The internal picture of the disease

The internal picture of health (HCH) is not the “inverse” concept of the internal picture of the disease, but is an independent result of a person’s cognitive activity. VKZ can be defined as the totality of a person’s ideas about his normal and pathological condition, as well as the image of the dynamics and severity of his illness, an understanding of his mental and physical resources. WKB, by definition, is part of the phenomenology covered by WCP ^[6] .

The content and dynamics of the internal picture of the disease does not reveal its specificity depending on the disease ^[1] . WKB is dynamic and meaningfully varies depending on the age, gender, severity of the disease or its duration, prognosis for the disease, etc. ^[1] . The influence of the psychological factor at the initial stage of the development of the disease is especially great ^{[1] [7]} , which is due to the fact that the patient’s cognitive activity begins at this stage and here reveals personal specificity ^[1] . At the late stages of a long illness, the influence of the personality factor decreases ^[8] , however, the internal picture of the disease becomes a supporting condition for the patient, but it can also become an additional factor in the formation of personality anomalies ^[1] . The content of the internal picture of the disease in itself can provoke psychogenic disorders ^[5] or be a provocateur of additional painful sensations ^[1] .

The WKB and the external picture of the disease described by the doctor may not coincide, the patient’s perception may seem inadequate from the point of view of the doctor, that is, differ from the medical model of the disease ^[5] .

The term "internal picture of the disease" was introduced by therapist Roman Albertovich Luria in 1935 in the book "Internal picture of the disease and iatrogenic diseases." He highlighted:

1. The external picture of the disease , by which I understood the objective data that the doctor obtains using special research methods, is all that can be recorded and described;
2. The internal picture of the disease , by which he understood the patient’s experiences about the disease, the whole set of sensations and general well-being, ideas about the causes of the disease. This is “the whole vast inner world of the patient, which consists of very complex combinations of perception and sensations, emotions, affects, conflicts, mental experiences and injuries” ^[2] .

The phenomenon “subjective picture of the disease” itself was first described by the doctor A. Golsheider (1926), calling it the “autoplastic picture of the disease” ^[9] . During the 20th century, a large number of terms from various authors arose: “autoplastic picture”; "Internal picture of the disease"; “Experiencing the disease” ^[10] ; “Adaptation reaction” ^{[11] [12]} ; "Position on the disease" ^[13] ; “Attitude to the disease” ^[14] ; “Consciousness of the disease" (Krasnushkin 1950, Poznansky 1966); “Image of one’s own disease” ^[15] ; “Autogenous idea of ​​the disease” (M. Balint, 1960). All these authors described one or another aspect of the phenomenon, the most integrative and comprehensive of them is the concept of an “internal picture of the disease” ^[1] .

The development of a theoretical understanding of the psychological aspects of the internal picture of the disease

Model R. A. Luria

Roman Albertovich Luria in his work “the internal picture of the disease and iatrogenic diseases” (1977) continued to develop the ideas of A. Goldsheider about the “autoplastic picture of the disease”. His idea of ​​the structure of WKB was reflected in the introduction of two components ^[1] :

• Sensitive includes sensations emanating from a specific disease or pathological change in the general condition of the patient, more precisely those that the subject is experiencing ^[1] .
• Intelligent is created by the patient in thinking about his illness, well-being and condition (otherwise called a rational assessment of the disease), and it happens that these representations do not have a real somatic base. It is a superstructure over the sensitive level ^[2] .

This separation reflects the somatic and mental dichotomy that existed in medicine at that time ^[1] .

An information-cybernetic model of the internal picture of the disease presented by T. N. Reznikova and V. M. Smirnov

In this model, the central concept is the “cerebral information field of the disease” (represented by sensory tissue, sensitivity, and cultural beliefs about the disease, own experience), which provides the development and material for the development of the “psychological information field of the disease” (conditionally can be represented as the meaning of sensory the tissue that a person commits). The basis of the assessment is its own “body scheme”. The internal picture of the disease is considered here as an element of self-awareness, formed as a result of self-knowledge ^[16] .

Through the “disease model”, “model of results”, “model of expected treatment results”, “model of the received treatment results” as components of the “psychological field of the disease”, the attitude towards the disease is formed, which, according to the model, can be “adequate” and “inadequate” ". This model also contains an indication of the influence of personality factors, namely needs and emotional experience ^[16] .

The concept of V.V. Nikolaeva

This model includes four components ^[1] :

1. Touch - the totality of all sensations, the main material of complaints. It includes the actual bodily sensations and the emotional tone of sensations, appearing as an image of bodily well-being burdened with negative characteristics ^[1] .
2. Emotional - an emotional reaction to the disease ^[1] .
3. Rational, intellectual - the totality of information about the disease in a patient, expressed in ideas and knowledge about the disease, their own experience of the disease and the expected results of treatment ^[1] .
4. Motivational - is associated with a certain attitude of the patient to his disease, with a change in behavior and lifestyle in the conditions of the disease and the actualization of activities to return and maintain health. It includes personal meaning, embedding the disease in the semantic structure of the personality ^[1] .

The concept of the internal picture of the disease of A. Sh. Tkhostov , G. A. Arina

In this concept, the process of forming the internal picture of the disease is studied as a form of cognitive activity, which relates the study of the phenomenon to the ideas about the process accumulated in general psychology and removes the disconnectedness of the intellectual and emotional component. The model of the internal picture of the disease is supposed to be a multilevel formation, the basis of which is the interaction of sensory tissue, primary and secondary meanings, personal meaning ^[1] .

It is assumed that in the formation of the internal picture of the disease, several stages can be conditionally distinguished:

1. The appearance of sensory tissue , which is manifested in the indefinite nature of bodily sensations without a clear localization. Sensory tissue is presented as the basis for constructing an image of the disease.
2. The stage of the primary meaning of sensory tissue is the stage at which the quality of bodily experience is mediated, as a result of which certainty, concreteness of sensations is acquired, and the possibility of awareness arises. As a result, a somatoperceptive image appears that can determine the change in the intensity of sensory tissue.
3. The stage of secondary signification is characterized by the mediation of bodily manifestations by a system of cultural ideas about the disease, stereotypes. As a result, the quality of sensations changes, bodily manifestations become symptoms of the disease. At this stage, the concept of disease is born.
4. The generation of the personal meaning of the disease determines the individual quality of the perception of the disease and lies in the fact that the image of the disease is associated with central meanings, core motives and values ​​of the individual. For example, the meaning of the disease as an obstacle to self-realization, a restriction ^[17] , is quite common.

That is, it was proposed to consider the internal picture of the disease as a complex ratio of the levels of mental reflection: sensual, emotional, intellectual and motivational (or the level of personal meanings). The relationship between the components allows us to assess the dynamics of the development of the internal picture of the disease, suggests the symmetry of the relationship from the sensory tissue to the personal meaning goes through the signification, also from the personal sense to the sensory tissue ^[18] .

G. Levintal's Common Sense Model

This model sees the patient in the role of constructing an understanding of his condition on the basis of the acquired cultural experience regarding this disease, the reaction of his immediate environment (including the doctor) and his own experience in order to comprehend the disease. The processes of interpretation and evaluation of one’s experiences, symptoms and their modifications are processes of self-regulation, are held with the aim of choosing a coping strategy . The object of self-regulation are emotions, sensations, symptoms, mood, the presentation of which is at the level of emotions and ideas. In response to each level of representation of the object, representations and coping strategies are offered, processes for each can compete with each other ^[19]

Several types of content of representations are distinguished, each of which proceeds at the two previously indicated levels ^[19] : the identity of the disease (a system of categorical designations of sensations), the cause, the temporary course of the disease, prognosis, and the treatment process. The specificity of representations in each of the representations determines mental well-being, emotional experiences, and functioning features ^[19] .

Based on this model, a questionnaire on “cognitive ideas about the disease” was compiled. It is used for the psycho-diagnosis of “assessing the effectiveness of coping in a disease situation” to display the results in the context of self-regulation. The questions reflect the scales of “helplessness”, “acceptance”, “perceived benefits”, connecting with the locus of control, anxiety-depressive symptoms and coping strategies ^[20]

The concept of the internal picture of the disease in the context of self-regulation

In the model presented jointly by A. Sh. Tkhostov, G.A. Arina, V.V. Nikolaeva, the internal picture of the disease is considered a consequence of the interaction of such self-regulation mechanisms as:

• Body mediation as a reflection of the dynamics of the influence of the features of intraceptive perception on the attitude to the disease;
• Emotional mediation as the influence of the characteristics of the emotional reaction on the attitude to the disease;
• Cognitive mediation is represented by those beliefs, knowledge, ideas that mediate the attitude to the disease;
• Motivational-semantic mediation , which is presented in this model in a narrow manner.

Introduction to the context of the general system of body self-regulation, however, in a special social development situation, allows this phenomenon to be associated with sociocultural factors, which provides the basis for studying cross-cultural differences ^[21] .

The semiotic model of the internal picture of the disease of A. Sh. Tkhostov

In this model, as the central postulate through which the model unfolds, it is concluded that the designation of a symptom implies an indication not only of the bodily sensations themselves, but also of what is not included in them, namely the disease. To clarify the appearance on the basis of the signified (bodily sensations) and signifier (bodily construct, formed body diagram) of the sign (signified bodily sensation, which can be concrete and amenable to comparison), quotation of R. Barthes is given: “the signifying itself is devoid of content, the sign is meaningful, it makes sense ”(Bart, 1989). Thus, the appearance of the sign is evidence of the transformation of the signified ^[22] .

The relationship of the signified and the signifier can be changed, revealing the formation of a secondary semiological system, otherwise mythological (Bart, 1989). In this system, the sign obtained as a result of the sign (signified bodily sensation) becomes the signified itself and leads, in combination with the signifier (the concept of illness), to the appearance of the sign (symptom) in this secondary mythological system ^[22] .

The subjective picture of the disease acquires significance and the possibility of awareness only by refracting in the structure of motives. The conflict of personal meaning due to the ambiguity of the significance of the disease with respect to the hierarchy of motives determines the complex dynamics of the formation of the image of the disease, which, due to a series of choices between the conditional benefit (positive personal sense of the disease) and rejection (negative personal sense of the disease), is becoming less and less close to primary intraceptive perception ^{[ 22]}

Developing an Attitude to Disease

The following concepts develop an understanding of the consciousness of the disease, linking factors related to the “gnosis of the disease” (sensations, knowledge about the disease, personal experience) and attitude to the disease (personal characteristics, specifics of the disease and social environment, etc.) ^[1]

Typology of reactions to the disease N.V. Borisova, E.S. Gruzdeva, A.E. Lichko, N. Ya. Ivanova

This typology is built on the basis of the assumed influence of such factors as the nature of the disease, attitude to the disease and personality type. Block types of relationships that do not imply a violation of adaptation ^[23] :

• The harmonious type of response implies the lack of reassessment and underestimation of the severity of the disease, the active promotion of treatment recommendations and their implementation, flexibility in changing interests towards affordable ones, caring for others in the event of an adverse outcome ^[23] .
• The ergopathic type involves an increase in the number of working hours, "going to work" ^[23] .
• The anosognosic type of response consists in actively denying the severity and prognosis of the disease, attributing the causes to random circumstances, and refusing treatment ^[23] .

Types of response to the disease, which are characterized by the presence of mental maladaptation ^[23] :

• Тревожный тип реагирования характеризуется мнительным беспокойством относительно течения и прогноза болезни, что подталкивает таких пациентов к постоянному поиску новой информации о болезни, новых методов лечения, результатов обследования, авторитетного мнения ^[23] .
• Ипохондрический тип реагирования предполагает преимущественную ориентацию на собственные ощущения, имеющие болезненное или неприятное качество, их преувеличенное значение. Для пациентов с таким типом реагирования характерно сочетание упорного стремления лечиться и опасения получения вреда от процесса лечения ^[23] .
• Неврастенический тип реагирования предполагает непереносимость боли, реагирование по типу «раздражительной слабости», когда вспышка гнева на почве недомогания сменяется слезливым раскаянием ^[23] .
• Меланхолический тип реагирования характеризуется пессимистическим видением прогнозов и их активной трансляции несмотря на объективные данные, опровергающие данную точку зрения ^[23] .
• Эйфорический тип реагирования предполагает необоснованно повышенное настроение, которое создает ощущение искусственного, чрезмерно легкомысленное отношение к болезни ^[23] .
• Апатический тип реагирования — особое безразличное отношение пациентов к своему состоянию здоровья, резко суженный круг их интересов ^[23] .
• Обсессивно-фобический тип предполагает фиксацию на крайних, маловероятных вариантах негативного течения болезни и лечения, так и активным привлечением ритуалов к защите от возникающей тревоги ^[23] .
• Сенситивный тип реагирования характеризуется страхами неприятия в связи со своей болезнью ^[23] .
• Эгоцентрический тип занят привлечением к себе максимального количества внимания за счет выставления тяжести и сложности переживания болезни в качестве особого права на исключительную заботу ^[23] .
• Паранойяльный тип характеризуется стремлением объяснить для себя болезнь и неприятные переживания в течение лечения результатом злобного умысла ^[23] .
• Дисфорический тип представляет собой тоскливо-озлобленное настроение ^[23] .

Нозогении в концепции А. Б. Смулевича

А. Б. Смулевич предполагает «нозогении», или психогенные реакции, возникающие в ответ на психотравмирующие влияния соматического заболевания, как одну из 4 групп состояний, которые можно отнести к психосоматическим расстройствам. Выделяются психологические, конституциональные, биологические и социальные детерминирующие факторы психогенных реакций. В психологическом измерении первостепенную роль играет отношение к болезни, которое предполагает наличие двух полярностей: переоценки болезни, или гипернозогнозии, и недооценки болезни, или гипонозогнозии ^[24] .

В соответствии с типологией А. Б. Смулевича рассматриваются три группы синдромов нозогений ^[24] :

1. Невротические, представленные гипернозогнозией и гипонозогнозией. Гипергнозии предполагают навязчивости и истероипохондрию, что выражается в демонстративности, развернутых жалобах и сопутствующих конверсионных расстройствах. Гипонозогнозия проявляется как диссоциация соматизированной тревоги и небрежного отношения к лечению, то есть синдромом «la belle indifference» ^[24] .
2. Аффективные синдромы также представлены в двух вариантах. Гипернозогнозия проявляется как синдром ипохондрической депрессии. Гипонозогнозия представлена как синдром «эйфорической псевдодеменции» ^[24] .
3. Патохарактерологические синдромы. Гипернозогнозия характеризуется проявлением сверхценных идей (ипохондрия здоровья), наряду с которым выделяется синдром «патологического отрицания болезни» ^[24]

Особенности становления внутренней картины болезни в детском возрасте

Согласно представлению В. В. Николаевой, опирающейся на модель онтогенеза телесности, условно можно выделить несколько периодов ^[1] :

• 5 — 10 лет. Этот период выделяется в связи с тем, что высшие психические функции недостаточно сформированы, как следствие, не хватает средств для того, чтобы обозначить телесный опыт. Внутренняя картина болезни начинает строиться без опоры на собственный телесный опыт, но через осознание ограничений поведения, с которыми сталкивается ребенок. Следовательно, в данный период большую роль в становлении внутренней картины болезни играет ближайший значимый взрослый или врач, которые с позиции своего опыта и представлений формируют и структурируют внутреннюю картину болезни ^[25] .
• 11 — 16 лет. Возможно изменение поведения по двум направлениям. Во-первых, со стороны возможности реализации ведущей деятельности данного возраста, общения ^[26] . При ограничении возможна реакция в виде сочетания враждебности с агрессивными тенденциями или в виде вторичной аутизации (произвольный, осмысленный отказ от контактов из-за комплекса неполноценности). Во-вторых, подростковый возраст — возраст направленности в будущее, построения дальнейших планов. Неопределенность прогноза не дает невозможность строить планы, что также остро переживается ^[25] .

Особенности становления внутренней картины болезни в пожилом возрасте

В пожилом возрасте эмоциональный компонент внутренней картины болезни выходит на первый план, дезорганизуя остальные уровни. Внутренняя картина болезни может продолжаться с окончанием болезни как инструмент привлечения внимания и заботы, но возможен вариант анозогнозии — многое также зависит от преморбидных характеристик личности ^[27] .

Понятие ятрогения (иатрогения) было введено О. Бумке в статье «Врач как причина душевных расстройств» для обозначения тех искажений внутренней картины болезни, которые может привнести врач используя своё влияния на пациента. Р. А. Лурия в своей монографии выделяет два типа подобных заболеваний ^[2] :

1. Первый тип характеризуется тем, что пациент не имеет серьезного органического заболевания, но скорее функциональные расстройства, но неправильно понимает слова врача, принимаю свою болезнь за неизлечимую или тяжелую ^[2] ;
2. Второй тип определяется как наличие у пациента тяжелого заболевания, которое усугубляется вслед за состоянием ухудшающеся неосторожными словами врача ^[2]

• Лурия, Роман Альбертович
• Тхостов, Александр Шамилевич
• Ятрогении