Bridging the Gap in Mental Health Approachesbetween East and West: The PsychosocialConsequences of Radiation Exposurellya 1. Yevelson,l Anna Abdelgani,1 Julie Cwikel,l andIgor S. Yevelson21Spitzer Department of Social Work, Ben-Gurion University of the Negev,Beer Sheba, Israel; 2Bryansk Regional Psychoneurological Hospital,Regional Psychiatric Expert Commission, Bryansk, Russia

Mental health professionals in Western countries and the Confederation of Independent States([CIS], the former Soviet Union) have been examining the social and psychological consequences

of the 1986 Chernobyl nuclear accident on the people who lived or are living in the exposedareas. Based on reviews of the literature, papers from international conferences, andcommunication between researchers in various countries, different perspectives have emergedon classifying distress and disorders and designing treatment programs. The origins of thesedifferences lie in philosophical, historical, and political developments in the West and the CIS.These different approaches often have made it difficult for mental health professionals from theCIS and the West to work together. The goal of this paper is 2-fold: to identify and recognize themain differences in these approaches and to propose specific solutions for bridging the gap. Thebasic approach of mental health professionals in the CIS is a physiological, nosological one-itfocuses on the etiology of the illness. Although their main diagnostic tool is the InternationalClassification of Diseases, 10th Revision, it has undergone adaptations that reflect the Sovietmedical and physiological attitude toward psychiatry. These changes have resulted in theabrogation and addition of disorder categories. For example, in the CIS edition of the ICD-9, thereis no mention of post traumatic stress disorder as a distinct disorder. In contrast, in the West, thedominant approach is a symptomatic, phenomenologic one. Emphasis is placed on a dynamicunderstanding of the disorder and treatment is conducted by mental health professionals(psychologists, social workers, psychiatrists). This contrasts with the approach used in the CIS,where psychological distress often is somaticized and treatment undertaken by physicians ratherthan mental health professionals. The authors of this paper call on researchers to come togetherand work jointly on the recognition and resolution of these differences. Then both groups will beable to offer concrete solutions and build tools that can benefit both sides. It is hoped that thesenew approaches will receive worldwide recognition and prove useful for other mental healthprofessionals working with persons affected by the accident at Chernobyl. Environ HealthPerspect 105(Suppl 6):1551-1556 (1997)

Key words: Russian, psychiatric approaches, PTSD, Chernobyl, technological disasters,mental health outcomes, liquidators, central nervous system, somatic complaints

IntroductionThe is general consensus that the handle this extensive psychosocial morbidity.Chernobyl nuclear accident caused wide- Some work has been done by the Unitedspread adverse psychologic effects among Nations Educational, Scientific and Culturalthe exposed population. However, there is Organization and local psychiatric institu-little clarity or agreement about how to tions to deal with the problems, but

This paper is based on a presentation at the International Conference on Radiation and Health held 3-7November 1996 in Beer Sheva, Israel. Abstracts of these papers were previously published in Public HealthReviews 24(3-4):205-431 (1996). Manuscript received at EHP 18 April 1997; accepted 19 June 1997.

Address correspondence to Dr. J. Cwikel, Spitzer Department of Social Work, Ben-Gurion University of theNegev, P.O. Box 653, Beer Sheba, Israel 84105. Telephone: 972 7 6472321 or 972 7 6472328. Fax: 972 76472933. E-mail: jcwikel@bgumail.bgu.ac.il

Abbreviations used: ARS, acute radiation sickness; CIS, Confederation of Independent States (former SovietUnion); CNS, central nervous system; DSM, Diagnostic and Statistical Manual; GHQ, General HealthQuestionnaire; ICD, Intemational Classification of Diseases; IES, Impact of Events Scale; NTC, national tradi-tional classification; PTSD, post traumatic stress disorder; SCL, Symptom Classification List.

understanding these efforts is hampered bylack of a common working languageamong mental health professionals. Thepurpose of this paper is to identify the dif-ficulties facing Western researchers inter-ested in working with investigators fromthe Confederation of Independent States([CIS]), the former Soviet Union) and tooffer possible solutions to overcome thesedifficulties. In addition, we note majortrends and approaches that appear in theCIS literature.

After the Chernobyl accident in 1986,researchers throughout the world joined inthe quest for knowledge about the effectsof radiation on the exposed population andthe need for a common language emerged.As a rule, the professionals from the Westtried to teach those from the East; littleknowledge was transmitted from the oppo-site direction. This happened despite thefact that much valuable information hasbeen amassed in the CIS over the years.A researcher from the West interested in

learning from his or her counterparts in theCIS must first overcome a number of techni-cal difficulties. To begin with, most CIS arti-cles are not translated into English and arenot published in Western journals. At best,Western researchers succeed only in obtain-ing abstracts of work undertaken. Second,most literature from the CIS is not associ-ated with a computerized database such asa CD-ROM. In the CIS articles are fre-quently exchanged at the personal level,often at conferences or when the CISinvestigator sends reports to his or herpeers. As a result, the West has a selectiveand inconsistent understanding of researchthat has been done in this area in the CIS.This is especially true of researchers who arejust beginning to study the area. However,Western researchers have more seriousproblems than these when they attempt touse Russian mental health materials. Forexample, lacking a comprehensive under-standing of the psychiatric world in theCIS, most researchers have a difficult timeunderstanding the few articles that havereached the West.

Differing ClassificationSystemsThis paper is based on a literature list thatwe feel is far from complete. In spite of thisobvious drawback, we believe we haveuncovered a number of important issuesthat need clarification. The first issue,which is central, is the discrepancy that

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Psychosomatic disorders

Somatogenic disordersI Somatogenic disoPsychoorganic development of personality

Encephalopathiapseudoneurotic and Endomorphic organic procespseudopsychophatic disorders E

Figure 1. Diagnoses of psychological disorders related to the Chernobyl nuclear accident. Adapted from Napreyenko and Logahanovsky (1).

exists between the West and the CIS intheir use of classification systems of mentaldisorders and the terminology used. At firstglance, the classification systems seem quitesimilar. The information that the westernresearchers receive is that the ICD-9(International Statistical Classification ofDiseases, Ninth Revision, World HealthOrganization) has been accepted for usein the CIS since 1978. In 1995, CISinvestigators began using the ICD-IO.However, a closer look reveals differencesthat are expressed in many ways.

These differences are discussed byNapreyenko and Logahanovsky (1)(Figures 1-3). In this paper, the authorstried to present the entire spectrum ofdiagnosed disorders in the exposed popula-tion after the Chernobyl accident. As wecan see in Figure 1, they used categories ofthe National Traditional Classification(NTC) and compared them to the acceptedcategories of the ICD-9 and ICD-IO.Examples of diagnoses that represent theNTC include post-psychotic personalitychanges and neurotic, post traumatic, psy-chosomatic, and psychoorganic personalitydevelopment. These diagnoses appear onthe right-hand side of Figures 1 to 3. TheNTC, as we understand, is a psychiatricperspective used by doctors in the CISand is comprised of the accumulatedknowledge available.

In articles aimed solely at CISresearchers, there is evidence that the scien-tific writing is strongly influenced by theNTC approach. This classification is basedmainly on the famous neurophysiologicwork of I.P. Pavlov, S.S. Korsakoff, andV.M. Bechterof. Both East and West sharethe incorporation of biologic and geneticresearch. This is in contrast with the psy-chologic theories that underlie Western

mental health approaches, which combinethe work of S. Freud (psychodynamic),B.F. Skinner (operant behaviorism), andA. Maslow (humanistic perspective).

Figure 1 shows some examples of theseclassification differences. For example,Napreyenko and Logahanovsky discuss veg-etative dystonia (autonomic nervous systemdysfunction), which is categorized underpseudoneurotic disorders and appears inFigure 2. This disorder is the most fre-quently reported in Russian literature [e.g.,(2)]. In the West, no such category exists.Napreyenko and Logahanovsky suggest thatthis disorder is comparable to a categorycalled Unspecified Disorders of AutonomicNervous System, Code 337.9 in the ICD-9.From personal conversations with Russianmental health professionals, we understandthat this diagnosis refers to various types ofphysical and neurologic symptoms that maybe psychogenic in origin. It appears toinclude a wide variety of symptoms ratherthan being specific. Besides the differencesin the NTC and the ICD-9, a differencealso exists between the ICD-9 and the ICD-10. This is because in the latter, theUnspecified Disorders of the AutonomicNervous System category no longer exists,but is partially covered by the groupSomatoform Autonomic Dysfunction(F45.3-35, including cardiovascular, gas-trointestinal, respiratory, genitourinary, andother organ systems). These subcategoriesare not mentioned specifically in theFigures. In the West (mainly in the UnitedStates and recently in Israel), the classifica-tion system of the DSM-IV(Diagnostic andStatistical Manual, American PsychiatricAssociation) is used. It is important to notethat the DSM and the ICD are not identi-cal. In two versions of the DSM, the cate-gory Somatoform Autonomic Dysfunction

does not exist; there is only SomatoformDisorders (see Figure 3).

In sum, we understand from CIS inves-tigators that they use the ICD classificationsystem basically for diagnoses intended forofficial purposes or when collaborating withWestern mental health professionals. Intherapy, CIS mental health professionalsapparently employ widely used terms andcategories from the old Russian classifica-tions based on national traditions. Theseare used with greater frequency than theICD. In Russia, there is a much strongeremphasis on the nosologic approach, whichis an etiologic approach. That is, there isstrong emphasis on placing each symptomin a category in which there is a clear rela-tionship between cause and symptom.Vegetative dystonia is only a partial exam-ple of this approach because it is viewed as asyndrome and does not use the nosologicapproach. On the other hand, this categoryoften is the diagnosis of choice when anexternal environmental cause is identified.In addition, there is emphasis on under-standing which mechanism is responsiblefor specific illnesses. The West, by com-parison, places much more emphasis onsymptoms and the approach is a pheno-menologic one. This distinction explainsthe impression gained from reading the lit-erature that Western researchers tend todefine disorders on their psychologic basis,whereas CIS investigators tend to look for aphysiologic basis.

For example, in the ICD-9 there is acategory called Physiological MalfunctionArising from Mental Factors (306.X). Inpractice, both this diagnosis and thecategory Unspecified Disorders of theAutonomic Nervous System describe simi-lar symptoms; however, the etiology is dif-ferent. Code 337.9 includes biologic as well

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Psychosomatic disorders )

Somatogenic disorders

Encephalopathia (pseudoneurotic,pseudopsychopathic disorders)ICD-9310 specific nonpsychotic mentaldisorders attributable to organic brain damage300.9 unspecified neurotic disorder301.9 unspecified personality disorder

Post-psychotic personality changesICD-9 NoneICD-10F-62.1 enduring personality changes after psychiatric illnessF-62.8 other enduring personality changes

zurotic development (condition) of personality)-9 None)-10B2.8 other enduring personality changesB8 other disorders of adult personality and behavior

Post-traumatic development of personalityICD-9 NonelCD- 10F-62.0 enduring personality changes aftercatastrophic experience

Psychosomatic development of personalityICD-9 NoneICD- 10F-21 schizotypal disorderF-34.1 dysthymiaF-45 somatoform disordersF-68 other disorders of adult personality and behavior

Psychoorganic development of personalityICD-9310.11-19 organic personality syndromelCD-10F-07 personality and behavioral disorders attributable tobrain disease, damage and dysfunction

Endomorphic organic processICD-9310.11-19 organic personality syndromesICD-10F-03 unspecified dementiaF-04 organic amnestic syndromesF-05 delirium)F-07 personality and behavioral disorder attributable tobrain disease, damage and dysfunctionF-09 unspecified organic or symptomatic mental disorders

Figure 2. Diagnoses of and ICD-9and ICD-lOcodes for psychological disorders related to the Chernobyl nuclear accident. Adapted from Napreyenko and Logahanovsky ( 1).

Figure 3. Example of psychological disorders related to the Chernobyl nuclear accident and ICD-9, lCD-1, and DSM-lVcodes. Adapted from Napreyenko and Logahanovsky ( 1).

as psychologic factors. It seems that CISresearchers use the category that includesbiologic factors. A second example comes

from Code 316.X-Psychic Factors,Associated with Physical Disease, ClassifiedElsewhere, which is an example of a disor-der that could be understood on the phe-nomenologic level and is suitable for thedescription of the symptoms associatedwith the Chernobyl accident. However, thiscategory was excluded from the adaptiveCIS ICD-9. These examples support theconclusion that for investigators in the CIS,the ICD is adapted to their mental healththeories and categories that do not fit intothis approach are excluded.

Changes that have been made in theRussian version of the ICD-9 include not

only exclusions but also extensions. In theEnglish version of the ICD-9 (Code 300.9),there is a category called UnspecifiedNeurotic Disorders. In the modified CISversion of the ICD-9, there is a categorycalled Unspecified Neurotic Disorder andPseudo-neurotic Condition due to ExogenicEtiologic Factors (3). In the English ver-

sion the only code is 300.9. By contrast,in the modified version this code isextended to 300.92-99.The modified CIScategories (ICD-9, Russian modification)are presented below, with their modifiedICD-9 codes:

* Intoxication, 300.92* Systemic infection, 300.93* Somatic non-infectious disease, 300.94* Metabolic disorder, 300.95* Menopause, 300.96* Involution, 300.97* Other (nonspecified), 300.98* Other (unknown), 300.99

When Western researchers begin workin this field, they may mistakenly believethat the CIS is using the same ICD-9 clas-sification system as they are. The Russianversion of ICD-10 is a much closer fit to

the Western version. However, as we haveshown, there are many differences. We donot recommend negating the CIS system,

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NeurosesICD-9300.0-300.8 neurotic disorderslCD- IOF-40 phobic anxiety disordersF-41 other anxiety disordersF-42 obsessive-compulsive disorderF-44 dissociative disordersF-48 other neurotic disorders

PTSDICD-9300.00 (anxiety disorder not otherwisespecified)ICD- 10F-43.1 (PTSD)

Cerebrostenia (pseudoneurotic,pseudopsychopathic disorders)ICD-9300.0 unspecified neurotic disorder301.9 unspecified personality disorders337.9 unspecified disorders of autonomicneural systemlCD- 10F-06 other mental disorders attributable tobrain damage and dysfunction to disease

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nor do we expect CIS researchers toabandon their rich tradition, do away withtheir classifications, and adapt the Westernversion of the ICD. However, we do rec-ommend that researchers working togethershould openly discuss their different prac-tices and perspectives, as they must under-stand and interpret their research findingsbased on some common ground. This isespecially important when categories ofone system do not appear in the classifica-tion scheme of another system. As a conse-quence, it often is impossible to compareresearch results because researchers arelooking at different disorders.

One of the disorders discussedfrequently in Western literature and whichis associated with technologic disasters ispost traumatic stress disorder (PTSD). Weuse this disorder as an example of thechanges and trends taking place in 1990sCIS scientific publications concerned withthe Chernobyl accident. These changes,we assume, are partly the result of jointresearch undertaken on the consequences ofthe Chernobyl accident by researchers fromthe CIS and from the West. There is nodoubt that the PTSD category is importantfor analysis of the psychologic consequencesof technologic catastrophes and has receivedmuch attention in the literature since itsintroduction as an independent diagnosticcategory in the 1980 DSM-III. Over theyears, the category has been redefined andenlarged (DSM-III-R in 1987; DSM-IVin1994). Despite methodologic argumentsabout whether invisible stressors such asthose diagnosed as a result of the Chernobylaccident should be included under thisdisorder, PTSD was included whenassessments were made. By contrast, inSoviet and CIS publications before 1993,PTSD did not appear as a diagnosis. This isbecause up until 1993, as mentioned previ-ously, the ICD-9 (which did not includePTSD) was used. PTSD appeared in theICD-1O in 1994 and was accepted in theCIS in 1995. In addition, in the NTCother kinds of disorders and symptomswere emphasized in place of PTSD. Whenreports began to be published from thejoint work of Western and Russian groupsworking with the DSM-III, PTSD beganbeing mentioned (4). Since the beginningof the 1990s CIS investigators haveincluded PTSD when undertaking researchon their own, and it has become a majortrend in their work (5,6).

Rumyantseva and colleagues (6)report of a cohort consisting of 632 adultrespondents aged 16 to 60 who applied for

psychotherapeutic help between 1992 and1994 because of neurotic complaints Allthe respondents came from the high-expo-sure area of Novozybkov (Bryansk region).They were examined individually by apsychiatrist who used instruments includ-ing the Symptom Classification List (SCL-50) (7), the General Health Questionnaire(GHQ-28) (8), a list of stressors, and theImpact of Events Scales (IES) (9). Theresults of the Rumyantseva et al. (6) studyshowed that 58% of the cohort had at leastone PTSD symptom (61% females and39% males) and 8% were diagnosed assuffering from clinical PTSD.

Tarabrina, in collaboration withAmerican Colleagues, (10) examined 46liquidators who participated in cleaningthe reactor after the Chernobyl accidentduring the period 1986 to 1988. The liq-uidators were examined by using theimagery method suitable for measurementof specific PTSD physiologic responses.The respondents were divided into twosubgroups according to DSM-III-R crite-ria. The researchers employed the follow-ing instruments: Questionnaire of MentalImagery (11), Mississippi PTSD Scale (12),IES, Minnesota Multiphasic PersonalityInventory (13), Spielberger AnxietyScales (14), SCL-90-R (15), and the BeckDepression Inventory (16). Thirteen liq-uidators were diagnosed as having PTSDand 26 fell within the norm on the intru-sion and avoidance scales. There was nodifference between the two groups onphysiologic reactivity. It was concludedthat unlike survivors of war trauma, thesurvivors of the invisible traumatic stres-sors of the Chernobyl accident showednone of the abnormally high physiologicreactivities typically elicited by recall ofpsychic trauma.

The above were two examples ofCIS research that used both Eastern andWestern instruments. This trend towardcooperation between the East and Westdemonstrates that there now exists a realpossibility to develop a more unified psy-chologic approach and to make comparisonsbetween populations that left the CIS forthe United States or Israel and populationsthat remained in the CIS.A psychologic basis is one of the most

important factors in pathogenesis. However,there is no consensus about the mecha-nisms that produce psychologic symptoms.Although some researchers believe thatsomatic and aesthenic signs have a psy-chogenic (psychologic) etiology, othersclaim that symptoms such as aesthenia

(a decrease in functioning), cognitivedisorders, pain symptoms, and otherneurologic symptoms may be the result oflow doses of radiation influencing the ner-vous system or the beginning of organicdiseases caused by exposure of the centralnervous system (CNS) to radiation (abiologic etiology) (17).

Somatic disorders have been found withgreater frequency among liquidators, (thosewho took part in cleanup operations at theChernobyl reactor site) and have beenreported by Nyagu (18). Evidence ofsomatic symptoms among those living inareas contaminated with radiation is contra-dictory and therefore still controversial.Many Russian authors fully recognize theinfluence of psychologic factors; however,they continue to focus on the pathophysio-logic disorders of the nervous system.Zdesenko (19) presented an analogy withthe syndrome of direct damage to the CNSobserved in clinics of acute radiation sick-ness (ARS). This indicates that for high andmiddle levels of radiation, effects on theCNS are part of the whole clinical picture ofARS. The picture is less clear for low levelsof radiation. However, Zdesenko assumesthat some CNS damage is possible. In a col-laborative paper by the Research Institute ofPsychiatry (Moscow) and the Moscow StateUniversity Department of Psychology(Moscow), Khomskaya et al. (20) reportedfindings concerning the neuropsychologicinvestigation of persons involved in thecleanup after the Chernobyl disaster. Theresearchers examined cognitive, motor,emotional, and personality characteristics ofliquidators during the 1986 to 1997 period.Neuropsychologic effects were apparent inall spheres studied. The most typical neu-ropsychologic syndromes were diencephalic,diencephalic frontal, and diencephalic righthemisphere. Khouskaya et al. (20) con-cluded that the psychiatric changes foundindicated the presence of stable organicchanges in the brain functions of theChernobyl liquidators. These changes arecharacterized by a mild dinical picture and apronounced vegetative problem, but thechanges cannot be considered to have onlypsychologic origins. In these studies, as inothers, it is difficult to evaluate the validityof the results because information is missingon research design and methods.

Summary of RussianPsychologic Studiesof the Chernobyl DisasterIn evaluating the quality of Russian researchon the effects of exposure to radiation in

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and after the Chernobyl accident, it shouldbe emphasized that most studies have notbeen published in Western peer-reviewedjournals. Therefore, in considering thesefindings one must keep in mind themethodologic caveats. However, forWestern researchers it is helpful to reviewthe main findings published in Eastern blocprofessional literature.

In commemoration of the 10thanniversary of the Chernobyl accident,Rumyantseva et al. (21) and Havenaar(22) summarized the main findings of CISinvestigators. The earliest publications onthe mental health aspects of the disasterappeared in 1987 to 1988 (23,24).Rumyantseva heads the leading Russianresearch group (25,26) that has also col-laborated with Western psychiatric investi-gators [e.g., Havenaar (22)]. The resultswere summarized as follows:

Contradictory information that circu-lated after the accident from both formaland informal sources increased stress lev-els among the exposed populations.Because of insufficient information orno information at all, there were peaklevels of stress disorders in 1989. Stresslevels peaked again in 1993 because ofexaggerated reports about the healthconsequences of the Chernobyl accident,and hopes rose about the possibility ofreceiving financial compensation.

* In areas exposed to radiation, radiationexposure was perceived to be the mostdangerous risk compared to other socialand economic risks.

* The level of stress symptoms wassignificantly higher in exposed areasthan in unexposed areas (1.5 timesmore) among evacuees (increased from40 to 62% between 1993 and 1995)and among liquidators (some type ofpsychologic disorder was diagnosed in84% of the liquidators, which was 3times higher than those diagnosedamong the exposed population).

* Among populations in exposed areascompared with control populations, themost frequent symptoms were somatic-functional-somatization in the form ofdifferent kinds of pains, senestopathias(unclear or bizarre sensations), andparastheses (irregular sensations accord-ing to the intensity of stimulus).Somatic reactions were more oftenobserved than depression and phobicreactions as expression of distress.

* A greater prevalence of sicknessbehavior (more complaints, decreasedsubjective evaluation of health, increased

visits to physicians, increased medi-cation use) was also observed amongexposed compared to comparison popu-lations. High levels of health-focusedanxiety were found more often inexposed populations than in non-exposed populations.

* So-called radiophobia was not found.The level of psychosis was unchangedby the accident.

* The most popular assessment instru-ment used was the 28-item version ofthe GHQ.

* High-risk groups included mothers withyoung children (born after 1987),physicians, and educators.Maladaptation clearly was present;

however, it was difficult to reach a consen-sus about the ways it produced psychologicsymptoms. Although some researchersbelieve that somatic and neurologic symp-toms are psychogenic (psychologic) in ori-gin, others claim that symptoms such asnervous system dysfunction, cognitive dis-orders, and pain may be the effect of lowdoses of radiation on the nervous system orthe beginning stages of organic diseases.

Rumyantseva (25) considered thecharacteristic psychologic patterns thatoccurred in persons living in contami-nated areas who were exposed to extremestress due to the Chernobyl accident.These were neuropsychologic syndromessuch as anxiety, aesthenia, somatoform,hysteria, and obsessive and affective disor-ders (25). In the last few years, however,the most commonly reported of theneurotic syndromes were aesthenia andvegetative dystonia.

In summary, the types of disordersreported by CIS researchers as being themost frequent lie in the range of the neu-roses and reactive psychologic states. Intraditional Russian psychiatry these arecalled pseudoneurotic disorders and aresimilar to neurotic disorders on the phe-nomenologic level; however, they are bio-logic or environmental in origin. Thatphysicians and educators are among thehigh-risk groups for symptoms and psy-chologic distress raises questions abouthow health risks are being presented tothe population, as physicians and educa-tors come into contact with large numbersof affected persons. Furthermore, they arein pivotal positions in formulating healthand social policy (whether to eat certainfoods, whether to spend time outdoors,whether to leave the area if possible) forindividuals and families in their care.Perhaps more effort should be made to

inform these people about the currentstate of research on Chernobyl-relatedhealth risks.

One of the most interesting findingsfor us was that CIS investigators empha-sized psychologic and physiologic phe-nomena that can be described as acombination of minor symptoms whichcannot be clustered under one diagnosticlabel. It is easier to treat a patient when aclear diagnosis exists. In the case ofChernobyl, it often is difficult to makesuch a clear diagnosis and as a result, manypeople suffering from these disordersremain without treatment. Available stan-dard tests cannot define their symptoms astypically neurologic, internal, psychiatric,or orthopedic. Many of the people whocame from the exposed regions fall intothis category. To the best of our knowl-edge, this point is not emphasized enoughin Western publications that deal with theconsequences of the Chernobyl accident.

What we can learn from the psychiatricapproach used in the CIS is that profes-sionals adhere to a multidisciplinaryapproach when treating people exposed tothe Chernobyl accident. This approachtypically combines clinical psychology,psychotherapy, neurology, internal medi-cine, and orthopedics (27-29). We are notrecommending that Western therapistsadopt this type of specialization; however,we do feel that this multidisciplinaryapproach could be adopted so that a jointdiscussion of a person's symptoms could beundertaken by health professionals work-ing together in a clinic. This approachwould solve the problem of disjointedinformation concerning the patient and,hopefully, provide a fuller picture of his orher status. In the West, treatment ofchronic pain is handled this way. There-fore, in our opinion, such an approachcould be used in treatment and diagnosisof persons exposed to radiation in theChernobyl nuclear accident.

ConclusionsWestern researchers face difficulties intrying to learn from the Russian experiencewith psychologic consequences among pop-ulations exposed in the Chernobyl accident.Recognizing the unique aspects of theRussian approach and being receptive tothe interests of Russian specialists in inte-grating into Western science, it becomesfeasible to find ways to overcome the diffi-culties inherent in two different culturescoming together to conduct research.

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1556 Environmental Health Perspectives * Vol 105, Supplement 6 a December 1997