Possibilities of psychological and psychiatric rehabilitation of adult patients after orthognatic surgery

Introduction

At the background of the development of maxillofacial surgery in recent decades, interest in the study of pathopsychological and mental disorders in patients with skeletal forms of malocclusions of the dentition has not weakened. The main vectors of research are aimed at describing constitutional and acquired personal anomalies, variants of pathological mental developments in patients with pathology of the maxillofacial region [1, 3, 7, 8, 12—15]. Some works present data on the role of surgical methods of treatment on the dynamics of psychopathological disorders [2, 6, 10, 11, 16—19]. In particular, in the study of A.V. Kovalenko and co-authors, it was noted that patients with skeletal forms of occlusion anomalies had a tendency to introversion in 24.18% of cases, a tendency to neuroticism in 19.44%, a tendency to dependence in 52% and a tendency to avoid fighting in 67%, which indicates the presence of problems when communicating in a group and poor social adaptation. After complex treatment, the author revealed a change in the psychological state of patients [5].

Individual features of the psychoemotional sphere of patients with skeletal occlusion anomalies complicate the course of the postoperative rehabilitation period, due to physical and functional discomfort, decreased social activity and emotional lability [10].

At the same time, there is almost no data on the impact of rehabilitation measures following the surgical stage of treatment on the course of mental and pathocharacteristic processes.

The aim of study was to assess the impact of methods of rehabilitation of adult patients after orthognathic operations on the psychoemotional state of patients.

Materials and methods

There was an examination of 42 patients (33 women, 9 men), hospitalized for planned orthognathic operations on the upper and lower jaws in the hospital of the clinic. The average age was 27.5±7.4 years.

The study included patients with diagnosed jaw anomalies aged 18—55 years who underwent orthodontic, surgical and rehabilitation stages of combined treatment.

The study did not include patients with myasthenia and myasthenia-like syndromes, acute infectious diseases, hemophilia, high myopia, somatic and mental (schizophrenia, affective disorders, schizoaffective psychosis) diseases in the acute stage, dementia, taking muscle relaxants, anticoagulants, antibiotics from the group of aminoglycosides, tetracycline, polymyxin, alcohol abusers, pregnant and lactating women.

During the rehabilitation procedures, the reprogramming of the bioelectric activity of the muscles of the maxillofacial region was carried out by the method of hardware myostimulation (MIO-STIM, Biotronic, Italy) in the relaxation mode, acupuncture and kinesiotapes Kine Xib Ultraviolet (China).

Methods of examination of patients included a psychometric method using validated scales and statistical analysis.

Psychometric examination of patients was carried out before the beginning of the course of rehabilitation procedures and after its completion. During the psychometric examination, a battery of scales and questionnaires was used to identify dominant personality traits, the presence of symptoms of anxiety and depression, and a questionnaire to assess the quality of life. The K. Leonhard questionnaire (1976) is designed to identify character accentuations. The questionnaire includes 88 questions, 10 scales corresponding to certain character accentuations. The first scale characterizes a person with high vital activity; the second scale shows excitable accentuation. The third scale indicates the depth of the emotional life of the subject. The fourth scale shows a tendency to pedantry. The fifth scale reveals increased anxiety, the sixth — a tendency to mood swings, the seventh scale indicates the demonstrativeness of the behavior of the subject, the eighth — the unbalanced behavior. The ninth scale shows the degree of fatigue, the tenth — the strength and severity of the emotional response.

The scale of assessment of the motivation of approval by D. Marlowe and D. Crown is aimed at identifying the motivation of approval and, consequently, the willingness of a person to appear better, to present himself to others as fully conforming to social norms [9].

The multifactorial personality questionnaire 16PF (Sixteen Personality Factor Questionnaire, 16PF) by R. Kettel is intended for writing a wide range of individual personality traits [4]. A distinctive feature of this questionnaire is its focus on identifying relatively independent 16 factors (scales, primary traits) of a person. The individual factors assessed using the questionnaire are combined into three blocks: intellectual, emotional-volitional block and communicative.

The hospital Anxiety and Depression Assessment Scale (HADS) allows us to reliably assess the absence/presence (“subclinically expressed” or “clinically expressed”) symptoms of anxiety and depression [24].

The methodology for assessing the quality of life SF-36 Health Status Survey consists of 11 sections, the results are presented in the form of scores on 8 scales, compiled in such a way that a higher score indicates a better quality of life [23]. The following indicators are quantified: the general assessment of the patient's current state of health (GH) and the prospects for treatment, physical functioning (PF), reflecting the degree to which health limits the performance of physical exertion (self-care, walking, climbing stairs, carrying weights, etc.), the influence of physical condition (RP) on role functioning (work, performing everyday activities), the influence of emotional state (RE) on role functioning (assumes an assessment of the degree of, in which an emotional state interferes with the performance of work or other daily activities, including an increase in time spent, a decrease in the volume of work performed, a decrease in the quality of its performance, etc.), social functioning (SF, is determined by the degree to which a physical or emotional state restricts social activity and communication), the intensity of pain (BP) and its impact on the ability to engage in daily activities, including housework and outside the home, vitality (VT, implies feeling full of strength and energy or, conversely, exhausted) and self-assessment of mental health (MH, characterizes mood, the presence of depression, anxiety, a general indicator of positive emotions).

Results

When assessing the socio-demographic characteristics of the surveyed, it was determined that all 43 (100%) patients in the sample worked or studied. More than half of the surveyed had a higher education, were not married and their age was in the range from 19 to 29 years (Table 1).

According to the assessment according to the Leonhard Questionnaire in patients undergoing rehabilitation, emotive, hyperthymic, exalted traits prevailed, which corresponds to the descriptions of hypercompensation variants of personal development found in the literature in patients with congenital anomalies of maxillofacial area (Table. 2) [20—22].

The dynamics of the indicator of seeking approval from others on the Scale of assessment of the motivation of approval by D. Marlowe and D. Crown (Table 3) showed a tendency to reduce the need of patients after rehabilitation for approval from others. An increase in the number of patients with low scores on the scale indicated that they acquired self-confidence without the need for external approval, adequate positive self-esteem, recognition of their right to make mistakes, and can also speak of a high level of self-demanding turning into self-criticism.

According to the hospital scale of anxiety and depression (Table. 4) the following correlations are established. Against the background of the rehabilitation course, subsyndromal depressive symptoms are completely reduced, while subclinical anxiety has multidirectional trends: in 2 patients, anxiety increases, in 3 patients it is reduced to the normal level. This can be explained both by the different effectiveness of the rehabilitation course, the presence/absence of complications of surgical treatment, and external psychoemotional stressors.

Analysis of the results of the Kettel test (Table. 5) indicated a positive distinct dynamics (improvement) of the patients' condition in terms of such indicators as “calmness”, “low anxiety”, “trustfulness” and “conformism”.

Negative dynamics (decreased severity) was noted in patients according to the indicators “timidity”, “suspicion”, “straightforwardness”, “conservatism”, “low self-control”, “isolation/introversion”, “sensitivity/vulnerability” and “conformity/dependence”.

The clinically described dynamics was realized by a decrease in indecision, insularity, resentment, suspicion, anxiety, irritability, short temper, difficulties in independent decision-making, while simultaneously expanding the circle of communication, increased activity, self-confidence, determination in the implementation of the plan.

Thus, there is an obvious tendency to the formation of psychological characteristics that increase the level of social adaptability and adaptation.

This conclusion was also confirmed by the results of the examination of patients using the SF-36 quality of life questionnaire (Table 6). According to the answers to the questions, by the end of rehabilitation, patients noted a decrease in the intensity of pain sensations and their impact on the ability to engage in daily activities, including work at home and outside the home, increased energy and improved overall health and social functioning with a positive assessment of the patient's current state of health and prospects for treatment in the future.

Conclusion

In the course of the study, data were obtained indicating a positive dynamics of the psychoemotional state of patients who underwent surgical treatment and are in rehabilitation.

The need for such rehabilitation from a psychiatric point of view is due to the presence of formed personality anomalies and reactive states of the anxiety-depressive spectrum in patients [2, 3, 6—8, 24].

In this study, it was found that persons with congenital anomalies are characterized by constitutional or acquired high sensitivity and impressionability, differ in the depth of experiences in the field of subtle emotions in spiritual life (35% of patients have emotive traits according to the Leonhard questionnaire), the ease of changing affect from joy to depression (23% of patients have exalted traits according to the Leonhard questionnaire) in combination with a thirst for activity, high activity, entrepreneurship (28% of patients have hyperthymic traits).

At the same time, against the background of surgical treatment and after a course of rehabilitation procedures, patients have a tendency to develop psychological characteristics that increase the level of social adaptability and adaptation. Thus, the data of the psychometric survey on the Scale of evaluation of the motivation of approval by D. Marlowe and D. Crown indicate that they have acquired self-confidence without the need for external approval, an adequate positive self-esteem. According to the multifactorial personal questionnaire, there is a decrease in indecision, isolation, resentment, suspicion, anxiety, irritability, short temper, difficulties in making independent decisions, while simultaneously expanding the circle of communication, increasing activity, self-confidence, and determination in the implementation of the plan.

The limitations of this study are the impossibility of a differentiated assessment of the contribution to the dynamics of the mental state of patients, the lack of catamnestic data to clarify the stability of the achieved effects.