuilding
Address for correspondence:
Connie J. Snider, First Link Coordinator, Alzheimer Society of Saskatchewan, Saskatoon
Resource Centre, Saskatoon, Saskatchewan, Canada e-mail: csnider@alzheimer.sk.ca
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Snider, Flaherty, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI:: http://doi.org/10.32437/mhgcj.v3i1.89
Submitted for publication: 14
June 2020
Received: 14 June 2020
Accepted for publication: 5
October 2020
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Introduction
COVID-19 continues to greatly impact the
ways ordinary citizens lead our lives. With the
shutdown of businesses, educational
establishments of all kinds, services, and almost
any kind of direct human contact outside of
family ‘bubbles’, there has been an increase in
the reported incidence of anxiety and depression
in particular. There has also been a change in the
ways that anxiety and depression are talked
about. Mental ill health in general, has become
a more acceptable topic of discussion on the
interpersonal, community and even the
international level. This article shares a preliminary
exploration of the ways that the pandemic
(COVID-19) has changed/shifted the relationship
between mental illness or mental ill health and
stigma for some and the various ramifications of
same. The article begins with an introduction to
COVID-19, the pandemic that has changed lives
and caused many deaths around the world. We
move to a discussion of mental health and the
stigma that often accompanies it. We then
explore the change in the relationship between
mental health and stigma in the first six months of
COVID-19 and consider the shifts to accessing
services for those living with mental health
challenges during these times. We conclude by
considering ways that the challenges of this
pandemic may be utilized for improvement in
approaches to mental health and wellbeing
(health promotion, services, service access,
service promotion and attitudinal change). This
article is further to an introductory article on
mental health and peacebuilding in Canada
and Ukraine (Flaherty, Sikorski, Hayduk, Klos, & Vus,
2020).
Purpose
This article explores the ways that a pandemic
(COVID-19) has changed/shifted the relationship
between mental illness or mental ill health and
stigma and the various ramifications, considering
mental health and illness in general and
dementia in particular as these are the areas of
our special interest. We note that this is a
preliminary discussion in the midst of a pandemic
that has been experienced for six months for
those of us who live in North America, but several
more months in different areas of the globe.
Methodology
A literature search was employed, combined
with informal interviews and observation.
Results and Discussion
COVID – 19
COVID-19 is the name attributed to the novel-
corona virus first reported to officials in Wuhan
City, China in December in 2019. The virus or
infections disease, first identified as connected to
a food market in Wuhan City spread very quickly
to other countries. Officially known as SARS-CoV-2,
the disease was identified as such in early
January 2020 and this disease has now been
found in all corners of the world (World Health
Organization, 2020). At the time of writing,
autumn 2020, there have been almost 929
thousand deaths out of almost 29.3 million cases
worldwide (BBC News, 2020). In response to the
speed the disease has spread, many countries
shut down work from offices, and closed all in-
person business by mid-March of this year. While
this is a global phenomenon which stopped
international travel for months and halted much
in-person communication for that same time
period and longer, many businesses have not re-
opened in Canada at the time of writing. When
they do open, it is with strict protocols about
wearing masks, sanitizing areas, and restricting
access (Government of Ontario, 2020) .
Both the responses to and the impact of
the virus have varied across sectors, often related
to a number of the social determinants of health,
including Indigeneity, food security and insecurity
and socio-economic resources in general
(Statistics Canada, 2020).
Mental Health
The Canadian Association of Social Workers’
(n.d.) provides a helpful definition of mental
health:
Mental health is the capacity of the individual,
the group and the environment to interact with
one another in ways that promote subjective well-
being, the optimal development and use of
mental abilities (cognitive, affective and
relational), the achievement of individual and
collective goals with justice and the attainment
and preservation of conditions of fundamental
equality.
Indeed, Helen Verdeli (2016) reflects on the
WHO’s 2001 statistics related to the challenges to
mental health and wellness, noting that one in
four people around the world will “experience at
some point in their lives a mental or neurological
condition” (Verdeli, 2016, p. 761). Verdeli is clear
that “cultural norms, beliefs and attitudes can
either exacerbate stigma and instill shame or
serve as protective factors by establishing clear
social roles and community structure” (p. 765) to
support good mental health and assist both
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individuals and communities to reach their full
potentials.
Indeed, while sometimes seen as controversial
and stigmatizing (DeFehr, 2020), the diagnosing
of mental ill health, often known as a “disorder”
has become critical in today’s medical
approach to health for individuals to access
many of the services that can help them live well,
particularly when dealing with what are
considered to be “major mental illnesses”, or
serious mental illness (SMI) – “mental, behavioral
or emotional disorder[s] resulting in serious
functional impairment, which substantially
interferes with or limits one’s major life activities”
(National Institute of Mental Health, 2019, para 4).
Even when symptoms are accurately reported to
medical practitioners, many people experiencing
mental ill health receive inadequate care. In
Canada for example, family doctors are often
overworked and overwhelmed with patients, and
as a result, many people are left without a family
doctor (Canadian News Facts, 2001; Dinshaw,
2016). This is troubling because the majority of
individuals who seek professional help for their
mental health turn to someone they know and
trust, their family doctor (Statistics Canada, 2017)
and it is often there a referral is made to more
specialized services, if they are available and
deemed necessary. We remember that these
are not preventative services, but rather
responding often to health challenges that will
have already impaired an individual’s ability to
function in society.
If one is fortunate enough to access a suitable
mental health care individual or service, there are
still challenges to accessing appropriate
treatment. A study with users of mental health
services and psychiatrists (Gunasekara, Patterson,
& James, 2017) revealed that it was not
uncommon for patients to feel as if they were
being judged in the process of accessing
treatment, and that their humanity was reduced
to a diagnosis.
In Canada, out of a population of just over 35
million people (Statistics Canada, 2017) over the
course of a year an estimated 4.9 million
Canadians over the age of 15 required
professional help for their mental health (Statistics
Canada, 2017). Many of those people were
unsatisfied with the quality of care they received
more than a third felt that they received only
adequate assistance (Statistics Canada, 2017).
Importantly, these numbers record only those
who actually received service and not the many
suffering who have not yet sought or received
help. An estimated 564,000 Canadians live with
Alzheimer’s disease and other dementias, yet
people with the illness often feel excluded or
treated differently (Alzheimer Society, n.d.).
Mental health and stigma
One of the greatest challenges facing people
experiencing mental health issues is stigma,
described by Goffman (1963) as the social
exclusion and reduction of an individual based
on an undesirable trait such as is found in the
negative views associated with those who
dealing with mental illness (Vogel, Heimerdinger-
Edwards, Hammer, & Hubbar, 2011). Numerous
researchers have noted the harmful impacts of
social stigma on those with mental health
conditions (see Chronister, Chou, & Liao, 2013;
Clement, et al., 2015; Corrigan, 2000).
Stigma surrounding mental health is
reproduced daily, found often in the language
used when discussing mental health with people
displaying mental illness or seeking treatment
called “crazy,” or “not being all there”, as if
because of their mental health they are missing
something (Larson, 2008; Corrigan, 2000). This
kind of hurtful language is the projection of
attitudes about mental health and illness (Marion,
Whitty-Rogers, & Panagopoulos, 2013). The
attitudes and language are found not only in the
general population but also, at times, amongst
health care professionals themselves (Hankir &
Zaman, 2015; Marion, Whitty-Rogers, &
Panagopoulos, 2013). While we have long talked
about stigma related to variety of illnesses such
as schizophrenia and bi-polar disorder, less often
do we acknowledge that this stigma extends to
people living with dementia (Alzheimer Society,
n.d.) and even to the their caregivers and others
associated with them (Werner & Heinik, 2008) . It
can be argued that stigma is the greatest barrier
to accessing and using mental health services
(Sartorius, 2007) with many people not bothering
to seek help because they feel marginalized by
any kind of diagnosis (Gearing, et al., 2015;
Corrigan P. , 2000; Vogel, Heimerdinger-Edwards,
Hammer, & Hubbar, 2011).
In addition to exposure to stigma from others,
people experiencing mental illness may also
contribute to the stigma themselves. Internalized
stigma, or self-stigma (Vogel, Heimerdinger-
Edwards, Hammer, & Hubbard, 2011) may
diminish one’s self-esteem and confidence
(Corrigan, 2004), impacting how one behaves in
the world and whether and how one seeks help
when struggling. Despite the educational
campaigns to reduce prejudice and increase
understanding of the often-genetic aspects to
mental illness, stigma remains strong, often
based on people’s personal interactions with
mental health challenges and what they see
portrayed in the media, which often focuses on
tragic events (Committee on the Science of
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Changing Behavioral Health Social Norms; Board
on Behavioral, Cognitive and Sensory Sciences;
Division of Behavioral and Social Sciences and
Education; National Academies of Science,
Engieering, and Medicine, 2016). Sigma is
fundamentally a social phenomenon rooted in
social relationships and shaped by the culture
and structure of society.
COVID and stigma
With the development of COVID -19 and the
increased challenges to people’s health and
wellbeing, there has been a noticeable shift in
the way people talk about mental health.
Anecdotally, and in our local media (Morton,
2020; Crawford, 2020) and health services
publications (e.g. CAMH, 2020), we can attest to
an increased discussion of mental health and
wellness as well as challenges to these since the
start of COVID-19. In other words, some of the
stigma has been reduced – at least for now.
Anxiety and depression, as part and parcel of life
in uncertain times, are now much more a part of
everyday discourse. This is reflected locally and
internationally. As early as the end of May, 2020
Statistics Canada (2020) reported the United
Nations’ concern about the adverse effects of
social isolation on the population’s mental health.
People speak about exacerbating causes: being
much more housebound, unable to access
regular activities used to maintain social
connection (family gatherings, clubs, concerts,
dining out) enrichment (theatre, cinema) and
deal with stress (physical activity, team sports,
attending fitness venues). However, while this new
isolation has become a much more “shared”
phenomenon, experienced by most of the world
to some extent, the impact of these shared
experiences has been mitigated or exacerbated
to some extent dependent upon economic
status, living conditions, access to resources and
even race, as these factors often become
intertwined.
Covid-19 and access to mental health
resources
Despite what appears to be an increased
focus on the need for better mental health
services and resources and more focus on
normalizing this need (CAMH, 2020) these
resources have actually become less accessible
during times of COVID-19, and we wonder about
the long term impact of the disappearance of
these resources. The availability of many
resources has drastically changed. Like many
other individual day and group services,
community based, subsidized programs are not
available for people with dementia due to COVID
restrictions – no Adult Day Programs, no in-facility
respite, less in home respite and less available
Home Care programs and services. This has put
an increased stress on the primary caregiver who
used to rely on these programs to provide respite
to the caregiver. People with dementia have
died at a disproportionately high rate during
Covid-19 (Livingston, et al., 2020), their physical
and mental health needs further challenged by
decrease in supports for themselves and their
caregivers. Further, with more people in need of
mental health services, fewer are accessing the
resources that are there (Canadian Mental Health
Association, 2020), with increased protocols such
as mask-wearing, reduced walk-in services, etc.,
some turning to drugs and alcohol to cope with
their challenges, increasing co-morbidity of
substance abuse and mental health challenges
(Chiappini, Guirguis, John, Corkery, & Schifano,
2020). This has a domino effect, increasing the
rate of homelessness in our locales as people are
not managing to pay rent.
Indeed, many in-person services are no longer
available, or if they are, only on a sporadic basis.
If not able to avail themselves of services in
person, individuals may be able to have a
medical or counselling appointment on line –
something not accessible to those who are not
familiar with computers, or don’t have one, and
perhaps do not even have a home. Someone
with dementia, in particular may have difficulty
accessing online services. With a lack of
understanding of how to connect, or use the
technology, services are not just a phone call
away! Organizations such as the Alzheimer
Societies across Canada have had to learn how
to deliver programs that were in person, to online
services assisting people to get connected. Far
fewer programs are available to people and
when they are, they may not be just what people
need. Anecdotally, one client shared her
experience of receiving a diagnosis of Alzheimer
disease from a neurologist over the phone with
no follow up provided. Her story joins many who
have identifiable illnesses and no available
resources.
Conclusions
COVID-19 has highlighted the need for a
different and expanded understanding of mental
health and mental health services. This is a multi-
faceted, complex issue. First, increased attention
is being paid to mental health and wellness
during Covid-19 as people who have not
commented previously talk about their anxiety
and depression, perhaps newly experienced,
and exacerbated for those with pre-existing
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conditions. Second, with the anxious uncertainty
and fewer material resources that accompany
COVID for many, there is a greater need for
services that would assist people experiencing
mental health challenges. Third, despite the
reality that more services are needed, many of
the resources that once were available have
disappeared, at least temporarily. Fourth, people
have become more creative in the ways that
they offer and utilize resources, using zoom and
telemedicine to share services. However, these
resources are out of reach for many with
cognitive challenges or any kind of financial
and/or housing instability. In short, with fewer
resources available, and changes in service
delivery to largely on-line resources, the reduction
in stigma has not meant better mental health
care and services, but rather further marginalized
some of the population.
The Canadian Association for Mental
Health notes concerns about the impact of
COVID-19 on the mental health of citizens and
calls for a long- term national strategy to improve
mental health care related to the pandemic and
beyond (Canadian Association for Mental Health,
2020). This is not the first time such a strategy has
been solicited; however, with the increased
acknowledgement of the impact of the COVID-
19 associated stressors on mental health for the
general population, there has been much more
social discourse about mental health. Clearly, an
international strategy with a focus on prevention
and good mental health as a part of our daily
discourse is needed. It is beyond time to return as
a global village to focus on the social
determinants of mental health outlined by the
World Health Organization in 2014 (World Health
Organization, 2014). The WHO notes, “Mental
health is integral to this conceptualization of
wellbeing, because it enables people to do and
be the things they have reason to value.
Conversely, being and doing things one has
reason to value contributes to mental health.”
(WHO, 2014, p. 13). This is not a luxury; it is about
agency and empowerment of citizens – a
necessity for our world’s survival.
Conflict of interest
The authors declare that they have no conflict
of interest.
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MHGCJ – 2020
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The Hippocratic account of Mental Health: Humors
and Human Temperament
Konstantinos Kalachanis
1
, Christos Tsagkaris
2
1
New York College, Athens, Greece,
2
University of Crete, Faculty of Medicine, Heraklion, Greece
Abstract
Introduction: A quintessential element of Hippocratic medicine is treatment of mental diseases
which was based on a detailed examination of the symptoms as well as the study of human
physiology and final outcome of the diseases which is based on humoral theory.
Purpose: The aim of the work is to highlight the contribution of Hippocrates to the study of
mental illness based on his theory of humors
Methodology: Our study consists of interpretations of the original text of Hippocrates including
extensive observations of anatomy and physiology of human body based on humoral theory.
Then the information was evaluated on the basis of modern literature in order to establish their
validity. A major limitation of the research is the lack of a systemic methodology to screen the
Hippocratic corpus for relevant passages which actually requires interdisciplinary research in
order to determine which aspects of Hippocratic medicine can be developed.
Results: In Corpus Hippocraticum, it is highlighting that maintaining a relative proportion of
humors in human body (apart from maintaining health) regulates the human temperament and
its behavioral manifestations. Hippocrates, has included in his work observations not only on
human physiology and diseases but also studies the environmental and geographical impact
on them, thus setting the stage for holistic approaches
Conclusion: Summarizing, Hippocratic medicine and particularly his observations on mental
disorders provides a clear picture of the methodology used by Hippocrates which can be a
guide for the adoption of good practices for contemporary scholars and clinicians on their
everyday practice.
Keywords
theory of humors, environment, temperament, eucrasia, Hippocrates.
Address for correspondence:
Konstantinos Kalachanis, MSc, PhD, New York College, Athens, Greece,. e-mail:
kkalachan@phys.uoa.gr
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Kalachanis, Tsagkaris, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI: http://doi.org/10.32437/mhgcj.v3i1.83
Submitted for publication: 15
June 2020
Received: 15 June 2020
Accepted for publication: 19
September 2020
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Introduction
Hippocrates was a Greek physician if the 5th
century BC, who is often referred to as the "Father
of Medicine”. A descendant of a priests –
physicians family himself, Hippocrates was a
pioneer in the scientification of Medicine.
Founding the Hippocratic School of Medicine, he
established medicine as an art with a scientific
approach, gradually distinguishing it from theurgy
(Kleisiaris et al., 1995).
Medicine at the time of Hippocrates had
close ties with philosophy. Hippocrates and his
disciples emphasized on detecting etiological
correlations through keen observation of patients
and diseases. Apart from putting together the
Hippocratic Oath, a standard of ethics, which is
still relevant and in use today, the Hippocratic
Corpus, a collective work of Hippocrates and his
disciples is credited for promoting the systematic
study of clinical medicine, summarizing the
medical knowledge of previous schools, and
establishing good practices for physicians
(Kalachanis, 2011).
Among others, the Hippocratic Corpus
includes an account of humors and human
temperament, depicting the scientific perception
of mental health at the time.
Purpose
The purpose of this article is to summarize the
Hippocratic account of mental health discussing
humors and human temperament.
Methodology
We studied the Hippocratic Corpus focusing
on temperament and mental health. We worked
on the original text of Hippocrates and retrieved
information from Aristotelian Corpus where there
are extensive observations of anatomy and
physiology of human body. The information
extracted from the texts was subsequently
evaluated on the basis of modern literature in
order to establish their validity.
Results
Impact of the humors on human behavior
A basic concept of Hippocratic medicine was
was the attempt to identify the causes of
diseases in the physiology of the human body
(Galen, Quod optimus medicus sit quoque
philosophus, 54, 2-4) but also in the influence of
harmful factors of the environment such as air,
water and nutrtion (Kalachanis, 2011;).
Hippocrates considers Medicine as a pure
scientific discipline that aiming at treating illnesses
thus setting the basis of modern Medicine (Kirsten
et al. 2009) In order to understand the causes of
illnesses he had to understand apart from the
anatomy of human body he had to determine
the basic elements from which is consisted. It is
worth to mention that Hippocrates was taught
Philosophy by Democritus (Soranus, Vita
Hippocratis, 1) whose (along with Leucippus)
major whose cosmological views referred to the
atoms (not divisible) as the fundamental
elements of the world (Simplicius De caelo 242,
18-21). In the same context Hippocrates claimed
the existence of four fundamental elements or
humors (χυμοί) which indeed correspond to the
basic elements of the Universe as described in
ancient philosophy. Each humors is secreted
from a specific organ (Nemesius De natura
homini 4, 8-12) and also differ from each other
(Galen, In Hippocratis de natura hominis librum
commentarii iii 15, 66, 1-3). When the proportion
of the four humors as well as their mixing is the
proper, a state similar to equilibrium and called
by Aristotle eucrasia (De partibus animalium,
673b, 26) health in human body is maintained
thus introducing a more mathematical approach
of medicine (Eftichiadis 1995). In case the
condition of the body deviates to the
pathological one, a corresponding therapeutic
intervention is required, depending of course on
its nature (Galen, 17a 98, 25).
HUMOR
ELEMENT
ORGAN
YELLOW BILE
FIRE
LIVER
BLACK BILE
EARTH
SPLEEN
PHLEGM
WATER
BRAIN
BLOOD
AIR
HEART
Table 1: Human behavior is not an effect that
comes only from the mixture of the humors but
includes also the place of residence, air, water and
generally climatic conditions (See Hippocrates, De
aëre aquis et locis,)
Moreover, a basic attribute of the humors is
that the predominance of everyone in man also
creates a typology of characters (Table 1) (Kiersey
1998). Human behavior is not an effect that
comes only from the mixture of the humors but
includes also the place of residence, air, water
and generally climatic conditions (See
Hippocrates, De aëre aquis et locis,)
HUMO
R
ORGA
N
TEMPERAMEN
T
ATTRIBUTE
S OF
CHARACTE
R
Blood
Heart
Sanguine
courageous,
hopeful,
playful, care-
free
Yellow
Bile
Liver
Choleric
ambitious,
leader-like,
restless, easily
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angered
Black
Bile
Spleen
Melancholic
despondent,
quiet,
analytical,
serious
Phlegm
Brain
Phlegmatic
calm,
thoughtful,
patient,
peaceful
Table 2: Humors, organa and typology of human
behavior
Galenus having interpreted the typology of
human character makes some interesting
observations thus saying that when the
melancholic (black bile) humor exceeds then
then the human character is malignant,
indigestible and generally a repulsive case for all.
On the other hand sanguine character (with
blood exceeding) identified as the most forgiving
and sweet character (Galenus, De constitutione
artis medicae ad Patrophilum, 1, 280, 1-9).
Hippocrates' work includes a large number
of case studies where he provides data on the
symptoms, the treatment and the final outcome
of the patients. Also apart from detailed
observation he used methods of palpation, and
auscultation in order to determine the patients
condition (Rektor et al. 2013) and study in detail
the symptoms. His experience in managing many
medical cases also allowed him to observe
environmental conditions such the place of
residence that affect not only diseases but also
human temperament diseases, thus observing
that “Tribes living in countries rugged, elevated,
and well-watered, and where the changes of the
seasons are very great, are likely to have great
variety of shapes among them, and to be
naturally of an enterprising and warlike disposition;
and such persons are apt to have no little of the
savage and ferocious in their nature;” On the
other hand, people living in low-lying places
which are not properly ventilated and exposed
into warm winds instead of cold, are not
courageous and also are not capable of
performing laborious enterprises (Hippocrates, De
aëre aquis et locis 24, 4-10).
Humoral theory and mental disorders
Mental illnesses was of major interest for
Hippocrates who was the first one to recognize
their different types using a terminology which is
used even in modern science such as Mania,
Melancholy, Phrenitis, Insanity, Disobedience,
Paranoia, Panic, Epilepsy and Hysteria (Kleisiaris et
al. 2014). His methodology apart from managing
case studies was to explain their causes to the
physiology of the human body and at the same
time to reject any divine intervention. A typical
case is the issue of epilepsy which the people of
his time called sacred, that is, they considered it
as sent by God which the people of his time
called sacred, that is, they considered it sent by
God because of its strange symptoms. This tactic
was established according to Hippocrates by
various magicians and purists who, although they
show reverence in reality, deceive people and to
hide their ignorance about the causes of the
disease they used God as an excuse. God also
according to Hippocrates could never infect a
body (Hippocrates, De morbo sacro, I, 2-24).
Currently, it is established that the onset of
epilepsy is linked to a paroxysmal alteration of
brain function. Excessive and hypersynchronous
discharge of neurons in the brain results to an
“epileptic seizure”. “Epilepsy” is the condition of
recurrent, unprovoked seizures. Epilepsy has
numerous causes – genetic and environmental,
intrinsic and extrinsic, but its onset indicates a
pattern of brain dysfunction (Shorvon et al. 2011;
Stafstrom & Carmant, 2015) as well as brain
injuries and ischemic damages (Reid & Roberts,
2005).
Actually in ancient Greek literature there are
many mentions that match the symptoms not
only of epilepsy but of mental illnesses. Such a
case is narrated by Herodotus about the Persian
king Cambyses, who went mad thus killing his
brother Smerdis, (Historiae, III, 30 ) and also
committed many other atrocities and crimes. The
cause for these actions was the sacred illness
since he was born (Historiae, III, 33). Hippocrates
although considers brain physiology as the cause
for this disease (De morbo sacro, VI).
Apart from the explanation of epilepsy
Hippocrates tries to explain melancholia which is
directly related to black bile and people who
suffer from this illness have symptoms of bad
mood (Aphorismi VI, 23, line 2) as well as
dangerous symptoms such as instillation of liquids
inside the body (ἀποσκήψιες) and apoplexies
(mania) while their lingual expression becomes
more interperate (ἀκρατὴς) (Aphorismi VII, 40, 1).
Also in a modern interpretation Hippocratic theory
on melancholia is mentioned that patients with
an excess of black bile may suffer from epilepsy,
seizures and depression in epilepsy and
depression. The clinical phenotype of black bile
excess depends on the “direction” of the malady;
if it bears upon the body, epilepsy, if upon the
intelligence, depression”. Hippocrates' claim that
“epileptics become melancholics” resonates with
contemporary knowledge, given that depression
is the most frequent psychiatric comorbidity
epilepsy (Rektor et al. 2013). Also Galen
mentions several cases of phrenitis (φρενίτις) and
insanity (παραφροσύνη) a disease similar to μανία
(mania) which also interpreted as insanity (Sani et
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al. 2017) or as a furious attitude, an acute mental
condition in the absence of fever (Routh, 1988).
These situations may result from yellow bile and
black bile (Galenus, De locis affectis libri vi VIII,
178, 5-9 and In Hippocratis prorrheticum i
commentaria XVI, 545)
Discussion
Despite its scientific methodology, Medicine
at the era of Hippocrates lacked the technical
means necessary to conduct research,
investigate and establish diagnoses. The
methodology of communicating science was
also different taking into account the negative
views of major intellectuals of the era such as
Socrates on books. The Hippocratic account of
temperament contributed to rationalizing mental
health and illnesses. At that time, conditions such
as epilepsy were considered as “sacred illnesses”
indicating the popular belief in their divine causes
and the – equally – popular disbelief in the ability
of physicians to diagnose and treat them.
Nowadays, mental health is facing a wealth of
controversies attributed to intrinsic and extrinsic
factors of the field. Scholars of the field have
pointed out the lack of funding, the gap between
basic and translational research, the limited
access to appropriate mental health care as well
as the widespread stigma of mental illnesses in
modern societies. Rationalizing mental illness and
establishing a trust between specialized
healthcare practitioners and the public is a
challenge that contemporary scientists face
(Wainberg et al., 2017).
It appears that this challenge is what
medicine today has in common with Hippocratic
medicine in terms of mental health. Although
humors are no more relevant, the interaction
between environmental factors and mental
wellbeing is still puzzling scientists. Despite the fact
that black bile is not the cause of depression, the
comorbidity of depression with seizures or mania
are quite relevant not only with regard to
treatment but also with regard to prevention and
early diagnosis.
Limitations of the study\Strengths of the
study
The potential of this study is limited due to the
lack of a systemic methodology to screen the
Hippocratic corpus for relevant passages. In a
broader sense, the fact that ancient texts might
have been lost weakens our assessment of the
Hippocratic account of mental health. On the
other hand, the fact that native Greek speakers
with backgrounds in Classics and Medicine share
authorship enhances the comprehension and
interpretation of these passages.
Conclusions
Revisiting the Hippocratic account of mental
health can be a source of inspiration and good
practices for contemporary scholars and
clinicians. Such good practices include but are
not limited to empathetic communication with
patients, thorough history taking and
communication of patients’ narratives with
colleagues. Future studies may identify such
practices and investigate their feasibility and
efficacy in contemporary mental health facilities.
Conflict of interest
The authors declare no conflict of interest with
regard to this study.
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The Modern-Day Feminine Beauty Ideal, Mental
Health, and Jungian Archetypes
Tetiana Danylova
National University of Life and Environmental Sciences of Ukraine
Abstract
Introduction: It can be argued that beauty is not only an aesthetic value, but it is also a social
capital which is supported by the global beauty industry. Advertising kindly offers all kinds of ways
to acquire and maintain beauty and youth that require large investments. Recent studies
demonstrate that physical attractiveness guided by modern sociocultural standards is
associated with a higher level of psychological well-being, social ease, assertiveness, and
confidence. What is behind this pursuit of ideal beauty and eternal youth: the life-long struggle
for survival, selfless love for beauty, or something else that lurks in the depths of the human
unconscious?
Purpose: The aim of the paper is to analyze the modern-day feminine beauty ideal through the
lens of Jungian archetypes.
Methodology: An extensive literary review of relevant articles for the period 2000-2020 was
performed using PubMed and Google databases, with the following key words: “Feminine
beauty ideal, body image, beauty and youth, mental health problems, C.G. Jung, archetypes
of collective unconsciousness”. Along with it, the author used Jung’s theory of archetypes,
integrative anthropological approach, and hermeneutical methodology.
Results and Discussion: Advertising and the beauty industry have a huge impact on women
and their self-image. Exposure to visual media depicting idealized faces and bodies causes a
negative or distorted self-image. The new globalized and homogenized beauty ideal
emphasizes youth and slimness. Over the past few decades, the emphasis on this ideal has
been accompanied by an increase in the level of dissatisfaction with their bodies among both
women and men. Though face and body image concerns are not a mental health condition in
themselves, they have a negative impact on women’s mental health being associated with
body dysmorphic disorder, social anxiety disorder, obsessive-compulsive disorder, panic
disorder, depression, eating disorders, psychological distress, low self-esteem, self-harm, suicidal
feelings. These trends are of real concern.
The interiorization of the modern standards of female beauty as the image of a young girl
impedes the psychological development of women and causes disintegration disabling the
interconnection of all elements of the psyche and giving rise to deep contradictions. This
unattainable ideal is embodied in the Jungian archetype of the Kore. Without maturity
transformations, the image of the Kore, which is so attractive to the modern world, indicates an
undeveloped part of the personality. Her inability to grow up and become mature has
dangerous consequences. Women “restrain their forward movement” becoming an ideal
object of manipulation. Thus, they easily internalize someone’s ideas about what the world
should be and about their “right” place in it losing the ability to think critically and giving away
power over their lives.
Conclusion: Overcoming the psychological threshold of growing up, achieving deep
experience and inner growth, a woman discovers another aspect of the Kore, ceases to be an
object of manipulation and accepts reality as it is, while her beauty becomes multifaceted and
reflects all aspects of her true personality.
Keywords
Beauty, youth, feminine beauty ideal, body image, mental health, C.G. Jung, the Kore
archetype.
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Address for correspondence:
Tetiana Danylova, Associate Professor, National University of Life and Environmental Sciences
of Ukraine. e-mail: danilova_tv@ukr.net
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Danylova, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI: http://doi.org/10.32437/mhgcj.v3i1.99
Submitted for publication: 07
May 2020
Received: 07 May 2020
Accepted for publication: 06
November 2020
Introduction
An American writer, journalist and social
activist N. Wolf in her book “The Beauty Myth”
debunks age-old notions of beauty as an
objective and universal value. She claims that
beauty is nothing more than a myth created as a
means of keeping women in subjection and
denies the evolutionary meaning of beauty.
Nowadays, the beauty myth is associated with
the institutions of power that represent the male
world and is used in a counteroffensive against
females: “Beauty is a currency system like the
gold standard. Like any economy, it is
determined by politics, and in the modern age in
the West it is the last, best belief system that
keeps male dominance intact. In assigning value
to women in a vertical hierarchy according to a
culturally imposed physical standard, it is an
expression of power relations in which women
must unnaturally compete for resources that men
have appropriated for themselves” (Wolf, 2002, p.
12). Beauty is seen as a mere commodity.
According to N. Wolf, beauty is a fiction used by
multibillion-dollar industries that create images of
beauty and trade them like opium for women.
Beauty takes women out of the structures of
power returning them to where men prefer to see
them.
The other voices are also heard in the beauty
discourse. For example, a Harvard psychologist
and researcher N. Etkoff in her book “Survival of
the Prettiest: The Science of Beauty” (2000) argues
that beauty is neither a myth, not a social
construct as the representatives of the feminist
movement believe, but beauty is a complex
phenomenon that deeply rooted in human
nature. In her opinion, this phenomenon was
biologically beneficial for the preservation of
homo sapiens and has eventually become an
aesthetic preference. Thus, the desire for a young
beauty is due to our genetic heritage.
Recent studies demonstrate that physical
attractiveness guided by modern sociocultural
standards is associated with a higher level of
psychological well-being, social ease,
assertiveness, and confidence (Datta Gupta,
Etkoff & Jaeger, 2016; Feingold, 1992; Mobius &
Rosenblat, 2006).
It can be argued that beauty is not only an
aesthetic value, but it is also a social capital
which is supported by the global beauty industry.
Advertising kindly offers all kinds of ways to
acquire and maintain beauty and youth that
require large investments. What is behind this
pursuit of ideal beauty and eternal youth: the life-
long struggle for survival, selfless love for beauty,
or something else that lurks in the depths of the
human unconscious?
Purpose
The aim of the paper is to analyze the
modern-day feminine beauty ideal through the
lens of Jungian archetypes.
Methodology
An extensive literary review of relevant articles
for the period 2000-2020 was performed using
PubMed and Google databases, with the
following key words: “Feminine beauty ideal,
body image, beauty and youth, mental health
problems, C.G. Jung, archetypes of collective
unconsciousness”. Along with it, the author used
Jung’s theory of archetypes, integrative
anthropological approach, and hermeneutical
methodology.
Results and Discussion
In pursuit of beauty and youth, women are
ready to expose themselves to the most painful
and risky procedures and purchase a thousand
jars that promise to return or maintain these
beauty and youth. In the contemporary world,
more and more people do not want to grow old.
And there is nothing new under the sun: for
millennia, sages have tried to create the elixir of
life or the pill of immortality. However, the
combination of social, medical, cultural, and
economic factors led to a surge of interest in the
fight against aging in the 20th century.
Maintaining the health and vitality of men, as well
as the fertility and attractiveness of women
became a priority after the First World War (Stark,
2020) and is especially evident today.
According to a 2017 survey, 31% of American
consumers spend between $ 26 and $ 50 per
month on cosmetics and personal care
products, while 18% of respondents spend more
than $ 100 per month. The United States is home
to the world’s largest cosmetics and personal
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care market. In 2019, its value was estimated at
approximately $ 93.35 billion up from $ 80.7
billion in 2015. Most of this market value is in the
hair and skin care segments (Average amount
consumers spend, 2019). Other studies show that
the average woman in the US spends about $
313 a month on her looks. This is up to $ 3,756
per year or $ 225,360 over a lifetime (McLintock,
2020). One of the reasons women spend huge
amounts of money on personal care (along with
skin needs and an obsession with cosmetics) is
due to social pressure.
The situation is just as serious in the beauty
market of the Far East. For example, in South
Korea physical beauty is associated with
superiority, as far as South Korea is a country of
hyper-competition for limited resources. Beautiful
appearance creates a competitive advantage
that helps in finding a job, choosing a partner,
achieving a higher social and financial status
(Luxen & Van De Vijver, 2006). Male dominance
in the East Asia region amplifies this
phenomenon. Gender discrimination in South
Korea has led to the objectification of women’s
bodies and desire to maximize social
competitive advantage through risky
appearance management such as cosmetic
surgery (Lim, 2004). A person who has a “culturally
appropriate” face and body is more likely to
access social resources. This leads to the fact
that women who do not meet these standards
consider themselves inferior, suffer from stress,
prejudice, and inequality (Kim & Lee, 2018;
Strahan et al., 2006).
Thus, unrealistic beauty standards have a
huge impact on women and their self-image.
Exposure to visual media depicting idealized
faces and bodies causes a negative or distorted
self-image (Grabe, Ward & Hyde, 2011). The new
globalized and homogenized beauty ideal
emphasizes youth and slimness. Over the past
few decades, the emphasis on this ideal has
been accompanied by an increase in the level
of dissatisfaction with their bodies among both
women and men (Tiggemann, 2004).
Though face and body image concerns are
not a mental health condition in themselves
(Mair, 2019), they have a negative impact on
women’s mental health being associated with
body dysmorphic disorder, social anxiety
disorder, obsessive-compulsive disorder, panic
disorder (Aderka et al., 2014), depression, eating
disorders, psychological distress, low self-esteem,
self-harm (Black, 2019; Octan, 2017), suicidal
feelings. For instance, “one in eight adults in the
UK have experienced suicidal thoughts or feelings
because of concerns about their body image”
(Mental Health Foundation, 2019). This situation is
becoming even more dangerous today, when
the COVID-19 pandemic has affected those
struggling with BDD (The Covid-19 Pandemic,
2020).
A philosopher and essayist S. Neiman in her
book “Why Grow Up?: Subversive Thoughts for an
Infantile Age” (2015) argues that the orientation of
the modern society on youth as the main value is
a disturbing symptom, since normal growing up is
perceived as a decline. By focusing on
consumption rather than satisfaction with work,
relationships, life in general, the world creates a
society of eternal adolescents. This is convenient
for the establishment, which, by satisfying the
material needs of people, distracts them from
something else, something deeper and more
important for the development of a human and
humankind. The cult of youth promotes control
over people who choose youth and beauty as a
main life goal mainly because of the need
imposed by society to meet established
standards for successful social functioning.
Although evolutionary biologists argue that
there are evolutionary reasons for using the
images of women of the most reproductive age
and men at the peak of their physical activity in
advertising, S. Neiman states that the goal of
humanity is not to maximize reproduction, no
matter what they talk about genes. Evolutionary
arguments fail to explain the enormous social
emphasis on youth. Debunking the
misconceptions about childhood as a state of
bliss and adulthood as an evidence of painful
experience, S. Neiman emphasizes that the state
of maturity is an ideal that is difficult to achieve,
but one must strive for it (2015).
These ideas resonate so closely with C.G.
Jung’s theory of the archetypes of the collective
unconscious and the individuation process. Within
the frame of Jungian terms, individuation means
the process of achieving self-realization by
bringing the individual and collective
unconscious into conscious – this is the
coherence of all components of the personality
that unites them into the one unified integral
system. C.G. Jung considered the reintegration of
the personality to be a necessary condition for
solving spiritual, social, ethical, and political
problems of humanity. Social health depends on
the health of individuals. As a psychiatrist and
psychoanalyst, C.G. Jung found that his patients
over the age of thirty-five were faced with the
problem of reintegration with a wider spiritual
reality (2017). According to the psychoanalyst,
such a situation indicates that reintegration is the
basis for the integrity of the psyche.
The interiorization of the modern standards of
female beauty as the image of a young girl (who
will never reach the age of 35) impedes the
psychological development of women and leads
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to disintegration disabling the interconnection of
all elements of the psyche and giving rise to
deep contradictions. In the Jungian pantheon of
archetypes, the young girl is personified by the
Kore (1980). This is one of the most mysterious
archetypal figures. C.G. Jung describes the Kore
as an image of female innocence. The Kore
belongs to the structure of the unconscious and is
a part of the “impersonal psyche” common to all
people. The Kore archetype has its psychological
counterpart in the archetypes of the Anima and
the Self: “When observed in the products of a
woman’s unconscious, it is an image of the
supraordinate personality or self. In a man, the
Kore is an aspect of the anima and partakes in
all the symbolism attached to his inner
personality” (Sharp, 1991). Like all psychic figures,
this archetype is capable of doubling; its
inseparable opposite is the archetypal Mother,
with whom the Kore is equal in significance, but
different in function.
Being inseparably linked with the figure of
Demeter, her mother, Kore/Persephone draws
socially accepted gender roles for the young
women, especially in traditional cultures. “In the
normal development of girls one can see the
imagery of the daughter archetype unfolding in
the plays, dreams and heroines which small girls
may indulge in – from the early pink princess
fantasy, playing with Barbie dolls, or listening to
the story of the Swedish Pippi Longstocking. In the
analysis of adults, images of the daughter
archetype will often mediate aspects of the Self
which should be made conscious and integrated
in the female personality to serve the female
individuation process. In so far they would tend to
support the differentiation from both traditional
gender roles and from identification with the
anima projections from men, they support the
development of ego consciousness and its
growing autonomy. The differentiation between
the Mother archetype and the Daughter
archetype is very important for women, just like
the differentiation of the anima from the mother
archetype is for men” (Skogemann, undated).
Given his practical observations, C.G. Jung
concludes that the Kore often appears in women
in the form of an unknown young girl or nymph,
maenad. The types of supraordinate personality
that C.G. Jung defines as a total person are
personified by Demeter and Hecate. The
chthonic and nocturnal character of Hecate,
which correlates with Demeter, and the fate of
the Kore (Persephone) are closely related and
correspond to the Triple Goddess of neo-
paganism, in particular Wicca (Graves, 2013).
Goddess-Maiden (Cora/Persephone) is the new
waxing moon, Goddess-Mother (Demeter) is the
full moon, and Goddess-Crone (Hecate) is the
waning moon. In the lunar cycle, these three
hypostases are inextricably linked and are
constantly transforming one into another
(Danylova, 2020; Graves, 2013). Outside the
context of eternal change, the image of the Kore
is perceived differently. Youth and beauty must
be preserved at any cost – such is the demand
of society. This suggests that Kore will never want
to transform into Demeter, and a woman, who
should already be led by Demeter, will in every
possible way resist the transition to the image of
Hecate and cling to the image of Kore with all
her might.
The tremendous striving to follow the standards
of beauty imposed by society impedes the
psychological development of women and leads
to disintegration, which disrupts the
interconnection of all elements of the
psychological system and creates deep
contradictions. Without maturity transformations,
the image of the Kore, which is so attractive to
the modern world, indicates an undeveloped
part of the personality. In this regard, C.G. Jung
notes: “…maidens are always doomed to die,
because their exclusive domination of the
feminine psyche hinders the individuation
process, that is, the maturation of personality”
(1980, p.190). An inability to grow up and
become mature leads to dangerous
consequences: “The maiden’s helplessness
exposes her to all sorts of dangers, for instance of
being devoured by reptiles or ritually slaughtered
like a beast of sacrifice. Often they are bloody,
cruel, and even obscene orgies to which the
innocent child falls victim” (Jung, 1980, p. 178).
Being psychologically fixated at the level of a
young girl, a woman slows down her inner growth
and cannot live a full life being limited to the only
one role. As long as a woman is young and
attractive, she may be satisfied with this role,
especially if she is ready to obey the men’s world
because of the seeming benefits it can bring, as
well as the respite from responsibility it promises
(Beauvoir, 2011).
This fixation does not allow a woman to
develop her potential and enjoy life as it is. She
feels the consequences of this fixation on the
Kore archetype in the second half of her life,
when the charm of youth evaporates and cannot
be maintained by any means. This is where a
deep psychological crisis comes in: “…as long as
a woman is content to be a femme à homme,
she has no feminine individuality. She is empty
and merely glitters – a welcome vessel for
masculine projections. Woman as a personality,
however, is a very different thing: here illusion no
longer works. So that when the question of
personality arises, which is as a rule the painful
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fact of the second half of life, the childish form of
the self disappears too” (Jung, 1980, p. 191).
In the myth, Kore/Persephone is a part of the
Demeter-Kore dyad, which can symbolize
wisdom and naivety respectively. By focusing on
the only one side of this complex figure of the
psyche, women “restrain their forward
movement” becoming an ideal object of
manipulation. Thus, they easily internalize
someone’s ideas about what the world should be
and about their “right” place in it losing the ability
to think critically. Being “squeezed” into the tight
stereotypes of gender representations covered
with an aesthetic veil and grounded by
evolutionary expediency, they unconsciously give
away power over their lives.
This state of the eternal girl is also supported by
the men’s unconscious. For him, the female
figure of the Anima is not a supraordinate
personality. In the products of a man’s
unconscious activity, Anima is manifested as the
Maiden and the Mother; therefore, a man’s
individual interpretation always reduces this figure
to his own mother or another real woman. Anima
is bipolar and can appear both positive and
negative. According to C.G. Jung, to the young
boy, the image of the Anima manifests itself in his
mother, and the same is true for infantile men:
“An infantile man generally has a maternal
anima; an adult man, the figure of a younger
woman. The senile man finds compensation in a
very young girl, or even a child” (1980, p. 192).
Due to the ambivalence of the Anima
archetype, its projection can be both positive
and negative, but anyhow this image is numinous
that causes fear and awe associated with
females (Danylova, 2015). Therefore, the
projection of the Anima as a young, less
experienced girl seems to a man to be safer than
the image of a loving but at the same time all-
consuming Mother. Evolutionary biologists
associate such psychological reactions with the
level of hormones and fertility of a woman without
taking into account the mechanisms that
dominate in the depths of our psyche. “We see
the images of the Kore everywhere. Advertising
loves “feminine innocence”. Males and females
alike get stuck on the image of the beautiful and
fair girl. In Jung’s terms this would reflect a
regressive movement backward toward youth,
rather than participation in psychic growth and
transformation that leads to maturity and wisdom”
(Jenna Lilla, 2013).
Limitations of the study\Strengths of the
study:
This study has limitations as well as strengths.
Lack of extensive research does not allow us to
draw unambiguous conclusions. However, this
theoretical study may provide an avenue for
more complex, interdisciplinary research in
mental health issues and ways to overcome
them.
Conclusions
Overcoming the psychological threshold of
growing up, achieving deep experience and
inner growth, a woman can discover another
aspect of Persephone/ Kore described by the
psychiatrist and Jungian analyst J.S. Bolen. This is
the Mistress of the Underworld with a great spiritual
experience, who has lost her fear of ageing and
death (Bolen, 2014). Realizing her indissoluble
connection with Demeter and Hecate, this
woman ceases to be an object of manipulation,
accepts reality as it is, feels comfortable and
confident in her own skin, while her beauty
becomes multifaceted and reflects all aspects of
her true personality.
Conflict of interest
The author declares no conflict of interests with
regard to this study.
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The role of metformin hydrochloride in complex
therapy of disorders of carbohydrate metabolism in
patients with paranoid schizophrenia treated with
atypical antipsychotics
Ivan Romash
Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
Abstract
Introduction. According to the literature, mortality among patients with schizophrenia is 1.5 -2
times higher than in the healthy population. One explanation for this is the complication of
neuroleptic therapy, which, according to various authors, occurs in 2 to 100% of cases.
Purpose. We aimed to study some indicators of carbohydrate metabolism disorders in patients
with paranoid schizophrenia who have been taking neuroleptics for a long time, to correct the
established changes by adding metformin hydrochloride to the standard regimen and to
monitor its effectiveness.
Methodology. The study was conducted based on Municipal non-commercial enterprise
"Precarpathian regional clinical center of mental health of Ivano-Frankivsk regional council. This
study included patients diagnosed with paranoid schizophrenia according to the criteria of ICD-
10 (F20.0). As a result of our studies in 63 patients, we found a violation of carbohydrate
metabolism, which accounted for 52% of all examined. Among them, 55 patients with
prediabetes: 12 (19.04%) patients with impaired glucose tolerance (IGT), 43 (68%) with impaired
fasting glycemia (IFG), and 8 patients (12.7%) with type 2 diabetes mellitus (T2D). Subsequently,
all these 63 patients were prescribed corrective therapy with a drug from the group of
biguanides - metformin hydrochloride at a dose from 500 to 1000 mg/day: in violation of IFG at
a dose of 500 mg/day; in case of IGT - 850 mg/day; in the case of T2D- 1000 mg/day. All studies
were performed before and after 3 months of metformin correction. These included fasting
glucose, postprandial hyperglycemia (PPG) (two hours after a meal), glycosylated hemoglobin
(HbAIc), immunoreactive insulin (IRI), and, if necessary, an oral glucose tolerance test (OGTT).
Fasting plasma glucose (FPG) was measured by the glucose oxidase method. HbAIc values
were determined by ion-exchange high-performance liquid chromatography (HPLC). The
determination of the IRI level was performed by enzyme-linked immunosorbent assay (ELISA)
Results and Discussion. The results of the research showed that 52% of all surveyed found
disorders of carbohydrate metabolism. They were prescribed corrective therapy with a drug
from the group of biguanides - metformin hydrochloride at a dose of 500 to 1000 mg/day. As a
result of the research, we found that in all groups of examined patients revealed a positive
dynamics of carbohydrate metabolism under the influence of this drug. A significantly higher
therapeutic effect of the treatment of carbohydrate metabolism disorders with metformin was
found in patients receiving the latter in combination with haloperidol. The combination of
metformin with risperidone and quetiapine showed a slightly lower clinical effect.
Conclusion. Our own clinical experience gives grounds to recommend metformin
hydrochloride as a medium for the correction of carbohydrate metabolism disorders in patients
with a paranoid form of schizophrenia in the treatment of this category of patients with
neuroleptics.
Keywords
carbohydrate metabolism, paranoid schizophrenia, atypical neuroleptics, metformin
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Address for correspondence:
Ivan Romash, M.D., Ph.D., assistant of professor Department of Psychiatry, Narcology and
Medical Psychology Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine, e-
mail: ivromash@ifnmu.edu.ua
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Romash, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI: http://doi.org/10.32437/mhgcj.v3i1.93
Submitted for publication: 11
June 2020
Received: 11 June 2020
Accepted for publication: 17
October 2020
Introduction
According to the literature, mortality among
patients with schizophrenia is 1.5 -2 times higher
than in the healthy population (1,2,3). One
explanation for this is the complication of
neuroleptic therapy, which, according to various
authors, occurs in 2 to 100% of cases (IHME,
2018; Maruta et al., 2015).
Patients with schizophrenia, which is
comorbid, need special attention somatic
pathology, in particular metabolic disorders,
which often go unnoticed by clinicians.
Concomitant metabolic disorders in
schizophrenia not only increase mortality but also
create serious problems, in particular, in providing
psychopharmacological care to this group of
patients. According to scientific data, patients
with paranoid schizophrenia comorbid with
diabetes in 45% of cases in the first place put the
treatment of somatic pathology, neglecting the
treatment of the underlying disease, the other
40% - on the contrary - leave concomitant
metabolic disorders without adequate correction
(Jungsun, 2019; Romash, 2016, a).
The emergence of a new generation of
antipsychotic pharmacotherapy, the so-called
atypical antipsychotics (AA), largely devoid of the
disadvantages of classical neuroleptics, has
certainly been an important step forward in the
treatment of patients with schizophrenia (Siskind
et al., 2016). Several studies have confirmed the
hypothesis of greater efficacy and safety of AA.
Also, comparative studies have identified
additional features of their clinical action: the
ability to reduce secondary and possibly primary
negative symptoms, reduce the severity of
cognitive impairment, reduce comorbid affective
symptoms, some drugs lack or low
hyperprolactinemia and effectiveness in some
cases, resistant to traditional neuroleptics (Siskind
et al., 2018; Freyberg et.al.,2017; Romash, 2016).
However, several large recent studies have
questioned the unconditional superiority of AA
over typical ones. This was due to the
appearance of information about the presence
of many metabolic side effects in AA, which lead
to extremely serious consequences for physical
health. According to the literature, the
prevalence of metabolic syndrome (MS) in
patients with schizophrenia is 37% -40%, which is
higher than in the general population (Siskind et
al., 2018; IHME, 2018; Maruta et al., 2015;
Romash, 2016).
Although "new" - atypical antipsychotic
drugs cause fewer neurological side effects, they
have a significant impact on the development of
metabolic processes (Romash et al., 2016). In our
recent studies were showed that neurological
complications occur significantly more often on
the background of taking a typical neuroleptic
haloperidol than risperidone or quetiapine. In
turn, a comparison of the presented AN showed
that risperidone has a statistically higher
probability of developing neurological
complications compared to quetiapine. These
data are consistent with recent studies by
Spielmans G.I. et all., Oh G.H., who showed that
of the currently known and widely used
neuroleptics, risperidone has the highest level of
akathisia, from 7% to 50%, and the lowest
incidence of akathisia is quetiapine (2 to 13%).
The incidence of akathisia in quetiapine is
significantly lower than that of risperidone from
2% to 13%. Complications from the functioning
of the autonomic nervous system were also more
common in patients of the haloperidol group.
According to the data obtained, it should be
noted that the use of atypical neuroleptics
risperidone or quetiapine has a lower risk of
developing late dyskinesia than with treatment
with haloperidol. The study indicates the benefits
of atypical antipsychotics mainly due to the lower
severity of most neurological symptoms. Only
some neurological symptoms in the examined
patients were more common on the background
of therapy with atypical antipsychotics. These
results are consistent with the data of other
authors who indicated a high probability of
extrapyramidal side effects, including severe
complications such as tardive dyskinesia,
toxicoallergic reactions and neuroleptic
malignant syndrome with haloperidol. Gardner M.
D. and sang. Geddes J. R. et al. noted the
development of tardive dyskinesia in patients
treated with haloperidol for one year 17 times
more often than with risperidone. However,
according to S. Leucht et al., the advantage of
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modern antipsychotics over drugs of previous
generations is variable.
Therefore, in recent years, in addition to
developing new drugs devoid of such side
effects, more and more scientists from around
the world have begun to look for rational
concomitant corrective therapy. In particular, in
their randomized 24-week double-blind,
placebo-controlled study, Dan Siskind and co-
authors studied the effect of concomitant
metformin on weight change when clozapine
was started. (Siskind et al., 2018) They
demonstrated that co-initiation of metformin with
the initiation of clozapine may reduce the burden
of clozapine on cardiovascular and metabolic
diseases.
Purpose
To investigate the effect of metformin
corrective therapy on insulin resistance (IR) in
patients with paranoid schizophrenia who had
been taking neuroleptics for a long time.
Methodology
The study was conducted based on Municipal
non-commercial enterprise "Precarpathian
regional clinical center of mental health of Ivano-
Frankivsk regional council. This study included
patients diagnosed with paranoid schizophrenia
according to the criteria of ICD-10 (F20.0). The
study was approved by the Bioethics Committee
of Ivano-Frankivsk National Medical University and
conducted following the principles of the Helsinki
Declaration of the World Medical Association
(Helsinki 1964, 2000 ed.). Before the study, all
patients signed voluntary informed consent.
As a result of our studies in 63 patients, we
found a violation of carbohydrate metabolism,
which accounted for 52% of all examined.
Among them, 55 patients with prediabetes: 12
(19.04%) patients with impaired glucose
tolerance (IGT), 43 (68%) with impaired fasting
glycemia (IFG), and 8 patients (12.7%) with type 2
diabetes mellitus (T2D). Subsequently, all these 63
patients were prescribed corrective therapy with
a drug from the group of biguanides - metformin
hydrochloride at a dose from 500 to 1000
mg/day: in violation of IFG at a dose of 500
mg/day; in case of IGT - 850 mg/day; in the case
of T2D- 1000 mg/day. The initial dose in all groups
was 500 mg once daily with meals (breakfast or
dinner), after 5-7 days, in the absence of
gastrointestinal side effects, the dose was
increased to 850-1000 mg after breakfast or
dinner. In case of side effects, the dose was
reduced to the previous one and increased
again after 5-7 days. Depending on the main 3-
month therapy of paranoid schizophrenia
preceding this stage of the study, patients were
divided as follows: the first (I) Group included 15
patients receiving the typical neuroleptic
haloperidol, the second (II) Group - 22 patients
receiving atypical neuroleptic (AN) risperidone, to
Group III - 15 patients who received atypical
neuroleptic quetiapine. The fourth (IV) Group was
a control group, which included 11 patients with
paranoid schizophrenia in remission who did not
receive neuroleptic therapy during the last 6
months. The duration of corrective therapy in
patients of the study groups was 3 months.
It should be noted that the drug for
concomitant corrective therapy was selected
taking into account its mechanisms of action:
reduces insulin resistance at the level of
peripheral tissues (fat, muscle), increases glucose
utilization by anaerobic glycolysis, slows glucose
absorption in the intestinal tract, stops
gluconeogenesis insulin in the liver and numerical
benefits: low risk of hypoglycemia, promotes
normalization and weight loss (anorexigenic
effect), improves lipid profile, reduces the risk of
developing type 2 diabetes in patients with
impaired glucose tolerance, has a potential
cardioprotective effect myocardial infarction in
patients with obesity and type 2 diabetes; a small
number of contraindications: hepatic
insufficiency, GFR <60 ml/min., creatinine ˃130
μmol/l in women and 120 μmol/l in men; and
rare side effects: gastrointestinal phenomena.
Also taken into account the experience of this
drug by scientists such as Batista T., Henderson D.
C. and Allison D. B. In addition, as proof of the
safety of this drug is the fact that it can be used in
children from 6 years. Therefore, it is important to
mention the scientific study of Anagnostou E. et
al. She used metformin hydrochloride to reduce
weight in children with auricular disorders (aged 6
years) who were taking AA. In her study,
metformin was more effective for weight loss with
antipsychotics than placebo in this category of
children (Anagnostou E. et al., 2016).
All studies were performed before and after 3
months of metformin correction. These included
fasting glucose, postprandial hyperglycemia
(PPG) (two hours after a meal), glycosylated
hemoglobin (HbAIc), immunoreactive insulin (IRI),
and, if necessary, an oral glucose tolerance test
(OGTT). Fasting plasma glucose (FPG) was
measured by the glucose oxidase method.
HbAIc values were determined by ion-exchange
high-performance liquid chromatography (HPLC).
The determination of the IRI level was performed
by enzyme-linked immunosorbent assay (ELISA).
We assessed carbohydrate metabolism
according to the criteria of the International
Diabetes Federation (IDF) -2005 classifications,
MHGCJ – 2020
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and the metabolic syndrome was diagnosed
according to the IDF-2007 criteria submitted by
the working group of authors in the Adapted
Clinical Regulation to the Unified Clinical
Secondary Protocol care for type 2 diabetes.
(Order of the Ministry of Health of Ukraine № 1118
of 21. 12. 2012. "On approval and
implementation of medical and technological
documents for the standardization of medical
care for type 2 diabetes").
Statistical processing of the obtained results
was performed using the program "STATISTICA
7.0." And the package of statistical functions of
the program "Microsoft Excel, 2016". The reliability
of the obtained results was confirmed based on
the calculation of the Student's ratio. The
arithmetic mean (M) and its error (m) were used
to describe the quantitative features, the mean
values were presented as M ± m.
Results and Discussion
Corrective metformin therapy lasted 3
months. We evaluated the results of the initial and
final data. Under the influence of corrective
therapy, in all studied groups significantly
decreased the rate of blood pressure (BP).
Among men, this figure decreased by an
average of 4.56%, reaching an average of 93.81
cm. Among women, BP decreased by 4.82%,
reaching 86.49 cm.
Due to corrective therapy with metformin for 3
months, a significant decrease in body weight
was found among patients of group I. Among the
studied II and III groups there was a tendency to
decrease body weight, but in comparison with
the control group, it remains higher. We found a
positive effect of biguanide therapy on body
mass index (BMI): it decreased by 5.68% in Group
I (haloperidol); by 3.79% - in Group II (risperidone)
and by 2.29% - in Group III (quetiron). In groups II
and III, BMI after 3 months of correction tended to
decrease but remained probably higher
compared to the Control group
1)a
1)b
Fig.1 a), 1b) Dynamics of changes in waist
circumference under the influence of
corrective therapy
Notes:
1. * - (p <0.05) data are reliable for indicators
before and after treatment.
2. ^ - (p <0,05) data are reliable in
comparison with the indices of the control group
As can be seen from the data in Fig.1 a), 1b),
in all groups studied significantly decreased waist
circumference (WC). Among men, this figure
decreased by an average of 4.56%, reaching an
average of 93.81 cm. Among women, WC
decreased by 4.82%, reaching 86.49 cm
Fig.2 Dynamics of body weight in patients
with paranoid schizophrenia before and after 3
months of correction with metformin
hydrochloride.
Notes:
1. * - (p <0.05) data are reliable for indicators
before and after treatment.
2. ^ - (p <0,05) data are reliable in
comparison with the indices of the control group.
Due to corrective therapy with metformin
for 3 months, we observe a probable decrease in
body weight among patients of group I. Among
the studied Groups II and III we see a tendency to
decrease body weight, but in comparison with
the control group, it is probably higher. We found
a positive effect of biguanide therapy on BMI: this
figure decreased by 5.68% in group I
(haloperidol); by 3.79% - in Group II (risperidone)
and by 2.29% - in Group III (quetiron). In Groups II
and III, BMI after 3 months of correction tended to
decrease but remained probably higher
compared to the control group (Fig. 2).
Consider the dynamics of carbohydrate
metabolism in patients with paranoid
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schizophrenia who received corrective therapy
with metformin. Fasting plasma glucose levels
(Fig. 3) decreased by an average of 14.86%,
reaching an average of 6.23 ± 1.76 mmol/l in all
groups compared with the initial value of 7.40 ±
0.26 mmol/l, which is statistically significant.
In Group I, fasting blood glucose decreased
from 7.01 ± 0.29 mmol/l to 6.35 ± 0.18 mmol/l
after hypoglycemic therapy.
In Group II, glycemic parameters after
corrective therapy had a significant decrease:
from 8.44 ± 0.23 mmol/l to 6.02 ± 0.22 mmol/l
(p <0.05).
In Group III, the indicators also had a positive
downward trend. Postprandial glycemia
decreased by an average of 27.35%, reaching
an average of 7.03 ± 0.38 mmol/liter
Fig. 3 Dynamics of fasting plasma glucose
levels under the influence of corrective therapy
with metformin.
Notes:
1. * - (p <0.05) data are reliable for indicators
before and after treatment.
2. ^ - (p <0,05) data are reliable in relation
to indicators in patients of the control group.
Statistially significant was the decrease of
PPG in all study groups (Fig. 4)
Fig. 4. Index of PPG in patients with paranoid
schizophrenia before treatment and after 3
months of metformin correction.
Notes:
1. * - (p <0.05) data are reliable for indicators
before and after treatment.
2. ^ - (p <0,05) data are reliable in relation
to indicators in patients of the control group.
The appointment of antidiabetic therapy had
a positive effect on the prognostic value of
HbA1c. (Fig. 5.) This indicator decreased by an
average of 16.01%: from 6.58 ± 0.11% to 5.12
± 0.12% in Group I; from 7.1 ± 0.15% to 5.8 ±
0.25% in Group II (p <0.05). In Group III there
was also a tendency to reduce this indicator from
6.6 ± 0.63% to 6.1 ± 0.63%.
Fig. 5. Dynamics of glycosylated
hemoglobin in patients with paranoid
schizophrenia before treatment and after 3
months of metformin correction.
Notes:
1. * - (p <0.05) data are reliable for indicators
before and after treatment.
2. ^ - (p <0,05) data are reliable in relation
to indicators in patients of the control group.
No less important in the diagnostic value is
the IRI indicator (Fig. 6). According to scientific
data, this indicator is used to assess the degree
of IR and functional activity of ß-cells of the
pancreas. In our case, IRI decreased by an
average of 26.96%: achieving a significant
decrease compared to the baseline of 25.56 ±
0.70 μIU/ml to 13.40 ± 0.35 μIU/ml in patients of
Group I (p <0, 05); from 28.85 ± 1.50 μIU / ml to
15.64 ± 0.33 μIU / ml - Group II (p <0.05); from
26.49 ± 0.69 μIU / ml to 14.56 ± 0.46 μIU / ml -
Group III
Fig. 6. Dynamics of IRI in patients with
paranoid schizophrenia before treatment and
after 3 months of metformin correction
Notes:
1. * - (p <0.05) data are reliable for indicators
before and after treatment.
2. ^ - (p <0,05) data are reliable in relation
to indicators in patients of the control group.
The value of the HOMA-IR index, which
characterizes the IR, decreased by an average
of 49.46%: from 7.96 ± 0.75 to 3.52 ± 0.55 in
the group of patients taking haloperidol (p
<0.05); from 10.82 ± 0.47 to 5.97 ± 0.5 -
risperidone (p <0.05); from 7.95 ± 0.98 to 4.15
± 0.98 - quetirone (p <0.05)
MHGCJ – 2020
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Fig. 7. Dynamics of the HOMA index in
patients with paranoid schizophrenia before
treatment and after 3 months of metformin
correction
Notes:
1. * - (p <0.05) data are reliable for indicators
before and after treatment.
2. ^ - (p <0,05) data are reliable in relation
to indicators in patients of the control group.
Another, no less important, IP index - Caro.
Under the influence of corrective therapy with
metformin, this indicator increased in all three
groups: in Group I by 74.04% reaching 0.47 ±
0.02 (p <0.05); in Group II by 31.03% and
amounted to 0.38 ± 0.03. In Group III, the Caro
index probably increased by 72% reaching an
average of 0.43 ± 0.04 (p <0.05)
Conclusions
It was found that in all groups of examined
patients revealed a positive dynamics of
carbohydrate metabolism under the influence of
metformin.
A significantly higher therapeutic effect of
the treatment of carbohydrate metabolism
disorders with metformin was found in patients
receiving the latter in combination with
haloperidol. The combination of metformin with
risperidone and quetiapine showed a slightly
lower clinical effect. Our own clinical experience
gives grounds to recommend metformin
hydrochloride as a medium for the correction of
carbohydrate metabolism disorders in patients
with a paranoid form of schizophrenia in the
treatment of this category of patients with
neuroleptics.
Conflict of interest
The author declares that he has no conflict of
interests
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MHGCJ – 2020
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MHGCJ – 2020
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Types of parent-child relationship and indicators of
neuropsychological development of preschool
children
Ekaterina Ermolova, Olga Shamshikova
Novosibirsk State Pedagogical University, Novosibirsk, Russia
Abstract
Introduction: During the last 20 years, in Russia and in many EU countries, there has been
significant change in the global social and cultural situation. Individualistic tendencies rose
sharply and there is a widespread destruction of the sense of belonging. In this regard, the type
of parent-child relationship is changing, which is one of the key dimension of the
neuropsychological development of children. There is a logical question for psychologists,
teachers and parents, what types of parent-child relationships are constructive, that is, they
favor normal neuropsychological development of children of preschool age (6-7 years).
Purpose: The purpose of the present work is to investigate correlation between types of parent-
child relationships and indicators of neuropsychological development of children, as well as
identifying constructive types of parent-child relationships for the normal neuropsychological
development of children.
Methodology: The study was conducted within the framework of the basic screening program
(pre-school stage). The Order of the Ministry of health of the Russian Federation of 03.07.2000 №
241 On approval of the Medical card of the child for educational institutions (together with the
Instruction on the procedure of an accounting form № 026/u-2000 (The Medical card of the
child for educational institutions of preschool, primary, basic, secondary (complete) general
education, primary and secondary vocational education, orphanages and boarding schools).
Determination of the correspondence of neuropsychological development to the child's age
was carried out according to the following indicators: thinking and speech; attention and
memory; positive emotions and social contacts; sensorimotor development. Types of parental
relationship was studied using the methodology of the Questionnaire “Parental relationship”
(QPR), A.Y. Varga, V.V. Stolin. The sample was formed from 94 respondents who were screened
in the framework of the basic screening program (preschool stage) at the health Center of the
MC “Gubernia” in Novosibirsk. The study of determination of the type of parent-child relationship
of 47 respondents (mothers) was conducted and the neuropsychic development of 47 children
of preschool age in the families (6-7 years) was evaluated.
Results and Discussion: The data obtained indicate that different types of parent-child
relationship such as “Cooperation” and “Symbiosis” positively interrelated with different indicators
(attention and memory; the development of positive emotions and the presence of significant
experiences in children) of the child's neuropsychological development. Such types of parent-
child relationship as “Infantilism” and “Acceptance-rejection” negatively interrelated with such
indicators of child's neuropsychological development as attention and memory; thinking,
speech and positive emotions and social contacts.
Conclusion: Children in groups with a more “constructive” parental relationship type have
higher cognitive scores and fewer behavioral problems. The materials of the study can be used
by child psychologists in the evaluation of neuropsychological development of the child. The
Bank of diagnostic techniques that quickly allow diagnosing the state of neuropsychic
development of the child in relation to the type of parental relations and thereby increasing the
effectiveness of its correction through work with parents is of practical importance
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Keywords
Mental health, parent-child relations; neuropsychic development; preschool age; indicators of
development.
Address for correspondence:
Ekaterina Ermolova, Professor of the Department of General Psychology and History of
psychology, Head of the Scientific Laboratory of “Developmental Psychology”, Novosibirsk
State Pedagogical University, Novosibirsk, Russia,. e-mail: shamka05@mail.ru
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Ermolova, Shamshikova, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI: http://doi.org/10.32437/mhgcj.v3i1.94
Submitted for publication: 3
July 2020
Received: 3 July 2020
Accepted for publication: 20
October 2020
Introduction
“Each cultural and historical epoch gives rise
to a certain set of life dominants which human
community perceives as a norm, a way of life
and a dominating world outlook. The modern era
in this respect is a crisis one” (Shamshikova et al,
2011. p. 17). The crisis (socio-economic)
manifests itself as a violation of the normal
functioning of society as a result of a sharp
aggravation of social contradictions and creating
a threat to the resilience of both society and the
individual in the environment (with the most
vulnerable is the personality of a child of
preschool age).
Over the past 20 years, there has been a
sharp change in the system of value orientations,
increased individualistic trends, there is a
widespread destruction of a sense of belonging;
new systems of interaction appear and space
“without borders expands”. In this regard, there is
an urgent question of studying a “new social
reality”, which changes the content of growing up
(development and socialization) of a child.
“Specific data collected by scientists show that
the change of historical situation has stimulated
the qualitative mental, psychological and
personality changes of a contemporary child”
(Feldstein, 2011, p. 385).
The irrepressible penetration of modern means
of communication and information technologies
into the world of childhood; the emergence of
new inflated social expectations and
requirements in relation to the intellectual skills of
a child; visible predominance of acceleration
over amplification (enrichment of development);
the change in the content and form of
education at different stages of the educational
process (Obukhova & Kotlyar, 2011) demand
today the need for in-depth study of the normal
(potential) neuropsychological development
(NPD) of a child. “... this potential of preschool
childhood could be realized, as was noted by
A.V. Zaporozhets, only by taking into account the
age-related psychophysiological characteristics
and psychological specificity of this childhood
stage” (Bolshunova & Ermolova, 2016, p. 377).
First, such consideration of the specifics of
age should be carried out by parents in the
organization of the system of activity of the child,
its development and education. This requires that
parents have certain role competencies and
have sufficient motivation to maintain adequate
parent-child relationships (Grusec & Danyliuk,
2019). However, modern parents are increasingly
exhibiting “low level of parental motivation, poor
command of communication skills in parents in
regard with children, poor organization of child's
leisure and daily schedule” (Feldstein, 2011, p.
386). Such parental characteristics are reflected
in different types of parental relationship (which is
the basis of the social situation of development)
and determine specific configurations of the
development of neuropsychic processes and
personal formations of preschool children.
Taking into account the relevance of the
revealed contradictions, we consider it important
in the current socio-cultural conditions to study
the normal neuropsychological development of
the child and the causes of abnormalities in the
neuropsychic development of children, where
one of the determining role of the functioning of
the personality of a preschooler is the type of
parent-child relations.
Purpose
The purpose of the present work is to
investigate correlation between types of parent-
child relationships and indicators of
neuropsychological development of children, as
well as identifying constructive types of parent-
child relationships for the normal
neuropsychological development of children.
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Methodology
We have formed a set of complementary
empirical methods: questionnaires, testing (blank
and projective), mathematical and statistical
methods of data processing. The study was
conducted within the framework of the basic
screening program (pre-school stage). The Order
of the Ministry of health of the Russian Federation
of 03.07.2000 № 241 On approval of the
Medical card of the child for educational
institutions (together with the Instruction on the
procedure of an accounting form № 026/u-2000
(The Medical card of the child for educational
institutions of preschool, primary, basic,
secondary (complete) general education,
primary and secondary vocational education,
orphanages and boarding schools) (2000).
Determination of the correspondence of
neuropsychological development to the child's
age was carried out according to the following
indicators: thinking and speech; attention and
memory; positive emotions and social contacts;
sensorimotor development.
The following methods were used for
diagnostic purposes:
1) The Questionnaire “Parental relationship”
(QPR), A.Y. Varga, V.V. Stolin (1982) (DYa
Raygorodsky, 1998); 2) The Orientation test of
school maturity of Core-Yerseke, which is a
modification of the test of A. Kern (1978); 3)
Methods of learning ten words by A.R. Luria
(1973); 4) Methods of “Nelepitsa (Nonsense)”, the
author is S.R. Nemov (1986); 5) The Interview – “A
Magic world” , the author is D.V. Lubowski (1982);
6) The Test “Draw a family”, the authors are V. Huls
(1952), L. Corman (1964) A. I. Zakharova (1982)
and others (I. Kniginoy, 1998). When analyzing the
results of the study, statistical data processing
methods were used: percentage distribution of
the trait and the correlation analysis
(nonparametric rs-Spearman criterion).
The sample was formed from 94 respondents
who were screened in the framework of the basic
screening program (preschool stage) at the
health Center of the MC “Gubernia” in
Novosibirsk. The study of determination of the
type of parent-child relationship of 47
respondents (mothers) was conducted and the
neuropsychic development of 47 children of
preschool age in the families (6-7 years) was
evaluated.
Results
With the help of the Bank of diagnostic tools
formed by us, diagnostics of preschool children
and their parents (only mothers took part in
research) was consistently by all methods carried
out. We received the following results:
- in terms of intellectual and sensorimotor
development screened preschoolers were
divided into three groups: ready for school 60%
(28 children), the average level of readiness –
36% (17 children) and 4% of cases (2 children)
require additional research to obtain more
objective data;
- by indicators of thinking and speech: high
level is revealed at 23% of cases (11 children),
average level – 68% of cases (32 children), at 9%
of cases (4 children) – low;
- according to the indicators of attention and
memory: high level of development was
revealed at 23% of the screened (11 children),
the average level – 68% (31 children), low level
was demonstrated by 9% of children (5 children);
- in terms of the degree of manifestation of
positive emotions and social contacts: high
degree is observed at 29% (14 children), an
average - 60% (28 people), low – at 11% of
cases (five children);
- in terms of the level of severity of needs,
strong emotions at the screened children: highly
formed at 21% (10 children), medium – 60% (28
children), low – 19% of cases (9 children).
In the study of the type of parental relationship
(PR), it was found that in terms of the scale
“Acceptance – rejection” (reflects the integral
emotional attitude to the child) refers to 29% of
the screened parents (14 people), to the PR
“Cooperation” – 8% (4 parents), “Symbiosis” – 4%
(2 parents), “Authoritarian hypersocialization” – 8%
(4 parents), “Infantilism” was detected in 12% of
cases (6 parents). In 20% of cases, the subjects
were found to have a combination of types of PR
scales “Acceptance – rejection and Infantilism”
and “Cooperation and Symbiosis”.
Thus, the most common types of PR were: a
combination of scales: “Acceptance – rejection”
and “Infantilism” – 20%; “Cooperation” and
“Symbiosis” – 20% and “Acceptance – rejection”
– 28%.
Next, we checked the relations between the
indicators of neuropsychic development of
children (according to the scales of
questionnaires) and the type of parent-child
relationship to the child. The results of the
correlation analysis by indicators of
neuropsychological development and scales of
parental relationship showed the following: such
types of parent-child relations as “Cooperation”
and “Symbiosis” directly correlate with indicators
of neuropsychological development: attention
and memory (p = 0, 001), positive emotions (p =
0, 001), strong emotions (p = 0, 04); in addition to
this type of PR “Symbiosis” has a negative
relationship with the indicator of intellectual and
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sensorimotor development (p = 0, 021). The type
of parent-child relations “Acceptance-rejection”
and “Infantilism” has an inverse relationship with
the indicator of positive emotions (p = 0, 004), as
well as the type – «Infantilism» has an inverse
relationship with the indicators of attention and
memory (p = 0, 01), strong emotions (p = 0,
008), and the type of PR “Acceptance-rejection”
has feedback with indicators of thinking and
speech (p = 0, 05).
Discussion
Based on the empirical data, we see the
expediency of assessing the neuropsychic
development of a child 6-7 years of age in
relation to the definition of the type of parental
relations. We proceed from the position that the
type of parent-child relations is an integral
characteristic of parental value orientations,
attitudes, emotional attitude to the child (Varga,
2006; Filippova, 1999; Spivakovskaya, 2000;
Holden, 1995; Shamshikova & Gorbatovskaja,
2020), and has one of the determining effects on
the level and content of neuropsychological
development of the child, determining its
emotional, sensorimotor and intellectual
development.
The data obtained indicate that the majority
of the screened children demonstrate an
average level of readiness for school, i.e. the
development of fine motor skills of the hand and
coordination of vision and hand movements
necessary for mastering writing, are able to
imitate the model and focus on one case without
being distracted for some time. Also, a greater
number of screened children (60-68%) have
average indicators of development of arbitrary
attention and short-term memory; average
indicators of thinking and speech (children have
elementary imaginative ideas about the world
and about the logical connections and relations
existing between some objects of this world:
animals, their way of life, nature; demonstrate the
ability to reason logically and express their
thoughts grammatically correct), the average
degree of positive emotions and social contacts
(most children show positive experiences –
emotions such as joy and interest, tenderness
and friendliness towards their family members;
realize and accept their place in the family
structure; have multiple positive social contacts
and adequate structure of sexual identification).
In most children, an average level of severity of
needs and strong emotions was found.
However, there were children who
demonstrated a low level of the examined
indicators: two children – boys – showed
unreadiness for school; four children were
diagnosed with a low level of development of
thinking and speech (these children could hardly
operate with ideas about objects, connections
and relations between them); five children
showed a low level of development of arbitrary
attention and memory. These children also found
problems in relations with others.
Also, children with a high level of severity of
the examined traits (according to different
indicators from 10 to 14 children) were identified.
These children are distinguished by active
mastery of the ways of practical and cognitive
activity; positive emotional attitude to the
environment in accordance with the values,
ideals and norms of society. In their general
structure of behavior, new forms of empathy and
empathy to another person, so necessary for joint
activity and communication, are shown.
According to D.B. Elkonin, preschool age
revolves around an adult, as around its center, its
functions, and its tasks. The adult acts in a
generalized form, as a carrier of social functions
in the system of social relations. The child is a
member of society, it cannot live outside of
society, its main need is to live together with other
people, but this cannot be done in current socio-
cultural conditions: the child's life takes place in
conditions of indirect, not direct connection with
the world (Elkonin, 1998; 2007). Parent plays the
key role in this context.
The leadership style of the adult is important
here. It should help to ensure that the child feels
like a full participant in joint activities, has the
opportunity to show initiative and independence
in achieving the goal. Excessive regulation of the
behavior of a preschool child, when he plays the
role of a mechanical performer of individual
orders of an adult, discourages the child, reduces
his emotional tone, leaves indifferent to the results
of the common cause (Obukhova, 2013).
Such types of parent-child relations as
“Cooperation” (when the parent is interested in
the affairs and plans of the child, tries to help
him, and sympathizes; appreciates the
intellectual and creative abilities of the child, feels
a sense of pride for him; encourages initiative
and independence of the child) and “Symbiosis”
(when the parent feels with the child as a whole,
tries to meet all the needs of the child, to protect
him from the difficulties and troubles of life;
worries for the child and seeks to devote him a lot
of time) positively affect the development of
such indicators of the level of neuro-mental
development of the child, as attention and
memory, the development of positive emotions
and the presence of significant experiences in
children.
Such type of parent-child relations as
“Symbiosis” negatively affects the indicators of the
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level of intellectual and sensorimotor
development of the child in the family. Such type
of PR as “Infantilism” (when parents seek to
attribute the child personal and social failure; see
a child younger than his real age is and consider
his interests, hobbies, thoughts and feelings not
serious; imagine a child unfit and unsuccessful) is
having a negative impact on such indicators of
the NPD children as attention and memory,
positive emotions, meaningful experiences.
The type of PR “Acceptance-rejection” (where
at high scores on this scale “rejection” is
diagnosed, the parent perceives his child bad,
unsuitable, unsuccessful; the parent considers
that the child will not succeed in life because of
low abilities, small mind, bad inclinations; the
parent more often feels anger, frustration,
irritation, resentment towards the child) is
negatively associated with such indicators of NPD
as thinking and speech, positive emotions and
social contacts.
Conclusions
The data obtained indicate that different
types of parent-child relationship such as
“Cooperation” and “Symbiosis” positively
interrelated with different indicators (attention and
memory; the development of positive emotions
and the presence of significant experiences in
children) of the child's neuropsychological
development. Such types of parent-child
relationship as “Infantilism” and “Acceptance-
rejection” negatively interrelated with such
indicators of child's neuropsychological
development as attention and memory; thinking,
speech and positive emotions and social
contacts.
As we can see, even before entering school
there are differences in the cognitive, emotional
and behavioral development of children,
depending on the type of family relations.
Children in groups with a more “constructive”
parent-child type have higher cognitive scores
and fewer behavioral problems. An important
part of these differences between children can
be explained by what parents “do” in terms of
educational activities, such as parental attitudes
and a style of upbringing children.
The materials of the study can be used by
child psychologists in the evaluation of
neuropsychological development of the child.
The Bank of diagnostic techniques that quickly
allow diagnosing the state of neuropsychic
development of the child in relation to the type of
family relations and thereby increasing the
effectiveness of its correction through work with
parents is of practical importance.
Conflict of interest
The authors declare no conflict of interests.
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