Alcoholism, drug addiction and smoking treatment according to Dovzhenko method. Expert's opinion.

RELAPSE CHARACTERISTICS
AND OUTCOME PROGNOSIS IN THE TREATMENT OF ALCOHOLIC PATIENTS BY THE DOVZHENKO METHOD
I. Ts. Epshtein, 0. I. Epshtein

Chronic alcoholism as an illness demonstrates a tendency to repeated relapses, which not infrequently leads to pessimism in the physician's evaluation of this heavy affliction.
Various authors report various treatment effectiveness, ranging from 20-to 30% within the first year of treatment. The figures are given both for general medical clinics and the LTP (penal-servitude medical institutions). We believe that the results for the latter arc overstated.
Several authors have reported considerably successful outcome in the treatment of alcoholism. Thus, in the Maritime and Khabarovsk Territories, V. S. Grebennikov applied halfstationary treatment in alcoholic patients, combined with the A. S. Makarenko personality overtraining techniques, demonstrating fairly good outcome. The methods, however, are labour-consuming and could only be applied to small numbers of patients and under certain territorial and demographic conditions.
The method of treating alcoholism suggested by A. R. Dovzhenko ensures both superior effectiveness and application in any conditions, besides having a large "capacity". All physicians using the method emphasize excellent outcome of the treatment, which makes the task of investigating relapse under this method all the more important. The available literature has not been known to discuss the matter to date.
The present paper bases on a relapse investigation in the patients treated by the A. R. Dovzhenko method in the Nizhnevartovsk self-supporting addiction treatment station in 1987-1990, and a comparison study of the abovementioned group and the total amount of patients treated for alcoholism by: this method.
In 1987-1990 we treated 4695 alcoholic patients in our station. Information has been available on 1730 patients, comprising 35.5% of the total amount treated. 353 of them relapsed, which comprises 20.6% of the total available information or 7.5% of the total amount treated. Besides, it should be emphasized that it is usually of relapses that we can receive information, so actual relapse percentage is somewhat between 20.4% and 7.5%, closer to 15%.
Of the relapses, in up to 3-month remissions were 79 patients (22.4%); for 3 to 6 months-102 (28.9%), for 6 months to 1 year-96 (27.2%); over a year-76 (21.5%).
"Decoded" before the relapse (i. e. refused further treatment) were 103 patients (28.1%) of total relapse; "decoded" after the relapse- 152 (41.3%); with only 98 patients (31.6%) not decoded for some reason; which once again indicates that the patients believe in the treatment. Besides, in order to be "decoded", the patients came from distant parts of the large Tiumen' Region and other parts of the Union.
The table given below compares several characteristics of the patients who relapsed with the total amount treated.

	Total amount treated in 1987-1990		Relapsed in 1987-1990
	Abs. fig.	in %	Abs.fig.	in %
Total amount of alcoholic patients treated	4,695	100%	353	100%
incl. women	570	12.1%	21	5.9%
Of total amount rural	347	7.2%	11	3.2%
age groups:
up to 25	231	4.8%	32	9.2%
26-30	938	19.6%	74	21.2%
31-40	2.413	51.4%	181	51.7%
41-50	906	19.2%	54	15.4%
over 60	11	0.3%	---	---
Medical advice taken
primary	2.060	43.9%	161	46.8%
secondary	2.635	56.1%	212	53.2%
Place of residence
a).Nizhnevatovsk	1.162	22.0%	160	41.1%
b).Tiumen' Region	3.260	69.9%	178	54.7%
c).Other parts	217	8.1%	15	4.2%
Social positions:
workers	3.581	76.2%	268	76.5%
collective farmers	56	1.2%	5	1.5%
office workers	663	13.6%	43	12.3%
retired	55	1.2%	2	0.7%
non-working	220	4.8%	35	10%
Marital status
marreid	3.689	78.5%	260	74.2%
single	376	8.0%	43	12.2%
divorced	620	13.5%	50	13.6%
Education
primary	80	1.6%	3	0.9%
secondary not completed	953	20.2%	53	25.1%
secondary	3.334	70.9%	256	73.9%
higher	418	7.3%	41	10.1%
Alcoholism stage:
voluntary heavy drinking	6	0.2%	2	0.6%
1 - stage	215	4.8%	19	5.4%
1 - 2 stage	382	8.2%	40	10.1%
2 - stage	3.495	74.5%	294	70.0%
2 - 3 stage	429	9.2%	31	8.8%
3 - stage	161	3.1%	18	5.1%
Illness duration
up to 5 years	1.447	37.9%	132	37.6%
6 - 10 years	1.888	40.4%	132	37.6%
11 - 15 years	388	8.4%	51	14.5%
16 - 20 years	426	9.4%	27	7.7%
over 20 years	136	2.9%	11	3.1%
Alcoholic psychoses in case history	188	4.0%	31	8.8%
Insufficient critical appraisal	3.919	83.3%	261	70.4%
Abstinence duration before the session - 2w.	539	11.4%	78	22.2%
3 - 4 weeks	3.170	67.0%	130	37.1%
1 - 2 months	616	13.1%	91	26.9%
over 2 months	370	8.5%	54	13.8%
Alcoholic inheritance	2.343	49.1%	182	51.7%
Alcohol-consumption forms:
pseudo-alcohol abuse	3.699	79.1%	288	80.2%
permanent, low-tolerant	269	5.9%	6	1.1%
permanent, high-tolerant	413	9.0%	24	6.8%
sporadic heavy drinking	305	8.0%	35	11.8%
Personality change:
absent	2.193	46.6%	197	56.2%
Sharpened personality
traits	1.939	41.6%	136	38.8%
Degradation	512	11.8%	24	5.8%
Encoding terms:
1 year	199	4.9%	9	2.6%
2 - 3 years	710	15.1%	50	14.8%
4 - 5 years	1.301	27.7%	119	33.8%
6 - 10 years	1.270	25.4%	68	19.3%
11 - 15 years	185	3.9%	15	4.2%
16 - 20 years	147	3.1%	11	2.7%
21 - 30 years	34	0.8%	11	2.7%
for the rest of one's life	851	18.1%	70	19.9%

From the analysis of the table several conclusions can be drawn. Thus, interestingly, women treated by the A. R. Dovzhenko method have been observed to relapse less frequently than men. The problem of alcoholism in women is very important, all authors admitting treatment outcome in women worse than in men. With the use of the A. R. Dovzhenko method, the relationship is conversed, which will undoubtedly contribute to the solution of female alcoholism problem.
One is struck by the highest percentage of relapse in younger patients (up to the age of 25). Younger people obviously require more consistent outpatient treatment; they should not be "hustled" to the A. R. Dovzhenko method. The most successful in the treatment is the older age group (over 40).
There arc no significant differences between the treatment outcome in primary and secondary patients, with the effectiveness slightly higher in the secondary group, which can be explained by a larger amount of ol-der patients therein.
It is interesting to note that relapse in Nizhnevartovsk residents is almost 2 times higher than in the residents of other towns and regions. This may be related to the fact that treatment is easily available for the former, so that even accidental patients not aiming at being treated can be admitted.
The patients' social position had no practical relation to outcome, but non-working patients relapsed two times more frequently than the work-ing ones. Similarly, single patients relapsed almost 1.5 times more often. The outcome is slightly better in office workers compared to other so-cial groups, but here one should remark those patients with higher educa-tion relapse more often than less educated patients.
There are some interesting data on the relationship between treatment outcome and illness stage. Higher stages have been believed to demon-strate better outcome. Our investigation, however, shows outcome in lo-wer stages worse than in higher ones, except in the third stage accompa-nied by defined degradation, where outcome is naturally worse. Patients with alcoholic psychoses in case history relapse 2 times more often than the others.
While the patient's critical appraisal of his illness is admittedly subjective, patients with low critical appraisal exhibit worse treatment outcome than those whose critical appraisal is sufficiently high. Slightly better outcome was shown in patients with no alcoholic inheritance com-pared to the reverse.
In compliance with the leading physician's demand, we had to admit a number of narcology department inmates (altogether 98 patients). It should be noted, however, that treatment outcome there was worse than in the main group. Besides, it discriminates indoor patients. We there-fore believe that the A. R. Dovzhenko method is not advisable for inpatient treatment.
An interesting relationship was demonstrated between treatment out-come and pro-treatment "abstinence duration". The best outcome was de-monstrated with the 3-4 week period. The 2-week period and, strange as it may seem, the 1-2 month and more "abstinence duration" were the worst. Also significant is the patients' selection of "abstinence duration". With longer encoding terms (over 10 years and "for the rest of one's life") outcome is worse than with shorter terms. The best encoding outcome was observed with 1-year terms. Obviously, "long" encoding terms sho-uld not be advised. Similarly, there is need to discuss the advisability of recommending adequate encoding terms for each individual patient.
Our attention was drawn by the fact that treatment outcome in per-manent alcohol-abusers (both high- and low-tolerant) was better than in pseudo-alcohol abusers and those practicing sporadic heavy drinking.
With sharpened personality traits and, paradoxically, degradation, outcome is better than when heavy changes are not observed.
Highly important, as we believe, are investigation results on the A. R. Dovzhenko treatment outcome in the original population of the North. The problem of alcoholism is known to be one of survival for these people, helpless against the vices of civilization. We treated 95 patients belonging to the aboriginal population of the North (the Khanty, the Mansi, the Nenets) and observed only one relapse. Not less important is that the A. R. Dovzhenko single treatment method is absolutely indi-spensable for the people, living far apart on the boundless tundra, where even a doctor's assistant's station is hundreds kilometers away, to say nothing of a narcological dispensary.
Our investigations permit certain conclusions on possible applications of the A. R. Dovzhenko method in each specific patient category and, to a certain extent, a prognosis on the treatment outcome.

Extraordinary response to the Dovzhenko method of treating alcoholic patients-89-93% positive response (in various sections)- can be explained by a complex of therapeutic factors involved. Dominating among them is the emotional and aesthetic effect on the patient, his emotional memory mechanisms fixating the injunctions to sobriety, blocking the alcoholic, dynamic stereotype and breaking psychological alcohol dependence.
Pathogenetic mechanisms of the effect not yet fully investigated seem to be polyfactorial. We believe that not the least important among them are the clinical principles of patient selection based on comprehensive evaluation of their condition: personality traits, dynamics and actual syndromologic manifestations of alcohol illness, evidence of somatic or psychosomatic pathologies, neurotic disorders.
Our clinical observations (740 alcoholic patients over one year) have shown that, along with positive treatment motivation, of great importance for successful treatment outcome are the patient's personality traits on the one hand, and on the other - alcohol disorder psychopathologic structure and disturbances of psychosomatic origin.
The most impressive and stable therapeutic outcome has been observed in patients with paranoiac-epileptoid and psychastenic characteristics which, rather curiously, are polar versions and psychopathies in clinico-psychological structure. It should be emphasized that the patients had a stable positive motivation for treatment and sobriety but, as a whole, the phenomenon is worth investigating.
Stable outcomes without any particular relation to personality traits have been observed in patients with the alcohol, syndrome structure dominated by psychic radical, and particularly - with a depression-anxiety-phobia component in evidence.
Stable positive response to the Dovzhenko treatment of alcoholism has also been observed with pathologies of psychosomatic origin, in particular with manifestations of somatized depression, cardialgias and abdominal algias with phobic inclusions, cancerophobias, symptoms of ischemia without actual changes in coronary vessels, evidence of hypothalamic syndrome.
Among the 7-8% of the patients not cured are primarily those with a marked conforming accentuation, where deficient will and susceptibility to the influence of drinking companies led to drinking relapses in the absence of alcohol addiction, "for company only". The same group (with high percentage of failures) contains patients with excitable and unstable forms of psychopathies and accentuations, as well as mental defects on a level of mental deficiency or mild debility.
The group also includes patients with defined depressive and neurotic disorders, compulsive alcohol addiction and actual alcohol abuse conditions in the case history.
All these patients (not treated successfully) require special psychotherapeutical and psychopharmacological support before and after the Dovzhenko stress-therapy, if it is thought advisable despite counterindications.
The clinical findings, therefore, provide certain orientation for patient selection, adequate preparation for treatment, if necessary, as well as prognosis and follow-up.

EXPERIENCE IN THE DOVZHENKO STRESS-THERAPY FOR ALCOHOLIC PATIENTS WITH ALCOHOLIC EPILEPSY COMPLICATIONS, CRANIOCEREBRAL INJURIES, AND THE BLIND.
A. I. Drozdov (Pskov)

The abovementioned groups of patients require strictly individualized selection standards (involving a comprehensive clinical condition evaluation) and a measured emotion-stress treatment for alcohol illness.
To avoid overdosing and negative effects, a session of emotion-stress therapy, while retaining the continuity of the treatment process, is divided into separate fragments, stages (cascades), which permits the psychiatrist to arrest the increase in treatment intensity at each specific stage immediately after a required therapeutic effect is attained, that is - to measure the loads in emotion-stress therapy.
Doses in this cascade, stage encoding were "measured" primarily with respect to the patient's vegetovascular reactions, making their quick-test diagnosis.
Special care must be taken in encoding patients with alcoholic epilepsy where there is actual danger of a major spasm within encoding or soon after. A certain amount of risk might be pardoned, but only when all other indications for the treatment of the primary disease - chronic alcoholism-by the Dovzhenko method are indisputable.
The essence of encoding in such patients was to find a, so to say, theoretical load-level where emotion-stress treatment would be both therapeutically effective and mild, if possible. This requires a long experience in psychotherapy, maximum of individualized approach to each patient, optimal psychological contact with the patient established in a short time and an ability to perform immediate release of excessive emotional and vegetative reactions.
In encoding the blind emphasis is made on acupuncture, verbal influence and specifically dosed loads on the patient's vestibular apparatus. The cascade-treatment principle is also applied here.
Our experience indicates that in encoding patients with craniocerebral injuries a psychotherapy session should be terminated with balancing the patient's psyche, relieving his psychic tension and vegetovascular reactions, for which purpose verbal suggestions can be accompanied by soft strokes on the patient's head and neck, or magnetic field influence (magnetors).
Catamnestic data over a year indicate that in the stage-version encoding with strictly individualized loads for each of the three patient groups discussed here response to the Dovzhenko stress-therapy is sufficiently high (85% positive response).

PSYCHOPHARMACOLOGICAL THERAPY IN THE SYSTEM OF TREATMENT OF ALCOHOLIC PATIENTS BY THE DOVZHENKO METHOD
л. л. Zikevskaia (Petersburg)

Chronic alcoholic patients examination and selection for treatment by the Dovzhenko stress-psychotherapy method (SPT) not infrequently revealed patients requiring treatment with pharmacologic means (in prescribing them, however, consideration was given to the fact that the Dovzhenko method depends on abstention from medications for 15-20 days before a session).
We examined 182 patients to whom psychotropic means were administered in individualized combinations and doses. In respect to personality traits and psychoneurotic disorder structure the patients could be divided in three groups:
1) patients with borderline psychoneurotic disorders-psychopathies, neuroses, defined character accentuations but without evidence of with-drawal by the start of examination - (102).
2) patients in mild but prolonged withdrawal conditions dominated by seemingly neurotic disorders with persistent obsessive alcohol addiction (47).
3) patients with marked withdrawal syndromes, physical and psychic discomfort evidence, vegetovascular disorders, steady alcohol addiction to an over-important level, sometimes compulsive (33).
Because of their specific condition, in particular of defined psycho-neurotic instability, all the patients had relative counterindications to the Dovzhenko method and in this respect could be considered risk group.
Psychopharmacological therapy for Group 1 patients was conducted preparatory to the SPT because of the advisability of releasing manifestations of emotional lability and tension, providing a steady background, normalizing sleep and appetite, compensating general psycho-neurotic condition.
Treatment in Group 2 depended on the need to arrest withdrawal manifestations, resolve seemingly neurotic symptomatology, reduce alcohol addiction. The objects were to attain maximum self-awareness and capacity for critical appraisal of the situation, to observe the regime of abstinence.
Psychopharmacological therapy in Group 3 seems necessary since out-patients in this Group would be unable to observe the required regime of abstinence without special pharmaceutical support.
Psychopharmacological therapy in all three groups was accompanied by rational psychotherapy and detoxification. In Groups 1 and 2 attention was at the time focused on rational psychotherapy, particularly in Group 1. Dominating in Group 3, together with psychopharmacological therapy, were detoxification measures.
Group 1 patients after the SPT course were, if indicated, offered counseling, administration of psychotropic means was resumed in small doses and short courses-up to two weeks. Similar support was given to Group 2 patients with persistent seemingly neurotic symptomatology. Courses there lasted up to 3-4 weeks.
We examined one more group (Group 4) of patients with disorders similar to those in Groups 1-3, but for some reasons not subjected to adequate Psychopharmacological therapy preparatory to the SPT.
The findings of one-year observations in Groups 1-3 as compared to Group 4, assumed as control group, indicated that treatment of alcoholic patients with psychotropic means preparatory to the SPT could increase therapeutic effectiveness by 9-12% (in various patient sections). Thus among patients subjected to the required psychopharmacological therapy 7-9% were decoded within a year after, while in control group the amount was 18-20%.
The findings suggest that for alcoholic patients with the background of pathologic personality traits or accompanying neurotic disorders, or acute character accentuations (risk group) referred for the Dovzhenko therapy psychopharmacological correction of psychosomatic condition and personality disorders is advisable. This correction is necessary for patients with defined withdrawal syndrome and compulsive alcohol addiction.
It should also be noted that examination and selection of patients for the SPT reveal patients with psychotic disturbances (paranoid states of schizophrenic origin, chronic alcoholic hallucinoses with tendency for delusions etc.). Such patients were not treated by the Dovzhenko method because of their deficient or absent critical appraisal of the disease and the danger of recurring delirious experiences. They were recommended psychotropic means (antopsychotics, antidepressants-sedatives, correctors) and observation in psychoneurologic dispensaries, and their relatives received relevant instructions.
In conclusion it should be emphasized that success in preparatory psychopharmacological therapy depends not on affecting the patient's alcohol addiction, but rather on strengthening his psychological resistance to emotional stresses.