"Sveikatos mokslai" Nr. 1-2

Transcription

SVEIKATOS
1-2(42-43)
2006’
MOKSLAI
HEALTH SCIENCES
Visuomenės
sveikata
Medicina
Slauga
Public
Health
Medicine
Nursing
Þurnalas spausdina mokslinius straipsnius lietuviø,
anglø ir kitomis kalbomis.
Visi straipsniai recenzuojami þymiø tos mokslo srities mokslininkø.
Straipsniams keliami reikalavimai atitinka
Lietuvos prestiþiniams mokslo leidiniams
keliamus reikalavimus
Þurnalas skirtas visø specialybiø gydytojams ir kitø srièiø specialistams
Þurnalas internete: www.sam.lt
2006
SAUSIS-KOVAS
Redakcijos kolegijos pirmininkas
Kolegijos nariai:
Tarptautiniai patarëjai:
Redakcija:
prof. A.JUOZULYNAS (Vilniaus universiteto Eksperimentinës ir
klinikinës medicinos institutas)
dr. V.ALEKNA (Vilniaus universiteto Eksperimentinës ir klinikinës
medicinos institutas)
prof. A.AMBROZAITIS (Vilniaus universitetas)
prof. I.BALÈIÛNIENË (Vilniaus universitetas)
prof. A.BARTUSEVIÈIENË (Vilniaus universitetas)
prof. A.BAUBINAS (Vilniaus universitetas)
dr. J.DIDÞIAPETRIENË (Vilniaus universiteto Onkologijos institutas)
doc. K.R.DOBROVOLSKIS (Vilniaus universitetas)
prof. D.GAIDAMONIENË (Respublikinë tuberkuliozës ir infekciniø ligø
universitetinë ligoninë)
prof. V.GRABAUSKAS (Kauno medicinos universitetas)
prof. A.IRNIUS (Vilniaus universitetas)
prof. K.JANKAUSKIENË (Kauno medicinos universitetas)
prof. D.KALIBATIENË (Vilniaus universitetas)
dr. D.KRIUKELYTË (Kauno medicinos universitetas)
prof. Z.KUÈINSKIENË (Vilniaus universitetas)
dr. J.KUMPIENË (Sveikatos apsaugos ministerija)
gyd. E.MAÈIÛNAS (Valstybinis aplinkos sveikatos centras)
prof. A.NORKUS (Kauno medicinos universitetas)
prof. V.OBELENIS (Kauno medicinos universitetas)
doc. J.PRAPIESTIS (Vilniaus universitetas)
dr. R.REKLAITIENË (Kauno medicinos universitetas)
doc. R. ÐUKYS (Vilniaus Gedimino technikos universitetas)
doc. G.ÐURKIENË (Vilniaus universitetas)
prof. K.P.VALUCKAS (Vilniaus universiteto Onkologijos institutas)
prof. G.VARONECKAS (Kauno medicinos universitetas)
prof. A.VENALIS (Vilniaus universiteto Eksperimentinës ir
klinikinës medicinos institutas)
prof. D.ÞEMAITYTË (Kauno medicinos universitetas)
doc. V.ÞYDÞIÛNAITË (Kauno technologijos universitetas)
prof. M.ANKE (Ðilerio universitetas, Vokietija)
prof. M.EGLITË (Latvijos medicinos akademija)
prof. J. JAÐÈANINAS (Ðèecino universitetas, Lenkija)
prof. L.L.MAÈIÛNAS (Pasaulio gydytojø katalikø federacijos
Europos asociacija)
doc. R.PETKEVIÈIUS (Pasaulio sveikatos organizacija)
prof. J.POKORSKI (Lenkijos Jogailos universitetas)
prof. O.SIVOÈIALOVA (Maskvos darbo medicinos institutas)
doc. A.ÐAULAUSKIENË (Pasaulio gydytojø "Uþ þmogaus gyvybæ" federacija)
prof. A. ZUPAN (Lublijanos reabilitacijos institutas, Slovënija)
Z.TARTILAS - vyriausiasis redaktorius, tel. 261 25 29
Z.GLAVECKAS - vyriausiojo redaktoriaus pavaduotojas, tel. 261 90 43
J.I.JANUŠKEVIČIŪTĖ - gydytoja konsultantė-vadybininkė, tel. 261 25 29
S.IGNATAVIČIŪTĖ - korektorė, tel. 261 90 43
Adresas: Ž.Liauksmino g. 5, LT-01101 Vilnius.
El. paštas: [email protected]
[email protected]
Leidžia UAB žurnalas “SVEIKATA”.
Spausdino UAB „Akritas”, Geležinio Vilko g. 2, Vilnius, tel. 231 16 56, faksas 231 16 57.
© “Sveikatos mokslai”, 2006.
Kaina 30 Lt
2006 m.
“Sveikatos mokslai” Nr.1-2
3
PRIEVARTOS PSICHIATRIJOJE TYRIMO METODOLOGIJA
A.DEMBINSKAS, A.NAVICKAS, V.RAÐKAUSKAS
Vilniaus universiteto Psichiatrijos klinika
Raktaþodþiai: prievartos priemonës, prievartinis hospitalizavimas, Eunomia.
Santrauka
Prievartos priemonës, taikomos psichiatrijoje,
yra: prievartinis hospitalizavimas, savo noru
hospitalizuoto paciento palikimas prievarta
psichiatrijos stacionare, fizinës suvarþymo priemonës, prievartinis vaistø skyrimas, izoliavimas.
Jø taikymas ávairiose Europos ðalyse labai skiriasi.
Ðiuos skirtumus daþnai sunku paaiðkinti, todël
daþnai iðkyla klausimas, ar kai kuriais atvejais
prievartinë hospitalizacija ir gydymas nesukelia
neigiamø pasekmiø ir kokie veiksniai tam daro átakà. Siekiant ávertinti situacijà ir pasiûlyti galimus
sprendimus, Europos komisijos buvo inicijuotas
mokslinio tyrimo projektas „Prievartos, taikomos
psichiatrijoje, ávertinimas Europoje ir geriausios
klinikinës praktikos modelio sukûrimas – EUNOMIA“ (2002 m.–2006 m.).
Vykdant tyrimà taikomas natûralistinis metodas:
bus iðanalizuotos 12-oje Europos regionø, tarp
jø ir Lietuvoje, prievartos priemonës. Iðanalizavus tyrimo metu gautus duomenis bei teisinæ
bazæ bus sukurtos prievartos priemoniø taikymo
metodikos.
Tyrime dalyvaujanèiø centrø aptarnaujamos teritorijos ávertintos taikant tarptautinius struktûrinius
tyrimo instrumentus: Europos sociodemografinio
ávertinimo vadovà (ESDS), Europos tarnybø kartografavimo vadovà (ESMS 3 versija), Tarptautiná
psichikos sveikatos prieþiûros klasifikavimo klausimynà (ICMHC).
ÁVADAS
Prievartos priemoniø taikymas psichiatrijoje nëra
pakankamai gerai iðtirtas [1]. Prievartai psichiatrijoje
priskiriama prievartinis hospitalizavimas á psichiatrijos
stacionarà, savo noru hospitalizuoto paciento palikimas
prievarta psichiatrijos stacionare, fizinës suvarþymo
priemonës, prievartinis vaistø skyrimas bei paciento
izoliavimas atskiroje patalpoje.
Prievartiniø hospitalizacijø á psichiatrijos stacionarus skaièius Europos ðalyse svyruoja nuo 3,2% ið visø
hospitalizacijø á psichiatrijos stacionarus Portugalijoje
(2000 m.) iki 30% Ðvedijoje (1997 m.) [2]. Dar didesni
skirtumai skaièiuojant prievartiniø hospitalizacijø á psichiatrijos stacionarus skaièiø 100 000 gyventojø – nuo
6 Portugalijoje (2000 m.) iki 218 Suomijoje (2000 m.)
[2]. Nors prievartos taikymo psichiatrijoje klausimai
tampa vis aktualesni, taèiau ðios srities tyrimø atlikta
gana nedaug, jø duomenys ryðkiai skiriasi [3] ir nëra
vieningø visos Europos prievartos psichiatrijoje taikymo
rekomendacijø ar standartø.
Analizuojant prievartos psichiatrijoje taikymà reikia
atsiþvelgti á tokius svarbius aspektus kaip þmogaus teisës,
visuomenës saugumas, adekvataus gydymo bûtinybë.
Taikant prievartos psichiatrijoje priemones pacientas ir
aplinkiniai gali bûti apsaugojami nuo galimø suþalojimø,
galima pradëti medikamentiná gydymà. Taèiau jø taikymas taip pat gali sàlygoti neigiamà psichologiná poveiká
pacientams ir personalui, vengimà gydytis ir jo sukeltà
bûklës pablogëjimà, dël bauginanèios gydymo aplinkos
kiti þmonës gali nesikreipti pagalbos.
Paskutiná deðimtmetá psichikos sveikatos paslaugø
vartotojø organizacijos reiðkia vis didesná susirûpinimà,
kad prievartos priemonës psichiatrijoje gali nepagrástai
varþyti þmogaus teises. Atsiþvelgiant á ðios srities svarbà
ir bûtinybæ iðanalizuoti esamà situacijà bei pateikti prievartos priemoniø optimalaus naudojimo psichiatrijoje
rekomendacijas buvo inicijuotas Europos komisijos finansuojamas 12-oje Europos ðaliø vykdomas mokslinio
tyrimo projektas „Prievartos, taikomos psichiatrijoje,
ávertinimas Europoje ir geriausios klinikinës praktikos
modelio sukûrimas – EUNOMIA“. Eunomia – graikø
mitologijoje tvarkos ir teisëtvarkos deivë [4].
Tyrimo tikslas – ávertinti prievartos priemoniø taikymà psichiatrijoje.
TYRIMO UÞDAVINIAI IR METODAI
Tyrimas atliekamas 12-os Europos ðaliø 13-oje centrø: Drezdene (Vokietija), Sofijoje (Bulgarija), Prahoje
(Èekija), Salonikuose (Graikija), Tel Avive (Izraelis),
Neapolyje (Italija), Vilniuje (Lietuva), Vroclave (Lenkija),
Michalovcuose (Slovakija), Granadoje ir Malagoje (Ispanija), Orebre (Ðvedija), Londone (Jungtinë Karalystë).
Kiekviename centre planuojama iðtirti 250 pagal ástatymà prievarta hospitalizuotø nuo 18 iki 65 metø amþiaus
4
1 lentelë. EUNOMIA tyrime pacientams ir jø duomenims
ávertinti taikomi tyrimo instrumentai.
pacientø, davusiø informuotà sutikimà dalyvauti tyrime.
Kita grupë pacientø, t.y. pagal ástatymà savo noru hospitalizuotø, bet hospitalizavimo metu jauèianèiø, kad
patiria prievartà, atrenkama skryningo bûdu naudojant
Mac Arthur hospitalizuojant patirtø iðgyvenimø tyrimo
Prievartos suvokimo skalæ.
Visi á tyrimà átraukti pacientai ávertinami per pirmà
savaitæ po hospitalizavimo, praëjus mënesiui po hospitalizavimo ir praëjus trims mënesiams po hospitalizavimo.
Tyrime taikomi instrumentai pateikti 1 lentelëje.
Lietuvoje projekto darbus vykdo Vilniaus universiteto
Psichiatrijos klinika. Tiriami á Vilniaus miesto psichikos
sveikatos centro ûmius skyrius hospitalizuojami pacientai. Projekto trukmë 45 mënesiai.
Tyrimo uþdaviniai:
1. Nustatyti pagal ástatymà prievarta hospitalizuotø
pacientø ir pagal ástatymà savo noru hospitalizuotø pacientø, bet hospitalizavimo metu jauèianèiø, kad patiria
prievartà, sociodemografines ir klinikines charakteristikas.
2006 m.
2. Nustatyti pagal ástatymà prievarta hospitalizuotø
pacientø ir pagal ástatymà savo noru hospitalizuotø pacientø subjektyvaus prievartos suvokimo pasireiðkimo
daþná ir intensyvumà.
3. Nustatyti, kokios prievartos priemonës taikomos
ðioms dviem pacientø grupëms.
4. Nustatyti prievartos priemoniø taikymo ðioms
dviem pacientø grupëms pasekmes.
5. Nustatyti ðiø dviejø pacientø grupiø prievartos
taikymo geresnes ar blogesnes pasekmes predisponuojanèius veiksnius.
6. Nustatyti 1-5 tyrimo uþdaviniø gautø rezultatø
skirtumus tarp tyrime dalyvaujanèiø ðaliø.
Tyrimo metu taip pat ávertintos ir centrø aptarnaujamos teritorijos. Taikant Europos sociodemografinio
ávertinimo vadovà (ESDS) [5] apraðytos centrø sociodemografinës charakteristikos. Taikant Europos tarnybø kartografavimo vadovà (ESMS 3 versija) [6] standartizuotai
suklasifikuotos ir apraðytos psichikos sveikatos prieþiûros
tarnybos. Taip pat panaudotas ligoniniø struktûriniø ir
organizaciniø charakteristikø apraðymo klausimynas.
Naudojant Tarptautiná psichikos sveikatos prieþiûros klasifikavimo klausimynà (ICMHC) [7] apraðytos psichikos
sveikatos prieþiûros intervencijos ûmiuose skyriuose.
APTARIMAS
Tyrimas atliekamas laibai skirtinguose Europos regionuose, besiskirianèiuose ávairiais kultûriniais, ekonominiais, sociodemografiniais aspektais. Taip pat skiriasi ðiø
ðaliø prievartos priemoniø psichiatrijoje taikymo tradicijos bei jø taikymà reguliuojantys teisës aktai. Pirmieji
duomenys rodo, kad tyrime dalyvaujanèios ðalys skiriasi
pagal psichiatrinës pagalbos organizavimo struktûrà.
Italijoje, Ispanijoje, Jungtinëje Karalystëje plaèiai iðvystytas bendruomeniniø psichikos sveikatos paslaugø
tinklas [8]. Personalo psichiatrijos skyriuose skaièius ir
struktûra taip pat skiriasi. Stebima tendencija, kad Rytø
Europos ðalyse (Lietuvoje, Bulgarijoje, Slovakijoje) yra
maþiau vienam pacientui tenkanèio slaugos personalo.
Ðiø ir kitø aspektø átakà prievartos priemoniø taikymui
bus siekiama ávertinti siejant juos su duomenimis, gautais
pacientø apklausos metu ir ið medicininës dokumentacijos. Iðanalizavus tyrimo metu gautus duomenis bei
teisinæ bazæ bus sukurtos prievartos priemoniø taikymo
metodikos ir rekomendacijos, leisianèios optimizuoti jø
taikymà klinikinëje praktikoje. Tyrimas taip pat paskatins
psichikos sveikatos specialistø, vartotojø, visuomenës
diskusijas ðia svarbia tema.
2006 m.
5
Literatûra
1.
Dressing H., Salize H.J. Compulsory admission of mentally
ill patients in European Union Member States. Soc. Psychiatry Psychiatr. Epidemiol. 2004, 2004, 39:797-803.
2.
Salize H.J. Compulsory admission and involuntary treatment
of mentally ill patients – legislation and practise in EU member states.
Final report. 2002.
3.
Zinkler M., Priebe S. Detention of mentally ill in Europe – a
review. Acta Psychiatr. Scand. 2002, 106:3-8.
4.
Souli S. Greek mythology. Techni S.A. 1998.
5.
Beecham J., Johnson S. and the EPCAT Group. The European
Socio-Demografic Schedule (ESDS): rationale, principles development.
Acta Psychiatr. Scand. 2000, 102 (Suppl. 405):33-46.
6.
Johnson S., Kuhlmann R. and the EPCAT Group. The
European Mapping Schedule (ESMS): development of an instrument
for the description and classification of mental health services. Acta
Psychiatr. Scand. 2000, 102 (Suppl. 405):14-23.
7.
de Jong A. Development of the International Classification
of Mental Health Care (ICMHC). Acta Psychiatr. Scand. 2000, 102
(Suppl. 405):8:13.
8.
Kallert Th. W., Glockner M., Onchev G., Raboch J., Karastergiou A., Solomon Z., Magliano L., Dembinskas A., Kiejna A., Nawka
P., Torres-Gonzalez F., Priebe S., Kjellin L. The EUNOMIA project
on coercion in psychiatry: study design and preliminary data. World
Psychiatry. 2005, Volume 4, Number 3:168-172.
TRY
METHODOLGY OF RESEARCH ON COERCION IN PSYCHIA-
A.Dembinskas, A.Navickas, V.Raðkauskas
Summary
Key words: coercive measures, involuntary hospitalization,
Eunomia.
Coercive psychiatric treatment (forced admission, involuntary
detention, seclusion, restraint and forced medication) varies widely
between European countries. These variations are often difficult to
explain, which raises the question whether in some cases coercive
psychiatric admission and treatment have therapeutically negative
effects and what factors influence it. In order to evaluate situation and
to propose possible solutions EU funded project European Evaluation
of Coercion in Psychiatry and Harmonisation of Best Clinical Practise
(EUNOMIA-Study) (2002-2006) was initialized.
The existing variation in coercive psychiatric treatment is being
analysed, using a naturalistic approach in 12 European regions, Lithuania among them. By integrating data and analysis of laws guidelines
on best clinical practise of coercive treatment in psychiatry will be
prepared.
The catchment areas covered by the study have been described
with structured and internationally validated instruments.
Gauta 2005-12-19

SUICIDES AND ZINC DEFICIENCY –
SUPPOSITIONAL LINKS FOR LITHUANIAN POPULATION
G.P.ÞUKAUSKAS1, M. JAKUBËNIENË1, S.ÐLIAUPA2, J.SATKÛNAS3, I.KERIMOV4
1
Institute of Forensic Medicine, Mykolas Romeris University, 2Institute of Geology and
Geography, 3Lithuanian Geological Survey, 4Azerbaijan Academy of Sciences
Key words: zinc deficiency, suicides, liver diseases,
geofactor, atomic absorption spectroscopy.
Summary
The level of general morbidity and mortality in
Lithuania has increased significantly during the
last ten years. There is the biggest suicide rate in
Lithuania among European countries – 44.5/100
000 inhabitants, nearly epidemic status with
tuberculosis -86/100 000, quite high levels of
alcohol delirium tremens and illicit drug users.
The most of these diseases and social malfunctions (suicides) in some way can be related with
zinc deficiency status of organism. The problem
of zinc deficiency has been known for more
than 40 years. Zinc is an essential bio-element,
which plays a fundamental role in a wide range
of biochemical process. This metal functions as a
cofactor of multiple enzymes, is a major component of various proteins and an important modulator of the mammalian immune and nervous
system. With zinc, playing such a crucial role in
normal biological and physiological functions,
a deficiency of this mineral would be expected
to result in a number of adverse physiological
consequences. Among possible causes of zinc
deficiency in human are mentioned: nutritional
factors (consumption of some vegetable food
grown in region with depleted content of zinc in
soil), excessive intake of alcohol, cirrhosis of the
liver, malabsorption syndrome, chronic renal disease, burns, iatrogenic causes, diabetes, genetic
disorders. The evaluation of all these factors might
be an object of voluminous study establishing
the zinc status of individual person and further
on the zinc status of concrete population. In the
6
frame of this article we will try to evaluate only
some of them: the nutritional factor (not directly,
but on the ground of such geochemical factor as
zinc content in soil); the influence of excessive
intake of alcohol on the development of liver
diseases and the zinc status of patients with liver
cirrhosis. The possible zinc deficient status of
some Lithuanian people is named as cause of
emotional disorder (mostly depression) that may
induce such malfunction as suicide.
INTRODUCTION
Clear evidence of human zinc deficiency began to
emerge during the 1960s, when Dr. Ananda Prasad first
reported cases of dwarfism and delayed sexual maturity
among Middle Eastern adolescents (1). Further investigation of zinc status in organism showed vital importance
of this element for normal physiology and function of
organism. Zinc functions as a required cofactor for over
200 zinc-dependent enzymes which exert important
influences on every major metabolic pathway, including the synthesis and degradation of carbohydrates,
lipids, proteins and nucleic acids (2,3). Zinc is also an
essential component of the endogenous storage forms
of pancreatic insulin (4). Zinc is required for each step
of cell cycle and is essential for DNA synthesis; the
catabolism of RNA appears to be zinc-dependent (5). A
growing body of evidence implicates a derangement of
zinc homeostasis in mood disorders (6).
With zinc playing such a crucial role in such an array
of normal biochemical and physiological functions, a
deficiency of this element would be expected to result
in a number of adverse physiological consequences.
Zinc deficiency in humans may manifest as severe,
moderate, or mild (7). The manifestations of severe zinc
deficiency include bullous pustular dermatitis, alopecia,
diarrhea, emotional disorder, weight loss, intercurrent
infections due to cell-mediated immune dysfunctions,
hypogonadism in males, neurosensory disorders, and
problems with healing of ulcers. This condition can
be fatal. Clinical manifestations of moderate and mild
levels of zinc deficiency include growth retardation and
male hypogonadism in adolescence, rough skin, poor
appetite, mental lethargy, delayed wound healing, cellmediated immune dysfunctions, abnormal neurosensory
changes, oligospermia in males, anergy, and decreased
lean body mass.
The symptoms of zinc deficiency can result from
various factors (8). When zinc deficiency status was first
defined for Middle Eastern adolescents such fact was be-
2006 m.
lieved to be the result of low zinc soil levels in this region
coupled with the widespread practice of consuming
largely unleavened whole-grain breads rich in phytic
acid that binds zinc (9). The future investigation showed
that some cultures (food crops) grown in the regions
with depleted content of zinc in soil have decreased
level of zinc and can result poor zinc diet consumption
(10). The most severe symptoms of zinc deficiency in
humans can result from such factors as excessive alcohol use, liver diseases, malabsorption syndromes, renal
disease, enteral or parenteral alimentation, and sickle
cell disease (8).
It is known that a considerable percentage of suicide victims had suffered from depression (11). On the
other side, zinc is involved in the pathophysiology and
therapy of depression (12). Moreover, the severity of
depression (assessed according to Hamilton Depression
Rating Scale) was negatively correlated with serum level
of zinc (13,14).
Since the zinc status of Lithuanian is still unknown
due to lack of systematic monitoring , we hypothesized
that there are some marks of zinc deficiency in Lithuanian population. We would like point out that clinical
symptoms of zinc deficiency are quite various. Their manifestations differ for each person and as each organism
is unique may result from different factors.
The aim of our study was on the background of pilot
investigation of zinc amount in blood serum of patients
with liver diseases (hepatitis and cirrhosis) and biological
media of people with alopecia to demonstrate that there
are some marks of zinc deficiency in Lithuanian people.
The causes of this conditioned zinc deficiency partially
could be excessive alcohol consumption and living in
zinc depleted area (nutritional factor). The possible zinc
deficient status of some Lithuanian people is named as
cause of emotional disorder (mostly depression) that may
induce such malfunction as suicide.
MATERIALS AND METHODS
Blood serum of 56 patients with liver diseases (hepatitis C and cirrhosis) was examined.
Suprapure grade reagents and high purity water were
used. Working standard solutions were prepared from
FLUKA stock standards containing 1000 mg/l of zinc by
diluting with 5% nitric acid solution.
Atomic absorption spectrometer model AAS3
from Zeiss Jena, German was used for determining
the concentration of metals. The continuous source
(Deuterium lamp) was used to make a “background”
correction. Method of standards addition was applied to
2006 m.
compensate for matrix effects of biological specimens.
Samples for zinc analysis were digested in the presence of concentrated nitric acid and perhydrol. Digests
were diluted with the 5% solution of nitric acid.
The rates of suicides in 45 administrative regions
of Lithuania were selected from official statistical data
about causes of death in Lithuania (15-17). The tools of
geographic information system (GIS) were used presenting the distribution of rates of suicides in conventional
maps of Lithuania. The data related to Baltic and Nordic
countries were selected from publication of Nordic Medico-Statistical Committee (NOMESCO) (18).
The zinc content in soil of Lithuania was selected
from Biochemical atlas of Lithuania (19).
RESULTS
Among possible causes of zinc deficiency in human
are mentioned: nutritional factors (consumption of some
vegetable food grown in region with depleted content of
zinc in soil), excessive intake of alcohol, cirrhosis of the
liver, malabsorption syndrome, chronic renal disease,
burns, iatrogenic causes, diabetes, genetic disorders (7).
The evaluation of all these factors might be an object of
voluminous study establishing the zinc status of individual person and further on the zinc status of concrete
population. In the frame of this article we will try to
evaluate only some of them: the nutritional factor (not
directly, but on the ground of such geochemical factor
as zinc content in soil); the influence of excessive intake
of alcohol on the development of liver diseases and the
zinc status of patients with liver cirrhosis.
Nutritional factor
The major source of the body’s trace elements is the
soil. There are various pathways through which the trace
elements find their way into the body. The concentrations
of trace elements in rocks vary by rock type and location
and are a fundamental control on the availability of trace
elements to humans. Trace-element concentrations are
modified by a variety of natural processes and deliberate
and accidental human activities. Agricultural chemicals
and pollutants may be added. Crops selectively remove
from the soil the elements they require for growth. The
drinking water contains trace elements leached from
rock and soil and may also have been polluted or chemically treated.
Zinc is a trace element that occurs in the soil in different forms, its abundance is strongly controlled by a
rock composition. The geochemical studies of Lithuania
indicate that zinc is lithogenic element, i.e. this group
shows the highest concentrations in the morainic and
7
glaciolacustrine sediments (dominated by clay and finegrained clastics), whereas indicating minimum abundances in fluvioglacial and aeolian sandy sediments (19).
Zinc also concentrates in the biogenic sediments (e.g.
soil). Besides to abundance in the soil, the mobility is an
important parameter for the intake of this element. Zinc
is mobile in the acid low-pH environment, composing
soluble complexes in the water. The high carbonate
content (e.g. north Lithuania) decreases its mobility. In
Lithuanian soil, Zn has most close direct correlation with
Cr, Cu, Ga, Sn, Ti, V, also La, Li, Nb, Rb, Sr.
Zn shows significant concentration variations across
Lithuania from 5 to 40 ppm. In average, the lowest values
are identified in southeast and east Lithuania (22-25 ppm
in Lazdijai, Varena, Salcininkai, Svencionys, Moletai
regions) that is mainly covered by aeolian and fluvioglacial sandy deposits (Fig. 1). Also, low concentrations
are identified in central and north Lithuania (25-28 ppm
in Joniskis, Siauliai, Radviliskis, Kupiskis, Panevezys,
Akmene regions). The highest average abundances are
documented in the soil of west Lithuania (32-40 ppm in
Plunge, Silale, Telsiai, Silute, Kretinga regions) and some
other regions dominated by morainic and glaciolacustrine litholgies. These relationships are well reflected
by statistical correlations; the correlation coefficient
between zinc and fliovioglacial sediment percentage
is -0.50, whereas +0.40 with glaciolacustrine sediment
percentage.
Lithuania is characterized by generally lowest concentration in the soil of the circum-Baltic region (20),
which implies that currently the average Lithuanian
Fig. 1. Zn concentrations (ppm) in the soil of Lithuania (lowpass filtered).
8
2006 m.
The excessive alcohol intake and
liver diseases
The excessive alcohol consumption is mentioned as one of the factors causing the zinc deficiency in
organism. Although alcohol affects
many organs in the body, it is especially harmful to the liver. Alcohol
is metabolized in the body, and the
liver performs most of the work, potentially incurring serious damage in
the process. Not only does alcohol
destroy liver cells, it also destroys
their ability to regenerate, leading
to a syndrome of progressive inflammatory injury to the liver. Alcoholic
inflammation of the liver will often
eventually progress to cirrhosis.
Fig. 2. The rates (events of death per 100.000 habitants) of suicides in different
The initial notice about abnorregions of Lithuania (average rate for four years: 1999, 2001, 2002, 2003).
mal zinc metabolism that occurs in
diet does not contain sufficient amounts of this element patients with alcoholic cirrhosis was described by B.L.
because of depletion of vital minerals in our soil. The Vallee in 1956 (21). In nowadays there is some variance
average content of zinc in Lithuanian soil is 20-30 ppm, of opinion as to haw often such phenomena occur in
while reaching 50-70 ppm in Sweden, Norway.
cirrhosis and other liver disease.
The relation of content of zinc in soil as the posSerum zinc concentrations were investigated in n=33
sible cause of zinc deficient diet which can result zinc patients with hepatitis (C) and in n=22 patients with liver
deficiency state of organism and rates of suicides in 45 cirrhosis. Figure 3 presents the results of this study.
different regions of Lithuania as well as in Baltic and
Nordic countries was investigated. Lithuania is country
DISCUSSION
which dominates in the world regarding to rate of suAccording to the report of International Zinc Nutrition
icides. Around 1500 people commit suicide every year consultative Group (IZiNCG) (22) one in five people
(11). The average rates of suicides in different regions worldwide lack enough zinc in diet. Long considered
of Lithuania for four years (1999,2001,2002,2003) are impossible, it has been calculated that substantial section
presented in Fig.2. This distribution show that the rates
of suicides differ considerably among various region of
Lithuania.
Calculating the average rate of suicides for 45 different regions the average rate of 44.5/100 000 was
obtained. The average rate of suicides in eleven region
of Lithuania (Lazdijai, Varena, Salcininkai, Svencionys,
Moletai, Joniskis, Siauliai, Radviliskis, Kupiskis, Panevezys, Akmene) with depleted content of zinc in soil was
obtained to be 49.0/100 000. Differently, the average
rate of suicides in regions with highest zinc abundance in soil (Plunge, Silale, Telsiai, Silute, Kretinga) was
obtained 39.7/100 000. Comparing these data we can
conclude, that rate of suicides in regions with depleted
content of zinc in soil exceeds average rate of suicides
per Lithuania and considerably exceeds rate of suicides Fig. 3. Zinc serum concentration in patients with hepatitis
in regions with highest zinc abundance in soil.
(left picture) and liver cirrhosis (right picture).
2006 m.
of the population of the United States are at risk from
suboptimal zinc nutrition (23). The investigation of Zn
deficiency on the behavioral effects in Chinese and
Mexican-American children showed beneficial effects
of Zn repletion on its neuropsychologic function. It was
given that research on cognition, behavioral activity and
brain electrophysiology as outcomes of Zn deficiency
and response to improved Zn nutrition was critical. So
it could be concluded that Zn deficiency is common
in both developing and developed countries (24). On
the ground of results of our study we can hypothesized
that there are some zinc deficiency marks in Lithuanian
population.
First of all, the most worrying question for Lithuanian
people is why the rate of suicides in our country is the
highest in the world. Making an attempt to answer this
question we would like to point up some chain of appearances which are in our mind interdependent. As
was mentioned the zinc deficiency status of organism
in strong way depends on nutritional factor and excessive intake of alcohol. The alcohol consumption in our
country is greatest among Baltic and Nordic countries
(18). As consequence the rate of liver diseases in Lithuania exceeds noticeably the one in other neighbour
countries (see Fig. 4).
Our study measuring zinc concentration in patients
with liver cirrhosis (the most common cause of liver
cirrhosis is alcohol abuse) and patient with hepatitis
showed that patient with liver cirrhosis had depressed
content of zinc in blood serum. This result confirmed
the data of others researches (25,26) that alcoholic liver
cirrhosis is associated with zinc deficiency.
The monitoring study of some region of Lithuania
(27) displays that zinc concentration in children and
pregnant women do not exceed 0,480 mg/dL in Ðiauliai
resident and 0,380 mg/dL in Vilnius resident. It is difficult
to evaluate these data because of lack of the normal
permissible values of zinc in biomedia for Lithuanian
population, but comparing this data with normal concentration from references (28-31) it seems is deficient.
The evaluation of the results for zinc in biological
media generally makes great difficulties. First of all, it
is unknown the dependence of concentrations of zinc
in various biomedia according to the age of patients.
Berfenstam (32) specifies that in newborn infants the
zinc content of the erythrocytes is only one-quarter of
the adult values, rising progressively over the first 12
years of life. A. Prasad et al. (28) indicate that plasma
zinc levels in the newborn are in the same range as in
adults. The levels fall to just below adult level within the
9
Fig. 4. Rates of alcohol liver disease in 2002 (18). Data for
Estonia could not be divided by sex, the total rate for men
and women was 37.8.
first week of life and continue to decline until 3 months,
finally reaching the adult level at 4 months of age. So
we can suppose that concentration of zinc in the whole
blood could rise progressively at least over the first 12
years of life. However the exact determination of zinc
level in blood according to the age of patients could be
the object of the special research in future.
The numerous study have shown that a variety of
mental and behavioral changes have also been associated with zinc deficiency in humans, including apathy,
lethargy, amnesia, irritability, depression and paranoia,
as well as mental retardation (33,34).
All these emotional disorders are directly related
with such social malfunction as suicides (11). So we
can find some relation between so huge rate of suicides in Lithuania and possible zinc deficiency status of
Lithuanian population. The possible nutritional factor
also can be confirmed comparing the rate of suicides
in various region of Lithuania with different content of
zinc in soil.
On the supposition that there is some indication of
zinc deficiency in Lithuanian population we would like
to attract attention to this problem. We can only hypothesize such zinc status for Lithuanian people, because
the establishment of zinc status requires more detailed
monitoring study of whole population. Additionally it
must be evaluated the interaction of zinc in organism
with another elements and the influence on health status
such geofactors as gravity and magnetic field, sub-soil
lithologies, relief, some other landscape feature, drin-
10
king water and soil chemistry. It is also very important
to compare obtained results with data for populations
of neighbour countries. The answers to these questions
will be the object of future studies.
CONCLUSION
Though a trace metal like zinc is, in weight terms,
only a minuscule part of the human metabolism, its
presence is absolutely vital in all the major metabolic
pathways. On the basis of current evidence it is necessary to initiate the more wide investigation of zinc
status in human. It will be done evaluating other factors
influencing this status: interaction of zinc in organism
with other elements and influence on health status such
geofactors as gravity and magnetic field, sub-soil lithologies, relief, some other landscape feature, drinking water
and soil chemistry. The fact, that 20% of the world’s
people suffer from zinc deficient diet, it is essential to
know how improve this condition, which may have
crucial significance on human health, behavior and
mental condition.
The obtained results of zinc investigation in biological media of patients with liver diseases can be useful as
experimental evidence verifying zinc deficiency status
of Lithuanian people.
References
1. Prasad A.S. Metabolism of zinc and its deficiency in human
subjects. In Zinc Metabolism (A.S.Prasad ed.), Charles C Thomas,
Sprienfield, Illinois, 1966, 250-302.
2. Underwood E. Trace elements in human and animal nutrition,
4th edition, New York, Academic Press, 1977.
3. Agget P.J. Physiology and metabolism of essential trace elements:
an outline. Clinics Endocrinol. Metab., 1985, 14, 513-543.
4. Murray M. Encyclopedia of Natural Medicine, Second ed.
Rocklin, CA, Prima Publishing, 1998.
5. Prasad A.S. Zinc deficiency in human subjects. Prog. Clin. Biol.
Res., 1983, 129, 1-33.
6. Nowak G., Kubera M., Maes M. Neuroimmunological aspects
of the alterations in zinc homeostasis in the pathophysiology and treatment of depression. Acta Neuropsychiatr., 2000, 12, 49-53.
7. Prasad A.S. Zinc in growth and development and spectrum of
human zinc deficiency. J. Am. Coll. Nutr., 1988, 7, 377-384.
8. Evans G.W. Zinc and its deficiency diseases. Clin. Physiol.
Biochem., 1986, 4, 94-98.
9. Rossander L., Sandberg A-S., Cederblad A. Absorption of of
zinc from lupin (lupinus angustifolis) based foods. Br. J. Nutr., 1992,
72, 865-871.
10. Kalaici M. et al. Grain yield, zinc deficiency and zinc comcentration of wheat cultivars grown in zinc deficient calcerous soil in
field and greenhouse. Field Crops research, 1999, 63, 87-98.
11. The suicide formula: collective scientific study. Ed. by
G.Zukauskas, Vilnius, 2004.
12. Nowak G., Szewczyk B. Mechanisms contributing to antidepressant zinc actions. Pol. J. Pharmacol., 2002, 54, 587-592.
13. Maes M., D’Haese P.C., Scharpe S.,.D’Hondt P.D, Cosyns P.,
2006 m.
De Broe M.E. Hypozincemia in depression. J. Affect Disorders, 1994,
31, 135-140.
14. Schlegel-Zawadska M., Ziæba A., Dudek D., Krosniak M.,
Szymaczek M., Nowak G. Effect od depression and of antidepressant therapy on serum zinc levels – a preliminary study. In Trace
Elements in Man and Animals 10, Kluwer academic Plenum Press,
2000, 607-610.
15. Causes of death. Statistics Lithuania. Statistica, Vilnius,2004.
16. Causes of death. Statistics Lithuania. Statistica, Vilnius,2000.
17. Causes of death. Statistics Lithuania. Statistica,
Vilnius,2002,2003.
18. Health statistics in the Nordic countries. MONESCO, 2004.
19. Kadunas V., Budavicius G., Gregorauskiene V., Katinas V.,
Kliaugiene V., Radzevicius A., Taraskevicius R. Geochemical Atlas of
Lithuania, Vilnius, 1999.
20. Reimann C., Siewers U., Tarvainen T., et al. Agricultural soils
in northern Europe: A geochemical atlas. Geochemisches Jarbuch
Sonderhefte. Reihe D, Heft SD5, 2003.
21. Vallee B.L., Wacker W.E.C., Bartholomay A.F., Hoch F.L. Zinc
metabolism in hepatic disfunction. I. Serum zinc concentration in
Laënnec’s cirrhosis and their validationequential analysis. N. Engl. J.
Med., 1956, 255, 403-408.
22. www.izincg.ucdavis.edu.
23. Sandstead H.H. Zink nutrition in the United States. Amer. J.
Clin. Nutr., 1973, 26, 1251-1280.
24. Penland J.G. Behaviour data and methodology issue in studies
of zinc nutrition in humans. J. Nutr., 2000, 130, 361S-364S.
25. Taniguchi S., Kaneto K., Hamada T. Acquired zinc deficiency
associated with alcoholic liver cirrhosis. Int. J. Dermatol., 1995, 34,
651-652.
26. Scholmerich J., Lohle E., Kottgen E., Gerok W. Zinc and vitamin A deficiency in liver cirrhosis. Hepatogastroenterology, 1983,
30, 119-125.
27. Ptashekas J., Ciuniene E., Barkiene M., Zurlyte I. et al. Environmental and health monitoring in Lithuanian cities: exposure to heavy
metals and benz(a)pyrene in Vilnius and Ðiauliai residents. J. Envir.
Pathol. Toxicol. Oncol., 1996, 15, 135-141.
28. Prasad A.S. et. al. Role of zinc in man and its deficiency in
sickle cell disease. In: Erythrocyte structure and Function, Progress in
Clinical and Biological Research, 1975, 1, 603-619.
29. Rose G.A., Willden E.G. Whole blood, red cell, and plasma
total and ultrafilterable zinc levels in normal subjects and in patients
with chronic renal failure with and withough hemodialysis. Brit. J.
Urol., 1972, 44, 281-286.
30. Iyegar G.V. et al. The elemental composition of human tissues
and body fluids. NY:VERLAG CHEMIE; 1978, 151.
31. Chelovek. Mediko-bioligicheskije danyje. Moskva: Medicina;
1977.
32. Berfenstam R. Studies of blood zinc. Acta Paediat., 1952,
41, 389-391.
33. Prasad A.S., Rabbani P., Abbash A. Experimental zinc deficiency in human. Ann. Inter. Med., 1978, 89, 483.
34. Sprinivasan D., Marr S., Wareign R., et al. Magnesium, zinc
and copper in acute psychiatric patients. Magnesium Bulletin, 1982,
1, 45-48.
SAVIÞUDYBËS IR CINKO DEFICITINË ORGANIZMO BÛSENA
– NUMANOMOS SÀSAJOS LIETUVOS POPULIACIJOJE
G.P.Þukauskas, M.Jakubënienë, S.Ðliaupa, J.Satkûnas, I.Kerimov
Santrauka
Raktaþodþiai: cinko deficitinë organizmo bûsena, kepenø ligos,
geofaktoriai, atominës sugerties spektroskopija.
2006 m.
11
Tiek sergamumas, tiek mirtingumas Lietuvoje þymiai iðaugo pastaruoju deðimtmeèiu. Lietuvoje didþiausias saviþudybiø skaièius tarp Europos ðaliø – 44,5/100 000 gyventojø, beveik epideminis tuberkuliozës
lygis – iki 86/100 000 gyventojø, labai aukðtas alkoholinio deliro bei
narkotiniø medþiagø vartojimo lygis. Daugumà ligø bei socialiniø
nesklandumø galima bûtø sieti su cinko (Zn) trûkumu organizme.
Jau daugiau kaip keturiasdeðimt metø þinomos Zn trûkumo organizme pasekmës. Zn yra vienas pagrindiniø bioelementø, vaidinantis
fundamentalø vaidmená daugelyje biocheminiø procesø. Ðis metalas
yra kofaktorius daugelyje fermentø, yra ávairiø baltymø sudedamoji
dalis ir aktyviai dalyvauja organizmo imuninëje veikloje bei centrinës
nervø sistemos funkcijose. Taigi, ðiam metalui dalyvaujant gausybëje
biologiniø ir fiziologiniø procesø, jo trûkumas gali lemti daugelá
patologiniø funkciniø-fiziologiniø procesø. Tarp prieþasèiø, galinèiø
lemti Zn trûkumà organizme, gali bûti: mitybos faktoriai (vartojant
maisto produktus, uþaugintus dirvoje, kurioje trûksta ðio elemento),
nesaikingas alkoholio vartojimas, chroninë inkstø patologija, nudegimai, diabetas, genetiniai sutrikimai, jatrogeninës prieþastys. Norint
nustatyti visus ðiuos faktorius reikëtø atlikti plaèius tyrimus, tuo paèiu
atsakant á klausimà apie Zn koncentracijà tiek individo organizme,
tiek jo kieká visoje populiacijoje. Savo darbe bandysime atsakyti á
keletà klausimø: apie mitybos faktoriø átakà (ne tiesiogiai, o remiantis
geocheminiais Zn koncentracijø tyrimais dirvoþemyje); nesaikingo
alkoholio vartojimo átakà kepenø patologijos vystymuisi, o taip
pat nustatant Zn koncentracijà pacientø, serganèiø kepenø ciroze,
kraujyje. Galimà Zn kiekio nepakankamumà organizme galima bûtø
laikyti ir emociniø sutrikimø (daugiausia depresija) prieþastimi, kuri
gali lemti ir saviþudiðkà elgesá.
Gauta 2006-01-16

DEPRESSION – A CULTURALLY SPECIFIC AILMENT?
ZDZISÙAW MAJCHRZYK
The Jagiellonian University, Cracow, Poland
Summary
Depression has become a fashionable disease
considered epidemic in 21st century. What is the
truth about it? Depression has been present in various cultures with varying intensity. In industrial
civilization and consumer society it appears more
intense due to the development and research conducted by pharmaceutical firms and economic
profit strategies. Does the popular Western model
of well being and happiness influence diagnosing
depression? Low spirit and sadness ring alarm
bells that “something is wrong”. Ideology of a
culture influences diagnosing depression in the
same way as cultures provide answers to the questions concerning the sense of human existence,
of happiness and suffering. Defining depression
Western culture underlines human reactions to
loss, which produce the feeling of hopelessness,
shame and suffering. It is not so in other cultures
(Buddhism). There hopelessness constitutes the
very center of the world, making life beautiful
but full of suffering and sadness caused by attachment, desire and longing. Freedom is achieved
by meditation that releases one from suffering.
Thus attitudes toward basic human problems (i.e.
suffering) influence the symptoms and diagnoses
of depression.
Depression appears to be a “fashionable” epidemic
in the 21st century. Does it relate to the industrial civilization, consumer society and the development and
research conducted by pharmaceutical firms and economic profit making strategies?
It is commonly acknowledged that in a culture views,
or strictly speaking, beliefs may influence the evaluation
of the experiences diagnosed as depression symptoms.
However, sufferings and frequent states of sadness that
accompany them come from the indispensable human
condition. So they are normal symptoms, which testify
to the depth of feelings and have nothing to do with
pathology.
Szasz (1970), a psychiatrist, maintains that all notions
of psychiatric disorders are only social value judgments
concerning human behavior disguised under quasi-objective scientific jargon. In other words, traditional terms
such as mental illness, pshychodiagnostics or psychiatric
hospital indicating that we have been dealing with traditional medicine, in reality diagnose social functioning
and pass value judgments on human behavior. Human
behavior is considered normal when it is made to conform social norms of what is permissible or not, when
the norms are transgressed. Thus, mental illness does not
exist in the same sense as tuberculosis or cancer.
Thomas Scheff (1984), a famous sociologist, believed
that the individuals who transgress social norms are
12
called “madmen” to keep society stable. Some time
ago, British psychiatrist, R.D.Laing (1967) maintained
that even such grave disorders as schizophrenia are
“normal” mental processes that help individuals cope
with certain forms of stress.
The existence of ethnic mental disorders such as
kayak angst among Greenland Inuit or koro in Southern
China indicate that there may exist vast cultural differences in mental disorders and its symptoms. Is it a
mistake to assume that transgressing Western norms and
values must be taken as universal mental disorders?
The popular model of well being and happiness encompasses good humour, satisfaction, carefree attitude
and being on the high. Bad mood and sadness are an
alarm signal and indicate that something is wrong.
Many philosophers (Solon, Plato, Croesus) asked the
question what brings happiness and who is happy. They
were also describing dissatisfaction and unhappiness. In
5th century BC, Hippocrates described melancholy as “an
aversion to eating, dejection, sleeplessness, irritability
and anxiety” (Jones, Withington 1923).
American Psychiatric Society (1994) considers “a
serious depressive episode” when the following five
symptoms last for at least two weeks: an almost daily
despondency (irritation in children), decrease of interest
in activities or inability to take pleasure in them, decrease
or increase of appetite, losing or putting on weight,
sleeplessness or excessive sleep, motoric agitation or
tranquility, constant fatigue, subjective feeling of inadequacy or sense of guilt, inability to think or concentrate
and recurrent thoughts of suicide or death.
US statistics show that 10 to 25% women and 5 to
12 % men have two depressive episodes in a lifetime,
usually lasting about 6 months. But depressive symptoms
differ from culture to culture. With the Indian population
the data are 6 times higher than the rest of the Americans
(Manson, Shore & Bloom 1985).
The question arises whether the symptoms Western
psychiatrists and psychologists call “depression” means
the same for non-Western cultures?
In fact, research has confirmed such a question. The
Nigerians (Leighton, Lambe, Hughes, Leighton, Murphy
& Macklin, 1963) the Chinese (Tseng & Ksu, 1969), the
Japanese (Tanaka–Matsumi & Marsella 1976) and the
Malaysians (Resner & Hartog, 1970) define depression
differently.
The problem may be partly resolved by comparing
results of psychiatrically defined disorders with corresponding descriptions from different cultures. Manson
and his team (1985) were researching mental disorders
2006 m.
of the Indian tribe of Hopi. They discovered that the Indians have no notion corresponding to depression. They
include depressive symptoms to 5 separate disorders:
•
Grieving
•
Sense of disaster
•
Suffering
•
Agitation similar to alcohol intoxication
•
Disillusionment seen on one’s face.
Each of these diseases has a different set of symptoms
and requires different treatment.
Most probably Indian psychiatrists would diagnose
and treat the Indians differently. From their perspective,
the Western category of depression was decisively too
wide to be therapeutically useful.
Murphy, Wittkower & Chance (1964) conducted
some interesting research on basic depressive individuals
from 30 countries. It turned out that in twenty-one countries the following symptoms appeared: despondency,
changing mood several times during a day, sleeplessness
and losing interest. In nine non-Western countries the
most symptoms were somatic: tiredness, lacking in appetite, weight loss weakening of libido.
Researching depressive Chinese Kleinman (1986)
noted lower sense of guilt and not too high self esteem
than in Western societies. With the Philippines and the
Senegalese the results were similar (German, 1972).
Several attempts were made to explain the difference.
Rare sense of guilt and low self-esteem would be linked
with intercultural differences in socialization processes.
El-Islam (1969) believes that pro-Western cultures tend
to blame others instead of an individual. Schieffelin
(1985) confirmed the same view. The Kaluli people of
New Guineas had no government. Power is exercised
by equal individuals, which brings about commitment,
willingness to achieve high status, decisiveness and
inventiveness. They are taught not to suppress their
emotions in the process of socialization. Public assertiveness means readiness to show anger. They eagerly
show sadness, anxiety or anger caused by frustration or
loss. Showing emotions is treated as the way to assert
one’s rights, to demand compensation from the person
responsible.
Schieffelin maintained that the ethnically uniform
Kaluli were trying to get compensation from the wrongdoers by showing anger or sadness. For this reason they
hardly ever experience depression in the Western sense
that is inward oriented. They do not blame themselves
for their own tragedy. According to this principle they
always direct their anger or sorrow outward. They feel
wronged and believe that others owe them something
2006 m.
instead of blaming themselves and feeling responsible
or feeling hatred.
As it appears the Kaluli blame others and not themselves for their setbacks and because of this they have
no word for depression in their language. Does it mean
that they experience no of Western defined depression?
Schieffelin believes that if there were a case of depression it would have somatic symptoms such as head
or stomach ache, lowered energy and reduced social
behavior. These symptoms would show when making
a complaint were considered unjustified.
Neither the Inuit nor the Yoruba have the words to
describe depression and anxiety though they denote the
symptoms, which Western psychiatrists usually associate
with depression. For instance, in the Yoruba language
there are expressions denoting “psychic anxiety that
makes sleep difficult” or “fear of other people”. The
Inuit speak of “an ease to be frightened”, “crying out of
sadness” or “body trembling”.
The absence of collective categories for anxiety
disorders and depression does not mean that these
societies are ignorant of the problems such disorders
bring. Both societies treat each symptom as a separate
disease to be treated by shamans. According to Murphy
(1965) such problems are far more common than the
formally labeled psychic disorders as nathkavihaki or
vere. Murphy believes that in Yoruba the quota of the
anxiety and depression to those called madmen is about
twelve to one. Among the Inuit the quota is even higher
and reaches about fourteen to one. It may be concluded
that depression and anxiety are more common than for
instance schizophrenia in these societies. Schizophrenia
may be considered similar to vere or nathkavihaki.
The problem whether it may be impossible to diagnose depression in a given culture is not new. Similarly,
old questions concern the sense of living, happiness and
suffering. Western culture stresses the reaction to loss in
defining depression. Such reaction entails the feeling of
hopelessness, suffering, shame and anger. Obeyesekere
(1995) states that such a description sounds strange for
a Buddhist for in Sri Lanka he would say we have been
dealing with a good Buddhist and not with a suffering
individual. According to Sri Lanka Buddhists hopelessness lies in the nature of the world and salvation depends
on understanding and overcoming it. Buddhist ideology
tells that life is full of suffering and sadness originating
from attachment, desire or longing. One can understand
and overcome suffering (by meditation) and be freed
from suffering.
Glorifying virtue, the stoics stated that a happy man
13
cannot meet with disaster and that a virtuous man will
be happy even inside Phalaris’ belly (Szestow (1993,
195). In the Book of Job, Job will say, ”The Lord gave
and the Lord has taken away; blessed be the name of
the Lord” (Job, 1, 21). “Remember him - before the silver
cord is severed, or the golden bowl is broken, before the
pitcher is shattered at the spring or the wheel is broken
at the well, and the dust returns to the ground it came
from, and the spirit returns to God who gave it. Vanity
of vanities, emptiness, says the preacher; all is vanity”
(Ecclesiastes12, 6-8). Salomon will speak in a similar
manner and nobody will call him depressed just asking
God for great wisdom.
In societies where suffering is considered normal,
diagnosing depression (individual pathological state)
does not make sense. Diagnosing people because of a
sad face and pessimistic outlook, discarding what the
world brings including success and affluence make a
shaky diagnostic basis. Prayer and meditation, even
in retreats, hopelessness and existential problems are
often defined as ‘suffering’, though they are nothing
exceptional in human existence and a natural order of
life and contemplation.
In individual and collective history of mankind there
are several instances that the depression people experienced was considered neither an illness nor a problem.
Though the symptoms were considered painful and
unpleasant, they were considered a natural course of
fate. The Book of Job relates: “So Satan went out from
the presence of Lord and afflicted Job with painful sores
from the soles of his feet to the top of his head. /…/ Then
his wife said to him: Are you still holding on to your integrity? Curse God and die! But he replied: ’You talk as
any wicked fool of a woman might talk. If we accepted
good from God, shall we not accept evil?’ Throughout
all this Job did not utter one sinful word.” (Job 2, 7- 10).
The biblical author does not consider it an illness neither
do Job’s friends trying to console him.
In many cultures, the fate, changeable and tragic, is
not met with sadness and sorrow, inability to concentrate
etc, which Western psychologists diagnose as depression. Specific features of a given culture make it possible
not to diagnose disorders. It would be too simple to say
that depression does exist in these cultures but is not
treated as an illness.
Analyzing depression without its religious and cultural context as an element of illness or disorder indicates
a hidden mistake similar to marking a sharp difference
between mental disease and sainthood.
The people coming from the Western culture and
14
from the outside (Inuit and Yoruba) differentiate real
mental disorders from other remarkable phenomena.
They differentiate the people suffering from mental disorders from those endowed with extraordinary faculties.
For instance, the shamans hear voices, see future events
or possessed by animal spirits. But no community calls
their leaders mad using the word nathkavihaki (madness)
suggesting malfunction of one’s mind. The Nigerian
tribe of Yoruba uses the word ‘vere’ to denote abnormal
behavior, similar to the English insanity. Likewise, a
majority of us would not consider a Western religious
leader (a priest) mad only because he states that God
answered his prayers. In some situations, religious leaders may go beyond their mind but not part with it. In
Western and non-Western cultures the people who lost
control over their strange behaviour is considered insane
(Murphy 1976).
There are proofs that that depression, as defined
in Western culture and psychiatric diagnosis is not so
common in non-Western cultures. That makes Obeyesekere (1985) ask whether we can be sure that depression is not only a traditional Western notion indicative
of a culturally specific illness just like koro (suk-yeong
– depersonalisation and panic about penis shrinking),
kayak-angst (derealization due to sensory deprivation),
amok or susto? Isn’t it just an expression of social maladaptation and resignation under the stress of the modern
speed of life?
Bibliography
1.
American Psychiatric Association (1994). Diagnostic and
statistical manual of mental disorders (4 ed.). Washington, DC.
2.
El-Islam F. (1969). Depression and guilt: A study at an Arab
psychiatric center: Social Psychiatry, 4, 56-58.
3.
German A. (1972). Aspects of clinical psychiatry in SubSaharan Africa. British Journal of Psychiatry, 121, 461-470.
4.
Jones, W.H.S., Withington E. (1923). Works of Hippocrates
(vol.1).Cambridge, MA: Harward University Press.
2006 m.
5.
Kleinman A. (1986). Social origins of distress and disease:
depression, neurasthenia, and pain in modern China. New Haven,
CT: Yale University Press.
6.
Laing, R.D. (1967). The politics of experience. New York:
Random House.
7.
Leighton A., Lambe T., Hughes C., Leighton D., Murphy J.,
Macklin A.M.(1963). Psychiatric disorders among the Yoruba. Ithaca,
NY: Cornel University Press.
8.
Manson S., Shore J., Bloom J. (1985). The depressive experience in American Indian communities: A challenge for psychiatric
theory and diagnosis, [in:] Kleinman A., Good B., (ed.), Culture and
depression. Berkeley: University of California Press.
9.
Murphy H., Wittkower E., Chance N. (1964), Cross-cultural
inquiry into the symptomatology of depression. Transcultural Psychiatric Research Review, 1, 5-21.
10. Murphy, J.M .(1976). Psychiatric labeling in cross-cultural
perspective. Science, 191,1019-1028.
11. Obeyesekere, G. (1985). Depression, Buddhism, and the
work of culture in Sri Lanka. [w:] Kleinman A., Good B.(ed.). Culture
and depression. Berkeley: University of California.
12. Resner, G., Hartog, J.(1970). Concepts and terminology of
mental disorders among Malays. Journal of Cross-Cultural Psychology,
1,369-381.
13. Scheff, T.(1984). Being mentally ill: A sociological theory
(2 ed.) Chicago: Aldine.
14. Schieffelin, L.(1985). The cultural analysis of depressive
affect: An example of New Guinea. [in:] Kleinman A., Good, B.(eds.)
Culture and depression. Berkeley: University of California Press.
15. Sechrest L. (1963). Symptoms of mental disorders in the
Philippines. Philippine Sociological Review, 7, 189-206.
16. Szasz, T.S.(1970). Ideology and insanity: Essays on the
psychiatric dehumanization of men. New York: Doubleday.
17. Szestow, L. (1993). Ateny i Jerozolima, Wyd. Znak.
18. Tanaka-Matsumi, J., Marsella, A.J. (1976). Cross-cultural
variations in the phenomenological experience of depression: word
association. Journal of Cross-Cultural Psychology, 7,33-39.
19. The New English Bible. (1974). Harmondsworth, Penguin
Books.
20. Tseng W., Hsu J.(1969). Chinese culture, personality formation and mental illness. International Journal of Social Psychiatry, 16,
5-14.
Gauta 2006-01-10

SAVASTIES FENOMENOLOGIJOS PRIELAIDOS IR SÀSAJOS
SU EMOCINE SAVIREGULIACIJA
G.GUDAITË, G.BUTKUS
Vilniaus universiteto Filosofijos fakultetas,
Valstybinë teismo psichiatrijos tarnyba prie Sveikatos apsaugos ministerijos
Raktaþodþiai: savastis, ego, kompleksai, archetipai,
afektø integracija.
Santrauka
Emocinës savireguliacijos sutrikimø mechanizmø
2006 m.
paieðka – viena ið prioritetiniø psichikos sveikatos
specialistø asmenybës psichopatologijos tyrinëjimo krypèiø. Ðiame straipsnyje siekiame analizuoti
ir integruoti ðiuolaikiniø psichodinaminës paradigmos krypèiø atstovø keliamas prielaidas apie
asmenybës savasties fenomenologinius ypatumus
emocinës savireguliacijos sutrikimø kontekste.
Iðvadose keliame hipotezes apie specifiniø savasties funkcijø ir afektinës integracijos ypatumø
tarpusavio sàsajas.
ÁVADAS
Paskutiniuosius deðimtmeèius psichodinaminës paradigmos atstovai kelia naujas hipotezes apie asmenybës
psichopatologijos prielaidas ir psichoterapinës strategijos
perspektyvà. Beveik kiekviename moksliniame þurnale
analizuojamos tokios kategorijos kaip subjektyvumas,
objektyvumas ir intersubjektyvumas [5,7,11,22,25,26].
Naujø paþiûrø besilaikantys autoriai vienos asmenybës
psichologijà pastato prieðprieðiais dviejø asmenybiø psichologijai [6,10,30]. Ðiame kontekste atvirai kritikuojami
klasikiniai psichoanalizës neutralumo ir abstinencijos
principai bei racionaliø terapiniø procedûrø prioritetas
[12,15,24]. Ðie pokyèiai glaudþiai susijæ su nauju psichikos problemø matymo kampu. Asmenybës psichopatologija labiau siejama su vidiniu tuðtumos jausmu,
kryptingumo gyvenime ir patikimø vertybiø stoka nei su
adaptacinëmis problemomis [3,18,28]. Psichikos centru
ávardijama savastis kaip visø narciziðkø investicijø objektas [12]. Subjekto trûkumai kildinami ið ankstyvøjø
santykiø tarp vaiko ir motinos sutrikimo: empatiðko
atspindþio stoka sàlygoja jausminës patirties deficità,
vidiná disbalansà, þemà frustracijos tolerancijà ir emociná
signalinës funkcijos neásisavinimà. Ðiuolaikinës psichodinaminës koncepcijos atstovai didþiausià dëmesá skiria
jausminio iðgyvenimo integracijai tarpusavio sàveikos
kontekste. Siûloma kitaip vertinti tokius psichoterapiniø
santykiø fenomenus kaip perkëlimas ir kontrperkëlimas.
Kita vertus, integracinë perspektyva bûtina ir paèioms
psichodinaminës paradigmos koncepcijoms. Naujos
idëjos keliamos keliose psichodinaminës paradigmos
kryptyse: objektø ryðiø teorijoje, savasties ir analitinëje
(jungistinëje) psichologijoje.
Straipsnio tikslas – analizuoti ir integruoti ðiø krypèiø
atstovø keliamas prielaidas apie savasties fenomenologijà, savasties ir ego ryðius, emocinës savireguliacijos
mechanizmus, naujus psichoterapinio proceso akcentus
bei iðkelti hipotezes apie specifiniø savasties funkcijø ir
afektinës integracijos ypatumø tarpusavio sàsajas.
15
KLINIKINË SAVASTIES REIKÐMË
Aanalitinës psichologijos pradininkas C. G. Jungas
këlë prielaidà, kad þmogus patiria savastá per jos atliekamà kompensatorinæ funkcijà, kuria siekiama atsverti jo
vienpusiðkà pozicijà [8]. Tipiðki tokios savireguliacijos
pavyzdþiai atsispindi sapnuose. Pavyzdþiui, kraðtutiniu
maskuliniðkumu pasiþymintys vyrai daþnai sapnuoja,
kad yra moterys, tuo tarpu tylûs ir nusileidþiantys asmenys sapnuose elgiasi agresyviai ir autonomiðkai [21].
Atvejø analizë atskleidë, kad kompensatorinë savasties
funkcija gali atlikti svarbø vaidmená ir psichoterapiniuose santykiuose [14]. Kita vertus, asmenybës potencialo
realizacija galima tik supanèios aplinkos dëka: psichopatologija kyla tais atvejais, kai asmeninë ankstyvøjø
santykiø patirtis nesuþmogina archetipiniø fantazijø.
Tuomet bûna paþeista asmenybës sàmoninga veikla, ir
gyvenama psichozinio lygio fantazijø pasaulyje. Asmeninë patirtis gali konsteliuoti tik vienà ið archetipiniø poliø.
Esant blogai santykiø patirèiai, aktyvizuojasi „blogos
motinos“ lûkesèiai, ir psichikà valdo tokios motinos
vaizdinys. Tuo tarpu idealizuojami santykiai sàlygoja
perdëtus lûkesèius ir menkina galimybes tvarkytis su
nusivylimais ir realiu gyvenimu. Kritikai daþnai nurodo,
kad C. G. Jungo apraðytas savasties fenomenas pernelyg
globalus ir prieðtarauja evoliucijos principams [2]. Todël
bûtina diferencijuoti savastá kaip centriná kolektyvinës
pasàmonës archetipà ir savastá kaip sàmonës ir pasàmonës integralinæ visumà, kurià E. Neumannas apraðë kaip
savasties – ego aðá [19]. Jo darbai apie vaiko ankstyvøjø
santykiø su motina svarbà asmenybës raidai laikomi
klasikiniais, jais remiasi ne tik analitinës pakraipos autoriai, bet ir objektø ryðiø teorijos atstovai [4]. Bandydamas
sintezuoti struktûriná ir evoliuciná poþiûrius á savastá, E.
Neumannas këlë prielaidà, kad savastis konsteliuojama
per pirmuosius kûdikio gyvenimo metus, sàveikaujant
kûno ir bendravimo patyriminiams procesams, o vëliau
savastis reiðkiasi ávairiais archetipais. Pirminio ryðio nesusiformavimas gali sugriauti þmogiðkàjá specifiðkumà,
paskatinti visiðkos negalios formas. Vëlesni savasties
patyrimo kokybiniai pokyèiai susijæ su naujomis vaiko
motorinëmis ir santykiø galimybëmis. Panaðu, kad bûtent
tuo metu formuojasi pagrindiniai kompleksai, nes vaikui
tampa prieinama asmeninë patirtis. Ugdomas pozityvus
motinos kompleksas sàlygoja vaiko gebëjimà kurti empatiðkus santykius, skatina vidiná augimà, sugebëjimà atlaikyti ið vidaus kylanèius destruktyvius impulsus. Trauminë
santykiø su globojanèiu asmeniu patirtis sàlygoja ego ir
savasties ryðio skilimà. Tokiais atvejais sutrinka ne tik
intrapsichinë sàveika, bet ir ryðiai su iðore: neatlaikomi
neigiami iðgyvenimai, „lûþtama“ vertinimo situacijoje.
16
Bûtent ðie psichodinaminiai ypatumai bûdingi narcizinio
tipo asmenybës sutrikimui. Treèiasis, psichodinaminis,
pokytis susijæs su integruoto ego, gebanèio realistiðkai
matyti pasaulá, atlaikyti emocinius iðgyvenimus, atsiverti
tarpasmeniniams santykiams, nebijant artimame ryðyje
prarasti save, susiformavimu. Panaðu, kad bûtent ðiame
etape modeliuojama tolerancija stresui ir frustracijai.
Kita vertus, pavojai gali kilti dël perdëtos konfrontacijos su natûraliais poreikiais ir vienpusiðkos orientacijos
á sëkmingà adaptacijà iðorëje. Apibendrinant galima
konstatuoti, kad E. Neumannas tarpusavyje siejo tokius
reiðkinius kaip pirminiai santykiai, ego – savasties ryðys ir
emocinio patyrimo integracija. Ðios E. Neumanno idëjos
artimos D. W. Winnicotto keliamai prielaidai, kad vaikas
savo atspindá patiria ir iðgyvena motinos veide [29]. H.
Kohutas ðià idëjà iðplëtë ir pritaikë terapiniø santykiø
kontekste [12]. Tuo tarpu D. Sternas, analizuodamas
savasties, kaip savæs patyrimo, dinaminius pokyèius,
rëmësi ne „klinikinio kûdikio“ modeliu, o tiesioginiais
kûdikiø stebëjimais, atverdamas galimybes savasties koncepcijos empiriniam ávertinimui [23]. D. W. Winnicottas
analizavo vaiko asmenybës raidà tikrosios ir netikrosios
savasties reiðkimosi kontekste. Tikroji savastis apibûdinama kaip visø ágimtø, savasties branduolyje slypinèiø
individo potencialø ir savybiø raiðkos forma. Netikroji
savastis – tai specifinë ego gynimo struktûra. Su kiekvienu nauju gyvenimo tarpsniu, kuriame tikrosios savasties
egzistavimas nebuvo rimtai sukliudytas, stiprëja realybës
pojûtis. Ðis jausmas ugdo gebëjimà toleruoti tikrosios
savasties gyvenimo trikdþius ir reaktyvius iðgyvenimus,
susijusius su paklusimu aplinkai, skatina separacijos
– individualizacijos procesà [16]. Galima kelti prielaidà,
kad tikrosios savasties iðgyvenimas fenomenologiðkai
tapatus E. Neumanno apraðytam ego – savasties ryðio
patyrimui. Tuo tarpu klaidingos savasties fenomenologija
artima narciziniam savasties deficitui, kaip tai apraðo H.
Kohutas [12]. H. McFarland Solomon áþvelgia analogijà
tarp klaidingos savasties ir personos konstruktø [17].
H. Kohuto apraðytus savasties polius galima sieti su giliausiais asmenybës identiðkumo ðaltiniais. Tarp dviejø
savasties poliø vyksta nuolatinë intrapsichiniø procesø
sàveika: baziniai tikslai þadinami individo ambicijomis
ir koreguojami jo idealais. Taip organizuota bipoliarinë
savastis sàlygoja sveiko individo giluminá identiðkumo ir
unikalumo jausmà. Akcentuodamas asmenybës deficito
modelá, autorius skatina atsiþvelgti á jausminës patirties
integracijos sunkumus, kuriø áveikimas galimas tik empatiniø santykiø psichoterapijoje dëka. Tuo tarpu D. Sterno
nuomone, naujagimiai patys sugeba iððaukti aplinkos
empatines reakcijas á save, nes gimstama su savasties
2006 m.
pojûèiu [23]. D. Sterno teigimu, periodai tarp 2 ir 3, 5
ir 6, 9 ir 12 bei 15 ir 18 mënesiø yra dideliø pasikeitimø
metas. Kokybiniai pokyèiai stebimi ávairiuose organizacijos lygiuose: pradedant elekroencefalograminiais
duomenimis, baigiant elgesio bei subjektyvios patirties
lygiu. Patyrimai yra instinktyviai perdirbami taip, kad
jie atrodo priklausà kaþkokiam unikaliam, subjektyviam
dariniui. D. Sternas iðskyrë tam tikrus gebëjimus, kurie
bûtini formuojant struktûruotà savasties pajautimà: savo
veiksmø autorystës atskyrimas; savo fizinës visumos,
turinèios apèiuopiamas ribas, pajautimas; struktûruotø
jausmø patyrimas; tæstinumo jausmo turëjimas. 2-7 mënesiø kûdikiai jau turi epizodinæ atmintá, kurios pagalba
patyrimas apibendrinamas ir reprezentuojamas neverbaliai. Panaðûs ávykiai apibendrinami á generalizuotas
sàveikos reprezentacijas, kurios sudaro identiðkumo
iðgyvenimo pagrindà. Tam tikru laikotarpiu (apie 9
mën.) motina intuityviai iðpleèia savo elgesá, virðydama
paprastos imitacijos ribas, ir pradeda naujà elgesio kategorijà, vadinamà emociniu derinimu. Maþdaug tarp 15
ir 18 mën. vaikas iðvysto naujà savæs ir kito patyrimo
kokybæ. Kokybiðkai naujas savasties aspektas remiasi
naujais sugebëjimais – mokëjimu objektyvizuoti savastá,
savirefleksija, sugebëjimu suprasti ir naudoti kalbà. Kita
vertus, kalba þmogaus gyvenimà paveikia dvejopai: ji
ne tik padeda bendrauti, bet ir atskiria dvi simultaniðko
patyrimo formas – tai, kas yra iðgyvenama, ir tai, kas yra
verbaliai reprezentuojama. Visgi su kalba labai iðsipleèia
vaiko galimybiø ribos – atsiranda simboliniai þaidimai,
uþdelsta imitacija. Vaikas pradeda suvokti psichologiná
ryðá tarp savæs ir modelio, o tam reikalinga savasties kaip
objektyvios visumos reprezentacija.
Apibendrinant galima teigti, kad minëti autoriai
bendrai pabrëþia, kad savasties patyrimo integracija
suþadinama ankstyvøjø santykiø kontekste. Giliausias
savæs iðgyvenimas yra projektuojamas daugkartinëse
globojanèio asmens ir vaiko interakcijose, o savasties
defektai tiesiogiai susijæ su emocinës savireguliacijos
sutrikimais.
EMOCINIØ IÐGYVENIMØ
PSICHODINAMINIAI YPATUMAI
Turbût pagrindinis visø emociniø iðgyvenimø psichodinaminis ypatumas tas, kad jie formuojasi dar neprasidëjus paþinimo ir kalbos raidai. Tai reiðkia, kad emociniø
ir kogntyviniø procesø integracija ámanoma tik tam
tikrame amþiuje. Kol pasiekiama ði pakopa, emociniai
iðgyvenimai bûna glaudþiai susijæ su pasàmoninëmis
fantazijomis ir apraðomi kaip afektai. Tuo tarpu integruoti
á ego struktûrà, susieti su kognityviniais ir tarpasmeniniais
2006 m.
ego aspektais iðgyvenimai apibûdinami kaip ilgalaikiai,
sàlyginiai, stabilûs ir áprasminti jausmai [13]. Psichodinaminës paradigmos atstovai vienaip ar kitaip analizavo
afektizuotø pasàmoniniø vaizdiniø turiná ir prielaidas. M.
Klein juos apibûdina kaip pamatinius konfliktus, atspindinèias pasàmonines fantazijas, W. Bionas – kaip „mintis
be màstytojo“, D. W. Winnicottas – kaip subjektyvius
objektus, H. Kohutas – kaip savasties reprezentacijas.
Bendrame afektizuotø vaizdiniø iðgyvenimo integracijos
modeliavimo kontekste galima iðskirti keturis pagrindinius mechanizmus: 1) afektø diferenciacija ið bendros
subjektyvios patirties matricos; 2) prieðtaringø afektiniø
iðgyvenimø sintezë; 3) afektiniø bûsenø tolerancija ir jø
naudojimas áspëjanèiø signalø pavidalu; 4) afektø apmàstymas. Afektø diferenciacijà galima bûtø apibrëþti
kaip pamatinæ emocinës savireguliacijos prielaidà. Raidos poþiûriu pirminës afektinës kûdikio reakcijos vyksta
bendrame psichomotorinio sujaudinimo kontekste. D.
Kalshedas jas apibûdina kaip kompulsinio tipo prasiverþimus, atspindinèius pasitenkinimo, diskomforto, skausmo patyrimus [9]. Patologijos atvejais nediferencijuotas
afektinis patyrimas aptinkamas regresyviose suaugusiøjø
bûsenose, susijusiose su totaliu nerimu, panika, fiziologiniu afektu. Su tokiais afektais susijæ vaizdiniai, jei jie
pasiekia sàmonës lygá, bûna grandioziðki ir groteskiðki.
Kita vertus, ankstyvøjø trauminiø atvejø analizë atskleidþia, kad disocijuota trauminë patirtis, kuriai bûdingas
visiðkas emocinës savireguliacijos sutrikimas, gali pasireikðti tik somatiniø sutrikimø pavidalu. Tokiu atveju
matomas afekto ir vaizdinio skilimo fenomenas: somatiniai ir vaizdiniai komponentai tarsi prasilenkia laike.
Afekto somatiniai komponentai patiriami kûno lygyje,
bet lieka disocijuoti nuo mintinio akto. Trauminë patirtis
inkapsuliuoja afektà somatiniuose simptomuose arba
neproduktyviose, nuo realybës atitrûkusiose nevalingose
fantazijose. Tokios fantazijos daþnai bûna perpildytos
visagaliø persekiojanèiø figûrø ir atspindi psichozinio
lygio arba disociacinius sutrikimus. Tuo tarpu gebëjimas
kurti produktyvius vaizdinius bûna reikðmingai sutrikdytas. Empiriniai tyrimai atskleidþia, kad nesugebantys
kurti vaizdiniø ir asociacijø pacientai turëjo empatiniø
santykiø problemø ankstyvojoje vaikystëje [1,5,20,27].
Prieðtaringø emociniø iðgyvenimø sintezë ámanoma tuo
atveju, kai aplinka blogus ir gerus vaiko emocinius reagavimus atspindi kaip vientisos vaiko esmës pripaþinimà.
Ðios funkcijos ávaldymas siejamas su asmenybës raidoje
pasiekta depresine pozicija [4]. Esminis ðios pozicijos
ypatumas – sugebëjimas atpaþinti visà objektà arba atradimas, kad geri ir blogi pirmøjø gyvenimo mënesiø
objektai – to paties priþiûrinèio asmens bruoþai. Tai
17
sàlygoja savo paties ambivalentiðkø impulsø, nukreiptø
á tà patá objektà, patyrimà ir sukelia nerimà. Jei aplinka
empatiðkai priima ðiuos ambivalentiðkus afektus, sudaromos sàlygos nenutrûkstamam savæs pajautimui.
Prieðingu atveju gali bûti ugdomas tapatinimasis tik
su pozityviàja emocine dalimi, tuo tarpu negatyvûs ir
nepriimtini afektai liks izoliuoti ir neásisavinti. Galima
kelti prielaidà, kad prieðtaringø iðgyvenimø sintezës
neávaldymas turi sàsajø su rigidiðko ego formavimusi.
Tuo tarpu afektiniø bûsenø tolerancijos integracija ir
ðiø bûsenø naudojimas áspëjanèiø signalø pavidalu
gali bûti tiesiogiai siejami su asmens atsparumu stresui ir frustracijai. Raidoje ðis gebëjimas pasiekiamas
sugerianèios ir pertvarkanèios afektinius impulsus
aplinkos dëka. Kitaip tariant, vaikà globojantis asmuo
modeliuoja afektinës bûsenos atlaikymà ir susiejimà
su mintimis. Bûtent atsparus objektas tampa savasties
dalimi, kuri padeda iðtverti nerimà, sulaikyti iðveikà ir
padeda mokytis ið patyrimo. Kita vertus, kaip raðo minëti
autoriai, pakankamai gera mama atlieka ne visø vaiko
troðkimø iðpildymo funkcijà [12,23,29]. Ðiame kontekste svarbesnë signalinë funkcija, skatinanti atsiþvelgti á
pakitusià vaiko bûsenà. Tai sudaro sàlygas integruoti
signalinæ funkcijà á emocinës savireguliacijos sàrangà.
Tokiame kontekste emocija veikia ne griovimo, dezorganizacijos ar fragmentacijos, o mobilizacijos kryptimi. Jei emocinë reakcija neneða signalinës funkcijos,
tai gali reikðti trauminës bûsenos, nuo kurios siekiama
izoliuotis ar disocijuotis, patyrimà. Afektø apmàstymas
– vëliausiai iðkylanti emocinës savireguliacijos sàranga.
H. Krystal teigimu, afekto evoliucija atspindi perëjimà
nuo ankstyviausiøjø afektø, besireiðkianèiø daugiausia somatine forma, iki jausmø, kurie gali bûti apibûdinami þodþiais ir áprasminami simboline forma [13].
Galima iðskirti keturis jausminio iðgyvenimo aspektus,
kurie turi bûti integruoti: elgesys, afektas, pojûèiai ir
þinojimas. Kitaip tariant, emocinio patyrimo pilna integracija apima somatinius, psichinius ir elgesio elementus.
Tai reiðkia emocinio iðgyvenimo turinio ásisàmoninimà,
kûno pojûèiø suvokimà, þodiná iðreiðkimà ir átraukimà á
naratyvinæ istorijà, kaip asmenybës tapatumo dalá.
IÐVADOS
1. Savasties, kaip globalinio asmenybës konstrukto, ásitvirtinimas psichodinaminëje paradigmoje simbolizuoja konfliktinio asmenybës modelio transformacijà á
intersubjektyvø asmenybës modelá.
2. Bendrame kontekste galima iðskirti tris pagrindines savasties funkcijas: 1) savastis kaip potencialumo
ir kûrybiðkumo neðëja; 2) savastis kaip empatiðkumo
18
tarpasmeniniuose santykiuose ðaltinis; 3) savastis kaip
psichosomatinës vienybës atspindys.
3. Mûsø keliamos hipotezës: 1) afektø diferenciacijos sutrikimai susijæ su simbolizavimo funkcijos
deficitu; 2) prieðtaringø afektiniø iðgyvenimø sintezavimo
sutrikimas susijæs su empatiðkumo funkcijos deficitu; 3)
gebëjimas naudotis afektine bûsena kaip áspëjanèiuoju
signalu susijæs su savasties kompensatorinës funkcijos
ásisavinimu; 4) afektø apmàstymo integracija susijusi su
naratyvine savasties funkcija.
Literatûra
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Bovensiepen G. Symbolic attitude and reverie: problems
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Dougherty N. J., West J. J. Character Structure: Awakening
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Jung C. G. Psichoanalizë ir filosofija. Vilnius, Pradai,
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i formirovanije identiènosti. Þurnal praktièeskoi psichologiji i psichoanaliza, 2005, 2.
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of dissociation: the „as if“ personality. Journal of Analytical Psychology,
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18. McWilliams N. Psychoanalytic Diagnosis: Understanding
Personality Structure in the Clinical Process. New York, Guilford Press,
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2006 m.
21. Samuels A. Jung and Post-Jungians. London, Routledge,
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Clinical Series, 1, 1-36.
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Infant Mental Health Journal, 1994, 15(1), 9-25.
24. Stern D., Sander L., Nahum J., Harrison A., Lyons-Ruth
K., Morgan A., Bruschweiler-Stern N., Tronick E. Non-interpretive
mechanisms in psychoanalytic therapy: The something more than
interpretation. The International Journal of Psychoanalysis, 1998, 79,
903-921.
25. Stolorow R. D. Dynamic, dyadic, intersubjective systems:
An evolving paradigm for psychoanalysis. Psychoanalytic Psychology,
1997, 14, 337-346.
26. Stolorow R. D. Psychoanalytic Treatment: An Intersubjective
Approach. New York, Analytic Press, 1987.
27. Zabriskie B. Imagination as laboratory. Journal of Analytical
Psychology, 2004, 49(2), 235-242. 28.
28. West M. Identity, narcissism and the emotional core. Journal
of Analytical Psychology, 2004, 49(4), 521-551.
29. Winnicott D. W. Teorija raditelsko-mladenèeskoi psichologiji. Þurnal praktièeskoi psichologiji i psichoanaliza, 2005, 2.
30. Woodhead J. “Dialectical process” and “constructive
method”: micro-analysis of relational process in an example from
parent-infant psychotherapy. Journal of Analytical Psychology, 2004,
49(2), 143-160.
THE ASSUMPTIONS OF THE PHENOMENOLOGY OF THE SELF
AND THE CONNECTION WITH EMOTIONAL SELF-REGULATION
G.Gudaitë, G.Butkus
Summary
Key words: self, ego, complexes, archetypes, integration of affects.
During the last decades mental health specialists raise new hypotheses about the preconditions of personality psychopathology and
the perspective of psychotherapeutic strategy. This context requires
to consider the emotional experience aspects of the self and of the
significant others. Our article aims to analyse and integrate the preconditions raised by the representatives of modern psychodynamic
paradigm trends about the phenomenology of the self, the relations
of the self and ego, emotional self-regulation criteria and new accents on the psychotherapeutic process. The generalisation of various
sources results in three key dimensions of the self: the self as a source
of potentiality and creativity, of empathy in interpersonal relations,
and of psychosomatic unity. Integration of these dimensions in the
ego level is linked to emotional self-regulation peculiarities. Clinical
descriptions of early traumatic cases disclose the phenomenon of the
split of the affect and the image. We hypothesize: the pathology of
affect differentiation is related to the disorder of symbolising the self
and compensatory function, the difficulties of experiencing unbroken
essence are related to the problems of mastering empathy, the ability
to use the affective condition as a warning signal reflects the mastering
of the compensatory function of the self, the cogitation of the affects
is related to the ability to give a sense to the experience in a symbolic
form and to include it into the narrative story as a component of personality identity. During the process of psychotherapeutic work the
therapist must analyse his own emotional and associative sensations.
They can be used as points of reference, endeavouring a more complete
integration of the affects, tormenting the patients.
Gauta 2006-01-24

2006 m.
19
PSICHOTRAUMUOJANÈIØ (STRESO SUKELTØ) FAKTORIØ
ÁTAKA MOTERØ IMPULSYVIAM IR AGRESYVIAM
NUSIKALSTAMAM ELGESIUI
V.KILIKEVIÈIENË
Valstybinë teismo psichiatrijos tarnyba prie Sveikatos apsaugos ministerijos
Raktaþodþiai: psichotraumuojantys faktoriai, impulsyvus, agresyvus, nusikalstamas elgesys, teismo psichiatrijos ekspertizë, nusikaltimas.
Santrauka
Pagrindinis tyrimo siekis – moterø agresyvaus
nusikalstamo elgesio, kuomet buvo ávykdyti
nusikaltimai kito asmens gyvybei ir sveikatai,
dësningumø, ryðio su psichotraumuojanèiais
faktoriais paieðka. Taip pat siekiama analizuoti,
kaip ðie moterø ávykdyti impulsyvûs bei agresyvûs nusikalstami veiksmai susijæ su asmenybës
struktûra, psichikos sutrikimais bei kokià átakà
ðiems sutrikimams pasireikðti turi asmeniui subjektyvûs psichotraumuojantys faktoriai (stresiniai,
socialiniai, psichologiniai faktoriai: traumuojanti
aplinka, besitæsiantys konfliktai ir kt.). Remiantis
tyrimo rezultatais keliamos hipotezës apie moterø
impulsyvaus ir agresyvaus nusikalstamo elgesio
ypatumus, ávykdþiusiø ðiuos nusikaltimus moterø
psichikos sutrikimus, jø asmenybiø struktûros
ypatumus; moterø impulsyvaus ir agresyvaus
nusikalstamo elgesio bei psichotraumuojanèiø
faktoriø tarpusavio sàsajas. Tyrimui naudota 50
moterø, kurioms buvo atliktos teismo psichiatrijos ekspertizës Valstybinëje teismo psichiatrijos
tarnyboje 2000-2004 metais po to, kai jos ávykdë
nusikalstamus veiksmus (kûno suþalojimus, nuþudymus), ekspertiziø dokumentacija.
ÁVADAS
Psichotraumuojantis stresiniø, socialiniø, psichologiniø faktoriø poveikis asmenybës reagavimui ið esmës
galimas jiems sutapus su psichogenine asmenybës reagavimo struktûra. Nestiprus stresas skatina mobilizuotis.
Besikartojantis stresas linkæs kauptis ir gali tapti traumuojanèiu. Paprastai situacijà apsunkina ir átakà elgesiui bei
sprendimams turi keliø psichotraumuojanèiø faktoriø
kombinacija. Ðiuolaikinis sisteminis poþiûris á agresyvø
– impulsyvø elgesá, apskritai á agresijà leidþia minëtus
ávykdytus agresyvius nusikaltimus diferencijuoti principu
pagal lytá, todël tyrimui pasirinktos tik moterys.
Vertinant moterø ávykdytà agresyvø nusikalstamà
veiksmà, svarbu asmenybës sutrikimo gilumo bei ðiø
sutrikimø stabilumo, paþintiniø funkcijø, laikinø dekompensacijos bûsenø psichiatrinis ávertinimas. Taip pat
svarbu suprasti, analizuoti, kiek tam tikroje konkreèiam
asmeniui (ðiuo atveju – moteriai) psichotraumuojanèioje
situacijoje psichikos anomalija (sutrikimas) nulëmë
asmens agresyviø veiksmø motyvacijà vykdant nusikalstamà veikà.
Darbo tikslas – iðanalizuoti moterø, ávykdþiusiø
impulsyvius ir agresyvius nusikalstamus veiksmus prieð
kito asmens gyvybæ ir sveikatà, psichikos ypatumus,
sutrikimus, ieðkoti ryðio tarp jø minëto impulsyvaus ir
agresyvaus nusikalstamo elgesio bei psichotraumuojanèios aplinkos; analizuoti, ar turi átakos impulsyviems
ir agresyviems veiksmams pasireikðti subjektyviai psichotraumuojantys faktoriai. Ðiame darbe psichotraumuojanèiais faktoriais laikomi visi stresiniai, socialiniai,
psichologiniai faktoriai: traumuojanti aplinka, besitæsiantys konfliktai ir kt. faktoriai, kuriuos tirtos moterys
paèios iðskyrë, kaip joms turëjusius didelæ subjektyvià
psichotraumuojanèià reikðmæ.
TYRIMO OBJEKTAS IR METODIKA
Tyrimo objektu pasirinktos moterys, ávykdþiusios nusikalstamus impulsyvius, agresyvius veiksmus prieð kito
asmens sveikatà ir gyvybæ (kûno suþalojimus, nuþudymus). Analizuota atsitiktiniu bûdu pasirinktø 50 moterø,
kurioms buvo atliktos teismo psichiatrijos ekspertizës
2000–2004 metais Valstybinëje teismo psichiatrijos
tarnyboje prie SAM, po ávykdytø minëto pobûdþio nusikaltimø, ekspertiziø dokumentacija. Ðiuos nusikaltimus
ávykdþiusiø moterø amþiaus ribos buvo nuo 21 iki 40
metø. Tyrimo metodas – reikiamø duomenø gavimas ið
ekspertinës dokumentacijos, baudþiamøjø bylø dokumentacijos, remiantis vienu specialiu klausimynu visoms
tiriamosioms.
20
1 lentelë. Moterø nusikalstamø agresyviø veiksmø aukos (procentais) neutralioje bei psichotraumuojanèioje aplinkoje.
1 grafikas. Moterø nusikalstamos agresijos pasireiðkimas
tam tikrø grupiø atþvilgiu (kuomet aukos vaikai, artimieji,
paþástami, nepaþástami) neutralioje bei psichotraumuojanèioje aplinkoje.
REZULTATAI
Tyrimo metu nustatyta, kad 65 proc. moterø ávykdytø
agresyviø nusikaltimø (kûno suþalojimø, nuþudymø) atvejais tæsdavosi stresinis, konfliktinis tarpusavio santykiø
su nukentëjusiuoju ar nukentëjusiàja periodas; agresyvios reagavimo formos ðioms moterims pasireikðdavo
ir anksèiau. 20 procentø ðios grupës moterø dël tokio
pobûdþio agresyviø – impulsyviø nusikalstamø veiksmø buvo patraukiamos baudþiamojon atsakomybën
anksèiau.
Tiriant moteris, ávykdþiusias ðio pobûdþio nusikaltimus, nustatyta, jog tarp jø vyrauja nusikaltimai, ávykdyti
paèiø artimiausiø þmoniø atþvilgiu, t.y. vaikø ir kitø jø
ðeimos nariø (1 lentelë, 1 grafikas).
Statistinei analizei, remiantis nukentëjusiøjø, aukø
nuo moterø agresyvaus elgesio, ðioms moterims psichotraumuojanèiose bei neutraliose situacijose, procentiniu
pasiskirstymu gautas koreliacijos koeficientas: 0,96.
Gautas skaièius rodo, kad tarp minëtø analizuojamø
faktoriø (moterø agresyvaus ir impulsyvaus elgesio bei
aplinkos) egzistuoja tiesioginis stiprus funkcinis ryðys
(kadangi rezultatas artimas 1).
Tyrimo metu atkreiptas dëmesys á ðioms moterims
nustatytus psichikos sutrikimus, ðiø sutrikimø diagnoziø
procentiná pasiskirstymà. Remiantis psichikos sutrikimø,
pasireiðkianèiø moterims jø nusikalstamos agresijos atvejais, neutralioje bei jas psichotraumuojanèioje aplinkoje,
procentiniu pasiskirstymu gautas koreliacijos koeficientas: 0,88 (2 lentelë). Tai taip pat rodo, kad tarp ðiø ana-
2006 m.
2 lentelë. Psichikos sutrikimai, daþniausiai pasireiðkiantys
moterims, ávykdþiusioms nusikalstamus veiksmus prieð kito
asmens gyvybæ, sveikatà joms neutralioje ar psichotraumuojanèioje aplinkoje (procentais).
lizuojamø faktoriø (psichikos sutrikimø, pasireiðkianèiø
moterims jø nusikalstamos agresijos atvejais, neutralioje
bei jas psichotraumuojanèioje aplinkoje bei aplinkos)
egzistuoja tiesioginis stiprus funkcinis ryðys (rezultatas
taip pat artimas 1). Rezultatai gauti remiantis statistinës
analizës metodu – koreliacine analize [7,8].
Gauti rezultatai rodo, jog specifiniai asmenybës
sutrikimai yra vyraujantys psichikos sutrikimai, diagnozuojami moterims, ávykdþiusioms ðio pobûdþio
impulsyvius–agresyvius nusikalstamus veiksmus neutraliose situacijose (kuomet psichotraumuojanèios aplinkos
poveikio nëra) tarp psichikos sutrikimø ir jie sudaro 50
procentø visø ðiø sutrikimø. Ir jau 10 procentø maþiau
– 40 procentø moterø, ávykdþiusiø ðiuos veiksmus, diagnozuojami analogiðki specifiniai asmenybës sutrikimai
joms subjektyviai reikðmingose, psichotraumuojanèiose
situacijose.
Tyrimø rezultatai leidþia iðskirti tokius daþniausiai
pasitaikanèius specifinius asmenybës sutrikimus. Tai
– emociðkai nestabilûs asmenybës sutrikimai (ribinis
ir impulsyvus tipai), histrioninis asmenybës sutrikimas,
priklausomo tipo asmenybës tipas, ðizoidinio tipo bei
miðrus asmenybës sutrikimai. Tyrimo metu daþniausiai
(32 proc. visø atvejø) kriminaliniai agresyvûs veiksmai,
nusikaltimai prieð kito asmens sveikatà bei gyvybæ daþniausiai buvo ávykdyti moterø, kurioms diagnozuotas
specifinis asmenybës sutrikimas – emociðkai nestabilaus
tipo asmenybës sutrikimas, impulsyvus variantas. Vaikø
nuþudymo atvejais vyravo moterys, ne tik turinèios
specifiniø asmenybës sutrikimø bei piktnaudþiaujanèios alkoholiu, narkotinëmis medþiagomis (45 proc.
visø atvejø). Pastebëta, kad visoms ðioms tiriamosioms
bûdingi tokie specifiniai asmenybës sutrikimo bruoþai
kaip egocentrizmas, demonstratyvumas, eksplozyvumas,
polinkis á stresines ir psichogenines situacijas reaguoti
nuotaikø svyravimais pagal disforiná tipà, bendra tokia
asmenybës savybë, kaip padidëjæs jautrumas. Tyrimo
metu gauti rezultatai rodo, kad depresinis sutrikimas
buvo diagnozuotas tik 10 procentø ávykdþiusiø ðio pobûdþio nusikaltimus moterø.
2006 m.
Taip pat tyrimo metu domëtasi moterø, ávykdþiusiø
impulsyvius agresyvius veiksmus, nusikaltimus, ne tik
asmenybës struktûra, bet ir ðiø moterø socialiniu statusu.
28 procentai tirtø moterø buvo bedarbës.
DISKUSIJA
Literatûros duomenimis, pastebëta, kad agresyviam
ir impulsyviam elgesiui pasireikðti taip pat labai svarbios
asmens savybës, vadinamos slopinanèiomis agresyvumà
savybëmis, bei faktoriai [4]. Jomis galima laikyti þmogaus
vertybiø sistemà, religinius ásitikinimus, teisiniø normø
supratimà. Taip pat slopinantiems impulsyvø agresyvø
elgesá veiksniams priklauso tokie faktoriai kaip bausmës
baimë, kaltës jausmas, empatija, priklausomybës poreikis, baimës jausmas; svarbûs gynybos mechanizmai,
suðvelninantys psichotraumuojantá streso poveiká bei
frustracijà. Alkoholis tarnauja savikontrolei, savikritikai
savo elgesiui sumaþinti arba dar tiksliau – agresijà slopinanèiø struktûrø poveikiui sumaþinti [4].
Emocinë átampa neleidþia tinkamai, adekvaèiai reaguoti, todël gali atsirasti ávairios motyvacijos pasitraukti
ið situacijos, suicidiniai veiksmai. Kai asmenybiniø gynybiniø mechanizmø iðsekimas sutampa su stresine ir
asmená psichotraumuojanèia situacija, tai irgi nulemia
agresyvø situacijos sprendimà [4]. Anot autoriø J.Gunn,
P.Taylor, lyginant su vyrais, moterø agresija daugiau yra
nukreipta á save, o ne á aplinkà, ir jei tarp vyrø daþnesnë yra instrumentinë agresija, tai tarp moterø vis dëlto
– verbalinë [4]. Minëtø autoriø nuomone, në viena nusikaltimø rûðis taip aiðkiai neiliustruoja asmens elgesio bei
lyèiø skirtumo kaip nuþudymai. Moterys þudo 10 kartø
reèiau nei vyrai (santykis 1:10) [4]. 1995 m. McCulloch
akcentavo, kad asmens elgesiui bei nusikaltimui ávykdyti
be psichopatologinio asmenybës charakterio didþiausià
reikðmæ turi 4 faktoriai: motyvacija, savikontrolë, supanèios aplinkos faktoriai bei psichopatologinis fenomenas.
Vadovaujantis ðiais faktoriais, elgesá bei nusikaltimus
galima iðskirti á motyvuotus ir situacinius [4]. Atliekami tyrimai leidþia manyti, kad pagrindiná vaidmená
agresyviuose moterø veiksmuose (kai tiriamosios nëra
psichozinëse bûklëse) vaidina agresijos mechanizmai
[4]. S.Safuanov nurodo, kad galima iðskirti 8 visuomenei
pavojingus agresijos tipus. Autorius akcentuoja agresijos
lygio svarbà bei aplinkos svarbà, kokia ji konkreèiam
asmeniui, frustruojanti ar neutrali. Jis iðskiria 4 agresijos
tipus, kurie pasireiðkia sàlyginai neutraliose situacijose ir 4 agresijos tipus, kurie pasireiðkia tam asmeniui
frustruojanèiose situacijose [4]. V.Melnik tyrimai rodo,
kad psichopatologinë simptomatika ypaè iðryðkëja,
paûmëja, kai prisideda organizme vykstantys endokri-
21
niniai pakitimai arba plius ima veikti tokie papildomi
egzogeniniai faktoriai kaip pakartotinës galvos smegenø traumos, alkoholizmas, stresiniai psichogeniniai
veiksniai [4,6]. Pastaruoju metu kalbama apie aplinkos
toká stresiná psichotraumuojantá poveiká, kai atsiranda
kumuliaciniai afektai [4]. Kumuliacinë genezë apriboja
galimybes ásisàmoninti ir reguliuoti savo veiksmus: turi
átakos sàmoningiems veiksmams bei elgesiui. Kai asmenybiniø gynybiniø mechanizmø iðsekimas sutampa
su stresine, asmená psichotraumuojanèia situacija, tai
ir nulemia afektiná agresyvø situacijos sprendimà [4,6].
Jei fiziologinis afektas yra pirmas ir vienintelis tiesioginis
reagavimas á frustracijà, avarinis sprendimo bûdas, grësmingoje asmeniui situacijoje, tai kumuliacinis afektas
– paskutinë iðeitis, likusi po visø kitø iðsekusiø subjekto
mëginimø iðsivaduoti ið psichikos traumos [4]. Socialinë–ekonominë átampa taip pat turi patologiná poveiká
sumaþinti atsparumà stresui [6]. Emocinis labilumas bei
eksplozyvios reagavimo formos sustiprëja nepalankiomis
mikrosocialinëmis sàlygomis [4].
IÐVADOS
1. Specifiniai asmenybës sutrikimai yra vyraujantys
psichikos sutrikimai, diagnozuojami moterims, ávykdþiusioms impulsyvius–agresyvius nusikalstamus veiksmus
prieð kito asmens sveikatà bei gyvybæ tiek neutraliose, tiek
subjektyviai asmená psichotraumuojanèiose situacijose.
2. Tyrimo metu gauti duomenys leidþia manyti,
jog esant analogiðkiems specifiniams asmenybës sutrikimams tiek neutralioje, tiek psichotraumuojanèioje
aplinkoje, moterø minëtas nusikalstamas impulsyvus ir
agresyvus elgesys pasireiðkia 20 procentø daþniau joms
subjektyviai psichotraumuojanèioje aplinkoje.
3. Tyrimø rezultatai leidþia daryti prielaidà, jog,
esant moterø specifiniams asmenybës sutrikimams ir
veikiant psichotraumuojantiems faktoriams, minëto
pobûdþio impulsyviø–agresyviø nusikalstamø veiksmø
padaugëja artimøjø þmoniø atþvilgiu. Ðio tyrimo metu
nustatyta, jog jø buvo 10 proc. daugiau ávykdyta psichotraumuojanèioje aplinkoje lygint su neutralia aplinka.
Literatûra
1.
Agresija ir smurtas – psichikos norma ir patologija. Vilnius,
2001, 31-188.
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Asnis G. M., Kaplan M. L., Hundorfean G. Violence and
homicidal behaviors in psychiatric disorders. Psychiatr. Clin. North.
Am., 1997, 20.
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Dembinskas A. Psichiatrija. Vilnius, 2003.
4.
Дмитриева Т. Б. Агрессия и психическое здоровье. Санкт–
Петербург, 2002.
5.
Haller R., Dittrich I., Kocsis E. How dangerous are patients
with mental didordes? Am.J.Psychiatry, 2004, 161.
22
6.
Кудрявцев И. А., Ратинова Н. А. Криминальная агрессия.
Москва, 2004, 102-150.
7.
Martinënas B. Eksperimento duomenø statistinë analizë.
Mokomoji knyga. Vilnius, 2004.
8.
Ðlekienë V. Statistiniai metodai moksliniame tyrime. Ðiauliø
universitetas, 2005.
INFLUENCE OF PSYCHOTRAUMATIZING (STRESS INDUCTING) SETTING ON THE IMPULSIVE AND AGGRESSIVE CRIMINAL
BEHAVIOR OF WOMEN
V.Kilikevièienë
Summary
Key words: a crime, psychtraumatizing setting, the impulsive and
aggressive criminal behavior, forensic psychiatric examination.
In this paper, the relation between the personality structure and
individual’s actions in some stressful situation is analyzed on the basis
of psychological studies of the aggression mechanisms triggered by
stress inducing setting. In the stressful conflict situation, the actions
of women are usually less or more situation-determined. Psychogenic
traumatizing factors determine appearance of the psychopathological
2006 m.
symptoms. The paper introduces the cases of women who committed
offence (body injury or homicide), focusing on short term and long term
stress situations before the crime committed by women; adaptation
disorder, which manifest in anxiety, tension, short term or prolonged
depression reaction before or after the crime; alcohol intoxication.
The paper verifies if all the women had had experienced psychotraumatic (stress inducing) situation before the committing crime. It gives
evidence that psychotraumatic factors (tension in the relationship,
conflicts in the family, unexpected pregnancy) are subjective, specific
in the individual cases and influence the perpetrator’s self control and
behavior. The stress factors may cause obvious neurotic, depression,
behavior and other mental disorders in the clinical representation. It is
the why women are not able to solve the conflict situations in positive
way. Among the women who had committed body injury or homicide,
prevail specific personality disorders. Dependencies are the second
factors (psychotic condition is not the subject of this paper).
Gauta 2006-01-25

COPING WITH STRESS IN WOMEN AND
MEN WITH ALCOHOL PROBLEM
IWONA JANICKA, GRAÝYNA PORAJ
Institute of Psychology, University of Lodz, Poland
Inevitability of stress has turned out to be an important reason for psychologists, theoreticians and
practitioners, to focus on search ways of coping with
it (Heszen-Niejodek, 2000, Lazarus, Walkman, 1984,
Selye, 1977). However, it is not an objective stress that
evokes trouble. The essence lies in a subjective stress,
that is a way of interpreting a particular event. Thus, what
is important is a person and his/her ways of functioning
in the surrounding reality. Some researchers claim that
there exist specific groups of personality traits which
define psychological susceptibility or immunity to stress.
There is evidence to state that individuals with unstable
self-image, fearful, underestimated, egocentric, with
low capability of self-realisation, perceive every stress
situation as their personal menace (Brzeziñska, Kofta,
1973; Matuszewski, 1976; Siek, 1986). Persons who
display traits of immature personality, are susceptible
to stress. They are characterised with lack of the sense
of security, low self-esteem, lack of the ability to enjoy
life, low insight, lack of realistic assessment of their own
behaviour, the sense of guilt, excessive operation of
defence mechanisms, pessimism, demanding too much,
lowering energy for activity (Blum, 1964; Horney, 1978;
Maslow, Mittelman, 1941; Murray, 1953).
Current interests of researchers concern first and
foremost ways of coping with stress. What decides about
stress results is not a stressing situation but the skill of
coping with it. The coping process means effective solving of different situations or demands that are perceived
by an individual as burdening too much or exceeding
one’s individual capabilities. Coping is considered as a
process, a strategy, and a style (Lazarus&Folkman, 1984).
Lendler and Parker, have described three major styles of
coping with stress. These comprise:
Focusing on a task encompasses undertaking efforts that serve solving a problem. An individual tries
to become aware of reasons of the tension, gathers
information on the stressor, analyses resources that are
accessible to him/her and may help coping with the
problem. A realistic assessment of stressors and resources
guarantees success.
Focusing on emotions means attending to oneself
2006 m.
Table 1. Styles of Coping with Stress in Alcohol Dependent
Women and the Healthy Ones.
and one’s own feelings. It serves lowering emotional
tension evoked by a stressor. To overcome an emotional
reaction, an individual may use different ways – positive,
as involvement in sport, work, relaxing, or negative, as
ignoring a problem or dissociating from it, for example,
with psychoactive drugs.
Avoidance is a fairly specific reaction to stress. It
is displayed in the aim at avoiding direct contact with
a stressor. In order not to think about stress and not to
experience negative emotions, an individual starts numerous substitute activities, in which he/she is deeply
engaged. An important role in this process of coping with
problems is played by defence mechanisms.
According to J. Mellibruda (2000), alcoholics have
very low self-esteem and they do not believe in effectiveness of their own activities, although they do not admit
it officially. They often live in stress, with a vision of an
inevitable failure. Thus, they have a very low level of
control over life situations, which allows for defining
them as persons who display immature personality traits.
It is assumed that long-lasting drinking leads to damages
in the emotional sphere of an individual (Johnson, 1992).
This phenomenon is referred to as the specific mechanism of psychic regulation. It is manifested, among other
things, as follows:
•
turning to drink in order to soothe unpleasant
emotional states,
•
strengthening the stress that evoked negative
emotions by negative consequences of drinking,
•
feeling physical pain which is soothed and
relieved with drinking,
•
cognitive deformations: temptation and hope for
positive feelings after drinking alcohol maintain illusions
of its effectiveness (Mellibruda, Sobolewska, 1999).
THE RESEARCH AIM
The aim of the research was to compare ways of coping with stress in persons with alcohol dependence and
those healthy ones. It has been assumed that improper
ways of coping may enhance alcohol dependence, and
at the same time, it is impossible to ignore the fact that
alcohol dependence restricts or even prevents proper
reactions to difficult situations, which applies to both
23
Table 2. Styles of Coping with Stress in Alcohol Dependent
Men and the Healthy Ones.
TASK – task strategies of coping with stress
EMOTIONS – emotional strategies of coping with stress
AVOIDANCE – avoidance strategies of coping with stress
M – mean
δ – standard deviation
women and men. It should be expected that women
would use emotional strategies more often, and men
would tend to use avoidance strategies of coping.
An assumption made that persons with alcohol
dependence would have lower sense of security than
the healthy ones. According to Maslow, fulfilment of
the security need determines proper development of an
individual (Uchnast, 1990), thus it should be expected to
determine also his/her proper behaviour in difficult situations. Deprivation of the sense of security determines
contrary behaviour. There is lack of acceptance, the sense
of being rejected, despised, hated, which evokes negative
attitude to the environment - distrust, dislike, and envy, or
even hostility to persons. Such a world perception may
lead to egocentric, individualistic behaviours (Uchnast,
1990), feeling lost in the world, and it may be related
to alcohol dependence.
METHOD AND PARTICIPANTS
Two questionnaire were used: the Coping in Stress
Situations Questionnaire (CISS) by Endler and Parker, in
the Polish adaptation by Wrzeúniewski (Szczepaniak,
Strelau, Wrzeúniewski, 1996) and the Sense of Security
by Uchnast (1990). Patients of an Alcohol Dependence
Clinic made the examination group (35 women and 35
men, mean age 41,7, 62% with primary and occupational education, 30% - with secondary education, and
only 8% - with higher education0. The control group (32
women and 32 men) was matched to the experimental
group with consideration to the age and education.
RESULTS OF THE RESEARCH
Coping with Stress in Alcohol Dependents
The sex of addicts does not differentiate their styles
of coping with stress, which is true for all the strategies (focusing on task, emotions, and avoidance).
Healthy women and men did not differ in task-oriented
and emotional styles of coping. Only the avoidance strategies of coping occur more often in women (M=45.25)
24
than in men (M=41,65), (p=.038) in the control group.
Most statistically significant difference was revealed
between the addicts and the healthy ones (table 1,2).
With regard to the task strategy of coping with stress,
alcohol dependent women and the healthy ones significantly differ (p= .002). Healthy women are characterised with a higher indicator of task-oriented reaction to
stress (M=56.03) than women with alcohol dependence
(M=47.6). Healthy women more often undertake activities aimed at task realisation, solving problems by means
of an attempt at changing a situation or by its cognitive
transformation. The remaining styles of coping – focusing
on emotions and avoidance – do not differentiate the
addicted women from the healthy ones. Still there are
tendencies to emotional strategies in alcohol addicted
women and tendencies to avoidance strategies of coping
in difficult situations in healthy women.
Styles of coping with stress are even more different
for alcohol dependent men and for the healthy ones.
The task strategies of coping appeared to occur significantly more often in healthy men (M=56.62) than in the
addicts (M=47.9), (p= .0001). This means that healthy
men are more oriented to solving problems by means
of an attempt to change a situation or to transform it
cognitively. The emotional (M=46.40) and avoidance
(M=44.48) strategies of coping turned out to be more
characteristic for alcohol dependent men than for
healthy ones (M=40.87 and M=41.65 respectively, p <
.05). In stress situations alcohol dependent men tend to
focus on themselves, their own feelings, emotions, and to
wishful thinking. Moreover, they avoid experiencing the
existing difficult situations by means of getting involved
in substitute situations and searching a company.
Sense of Security in with Alcohol Dependent Women
and Men
Sex did not differentiate the sense of security in
persons with alcohol dependence from that in healthy
persons. However, the sense of security in alcohol dependent women (M=42.11) and men (M=41.3) turned
Table 3. The Sense of Security in with Alcohol Dependent
Women and the Healthy Ones.
Table 4. The Sense of Security in Men Alcohol Dependence
and the Healthy Ones.
2006 m.
out to be significantly lower than the sense of security
in healthy women (M=50.84) and men (M=51.81), (p=
.001).
The Sense of Security and Coping with Stress in
Alcohol Dependent Persons and Pearson’s correlation
coefficients for the sense of security and styles of coping with stress in alcohol dependents as compared with
healthy persons are presented in tables 5 and 6.
It appears that a higher sense of security in alcohol
dependent women exerts an influence upon growth in
their task strategy of coping with stress. Alcohol dependent men reveal some correlation between the sense of
security and emotional strategies of coping. This correlation is of negative character, which means that growth in
the sense of security limits emotional, not very effective,
strategies of coping. A similar analysis was made in the
control group.
In healthy persons (both women and men) there exists a negative correlation between the sense of security
and the emotional strategy of coping. This means that
growth in the sense of security limits the emotion-oriented ways of coping. In the group of healthy persons,
there is no dependence between the sense of security
and the task-oriented and avoidance strategies of coping with stress.
CONCLUSIONS
1. In the group of alcohol dependents, there are
no significant differences between women and men
with regard to styles of coping with stress. In the control
group, only avoidance strategy is more characteristic for
women than for men (p= .038).
2. The task strategy of coping with stress is statistically significantly less expressed in alcohol dependent
women than in healthy ones (p= .002) and in alcohol
dependent men than in healthy ones (p= .0001).
3. The emotional and avoidance strategies of copTable 5. The Sense of Security in Women and Men
with Alcohol Dependence
and Their Styles of Coping
with Stress.
Table 6. The Sense of Security and Styles of Coping with
Stress in Healthy Women
and Men.
2006 m.
25
ing turned out to be more characteristic for alcohol dependent men than for the healthy ones (p< .05). In stress
situations alcohol dependent men have the tendency to
focusing on themselves, their feelings, emotions, and
to wishful thinking. They avoid experiencing the existing difficult situations by means of getting involved in
substitute situations or searching a company.
4. Alcohol dependent persons (both women and
men) are characterised with a significantly lower sense
of security, in comparison to the healthy (p= .001).
5. The growth in frequency of emotional strategies
of coping with stress exerts an influence upon lowering
of the sense of security, which applies to healthy persons
and to alcohol addicted men. In women with alcohol
dependence the sense of security correlates with the task
strategies of coping with stress. It should be expected
that with a higher sense of security there would be more
task-oriented strategies in women.
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Wyd. UŒ.
Gauta 2006-01-26

26
2006 m.
SLAUGYTOJØ PATIRIAMAS SMURTAS IR JO VERTINIMAS
M.SKVARÈEVSKAJA, A.RAZBADAUSKAS
Respublikinë Vilniaus psichiatrijos ligoninë, Klaipëdos universitetas
Raktaþodþiai: slaugytoja, smurtas, emocinis smurtas,
fizinis smurtas, stresas.
Santrauka
Straipsnyje apþvelgiama slaugytojø patiriamo
emocinio bei fizinio smurto problema Lietuvoje
ir kitose ðalyse. Siekiama ávertinti smurto rizikà
dirbant su pacientais, serganèiais priklausomybës
ligomis, bei patirto smurto pasekmes. Atliktas kiekybinis tyrimas panaudojant anoniminæ anketinæ
apklausà ir pateikti tyrimo rezultatai.
Tyrime dalyvavo 98 ávairaus amþiaus slaugytojos,
dirbanèios su priklausomybës ligomis serganèiais
pacientais.
Tyrimo rezultatai parodë, kad slaugytojos, dirbanèios su priklausomybës ligomis serganèiais
pacientais, daþniau patiria emociná (96,94%) nei
fiziná (35,71%) smurtà.
57,14% slaugytojos pirmà kartà patyrë smurtà bûdamos 20-25 m. amþiaus, net 46,39% slaugytojø
pirmà kartà patyrë smurtà pirmais darbo metais,
bûdamos 20-25 m. amþiaus (p<0,005).
Emocinio smurto daþniausiai patiriama iðraiðka
– þodinë agresija – 80,61%, 47,96 % – áþeidinëjimai, 44,90% – þeminimas. Slaugytojø reakcija
á emociná smurtà yra stresas, kuris pasireiðkia:
vegetacine simptomatika, baime, bejëgiðkumu,
pykèiu, aðaromis.
Ið patyrusiø fiziná smurtà 28,57% slaugytojø já patytë bent 1 kartà. Fizinis smurtas visada lydimas
emocinio smurto. Patyrus fiziná smurtà lieka:
nuotaikos svyravimai, miego sutrikimai, baimë,
hipertenzija.
Dauguma slaugytojø patiria stresà darbo vietose.
Dël ilgalaikio ir stipraus streso gali atsirasti somatinë patologija.
ÁVADAS
Agresija ir smurtas prieð slaugytojà didëja visame
pasaulyje. Daugiausia smurto atvejø pasitaiko specializuotuose ir psichiatrijos skyriuose [9]. Slaugytojos
rizikuoja keturis kartus daugiau tapti smurto aukomis
negu kiti sveikatos apsaugos darbuotojai [15].
Smurto paplitimas prieð slaugytojà analogiðkai ryðkë-
ja ir Lietuvoje. Pavojus kyla dirbant greitosios pagalbos
sferoje, ligoninëse, pradedant nuo priëmimo skyriaus.
Net operacinëje slaugytojos nëra saugios [2,3,10].
Smurtas sveikatos apsaugos sistemoje tampa vis
daþnesniu reiðkiniu pasaulyje ir yra tarptautinë problema, taèiau trûksta tarpkultûriniø smurto prieð slaugytojas tyrimø. Tokie tyrimai leistø sukurti priemones,
padedanèias sumaþinti problemos mastà, nes smurto
ignoravimas sukelia daugybæ nepageidaujamø reiðkiniø
– tai ir slaugytojø ligos, slaugytojø trûkumas, slaugos paslaugø nepakankamas prieinamumas, slaugos kokybës
blogëjimas.
Apie slaugytojø patiriamà smurtà Lietuvoje nëra statistikos, smurto prieþasèiø analizës, nëra reabilitacijos
bei prevencijos programø. Atrodytø, kad nëra net paèios
problemos.
Remiantis duomenimis apie slaugytojø patiriamà
smurtà ir jo pasekmes kitose pasaulio ðalyse, atliktas
slaugytojø tyrimas.
Darbo objektas – smurtas prieð slaugytojà darbo
vietoje.
Darbo tikslas – ávertinti priklausomybës ligomis serganèiøjø smurto prieð slaugytojà problemà.
TYRIMO METODIKA IR KONTINGENTAS
Atliktas kiekybinis tyrimas. Tyrimo metodas – apklausa. Apklausos rûðis – anketinë anoniminë apklausa.
Anketos buvo pateiktos 100 respondentø, taèiau
tyrime dalyvavo 98 respondentai.
Statistinë duomenø analizë (pateikti absoliutûs ir procentiniai daþniai) atlikta naudojant statistinës analizës
SPSS programiná paketà.
TYRIMO REZULTATAI
Tiriamøjø amþius: nuo 20 metø iki daugiau nei 60
metø (p<0,001) – 1 pav.
Slaugytojos dirba ávairiuose skyriuose: 51 (52,04%)
psichiatrijos skyriuose, 15 (15,31%) priklausomybiø
skyriuose, 12 (12,24%) reanimacijos ir intensyviosios
terapijos skyriuose, 11 (11,22%) priëmimo skyriuose, 9
(9,18%) traumatologijos skyriuose.
Slaugytojø darbo staþas su serganèiais priklausomybës ligomis ávairus (p>0,14140) – 2 pav.
Tiriant, kada slaugytojos pirmà kartà patyrë emociná
2006 m.
27
1 pav. Tiriamøjø amþius: 1. 20-25 m. amþius. 2. 26-30 m.
amþius. 3. 31-40 m. amþius. 4. 41-50 m. amþius. 5. 51-60 m.
amþius. 6. Daugiau nei 60 metø.
3 pav. Vertikaliai iðdëstytas slaugytojø, pirmà kartà patyrusiø
smurtà, amþius: 1. 20-25 m. 2. 26-30 m. 3. 31-40 m. 4. 41-50
m. 5. 51-60 m. 6. Daugiau kaip 60 metø. 7. Neatsimena.
Horizontaliai – kokiu laikotarpiu patyrë emociná smurtà, atitinkamai: 1. Pirmais darbo metais. 2. Nuo 1 iki 5 m. 3. Nuo
6 iki 10 m. 4. Daugiau kaip 10 metø.
2 pav. Slaugytojø darbo skyriuose staþas: 1. 1-5 metø. 2. 610 metø. 3. 11-20 metø, 4. 21-30 metø. 5. Daugiau kaip 30
metø.
smurtà, gauti rezultatai (p<0,001): 68 (70,10%) slaugytojos emociná smurtà patyrë pirmais darbo metais, 14
(14,43%) slaugytojø patyrë emociná smurtà per pirmuosius 5 darbo metus, 6 (6,19%) slaugytojos patyrë emociná
smurtà 6-10 metø darbo, 9 (9,28%) slaugytojos emociná
smurtà patyrë atidirbusios daugiau nei 10 metø.
Duomenø, kokio amþiaus buvo slaugytojos, patyrusios emociná smurtà pirmà kartà, ir kokiu laikotarpiu,
ryðá atspindi 3 pav.
Kaip matome, net 45 (46,39%) (p<0,005) slaugytojos
patyrë emociná smurtà per pirmuosius darbo metus 2125 metø amþiaus.
Á klausimà, kokia emocinio smurto forma buvo panaudota prieð slaugytojà, respondentës pateikia po keletà
atsakymø. Tyrimo rezultatai rodo, kad daþniausiai – 52
(53,06%) slaugytojos – patyrë áþeidinëjimà, 35 (35,71%)
slaugytojos buvo þeminamos, 32 (32,65%) slaugytojos
patyrë priekabiavimà, po 24 (24,49%) slaugytojas patyrë
tyèiojimàsi ir verbalinæ agresijà, 14 (14,29%) slaugytojø
patyrë fizinæ prievartà, 6 (6,12%) slaugytojos patyrë
seksualinæ prievartà ir 2 (2,04%) slaugytojos patyrë
izoliacijà.
Þinoma, ne visi vienodai reaguoja á emociná smurtà.
Panaudoto emocinio smurto ir respondenèiø reakcija
atsispindi 4 pav.
Nagrinëjant atskiras reakcijas á emociná smurtà gauti
tokie rezultatai: realus mirties ar fizinio suþalojimo pavojus – 19 (19,39%) (p<0,001), beviltiðkumo pojûtis –19
(19,39%) (p<0,001), baimë – 32 (32,65%) (p>0,0006),
pasipiktinimas – 49 (50%) (p>1,0000 – rezultatas nepatikimas), vegetacinë simptomatika atsirado pas 30
(30,61%) slaugytojø (p<0,001).
Po kiekvienos stresinës reakcijos iðlieka reiðkiniai,
apie kuriuos slaugytojos atsakë po kelis variantus. Visø
atsakymø patikimumas p<0,0001, ir duomenys tokie:
nieko neliko – 28 (28,57%), miego sutrikimai – 18
(18,37%), baimë –18 (18,37%), depresija –3 (3,06%),
apetito sutrikimas – 2 (2,04%), bloga nuotaika – 46
(46,94%) slaugytojos, bet ðiuo atveju p<0,5445, somatiniai negalavimai – 11 (11,22%). Apklausos duomenimis,
70 slaugytojø liko vieni ar kiti liekamieji reiðkiniai.
Jei yra rizika patirti fiziná ir emociná smurtà, tai
patiriant fiziná smurtà visada bus ir emocinis smurtas.
Respondentës buvo paklaustos, kokià smurto formà rizikuoja patirti kasdieniniame darbe daþniausiai. Gauti ðie
rezultatai: 35 (35,71%) slaugytojos rizikuoja patirti fiziná
smurtà (p>0,0047), 95 (96,94%) slaugytojos rizikuoja
patirti emociná smurtà (p<0,0001).
22 (22,45%) slaugytojos teigë, kad nëra patyrusios
fizinio smurto, 76 respondentës patyrë fiziná smurtà bent
kartà, o 48 respondentës patyrë fiziná smurtà 2 kartus
ir daugiau.
Patyrusios fiziná smurtà slaugytojos jauèia jo liekamuosius reiðkinius (p<0,0001): 3 (3,06%) slaugytojos turi
likusá randà, 3 (3,06%) – teigia, kad jauèia depresijà, 16
(16,33%) – turi baimës jausmà, 22 (22,45%) – kenèia
28
2006 m.
slaugytojos teigia, kad skrandþio
opa atsirado streso pasekmëje, o 7
(7,14%) skrandþio prievarèio spazmai ir 7 (7,14%) pykinimas atsirado
dël stresinës situacijos.
APIBENDRINIMAS
Fizinio ir emocinio smurto prieð
psichikos sveikatos slaugytojas paplitimà ir pasekmes nagrinëja daugelio
ðaliø mokslininkai. Tyrimo metu gauti
rezultatai daug kuo panaðûs á rezultatus, gautus tiriant ðià problemà kitose
pasaulio ðalyse.
Kuveite atliktas tyrimas smurto
4 pav. Panaudotas smurtas ir reakcija á já.
paplitimo ir jo efekto prieð psichikos sveikatos slaugytojas rodo, kad
70 ið 81 slaugytojø patyrë verbaliná
áþeidinëjimà, verbalinæ agresijà, bauginimà ir 13 nukentëjo fiziðkai. 67 ið
70 slaugytojø – po patirto vieno ar
daugiau smurto atvejø – paþymi nemigà, baimæ, depresijà arba laikinà
nedarbingumà [6].
Naujojoje Zelandijoje atliktas
slaugytojø tyrimas, kurio tikslas ávertinti smurto rizikà prieð slaugytojà pirmais darbo metais. Tyrime dalyvavo
551 respondentas. Daþniausiai (192)
slaugytojos patiria þodinæ agresijà,
5 pav. Liekamieji reiðkiniai po patirto smurto ir somatinë patologija.
167 slaugytojos ávardija verbaliná
seksualiná áþeidinëjimà, priekabiavinuo miego sutrikimo, 44 (44,90%) (p<0,3124) – jauèia mà ir 161 slaugytoja ávardija fiziná bauginimà. Tyrimo
nuotaikos svyravimà, 11 (11,22%) (p<0,0001) – nurodo iðvadose nurodoma, kad slaugytojos pirmais darbo
metais rizikuoja patirti smurtà [13].
hipertenzijà kaip fizinio smurto pasekmæ.
Didþiojoje Britanijoje atliktas palyginamasis pacientø
Patyrusios fiziná smurtà slaugytojos iðgyvena stiprià
stresinæ reakcijà, po kurios: 53 (54,08%) slaugytojos agresijos bendro tipo ligoninëje ir psichikos sveikatos
labai jautriai reaguoja á maþiausius stresus, 19 (19,39%) sferoje darbas. Psichikos sveikatos aplinkoje daugiau ag– ilgai trunka pykèio priepuoliai, 21 (21,43%) liko ne- resijos, ypaè agresyvûs pacientai, kurie vartoja alkoholá,
rimas, 14 (14,29%) – baimë, 1 (1,02%) – neadekvatus linkæ á verbaliná grasinimà. Tyrimo duomenimis, 60% visø
incidentø teko psichikos sveikatos slaugytojoms [8].
elgesys.
Atliktas palyginamasis Anglijos ir Ðvedijos slaugytojø
Tiriant stiprios stresinës situacijos po patirto smurto
liekamøjø reiðkiniø poveiká somatinei patologijai gauti patiriamo smurto tyrimas. Tyrime dalyvavo 296 Anglijos
slaugytojos ir 720 Ðvedijos slaugytojø. 61% Anglijos ir
ryðio statistiniai duomenys pateikiami 5 pav.
Dominuojanti patologija respondenèiø ávardinta 30% Ðvedijos slaugytojø buvo iki 40 metø amþiaus. 71%
kaip stresinës situacijos pasekmë – galvos skausmai 55 Anglijos slaugytojø ir 59% Ðvedijos slaugytojø teigë,
(56,12%) (p> 0,2254). 15 (15,31%) (p < 0,0001) – streso kad patyrë smurtà tiriamuoju laikotarpiu. 60% Anglijos
pasekmëje atsirado tachikardija, 10 (10,20%) (p<0,0001) ir Ðvedijos slaugytojø teigë, kad smurtà patiria kartais,
– nervinës kilmës odos ligos, 11 (11,22%) – stenokardija, o 27% Anglijos ir tik 10% Ðvedijos slaugytojø – labai
9 (9,18%) – aritmijos, 9 (9,18%) – gastritas. 7 (7,14%) daþnai [14].
2006 m.
Turkijoje pagal atliktà tyrimà 75% apklaustøjø patyrë seksualiná priekabiavimà dar praktikos metu [11].
Vëliau to paties autoriaus dviejose gydymo ástaigose
atliktas tyrimas parodë, kad 127 ið 251 respondenèiø
patvirtino, jog buvo seksualinio priekabiavimo objektais
darbo vietose. Autorius pabrëþia, kad tai besivystanèiø
ðaliø problema ir jos negalima ignoruoti [12].
Dar vienas Turkijoje atliktas tyrimas leidþia teigti, kad
dauguma slaugytojø (405 ið 467) yra patyrusios þodinæ
agresijà. 92% slaugytojø teigia, kad þodinë agresija
neigiamai veikia jø moralæ [17].
Emocinis smurtas nëra taip akivaizdþiai pastebimas
kaip fizinis. Taèiau jis paþeidþia psichologinæ þmogaus
gerovæ. Po patirto streso slaugytojos kenèia nuo tipiniø
simptomø: susirûpinimo ir silpnumo, prisiminimø, kurie
daugkart stipresni [1]. Emocinë prievarta kenkia savæs
suvokimui ir savigarbai. Taip þmogus praranda pasitikëjimà savimi, jauèiasi nesvarbus, menkas ir nevertingas
[9]. Smurto pasekmës turi negatyvø poveiká slaugytojø
darbui [14]. Slaugytojos patiria kanèià ir net mirðta darbo
vietoje dël smurto [4,5].
Sveikatos ir saugos tarnyba Didþiojoje Britanijoje
identifikavo slaugà kaip labiausiai pavojingà profesijà.
Smurto pavojus sveikatos apsaugoje gal niekada nebus
likviduotas visiðkai, bet yra dalykø, su kuriais galima
susidoroti, tai galimybë sumaþinti problemà [10].
Iðnagrinëjus mokslinæ literatûrà, smurto prieð slaugytojà problemos analizës ir atlikto tyrimo rezultatai
atspindi tos paèios problemos aspektus.
Tyrime dalyvavo 98 slaugytojos (ið 100), kuriø
amþius nuo 20 iki 66 metø. Didesnë grupë slaugytojø
buvo 41-50 m. amþiaus. Respondentës dirba ávairiuose
skyriuose, bet dauguma – psichiatrijos ir priklausomybës
ligø skyriuose.
Ádomu pastebëti, kad á klausimà, kada slaugytojos
pirmà kartà patyrë emociná smurtà, absoliuti dauguma
– 68 slaugytojos – atsakë, jog pirmais darbo metais, ir
tik 14 slaugytojø – dirbant 1-5 metus.
Atlikus statistinæ duomenø apie slaugytojø amþiø,
kai pirmà kartà buvo patirtas emocinis smurtas, ir darbo
patirties laikotarpá analizæ, gauti rezultatai rodo, kad
dauguma (net 45 slaugytojos) patyrë emociná smurtà
pirmais darbo metais ir bûdamos 20-25 metø amþiaus.
Iðtyrus, kokia smurto iðraiðka tuo metu buvo panaudota ir kokios buvo reakcijos bei remiantis statistiniais
duomenimis, galime ðiuo klausimu daryti kai kuriuos
apibendrinimus. Pacientai, sergantys priklausomybës
ligomis, daþniau áþeidinëjo, priekabiavo, þemino slaugytojas, tyèiojosi bei naudojo verbalinæ agresijà. Slaugytojø reakcija á kiekvienà smurto formà skirtinga. Tai
29
buvo ir pasipiktinimas, ir baimës jausmas, ir atsiradusi
vegetacinë simptomatika. O esant verbalinei agresijai
atsiranda ne tik pasipiktinimas, bet ir iðkyla realus mirties ar fizinio suþalojimo pavojus. Patyrusios seksualinæ
prievartà, slaugytojos patyrë beviltiðkumo pojûtá, baimæ.
Daugumai (46) slaugytojø po iðgyventos stresinës situacijos liko bloga nuotaika, kitoms miego sutrikimai, baimë.
Ádomu pastebëti, kad net 28 slaugytojoms neliko jokiø
liekamøjø reiðkiniø. Á uþduotà klausimà, kokià smurto
formà slaugytojos rizikuoja patirti kasdieniniame darbe,
absoliuti dauguma nurodo emociná smurtà.
Daþniausia slaugytojø reakcija yra stresas, kuris pasireiðkia vegetacine simptomatika, bejëgiðkumu, baime,
pykèiu, aðaromis. Ir tik 6 slaugytojos nejauèia jokios
reakcijos.
Po patirto fizinio smurto dauguma slaugytojø jauèia
nuotaikos svyravimà, kitos kenèia dël miego sutrikimø,
baimës jausmo, hipertenzijos, depresijos, o 3 slaugytojos
turi likusá randà.
Patyrusios fiziná smurtà, slaugytojos iðgyvena stiprià
stresinæ reakcijà, po kurios liko ávairiø reiðkiniø. Dauguma
(53) slaugytojø teigia, kad labai jautriai reaguoja á maþiausius stresus, kitoms ilgai trunka pykèio priepuoliai, liko
nerimas, baimë, o vienai atsirado neadekvatus elgesys.
Tuo tarpu darant streso sukeltos somatinës patologijos analizæ, dominuojanti patologija – galvos skausmai
(55). Joms atsirasti reikðmës turi labai jautri reakcija á
maþiausius stresus, nerimas, ilgai trunkantys pykèio
priepuoliai, baimë.
Slaugytojø patiriamo smurto pasekmës turi vien
negatyvius poveikius jø gyvenimo kokybei bei darbo
efektyvumui.
Kadangi slaugytojos savo darbo vietose visada rizikuoja susidurti su smurtu, tai Britø slaugos þurnalo
redaktorës Helen Scott nuomone, bûtent slaugytojoms
turi bûti teikiama pirmenybë ruoðiant smurto pasekmiø
likvidavimo programas [15].
Apþvelgtos literatûros ir tyrimo rezultatø apibendrinimas rodo, kad smurto prieð slaugytojà problema
egzistuoja ir yra nagrinëjama, bet dar nepakankamai.
Jos gilesnis iðtyrimas leistø daryti svaresnius apibendrinimus.
IÐVADOS
1. Darbo vietose slaugytojos patiria emociná bei fiziná smurtà. 35,71% slaugytojø rizikuoja
patirti fiziná smurtà (p>0,0047), 96,94% slaugytojø rizikuoja patirti emociná smurtà (p<0,0001).
2. 57,14% slaugytojø pirmà kartà patyrë smurtà
bûdamos 20-25 m. amþiaus (p<0,0001).
30
3. 46,39% slaugytojø pirmà kartà patyrë smurtà
pirmais darbo metais, bûdamos 20-25 m. amþiaus
(p<0,005).
4. Emocinio smurto daþniausiai patiriama iðraiðka
– þodinë agresija – 80,61%, 47,96% – áþeidinëjimai,
44,90% – þeminimas, 27,55% – tyèiojimasis, 19,39%
– priekabiavimas ir 2,04% – izoliacija. Slaugytojø
reakcija á emociná smurtà daþniausiai yra stresas, kuris
pasireiðkia: 23,47% – vegetacine simptomatika, 20,41%
– baime, 28,57% – bejëgiðkumu, 31,63% – pykèiu,
14,29% – aðaromis.
5. Patyrusios fiziná smurtà, slaugytojos jauèia jo liekamuosius reiðkinius (p<0,0001): 3,06% – likusá randà,
3,06% – depresijà, 16,33% – baimæ, 22,45% – miego
sutrikimus, 44,90% (p<0,3124) – nuotaikos svyravimus,
11,22% (p<0,0001) – hipertenzijà, kaip fizinio smurto
pasekmæ.
Literatûra
1.
Baldwin Pamela. 1999. Nursing. Stress in Health Professionals, p.93-102. Curtin University of Technology, Western, Australia.
2.
Agresyvus elgesys ligoninëje. Gydymo menas, 2000, Nr.
10.
3.
Ligoniniø medikai – bejëgiai prieð pacientø agresijà. Lietuvos medicinos kronika, 2000, Nr.3.
4.
Anderson DG., 2004. Workplace violence in long haul
trucking: occupational health nursing update. AAOHN Journal 52 (1):
23-7. University of Kentucky, USA.
5.
Archer-Gift C, 2003, Violence towards the caregiver. A
growing crisis for professional nursing. Mich Nurse, 76 (1), 11-12.
6.
Atawneh FA, Zahid MA, Al-Sahlawi KS, Shahid AA, Al-Farrah MH. 2003. Violence against nurses in hospitals: prevalence and
effects. Journal Nursing 12 (2) 102-107, Mubarek-al Kabeer Hospital,
Kuwait.
7.
Brennan W. 2000. We don‘t have to take this: dealing with
violence at work. Journal Nurs Stand 14, 3-17.
8.
Duxbury J. 1999. An exploratory account of registered
nurses’ experience of patient aggression in both mental health and
general nursing settings. Journal of Psychiatric and Mental Health
Nursing 6, 107-114.
9.
Gates D.M. 2004.The epidemic of violence against healthcare workers. Journal Occupational and Environmental Medicine 61,
649-650.
10. Jones J., Lyneham J. 2000. Violence: part og the job for
Australian nurses? Aust. Journal Adv Nurs. 18(2): 27-32.University of
South Australia, Adelaide.
11. Kisa A., Dziegielewski SF. 1996. Sexual harassment of
female nurses in a hospital in Turkey. Health Serv Manage Res 9(4):
243-53.
2006 m.
12. Kisa A., Dziegielewski SF., Ates M. 2002. Sexual harassment
and its consequences: a study within Turkish hospitals. Journal Health
Soc Policy 15(1): 77-94. Baskent University, Turkey.
13. McKenna BG, Poole SJ, Smith NA, Coverdale JH, Gale CK.
2003, March. A survey of threats and violent behavior by patients
against registered nurses in their first year of practice. Mental Health
Nurs. 12(1), 56-63, New Zeland.
14. Nolan P, Soares J, Dallender J, Thomsen S, Arnetz B. 2001.
A comparative study of the experiences of violence of English and
Swedish mental health nurses. Pergamon. International Journal of
Nursing Studies 38, 419-426, Sweden.
15. Scott H. 2003. Violence against nurses and NHS staff is on
the increase. British Journal of Nursing, 12(7), 396.
16. Uzun O., 2003. Perceptions and experiences of nurses in
Turkey about verbal abuse in clinical settings. Journal Nurs Scholarsh
35(1): 81-5. Ataturk University School of Nursing.
VIOLENCE OF ADDICTED PATIENTS AGAINST NURSES
M.Skvarèevskaja, A.Razbadauskas
Summary
Key words: nurse, violence, forms of violence, stress.
The problem of violence against nurses in Lithuania and some
other countries is reviewed in this paper. The risk of violence working with addicted patients and the outcome of experienced stress are
evaluated. The results of study using anonymous questionnaire testing
are presented.
98 nurses of different age working with addicted patients took
part in the study.
The results of the study have shown that the nurse working with
addicted persons have experienced emotional violence more frequently (96,94% of respondents), then physical aggression (35,7%).
The emotional violence usually is experienced during the first year of
work (70,1%) and at the age of 20-25 years (46,4%).
The most frequent forms of violence were: verbal insults (53%),
intimidation (35,7%), verbal sexual harassment (32,65%). The reaction of nurses to violence was stress, which manifested itself as
autonomic nervous system distress, reactions of fear, anger, feeling
of helplessness.
28,57% of nurses have experienced physical violence at least
one time. Physical violence is always accompanied by emotional
violence. After the epizodes of physical violence against them the
nurses had disturbances of sleep and mood, their blood pressure
tended to be elevated.
The greater part of respondents (80,6%) more markedly reacted to
verbal aggression. The results of the study have shown, that prolonged
and severe stress can also result in somatic pathology.
Gauta 2005-11-29

2006 m.
31
SEKSUALINËS PRIEVARTOS SUKELTA TRAUMA,
PSICHOPATOLOGIJOS IÐSIVYSTYMAS
P.RUDALEVIÈIENË
Vilniaus miesto psichikos sveikatos centras
Raktaþodþiai: seksualinë prievarta, psichopatologija,
psichiatras, pagalba, epidemiologiniai rodikliai.
Santrauka
Dël seksualinës prievartos vaikystëje sukeltos
traumos iðsivysto psichopatologija, kuri trunka
visà gyvenimà. Pagalbos tokiai bûsenai organizavimui reikalinga teisinës bei socialinës sistemos
intervencija. Psichiatrinis, psichoterapinis gydymas bûtinas uþsitæsusiai ir toliau besivystanèiai
psichopatologijai jau suaugusiojo amþiaus laikotarpiu kupiruoti. Pateikiami kai kurie epidemiologiniai rodikliai kasdienio klinikinio darbo metu
iðaiðkinus seksualinës prievartos atvejus.
ÁVADAS
Mokslinës literatûros duomenys nurodo, kad asmenys, vaikystëje patyræ seksualinæ prievartà, streso
bûsenoje gyvena visà savo gyvenimà, iki pat mirties.
Jie sudaro potencialià suicidø ir homicidø rizikos grupæ
[1].
Seksualinës prievartos prieð vaikus paplitimo apskaièiavimai svyruoja tarp 5–30 proc. gyventojø skaièiaus
(Didþiojoje Britanijoje). Didesni rodikliai nustatomi
tuose bendruomenës sluoksniuose, kurie kreipësi á psichiatrà pagalbos.
Seksualine prievarta yra apibrëþiama seksualinë patirtis, apimanti fiziná kontaktà, kuris ávyko prieð vaiko
valià. Seksualinë prievarta gali bûti panaudojama tiek
prieð berniukus, tiek prieð mergaites. Beveik ketvirtadalis
aukø yra jaunesni negu penkeriø metø vaikai [2].
Teisinës, socialinës ir psichiatrinës tarnybø bendras
darbas
Ávairios profesionalø grupës, tokios kaip policija,
civiliniai ir baudþiamieji teismai, vaikø rûpybos ástaigos
ir psichinës sveikatos profesionalai bei plaèioji visuomenë supranta, kad seksualinë prievarta prieð vaikus
yra problema. Sunkumas, iðkylantis profesionalams, yra
kompetencijos suvokimas, kuriai sistemai bei kuriuo
momentu priklauso rûpintis problemos sprendimu.
Tikslinga atskirti teisinius ir socialinius aspektus nuo
psichologiniø [3].
Socialinë ir teisinë bûtinybë dirbti su seksualinæ prievartà patyrusiais vaikais kyla dël vieningos nuomonës,
kad seksualinis vaikø iðnaudojimas yra moraliðkai neteisingas ir kad vaikai turi „teises“, ið kuriø viena yra nepatirti blogo seksualinio elgesio su jais. Bendras noras yra
uþtikrinti paþeidþiamø þmoniø, tarp jø vaikø, saugumà.
Taip pat turëtø bûti aiðku, kad ðá kodà paþeidþiantiems
asmenims, naudojantiems prievartà prieð vaikus, reikalinga socialinë kontrolë, taip pristatant baudþiamuosius
problemos aspektus. Taigi keletas skirtingø profesionalø
ir socialiniø sistemø kartu su psichologinës bei psichiatrinës pagalbos komandomis yra átrauktos á „darbà“ su
seksualine prievarta [4].
Psichologinës bei psichiatrinës komandos ásitraukia
á darbà, spræsdamos seksualinës prievartos poveiká
vystymuisi ir psichikai visam gyvenimui. Ðiuo metu yra
nenuginèijamø árodymø, patvirtintø klinikiniais stebëjimais, kad daug simptomø, susijusiø su vaiko seksualine
prievarta, atsiranda tiek vaikystëje, tiek vëlesniame suaugusio þmogaus gyvenime.
Taèiau taip pat yra aiðku, kad seksualinës prievartos
padariniai yra neatskiriamai susijæ su dviem kitais svarbiais aspektais, kuriø daþniausiai neámanoma atskirti nuo
paèios seksualinës traumos. Egzistuoja situacija, kurios
metu vyksta seksualinë prievarta ir tolimesni gyvenimo
ávykiai [5].
Kiti iðoriniai veiksniai, sàlygojantys psichopatologijos vystymàsi
Situacijos veiksniai, turintys átakos poveikiui, apima
ðeimos disharmonijos laipsná, bet kokias kitas ar neprieþiûros formas bei palaikanèio tëvo ar globëjo dalyvavimà blogo elgimosi su vaiku metu. Toliau labai svarbûs
ávykiai yra paties vaiko prisitaikymas bei metodai, padedantys susitvarkyti su prievarta, paskesnës netektys,
tokios kaip mirtis, ðeimos iðirimas ar patekimas globon,
taip pat gerëjantys santykiai mokykloje ar pozityvûs
socialiniai santykiai. Patyrus seksualinæ prievartà neiðskiriamas jos poveikis vaikystëje ar jau tapus suaugusiu.
Yra ávairiø nuomoniø apie psichiatrinës simptomatikos
debiutà po seksualinës prievartos. Neaiðku, ar pradþioje
nepasireiðkus simptomams, ðiems vaikams jie neatsiras vëliau, taèiau daugëja poþymiø, kad bent kai kurie
32
vaikai, kuriems nepasireiðkia simptomai, jie pasireiðkia
vëlesniais metais arba net jam tapus suaugusiu [6].
Tolimesniø stebëjimø bei moksliniø tyrimø reikalauja ir
klausimas, ar ankstyvas ásikiðimas vaikystëje apsaugos
nuo ðiø „mieganèiø pasekmiø“, atsirasianèiø vëliau.
Nëra në vieno veiksnio, teorijos ar paprasèiausio
modelio, kuris paaiðkintø vaikø prievartos, áskaitant
seksualinæ prievartà, atvejus ar pasekmes. Taèiau vyrauja
bendras sutarimas, kad modeliai, kuriuose yra keli skirtingi veiksniai, darantys átakà blogo elgesio atsiradimui
ir poreikiui, galëtø bûti tinkamiausi – tokiu principu yra
organizuojama seksualinës prievartos tarnyba Didþiojoje
Britanijoje (Nacionalinë tyrimø taryba, 1993). Ðiame sutarime iðkyla dvi temos. Pirmoji – tai paaiðkinanèiø modeliø bûtinybë átraukti skirtingus socialinio sudëtingumo
lygius, susijusius su poveikiu, pasekme, prieþastimi.
Antroji tema – tai pagrindinë vystymosi veiksniø
svarba. Ðis poþiûris pabrëþia faktà, kad gyvenimo eigoje
vaikas tampa vis labiau organizuota ir sudëtinga asmenybe. Taip pat suvokiama keleto skirtingø vaiko vystymosi
lygiø átaka, nuo genetinës iki fizinës ir psichologinës
átakos, taip pat ðeimos, kaimynø bei kultûrinës átakos.
Adaptacija – tai pagrindinis vystymosi teorijos principas,
kai vaikas iðlaiko biologiniø funkcijø integralumà. Kitas
labai svarbus principas – tai, kad kai tik asmuo pasiekia
meistriðkumà vienoje srityje, paruoðiamas tolimesnis
kelias progresui tiek toje srityje, tiek kitose vystymosi
srityse. Taigi patologinis vystymasis suprantamas kaip
integracijos stoka, privedanti prie þlugimo, nutraukianèio
vystymosi procesà. Tolimesnis poveikis vaikui gali bûti
tiek gerinantis, tiek ir toliau veikiantis ankstyvà padarytà
þalà [7].
Mokslinës literatûros duomenys nurodo, kad ypaè
svarbi yra motiniðka parama, ir ji nuosekliai siejama
su pasekmëmis: vaikai, jauèiantys didesnæ motiniðkà
paramà, pasiekia geresniø rezultatø, negu tie vaikai,
kurie jos nejauèia.
Nemaþai ásiterpianèiø veiksniø turi átakos nukentëjusio psichinës bûklës dinamikos pasekmëms. Jiems
galima priskirti: 1) individualø vaiko bûdà susidoroti su
problema; 2) vaiko prisitaikymà prie blogo elgesio, kurá
jis patyrë; 3) tëvø ir ðeimos paramà; 4) sistemos poveiká
(pvz., teismø poveikis); 5) profesionalø intervencijos
átakà. Visi ðie faktoriai daro átakà vaikui, taigi juos gali1 lentelë. Seksualinës prievartos iðsiaiðkinimo bûdai.
2006 m.
ma laikyti potencialiai kompensuojamaisiais, arba – ið
kitos pusës, turi potencialà pabloginti pasekmes vaikui.
Pati pasekmë gali bûti svarstoma pagal vaiko elgesá ir
emocijas, màstymo bûdà arba jo asmenybæ ir santykius
su kitais reikðmingais asmenimis.
Visi seksualinæ prievartà patyrusio vaiko atþvilgiu
turimi darbo tikslai, darbas su ðeima ir rûpinimasis vaiko
socialine aplinka, turëtø apimti ðiuos dalykus: 1) sustabdyti priekabiavimà; 2) uþtikrinti atitinkamà prieþiûrà; 3)
skatinti tarpasmeninius vaiko ir ðeimos nariø santykius;
4) psichologiniø simptomø ir psichiatriniø sutrikimø
gydymà; 5) seksualiai agresyvaus, iðnaudotojiðko elgesio
su vaiku valdymà [6,7].
Sëkmingas darbas siejamas su veiksminga partneryste tarp profesionalø ir jø klientø. Partnerystëje svarbu nukentëjusiøjø bei jø tëvø iniciatyva. Seksualinës
prievartos atveju partnerystë yra reikðminga tada, kai
dëmesys sutelkiamas ties vaiko gerove ir saugumu kartu su teigiamu susivienijimu, atvirumu bei pasidalinta
informacija [5,6,7].
Darbo tikslas: ávardyti problemà, pristatyti Lietuvoje
esantá seksualiná vaikø iðnaudojimà. Pristatyti kai kuriuos
epidemiologinius rodiklius, nustatytus 2001–2002 m.
laikotarpiu pacientams, konsultuotiems Vilniaus miesto psichikos sveikatos centro (VPSC) Konsultaciniame
centre (KC).
Metodas. Tai klinikine praktika pagrásti seksualinës
prievartos, ávykdytos vaikystëje, tyrimo atvejai, nustatyti
psichiatro konsultacijø metu VPSC Konsultaciniame centre. Pacientai buvo konsultuojami dël bendros psichinës
bûklës ir gydymo. Seksualinës prievartos vaikystëje atvejai buvo iðaiðkinami suaugusiems pacientams dviem
bûdais: pirma, renkant anamnezæ ir uþdavus specifinius tiesioginius klausimus, kalbant su pacientu apie
jo seksualinæ patirtá; antra – kiti seksualinës prievartos
atvejai bûdavo iðaiðkinami psichoterapijos metu, jau
paþengus gydymui, psichoterapinës dinamikos eigoje.
Per 2001–2002 m. laikotarpá nustatyta 60 seksualinës
prievartos vaikystëje atvejø. Ðio tyrimo metu pateikiami
ðie duomenys: amþius, kuriame pacientas pirmà kartà
patyrë seksualinæ prievartà; nukentëjusiøjø lytis; nurodyta iðnaudotojø tapatybë.
Rezultatø analizë. Pacientai, kurie buvo vaikystëje
seksualiai iðnaudojami, tokio skundo nesuformulavo.
Visi jie lankësi pas psichiatrà dël blogos dvasinës savijautos, dël blogø santykiø ðeimoje, darbe, blogø santykiø su
savo vaikais, tëvais ar seksualiniais partneriais. Kai kurie
seksualinës prievartos atvejai buvo iðaiðkinti psichiatrinio
interviu (þr. 1 lentelë) aptariant paciento seksualinæ patirtá arba santykius su tëvais, santykius tarp ðeimos nariø.
2006 m.
2 lentelë. Asmenø, vykdþiusiø seksualinæ prievartà, identifikavimas.
33
5 lentelë. Aukos amþius, kuriame ávyko pirmoji seksualinë
prievarta.
3 lentelë. Aukø skaièius pagal lytá.
6 lentelë. Aukos amþius, kuriame ávyko pirmoji seksualinë
prievarta %.
4 lentelë. Aukos pagal lytá %.
Kiti seksualinës prievartos atvejai paaiðkëjo jau paþengus
psichoterapijai. Viena pacientë savo vaikystëje patirtà
seksualinæ prievartà ávardijo po keleriø metø psichoterapijos, apraðydama pati tà atvejá vieno namø darbo,
uþduoto raðtu, metu. Mokslinës literatûros duomenys
nurodo, kad asmenys, vaikystëje patyræ seksualinæ prievartà, streso bûklëje gyvena visà savo gyvenimà. Tokie
asmenys gali bûti laikomi suicido ir homicido rizikos
grupëmis. Jie dël neðiojamø ir slepiamø dvasiniø kanèiø
ir iðsivysèiusios psichiatrinës simptomatikos anksèiau ar
vëliau patenka á psichiatrø akiratá [8].
Suaugusieji pacientai, konsultuoti KC, savo psichiatrinæ simptomatikà, iðsivysèiusià po vaikystëje patirtos seksualinës prievartos, neðiojosi visà laikà, tyliai kentëdami
ir jà slëpdami, iki kontakto su psichiatru, ir netgi – iki tam
tikrø gydytojo uþduodamø klausimø. Kai kurie pacientai
nurodë mëginæ apie tai dar vaikystëje, prievartos metu,
kalbëtis su suaugusiais, taèiau buvo atstumti, iðbarti,
apkaltinti melavimu bei ðmeiþimu. Pavyzdþiui, viena
pacientë papasakojo, kaip jà, 8–9 m. (ir vëliau – iki 13
m.) lytiniam pasitenkinimui naudojo senelis, kai vasaros
atostogø metu tëvai jà nuveþdavo á kaimà. Ji skundësi ir
moèiutei, ir savo mamai, taèiau buvo apðaukta melage ir
nubausta – vienos ðeimyninës ðventës metu ji buvo viena
uþrakinta kambaryje, kad „nesugalvotø prie visø kalbëti
tø nesàmoniø“. Jau pacientei suaugus, sulaukus 30 m.,
jos senelis mirë. Jo mirties dienà pacientë ávardijo kaip
laimingiausià bei atðventë kaip ðventæ. Dël tokio elgesio
vaikystëje ir vëliau brandþiame amþiuje ði jauna moteris
buvo atstumta ðeimos ir giminës, tarpasmeniniai ryðiai su
jais buvo nutraukti ir traumuoti. Ið pirmoje lentelëje pateiktø duomenø matome, kad net 15 atvejø (25%) ið visø
á tyrimà átrauktø pacientø faktai apie vaikystëje patirtà
seksualiná iðnaudojimà buvo iðaiðkinti psichoterapinës
dinamikos metu. Kiti 45 atvejai (75%) buvo nustatyti
psichiatrinio interviu metu.
2 lentelëje pristatomi „skriaudëjai“, kaip juos identifikavo pacientai pokalbio metu. Gauti duomenys rodo,
kad didþiausià grupæ, 40 atvejø, sudaro patëviai. Antrà
pagal dydá grupæ – 10 atvejø, sudarë kiti asmenys (á ðià
grupæ buvo átraukti tokie apibûdinimai, kaip „miestelio
keistuolis, mylëjæs vaikus ir vaiðinæs juos saldainiais“,
„nepaþástamas vyriðkis parke, paþadëjæs nupirkti lëlæ“
ir pan. Á ðià grupæ átraukta ir „mama“, kuri seksualiai iðnaudojo dar ir „brolá bei sesutæ“); treèià pagal dydá grupæ
– 7 atvejai – sudaro ávardyti „kaimynai“, kurie buvo geri
tëvø draugai; dviem atvejais ávardyti „senelis“, pas kurá
nuveþdavo tëvai praleisti vasaros ir su kuriuo reikëdavo
miegoti vienoje lovoje; vienu atveju ávardyta seksualinë
patirtis vaikø darþelyje su „pas auklëtojà ateinanèiu
graþiu vyriðkiu“.
34
Apklausti pacientai pagal lytá pasiskirsto taip (þr. 3,
4 lenteles): 7 aukos (13,3%) buvo vyriðkos lyties ir 53
(86,7%) – moteriðkos lyties (èia turiu savo pastebëjimà,
kad moterys daþniau lankosi psichoterapijos – tai galëtø
bûti tokia lyèiø disproporcijos prieþastis).
Lentelës 5 ir 6 pateikia duomenis apie amþiaus laikotarpá, kuriame pirmà kartà pacientu(e) buvo pasinaudota
seksuliai. Pagal ðias lenteles didþiausià grupæ sudaro 6–7
m. amþiaus vaikai (30 atvejø, 50% visø apklaustøjø);
toliau – 7–8 m. vaikai (15 atvejø, 25%); treèia pagal
dydá grupë bûtø 8–9 m. vaikai (9 atvejai, 15%); toliau
– 5–6 m. vaikai (4 atvejai, 6,66%) ir 2 atvejai (3,33%)
nurodomi 12–13 metø, kai buvo ávykdytas pirmasis
seksualinës prievartos aktas.
IÐVADOS
1. Seksualinë prievarta egzistuoja Lietuvoje.
2. Vaikystëje patirta seksualinë prievarta traumuoja
psichikà, dël to vystosi psichopatologija.
3. Vaikystëje patirta seksualinë prievarta sukelia
psichiatrinius simptomus ir suaugusiame amþiuje.
Literatûra
1. Mullen, P. E., Martin, J. L., Anderson, J. C., et all (1993) Childhood sexual abuse and mental health in adult life. British Journal of
Psychiatry, 163, 721–730.
2. Van Scoyk, S., Gray, J. and Jones, D. P. H. (1988) A theoretical
framework for evaluation and treatment of the victims of child sexual
assault by a non-family member. Family Process, 27, 105–112.
3. Roland C. Summit, The child sexual abuse accommodation
syndrome, Child Abuse and neglect, Vol. 7, p.p. 177–193, 1983.
4. Dante Cicchetti and Vicki Carlson, Child maltreatment, Theory
2006 m.
and research on the causes and consequences University Press, Cambridge (1989).
5. Beitchman, J., Zuchker, K., Hood, J., et all (1991) A review of
the short term effects of child sexual abuse. Child and neglect, 15,
537–554.
6. Kennedy, H. G. and Grubin, D. H. (1992) Patterns of denial in
sex offenders. Psychological Medicine, 22, 193–196.
7. Belsky, J. (1980) Child maltreatment: an ecological integration.
American Psychologist, 35, 320–335.
8. Jody Messler Davies, A relational Psychoanalytic Approach to
the Treatment of Adult Survivors of Child Sexual Abuse, 12th annual
Summer seminars of Harvard medical School, 2001.
SEXUAL ABUSE TRAUMA, DEVELOPMENT OF PSYCHOPATHOLOGY
P.Rudalevièienë
Summary
Key words: sexual abuse, psychopathology, psychiatrist, intervention, epidemiological data.
Sexual abuse is lifetime experience. Several different professionals and social systems should be involved in managing sexual abuse
trauma, in addition to mental health system involvement. Equally
this should be essential that those who violate the law by abusing
children require social control, which introduces criminal aspects of
the problem. Psychiatrists become involved in managing the problem
through the effects of sexual abuse on development and psychological
functioning, throughout the life time course. There is strong evidence,
confirming clinical impression of wide range of psychological symptoms and psychopathology associated with child sexual appearing
both in childhood and in later adult life.
60 cases have been introduced, all found during everyday clinical performances with adult psychiatric patients. Data found while or
during psychotherapy. This is evidence based study.
Gauta 2005-12-28

THE STRESS OF IMPRISONMENT AND
ARTERIAL HYPERTENSION
JERZY POBOCHA1, JOANNA GIELO2
University of Szczecin, The Faculty of Law and Administration,
Forensic Section Polish Psychiatry Association,
2
Department of Internal Medicine, Detention Centre in Szczecin, Poland
1
Art. 259 of the Polish Penal Proceedings Code
forbids imprisonment whenever a serious threat to life
or health could arise. Elevated arterial pressure is one
of the most common symptoms of stress. Medical and
psychiatric examinations ordered by courts in prisoners
with elevated blood pressure are often flawed by excessive intuition or paternalism due to lack of knowledge
by the expert about the management of hypertension
during imprisonment and because empirical studies in
this area have not been undertaken. We have studied
the results of treatment in 133 males hospitalized at the
Department of Internal Medicine of the Detention Centre in Szczecin. Arterial hypertension grade I or II was
diagnosed in all but three prisoners who demonstrated
2006 m.
grad III according to WHO classification. The age of
the subjects ranged from 25 to 75 years (mean 51.2).
Treatment lasted from 2 to 79 days (mean 25.7). Conventional antihypertensives, including beta-blockers,
convertase inhibitors, and diuretics were administered.
Systolic blood pressure prior to treatment ranged from
160 to 230 mmHg (mean 168.7), while diastolic pressure
ranged from 90 to 140 (mean 101.8).
At the end of treatment, systolic blood pressure ranged from 100 to 160 (mean 131.7) and diastolic pressure
ranged from 70 to 120 (mean 81.4). Treatment was unsuccessful in six prisoners (systolic and diastolic blood
pressures were 150-160 and 110-120, respectively).
Management of arterial hypertension can be effective during imprisonment and stress does not preclude
successful medication without the need to refer the
hypertensive prisoner to an external institution. The
opinion by an expert physician as to the risk of stress and
prognosis as to the outcome of management of arterial
hypertension during imprisonment should be based on
empirical studies instead of intuition or paternalistic
attitudes.
Depriving a man of freedom for the reason of committing a crime by him makes typical stress situation pointed out in stress scale (6, 9, 10). The matter of isolation
experienced in prison is depriving possibility of deciding
ones own life, limited communication with other people
is closed, frequently diminished area. Shock incarceration is dominated for fear of the punishment and also of
other prisoners (2, 3, 19). Circulatory system responds
in typical way by elevating arterial blood pressure as
well as pulse while facing stress or fear (6, 18, 28, 29).
Number of researches have been conducted in relation
to this topic. In MedLine database after I had introduced
key words: arterial hypertension, emotional psychological stress, I have found 60 thesis’s and 38 Russian
researchers herein, who have been analyzing fluctuation
of human and animals blood pressure regarded as the
result of being exposed to stress (7, 8, 13, 15, 16, 23,
25, 26, 27, 28). In psychological model the individual
role of the stressor is being highlighted (14).
Recognizing the psychological stressor depends on
hitherto gained experience and mental structure of this
person. It makes, that adapting to prison conditions is variegated and is called the prisonization (3). It can be based
on performing diverse attitudes: of backing out, revolting,
of settling in or conversing (3). Engaging defense mechanisms of personality the most often is attitude on fixating
the movements and behaviour, e.g.: walking around the
cell, perfection as for tidiness and cleanness, etc (3).
35
Landowski J., 2002 (14).
Figure 1. Psychosocial model of stress.
Nurse J., Woodcock P., Ormsby J. 2003 (19).
Figure 2. Influence attitude of staff on the prison emotional stress.
Examinated influence for hypertension of: alexitymia
(12), genetical condition for stress (29), not expressed
anger (17), life events (16), qualify of life (13), psychoemotional factors ( 25), psychophysiologic markers (18),
cognitive stress (8), holocaust (1), brain catecholamines
(15), model distress in psychopaths (10) and all.
In MedLine database within 11 mln of thesises I have
found only one devoted to occurring hypertension in
the relation to long-term imprisonment in concentration
camp (30). However I have not found any thesis which
would provide results of undergoing hypertension treatment among prisoners. The case of intentional simulating
inducing of arterial hypertension was described (24).
Occurring psychosomatic disease resulted from
incarceration shock is of legal as well as judge importance for forensic-medical and forensic-psychiatrical
evaluation (2, 4, 7, 19, 20, 21).
In Poland regulations which allow to abandon an
36
action of temporary detention whether executing penalty
of imprisonment are put together in art. 259 § 1 and 22
§ 1 of the Polish Penal Proceedings Code and art. 150
§ 1 and § 2 of Penal Executive Code.
Art. 259 § 1 of Penal Proceedings Code:
In case when particular consideration are not in the
way it is necessary to abandon an action of temporary imprisonment, especially in case when leaving accused free:
would cause serious danger for his/her life and health.
Art. 22 § 1 of Penal Proceedings Code:
In case when there is long-lasting obstacle unabling
of performing penal proceedings and especially in case
when capturing of accused is impossible or he/she
cannot take part during penal proceedings resulted
from mental disorder or other serious illness, then the
proceedings ought to be suspended pending suit an
obstacle.
Art. 150 §1 of Penal Executive Code:
Carrying out custodial punishment in case of mental
disorder or other serious disease enabling performing
such punishment, is stand over by the penal court till
the moment of caeasing of obstacle.
§ 2. As serious disease is considered as such state
of convict, in which putting him in penitentiary could
endanger his/her life or cause serious hazard for his/her
health.
Absence of empirical elaborations establishing possibility of treatment of arterial hypertension while incarceration is contradictory with the principles of medicine
and making opinions based on facts.
It tilts towards making estimated-intuitive opinions,
frequently from paternalistic, carring- consueling point
of view (21, 22).
Soundness of opinion on ability to be isolated in
prison depends on numerous factors.
That is why just making opinions based on empirical
data, indicating practical possibilities of hypertension
treatment and risk level and prognosis, allows to give
2006 m.
treatment resistant hypertension
taking medicines refusal with pretending of
taking thereof
taking hypertensives drugs: large doses of
caffeine, bronchodilators, etc.
Figure 4. Reasons of arterial hypertension treatment failure.
forensic-medical opinion.
The quality of opinion on ability to be temporary
under arrest depends on:
soundness and confidence of diagnosis
evaluation (exclusion) of simulating and aggravating
soundness and confidence of therapy
suicide and/or self-inflicted wound risk evaluation
evaluation of diagnostic and therapeutic competences of penitentiary health service
actual possibilities and treating psychosomatic
diseases and mental disorders while incarceration
evaluation of reality and treatment costs beyond
prison
In Poland treating of people being under temporary
arrest is Prison Health Service’s task. The number of
diverse medical services is listed below:
Arterial hypertension therapy at prisoners in Poland
is carried out by i.a. 11 Internal Departments of hospitals
1. Number of prisoners – on average – 80
239.
2. Ambulatory consultation on DC/PI area – 1
745 681.
3. Ambulatory consultation beyond DC/PI area
– 17 496 (1%).
1. Psychiatric consultation – 60 337.
2. Deaths – 67.
3. Deaths of self-aggression – 30.
Figure 5. Prison Health Service in 2004.
Figure 3. Making estimated-intuitive opinions.
in Detention Center and Penal Institutions.
Prison Health Service in Poland is divided into
following Internal Diseases Departments of Detention
Centre (DC) and Prison Institutions (PI):
DC in Bydgoszcz, DC in Bytom, DC in Gdañsk,
DC in Cracow, DC in Poznañ, DC in Szczecin, DC in
Warsaw and PI in Barczew, PI in Czarnem, PI in Ùódê,
PI in Wrocùaw.
2006 m.
The goal of this thesis was analysis of treatment
results possibilities of arterial hypertension at prisoners
put in Detention Centre in Szczecin in Internal Disease
Department.
MATERIAL AND METHOD
In order to carry out analysis of all prisoners treated
for arterial hypertension in 1999-2001 in Internal Diseases Department of Hospital of DC in Szczecin. The
hospital of detention centre has recently been restored
and have well-equipped premises and professional
personnel, it is divide into three departments, including
20 beds pertaining to internal medicine. Arterial hypertension grade I or II was diagnosed in all but three prisoners who demonstrated grade III according to WHO
classification. 133 prisoners were treated, the age of
the subjects ranged from 25 to 75 years (mean 51.2).
Treatment lasted from 2 to 79 days (mean 25.7). Urine
and blood analysis was carried out at all patients, the
analysis did not revealed any important abnormalities.
At least one electrocardiographic investigation was also
performed, which revealed no pathological changes in
49 patients. Other patients: 14 suffered from heart attack, 19 suffered from superior bundle of left His bundle
branch block, 4 suffered from incomplete left His bundle
branch block and superior bundle of left His bundle
branch block, 13 suffered from incomplete right His
bundle branch block, 5 suffered from incomplete right
His bundle branch block and superior bundle of left His
bundle branch block, 10 – symptoms of left ventricle
hypertrophy. Beta-blockers, convertase inhibitors and
diuretics were administered. In this group, 2/3 of patients
apart from being given treatment against hypertension,
were also administered with sedatives and half of them
took psychiatric consultation. Stated: symptoms of abnormal personality, affective disorders. All patients used
educators’ help (4, 5,11), kept corresponding with family
and convicts also had possibility to make phone calls,
in one for five cells there was a TV set.
The patients treated for hypertension were divided
into two groups:
First group: 127 prisoners – revealed normalization
of treatment,
Second group: 6 prisoners – revealed no full normalization.
In relation to none of prisoners the motion regarding
dismissal was not proposed because there was no medical-code reasons, i.e. the situation in which it is not
possible to reduce hypertension and which state makes
up actual endanger for health and/or life of the prisoner
37
(like in art. 259 § 1 and 22 § 1 ppc or art. 150 § 1 and
§ 2 pec).
Arterial blood pressure values at 127 prisoners (in
mmHg)
1. Before treatment in hospital:
Systolic pressure: 160-230, mean 168,7
Diastolic pressure: 90-140, mean 101,8
2. After treatment in hospital:
Systolic pressure: 100-160, mean 131,7
Diastolic pressure: 70-120, mean 81,4
Arterial blood pressure values at 6 prisoners after
treatment in hospital with no full normalization of pressure (in mmHg)
1. Systolic pressure: 150-160
2. Diastolic pressure: 110-120
DISCUSSION
Obtained results confirm the hypothesis on possibility
of treating for arterial hypertension while incarceration
– in prison hospital. The fact that at 6 prisoners, which
is 4,8% of the group, the full improvement was not
obtained, does not make that it diverge from results of
hypertension treatment beyond penitentiary institutions,
that is why it cannot state the thesis on impossibility of
treating such psychosomatic disease in these conditions.
Carried out researches, which can be repeated in other
prison hospitals’ departments, points out that possibilities and results of Prison Health Service, no matter the
well-known influence of prison isolation on inducing
stress and elevating arterial blood pressure, do not fundamentally diverge from abilities of other health service
institutions (2, 4, 11, 16, 19, 23). Collecting empirical
data which allow to verify hypothesis is the point to
carrying out further elaborations, which will let us to
resign from estimated-intuitive and paternalistic attitude
towards making opinions based of facts (11, 21, 22).
CONCLUSIONS
1. Treating prisoners for arterial hypertension in
prison hospitals is possible – in Detention Centre Hospital. The incarceration stress does not preclude possibility
to obtain, by means of pharmacotherapy, normalization
of the pressure and for that reason does not require taking
up treatment beyond penitentiary institution.
2. Experts’ opinions regarding stress exposure level and ability of arterial hypertension treatment while incarceration should take into consideration results of empirical researches and in
minor degree be based on expert’s intuition and
his/her paternalistic tendencies while making opinions.
38
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Gauta 2006-01-13

2006 m.
39
PRIVERÈIAMØJØ MEDICINOS PRIEMONIØ
REIKALINGUMAS VERTINANT PAKALTINAMØ
ASMENØ SU REAKTYVIAIS SUTRIKIMAIS VEIKSNUMÀ
BAUDÞIAMAJAME PROCESE
J.MARCINKEVIÈIENË, A.DEMBINSKAS
Valstybinë teismo psichiatrijos tarnyba prie Sveikatos apsaugos ministerijos,
Vilniaus universitetas, Medicinos fakultetas
Raktaþodþiai: baudþiamasis procesinis veiksnumas,
reaktyvus sutrikimas, priverèiamosios medicinos priemonës, teismo psichiatrija.
Santrauka
Baudþiamosios teisës aktai neapibrëþia procesinio veiksnumo, jo ribojimo ar netekimo.
Iðkilus klausimui dël teisiamojo sugebëjimo suprasti bylos aplinkybes ir naudotis savo teisëmis,
teismas vadovaujasi bendra nepakaltinamumo
formule. Taèiau pakaltinamiems, iki patraukimo
baudþiamojon atsakomybën psichiðkai sveikiems
asmenims gali pasireikðti ne tik simuliacija, bet ir
reaktyvus sutrikimas. Autoriai atrinko ir iðtyrë 161
grynai psichogeninio reaktyvaus sutrikimo atvejá
ið 353, diagnozuotø Valstybinës teismo psichiatrijos tarnybos ekspertø per 1997-2002 metus.
124 atvejais prireikë kartotinës ekspertizës, ið jø
98 buvo toliau stebimi ir gydomi iki veiksnumo
atstatymo teismo psichiatrijos stacionare. Reaktyvinë bûsena stacionare tæsësi tik 24 atvejais,
kitiems ji buvo jau praëjusi. 51 atveju nustatyta
simuliacija arba metasimuliacija. Tik 11 tiriamøjø
reaktyvinë bûsena pasikartojo. Veiksniais nebuvo
ámanoma pripaþinti tik 6 atvejø (3,72%), kurie
palikti priverèiamajam gydymui.
ÁVADAS
Baudþiamojo proceso teisës aktai nenusako veiksnumo bei jo ribojimo ar netekimo [3]. Taèiau ðios
problemos iðkëlimas visiðkai atitinka teisës aktø esmæ.
Tai galima matyti ið praktikoje teismo psichiatrijos ekspertizei uþduodamø klausimø. Todël ðios problemos
sprendimas yra aktualus.
Teisës aktuose nëra teisinio kriterijaus, kuris apibûdintø baudþiamàjá procesiná neveiksnumà. Ðio teisinio
kriterijaus formuluoèiø analizë rodo, kad labiausiai
paplitusi yra formuluotë, primenanti teisiná nepakaltinamumo kriterijø: subjektas pripaþástamas procesiðkai
neveiksniu, jeigu jis ikiteisminio tyrimo bei teismo metu
negali suprasti savo veiksmø esmës ir jø valdyti [2].
Analizuojant baudþiamojo procesinio veiksnumo
teisinio kriterijaus formuluotæ, nepaisant galutinës versijos, svarbu suprasti tai, kad veiksnus subjektas, turintis
psichikos sutrikimà, turi galimybæ pasinaudoti visomis
jam suteiktomis teisëmis, kurios uþtikrintø jo saugø dalyvavimà procese. Tam jam bûtinas ne tik teisingas bylai
svarbiø aplinkybiø suvokimas, bet ir teisingi parodymai.
Procesinio veiksnumo neámanoma iðsaugoti tik prasmingu teisiðkai reikðmingø ávykiø iðorinës pusës bei turinio
supratimu, taèiau daþniausiai ðito pakanka siekiant
konstatuoti gebëjimà duoti parodymus. Kadangi teisës
normos, kurias reguliuoja baudþiamojo proceso teisë,
yra teisiðkai vertingo pobûdþio, tai veiksnus subjektas turi
suprasti ávykius ið socialinës pusës. Be to, bûtina iðsaugoti
asmeninio lygio supratimus. Kitaip tariant, subjektas turi
suvokti teisiðkai reikðmingø aplinkybiø, kurios susidaro
teismo proceso metu, teisinius aspektus, taip pat tas
teisës normas, kurios reguliuoja patá procesà [1].
Ðiame darbe klausimas apie reaktyvius sutrikimus
turinèiø asmenø pakaltinamumà iðsprendþiamas ne be
sunkumø net ir tais atvejais, kai tiksliai nustatyta, kad
psichikos sutrikimai atsirado po nusikaltimo ávykdymo
ir neabejojama dël jo psichogeninio charakterio.
Pakaltinamumas nustatomas pasibaigus reaktyviai
bûsenai, kai nelieka abejoniø dël psichogeninës sutrikimø kilmës ir nerandama „patologinio pagrindo“,
uþslëpto po reaktyviais sluoksniais. Reèiau taip manoma
tada, kai reaktyvûs sutrikimai neleidþia nustatyti tiriamojo psichikos bûklës nusikaltimo ávykdymo metu.
Tokiais atvejais rekomenduojamas priverstinis gydymas iki iðëjimo ið reaktyvios bûsenos pabaigos bei
pakaltinamumo nustatymo.
Tais atvejais, kai dël pakaltinamumo neabejojama,
40
bet reaktyvi bûsena trukdo tiriamajam dalyvauti ikiteisminio tyrimo-teismo procese, tiriamasis siunèiamas
priverstinai gydytis iki pasveikimo, nustatant asmens
pakaltinamumà.
Reèiau, kai reaktyvios bûsenos uþsitæsia ir pereina
á negráþtamus psichikos sutrikimus, ðie asmenys atleidþiami nuo bausmës (pagal LR baudþiamojo kodekso
76 str. 3 d.) ir baudþiamojo proceso nustatyta tvarka
sprendþiamas klausimas dël priverèiamøjø medicinos
priemoniø taikymo (pagal LR baudþiamojo proceso
kodekso 393 str.) [2,3].
Darbo tikslas – nustatyti teismo psichiatrijos reaktyviø
sutrikimø, atsirandanèiø psichiðkai sveikiems asmenims
ikiteisminio tyrimo–teismo situacijose, vertinimo kriterijus, jø poveiká galimybei dalyvauti baudþiamajame
procese, taip pat medicinos priemoniø taikymà.
TYRIMO MEDÞIAGA IR METODAI
Tyrimas buvo atliekamas 1997 m. sausio 1 d.– 2002
m. gruodþio 31 d. Valstybinëje teismo psichiatrijos
tarnyboje prie SAM. Tyrimams atlikti gautas Lietuvos
bioetikos komiteto leidimas.
Iðtirti 353 atvejai, kuriais buvo diagnozuotas reaktyvus sutrikimas. Ið 353 atvejø buvo atrinktas 161 atvejis,
kuriuo psichogeninis sutrikimas buvo traktuojamas kaip
neurozinis. Po psichikà traumuojanèios ikiteisminio
tyrimo–teisminës situacijos iðryðkëdavo psichogeniniai
psichikos veiklos sutrikimai, sudarantys kliûtis dalyvauti
ikiteisminio tyrimo–teismo procedûrose, taèiau visi jie
buvo pripaþinti pakaltinamais. Visø tiriamø atvejø numatomos bausmës atlikimo laikas buvo ne maþiau kaip
5 metai (tai taip pat vienas ið atrankos kriterijø).
Visus tiriamuosius patvirtino ekspertø komisija: 137
asmenys (85,09%) buvo psichiðkai sveiki arba buvo pastebëti iðryðkëjæ psichopatiniai charakterio bruoþai – 24
asmenys (14,90%), iki ikiteisminio tyrimo pradþios.
Tyrimà sudarë tiek archyvinës medþiagos analizë
(1997–1999 m.), tiek darbo autoriø atliktø ekspertiziø
2000–2002 metø medþiaga. „Daþnumo“ árodymui,
eliminuojant psichikos patologijà iki ikiteisminio tyrimo
pradþios, buvo keliami grieþti reikalavimai. Atrinkti tik
vyrai nuo 20 iki 45 metø amþiaus. Apatinë amþiaus riba
– 20 metø – leido eliminuoti asmenybës ir elgesio sutrikimø formavimàsi, o virðutinë – 45 metai – involiuciniø
ir kraujagysliniø sluoksniniø dariniø prisijungimà.
Tyrimo metodas – informacijos atrinkimas ið baudþiamøjø bylø ir ekspertinë dokumentacija pagal specialø
klausimynà.
Kadangi ðiuo metu dar nesukurta nei asmenybës vertybinës orientacijos koncepcija, nei asmenybës vertybiø
2006 m.
kryptingumo nustatymo metodika, tai tiriant tiriamøjø
iki ikiteisminio tyrimo pradþios periodo ypatumus, buvo
panaudota bendra bei vaisinga biografinio asmenybës
tyrimo metodika. Ðios metodikos privalumas tas, kad
analizuojant ekspertinio tyrimo medicininæ dokumentacijà galima ávertinti asmenybës bruoþus. Biografinis
medicininiø dokumentø bei bylos duomenø analizës
metodas yra objektyvesnis, nes sàmoningos ir nesàmoningos maskuotës bei apsaugos mechanizmai trukdo
ásiskverbti á nusikaltëlio intymø pasaulá.
Skaièiavimams naudotasi SAS programiniu paketu.
REZULTATAI IR JØ APTARIMAS
Reaktyviø bûsenø vertinimas pagal jø eigà leido
iðskirti gráþtamas reaktyvias psichozes, apie kuriø gráþtamumà buvo spræsta tik pasibaigus reaktyviai bûsenai,
o retesni uþsitæsæ eigos atvejai buvo prilyginti lëtiniams
psichikos sutrikimams.
Á pirmà grupæ átraukti ûmûs arba poûmiai atvejai, su
isterinio pobûdþio klinika ir neturintiems poreaktyviø
asmenybës sutrikimø, pasibaigus reaktyviai bûsenai.
Tai daugiausia tokie atvejai, kai labiau iðryðkëja tikslinës gynybos nuostatos negu somatovegetaciniai nukrypimai ir afektogeniniai psichikos nukrypimai. Tokiø
reaktyviø bûsenø eiga vienatipë, apibrëþtos ir vientisos
simptomatikos. Reaktyvios bûsenos pasibaigia daþniau
teismo psichiatrijos ekspertizës metu. Tai ekspertizës
neapsunkina.
Tokiais atvejais (60,86%) tiriamieji (ið 98 atvejø) buvo
siunèiami priverstiniam gydymui á psichiatrijos ligonines
iki reaktyvios bûsenos pasibaigimo, diagnozës nustatymo bei ekspertizës atlikimo. Tai pateisino katamnestiná
asmenø palyginimà su asmenimis, kuriems galutine
ekspertize diagnozuota ðizofrenija.
Skiriasi tiriamøjø pirminë ir antrinë diagnozë dël
skuboto ir nepakankamai pagrásto ðizofrenijos diagnozavimo reaktyviø sutrikimø turintiems tiriamiesiems,
taip pat tais reaktyviø bûsenø atvejais, kai priverstinis
gydymas psichiatrinëse ligoninëse buvo netikslingas ir
nepateisinamas, nes katamnezë parodë, jog kai kuriems
asmenims arba nebuvo pastebëta reaktyviø bûsenø
poþymiø, arba ði bûsena praeidavo stacionare po 1-2
savaièiø. Somatovegetaciniø sutrikimø nebuvimas, negili ir neilga psichikos sutrikimø eiga, jø maksimalus
sutapimas su normaliomis psichologinëmis reakcijomis
kelia abejones dël siuntimo priverstiniam gydymui tikslingumo.
Dël psichikos sutrikimø, tarp jø ir reaktyviø bûsenø,
patomorfozës á reaktyviø sutrikimø teismo psichiatriná
vertinimà þvelgiama naujai. Pirmiausia atkreipiamas

"Sveikatos mokslai" Nr. 1-2

Transcription

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