Analysis of the structure of psycho-emotional disorders in patients with consequences of CVA who underwent rehabilitation at the FSCCRR in conditions of social and communicative deprivation

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Introduction

The coronavirus pandemic, which began in 2019, is still having a profound impact on the global community and the course of history. It caused changes in the society, which affected all aspects of people’s life and the humanity as whole (economic, social, personal), led to a crisis not only financial, but also existential. The introduced unvoluntary self-isolation regime has affected all countries, and the deprivation conditions that had a negative effect on mental health of almost every person, which, in our opinion, enhances the relevance of the scientific study of this problem.

Some research into the effect of social isolation on a person and his/her mental health was carried out in the past (isolation on expeditions, in places of confinement, in space) [8, 11, 15]. All studies observed that both lone and group isolation causes various changes in the person’s state of mind, creating psycho-emotional tension, inadequate psychological reactions, in some cases leading to neuroses and reactive psychoses. Such reactions are a consequence of the influence of psychogenic factors accompanying unvoluntary isolation: monotony, misalignment of the rhythm of sleep and wakefulness, information restriction, vitality threat [8, 10].

Institutions of the penitentiary system are examples of unvoluntary long-term isolation without the possibility of its termination by the isolated person [15]. The main pathogenic factors of isolation cause a sharp change in the life routine, monotony of existence, decreased motor activity, limitation and / or qualitative change in sensory information [11]. The same factors can be identified as the main ones for cases of isolation introduced due to the coronavirus pandemic.

Monotony leads to the feeling of loss of connection with reality, to distortion of space and time perception, to feeling down, to tension rise and anxiety [9].

Changes in the usual daily routine and sleep pattern lead to disruption of the endogenous and exogenous rhythms of the body and in turn lead to increased anxiety, imbalance, emotional lability and as a result to the development of neuroses and depression. Group isolation, such as a long stay in a hospital, can result in manifestations of depression, hostility, sleep disturbances and reduced of cognitive abilities [14].

Patients of FRCC ICMRR undergo rehabilitation after "cerebral accidents" of acute cerebrovascular accident (ACVA), Traumatic Brain Injury (TBI), brain surgery. The state of the majority of these patients can be defined as "the moderate severity condition". What lies behind this technical term? Several days or weeks in a coma, a month or more of loneliness, away from family and loved ones, in conditions of "isolation". In 2020 (the year of the pandemic) and in the current year 2021, the hard life of patients dealing with the disease is made more difficult by the visits ban.

The research of deprivation effects on a person in isolation needs to consider the psychological consequences of sensory and social deprivation. Sensory deprivation is caused by a reduced intensity and variety of the of external stimuli. Social deprivation is the inability to communicate with other people, or communication is possible only with a limited group of people. A person who does not receive the usual socially significant information is unable to have sensory-emotional contacts which take place when communicating with other people in normal circumstances without restrictions [6, 14].

External visits are restricted in most hospitals, and this helps contain the virus, but it also reduces the amount of non-verbal, tactile contact. Research by psychologists has shown that hugging and other types of touching can relieve even physical pain and the discomfort subsides.

When patients are visited in a hospital they feel the support and care of loved ones, which is called "their skin". Relatives could come, hold the hand, stroke the head, comb, wash, and thus non-verbally express their love and care. Not everyone manages to find words suitable for the occasion, not everyone has a gift of expressing their feelings verbally. Nothing can replace the care of loving hands, the warmth of the breath of loved ones next to you, empathy, love and support expressed by the visitors’ eyes. Audio and video communication can replace personal communications only some extent, especially for people who, due to brain damage of various degree, have impaired communicative function, i.e. disfunctions of the impressive or expressive aspects of speech. In this case verbal communication does not have the informative value for the patient.

The problems of deprivation, reduction or complete loss of the ability to satisfy basic psychophysiological and social needs are particularly strong in the acute and subacute periods of CVA and TBI. When patients wake up in the hospital and then when they are transferred from the hospital to the rehabilitation centre they can see only the medical staff. Unfamiliar strangers treat them, feed them, change clothes, take care of them. Illness, infirmity, disorientation, anosognosia, pain, loss of independence cause negative thoughts and emotions,  destructive feelings: increased anxiety, self-doubt, uncertainty about the prospects for recovery, the experience of loneliness (abandonment), own failure, helplessness, a feeling of burden for loved ones, an assumption that someone is trying to get rid of them and so on.

The loss of usual social ties is fraught with serious problems, and the longer the isolation lasts, the worse can be the consequences of a social stress disorder which destroys the personality and worsens the isolated person’s mental health. Patients are particularly worried about several questions: What is wrong with me? Who can help me? How long will I be here? Whose support can I count on now and who can I tell about my feelings - fear, pain, anxiety, despair? What will help me get through difficult times (can become a resource for me)? How to manage without active "face-to-face" support of loved ones?

During illness the situation of unvoluntary isolation is especially depressogenic, since the control over meaningful events seems impossible to the patient. Typical conditions during their stay in long-term inpatient treatment are homesickness, missing relatives, waiting for changes, a state of being doomed. The main difficulties experienced in the first period of awareness of the disease include lack of knowledge of its passing, bewilderment from the physical limitations that initially arose, embarrassment from the inability to perform the routine hygienic procedures and an urgent need for somebody’s help to carry them out. The experience of stress from unvoluntary isolation in a situation of illness acts as an etiological, or provoking and predisposing factor in the development of depressive syndrome, social stress disorder, or post-traumatic stress disorder (PTSD).

Taking into account individual differences in the ability to adapt, internal resources of the individual and the adaptive barrier (i.e. the extreme degree of life difficulties that a person can withstand without disrupting the mechanisms of mental adaptation) everyone who is admitted into a medical institution without the possibility of personal communication with loved ones, either copes with this problem, or suffers from various adaptation disorders – from a short-term depressive reaction to severe disorders of emotions and behaviour.

The stress of hospitalisation and unvoluntary isolation makes patient’s mental health much worse, causes mental maladjustment, and often manifests itself in the development of anxiety-depressive pathopsychological symptoms [12]. Anxious behaviour is caused by the feeling of uncertainty, a lack of understanding of what is happening to them and why, what caused their isolation and how long it will take. In depression however there is no feeling of uncertainty, but rather confidence in the negative outcome is formed.

Anxiety is a mobilizing emotion associated with an active response to a situation, whereas a depressive state is a passive-defensive type of response. The state of depression is characterised by a pathological low mood with the experience of melancholy, sadness, motoric and mental retardation; disfunction of social communication: distortion of perception and interpretation of emotional expression; disfunction of behavioural cintrol [7].

Purpose of the study:

To identify the frequency of occurrence, as well as the severity of anxiety and depressive disorders in conditions of deprivation caused by the limited communication of patients with relatives, as a result of a long stay in hospital, and a pandemic COVID-19.

Materials and methods

The total number of preliminarily analysed medical records: 132 people in the control group for comparison and 104 people in the study group. The study group included patients who were admitted to the neurorehabilitation treatment departments of the Research Institute of Rehabilitation of the FRCC ICMRR after restrictions were imposed on visits by relatives, i.e. face-to-face contacts are not allowed due to the COVID-19 pandemic (from May 2020 to April 2021). The control group included patients who underwent treatment in the departments of the Research Institute of Rehabilitation of the FRCC ICMRR in 2019.

The patients were selected with the necessary balance in terms of gender, age and social activity in mind. The priority characteristic was the severity of the neurological deficit (mild and moderate severity of the lesion) and its localisation. Patients with high social-communicative activity were selected: in the period before inpatient treatment, they had a high degree of socialisation, social activity, close emotional contact with relatives and friends.

The study did not include patients:

• with short hospitalization periods (less than 2 weeks);
• significant communicative speech disfunction;
• significant cognitive impairment.

Based on the selection results, after studying the medical documentation, 2 groups of patients were formed that meet the selection requirements: study group - 21 people; control group - 24 people.

Table 1 shows the sociodemographic indicators of the comparison group and the study group.

Table 1. Gender and age characteristics of the sample

Since the priority characteristic was the distribution of the severity of neurological deficits

(mild and moderate severity of the lesion), it is interesting to note that the proportion of male patients in the study group is almost twice as large.

In the study group, the proportion of younger patients (41-50 years old) is higher due to a decrease in the number of the oldest patients (61-70 years old). The age distribution within the groups is illustrated in Figure 1.

Figure 1. Age distribution in the study group (2020-2021) and comparison group (2019)

All patients of the study group felt melancholy, hopelessness, communication deficit; noted a significant aggravation of negative feelings from hospital stay during restrictions on visiting relatives. All patients in this group felt loneliness, isolation from their family, said that communication on the phone, the knowledge that they were visited (receiving "parcels") and other such information could not replace the live face-to-face communication.

Techniques used in the study:

• Observation, interviews.
• Study and analysis of medical records.
• Hospital Anxiety and Depression Scale (HADS).
• Scale for psychological express diagnostics of semi-structured depressive disorders.
• C.D. Spielberger - Yu.L. Khanin – for determining the level of situational and personal anxiety.
• Organizational-comparative method; differentiation of material by groups, its analysis.

Hospital Anxiety and Depression Scale (HADS) [17].

This scale was developed by Zigmond A.S. and Snaith R.P. in 1983 to identify and assess the severity of depression and anxiety in general medical practice. The scale is easy to use and process results (filling it out takes little time and does not cause difficulties and negative reactions of the patient), which makes it possible to use the scale in practice for the primary detection of anxiety and depression in patients. The questionnaire has high discriminant validity for both anxiety and depression disorders.

The Depression subscale questions are selected from the most common complaints and symptoms and reflect the anhedonic component of the depressive disorder. The questions on the Anxiety subscale reflect primarily the psychological manifestations of anxiety.

Scale for express psychological diagnostics of semi-structured depressive disorders (ODS-2) [18].

The scale is designed to identify moderate and mild depressions, including poorly structured dysthymic conditions. The questionnaire contains two scales corresponding to nosological specifics:

(1) Neurotic depression;  

(2) Psychotic (endogenous) depression.

The results on this scale help to determine the presence of a depressive background of mood in a clinically low degree of severity and to assess the belonging of the syndrome to a certain class of depression - neurotic or psychotic. Conclusions based on the test results are of an express diagnostic, preliminary character. In the diagnostic procedure, two scales are used: a scale (D-N) and a scale (MDP-D, neuroses). Features of the scales:

(a) The first D-N scale solves the problem of obtaining comparable results with MDP and neuroses. The scale is applicable for both men and women. It can be used alone to identify a general depressive background.

(b) The second scale is intended for the primary assessment of the quality of depression: the level of "mild" depression, close to the neurotic spectrum; or a "major" depression.

Spielberger's Anxiety Scale (State-Trait Anxiety Inventory - STAI) as adapted by Yu.L. Khanin [19].

This scale is an informative way of self-assessment of the level of anxiety at the current moment (the condition of reactive, situational anxiety) and personal anxiety (as a stable characteristic of a person), and the higher the final indicator, the higher the level of anxiety (situational or personal). Comparison of the results for both subscales allows to assess the individual significance of the stressful situation for the person.

The Spielberger-Khanin scale, due to its relative simplicity and effectiveness, is widely used clinically for various purposes: determining the severity of anxious feelings, assessing the  dynamics of the condition, etc.

Results

When working with patients in 2020-2021 we observed the presence of "special" patients, whose somatic and mental state did not correspond to the severity of the neurological deficit. These patients underwent all of the above techniques. A total of 104 such patients were examined. From this group, 24 patients with the most pronounced emotional and personality disorders were selected for further analysis. In addition, the study group underwent a gender and age structure analysis.

To form a control group, an analysis of 132 medical records of patients who were treated at the FRCC ICMRR in 2019 was carried out. From these cards, patients were selected who had results according to the above methods, and gender and age characteristics comparable to the study group. In the obtained samples, patients were analysed in order to identify the most vulnerable groups:

1. Localisation (location of the focus) of ACVA lesions;
2. The results of the study of the psycho-emotional conditions according to 3 methods:

• Hospital Anxiety and Depression Scale (HADS) [17].
• The scale for psychological express diagnostics of semi-structured depressive disorders (ODS-2) [18].
• Ch.D. Spielberger - Yu.L. Khanina – for determining the level of situational and personal anxiety (STAI) [19].

Table 2 and Figure 2 show the results of the distribution in groups according to the peculiarities of the localisation of the process.

Table2. Distribution according to the peculiarities of the process localization (ACVA - acute cerebrovascular accident)

As a result of the analysis of medical documentation data, the location of the lesion in the brain in the comparison and study groups revealed the identity of the composition of both groups. These results indicate that there is no effect of localisation of the affected area on the occurrence and severity of depressive and anxious states.

 

Figure 2. Distribution by process localization features (%)

Patients in both groups have similar characteristics of neurological deficit (mild to moderate severity of damage) and localisation of brain lesions. All patients before the disease had a high degree of socialisation, social activity, close emotional contact with relatives and friends.

Based on the results of the analysis of medical records, observation and clinical interviews, information was obtained confirming the presence of a friendly family, caring for loved ones, strong family ties, psychological and social support in both groups of patients.

The concept of social activity in this work includes marital status and breadth of social contacts (friends, workplace, other surroundings). Thus, all patients involved in the study had an extended family with a high degree of emotional contact.

Table 3 shows results of the analysis of the responses of the control group and the study group according to the selected techniques.

Table 3. Analysis of the severity of manifestations of anxiety and depression in the study and comparison groups according to the Hospital Anxiety and Depression Scale (HADS)

According to the results of the HADS questionnaire, the frequency of manifestations of anxiety among patients during the period of unvoluntary isolation increased by more than 3.5 times, and depressive disorders by 2 times. In women, the severity of anxiety symptoms increased by 2 times, while in men - almost 10 times (increased from 7.7% to 75%); depressive disorders became more often detected among women almost 2.5 times more often; among men 2 times more often.

Table 4. Analysis of indicators of anxiety in patients with social deprivation in comparison with the previous year on the C.D. Spielberger - Yu.L. Khanin (STAI) scale

The analysis of the severity of anxiety on the Spielberger (Table 4) scale has shown the following results:

• personal anxiety increased significantly: in general by 3 times in the study group; 7.5 times among men and 1.6 times among women;
• situational anxiety increased almost 2.5 times among men, among women it remained within 80% (increased slightly, by 7%); in the group as a whole - increased by 1.5 times.

 

Table 5. Evaluation of the frequency of occurrence of neurotic and depressive states in patients in the study and comparison groups according to the scale for psychological express diagnostics of poorly structured depressive disorders (ODS - 2)

According to the results of the ODS-2 (Table 5) questionnaire, not a single case of neurosis was revealed among patients of both groups. Endogenous depression was rarely detected both before the pandemic and during the period of isolation caused by quarantine, but it increased from 4% to 14% (3.5 times).

Discussion of results

The COVID-19 pandemic, in addition to its threat to the health of each individual and the healthcare system as a whole, has a pronounced negative impact on people’s mental health. Social and psycho-emotional problems have significantly increased, undermining the emotional well-being of a person.

The severity of anxiety-depressive symptoms in the perception of the disease, especially in those who became ill for the first time, is aggravated by the psycho-emotional stress formed in the pre-stationary period. High rates of situational anxiety and feelings of loneliness indicate that patients experienced stress due to the uncertainty of their situation and of the future. Destructive consequences, such as an increased level of anxiety and loneliness, are more common for those who became ill for the first time. This is aggravated by isolation, unvoluntary separation from the family, and limitation of face-to-face communication.

This significantly complicates the rehabilitation process, because it increases the range of problems that need to be addressed a s matter of priority: lack of acceptance of their own problems and the consequences of the disease, lack of motivation to recover, the difficulty of creating perception of themselves in a situation "after illness".

Research of psychologists suggests that people during the coronavirus pandemic have a high level (22%) of the need for psychological assistance associated with an increased level of stress, an increase in psychopathological symptoms, and a decrease in the ability to adequately cope with stress. For example, earlier studies identified only 1-2% of respondents who the need psychological assistance [4].

To reduce the negative consequences of psycho-emotional stress from unvoluntary isolation, to prevent the formation of social-stress disorder, it is necessary:

• carry out educational, psycho-educational and supportive work through the media:

1. teaching the skills of emotional regulation, expanding the methods of self-correction; using constructive ways to cope with feelings of anxiety and fear;
2. teaching the use of digital alternatives to replace the usual leisure time;
3. to objectify information about the current epidemic situation, reduce the subjective significance of symptoms of common cold, restore the barrier of emotional response;
4. informing about the ways of normalising sleep under conditions of physical inactivity and exposure to a stress factor,

• strengthen the official emotional support for people who comply with the recommended pandemic response measures [4],
• to provide an opportunity to receive professional psychological support to all those in need: to carry out individual psychological correction aimed at reducing the impact of the consequences of isolation: worrying, anxiety, fears; at the restoration and formation of a stable basic structure of images of oneself, the surrounding world, disease; formation and accumulation of positive attitudes, coping strategies with stress and its consequences; search and consolidation of personal resources to overcome the consequences of complex deprivation.

 

Conclusions

1. All patients in the study group (100%) noted a significant aggravation of the sensations of being in the hospital during restrictions on visiting relatives.
2. All patients in this group stated that non-face-to-face communication (including by phone) cannot replace live communication and socialising.
3. Among the patients of the Center, the severity of negative characteristics that affect psycho-emotional stability (worrying, depression, anxiety) has significantly increased from 1.5 to 10 times (clinically expressed anxiety is 10 times higher than normal among men).
4. The severity of symptoms is aggravated by psycho-emotional stress formed in the pre-stationary period, which in turn complicates the rehabilitation process – due to lack of acceptance of own problems and the consequences of the disease, the motivation for healing is not created (reduced), the perception of oneself in a situation “after the illness” is more difficult.
5. The severity of the patient's condition is not due of the neurological deficit, but to social deprivation caused by forced isolation getting worse.

About the authors

Milena V. Martynova

Federal Scientific and Clinical Center of Intensive Care Medicine and Rehabilitology

Email: mmartinova@fnkcrr.ru
ORCID iD: 0000-0002-6757-5541

MD

Russian Federation, 25-2, Petrovka street, Moscow, 107031

Margorita V. Petrovskaya

Federal Scientific and Clinical Center of Intensive Care Medicine and Rehabilitology

Email: mpetrovskaya@fnkcrr.ru
ORCID iD: 0000-0002-1517-8587

MD

Russian Federation, 25-2, Petrovka street, Moscow, 107031

Marina V. Stern

Federal Scientific and Clinical Center of Intensive Care Medicine and Rehabilitology

Author for correspondence.
Email: mstern@fnkcrr.ru

MD, Cand. Sci. (Med.)

Russian Federation, 25-2, Petrovka street, Moscow, 107031

Alexandr S. Kulikov

Federal Scientific and Clinical Center of Intensive Care Medicine and Rehabilitology

Email: fenikcnew@list.ru

MD

Russian Federation, 25-2, Petrovka street, Moscow, 107031

Elena V. Milovanova

Federal Scientific and Clinical Center of Intensive Care Medicine and Rehabilitology

Email: elenitamsk@yandex.ru

MD

Russian Federation, 25-2, Petrovka street, Moscow, 107031

Marina V. Petrova

Peoples' Friendship University of Russia

Email: mail@petrovamv.ru
ORCID iD: 0000-0003-4272-0957

MD, Dr. Sci. (Med.), Assistant Professor

Russian Federation, Moscow

References

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