BIOMEDICINA 3091 - sam.lrv.lt · BIOMEDICINA. 2010 m. “Sveikatos mokslai” Nr.2 3093 Panikos sutrikimo daþnis populiacijoje aiðkiai svyruo-ja nuo 1,4% iki 7,1%. Remiantis 1997

30912010 m. “Sveikatos mokslai” Nr.2

uþregistruotø N400 atsakø á neteisingus ir teisingus sakinius kitimui pavaizduota 3 pav.

Apibendrinant galima teigti, kad MGT potencialiai gali turëti teigiamà poveiká ðizofrenija sergantiems pacientams. Ðiai iðvadai pagrásti reikia atlikti daugiau panaðiø tyrimø.

IÐVADOS1. MGT taikymas kartu su áprastu medikamentiniu

gydymu gali suðvelninti tiek negatyviàjà, tiek pozityviàjà ðizofrenija serganèiøjø simptomatikà, sukurti prielaidas efektyvesniam ir kokybiðkesniam jø santykiui su ap-linka, padëti áveikti socialinæ ir emocinæ izoliacijà bei atsiribojimà.

2. Labai svarbu, kad uþsiëmimus vestø asmuo, þinantis ir suprantantis serganèiøjø ðizofrenija problemas bei turintis praktinio darbo su jais patirtá, prieðingu atveju nepavyktø suformuoti pacientø motyvacijos darbui.

3. N400 potencialo tyrimas parodë, kad MGT gali turëti poveiká pacientø reakcijai á semantiðkai teisingus sakinius.

Literatûra1. Kumar N, Debruille B. Semantics and N400: insights for

schizophrenia. J Psychiatry Neurosci. 2004; 29(2):89-98.2. Kutas M, Hillyard SA. Reading senseless sentences: Brain

potentials reflect semantic incongruity. Science. 1980; 207:203-5.3. Kutas M, Kluender R. What is who violating? A reconsidera-

tion of Linguistic Violations in Light of Event-Related Brain Potentials. In: H.-J. Heinze, T. F. Münte, and G. R. Mangun (Eds.). Cognitive Electrophysiology, Birkhauser Boston. 1994; 183-210.

4. Kutas M, Van Petten CK. Psycholinguistics Electrified. Event-Relates Brain Potential Investigations. In M. A. Gernsbacher (Ed.), Handbook of psycholinguistics. San Diego, Academic Press, 1994; 83-143.

5. Maèiulis V., Marèënienë S., Banaitis V., Dapðys K., Utkuvienë J. Metaglossotherapy in treatment of schizophrenia. Ab-stracts of 1st Eastern European Psychiatric Congress, Thessaloniki, September 21-23, 2007. Psychiatriki. 2007; 18(1):110.

6. Mathalon DH, Faustman WO, Ford JM. N400 and Automa-tic Semantic Processing Abnormalities in Patients With Schizophrenia. Arch Gen Psychiatry. 2002; 59:641-8.

7. Matulis AC. Language... a hope: an introduction to metag-

lossotherapy. 1977, National Research Institute for Psychoanalysis and Psychology (Detroit), 113.

8. Matulis AC. A New-Foreign Language In The Treatment of Schizophrenia: an Application Of Metaglossotherapy. Metaglossothe-rapy: As presented in Rome Italy in 1984 to the Lithuanian Catholic Academy of Sciences. National Research Institute for Neurology and Psychology:

. 9. Sitnikova T, Salisbury DF, Kuperberg G, Holcomb PJ. Elec-

trophysiological insights into language processing in schizophrenia. Psychophysiology. 2002; 39:851-60.

METAGLOSSOTHERAPY IN TREATMENT OF SCHIZOPHRENIA Valentinas Maèiulis, Sonata Marèënienë, Kastytis Dapðys, Valdas

Banaitis, Janina Utkuvienë, Akvilë JarmalavièiûtëSummaryKey words: metaglossotherapy, schizophrenia, neurophysiology,

brain evoked potential N400.Metaglossotherapy (MGT) is the method of treating schizophrenic

patients by teaching them a new foreign language. Training of brain and establishing new associations during the course of MGT treatment has a positive influence on schizophrenic patients.

The aim of the study was to evaluate the efficacy of MGT in treating schizophrenic patients.

Methods. 7 long-stay male schizophrenic patients took part in the program, which lasted 5 months, 5 sessions of MGT a week. Patients were learning English. Evoked potential N400 was registered at baseli-ne and after MGT in order to evaluate the effectiveness of the therapy. Dynamics of mental state was evaluated with help of PANSS.

Results. During MGT significant changes in motivation, behaviour, non-verbal expressions and emotional state of patients were observed. PANSS: negative and positive symptoms became milder, changes are statistically significant. N400 responses of schizophrenic patient do not depend on the congruity of sentence endings. Compared with healthy subjects patients generate N400 with smaller amplitude and larger latency.

Conclusions. Application of MGT can create possibilities for schi-zophrenic patients for better relationships with the environment, to help them overcome social and emotional isolation. It is very important that activities would be led by the persons who have practical experience to work with schizophrenic patients. MGT may affect patient’s response to semantic congruent sentences.

Correspondence to: [email protected]

Gauta 2009-12-06

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“Sveikatos mokslai” Nr.2 2010 m.3092

Raktaþodþiai: panikos sutrikimas, panikos priepuoliai, ðirdies ir kraujagysliø ligos.

SantraukaPaskutiniuose tyrimuose vedamos paralelës tarp panikos sutrikimo bei ðirdies ir kraujagysliø ligø. Panikos sutrikimø raiðka populiacijoje – 4,7 %, o tarp serganèiøjø pirmine arterine hipertenzija, 1999 m. atliktos studijos duomenimis, panikos su-trikimo daþnumas yra didesnis, ðá teiginá patvirtina ir 2008 m. M. Esler publikuotas straipsnis, kuriame teigiama, kad panikos sutrikimas pasitaiko tris kartus daþniau tarp serganèiøjø pirmine arterine hipertenzija nei bendroje populiacijoje. Abiejø bûkliø metu stebimas kortizolio, adrenalinà sin-tezuojanèio hormono koncentracijos didëjimas, simpatinë aktyvacija, suintensyvëjæs adrenalino iðskyrimas ir sutrikusi noradrenalino reabsorbcija. Gausëja árodymø, kad oksidacinis stresas ir uþde-giminis komponentas svarbus panikos sutrikimo bei kardiovaskuliniø ligø patogenezëje. Aukðtas nerimo lygis skatina reaktyviø deguonies radika-lø susidarymà, dël jo didëja oksidacinio streso indeksas ir ûmios fazës baltymø koncentracija. Kardiologø atliekamuose tyrimuose oksidacinis stresas siejamas su miocitø gynybos mechaniz-mø bei mitochondrijø paþeidimais, nustatyta, kad jis sukelia endotelio disfunkcijà, lemdamas koronarinës ðirdies ligos iðsivystymà. Lietuvoje, tiriant panikos sutrikimà, ávertinus jo poveiká kardiovaskulinei sistemai ir gautus rezultatus pritaikius gydymo praktikai, bûtø galima pasiekti þymiai geresniø gydymo rezultatø.

ÁVADASPaskutiniuose tyrimuose vedamos paralelës tarp pani-

kos sutrikimo bei ðirdies ir kraujagysliø ligø, vis daþniau prabylama apie panikos sutrikimo komorbidiðkumà su ðirdies kraujagysliø ligomis, atrandama bendrø patogene-zës mechanizmø. Panikos sutrikimas – nepriklausomas rizikos veiksnys, lemiantis koronarinæ ðirdies ligà.

Darbo tikslas - árodyti didesná sergamumà panikos sutrikimu tarp ðirdies kraujagysliø ligomis serganèiøjø bei ávertinti pasikartojanèio ilgalaikio streso sukeliamus pakitimus.

METODIKAPanikos sutrikimo istorijos pradþia laikomas Da Costa

sindromas, pavadintas pagal 1871 m. publikacijà, ap-raðanèià Amerikos civiliniame kare dalyvavusiø kareiviø sveikatos sutrikimus. Panaði bûsena vadinta neurocir-kuliacine astenija, pastangø sindromu, dirglios ðirdies sindromu, kareivio ðirdimi, kardiovaskuline neuroze [1]. 1895 m. Z. Freudas iðkyrë neurastenijà – nuolatinio, vidutinio nerimo bûsenà ir epizodiðkai uþeinanèius in-tensyvaus nerimo priepuolius (ûmi nerimo neurozë). T. Lewis 1933 m. raðë, kad sindromas nëra bûdingas vien sergantiems kareiviams ar atletams, taèiau daþnai pasi-reiðkia nejudriems miestø gyventojams [2]. J.L. Caughey 1939 m. apraðo kardiovaskulinæ neurozæ [1], kuri suside-da ið sumiðusiø psichologiniø ir fiziologiniø komponentø ir mëgdþioja organinës ligos sukeltus simptomus, taèiau negali bûti paaiðkinta patologiniais kardiovaskulinio aparato pokyèiais. Medicininëje nomenklatûroje ter-minas panikos sutrikimas pirmà kartà pavartotas 1980 m. DSM-III redakcijoje, iðleistoje Jungtinëse Amerikos Valstijose [3].

Panikos sutrikimas – sunki, varginanti ir daþna liga. Esminis sutrikimo poþymis yra pasikartojantys stipraus nerimo priepuoliai, nesusijæ su kokia nors specifine situ-acija ar aplinkybëmis, psichoaktyviøjø medþiagø varto-jimu, todël jø negalima prognozuoti. Panikos priepuolis prasideda netikëtai, staigiu autonominës nervø sistemos simptomø augimu ir daþniausiai praeina savaime per 10-20 minuèiø. Panikos priepuolio metu kylantys simptomai ávairûs ir intensyvûs – oro trûkumas, springimo jausmas, diskomfortas ðirdies plote, pykinimas, tirpimas, galvos svaigimas, baimë prarasti situacijos kontrolæ, iðprotëti ar numirti. Panikos sutrikimas diagnozuojamas, kuomet panikos priepuoliai kartojasi, praëjus iðlieka baimë, kad iðtiks kitas priepuolis ir, þinoma, atmetama kita somatinë patologija ar psichikos liga.

PANIKOS SUTRIKIMAS IR JO RYÐYS SU ÐIRDIES IR KRAUJAGYSLIØ LIGOMIS

INDRAJA VELIÈKIENË1, VITA DANILEVIÈIÛTË1, VALMANTAS BUDRYS21 Vilniaus universiteto Medicinos fakulteto Psichiatrijos klinika,

2 Vilniaus universiteto Medicinos fakulteto Neurologijos ir neurochirurgijos klinika

Adresas susiraðinëti: Indraja Velièkienë, el. p.: [email protected]

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Panikos sutrikimo daþnis populiacijoje aiðkiai svyruo-ja nuo 1,4% iki 7,1%. Remiantis 1997 m. atliktais epide-miologiniais tyrimais, JAV panikos sutrikimas nustatomas 3,4% gyventojø gyvenimo laikotarpiu; Italijoje – 2,9%, o Taivane – tik 0,4% gyventojø [4]. R.C. Kessler 2005 m. atlikto tyrimo duomenimis, panikos sutrikimas diagno-zuojamas 2,7% gyventojø per paskutinius 12 mënesiø, o gyvenimo laikotarpiu – 4,7%. R.C. Kessler 2006 m. JAV atliktø tyrimø rezultatai rodo, kad panikos sutrikimas be agorafobijos vargina 3,7% gyventojø gyvenimo laikotar-piu ir 1,1% gyventojø pasitaiko panikos sutrikimas su agorafobija [5], taèiau tyrinëtojø pateikiami duomenys labai skiriasi, pavyzdþiui, 1993 m. D.A. Katerndahl ir J.P. Realini tyrime apraðoma, kad net 15% amerikieèiø savo gyvenime yra patyræ panikos priepuoliø ar sirgæ panikos sutrikimu. Tokius skirtingus duomenis galëtø paaiðkinti tyrimø metodikos ypatumai ir kartu tai rodo, kad tikslinga tobulinti metodikas ir diagnostikà. Lyginant serganèiøjø panikos sutrikimu lyèiø skirtumus K.A. Yonkers 1998 m. atliktoje studijoje nustatyta, kad moterys serga 2,5-3 kartus daþniau nei vyrai ir joms priepuoliai po pasiektos remisijos pasikartoja daþniau. Tà patvirtina ir japonø H. Kaiya su bendraautoriais 2005 m. atliktas tyrimas, kurio duomenimis, moterys du kartus daþniau serga panikos sutrikimu ar patiria panikos priepuoliø, tai ypaè iðryðkëja vyresniame amþiuje apie penkiasdeðimtuosius gyvenimo metus [6].

Panikos sutrikimo patogenezëje iðskiriamos trys pagrindinës teorijos: psichodinaminë, kognityvinë bei neurobiologinë. Psichodinaminë teorija panikos sutriki-mà paaiðkina uþslopintais intensyviais jausmais, tokiais kaip pyktis (B. Milrod ir M.K. Shear, 1991). Patogenezëje svarbûs veiksniai gali bûti iðsiskyrimas su tëvais, jø, ypaè motinos netektis [7].

Kognityvinë teorija teigia, kad pacientams, linku-siems susitelkti ties kylanèiais vidiniais pojûèiais (D.M.A. Clark, 1986 m.)[8], bûdinga iðreikðta baimë susirgti sunkia fizine ar psichine liga, o panikos priepuolio metu prasidedantys fiziniai simptomai sukelia dar didesná ne-rimà, sustiprina baimæ sirgti sunkia liga. Neurobiologinëteorija paremta tuo, kad panikos priepuolá galima sukelti eksperimentiniu bûdu (ypaè pacientams, linkusiems sirgti panikos sutrikimu [9]) ir slopinti panikos prie-puolá medikamentais. Panikos priepuoliai sukeliami eksperimentais, naudojant anglies dioksidà (CO2), laktatà, kofeinà, cholecistokinino tetrapeptidà (CCK-4), isoproterenolá, johimbinà, kortizolá, 5-hidroksitriptamino receptoriø, agonistus ir kt. medþiagas.

D.F. Klein 1993 m. pateikë uþdusimo pavojaus teo-rijà, pagal kurià pacientai jautriai reaguoja á didëjanèià

anglies dioksido koncentracijà kraujyje, taèiau atlikus tyrimus paaiðkëjo, kad pacientai jautriai reaguoja ir á anglies dioksido koncentracijos padidëjimà, ir á hiper-ventiliacijà (anglies dioksido koncentracijos sumaþëji-mà) [10]. Vertinant panikos sutrikimu serganèiø pacientø CO2 koncentracijà, kvëpavimo daþná, kvëpuojamàjá oro tûrá bei minutiná kvëpavimo tûrá, iðryðkëjo kvëpavimo rodikliø kitimai ir tai gali bûti kvëpavimo funkcijos ne-stabilumo þymuo [9]. 2004 m. E. Berzak ir bendraautoriø atlikto tyrimo duomenimis, pacientai, sergantys panikos sutrikimu, intensyviau reagavo á padidëjusià CO2 kon-centracijà ákvepiamame ore, atsiradusius simptomus buvo linkæ vertinti kaip panikos priepuolá; vienà kartà gyvenime patyræ panikos priepuolá á CO2 koncentraci-jos pokyèius nereagavo. Tokiø tyrimø jautrumas 41%; specifiðkumas 100%, tad jie gali bûti taikomi praktikoje diferencijuojant vienà kartà gyvenime buvusá panikos priepuolá su panikos sutrikimu ir polinkiu priepuoliams kartotis [11]. Matuoti CO2 koncentracijà panikos prie-puolio metu sunkiau, tad naudingesnis laktatø tyrimas. Laktatai parodo kompensaciná metaboliná atsakà, atsi-radusá dël respiracinës alkalozës, atvykus po panikos priepuolio [6, 35].

Kita svarbi anksèiau minëta medþiaga – cholecis-tokinino tetrapeptidas (CCK-4) – dalyvauja ávairiuose fiziologiniuose procesuose, pvz., po valgio sukelia hiperemijà þarnyne, veikia þarnyno motorikà, didina smegenø barjero pralaidumà leptinui, per vidurines smegenis, pagumburá veikia kardiovaskulinæ sistemà, skatindamas stresiniø hormonø iðsiskyrimà. Ðis peptidas svarbus ûmiam kardiovaskuliniam atsakui ir elgesio po-kyèiams á iðskirtinius fizinius bei psichologinius iððûkius, taèiau ilgai trunkantis CCK -4 sistemos stimuliavimas sukelia panikos sutrikimà ar lëtiná skausmà, iðreikðtà autonominës aktyvacijos bûklæ. CCK-4 sukelia eksperi-mentinius panikos priepuolius, jø metu didëja arterinis kraujo spaudimas, intensyvëja adrenokortikotropinio hormono, prolaktino bei augimo veiksnio iðskyrimas, ðie pokyèiai akivaizdesni sergantiesiems panikos sutrikimu [12]; remiantis 2008 m. D. Eser su bendraautoriais atliktu tyrimu, galima daryti prielaidà, kad CCK-4 sukeltø pani-kos priepuoliø metu labiau intensyvëja neurobiologiniai nei psichologiniai veiksniai.

REZULTATAIIeðkant biologiniø árodymø dar 1999 m. atliktoje

studijoje nurodomas didesnis panikos sutrikimo daþnis tarp serganèiøjø pirmine arterine hipertenzija, ðá tei-giná patvirtina ir 2008 m. M. Esler su bendraautoriais publikuotas straipsnis, kuriame teigiama, kad panikos

BIOMEDICINA


sutrikimas pasitaiko tris kartus daþniau tarp serganèiøjø pirmine arterine hipertenzija nei bendroje populiaci-joje [13]. Panikos sutrikimo patogenezëje iðryðkëjantis plazmos kortizolio koncentracijos padidëjimas, adrena-linà sintezuojanèio hormono koncentracijos didëjimas, simpatinë aktyvacija, suintensyvëjæs adrenalino iðsky-rimas ir sutrikusi noradrenalino reabsorbcija inicijuoja morfologinius pokyèius, bûdingus kardiovaskulinëms ligoms [13]. M. Esler atlikto tyrimo rezultatai rodo, kad kortizolio koncentracija buvo didesnë ir pirmine arterine hipertenzija, ir panikos sutrikimu serganèiøjø grupëse, panaðûs duomenys gauti M. Hamer su bendraautoriais [14] ir G.G. Manfro su bendraautoriais atliktø tyrimø metu [15]. Prieðtaringus duomenis pateikia K. Petrowski su bendraautoriais, tyræ kortizolio koncentracijà seilëse. Ðiø tyrimø duomenimis, ir serganèiø panikos sutrikimu, ir sveikø tiriamøjø kortizolio koncentracija seilëse buvo panaði prieð taikant laboratorinio streso protokolà (Trier‘o socialinio streso testà), taèiau po testo ðirdies susitrau-kimø padaþnëjimas buvo bûdingas abiems grupëms, o kortizolio koncentracija seilëse skyrësi: kontrolinëje grupëje kortizolio koncentracija didëjo, o panikos sutri-kimu sergantiems, kortizolio koncentracijos padidëjimo nustatyta nebuvo [16]. Panikos priepuolio metu iðsiskiria katecholaminai, sukeliantys hipertenzijà, ir suaktyvëja lipoproteinlipazë, kuri sukelia hiperlipidemijà [17], ir tai yra vienas paaiðkinimø, kodël panikos priepuoliai patogenetiðkai siejami su ðirdies kraujagysliø ligomis. Paroksizminë hipertenzija bûdinga panikos sutrikimu sergantiems pacientams, atmetus kitas galimas prieþastis, pateikiamos rekomendacijos gydyti ir kardiologui, ir psichiatrui [18]. Pacientams, kurie serga arterine hiper-tenzija, panikos priepuoliø metu labiau iðryðkëja auto-nominë disfunkcija – prakaitavimas, veido paraudimas, ðirdies ritmo sutankëjimas, nei normotenziniø pacientø grupëje [19], tokie duomenys pabrëþia hipertenzijos ir panikos priepuoliø ryðá. Pirmine arterine hipertenzija sergantiesiems yra bûdingas noradrenalino reabsorbcijos sutrikimas [20], stipriau pasireiðkiantis normosteninio kûno sudëjimo pacientams nei turintiems antsvorá. 2004 m. tyrimo duomenimis, sergantiesiems panikos sutrikimu daþniau pasitaiko arterinio kraujo spaudimo padidëji-mas, ir tai gali bûti viena ið padidëjusio mirtingumo dël kardiovaskulinës patologijos prieþasèiø [21].

Panikos priepuolio metu simpatiniuose nervuose pa-stebima staigi aktyvacija, uþraðoma atliekant klinikinæ mikroneurografijà, ir nustatomas noradrenalino pertek-lius, sutrikusi reabsorbcija. Stipri simpatinë aktyvacija kitø bûkliø metu, pvz., ðirdies nepakankamumo atveju, lemia padidëjusià kardiovaskulinæ rizikà [22]. Taip pat

svarbus simpatiniø nervø kotransmiteris neuropeptidas Y, iðsiskiriantis panikos priepuolio metu ir lemiantis koronariniø arterijø spazmà [22]. Streso metu padidëjæs neuropeptido Y iðskyrimas skatina vazokonstricijà bei sukelia kraujagysliø paþeidimus, bûdingus ateroskle-rozei [22-24].

D.A. Katherndahl 2005 m. apþvelgia panikos sutri-kimo ir ðirdies kraujagysliø ligø komorbidiðkumà (nuo 8% iki 21%), iðskirdamas teiginius, kad sergantiesiems ðirdies kraujagysliø ligomis gretutinis panikos sutrikimas gali lemti pagalbos ieðkojimà, taip pat ir kardiologiná ávyká [25]. Panikos sutrikimas – nepriklausomas rizikos veiksnys susirgti ûmiu miokardo infarktu, metø laiko-tarpiu diagnozavus panikos sutrikimà: 4,77% pacientø ávyko miokardo infarktas, kontrolinëje grupëje – 2,73%, tad statistiðkai patikimai rizika didesnë 1,75 karto [26].

Paskutiniuose psichiatrijos ir kardiologijos mokslo tyrimuose minimas oksidacinis stresas, kuris susijæs su vëþiu, kardiovaskulinëmis ligomis, nerimo sutrikimais. Aukðtas nerimo lygis skatina reaktyviø deguonies radi-kalø susidarymà periferiniame kraujyje: limfocituose, granuliocituose bei monocituose [27]. G.G. Manfro apraðo serganèiøjø panikos sutrikimu imunologinius pokyèius, IL-2 koncentracijos padidëjimà bei limfocitø pavirðiaus molekuliø (L-selektinø) ekspresijà [15].

2008 m. M.A. Ersoy ir bendraautoriø atliktame tyri-me nustatytas oksidacinio streso indekso ir ûmios fazës baltymø koncentracijos padidëjimas sergantiesiems panikos sutrikimu lyginant su kontroline sveikø þmoniø grupe [28]. L. de la Fontain 2009 metais atlikto tyrimo duomenimis, sergantiems panikos sutrikimu pacientams nustatomas IL-6 koncentracijos padidëjimas, ryðkiausias praëjus dviem valandoms po eksperimentiniu bûdu sukelto panikos priepuolio [29]. IL-6 koncentracijos padidëjimas nustatytas ir pacientams, persirgusiems miokardo infarktu (praëjus 3-9 mënesiams po ávykio), taip pat vertintos fibrinogeno ir C reaktyvaus baltymo koncentracijos, nustatyti jø padidëjimai [30].

Kardiologø atliekamuose tyrimuose akcentuojama oksidacinio streso sukeliami miocitø gynybos mechaniz-mø bei mitochondrijø paþeidimai. Ûmus bei lëtinis stre-sas sutrikdo pusiausvyrà pro- bei prieð- ateroskleroziniø veiksniø, kurie sukelia kraujagysliø endotelio disfunkcijà ir veda link koronarinës ðirdies ligos bei miokardo in-farktà [31]. Paskutiniø metø Minamino T., Kitakaze M. atliktuose tyrimuose atkreipiamas dëmesys á oksidacinio streso poveiká làsteliø endoplazminiam tinklui, kurio paþeidimai sutrikdo baltymø sintezæ ir net gali sukelti kai kuriø làsteliø apoptozæ, ðie mechanizmai dalyvauja

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kardiovaskuliniø ligø, aterosklerozës patogenezëje[17]. B. Bringager su bendraautoriais vertino panikos su-

trikimo átakà mirtingumui, sergamumui bei gyvenimo kokybei – ryðkesniø skirtumø mirtingumui tarp tiriamøjø ir kontrolinës grupës neiðryðkëjo, taèiau gyvenimo koky-bë buvo pablogëjusi, vargino gretutinës ligos bei sutrikæs funkcionavimas [32]. 2005 m. R. Fleet su bendraauto-riais tyrë pacientus, kuriems diagnozuotas panikos su-trikimas, panikos priepuolio metu, nepaisant gydymo, iðryðkëjo ðirdies raumens perfuzijos sutrikimas, autoriø pateikiamos iðvados – panikos sutrikimas kenksmingas ðirdþiai [33].

2008 metais Jungtinëje Karalystëje buvo atliktas vienas didþiausiø tyrimø: „Panikos sutrikimas ir naujai prasidëjusios koronarinës ðirdies ligos, ûmaus miokardo infarkto ir mirtingumo dël kardiologinës patologijos rizika: kohortinis tyrimas, atliktas naudojant bendrosios praktikos tyrimø duomenø bazæ“ (angl. Panic disorder and risk of new onset coronary heart disease, acute miocardial infarction and cardiac mortality: cohort study using the general practice research database), kuriame dalyvavo daugiau nei 400 tûkst. tiriamøjø. Lygintos grupës: 57615 pacientø, kuriems diagnozuota panikos sutrikimas/priepuoliai, bei 347039 asmenø kontrolinë grupë. Tyrimo metu paaiðkëjo, kad diagnozuotas panikos sutrikimas/priepuoliai jaunesniems nei 50 metø amþiaus grupës tiriamiesiems këlë þymiai didesnæ rizikà susirgti miokardo infarktu nei vyresniøjø grupës tiriamiesiems ir, nepriklausomai nuo amþiaus, pacientai, kuriems buvo diagnozuotas panikos sutrikimas/priepuoliai, daþniau sirgo koronarine ðirdies liga. Mirtingumas dël kardiovaskulinës patologijos buvo sumaþëjæs panikos sutrikimà/priepuolius patirianèioje grupëje [34]. Tokius duomenis galima bûtø paaiðkinti intensyvesniu pacientø, kuriems diagnozuotas panikos sutrikimas stebëjimu, kompleksiniu gydymu.

IÐVADOSPanikos sutrikimas diagnozuojamas 4,7% þmoniø

bendroje populiacijoje ir net tris kartus daþniau nu-statomas sergantiesiems ðirdies ir kraujagysliø ligomis. Gausëja árodymø, kad oksidacinis stresas ir uþdegiminis komponentas svarbus panikos sutrikimo bei kardiovas-kuliniø ligø patogenezëje, panikos sutrikimas vertinamas kaip nepriklausomas rizikos veiksnys susirgti koronarine ðirdies liga. Lietuvoje, tiriant panikos sutrikimà, ávertinus jo poveiká kardiovaskulinei sistemai ir gautus rezultatus pritaikius gydymo praktikai, bûtø galima pasiekti þymiai geresniø gydymo rezultatø.

Literatûra1. Caughey JL. Cardiovascular Neurosis. Psychosomatic me-

dicine. 1939; 1(2):311-324.2. Wooley ChF. Where are the Diseases of Yesteryear? Circu-

lation. 1976; 53:749-751. 3. American Psychiatric Association (APA). Diagnostic and

Statistical Manual of Mental disorders (3rd ed.). Washington, DC, American Psychiatric Association, 1980.

4. Weissman M, Bland RC, Canino GJ. et al. The Cross-na-tional Epidemiology of Panic Disorder. Arch Gen Psychiatry. 1997; 54(4):305-309.

5. Kessler RC. The Epidemiology of Panic Attacks, Panic Disor-der, and Agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006; 63(4):415-424.

6. Kaiya H, Umekage T, Ðarada S. et al. Factors Associated with the Development of Panic Attack and Panic Disorder: Survey in Japanese population. Psychiatry and Clinical Neurosciences. 2005; 59:177-182.

7. Gabbard GO. Psychodynamics of panic disorder and social phobia. Bulletin of The Menninger Clinic. 1992; 56:2A.

8. Clark DMA. cognitive approch to panic. Behav Res Ther. 1986; 24(4):461-70.

9. Niccolai V, Duinen MA, Gertz EJ. et al. Respiratory Patterns in Panic Disorder Reviewed: a Focus on Biological Challenge Tests. Acta Psychiatrica Scandinavica. 2009; 120(3):167-77.

10. Schmidt NB, Telch MJ, Jaimez TL. Biological challenge manipulation of PCO2 levels: a testo f Klein‘s (1993) suffocation alarm theory of panic. Journal of Abnormal Psychology. 1996; 105(3):446-54.

11. Berzak E, Reznik M, Narsia O, Benjamin J. Sensitivity to Carbon Dioxide in Subjects with a Single Lifetime Panic Attack: Pos-sible Clinical „Bedside“ Predictive Test for Panic Disorder after a First Panic Attack. Depression and Anxiety. 2005; 20:48-50.

12. Koszycki D, Zacharko MR, Melledo JM, Bradwejn J. et al. Behavioral, Cardiovascular, and Neuroendocrine Profiles Following CCK-4 Challenge in Healthy Volunteers: a Comparison of Panickers and Non Panickers. Depression and Anxiety. 1998; 8(1):1-7.

13. Esler M, Eikelis N, Schlaich M. et al. Chronic Mental Stress is a Cause of Essential Hypertension: Presence of Biological Markers of Stress. Clinical and Experimental Pharmacology and Physiology. 2008; 35(4):498-502.

14. Hamer M, O‘Donnell K, Lahiri A, Steptoe A. Salivatory cortisol responses to mental stress are associated with coronary artery calcification in healthy men and women. European Heart Journal. PMID:19744954, 2009; 10.

15. Manfro GG, Pollack MH, Otto MW. et al. Cell-surface expression of L-selectin(CD62L) by blood lymphocytes: correlates with affective parameters and severity of panic disorder. Depression and Anxiety. 2000; 11:31-37.

16. Petrowski K, Herold U, Joraschky P. et al. Astriking pattern of cortisol non-responsiveness to psychosocial stress in patients with panic disorder with concurrent normal cortisol awakening responses. Psychoneuroendocrinology. PMID19913360, 2009.

17. Minamino T, Kitakaze M. ER stress in cardiovascular dis-sease. J Mol Cell Cardiol. PMID: 19913545, 2009.

18. Pickering TG, Clemow L. Paroxysmal hypertension: the role of stress and psychological factors. Journal of Clinical Hypertension. 2008;10(7):575-81.

19. Davies SJ, Jackson PR, Lewis G. et al. Is the association of hypertension and panic disorder explained by clustering of autonomic panic symptoms in hypertensive patients? J Affective Disorders. 2008; 111(2-3):344-50.

BIOMEDICINA


20. Rumantir MS, Kaye DM, Jennings GL. et al. Phenotypic Evidence of Faulty Neuronal Norepinephrine Reuptake in Essential Hypertension. Hypertension. 2000;36:824-829.

21. Yeragani VK, Mallavarapu M, Radhakrishna RK, Tancer M, Uhde T. Depression and Anxiety. 2004; 19(2):85-95.

22. Esler M, Alvarenga M, Lambert G. Cardiac Sympathetic Nerve Biology and Brain Monogamine Turnover in Panic Disorder. Annuals N.Y. Academy of Sciences. 2004; 1018: 505-514.

23. Kuo EL, Zukowska Z. Stress, NPY and vascular remodeling: implications for stress-related diseases. Peptides. 2007; 28(2):435-440.

24. Hass M. Neuropeptide Y: a cardiac sympathetic cotransmit-ter? Catecholamines – Bridging basic Science With Clinical Medicine. Academic Press, 1998; 129-132.

25. Katherndahl DA. The association between panic disorder and coronary artery disease among primary care patients presenting with chest pain: an updated literature review. Journal of Clinical Psy-chiatry. 2008;10(4):278-282.

26. Chen YH, Tsai SY, Lee HC, Lin HC. Increased risk of acute myocardial infarction for patients with panic disorder: a nation wide population-based study. Psychosomatic Medicine. 2009; 71(7):798-804.

27. Rammal H, Bouaved J, Younos C, Soulimani R. The impact of high anxiety level on the oxidative status of mouse peripheral blood lymphocytes, granulocytes and monocytes. Eur J Pharmacol. 2008; 589(1-3):173-5.

28. Ersoy MA, Selek S, Celik H. et al. Role of oxidative and antioxidative parameters in ethiopathogenesis and prognosis of panic disorder. Int J Neurosci. 2008; 118(7):1025-37.

29. Fontain L, Schwarz MJ. Eser D. et al. Effects of experimen-tally induced panic attacks on neuroimmunological markers. J Neural Transm. 2009; 116:699-702.

30. Lowe GD, Woodward M, Rumley A. Associations of plazma fibrinogen assays, C- reactive protein and interleukin-6 with previuos myocardial infarction. J Thromb Haemost. 2003; 1(11):2312-6.

31. Nickel T, Deutschmann A, Hanssen H. et al. Modification of endothelial biology by acute and chronic stress hormones. Microvasc Res. 2009; 78(3):364-9.

32. Bringager BC, Arnesen H, Friis S. et al. A long-term follow-up study of chest pain patients: effect of panic disorder on mortality, morbidity, and Quality of life. Cardiology. 2008; 110(1):8-14.

33. Fleet R, Lesperance F, Arsenault A. et al. Myocardial per-fusion study of panic attacks in patients with coronary artery disease. American Journal of Cardiology. 2005; 96(8):1064-8.

34. Salters K, Rait G, Petersen I, Williams R, Nazareth I. Panic disorder and risk of new onset coronary heart disease, acute miocardial infarction and cardiac mortality: cohort study using the general practice research database. European Heart Journal. 2008; 29:2981–2988.

35. Ueda Y, Aizawa M, Takahashi A. Exaggerated compensatory response to acute respiratory alcalosis in panic disorder is induced by increased lactic acid production. Nephrol Dial Transplant. 2009; 24(3):825-8.

THE LINK BETWEEN PANIC DISORDER AND CARDIOVASCU-LAR DISEASES

Indraja Velièkienë, Vita Danilevièiûtë, Valmantas BudrysSummaryKey words: panic disorder, panic attacks, cardiovascular diseases.

At the present time, the question of chronic mental stress links with vari-ous kinds of somatic diseases and parallels between panic disorder and cardiac diseases especially, arises. It is being emphasized that panic disorder is one of the states which provide a clinical model of recurring stress responses. There is 4,7 percent prevalence of panic disorder in general population. The rate of panic disorder among cardiac patients is three times more frequent in comparison to general population. The aim of the paper is to discuss biological and psychological peculiarities of the stress response and to define the link between cardiovascular diseases and panic disorder. In the both conditions there is the arousal of the sympathetic nervous system, increase of CO2; lactate; cortisol; adrenalin synthesizing hormone concentrations in blood. The mental stress initiates an increase in oxidative stress parameters and alters the defence mechanisms in myocytes, the malfunction of endothelium leading to cardiovascular events. There is evidence that the inflam-matory component as well as oxidative parameters plays an important role in panic disorder and cardiovascular diseases pathogenesis. As far as panic disorder is seldom discussed, it is important to diagnose, estimate the high risk groups and use the preventive means and treat-ment methods.


Gauta 2009-12-08

BIOMEDICINA

30972010 m. “Sveikatos mokslai” Nr.2 APÞVALGA

Raktaþodþiai: Catha edulis, katas, katinas, katinonas, amfetaminai, Salvia divinorum, Salvinorinas A, psi-choaktyvûs augalai, haliucinogenai.

Santrauka Piktnaudþiavimas stimuliaciniais preparatais - didþiulë problema pasaulyje. Psichostimuliaciniø savybiø turinèiø ávairiø þoliniø preparatø prieinamumas lengvëja, vartojimas didëja. Populiariuose interneto puslapiuose jie siûlomi pirkti tarsi legali þolinë alternatyva nelegaliems haliucino-genams. Ðiame apþvalginiame straipsnyje aptariami nauji psichoaktyvûs þoliniai preparatai: katas (Catha edulis), daugiametë mëtø ðeimos þolë – kvaitulinis ðalavijas (Salvia divinorum), keletas Pietø Afrikos augalø rûðiø („Kanna þolelës“, gyslotojo vyklio sëklos, „Spice“ þoliø miðiniai). Bendriausia piktnaudþiavimo vaistais forma Rytø Afrikoje yra kato (Catha edulis) lapø ir ûgliø kramtymas ir seiliø nurijimas. Þolininkai katu gydo depresijà, nuovargá, nutukimà ir skrandþio opas. Kato augale yra du aktyvûs alkaloidai: katinas ir katinonas. Pastarasis yra veiklesnis psichostimuliatorius. Kvaitu-linis ðalavijas dël savo psichoaktyvaus poveikio buvo vartojamas daugelá ðimtmeèiø. Aktyvusis komponentas yra salvinorinas A – beazotinis, nealkaloidinis selekty-vus kappa opioidiniø receptoriø agonistas. Jis sukelia ryðkias, trumpalaikes haliucinacijas. Straipsnyje aptar-iama ðiø augalø, kaip psichostimuliatoriø, vartojimas, epidemiologija, vartojimo bûdas, farmakokinetika, toksikologija, diagnostikos metodai, pateikiamos þinios apie jø vartojimo legalumà.

ÁVADASGyvenimo tempas, begalë rûpesèiø, socialinës,

ekonominës, ðeimyninës problemos lemia daþnëjantá nuovargio jausmà, adaptacijos sutrikimus. Visi nori jaus-tis þvalûs, energingi, sveiki, lengvai bendrauti, maþiau galvoti apie kasdienybæ. Todël, ypaè nuo XX a., iðplito ir toliau plinta ávairiø psichostimuliatoriø vartojimas. Sintezuoti (amfetaminai ir kt.) bei augaliniai alkaloidai

(kokainas, efedrinas ir kt.) visuomenei jau tapo þinomi kaip draudþiami, nelegalûs, kenksmingi [1]. Kaip al-ternatyva jiems padaþnëjo naujø augaliniø preparatø, neretai vertinamø kaip legaliø, tiek reklamavimas, tiek vartojimas. Supaþindiname su keletu jø.

Katas Katas (khat, qut, kat, chaat, Kus es Salahin, Tchaad,

Gat) tai psichostimuliacinis augalas Catha edulis, pri-klausantis Celastaceae ðeimai. Já apraðë ir pavadino (arabiðkà pavadinimà khat pakeitæs á panaðø Catha) botanikas Peter Forsskal, þuvæs Jemene 1763 m. [2].

Catha edulis amþinai þaliuojantis krûmas (dabar ir kultivuojamas), augantis virð jûros lygio rytinëje ir pietø Afrikoje, Afganistane, Jemene ir Madagaskare [2-7].

Ðio krûmo þali lapai ir ûgliai dël malonaus euforinio, nuovargá ðalinanèio poveikio vartojami jau daugiau nei 600 metø [2, 12], paprastai Rytø Afrikoje, Vidurio Rytuo-se, Arabø pusiasalyje [12]. Vien Rytø Afrikoje juos vartoja apie 10 mln. þmoniø, o visame regione – apie 20 mln. [5-11]. Kato lapø kramtymas tiesiog tapæs tø gyventojø tradiciniu áproèiu. Lapai kramtomi ávairiose þmoniø sueigose, religinëse ceremonijose, ypaè savaitgaliais ar dienà po pietø iki vakarinës maldos. Arbatos parduo-tuvëse kato galima ásigyti visà parà. Minëtame regione piktnaudþiavimas katu, kaip psichoaktyvia medþiaga, uþima I-à vietà [7]. Daþniau já vartoja vyrai, bet kramto ir moterys, net nëðtumo ir laktacijos metu. Vien Jemene já nors kartà yra vartojæ 81,6% vyrø ir 43,3% moterø [2]. Kato lapø kramtymas ypaè padaþnëja ávairiø religiniø, politiniø konfliktø metu. Pvz., Somalyje já vartoja per 80% vyrø [5], apie 70,1% kareiviø [8].

Katà vartoja ne tik kaip centrinës nervø sistemos stimuliantà, bet vietiniai þolininkai juo gydo depresijà, nuovargá, skrandþio opà [12].

Ilgus metus katas buvo paplitæs tik minëtame regione, dabar, dël pagerëjusiø transportavimo sàlygø, didëjanèio imigrantø skaièiaus ið tø srièiø, jau keli deðimtmeèiai plinta ir Vakaruose [7, 8, 11]. Jo kramtymas uþdraus-tas Kanadoje, Amerikoje, Europos Sàjungoje (iðskyrus Jungtinæ Karalystæ ir Olandijà) [5]. Dël to dabar visame pasaulyje kasdien sukramtoma 6 mln. kato porcijø (8).

ÁVAIRIØ ÞOLINIØ PREPARATØ PSICHOSTIMULIACINIS POVEIKIS DAGMARA REINGARDIENË1, JOLITA VILÈINSKAITË2

1 Kauno medicinos universiteto Intensyviosios terapijos klinika, 2 Kauno medicinos universiteto klinikø

Centrinës reanimacijos ir intensyviosios terapijos skyrius

Adresas susiraðinëti: Dagmara Reingardienë, el. p.: [email protected]

“Sveikatos mokslai” Nr.2 2010 m.3098 APÞVALGA

Vartojimo bûdas. Smulkûs ryðulëliai ið catha edulis lapø ir plonø ûgliø parduodami vietinëse parduotuvë-se. Pagrindinis kato vartojimo bûdas yra jo kramtymas. Kramtoma laikant lapus vienoje burnos pusëje. Susi-daranèios seilës praryjamos. Rutuliuko formos likutis laikomas uþ skruosto ir iðspjaunamas tik sueigos, ce-remonijos pabaigoje. Retai ið lapø ir ûgliø verdama ir geriama arbata [7, 12].

Toksinës catha edulis sudëtinës dalys. Augalo sudë-tyje yra du bioaktyvûs alkaloidai, netiesiogiai veikiantys simpatomimetikai, savo chemine struktûra ir poveikiu panaðûs á amfetaminà. Todël literatûroje paprastai minimi ir nagrinëjami amfetaminø ir jø derivatø grupëje [1, 13]. Tai katinas (cathine – norpseudoephedrine) ir katinonas (cathinone – fenilalkilaminas α – aminopropiophenone). Pastarasis, kaip stimuliantas, yra veiklesnis. Katinonas randamas tik ðvieþiuose lapuose. Jis reliatyviai nestabilus ir greit metabolizuojamas á katinà ir norefedrinà. Todël kato lapai vartojami ðvieþi, o nuskinti turi bûti sunaudoti per savaitæ. Iðdþiovintuose lapuose ir stiebuose yra jau tik 0,1 – 0,2% katino, kuris turi tik apie 1/10 D-amfetamino stimuliacinio poveikio. Dþiovinti lapai yra nepopuliarûs ir retai vartojami [2, 7, 9, 10, 12-15]. Ðvieþiø lapø su-dedamoji dalis katinonas yra vadinamas ir natûraliu ar þoliniu ekstaziu [11]. Kato lapuose dar yra ir kitø alka-loidiniø junginiø (fenilpentenilaminai, katedulinai). Jie gali irgi prisidëti prie kato poveikio [10].

Catha edulis lapai turi ir taninø, askorbininës rûgðties, maþà kieká esminiø riebaliniø rûgðèiø, sterolø, triterpenø, tiamino, riboflavino, niacino, geleþies ir amino rûgðèiø [7]. Kramtant katà per 90% jo alkaloidinës sudëties yra ekstraguojama á seiles ir didþioji jø dalis absorbuojama jau per burnos gleivinæ [3, 10].

Katinono metilinis derivatas methcathinone che-miðkai sintezuojamas ið efedrino. Jo poveikis panaðus á metamfetamino. Ðiuo preparatu daugelá metø piktnau-dþiauta Rusijoje ir kitose Tarybø Sàjungos ðalyse. Piktnau-dþiavimas juo pirmà kartà apraðytas 1990 m. Mièigane. Methcathinone vadinamas dar ir efedronu (ephedrone), o gatvëse perkamas pavadinimais „cat“ ar „Jeff“ [15].

Ðalutiniai kato poveikiai. Katinonas labiausiai tok-siðkas centrinei nervø sistemai ir ðirdþiai, taèiau jo su-keltos adrenerginës komplikacijos yra daug retesnës ir ðvelnesnës nei nuo amfetaminø.

Centrinë nervø sistema [10, 11, 15-17]. Pradinis efektas: euforija, padidëjæs budrumas, hiperaktyvumas, nerimas, nemiga. Vëliau atsiranda psichologinë priklau-somybë, stimuliacijos ar sedacijos reiðkiniai. Daþnas ir gausus kato naudojimas susijæs su psichozëmis, agresy-viu elgesiu, hipomanijomis. Odenwald M. ir bendr. [8] ið Somalio vyrø nustatë ryðá tarp kato kramtymo kiekio (didelis kiekis > 2 ryðulëliai/d) (p < 0,05), kramtymo staþo

(p < 0,001) ir psichozës simptomø pradþios. Piktnaudþia-vimo katu ryðá su protine negalia pastebi ir kiti [5, 18]. Taèiau nurodoma, kad, jeigu kramtomi tik vidutiniai kato kiekiai, tai turi tik socialiniø padariniø kaip ir alkoholio vartojimas [5, 18]. Pvz., Somalis viena ið neturtingiausiø ðaliø pasaulyje. 60% jo þmoniø pragyvena maþiau nei uþ 1 dolerá per dienà. Per 80% Somalio vyrø, kramtydami katà, tam iðleidþia 4 dolerius kasdien [5].

Þiurkëms katas sukelia ir stiprina agresyvø elgesá, galbût maþindamas serotonino ir jo metabolitø kieká. Á ðá procesà gali bûti átrauktas ir dopamino metabolizmas [6].

Retai [2] piktnaudþiavimo katu ryðys su psichiniu, psichologiniu sergamumu yra neigiamas.

Kardiovaskulinë sistema. Kato kramtymas gali sukelti ávairias aritmijas, hipertenzijà, krûtinës anginà ir net miokardo infarktà [3, 10-13, 15, 16, 19]. Apraðytos dvi nëðèiosios [11], kurioms vienkartinis kato kramtymas sukëlë aritmijas ir skausmus krûtinëje. Savanoriams kato kramtymas padidina arteriná kraujospûdá, kurio pa-didëjimas sutampa su katinono koncentracijos plazmoje padidëjimu (kramtant po 1,5 – 3,5 val.) [14]. Katinono poveikis tirtas jûrø kiaulytëms, jis sukëlë þenklià vaini-kiniø arterijø vazokonstrikcijà [14]. Poveikis inotropinei ir chronotropinei ðirdies funkcijoms, kaip parodë ekspe-rimentas, ávairus [14].

Kiti galimi ðalutiniai reiðkiniai. Kraujyje ir ðlapime kato alkaloidai nustatomi skystos chromatografijos, masës spektrometrijos metodu [3, 4, 10].

Katas (catha edulis) tik pastaraisiais metais, dël gau-sëjanèiø imigrantø ið Afrikos, pradëjo patekti á Vakarø Europà, Amerikà, kartà buvo patekæs ir á Lietuvà. Tai mû-suose galinti atsirasti nauja psichostimuliacinë medþiaga, todël apie piktnaudþiavimà ja reikia þinoti.

Kvaitulinis ðalavijas Kvaitulinis ðalavijas (Salvia divinorum, S. divinorum)

– psichoaktyvus haliucinogeninis augalas. Nors jo, kaip haliucinogeno, vartojimas pasaulyje pradëjo plisti tik nuo 1990 m., já jau nuo XVI a. vartojo indënai Meksikos ðiaurës rytø kalnø regione. Vartojo tradicinëms religinëms apeigoms religiniø vizijø, ateities numatymo, pranaðiðkø atsakymø apie draugus, prieðus, gimines sukëlimui. Já naudojo ir vietiniai daktarai (hileriai) galvos skausmø, reumato, diarëjos, ascito gydymui [20-22, 24-26].

Ðis daugiametis augalas yra mëtø (Lamiaceae) ðei-mos atstovas. Nors ðalavijø rûðiø pasaulyje yra beveik 1000, S. divinorum dël savo savybiø yra laikomas at-skiru augalu. Jis uþauga daugiau kaip 1 m aukðèio, turi didelius þalius lapus, tuðèiavidurá tiesø stiebà ir baltus þiedus su purpurinëmis taurelëmis. Susidaro tik kelios, retai sudygstanèios sëklos [24, 25]. Áprastai auga tik Meksikoje, saulëto, ðvelnaus klimato sàlygomis. Dabar kultivuotas Kalifornijos universitete ir botanikos kolek-


cijose yra maþiausiai keturios ðio ðalavijo atmainos. Pirmà kartà literatûroje paminëtas 1939 m. JB John-

sono, studijavusio vietiná ðamanizmà. Jo þentas R.G. Weitlaneris ðá augalà, kaip Marijos þolæ, apraðë 1952 m. 1962 m. R.G. Wassonas ir A. Hoffmanas pirmàjá augalo pavyzdá gavo ið indënø ir apraðë já kaip pakaitalà haliuci-nogeniniams grybams (tikslus augalo poveikis iðaiðkintas tik 2002 m.). Ðá augalà minëti tyrëjai atveþë Amerikos botanikams C. Eplingui ir M.C. Jativai. Jie 1962 m. su-klasifikavo já kaip mëtø ðeimos atstovà ir C. Eplingas já pavadino S. divinorum vardu [20, 23, 24, 27].

Vartojimo paplitimas, priklausomybës problemos. S. divinorum, tarsi galimai legalaus ir alternatyvaus nelegaliems narkotikams haliucinogeno, vartojimas pa-staruosius du deðimtmeèius plinta [25]. Beveik visame pasaulyje jis parduodamas ávairiose maþose parduotu-vëlëse ir já gali ásigyti tiek jauni, tiek seni [23]. Ilgalaikio augalo vartojimo poveikis netirtas [23], pripratimo, tolerancijos padidëjimo jam ar vartojimo nutraukimo simptomai dar neapraðyti [21, 23].

Farmakologija. Kvaitulinio ðalavijo psichoaktyvioji dalis – salvinorinas A (C23 H28 O8). Jo koncentracija la-puose svyruoja nuo 0,89 iki 3,70 mg/g sauso svorio [24]. Tai neazotinis nealkaloidinis diterpenoidas, savo struk-tûra nepanaðus á joká þinomà haliucinogenà ir lengvai praeinantis per kraujo – smegenø barjerà [20, 21, 28]. Salvinorinas A vienas ið stipriausiø natûraliøjø haliuci-nogenø, labai selektyvus κ (kappa) opioidiniø receptoriø agonistas (in vitro ir in vivo). κ receptoriai randami tiek galvos, tiek nugaros smegenyse. Jø stimuliacija sukelia spinalinæ analgezijà, miozæ, diurezæ, psichotomimezæ, disforijà, supraspinalinæ analgezijà. Kvëpavimo neslo-pina. Haliucinacijø biologinis mechanizmas neþinomas [20-22, 24, 25, 27, 28]. Salvinorinas A savo þymiu haliucinogeniniu poveikiu panaðus sintetiniam haliuci-nogenui LSD (lizerginës rûgðties dietilamidui) [26].

Farmakokinetika. Intraveninio salvinorino A poveikis netirtas, nes ðis diterpenas vandenyje netirpsta [20, 21]. Geriamasis salvinorinas A, net iðgërus jo 10 mg, jokio poveikio nesukelia. Galvojama, kad já tuoj deaktyvuoja virðkinimo fermentai [20, 21, 25].

Kramtant lapus ir juos laikant burnoje apie 10 min. ak-tyvioji jø dalis rezorbuojasi pro burnos gleivinæ ir povei-kis prasideda po 5-15 min., pasiekia maksimumà per 30 min.-1 val. ir tuomet silpnëja per 1-2 val. [20, 21, 23, 25].

Rûkant dþiovintus lapus ar garinant lapø sultis ir jas inhaliuojant poveikis gali atsirasti per keletà sekundþiø, maksimaliai per 5-10 min. Efektas trunka iki 20-30 min. [20, 21, 25]. Apklausus 500 þmoniø, rûkiusiø ar inha-liavusiø S. divinorum, 25,8% jø nurodë, kad pagerëjusi nuotaika ir antidepresantinis poveikis uþtruko 24 val. ar net ilgiau. Slenkstinë, haliucinacijas sukelianti salvino-

rino A dozë rûkant já grynà ar inhaliuojant yra 200-500 µg [21, 23].

Metabolizmas gerai neiðtirtas, bet eksperimentas su beþdþionëmis parodë, kad salvinorinas A iðskiriamas ir pro inkstus, ir pro tulþies takus [27].

Iðtyrus 2 vyrus ir 2 moteris pasirodë, kad salvinorino A pasiskirstymas ir eliminacija priklauso nuo lyties. Jie greièiau veikia vyrus [20].

Kvaitulinio ðalavijo vartojimo bûdai: • Lapai gali bûti kramtomi ir po to praryjami.

Kadangi salvinorinas A rezorbuojasi pro burnos gleivinæ, tai kramtomus lapus reikia palaikyti burnoje kiek galima ilgiau, nors tie lapai yra itin kartûs.

• Rûkomi dþiovinti lapai arba rûkomas, inhaliuo-jamas ið þaliø sutraiðkytø lapø gautas ekstraktas.

• Minëtas ekstraktas sumaiðomas su vandeniu ir geriamas. Geriama ir lapø arbata. Tik tuos gërimus reikia ilgiau palaikyti burnoje. Ðiuo metu vartojamas ir iðgrynintas salvinorinas A [20, 23-25, 29].

Klinika. Ûminis kvaitulinio ðalavijo poveikis: haliu-cinacijos ir sinestezijos (synesthesia – jausmas, jutimø maiðatis, girdëjimas spalvø ar uþuodimas garsø, ðis po-veikis nëra specifinis). Haliucinacijos ryðkios, gyvos. Gali bûti regëjimo, klausos ar uoslës haliucinacijos. Spalvos matomos ðviesesnës, su ðvieèianèia aureole apie daik-tus. Regëjimo haliucinacijos baigiasi, kai jas pertraukia triukðmas, ðviesa. Sustiprëja intuicija, pagerëja nuotaika, apima ramybë, mintys apie likimà, taip pat – plaukimo, skraidymo jausmai, kelionës per laikà ar erdvæ jausmas, juntamas ryðys su gamta, pasauliu. Gali padidëti prakai-tavimas, uþplûsti ðilumos ir karðèio jausmas kûne, gali prasidëti galvos svaigimas, pykinimas, koordinacijos sutrikimai, motorinës funkcijos pablogëjimas, neaiðki kalba, suretëjæs ðirdies susitraukimø daþnis, ðaltkrëtis [20,21,23-25,27,29].

Kokie nors grësmingi ðalutiniai reiðkiniai, pavartojus S. divinorum neapraðyti. Tik viename tyrime 4,4% ið 500 vartotojø apraðë uþtrukusius (24 val. ar ilgiau) neigiamus poveikius, daþniausiai – nerimà.

Lëtinio vartojimo toksiðkumas taip pat neapraðytas. Tai rodo kvaitulinio ðalavijo saugumà ar gydytojø ne-galëjimà paþinti ilgalaikiø jo vartotojø [20, 21].

Laboratorinë S. divinorum vartojimo diagnostika. Ilgà laikà salvinorino A ir B kiekiai þmogaus organizme nebuvo tiriami [25]. Ðiuo metu skystos chromatografijos ir spektrometrijos metodu atlikti tik pavieniai kiekybiniai diterpenø tyrimai seilëse, prakaite, ðlapime [20-22, 30].

Vartojimo legalumas. Kadangi ðio haliucinogeninio augalo poveikis trumpas, neþinoma jo vartojimo rizika sveikatai, neþinomas priklausomybës ir jos iðraiðkos iðsi-vystymas, todël daug kur S. divinorum laikomas legaliu kanapiø pakaitalu. Internete pateikiamas taip pat kaip


legalus haliucinogenas, propaguojama prekyba jo ðvie-þiais ir dþiovintais lapais, ávairaus stiprumo ekstraktais bei sëklomis, ûgliais kvaitulinio ðalavijo auginimui. Visa tai nebrangu ir lengvai gaunama. Jo vartotojø gretose vyrauja moterys (30 : 1) ir paaugliai, nes salvinorinas A organizme praktiðkai netiriamas. JAV kasmet já vartoja apie 1,8 mln. þmoniø (12 metø ar vyresni) ir apie 750000 per metus tai iðbando pirmà kartà. Taèiau, nepaisant jo didelio prieinamumo, S. divinorum nëra vakarëliø, jaunimo susibûrimø preparatas, nes já geriausiai vartoti vienam ar su keliais gerais draugais, ramiame, tamsiame kambaryje [20, 21, 23-27, 31].

Taèiau paskutiniu metu kai kurios ðalys jo vartojimà yra uþdraudusios ar tà vartojimà kontroliuoja. Tai kelios JAV valstijos, Australija, Belgija, Danija, Estija, Suomija, Ðvedija, Italija, Ispanija, Pietø Korëja [20, 21, 23-25]. 2008 05 Lietuvoje kvaitulinis ðalavijas ir salvinorinas A átraukti á kontroliuojamø vaistø sàraðà.

NAUJIEJI PSICHOTROPINIAI AUGALAI LIETUVOJE „Kanna“ þolelës Iðgaunamos fermentuojant Sceletium tortuosum

(lot.). S. tortuosum yra pluoðtagëliniø (Aizoaceae) ðeimos augalas, kilæs ið Pietø Afrikos, taip pat þinomas kaip Kan-na arba Kauwgoed. Ðimtus metø jis buvo naudojamas kaip nuotaikos stiprintojas, relaksantas ir empatogenas. S. tortuosum buvo kramtoma, rûkoma bei uostoma, kas pirmiausia sukeldavo euforijà, stimuliuodavo ir palaips-niui pereidavo á sedacijà [32, 33]. Kramtant, ji veikdavo kaip lengvas anestetikas ir kai kuriø Afrikos genèiø buvo vartojama raunant dantis ar malðinant pilvo dieglius vaikams. Ið S. tortuosum virta arbata buvo vartojama atpratinti alkoholikus nuo alkoholio, taip pat apetito maþinimui. Augalas pirmà kartà apraðytas 1662 metais Olandijos karo laivyno gydytojo Jano van Rybeko (angl. Jan van Riebeck) [35].

S. tortuosum poveikis pagrástas alkaloidais, kuriø jis turi bent 9, pvz., mesembrino, mesembrenolio ir tortuo-samino (angl. mesembrine, mesembrenol, tortuosamine) [32, 33]. Jie sàveikauja su galvos smegenø dopamino ir serotonino receptoriais. Mesembrinas yra pagrindinis alkaloidas, esantis S. tortuosum. Manoma, jog jis yra serotonino reabsorbcijos inhibitorius [34]. S. tortuosum yra 1-1,5 % visø alkaloidø, apytiksliai 0,3 % mesembrino yra lapuose ir 0,86 % augalo stiebuose [32].

Paðalinis poveikis: lengvas galvos skausmas, apati-ja, apetito stoka, pykinimas be vëmimo, viduriavimas, nemiga. Patariama nevartoti kartu su raminamaisiais, migdomaisiais, antidepresantais, antipsichotiniais bei ðirdá veikianèiais vaistais. Apie pripratimà ir abstinencijà vartojant ilgai duomenø nëra, taip pat nurodoma, kad au-

galas ne haliucinogenas. Nesenai buvo pradëtos gaminti S. tortuosum tabletës bei kapsulës, kurios duoda puikiø rezultatø gydant nerimà, lengvo ar vidutinio sunkumo depresijà, keliant nuotaikà, maþinant stresà ir átampà, su-teikiant energijos [32]. Áprastais narkotikø testais kvaiðalas nerandamas. Legaliai pardavinëjamas JAV, Australijoje, Nyderlanduose, Lenkijoje bei Lietuvoje. Kaina Lietuvoje veikianèiose internetinëse parduotuvëse – 5 g apie 35 Lt.

Gyslotojo vyklio sëklos Kitas labai populiarus produktas yra gyslotojo vyklio

(lot. Argyreia nervosa, angl. Hawaiian Baby Woodrose, Elephant creeper) sëklos. Gyslotasis vyklys yra vijokliniø (Convolvulaceae) ðeimos augalas, kilæs ið Indijos, taèiau randamas ávairiose vietovëse, pvz., Havajuose, Afriko-je, Karibø jûros regione. Jo haliucinogeninës savybës atrastos palyginti neseniai – apie 1960 metus. Indijoje paprastai buvo vartojamos jo ðaknys bei lapai, kurie neturi psichoaktyvaus poveikio, bet veikia antiseptiðkai bei prieðuþdegimiðkai. Jo sëklose gausu alkaloidø, kurie struktûriðkai panaðûs á LSD, todël sukeliamas efektas yra panaðus, tik silpnesnis. Sukelia haliucinacijas, nuotaikos pakilimà, mieguistumà, realistiðkus sapnus, nestabi-lumo jausmà, suaktyvina pojûèius ir kt. Ðis produktas priskiriamas vadinamajai LSA, t.y. d-lizerginës rûgðties amidø kategorijai [35, 36]. Preparatas veikia apie 5-8 val., stipriausias poveikis bûna po 20-60 min. Paprastai, efektui sukelti, vartojamos 5-8 sëklos [35]. Paðaliniai poveikiai: nerimas, baimë, panika, delyras, pykinimas, vëmimas, pilvo diegliai [35, 36]. Apie pripratimà ilgai vartojant duomenø nëra. Nurodoma, jog standartiniais bei iðplëstais narkotikø testais kvaiðalas nerandamas. Daugumoje pasaulio ðaliø ði medþiaga pardavinëjama legaliai, t.y. JAV, Brazilijoje, Vokietijoje, Lenkijoje, Lietuvoje, uþdrausta – Australijoje bei Italijoje. Kaina Lietuvoje veikianèiose internetinëse parduotuvëse – 10 sëklø apie 25 Lt.

„SPICE“ miðiniaiManoma, jog ðiuo metu vieni stipriausiai veikianèiø

ir populiariausiø yra rûkomieji „SPICE“ miðiniai, susi-dedantys ið ávairø þoleliø. Pagal stiprumà jie skirstomi atitinkamai á „SPICE silver/gold/diamond“). Ðiø ávairiø augalø miðinys veikia panaðiai kaip kanapës. Ne visi miðinio ingredientai turi psichoaktyvø veikimà – kai kurie veikia sinergistiðkai su kitais, o kai kurie yra tik kvapnieji priedai. Paprastai rûkomas bongais (vandens pypkëmis) arba maiðomas su tabaku. Veikimas prasideda po keliø minuèiø, trunka apie 4-5 val.. Sukelia galvos sukimàsi, juokà, euforijà, ekstazæ, nestabilumo jausmà, haliucinacijas [37].

Sudëtis [37-39]: Jûrinë kardapupë (lot. Canavalia maritima, angl. Bay Bean), taip pat þinoma kaip Mac-kenzie pupa. Tai paþemiui augantis augalas, randamas


pietryèiø Floridos bei Meksikos paplûdimiuose ir smë-lynuose, jos sëklos buvo naudojamos nuo 300 m. pr. Kr. Sukelia ramumo jausmà, nors jos psichoaktyvios savybës neárodytos.

Mëlynasis lotosas (lot. Nymphaea caerulea, angl. Blue Lotus) – tai lûgniniø (Nymphaeaceae) ðeimos augalas, naudotas senovës Egipte, kaip geros sveikatos, sekso ir atgimimo raktas, taip pat – afrodiziakas. Veikia tonizuo-jamai, maþina skausmà, stimuliuoja kraujo cirkuliacijà, gali sukelti euforijà ir haliucinacijas. Manoma, jog jame yra fitosterolio, bioflavonoidø bei fosfodiesterazës.

Rieðutinis lotosas (lot. Nelumbo nucifera, angl. Pink lotus) – tai lotosiniø (Nelumbonaceae) ðeimos augalas, nacionalinë ðventa Indijos gëlë, uþimanti unikalià vietà Indijos mitologijoje. Vartojant didesnëmis dozëmis gali sukelti euforijà, haliucinacijas, sumaþinti arteriná kraujo spaudimà.

Maþoji kalpokë (lot. Scuttelaria nana, angl. Dwarf skullcap) – notreliniø (Lamiaceae) ðeimos augalas, veikiantis atpalaiduojamai, migdomai, gali bûti naudo-jamas sumaþinti nerimà. Nuo senovës buvo vartojamas Ðiaurës Amerikos indënø genèiø gerinti miegui bei maþinti baimei.

Tankiaþiedë glindë (lot. Pedicularis densiflora, angl. Indian Warior) – dþiovekliniø (Orobanchaceae) ðeimos augalas. Tai daugiametis vaistinis augalas, nuo senovës vartotas Ðiaurës Amerikos indënø genèiø. Jis veikia ram-inamai, atpalaiduoja raumenis, yra afrodiziakas.

Tikroji liûtausë (lot. Leonotis leonurus, angl Lion’s Tail) – notreliniø (Lamiaceae) ðeimos augalas, nuo senoves Pietø Afrikoje vartotas kaip vaistinis augalas, turintis nervø sistemà atpalaiduojantá poveiká. Jo svar-biausias alkaloidas yra leonurinas (angl. leonurine). Taip pat sukelia euforijà, svaigulá ir ramumo jausmà. Naudotas nuo kosulio, perðalimo, diabeto, hipertenzi-jos, egzemos, epilepsijos, þarnyno kirminams gydyti, obstipacijoms, kaip prieðnuodis nuo vorø, gyvaèiø bei skorpionø ágëlimø.

Plaèialapë zornija (lot. Zornia latifolia, angl. Ma-conha Brava) yra pupiniø (Fabaceae) ðeimos augalas, kilæs ið Pietø Amerikos. Tai daugiametis vaistinis auga-las, kurio lapai ir sëklos Brazilijoje buvo rûkomi vietoj kanapiø. Gali sukelti haliucinacijas.

Sibirinë sukatþolë (lot. Leonurus sibiricus, angl. Si-berian Motherwort) yra notreliniø (Lamiaceae) ðeimos augalas, kilæs ið centrinës Azijos. Jos preparatai ra-mina nervø sistemà, maþina kraujospûdá, lëtina ðirdies ritmà.

Vaistinë svilaroþë (lot. Altheae officinalis, angl. Marshmallow) – dedeðviniø (Malvaceae) ðeimos daugia-metis þolinis augalas. Paprastai vartojamas kvëpavimo takø ligoms gydyti, atsikosëjimui lengvinti, nes skystina bronchø sekretà, taip pat skatina diurezæ bei veikia

antiuþdegimiðkai. Neturi psichoaktyvaus poveikio. Kiti nurodomi ingredientai: raudonasis dobilas (lot.

Trifolium pratense, angl. Red Clover), roþës, vanilë bei medus. Ðie preparatai neturi jokio psichoaktyvaus vei-kimo, naudojami kaip skaninamieji priedai.

Tiksli „SPICE“ preparatø sudëtis yra ne visai tokia, kokià nurodo gamintojai. Vokietijoje 2008 metø gruo-dþio mënesá atliktø tyrimø duomenimis, „SPICE“ sudëtyje buvo rasta modifikuotø sintetiniø kanabinoidø (JWH-018), kurie labai panaðûs á kanapëse esantá tetrahidro-kanabinolá. Maþa to, jø analgezinis poveikis yra nuo 5 iki 10 kartø, o afinitetas kanabinoidiniams receptoriams – nuo 3 iki 28 kartø stipresnis nei tetrahidrokanabinolio. Vartojant ðiuos preparatus kyla rizika priprasti ir perdo-zuoti. Áprastais narkotikø testais kvaiðalas nerandamas [40]. Verta paminëti, jog JAV ðis miðinys yra uþdraustas kaip Nyderlanduose, Vokietijoje, Ðveicarijoje, Austrijoje. Legaliai pardavinëjamas Lietuvoje. Kaina Lietuvoje vei-kianèiose internetinëse parduotuvëse – 1 g apie 50 Lt.

Apsinuodijimø kontrolës ir informacijos centro duo-menimis, ðiø metø pradþioje Lietuvoje sudaryta darbo grupë, tirianti ðiø internetinese parduotuvese paplitusiø kvaiðalø galimà átakà sveikatai, jø prekybos apribojimà ar uþdraudimà.

Neabejojama, kad tai ne vieninteliai legaliai pri-einami preparatai, pasiþymintys psichoaktyviu poveikiu ir nerandami áprastais narkotikø testais. Panaðu, kad narkobiznio atstovai, manipuliuodami ðiuo metu itin populiaria natûralumo koncepcija, rado naujà niðà rin-koje. Dalis þmoniø gali pradëti vartoti minëtus augalus net neþinodami apie jø poveiká sveikatai bei galimà priklausomybæ jiems. Manoma, jog netrukus gali pasi-rodyti dar daugiau tokio tipo preparatø, kurie neabejo-tinai sukels didelá iððûká toksikologams bei teisësaugos struktûroms.

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24. Vortherms T.A., Roth B.L. Salvinorin A : from natural product to human therapeutics. Molecular Interventions 2006; 6 : 259-67.

25. Babu K.M., Ferm R.P. Hallucinogens. In : Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS. Goldfrank‘s toxicologic emergencies. McGraw – Hill. New York, 2006; p. 1202-11.

26. Prisinzano T.E. Psychopharmacology of the hallucinogenic sage Salvia divinorum. Life Sciences 2005; 78 : 527-31.

27. Hooker J.M., Xu Y., Schiffer W., Shea C., Carter P., Fowler J.S. Pharmacokinetics of the potent hallucinogen, salvinorin A in primates parallels the rapid onset and short duration of effects in humans. Ne-uroIimage (2008), doi : 10.1016/j.neuroimage, 2008.03.003; p.1-7.

28. McCurdy Ch.R., Sufka K.J., Smith G.H., Warnick J.E., Nieto M.J. Antinociceptive profile of salvinorin A, a structurally unique kappa opioid receptor agonist. Pharmacology, Biochemistry and Behavior 2006; 83 : 109-13.

29. Gonzalez D., Riba J., Bouso J.C., Gomez – Jarabo G., Barba-noj M.J. Pattern of use and subjective effects of Salvia divinorum among recreational users. Drug Alcohol Depend 2006; 85 : 157-62.

30. Schmidt M.S., Prisinzano T.E., Tidgewell K. Determination of Salvinorin A in body fluids by high performance liquid chromatography – atmospheric pressure chemical ionization. J Chromatogr B Analyt Technol Biomed Life Sci 2005; 818: 221-5.

31. Dennehy C.E., Tsourounis C., Miller A.E. Evaluation of herbal dietary supplements marketed on the internet for recreational use. Ann Pharmacother 2005; 39: 1634-9.

32. Scott G., Springfield E.P. Sceletium tortuosum herba. Phar-maceutical monographs for 60 South African plant species used as tra-ditional medicines 2004. Available from URL: http://www.plantzafrica.com/medmonographs/scelettort.pdf

33. Patnala S., Kanfer I. Investigations of the phytochemical content of Sceletium tortuosum following the preparation of “Kougoed” by fermen-tation of plant material. Journal of Ethnopharmacology 2009; 121: 86-91.

34. Chesselet P. Sceletium tortuosum (L.) N.E.Br. Compton Herbarium 2005. Available from: URL: http://www.plantzafrica.com/plantqrs/scelettort.htm

35. Erowid. Hawaiian Baby Woodrose. Erowid.org, 2007. Avai-lable from: URL: http://www.erowid.org/plants/hbw/hbw.shtml

36. Sewell R.A., Reed K., Cunningham M.. Response of cluster headache to self-administration of seeds containing lysergic acid amide (LSA). 2007. Available from: URL: http://www.erowid.org/chemicals/lsa/lsa_article2.pdf

37. Wodarz N., Tretter F. SPICE – berauschender Kräutermischung aus diversen Herkunftsländern (SPICE – dizzy herbal blend from diverses lands). Bayerische Akademie für Suchtfragen 2008. Available from: URL:

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38. Scott G., Springfield E.P. Leonotis herba. Pharmaceutical monographs for 60 South African plant species used as traditional medicines 2004. Available from: URL: http://www.plantzafrica.com/medmonographs/leonotleon.pdf

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40. Auwärter V., Dresen S., Weinmann W., Müller M., Pütz M., Ferreirós N. “SPICE and other herbal blends: harmless incense or canna-binoid designer drugs?” Journal of Mass Spectrometry 2009; 45:1-6.

PSYCHOACTIVE PROPERTIES OF VARIOUS HERBAL PLANTS Dagmara Reingardienë, Jolita Vilèinskaitë SummaryKey words: Catha edulis, Khat, cathine, cathinone, amphetamines,

Salvia divinorum, Salvinorin A, psychoactive plants, hallucinogens. Stimulant abuse is a major problem in the world. There has been a

rise in the availability and recreational use of various herbal plants as psychoactive agents. Numerous internet websites have advertised it for sale as a legal herbal alternative to illegal hallucinogens. In this review article there are discussed about new psychoactive herbal plants : khat (Catha edulis), perennial herb of the mint family Salvia divinorum, and several South African plant species (Selectium tortuosum, Argyreia nervosa, “Spice” herbal blends). A common form of drug abuse in East Africa involves chewing the leaves and stems of the khat plant and swal-lowing the juice. Khat is used by herbalist to treat depression, fatigue, obesity, and gastric ulcers. The two active compounds alkaloids in khat are cathine and cathinone, the more active stimulant. Salvia divinorum has been used for its psychoactive effects for many hundreds of years. The active component of Salvia divinorum is Salvinorin A – non – ni-trogenous, non – alkaloid kappa opioid receptor selective agonist. It produces intense, short – lived hallucinations. We are discussed about recreational use of these plants, the epidemiology and use patterns of them, pharmacokinetics, toxicology, the diagnostic detection, informa-tion about legality of users of these herbal plants.


Gauta 2009-12-06


Key words: adaptation/disadaptation, cross-cultural psychology, M. K. Èiurlionis.

Summary Stressing the role of culture, tradition and lan-guage, cross-cultural psychology may be better equipped to account for migrants’ (dis)adaptation in the globalizing world. It may also offer a more inquisitive assessment of M. K. Èiurlionis’ artistic achievements seemingly clashing with his life history.

MATERIAL AND METHODSAs the title appropriates Hamlet’s famous query “to

be or not to be”, the question is still topical, more so in our times, for it indicates the issue whether to exist or not to exist (or how to exist) in some unknown reality, place, country. The problem of adaptation is old, though cross-cultural psychology is fairly new.

In psychology, adaptation denotes outward behavior serving/helping to secure the most basic needs of an individual. It is usually linked with mass migration due to economic reasons. In psychology and sociology, it denotes a shift in sociological or cultural disposition. One is said to ‘adapt’ to a new environment [10]. The phrase ‘cultural disposition’ indicates that there are prob-ably other areas and other ways, and also other needs to be taken into account when a certain adaptive norm or practice is established. The situation changes when adaptation is to reach innermost and personal problems, such as identity, accepted or rejected universals, a sense of purpose in life, etc. In other words, when it is not the problem of health after illness or normality after medication. It is a psychological problem of a different nature, of individual choices and consequences going well beyond ‘normal functioning’ and everyday affairs, projecting on the individual’s functioning in a foreign society, unknown culture and strange linguistic milieu.

From time immemorial people used to travel, fight, fall in love, marry and die on foreign soil, which were just a few reasons for changing their place or country of origin. In our part of the world migrating Lithuanians,

Poles, Italians, Irish have created their own nomadic his-tory due to historical upheavals and individual decisions, in result establishing influential Diasporas in various parts of the world.

Old travelogues, accounts of voyages, diaries, let-ters, novels and several eyewitness accounts, films and videos, magazines and reports describing foreign places form an important part of national, literary and popular traditions. Before and now people used to be and still are faced with several choices – whether they are aware of them or not – how/whether to fit into new circumstances. All these have been happening before cross-cultural psychology or any similar studies were launched. The catalogue of queries modern societies, individuals and psychologists struggle with are numerous:

• How does the idea of Diaspora combine with adaptation or acculturation, homogeneity and globali-zation? Is there a norm (to be) established?

• Why does migration almost always mean lowe-ring social status, taking a job below one’s qualifications and a general worsening of the quality of life (with the exception of some measurable economic success)?

• What are the reasons for the generation gap between parents and children in migrants’ families? Is this linked with the new identity of the next generation of migrants?

• Why do migrants so often flare up against their adopted country’s authorities? Why are the police of host countries accused of unequal treatment of representati-ves of other races and nationalities?

And, finally, the problems psychologists should not ignore:

• Why have there been so many suicides of com-monly known men of letters and mental disorders other seemingly successful emigrant artists (Jan Lechoñ, Ma-rek Hùasko, Jerzy Kosiñski and Mikalojus Konstantinas Èiurlionis)?

• Why are there so few ‘success stories’ among emigrants? Does it relate to adaptation or its absence? Does it stand for adaptation if a successful migrant states: “The language is beginning to invent another me” [4, 121]?

TO ADAPT OR NOT TO ADAPT – ISSUES IN CROSS-CULTURAL PSYCHOLOGY

MARTA WISZNIOWSKA – MAJCHRZYK Cardinal Stefan Wyszyñski University, Warsaw, Poland

Correspondence to: Marta Wiszniowska – Majchrzyk, e-mail: [email protected]

INFORMACIJA


Several attempts have been made to explain at least some of the above. In the seventies John Berry provided an answer in his acculturation model. The term accultu-ration has been defined in a variety of ways, including the notion of cultural modification of individuals or groups adapting or borrowing from another culture but also merging with that culture. Some definitions state that it is the culture of a given society acquired from infancy [1]. Berry’s model has been widely discussed and adopted [3] [Fig. 1]. Its main forte is accounting for several choices and consequences that follow such choi-ces. Individuals may either participate in another culture while maintaining his/her own and in result get either assimilated or marginalized. The problem of marginali-zation has become such a burning issue in various parts of the world, worrying psychologists, psychiatrists, social workers, criminologists, judges, teachers, representatives of various religious denominations – almost all who try to organize, educate, treat and … penalize.

So unsurprisingly, modern anthropology, sociology and recently cross-cultural psychology have taken up psychological problems of long-term residence in foreign countries. Yet, early studies mainly concentrated on living conditions, environment, eventual success, as-similation, or its absence. They devoted little attention to cultural clash experienced by immigrants encountering foreign customs, religion, language, living conditions, etc. It is only recently that it has been accepted that hu-man behavior depends very much on cultural traditions that human beings carry with themselves. Indeed, the principle of “culture – bound nature of most human behavior” [7, X] is comparatively new and the relation-ship between psychology and culture dates back from WW II.

Cross-cultural psychology has been defined in a variety of ways [2, 1]. The basics of those definitions

necessitate following, scientific and systematic approach to how human behaviours are shaped and influenced by social and cultural forces, studying individuals from more than two cultures, finally, how they are influenced by culture and how it leads to changes in existing culture [Fig 2] (2,7).

The proposed goals and their topicality seem beyond doubt but looking into the problem we may easily en-counter other difficulties, namely how to make a set of coherent assumptions and tools to study a discipline so vast, varied and of already established methods, which may or may not be made compatible. Then, what may cross-cultural psychology amount to; a chance, a chal-lenge or a humbug? The gains seem obvious as the study aims at covering both the individual and social level, taking into account several variables, the approach seemingly open with few (if any) preconceived ideas. The danger is that such a variety of disciplines may lead to chaos and turn un-scientific, and the difficulties in designing a coherent method of study insurmountable.

Before the difficulties are ironed out, the problems individuals and societies encounter when in new sur-roundings must be analyzed from various theoretical and practical standpoints.

The earliest case of disadaptation in European culture is probably the story of Odysseus as presented in Homer’s Odyssey (VIII c. B.C.). When after the fall of Troy Odysseus was trying to sail back to his native Ithaca and encountering various dangers and adven-tures, he neither accepted nor wanted to adapt to new circumstances offered to him but, if need be, he could pretend in order to survive and successfully reach his kingdom, his wife, Penelope, and his son, Telemachus. Thus, Odysseus’ tactics was skin-deep adaptation, flex-ibility and cunning.

Leaving aside the ancient archetype of a modern migrant, one encounters several cases for whom adap-tation or its absence cannot be defined and who turn it into completely different uses. This is the case of

Fig. 2 Cross-cultural psychology in relation to other dis-ciplines [2,7]Fig. 1 John Berry’s acculturation model [3]

INFORMACIJA


Mikalojus Konstantinas Èiurlionis. It might appear that Kæpiñski had him in mind when dedicating his famous Schizophrenia:” To those who feel more and understand differently and because of this suffer more, and whom we often call schizophrenics.” [8]

The unquestionable greatness and uniqueness of Èiurlionis is beyond discussion [11]. However, cross -cultural psychology may offer a different view on his disorder, at that time diagnosed as schizophrenia (thus stating the norm and pointing to pathology). Èiurlionis’s disorder could very well be taken for an eruption of free-dom and creative energy, for breaking away from artistic constraints, a flight to happiness, a struggle against the norms enslaving his inner world and his many-sided tal-ent. And yet, he was a patient and an outsider, though well versed in languages and cultures, in artistic trends of the epoch, he seemed to have decided NOT to belong and NOT to conform.

Psychiatry and psychology can differentiate between what is normal and what is not by conducting tests and assessing symptoms. Èiurlionis did not match up, twist-ing and turning rules, which shows in his music and his paintings (cf. Ramybe and Angelas Preliudas). What can be said about the man who wrote to his friend:

”Look among the snowy crowns of the mountains, spiry mountains. Soaring almost up to the sky, stands a man. At his feet cloud has covered the whole earth; down there earthly history proceeds, muddle, din, babble, but the cloud has covered all. Silence. White, strange crowns around. Strangely huge, strangely beautiful of opals and pearls, of topaz and malachite, of crystal and diamonds. Strangely magnificent, huge crowns and among them stands the man and looks with his eyes, wide open, looks and waits. He promised that at sunshine – the moment when the crowns are on fire, when colors mingle and

rays dance – he would sing a hymn to the sun. A hymn to the sun! “[ 9 ]

Standard methods of assessment fail to adequately describe his art and him as an entity. Though interna-tionally recognized after his death, he remains outside Berry’s diagram, various diagrams and globalization/ ethnicity/ adaptation conflicting evidence.

Cross-cultural psychology can better account of the importance of tradition and language and also tremen-dous efforts migrants make in order to adapt to living in a new society, another country, among complete strangers. Eva Hoffman, who immigrated to Canada in her teens and made a career there as a Harvard gradu-ate and university lecturer and, also a writer, is the case in point. The manner she describes her personal road toward adaptation is revealing and would justify cross-cultural studies, something well beyond the norm and pathology issue:

“I think every migrant becomes a kind of amateur anthropologist – you do notice things about the culture or the world that you come into that people who grow up in it, who are embedded in it, simply don’t notice/…/ At first you notice the surface things, the surface differences. And gradually you start noticing the deeper differences. And very gradually you start with understanding the inner life of the culture, the life of those both large and very intimate values.” [5 ]

Mikalojus Èiurlionis. Ramybë (Tranquility) http://en.wiki-pedia.org/wiki/File:Mikalojus_Ciurlionis_-_Tranquility_(Ra-mybe).jpg

Mikalojus Èiurlionis. Angelas. Preliudas (Angel Prelude). http://en.wikipedia.org/wiki/File:Angelas.Preliudas.jpg

INFORMACIJA


Compared to putting on a new skin, adaptation was long and painful, as the writer had to re-write herself in the new language, as she states, “For I did not want to say ‘ Now I am American, point, the end.’ For I had to go through the process of translating myself. And it was really translating not chameleoning, though there may have been some elements of it. I always wanted to save a thread of myself in the process, trying to understand the new world and enter it somehow.” [6]

The above cases support the need for some new ap-proach to the study of adaptation to new surroundings, culture, language and society. For adaptation is more than norm or pathology, it is more than conforming or paying lip service to prevailing ideologies. Numerous studies indicate how complex the problem is and how vital in our times. To assess it must be personalized because some extraordinary individuals can use their seclusion and loneliness, illness, etc. to achieve unbe-lievable results struggling with various constraints. So far, psychology was geared mainly to pathological processes more than to welfare, to interpreting statistical data in-stead of individual’s growth-oriented functioning.

Cross- cultural psychology is more likely to assess gains and losses of adaptation processes. Some gains are obvious, such as new horizons, experiences, personal development, eventually recognition, or fame. So are loses, such as lost or modified identity, nostalgia, (a pass-ing) phase of shock, inability (or refusal) to adapt, etc.

Besides, some re- assessment is needed to re-define the role of language and tradition one carries with him/her as one’s most personal trait. Perhaps cross-cultural psychology can help assess the problem, offering a more complex view on how individuals adapt in/to the changing world.

References1. Acculturation, def. http://www.merriam-webster.com/dic-

tionary/acculturation 2. Berry J.W., Poortinga,Y.H., Segall, M.H., Dasen, P.R. Cross-

Cultural Psychology. Research and Applications. CUP, Cambridge, (1992) 1999.

3. Chika Assai E., Durham J., Halvorson A., Holte S. Counseling and Student Affairs. Minnesota State University. HTML version: w2.edutech.nodak.edu/ndca/conference/.../amyhalvorson.ppt

4. Hoffman E. Lost in Translation: A Life in a New Language. Vintage Books, London,(1989)1998.

5. Hoffman E. Identity Theory Interview http://www.identityt-heory.com/interviews/birnbaum157.php

6. Hoffman E. Nie Chcæ Ýyã w Wædrówce http://free.art.pl/akcent_pismo/pliki/siec/hoffman.html (transl. by MWM)

7. Jahoda G. Foreword in: Berry J.W. 1999. X-XII.8. Kepiñski A. Schizofrenia. PZWL, Warszawa, 1972,.9. Okulicz-Kozaryn R. The Language of Luminous Love:

M.K. Ciurlionis among Heirs to the King-Spirit http://www.lituanus.org/2003/03_4_04.htm#foots

10. Reber A.S. The Penguin Dictionary of Psychology. Penguin Books 1995.

11. Siedlecka J. Mikoùaj Konstanty Èiurlionis 1875-1911. Pre-ludium Warszawskie. Wyd. AgArt Warszawa, 1996.

PRISITAIKYTI AR NEPRISITAIKYTI – TRANSKULTÛRINIAI IÐÐÛKIAI

Marta Wiszniowska – Majchrzyk SantraukaRaktaþodþiai: adaptacija/disadaptacija, transkultûrinë psicholo-

gija, M.K.ÈiurlionisTranskultûrinë psichologija, kuri remiasi kultûrø, tradicijø ir kalbos

vaidmeniu, turi didesnes galimybes paaiðkinti migrantø (dis)adaptacijà ðiame globalëjanèiame pasaulyje. Ji gali suteikti geresnës áþvalgos vertinant M.K.Èiurlionio meninius pasiekimus, kurie tarsi prieðtarauja jo biografijos faktams.

Adresas susiraðinëti: [email protected]

Gauta 2009-12-05

INFORMACIJA


Key words: effectiveness of therapy of the imprisoned offenders, aggression, a sense of purpose in life, coping with stress styles.

SummaryThe present paper discusses the effectiveness of therapy of the imprisoned addicted offenders. The effectiveness of specially designed therapeutic program for in-prison treatment is evaluated by comparing the changes in behavioral aggression indicators, a sense of purpose in life and coping with stress styles and, in result, changes in social adaptation.

MATERIAL AND METODS Legal foundations for the treatment of addicted

offenders in Polish penal system. Art. 96 § 1 Polish Penal Code states (an unofficial translation): “Offenders with non-psychotic disorders serve prison sentence in a therapeutic system, including those sentenced upon art. 197-203 Polish Penal Code for offences linked with disturbed sexual preferences, mental impairment, alcohol or psychoactive drugs addiction, physical handicaps – requiring specialist treatment, in particular psychological, medical or rehabilitation.”

The next relevant paragraph states (unofficial tran-slation):

“Executing the sentence in therapeutic system ac-counts for a particular need to prevent further deepening of pathological personality traits, regaining psychic ba-lance and helping develop social relations and preparing for self-reliant life. “Art. 97 § 1

Imprisoned offenders undergo systematic therapy with individual therapeutic programs that include:

• Kinds and forms of therapeutic activities (espe-cially psychological, medical and rehabilitating)

• Activities included in systematic re-socializing and adapting programs (General Prison Service, Direc-tive (19).

Such understanding of resocializing and therapy aim

at the following objectives:Minimal aim: such state of the prisoner’s personality

that allows functioning in society (after release) without re-offending

Maximal aim: the state of the prisoner’s personality, which allows functioning in society without re-offending and with respecting several significant social norms.

Effectiveness of therapeutic activities in prison con-ditions. Those dealing with the problems of resocializing and therapy in prison condition reveal certain skepticism toward its effectiveness. It is often maintained that on release offenders are far worse than before they served their term. J. Pinatel (13) assumes that no prison can be-come a proper place for corrective actions. H.J.Schneider (16) talked about the failure of any activity due to the artificiality and isolation in prison. K.Pospiszyl (14,15) believes that therapy of psychopaths is only apparent and utterly ineffective, and the process of change and psychotherapy effectiveness comes from a desire to show off and is a manipulative action to achieve per-sonal goals.

There are few researches that point to positive results of therapy on the offenders’ functioning. Z. Lenartowicz and W. Piekarski (10) point to the following positive results of in-prison therapy such as better adaptation to prison conditions, lowering anxiety and hostility. K. Pospiszyl (15) maintains that group therapy is the best resocialization method for psychopaths.

Conducting in-prison addiction therapy, J.Górski (7), J.Górny (6), K. Linowski and J.Nowicka (11) point to the effectiveness of therapy in small prisons. There, therapy can be of motoric, individual, occupational and artistic. The patient’s attitude, his will to change attitudes and offensive p

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