Engrami br 01 2015 by Engrami

ČASOPIS ZA KLINIČKU PSIHIJATRIJU, PSIHOLOGIJU I GRANIČNE DISCIPLINE JOURNAL FOR CLINICAL PSYCHIATRY, PSYCHOLOGY AND RELATED DISCIPLINES Časopis ENGRAMI osnovao je prof. dr Dimitrije P. Milovanović 1979. Glavni i odgovorni urednik / Editor in chief

SRĐAN D. MILOVANOVIĆ Zamenik glavnog i odgovornog urednika Supplement editor in chief

MILAN B. LATAS Pomoćnici urednika / Associate editors

MAJA PANTOVIĆ STEFANOVIĆ BOJANA DUNJIĆ KOSTIĆ SRETEN VIĆENTIĆ Uređivački odbor / Editorial board

ALEKSANDAR JOVANOVIĆ ALEKSANDAR DAMJANOVIĆ MILICA PROSTRAN ŽELJKO ŠPIRIĆ MAJA IVKOVIĆ NAĐA MARIĆ DUBRAVKA BRITVIĆ OLIVERA VUKOVIĆ SRĐA ZLOPAŠA DRAGANA DUIŠIN JASMINA BARIŠIĆ NADA JANKOVIĆ DRAGAN PAVLOVIĆ OLIVERA ŽIKIĆ PETAR NASTASIĆ DEJAN LALOVIĆ VLADIMIR JANJIĆ SVETLANA JOVANOVIĆ

Izdavački savet / Consulting board

LJUBIŠA RAKIĆ JOSIP BERGER MIROSLAV ANTONIJEVIĆ JOSIF VESEL MIRKO PEJOVIĆ JOVAN MARIĆ MIROSLAVA JAŠOVIĆ GAŠIĆ SLAVICA ĐUKIĆ-DEJANOVIĆ DUŠICA LEČIĆ TOŠEVSKI VLADIMIR KOSTIĆ RATOMIR LISULOV (Novi Sad) Internacionalni redakcioni odbor International editorial board

N. SARTORIUS (Geneve) D. KOSOVIĆ (New York) P. GASNER (Budapest) D. ŠVRAKIĆ (St. Louis) G. MILAVIĆ (London) V. STARČEVIĆ (Sydney) V. FOLNEGOVIĆ-ŠMALC (Zagreb) M. JAKOVLJEVIĆ (Zagreb) S. LOGA (Sarajevo) J. SIMIĆ-BLAGOVČANIN (Banja Luka) Z. STOJOVIĆ (Herceg Novi) L. INJAC (Podgorica) A. TOMČUK (Kotor) A. MIHAJLOVIĆ (Chicago) N. TRAJANOVIĆ (Toronto) Sekretar / Secretary

GORDANA MARINKOVIĆ Lektor za srpski i engleski jezik SONJA ĐURIĆ

Časopis ENGRAMI izlazi četiri puta godišnje. • Rešenjem Sekretarijata za kulturu SRS broj 413-124/80-2a časopis ENGRAMI je proizvod iz čl. 36, st. 1, tačka 7, Zakona o operezivanju proizvoda i usluga u prometu za koji se ne plaća porez na promet proizvoda. • IZDAVAČ / EDITED BY: KLINIKA ZA PSIHIJATRIJU KLINIČKOG CENTRA SRBIJE I UDRUŽENJE PSIHIJATARA SRBIJE; THE CLINIC FOR PSYCHIATRY CLINICAL CENTRE OF SERBIA AND SERBIAN PSYCHIATRIC ASSOCIATION • ADRESA UREDNIŠTVA / ADDRESS OF EDITORIAL BOARD: ENGRAMI, Klinika za psihijatriju KCS, Pasterova 2, 11000 Beograd, E-mail: klinikazapsihijatrijukcs@gmail.com • časopis ENGRAMI je referisan u SCIndeks bazi (Srpski nacionalni citatni indeks); Journal ENGRAMI is listed in SCIndeks (Serbian national citation index)• Copyright © 2015 ENGRAMI. Sva prava zaštićena.

SADRŽAJ CONTENTS

ORIGINALNI RADOVI / ORIGINAL ARTICLES Sreten Vićentić, Milan Latas, Jasmina Barišić, Marija Matić, Maja Pantović Stefanović, Aleksandar A. Jovanović, Srđan Milovanović

BURNOUT IN MEDICAL STUDENTS IN SERBIA – PRECLINICAL AND CLINICAL DIFFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 SINDROM SAGOREVANJA KOD STUDENATA MEDICINE U SRBIJI – PREDKLINIČKE I KLINIČKE RAZLIKE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Petar Vojvodić, Goran Mihajlović, Jelena Đorđević, Jovana Vojvodić, Katarina Radonjić

PSYCHOPHARMACOLOGICAL APPROACH TO THE TREATMENT OF ADOLESCENTS IN THE FIRST PSYCHOTIC EPISODE . . . . . . . . . . . . . . . . . . . . . . . . 17 PSIHOFARMAKOTERAPIJSKI PRISTUP TRETMANU ADOLESCENATA U PRVOJ PSIHOTIČNOJ EPIZODI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

KONSULTATIVNI PSIHIJATRIJSKI PREGLEDI PACIJENATA HOSPITALIZOVANIH U OPŠTOJ BOLNICI UŽICE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 LIAISON INPATIENT PSYCHIATRIC TREATMENT OF PATIENTS AT THE GENERAL HOSPITAL UŽICE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Maja Pantović Stefanović, Bojana Dunjić- Kostić, Mirjana Gligorić, Maja Lačković, Aleksandar Damjanović, Maja Ivković

EMPATHY PREDICTING CAREER CHOICE IN FUTURE PHYSICIANS. . . . . . . . . . . . . 37 EMPATIJA KAO PREDIKTOR IZBORA SPECIJALIZACIJE KOD BUDUĆIH LEKARA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Ivana Jelić

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Nebojša Popović, Marina Ilić

CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND DEPRESSION . . . . . . . . . . . . 49 HRONIČNA OPSTRUKTIVNA PLUĆNA BOLEST I DEPRESIJA. . . . . . . . . . . . . . . . . . . . 53 3

REVIJALNI RAD / REVIEW ARITCLES Bojana Dunjić-Kostić, Maja Pantović Stefanović, Maja Ivković, Aleksandar Damjanović, Maja Lačković, Miroslava Jašović Gašić

SHIZOFRENIJA I CITOKINI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 SCHIZOPHRENIA AND CYTOKINES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Srđa Zlopaša

SUBJEKTIVNOST U PSIHOANALIZI I PSIHIJATRIJI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 SUBJECTIVITY IN PSYCHOANALYSIS AND PSYCHIATRY . . . . . . . . . . . . . . . . . . . . . . . 73 Svetlana Jovanović, Srđan Milovanović, Jelena Mandić, Siniša Jovović

SISTEMI ZDRAVSTVENE ZAŠTITE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 HEALTH CARE SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

PRIKAZ SLUČAJA / CASE REPORT Kristina Brajović Car, Patrick Ellersich

TRANSACTIONAL ANALYSIS PSYCHOTHERAPY OF MIXED PERSONALITY DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

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PRIKAZ TRANSAKCIONO-ANALITIČKE PSIHOTERAPIJE MEŠOVITOG POREMEĆAJA LIČNOSTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

ISTORIJA MEDICINE / HISTORY OF MEDICINE Albina Stanojević, Irena Popović, Dragan Milošević, Ivana Tešanović

ISTORIJAT SPECIJALNE BOLNICE ZA PSIHIJATRIJSKE BOLESTI “GORNJA TOPONICA” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 HISTORICAL FACTS ABOUT THE SPECIAL PSYCHIATRIC HOSPITAL “GORNJA TOPONICA“ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 UPUTSTVO AUTORIMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Sreten Vićentić1 Milan Latas1,2 Jasmina Barišić1 Marija Matić2 Maja Pantović Stefanović1 Aleksandar A. Jovanović1,2 Srđan Milovanović1,2 UDK: 613.96.001[497.11]

Clinic for Psychiatry, Clinical Center of Serbia, Belgrade, Serbia

School of Medicine, University of Belgrade, Belgrade, Serbia

Summary Introduction/objective: The burnout syndrome is insufficiently investigated within the population of students. The aim of this study was to determine the level of burnout in medical students of medicine in Belgrade with the emphasis on preclinical/clinical differences, as well as differences according to gender and average grade. Methods: The Maslach Burnout Inventory Student Survey (MBI SS) was used to conduct the research among the students of medicine, consisting of emotional exhaustion subscale (MBI-EE), cynicism subscale (MBI CY) and academic efficiency subscale (MBI EF). Results: High level of burnout according to the MBI EE of the entire sample was confirmed in 84.4 % of students; medium level of burnout according to the MBI CY in 40.7 % and high in 31.7 %. According to the MBI EF, 61.2 % of the students had a medium and 16.9 % high level of burnout. The MBI EE and MBI EF scores were significantly higher in first year students, while the MBI CY score was higher with fifth year students (p<0.01). No gender difference was detected (p > 0.05) nor was the difference between the students with higher and lower average grade (p > 0.05) detected. Conclusion: The high burnout level in this study indicates the need for research on a larger sample, aiming at preserving the health of the future medical practitioners. It also causes concern about high scores especially in the preclinical, as well as in the clinical academic years. Key words: syndrome, burnout, medical students, undergraduate, studies

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BURNOUT IN MEDICAL STUDENTS IN SERBIAPRECLINICAL AND CLINICAL DIFFERENCES

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INTRODUCTION

The burnout syndrome studies around the world and in our country, conducted within the past twenty and something years, indicate that the individuals employed in health and social services, the so called ‘helping services’ have a higher inclination to develop a such syndrome, especially if they are confronted with violence, emotional abuse and deaths [1, 2]. Emotional (and physical) exhaustion, depersonalization (altered treatment of patients with negative and cynical attitude, lack of care, attaching stereotypes to patients and emotional distancing from them), altered perception of their ability to work and its subsequent loss (lack of professional competence and success, reduced efficiency at work) are given as the most significant components of this syndrome among health care professionals [3]. The burnout syndrome is described in the professional literature of the students of medicine, but the number of publications is negligible in comparison with the ones referring to the employed [4-7]. Analogous to the aforementioned, the main components of the syndrome in the student population are a sense of emotional exhaustion due to their studies (fatigue at the end of their day at the faculty and general tiredness), cynicism (diminished interest in and enthusiasm for their studies, suspicion in the benefits and significance of their studies) and diminished academic efficacy (diminished efficiency in problem solving during the studies and in dealing with the material required for the studies) [8]. The burnout research of the students of medicine was mostly focused on the students of the final years [7], while one smaller part compared the

differences in the level of the burnout during the preclinical and clinical years of the studies [9-13]. In further studies dealing with this difference, the MBI-HSS version of the questionnaire intended for the employed or its partial modifications will be used [7, 12-14]. While observing the connection between the demographic factors and the burnout syndrome within the students, the analysis according to the sex showed extremely heterogeneous results [13, 14]. According to our findings, the information in the world literature on connections between students’ average grade and the level of burnout are very scarce. The primary aim of this study was to determine the burnout risk level with the students of the Faculty of Medicine in Belgrade. The secondary aims were to investigate the differences in the level of burnout with the students of the first year (preclinical level) and the fifth year (clinical level), as well as the difference between male and female students, and between the students with higher and lower average grade.

MATERIAL AND METHODS Study design and participants The research was devised as a crosssection study and it was conducted at the beginning of 2012 at the School of Medicine of University of Belgrade. A total of 280 questionnaires were handed out, 237 students took part in it, 123 students of the first year and 114 students of the fifth year of studies, which represents a high response rate of 85 %. There were 45 male and 78 female respondents in the first year and 40 male and 74 female respondents in the fifth year of studies. Re-

Data collection The questionnaire was handed out to the first year students at the beginning of the second semester, while it was handed out to the fifth year students also at the beginning of the second semester of the current year which is during their tenth semester. Following the explanations for this type of research, all the participants gave their informed consent and were able to reply anonymously. The research was permitted by the ethical committee of the School of Medicine of the University of Belgrade.

Instruments The most common instrument to measure the burnout syndrome, also used in this study, is the Maslach Burnout Inventory – MBI [2]. The MBI-GS version (General Survey) measures the burnout risk in professions not directly oriented to people and has 3 subscales: emotional exhaustion, cynicism and professional efficiency [9]. The MBI-GS was modified for the purpose of determining the burnout level in students (for example, ‘I feel exhausted with my job’ was replaced by ‘I feel exhausted with my studies’ [10]) and measured the level of emotional exhaustion, cynicism and professional success in students [11]. The MBI-SS (Student Survey)

[8] is comprised of 15 claims divided into 7 categories ranging from 0 to 6 (0 - never, 1 - a couple of times a year or less frequently, 2 - twice a month or less frequently, 3 - a couple of times a month, 4 once a week, 5 – a couple of times a week, 6 – every day). The Emotional exhaustion subscale (MBI-EE) is consisted of 5 items; the cynicism subscale (MBI-CY) of 4 and the academic efficacy subscale (MBI-EF) of 6 items. Each subscale results are presented within 3 categories of the burnout risk – as low, medium and high burnout risk.

Statistical analysis The description of the numeric features was conducted by the means of the classical methods of descriptive statistics, which are the arithmetic mean and median. For the comparison of the mean values of the parametric features, i.e. the burnout scores of first and fifth year students, and the difference between the male and female students, we used the Student’s t-test. The Non-parametric MannWhitney test was used to determine the difference between the burnout levels in students with higher and lower average grade, and the Pearson’s correlation was used to show the connectivity of average grade and Burnout subscales’ scores. The SPSS program V.15, was used to conduct the statistical data analysis.

RESULTS The analysis of the reliability of the subscales showed satisfactory results. Cronbach’s alpha coefficient for all three subscales was higher than 0.7 that is 0.83 for MBI EE, 0.79 for MBI CY and 0.81 for MBI EF.

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garding the age, both groups were homogenous (p > 0.05). Since the first year students did not have the representative number of exams, only the fifth year students responded to the questions about their average grade (only three withheld such information). Regarding the arithmetic mean, they were categorized as students with higher and lower average grade.

According to the distribution of the burnout risk categories, the overall sample showed that a high risk of emotional exhaustion was present among 84.4 % of students and that as many as 94.3 % of the first year students and 73.7 % of the fifth year students had a high burnout risk. Furthermore, the subscale of cyni-

cism (MBI CY) on the overallsample showed a medium level of the burnout risk of 40.7 % and a high of 31.7 % and that the fifth year students have a higher occurrence of the burnout risk (41.2 %) than the first year students (22.8 %). Similarly, the MBI EF showed that 61.2 % of all respondents were in the category of

Table 1. Burnout risk level in medical students of the first and fifth year and in the total sample Year Subscales

First N -

low burnout risk MBI EE

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MBI CY

MBI EF

N 2

Fifth % 1.8

Total N 2

% 0.8

5.7

24.6

14.8

high burnout risk

116

94.3

73.7

200

84.4

Total

123

100 %

114

100 %

237

100 %

low burnout risk

35.8

18.4

27.4

medium burnout risk

41.5

40.4

40.9

high burnout risk

22.8

41.2

31.7

Total

123

100 %

114

100 %

237

100 %

low burnout risk

26.8

16.7

21.9

medium burnout risk

63.4

58.8

145

61.2

high burnout risk

9.8

24.6

16.9

Total

123

100 %

114

100 %

237

100 %

Table 2. Total burnout score according to the year of training (t-test)

MBI EE MBI CY MBI EF

medium burnout risk

% -

Year of training 1st

Mean

123

20.63

4.59

5th

114

18.46

6.25

1st

123

4.93

4.51

5th

114

8.55

6.50

1st

123

27.41

4.62

5th

114

25.02

6.68

3.064

0.002

-5.007

0.000

3.232

0.001

medium burnout risk and 16.9 % in the category of high burnout (Table 1). Table 2 shows a statistically higher significant differences (p <0.01) between the values for all three subscales for the first and fifth year students. The MBI EE

and MBI EF were higher with the first year students, while the MBI CY was higher with the fifth year students. Although the high and medium burnout risk was dominant with both sexes, there were no statistically significant differen-

Table 3. Total Burnout score according to students’ gender (t-test)

MBI EE MBI CY MBI EF

Gender

Mean

male

18.95

5.71

female

152

19.93

5.44

male

6.45

6.13

female

152

6.80

5.68

male

25.65

5.92

female

152

26.61

5.75

-1.309

0.192

-0.449

0.654

-1.217

0.225

MBI EE MBI CY MBI EF

Average grade lower

Mean Rank

58.45

Sum of Ranks 3974.50

higher

52.13

2241.50

lower

56.82

3863.50

higher

54.71

2352.50

lower

53.25

3621.00

higher

60.35

2595.00

-1.010

0.313

-4.502

0.000

-1.134

0.257

Table 5. Correlation of the average grade and the Burnout subscales’ scores MBI EE MBI CY

Average grade

MBI EF

Pearson Correlation

-0.082

-0.085

0.196*

Sig. (2-tailed)

0.395

0.378

0.040

111

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Table 4. Burnout score vs. lower/higher grade in the fifth year students (Mann-Whitney test)

* Correlation is significant at the 0.05 level (2-tailed) ** Correlation is significant at the 0.01 level (2-tailed)

ces (p > 0.05) in the analysis according to the gender of the students (Table 3). The arithmetic mean of the average grade for the 111 fifth year students was 8.29. Forty-three students had the average grade higher than 8.29 and 68 students lower than that. By observing the connection between the burnout risk and the average grade, we confirmed no significant difference (p > 0.05) in the MBI EE and MBI EF subscales. Only in the MBI CY subscale, the students with a lower average grade had significantly higher values (p < 0.01) (Table 4). Further, the Pearson correlation of average grade and subscales’ scores showed significancy (p< 0.05) only in the MBI EF subscale (Table 5).

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DISCUSSION

The aim of this study was to determine the prevalence of the burnout risk in the students of the Faculty of Medicine and to investigate the possible differences in terms of preclinical and clinical years of studies, gender and average grade. The burnout risk analysis (Table 1) showed that according to the MBI EE subscale, which is highly representative [2], as many as 84.4 % of students, 94.3 % of the first year students and 73.7 % the fifth year students had a high burnout risk. The MBI CY subscale showed a prevalence of a medium (moderate) risk with 40.9 % and a high with 31.7 %, where 72.6 % of the overall sample was exposed to a medium and high level of risk. According to the MBI EF subscale of academic efficiency, 61.2 % and 16.9 % of the students had a medium and high burnout risk respectively. All these figures are higher than in currently available studies worldwide. According to the eminent work of the Uni-

versity of Manchester, the burnout risk rate was considerably lower and ranged between 5.2 % for the MBI EF up to 7.1 % for the MBI CY (that is DP-depersonalization since the MBI-HSS version was used) and up to 16.1 % for the MBI EF (that is PA) [13]. Even though they used another, also verified instrument to measure the burnout (Oldenburg Burnout Inventory), Dalin and Runesson (1997) reported a high prevalence of the burnout from 21.7 % to 54.3 % [15]. Similarly, data from an investigation in Nashville in the USA confirmed a moderate and high burnout ranging from 21 to 43 % [14], while results published in Australia ranged from 14 % for the MBI EE to 27 % for the MBI CY (that is DP) [7]. Generally speaking, a high level of burnout in students was caused by both the organization of lectures at faculty and the quality of their lifestyle [15-20]. Hypothetically, the difference in the curriculum would be only one of the reasons for such a significant discrepancy between the results we obtained and the results found in the world literature. However, such a high burnout rate raises and imposes the need for a thorough investigation of the problem among students, and subsequently for a certain international study. There is a significant difference in the results between preclinical (first, second, third) and clinical (fourth, fifth and sixth) years of medical studies, especially regarding the organization of the lectures [10]. In the clinical years of the studies, the students mostly have practical lectures in hospitals and are in direct contact with the patients while in the preclinical years of the studies, the students mostly have theoretical lectures with minimum contact with patients [10]. Our study confirmed significantly higher statistical results (p<0.01) on the MBI EE and MBI EF sca-

dents a had higher burnout risk than the first year students, but that this difference was statistically insignificant [13]. The differences in the organization and content of lectures, at least in certain segments, contribute to the heterogeneous results of the students in Belgrade when compared with their counterparts in other countries. In spite of the obvious significance of the analysis of the above mentioned results, it currently exceeds the framework of this research. In the light of the extremely high burnout rate in the first year of studies, it might be concluded that future research of chronologically following the level of burnout at the beginning, middle and end of the first year could produce more solutions to the problem. Research of the problem of burnout with male and female students also gave different results. Some show that there is a significant difference, and that the males are exposed to the higher burnout risk [7] while other show no difference at all [14, 23, 24]. Others show that the females have a higher burnout risk [25, 26]. Our research showed that a slightly higher number of women had a borderline scores of high burnout risk. However, this difference according to the gender was not statistically significant (Table 3). This result could be substantiated by a bigger participation of women in the overall student sample. The analysis of the burnout risk levels between students with higher and lower average grade (Table 4) showed that the students with a somewhat lower average grade had subsequently a higher burnout risk, but that, apart from the MBI CY subscale, this difference was statistically insignificant. According to our literature, research analyzing the connection between the burnout level and the average grade are very rare. Some of the results showed no

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les in the first year students and on the MBI CY subscale in the fifth year students (Table 2). It might be possible to explain the difference with the fact that the first year students encounter the faculty for the first time, which, as opposed to highschool, has a different organization of the lectures and practice resulting in a certain level of fear of the new education system where they have to familiarize with the new curriculum and meet each other. In addition, moving to Belgrade (the capital city) and separation from family can also be factors that cause stress [21, 22]. The difference in the burnout level could be explained by the curriculum difference in the first (preclinical) and the fifth (clinical) years of studies. The fifth year students are ‘at the end’ of their studies, which might imply they are more satisfied and disburdened as they are about to finish their studies. If we look at one of the definitions of the cynicism subscale (MBI CY), as ‘diminished interest in and enthusiasm about studying’, then the higher values with clinical of the fifth year students would be expected. There are different findings in the international literature, however. Research conducted among the students of medicine in Spain showed a high burnout risk among 14.8 % of the third year students and 37.5 % of the sixth year students, which is inverted in comparison with our results where the preclinical students had a significantly higher scores [10]. However, this study takes into account the third year of studies as preclinical, which differs from the first year (preclinical year in our study) since we expect that the students have adapted and acquired certain experience during the first two years and as a result have a lower adaptation stress. The aforementioned research of the University of Manchester showed that the fifth year stu-

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statistically significant connections [27] while others showed a small and statistically negative connection between the burnout level and the average grade during one’s studies [28], which is in compliance with our findings on the MBI CY subscale. The correlation of the average grade in total of the fifth year sample and subscales’ scores showed significancy (p < 0.05) only in the MBI EF subscale (Table 5), which is also consistent with the above mentioned results. However, this study has its limitations. Firstly, the sample, although marked as a larger sample, should be additionally enlarged with other Universities in the country as, according to our knowledge, there are certain differences in curriculums. Secondly, the design of the study could be taken as another disadvantage as the crosssection study does not allow establishing of a causative link between the variables where prospective design would probably give much more information. Furthermore, it would be advisable to enlarge the range of the socio-demographic variables i.e. questions on the quality on one’s life, in future research. It would be also interesting to include the question about the idea of dropping out of (or changing) medical studies since certain studies support such an approach [17, 29]. However, it would be important to investigate the psychological profile of the students as an obvious factor that affects the level of the burnout risk [30, 31], unfortunately it wasn’t a primary goal of this study. One of the advantages of our study is the fact that, according to our knowledge, the research into burnout risk had never been conducted among preclinical students of medicine in our country and is seen as necessary in the light of the delicate and stressful nature of the profession

these students are studying for [12]. It is also important to investigate the burnout risk in all the years of studies as the burnout risk level is reversible among the students and there is also a possibility of recovery within one year (around 26 %) [13]. Generally speaking, only a small number of published researches compare the clinical and preclinical differences in the level of the burnout risk with the students of medicine. It is also important to emphasize that the most refined and highly verified burnout evaluation instrument, the MBISS version [8], was used in our study, as opposed to most research worldwide where the MBI version for the employed [2, 9] or its modification was applied.

CONCLUSIONS The burnout syndrome among students is an area that needs to be explored in our country, not only among the students of medicine, especially in the light of the fact that there is insufficient research done on this subject. The extremely high burnout risk rate ranging from 31.7 % to as high as 94.3 %, according to the different MBI subscales among the first year and the fifth year students of the School of Medicine in Belgrade is alarming and worrying. These burnout findings imply serious need for further and more thorough evaluation of such a complex problem, especially for the purpose of protecting mental health of the future medical practitioners as well as for the purpose of more precise definition of the factors that affect the quality of studying. It would be also important to implement some educational programs that would assist the students in developing necessary strategies and skills of defense in contact with patients as well as in everyday lectures at their faculties.

Sreten Vićentić1 Milan Latas1,2 Jasmina Barišić1 Marija Matić2 Maja Pantović Stefanović1 Aleksandar A. Jovanović1,2 Srđan Milovanović1,2

Klinika za psihijatriju, Klinički centar Srbije, Beograd, Srbija

Medicinski fakultet, Univerzitet u Beogradu, Beograd, Srbija

Kratak sadržaj Uvod/cilj: Sindrom sagorevanja je nedovoljno istražen u studentskoj populaciji. Cilj rada bio je utvrđivanje nivoa “sagorevanja” kod studenata medicine u Beogradu, sa akcentom na razlike izmedju grupe studenata koja pohadja nastavu iz predkliničkih i grupe studenta koja pohadja nastavu iz kliničkih predmeta, kao i razlike prema polu i prosečnoj oceni. Metode: Korišćen je Masleč Inventara Izgaranja za ispitivanje studenata (MBISS), koji se sastoji iz subskale emocionalne iscrpljenosti (MBI EE), subskale cinizma (MBI CY) i akademske efikasnosti (MBI EF). Rezultati: Visok rizik za “sagorevanje” na MBI EE u ukupnom uzorku imalo je 84,4 % studenata, na MBI CY se beleži srednji nivo “sagorevanja” od 40,7 % i visok od 31,7 %, a na MBI EF 61,2 % ima srednje “sagorevanje”, i 16,9 % visok. Skorovi na MBI EE i MBI EF viši su značajno kod studenata prve, dok su na MBI CY viši kod studenata pete godine (p<0,01). Razlika prema polu nije nađena (p>0,05), kao ni razlika kod studenata sa nižim i višim prosekom (p>0,05). Zaključak: Visok nivo “sagorevanja” u ovoj studiji implicira potrebu za istraživanjem na većem uzorku radi očuvanja zdravlja budućih lekara. Takođe, zabrinjava što su visoki skorovi dobijeni i na prekliničkim i kliničkim godinama studija. Ključne reči: sindrom, sagorevanje, studenti medicine, osnovne studije

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SINDROM SAGOREVANJA KOD STUDENATA MEDICINE U SRBIJI – PREDKLINIČKE I KLINIČKE RAZLIKE

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References:

1. Weber A, Jaekel-Reinhard A. Burnout syndrome: a disease of modern societies. Occup Med 2000; 50(7): 512-7 2. Maslach C, Jackson SE, Leiter M. Maslach Burnout Inventory, Manual. Palo Alto California: Consulting Psychologists Press, Inc 1996. 3. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. Journal of general internal medicine 2009; 24(12): 1318-21 4. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self- reported patient care in an internal medicine residency program. Ann Intern Med. 2002; 136: 358–67 5. Kahill S. Symptoms of professional burnout: A review of the empirical evidence. Canadian Psychology 1988; 284-97 6. Whitley TW, Allison EJ Jr, Gallery ME. Work-related stress and depression among practicing emergency physicians: an international study. Ann Emerg Med 1994; 23(5): 1068-71 7. Willcock S, Daly M, Tennant C, Allard B. Burnout and psychiatric morbidity in new medical graduates. MJA 2004; 181: 35760 8. Schaufeli WB, Martinez I, Marques Pinto A, Salanova M, Bakker A. Burnout and engagement in university students: a cross-national study. Journal of CrossCultural Psychology 2002; 33(5): 464-81 9. Schaufeli WB, Leiter MP, Maslach C, Jackson SE. The Maslach Burnout Inventory: General Survey (MBI-GS). In: The Maslach Inventory- test manual, 3rd edition. Palo Alto: Consulting Psychologists Press 1996; p. 19-26.

10. Galan F, Sanmartin A, Polo J, Giner L. Burnout risk in medical students in Spain using Maslach Burnout Inventory- Student Survey. Int Arch Occup Environ Health 2011; 84: 453-9 11. Obradović D, Pantić M, Latas M. Procena psihičkog stanja studenata medicinskog fakulteta. Engrami - časopis za kliničku psihijatriju, psihologiju i granične discipline 2009; 31 (3-4): 47-55 12. Guthrie E, Black D, Shaw C. Psychological stress in medical students:a comparison of two very different courses. Stress Med 1997; 13: 179-84 13. Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: a five years prospective longitudinal study. J R Soc Med 1998; 91: 237-43 14. Đurić V, Latas M, Trajanović N, Jovanović D, Milovanović S. Analiza predispitne nesanice kod studenata Medicinskog fakulteta. Engrami - časopis za kliničku psihijatriju, psihologiju i granične discipline 2009; 31 (1-2): 61-8 15. Dahlin M, Runeson B. Burnout and psychiatric morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study. BMC Med Educ 2007; 7: 6-14 16. Dyrbye LN, Thomas MR, Huntington JL. Personal life events and medical students burnout: a multicenter study. Acad Med 2006; 81: 374-84 17. Dyrbye LN, Thomas MR, Harper W. The learning environment and medical student burnout: a multicenter study. BMC Med Educ 2009; 43: 274-82 18. Dyrbye LN, Thomas MR, Power DV. Burnout and serious thoughts of dropping out of medical school: a multi-institutional study. Acad Med 2010; 85: 94-102

27. Balogun JA, Helgemoe S, Pellegrini E, Hoeberlein T. Academic performance is not a viable determinant of physical therapy students’ burnout. Perceptual and Motor Skills 1996; 83: 21-2 28. McCarthy ME, Pretty GM, CatanoV. Psychological sense of community and student burnout. Journal of College Student Development 1990; 31: 211-6 29. Costa EFO. Burnout Syndrome and Associated Factors among Medical Students: A Cross-Sectional Study. Clinics 2012; 67 (6): 573-9 30. Ranđelović D, Minić J. Prediktori zadovoljstva životom kod studenata. Engrami- časopis za kliničku psihijatriju, psihologiju i granične discipline 2012; 34: 59-68 31. Lue BH, Chen HJ, Wang CW, Cheng Y,Chen MC. Stress, personal characteristics and burnout among first postgraduate year residents: a nationwide study in Taiwan. Med Teach 2010; 32(5): 400-7

Sreten Vićentić Clinic of Psychiatry, Clinical Center of Serbia Pasterova 2, Belgrade 11000, Serbia Tel: +381 11 366 20 90 Email: sretenvicentic@gmail.com

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19. Dyrbye LN, Thomas MR, Massie FS. Burnout and suicidal ideation among US medical students. Ann Intern Med 2008; 149: 334-41 20. Dahlin M, Joneborg N, Runeson B. Performance-based selfesteem and burnout in cross-sectional study of medical students. Med Teach 2007; 29: 43-8 21. Eller T, Aluoja A, Vasar V, Veldi M. Symptoms of anxiety and depression in Estonian medical students with sleep problems. Depression and Anxiety 2006; 23(4): 250-6 22. Johns MW, Dudley HAF, Masterton JP.The sleep habits, personality and academic performance of medical students. Medical Education 2009; 10(3): 158-62 23. Firth J. Levels and source of stress in medical students. BMJ 1986; 292: 1177-80 24. Miller PMcC, Surtees PG. Psychological symptoms and their course in first-year medical students as assessed by the Interval General Health Questionnaire (I-GHQ). Br J Psychiatry 1991; 159: 199-207 25. Borrill CS, Wall MA, West GE. Mental Health of the Workforce in NHS Trusts. Final Report. Sheffield: Institute of Work Psychology, University of Sheffield/Leeds: Department of Psychology, University of Leeds, 1996. 26. Hojat M, Glaser K, Xu G, Veloski JJ, Christian EB. Gender comparisons of medical students’ psychosocial profiles. Med Educ 1999; 33: 342-9

Petar Vojvodić1 Goran Mihajlović2,3 Jelena Đorđević1 Jovana Vojvodić1 Katarina Radonjić3 UDK: 616..895-085

Clinic for Mental Disorders “Dr Laza Lazarevic”, Belgrade, Serbia

Clinic for Psychiatry, Clinical center Kragujevac, Kragujevac, Serbia

Faculty of Medical Sciences University of Kragujevac, Kragujevac, Serbia

Summary Introduction. The first psychotic episodes in adolescents represents a great challenge in the psychopharmacologic and diagnostic point of view. Atypical antipsychotics are the first line treatment of children and adolescents with psychotic disorders. Typical antipsychotics are used as second-line treatment. Objective. The aim of the study was to assess, analyze and present data on psychopharmacologic treatment of first psychotic episodes in adolescents who were hospitalized at the Clinic for Mental Disorders “Dr Laza Lazarevic” in the Clinical department for older adolescents. Method. The research was conducted as a retrospective naturalistic study conducted in the period from 01.07.2012. to 08.30.2014. The sample consisted of 60 hospitalized patients with a first psychotic episode. The therapy administered at discharge was recorded. The survey instrument was a closed questionnaire composed for this article. Data analysis was performed by means of descriptive statistics. Results. Out of 60 patients incidence of those treated with typical antipsychotic was 40 %, atypical 33.33 %, while the incidence of combined therapy with typical and atypical was 26.67 %. The average length of treatment of patients on monotherapy _typical antipsychotic was 28.79 _ days (X = 28.79), atypical 24.15 (X = 24.15) and a combination of typical and _ atypical 27.44 (X = 27.44). Hallucinations show a better response to typical antipsychotics, while delusions respond about the same in both drug groups. Conclusion. Successful treatment of initial psychotic episode, especially among adolescents, is crucial for minimizing the consequences for the personal and social functioning. In relation to the course of the disease, duration of treatment and side effects, atypical antipsychotics have the advantage over the first-generation drugs, as has been shown by the results of the study. Key words: adolescent, first psychotic episode, typical antipsychotic, atypical antipsychotic

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PSYCHOPHARMACOLOGICAL APPROACH TO THE TREATMENT OF ADOLESCENTS IN THE FIRST PSYCHOTIC EPISODE

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INTRODUCTION

Psychopharamacological approach to the treatment of adolescents in the first psychotic episode presents a considerable challenge. Psychosis at an early age can manifest in a more rapid clinical picture in relation to psychotic episode which first occurs in adulthood. Diagnosing and determining the adequate psychopharamacological treatment plan can be complicated due to the difficulty in differentiating between the primitive forms of cognitive reasoning such as magical thinking, which often occurs in children and adolescents, and real symptoms such as delusions [1]. The clinical picture is often less clear, since the development of personality is stopped or slowed due to the progression of the disease [2, 3]. Good therapeutic efficacy during the first episode may delay or prevent the development of a complete clinical picture of a psychotic disorder [4]. Although there are a number of guides on the use of antipsychotic drugs in adult patients, the same cannot be applied in adolescents. Pharmacotherapy of psychotic disorders in adolescents is specific in both pharmacodynamic and pharmacokinetic aspects compared to adult patients [5]. As a rule, in patients with the first psychotic episode the experience of the previous response to therapy is not available. Deciding on the therapy for these patients must be based on the results of research, and not on the current experience the administration a particular drug had [6]. Studies have shown that the outcome of the first two years of treatment can predict the future course of a disease [7]. There are relatively few epidemiological studies on the first psychotic episodes in adolescents. It is known that the inci-

dence of psychoses, especially schizophrenia increases during adolescence, predominantly in men compared to women [8]. In more than 40 % of cases, the first psychotic episode occurs between 15 and 18 years of age [6], which is a period of great importance in relation to the development of personality and obtaining a social role [9]. The aims of treating psychotic episodes are withdrawal of the symptoms, relapse prevention, establishing remission and achieving functional recovery and social reintegration [2]. In the treatment of first psychotic episodes antipsychotics should be introduced very cautiously, because of the higher risk of extrapyramidal symptoms, applying the lowest effective dose of medication (lower dose in the standard dosage range). In clinical practice, atypical antipsychotics, antagonists of serotonin and dopamine, are the first-line treatment of children and adolescents with schizophrenia. They have been suggested to be more efficient in the reduction of positive and negative symptoms of schizophrenia and to carry a lower risk of extrapyramidal symptoms. In addition, atypical antipsychotics such as quetiapine, ziprasidone and aripiprazole are also antagonists of serotonin and dopamine, which are used in clinical practice for children and adolescents with psychotic disorders who do not respond to other atypical antipsychotics. Typical antipsychotics, such as haloperidol and chlorpromazine are used as the second-line treatment, although the use of chlorpromazine is more favorable due to a lower risk of occurrence of dystonic reaction [10].

The aim of this study is to assess, analyze and present data on psychopharmacologic treatment of psychotic disorders in adolescents who were hospitalized at the Clinic for Mental Disorders “Dr Laza Lazarevic” in the Clinical department for older adolescents in the first psychotic episode. The result provides insight into the current approach of the treatment of these patients and could provide important information for planning and developing strategies for treatment as well as pointing out the limitations and dilemmas in the treatment of adolescents in the first psychotic episode.

METHOD Our research was conducted as a retrospective naturalistic study carried out at the Clinic for Mental Disorders “Dr Laza Lazarevic” in the Clinical department for older adolescents in the period from 01.07.2012. to 08.30.2014. when the first 60 hospitalizations of patients with psychotic episode occurred. Criteria for inclusion of patients in this study were: • The patient was hospitalized at the, Clinic for Mental Disorders “Dr Laza Lazarevic” in the Clinical department for older adolescents in the period from 01.07.2012. to 30.08.2014. • The patient was aged between 14 and 18 years including both sexes. • That the patient was diagnosed according to the International Classification of Diseases (ICD- 10), as psychotic in schizophrenic spectrum of groups F20 to F29

• If the patient was categorized with a level of intelligence satisfactory for regular education • The patient had no history of addictions and/or has not had contact with psychoactive substances for 3 months previous to the study The criteria for exclusion of patients from the study were: • That the patient was previously treated in another psychiatric institution under the above diagnoses. • The patient was suffering from neurological and somatic diseases. • If the patient left the clinic on the personal request of parents prior to the diagnosis and treatment. Parents or legal guardians of patients were provided with a written consent for the use of medical records for the purposes of our study. Information on psychopharamacologic treatment of the sample were obtained by examining the discharge lists of the patients and prescriptions lists. The therapy administered at discharge was recorded. The survey instrument was a closed questionnaire composed for this research. Medical histories of hospitalized adolescents were used for filling the data in the questionnaire. Data analysis was performed by means of descriptive statistics.

RESULTS At the Clinic for Mental Disorders “Dr Laza Lazarevic” in the Clinical department for older adolescents in the period from 01.07.2012. to 08.30.2014. sixty hospitalizations of adolescents in the first psychotic episode occurred, which fulfill the conditions stipulated by the design of the study. The average age

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OBJECTIVE

of patients was 16.1 ± 0.94 years, of which 22 (36.7%) were females and 38 (63.3%) males. Viewed by diagnosis (ICD-10), there were 58 (96.7%) patients with F23 and 2 (3.3%) patients with F29 diagnosis at discharge. The methods of descriptive statistics showed that out of 60 patients who were treated with antipsychotics, the incidence of those treated with typical antipsychotic was 40%, atypical antipsychotic 33.33%, while the frequency of the prescribed combination therapy of typical and atypical antipsychotics was 26.67% shown in Table 1 and Figure 1. The average length of treatment of patients on monotherapy typical an_ tipsychotic was 28.79 days (X = 28.79),

_ atypical 24.15 days (X = 24.15) and a combination_ of typical and atypical 27.44 days (X = 27.44) shown in Figure 2. When the results are viewed in terms of clinical signs or prominent manifestations of hallucinations or delusions in relation to the type of applied antipsychotics, the following results: When hallucinations were present, typical antipsychotics were administered in 26.67%, atypical antipsychotics in 15%, and the combination of drugs in 11.67% of patients. Shown in Table 2. Delusions are reduced using the typical antipsychotics in 36.67%, 31.67% using of atypical antipsychotics and 15% of treated patients received a combination

Table 1. Therapy of study patients on discharge Tabela 1. Terapija ispitanika pri otpustu

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Typical antipsychotic Tipiþni antipsihotik N 24

% 40

Atypical antipsychotic Atipiþni antipsihotik N 20

% 33,3

Combination of typical and atypical antipsychotics Kombinacija tipiþnog i atipiþnog antipsihotika N % 16 26,67

Graph. 1. Therapy of study patients on discharge Grafikon 1. Terapija ispitanika pri otpustu 20

of drugs. Shown in Table 3. The results obtained in our study were not compared in terms of statistical significance given that the survey was conducted in a short period of time and using relatively small sample.

DISCUSSION Available literature on pharmacotherapy in children and adolescents with psychosis is critically examining both first and second generation antipsychotics [11]. On the basis of National institute for health and care excellence (NICE)

guide all antipsychotics, which are recommended for use in adults can be applied in children and adolescents with special caution in relation to the age of patients (dose modification) [12]. Administration of depot medication in the population of children and adolescents is not clinically justified. Also, caution is necessary when administering antipsychotics because the side effects are more pronounced than in adults. It is recommended to start with a low dose of antipsychotic drugs, with a gradual increase in the daily dose. It is important to note that the use of an-

Table 2. Therapy of study patients on discharge in regard to halucinations Tabela 2. Terapija ispitanika pri otpustu u odnosu na prisu

Present Prisutne Absent Nisu prisutne

Atypical antipsychotic Atipiþni antipsihotik N %

Combination of typical and atypical antipsychotics Kombinacija tipiþnog i atipiþnog antipsihotika N %

26,67

11,67

13,33

18,33

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Halucinations Halucinacije

Typical antipsychotic Tipiþni antipsihotik N %

Figure 2. Duration of hospitalisation compared to therapy Grafikon 2. Trajanje hospitalizacije u poreðenju sa terapijom 21

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Table 3. Therapy of study patients on discharge Tabela 3. Terapija ispitanika pri otpustu Delusions Sumanute ideje Present Prisutne Absent Nisu prisutne

prazole are used in clinical practice on adolescents who do not respond to other atypical antipsychotics [15]. On the other hand, certain studies showed no significant differences in treatment efficacy between risperidone, olanzapine and quetiapine in the six-month followed treatment [16]. According to international studies typical antipsychotics should represent a second line of treatment. However, lowpotent antipsychotic drug such as chlorpromazine may be more suitable for adolescents, because of the reduced possibility of the occurrence dystonic reactions [17]. The results of our study have shown that remission with reduction of psychotic phenomenology, agitation and behavioral discontrol in 60 patients treated with antipsychotics, was achieved using typical antipsychotic haloperidol, chlorpromazine or fluphenazine, in 40% of cases, atypical antipsychotic risperidone, clozapine or olanzapine in 33.33% of patients, while the frequency of the prescribed combination therapies of typical and atypical antipsychotic was 26.67%. These results could be explained by the fact that the use of typical antipsychotics remains dominant in the management of psychotic phenomenology, especially in emergency psychiatric care units when it

tipsychotics in children and adolescents is not on the indication list described in the patient information leaflet. For this reason it is important to inform parents / guardians, as well as children and adolescents that even though the given drugs are not recommended for use in children they are essential in the treatment. Therefore, it is often said that children use licensed medication - antipsychotics, for an unlicensed indication - for treatment of psychosis in children and adolescents, which is why the informed consent of a parent or guardian is very important [13]. According to guidelines atypical antipsychotics are first choice drugs in the treatment of adolescents with psychotic episodes. Drugs such as risperidone, olanzapine and clozapine differ from classical antipsychotics in terms of fewer predominance D2 receptor antagonism and are considered to be effective in reducing symptoms of psychosis, with a reduced risk of extrapyramidal symptoms [14]. Recently published case studies and larger controlled studies have demonstrated efficacy of risperidone in the treatment of psychosis in adolescents with the same potency that typical antipsychotics have, such as haloperidol. Antipsychotics such as quetiapine, ziprasidone and aripi-

Typical antipsychotic Tipiþni antipsihotik N %

Atypical antipsychotic Atipiþni antipsihotik N %

Combination of typical and atypical antipsychotics Kombinacija tipiþnog i atipiþnog antipsihotika N %

36,67

31,67

3,33

1,67

The properties of atypical antipsychotics are such that it is expected that the rate of recovery and reintegration will be much higher than the typical antipsychotics despite the fact that in acute treatment no significant distinction between these two groups of drugs [19].

CONCLUSION Successful treatment of initial psychotic episode, especially among adolescents, is crucial for minimizing the consequences for the personal and social functioning. Control of unusual and conspicuous behavior associated with positive symptoms enables better re-socialization of the patient and involvement in everyday activities. Applying typical antipsychotic during the initial phase of treatment is still an essential part of treatment, due to the potency of drugs, and because of the possibility to administer them in parenteral form. In relation to the course of the disease, duration of treatment and side effects, atypical antipsychotics have the advantage over the first-generation drugs, as showed the results of the study. Clinical department for older adolescents at the Clinic for Mental Disorders “Dr Laza Lazarevic”, in addition to interventions in the first psychotic episodes, addresses and early recognition and prevention of psychosis in accordance with applicable guidelines for good clinical practice. Past experience indicates that further research is necessary due to the low rates of remission, narrow therapeutic action of drugs and frequent side effects.

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is necessary to achieve rapid therapeutic effect in terms of eliminating psychomotor agitation and sedating the patient [18]. Department in which the survey was conducted primarily deals with urgent psychiatric conditions in terms of agitation, disorganized behavior and aggressiveness, and the results of the research in terms of more frequent use of typical antipsychotics may explain this fact. Also a non-compliant patient, especially with psychotic phenomenology limits the possibility of applying per oral medications, and requires the use of drugs that can be administered parenteraly, which are in our country, for now, only available in the form of typical antipsychotics. According to results of our research, reduction of hallucinations is better achieved using typical antipsychotics while delusions respond about the same in both first and second generation. The differences in therapeutic response may be based upon the fact that delusional contents can basically have hallucinatory experiences that respond better to typical antipsychotic drugs, but still delusional contents in relation to hallucinatory phenomenology give greater priority to the second generation. After the initial stage of treatment and achieved reduction of symptomatology, further treatment, according to protocols, included pharmacotherapy of atypical antipsychotic monotherapy or combination of typical and atypical which indicated that the faster therapeutic effect and recovery is achieved primarily using atypical antipsychotics, which is in line with the current therapeutic guidelines.

PSIHOFARMAKOTERAPIJSKI PRISTUP TRETMANU ADOLESCENATA U PRVOJ PSIHOTIČNOJ EPIZODI

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Petar Vojvodić1 Goran Mihajlović2,3 Jelena Đorđević1 Jovana Vojvodić1 Katarina Radonjić3

Klinika za psihijatrijske bolesti “Dr Laza Lazarević”, Beograd, Srbija

Klinika za psihijatriju, Klinički centar Kragujevac, Kragujevac, Srbija

Medicinski fakultet, Univerzitet u Kragujevcu, Kragujevac, Srbija

Kratak sadržaj Uvod. Prva psihotična epizoda kod adolescenata predstavlja sa dijagnostičke i psihofarmakoterapijske tačke gledišta veliki izazov. Atipični antipsihotici su prva linija tretmana dece i adolescenata sa psihotičnim poremećajem. Tipični antipsihotici se koriste kao druga linija tretmana. Cilj rada. Cilj istraživanja je sagledavanje, analiza i prezentovanje podataka o psihofarmakoterapijskom tretmanu prve psihotične epizode kod adolescenata koji su hospitalizovani na Odeljenju za starije adolescente Klinike za psihijatrijske bolesti „Dr Laza Lazarević“. Metod rada. Istraživanje je sprovedeno kao retrospektivna naturalistička studija obavljena na Klinici za psihijatrijske bolesti „dr Laza Lazarević“ na odeljenju za starije adolescente u periodu od 01.07.2012. do 30.08.2014. godine. Uzorak je činilo 60 hospitalizovanih pacijenata sa prvom psihotičnom epizodom. Roditelji, odnosno zakonski staratelji bolesnika su dostavili pisanu saglasnost za korišćenje medicinske dokumentacije za potrebe našeg istraživanja. Uvidom u otpusnu listu bolesnika i terapijski karton evidentirana je terapija ordinirana na otpustu. Instrument istraživanja bio je upitnik zatvorenog tipa sastavljen za potrebe ovog rada. Analiza dobijenih podataka obavljena je metodama deskriptivne statistike. Rezultati. Prosečna starost pacijenata je 16,1 ± 0.94 godine, od kojih je 22 (36,7%) ženskog pola i 38 (63,3%) muškog pola. Deskriptivnom statistikom utvrđeno je da od 60 pacijenata koji su lečeni antipsihoticima, učestalost lečenih tipičnim antipsihotikom je 40%, atipičnim 33.33%, dok je učestalost kombinovane terapije tipičnog i atipičnog bila 26.67%. Prosečna dužina le_ čenja pacijenata na monoterapiji tipičnim antipsihotikom iznosila je_28,79 dana (X = _ 28.79), atipičnim 24,15 (X = 24.15) i kombinacijom tipičnog i atipičnog 27,44 (X = 27.44). Halucinacije pokazuju bolji odgovor na tipične antipsihotike, dok je redukcija sumanutosti približno ista za obe grupe lekova. Zaključak. Uspešan tretman inicijalne psihotične epizode, posebno u populaciji adolescenata, je krucijalan za minimiziranje posledica po lično, socijalno i društveno funkcionisanje. U odnosu na tok bolesti, dužinu lečenja i neželjene efekte, atipični antipsihotici imaju prednost nad prvom generacijom lekova, što je i pokazano rezultatima studije. Ključne reči: adolescenti, prva psihotična epizoda, atipični antipsihotik, tipični antipsihotik

1. Castro-Fornieles J, Parellada M, GonzalezPinto A, Moreno D, Graell M, Arango C, et al. The child and adolescent first-episode psychosis study [CAFEPS]: design and baseline results. Schizophrenia Research 2007;91[1-3]: 226-237. 2. Kane J. Treatment strategies to prevent relapse and encourage remission. The Journal Of Clinical Psychiatry 2007; 68: 142730. 3. Masi G, Liboni F. Management of schizophrenia in children and adolescents: focus on pharmacotherapy. Drugs 2011; 71[2]: 179208. 4. Marić NP, Jašovic-Gašic MM. Rane intervencije u psihozama - koncept, sadašnje stanje i perspektive. Engrami - časopis za kliničku psihijatriju, psihologiju i granične discipline 2010;32[4]:5-17. 5. Funk RS, Brown JT, Abdel-Rahman SM. Pediatric pharmacokinetics: human development and drug disposition. Pediatr Clin North Am. 2012;59:1001–16. 6. Ballageer T, Malla A, Manchanda R, Takhar J, Haricharan R. Is adolescent-onset firstepisode psychosis different from adult onset?. Journal Of The American Academy Of Child And Adolescent Psychiatry 2005; 44[8]: 782-789. 7. Abdel-Baki A, Lesage A, Nicole L, Cossette M, Salvat E, Lalonde P. Schizophrenia, an illness with bad outcome: myth or reality?. Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie 2011; 56[2]: 92101. 8. Radmanovic M. First-psychotic episode in childhood and adolescence. Psychiatria Danubina 2012; 24:3:S388-S391. 9. Patel V, Flisher A, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. Lancet 2007; 369[9569]: 1302-1313. 10. Benjamin James S, Virginia Alcott S. Concise textbook of child and adolescent psychiatry. Lippincott Williams & Wilkings Kluwer business 2009; 166-170. 11. Rabinovitch M, Béchard-Evans L, Schmitz N, Joober R, Malla A. Early predictors of nonadherence to antipsychotic therapy in firstepisode psychosis. Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie 2009; 54[1]: 28-35.

12. NICE. Psychosis and schizophrenia in children and young people. NICE. The British Psychological Society & The Royal College of Psychiatrists, 2013. 13. Lečic Toševski D, Đukic Dejanović S, Mihajlović G et al. Nacionalni vodič dobre kliničke prakse za dijagnostikovanĽe i lečenĽe shizofrenije. Ministarstvo zdravlĽa Republike Srbije 2013; 18-19. 14. Stahl S. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, Cambridge Univesity Press. New York, 2008. 15. Remschmidt H, Hennighausen K, Clement HW, Heiser P, Schulz E. Atypical neuroleptics in child and adolescent psychiatry. Eur Child Adolesc Psychiatry. 2000;9(1):I9-19. 16. Castro-Fornieles J, Parellada M, Soutullo CA, et al. Antipsychotic treatment in child and adolescent first-episode psychosis: a longitudinal naturalistic approach. J Child Adolesc Psychopharmacol. 2008;18(4):327-36. 17. Benjamin James S, Virginia Alcott S. Concise textbook of child and adolescent psychiatry. Lippincott Williams & Wilkings Kluwer business 2009; 166-170. 18. Pavel Mohr, Ján Pečeňák, Jaromír Švestka, Dave Swingler & Tamás Treuer. Treatment of acute agitation in psychotic disorders. Neuro Endocrinol Lett. 2005;26(4):327-35. 19. Benedetto Vitiello, Christoph Correll, Barbara van Zwieten-Boot et al. Antipsychotics in children and adolescents: Increasing use, evidence for efficacy and safety concerns. European Neuropsychopharmacology 2009.

Petar Vojvodić Clinic for Mental Disorders “Dr Laza Lazarevic” Visegradska 26, 11000 Beograd Tel.:+381 64 22 88 885 E mail: petar.vojvodic@gmail.com

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References:

Nebojša Popović Marina Ilić UDK: 616.89:614.2[497.11]

Odeljenje psihijatrije, Opšta bolnica Užice, ZC Užice, Užice, Srbija

Kratak sadržaj Uvod: Imajući u vidu da se kod velikog broja hospitalizovanih somatskih pacijenata u toku lečenja javljaju psihijatrijski simptomi, prisustvo konsultativne psihijatrije u drugim medicinskim oblastima je veoma značajno, kako sa stručno-metodološkog, tako i u pogledu isplativosti. Cilj rada: Cilj rada je bio da se utvrdi koja odeljenja Opšte bolnice Užice su imala najviše prijavljenih psihijatrijskih konsultacija i zbog kojih dijagnoza, kao i koje su to psihijatrijske dijagnoze najčešće zastupljene među pacijentima hospitalizovanim na nepsihijatrijskim odeljenjima. Materijal i metode: retrospektivnim istraživanjem obuhvaćeno je 893 pacijenta hospitalizovana na napsihijatrijskim odeljenjima OB Užice, koje su pregledali konsultanti psihijatri u periodu septembar 2013 - septembar 2014. godine. Kao instrument istraživanja korišćena je medicinska dokumentacija koja prati konsultativni pregled. Rezultati: Najveći broj psihijatrijskih konsultacija prijavljen je na internom odeljenju (30,10%), ortopediji (16,57%), hirurgiji (13,33%) i neurologiji (8,85%). Najčešće postavljane psihijatrijske dijagnoze tokom konsultativnih pregleda bile su dijagnoze hroničnog psihoorganskog sindroma (28,12%), depresivnih poremećaja (14,12%), različitih oblika demencija (10,07%), akutnog psihoorganskog sindroma (9,97%) kao i poremećaja udruženih sa somatskom bolešću (6,83%) i poremećaja udruženih sa alkoholizmom (6,27%). Sve ostale psihijatrijske dijagnoze bile su zastupljene sa 15 %. Zaključak: Najviše psihijatrijskih konsultacija obavljeno je na odeljenjima interne medicine, ortopedije, hirurgije i neurologije. Najčešće postavljane dijagnoze tokom konsultativnih pregleda potvrđuju činjenicu da kognitivni poremećaji i dalje predstavljaju glavno područje rada konsultativne psihijatrije. Ključne reči: konsultativna psihijatrija, hospitalizovani pacijenti, dijagnoza

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KONSULTATIVNI PSIHIJATRIJSKI PREGLEDI PACIJENATA HOSPITALIZOVANIH U OPŠTOJ BOLNICI UŽICE

UVOD Konsultativna psihijatrija se definiše kao oblast psihijatrije koja se bavi dijagnozom, lečenjem i proučavanjem, kao i prevencijom psihičkih poremećaja kod fizički obolelih pacijenata hospitalizovanih na nepsihijatrijskim odeljenjima [1]. Još je začetnik konsultativne psihijatrije, Eduard Bilings, 40-tih godina prošlog veka, utvrdio da su pacijenti koje je, pored njihovih lekara, lečio i psihijatar, ležali 12 dana kraće od ostalih sa sličnim tegobama, ali bez konsultativne pomoći [2]. Više novijih studija, koje su se bavile zastupljenošću psihijatrijskih dijagnoza kod pacijenata hospitalizovanih na nepsihijatrijskim odeljenjima, prateći rad konsultativnih psihijatrijskih službi, potvrđuje značaj prisustva konsultativne psihijatrije

u drugim medicinskim oblastima, kako sa stručno-metodološkog, tako i sa aspekta odnosa uloženog i dobijenog [3]. Cilj istraživanja bio je da se utvrdi koja odeljenje Opšte bolnice Užice su imala najviše prijavljenih psihijatrijskih konsultacija i zbog kojih psihijatrijskih dijagnoza, kao i koje su to psihijatrijske dijagnoze najčešće zastupljene među pacijentima hospitalizovanim na nepsihijatrijskim odeljenjima.

MATERIJAL I METODE Studija je dizajnirana kao retrospektivno istraživanje koje je obuhvatilo period od dvanaest meseci (septembar 2013. godine – septembar 2014. godine). Istraživanje je obuhvatilo hospitalne pacijente OB Užice za koje je u navedenom

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Tabela 1. Distribucija psihijatrijskih konsultativnih pregleda po razliþitim opdeljenjima OB Užice Table 1. Distribution of psychiatric consultative examinations among different departments of General Hospital Uzice

Odeljenje / Department Interno odeljenje / Department of internal medicine Ortopedija / Orthopedics Hirurgija / Surgery Neurologija / Neurology Infektivno / Infectious diseases Rehabilitacija / Rehabilitation Pneumoftiziologija/Pneumophtiziology HITIN / Surgical intensive care PUS / ER Kožno / Dermatology Ginekologija / Gynecology Urologija / Urology Pedijatrija / Pediatrics ORL / ORL Oþno / Ophtalmology

Broj psihijatrijskih konsultacija Number of psychiatric consultations

269

30, 10

148 119 79 58 53 49 24 18 17 15 15 14 10 5

16, 57 13, 33 8, 85 6, 5 5, 93 5, 49 2, 69 2, 06 1, 90 1, 68 1, 68 1, 57 1, 12 0, 56

REZULTATI Ukupan broj pacijenata hospitalizovanih na nepsihijatrijskim odeljenjima OB Užice, pregledan od strane psihijatra u periodu septembar 2013. god – septembar 2014. god, iznosi 893. Distribucija konsultacija po različitim odeljenjima OB Užice u pomenutom periodu prikazana je u Tabeli 1. Na prvom mestu po broju traženih konsultacija u pomenutom periodu bilo je Interno odeljenje (N=269, 30,1%). Distribucija konsultacija po različitim odsecima Internog odeljenja prikazana je na Tabeli 2. Od svih odseka Internog odeljenja, najveći broj konsultacija tražio je odsek gastroenterologije (N=77, 28,62% svih konsultacija na internom odeljenju, odnosno, 8,62% ukupnog boja konsultacija psihijatara na svim odeljenjima OB Užice). Najčešće dijagnoze postavljene na psihijatrijskim konsultacijama na gastroenterologiji bila su dijagnoze duševnih poremećaja povezanih sa somatskim bo-

Tabela 2. Distribucija psihijatrijskih konsultativnih pregleda po razliþitim odsecima Internog odeljenja OB Uzice Table 2. Distribution of psychiatric consultative examinations among different divisions of Internal medicine department at the General Hospital Uzice Odsek internog odeljenje Division of internal medicine department Gastroenterologija / Gastroenterology IIN / Internal intensive care Hematologija / Hematology Endokrinologija / Endocrinology Alergologija / Alergology Reumatologija / Rheumatology Koronarna jedinica / Coronary unit Nefrologija / Nephrology Kardiologija / Cardiology Pulmologija / Pulmology

Broj psihijatrijskih konsultacija Number of psychiatric consultations 77 52 29 22 19 16 16 16 13 9

% 28, 62 19, 33 10, 78 8, 18 7, 06 5, 95 5, 95 5, 95 4 , 83 3, 34

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period bio neophodan konsultativni psihijatrijski pregled (N=893). Konsultativne psihijatrijske preglede obavilo je sedam psihijatara (5 specijalista psihijatrije, 1 specijalista psihijatrije – subspecijalista sudske psihijatrije i 1 specijalista psihijatrije – subspecijalista dečije psihijatrije). Instrument istraživanja bio je polustrukturisani upitnik koji je sadržao pitanja vezana za socio-demografske informacije o pacijentima, razlog konsultativnog pregleda, stepen hitnosti tražene konsultacije, odeljenje na kome je pacijent hospitalizovan i ime ordinirajućeg lekara koji je zahtevao psihijatrijsku konsultaciju. Upitnik je popunjen na osnovu raspoložive medicinske dokumentacije (evidencija koju popunjava psihijatar-konsultant po svakoj obavljenoj konsultaciji). Za statističku obradu dobijenih podataka istraživanja korišćeni su metodi deskriptivne i analitičke statistike.

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lestima, 27,27%, zatim dijagnoza hroničnog psihoorganskog sindroma 15,58% i, na trećem mestu po učestalosti, dijagnoze poremećaja povezanih sa alkoholizmom 11,7%. Drugo odeljenje po učestalosti traženja konsultacija je odeljenje ortopedije (N=148, 16,57% konsultativnih pregleda). Najčešće dijagnoze postavljene tokom konsultacija na ortopediji bile su dijagnoze psihoorganskih sindroma, i to hroničnog psihoorganskog sindroma 48,65%, akutnog psihoorganskoh sindroma 18,24%, dok su na trećem mestu bile demencija sa 12,16%. Na trećem mestu po učestalosti traženja konsultacija nalazi se odeljenje hirurgije (N=119, 13,33 % traženih konsultacija). Najčešće dijagnoze postavljene u konsultacijama na ovom odeljenju bile su, kao i na ortopediji, dijagnoze psihoorganskog sindroma i to hronični psihoorganski sindrom 30,25 % a akutni psihoorganski sindrom 16,8% . Na trećem mestu po

učestalosti na ovom odeljenju nalaze se dijagnoze depresivnih poremećaja i demencija sa po 8,4%. Odeljenje neurologije, u pomenutom periodu prijavilo je 79 konsultacija, odnosno 8,85 % ukupnog broja konsultacija, što ga svrstava na četvrto mesto po učestalosti traženja konsultativnih pregleda. Najčešća dijagnoza postavljana tokom konsultacija na ovom odeljenju bila je hronični psihoorganski sindrom – 18.98% a zatim slede poremećaji povezani sa alkoholizmom – 11,4% i demencije 10,13%. Konsultativni psihijatrijski pregledi na svim ostalim odeljenjima OB Užice, bili su znatno manje zastupljeni, ukupno 278, tj. 31,13%. Najčešće postavljana dijagnoza na svim konsultativnim pregledima u pomenutom periodu, bez obzira na odeljenje, bila je dijagnoza hroničnog psihoorganskog sindroma – 251, tj. 28,12% svih dijagnoza. (Tabela 3).

Tabela 3. Psihijatrijske dijagnoze kod pacijenata hospitalizovanih na nepsihijatrijskim odeljenjima OB Užice Table 3. Psychiatric diagnoses of patients hospitalized on non-psychiatric departments of General Hospital Uzice Psihijatrijska dijagnoza Psychiatric diagnosis Hroniþni psihoorganski sindrom / Chronic psychoorganic syndrome Depresivni poremeüaji / Depressive disorders Demencije / Dementias Akutni psihoorganski sindrom / Acute psychoorganic syndrome Psihiþki poremeüaji povezani sa somatskom bolešüu / Psychological disorders associated with somatic disease Poremeüaji povezani sa alkoholizmom / Disorders associated with alcoholism Ostale dijagnoze / Other diagnoses

Ukupan broj postavljenih dijagnoza Total number of psychiatric diagnoses

251

28, 12

126 90

14, 12 10, 07

9, 97

6, 83

6, 27

134

DISKUSIJA U toku jednogodišnjeg perioda koji je statističkom analizom obuhvaćen ovim istraživanjem (septembar 2013. – septembar 2014. godine), na odeljenjima OB Užice, prijavljena su 893 zahteva za psihijatrijski konsultativni pregled. Konsultacije je prijavljivao ordinirajući lekar somatskih pacijenata koji bi, na osnovu ispoljavanja nekih psihijatrijskih simptoma, procenio da je pacijentu potreban psihijatrijski pregled. Svaki zahtev za konsultaciju, bilo preko odeljenja ili upućen lično konsultantu, beleži se, zajedno sa generalijama pacijenta i obrazloženjem zašto se traži konsultacija kao i stepenom hitnosti konsultacije u evidenciju prijavljenih konsultacija, koju smo, između ostalog, koristili i kao instrument ovog istraživanja. Tokom konsultativnih pregleda psihijatara, kod pacijenata na nepsihijatrij-

skim odeljenjima, najčešće (u više od jedne trećine slučajeva) je postavljana dijagnoza psihoorganskih sindroma - hronični psihoorganski sindrom 28,12%, akutni psihoorganski sindrom 9,97%, a zatim slede dijagnoze demencija (kod svakog desetog ispitanika). Ovi podaci, koji ne odstupaju od podataka dobijenih u drugim opštim bolnicama, kako u zemlji, tako i u inostranstvu, potvrđuju da kognitivni poremećaji još uvek predstavljaju glavno područje rada konsultativne psihijatrije [4]. Kako je poznato da su osnovna bolest (infekcija, trauma, moždano oštećenje, endogena intoksikacija), udružena sa opštim stanjem organizma (starost, komorbiditet), dejstvom medikamenata i, naročito, eventualno primljenim anesteticima, predisponirajući faktori za nastanak psihoorganskog sindroma, to je, očekivano, najveći broj ovih konsultacija bio na odeljenjima orotopedije, hirurgije, neurologije, kao i na internom odeljenju, gde su i hospitalizovani najteži bolesnici. Organski delirijum (akutno konfuzno stanje) je mentalni poremećaj koji se karakteriše naglim početkom, fluktuirajućim tokom, poremećajem cirkadijalnog ritma, poremećajem orijentacije i ponašanja kao i brojnih psihičkih funkcija – svesti, mišljenja, pamćenja, percepcije [5]. Kako klinička slika ovog poremećaja zna da bude prilično dramatična, to su i konsultacije označene kao hitne, u našem istaživanju, najčešće tražene upravo zbog akutnog psihoorganskog sindroma i to u situacijama kada su pacijenti izrazito uznemireni, psihomotorno agitirani i agresivni, kao i kada osoblje nije moglo da ih umiri. U više istraživanja je potvrđeno da je pojava delirijuma kod pacijenata na nepsihijatrijskim odeljenjima povezana sa lošijim funkcionalnim statusom ovih

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Na drugom mestu po učestalosti nalaze se depresivni poremećaji – 125, tj. 14,12%, a zatim slede poremećaji iz spektra demencija (90-10,07%), akutni psihoorganski sindromi (89-9,97%), anksiozni (86-8,63%) i psihosomatski poremećaji (61-6,83%). Poremećaji povezani sa alkoholizmom su bili dijagnostifikovani 56 puta, tj u 6,27% svih konsultacija. Prilikom prijavljivanja konsultacija psihijatra, 36 konsultacija, tj. 4,03% je prijavljeno sa oznakom “hitno”, dok su ostale bile redovne konsultacije. Najčešća dijagnoza postavljena tokom hitnih konsultacija bila je dijagnoza akutnog psihoorganskog sindroma – 19,44% svih hitnih konsultacija, a odeljenje koje je najčešće tražilo hitne konsultacije bila je hirurgija – 27,8% svih hitnih konsultacija.

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pacijenata, ne retko pogoršanjem njihove osnovne bolesti i produženjem bolničkog lečenja [6]. Organski delirijum ima znatno veću prevalencu među populacijom starijih pacijenata i kao takav je jedan od faktora rizika za demenciju [7]. Sa druge strane, kod pacijenata koji već boluju od demencije, postoji čak 40% veća verovatnoća za pojavu delirijuma [5]. U praktičnom radu, često se klinička slika delirujuma javlja udruženo sa demecijom, što govori u prilog tome da će i u budućnosti, sa produženjem životnog veka pojedinca i starenjem populacije, najverovatnije rasti broj delirijuma i demencija dijagnostifikovanih u okviru konsultativnog rada u psihijatriji. Naši podaci se uklapaju u druga slična istraživanja koja pokazuju da među dijagnozama postavljenim tokom konsultativnih psihijatrijskih pregleda, postoji značajan porast kognitivnih poremećaja [8]. Konsultativni pregledi psihijatara, naročito u opštim bolnicama, često se nepravedno poistovećuju sa smirivanjem naglo nastalog delirijuma – prema jednom istraživanju, čak 1/2 konsultativnih pregleda psihijatara kod starijih hospitalizovanih pacijenata, zatražena je zbog naglo nastale uznemirenosti [9]. Imajući to u vidu, na prvi pogled iznenađuje rezultat našeg istraživanja koji pokazuje da je dijagnoza hroničnog psihoorganskog sindroma znatno češće zastupljena od dijagnoze organskog delirijuma. Ovo se može objasniti činjenicom da se na nepsihijatrijskim odeljenjima sprovodi sveobuhvatna somato-neuro-psihijatrijsku eksploracija pacijenata u cilju što bržeg dijagnostifikovanja i što adekvatnijeg lečenja kako osnovne somatske bolesti zbog koje je pacijent hospitalizovan, tako i pratećih psihijatrijskih komlikacija.

Na drugom mestu po učestalosti postavljenih dijagnoza tokom konsultativnih pregleda psihijatara u OB Užice, nalaze se depresivni poremećaji. Anksiozni poremećaji su, takođe, zastupljeni u značajnom procentu i zauzimaju četvrto mesto po učestalosti. Ovakav rezultat je u saglasnosti sa istraživanjima u svetu, gde, poslednjih godina, dijagnoze poremećaja raspoloženja dominiraju među dijagnozama postavljenim tokom konsultativnih psihijatrijskih pregleda [10]. Iako se poremećaji iz ovog spektra obično ne manifestuju psihičkim simptomima koji zahtevaju hitnu konsultaciju psihijatra i nisu među vodećim dijagnozama na odeljenjima koja su najčešće tražila konsultacije, ipak je značajan broj ovih dijagnoza postavljen u konsultativnim pregledima. Dijagnoze depresivnih poremećaja odnose se kako na novootkrivene depresije, na čiji nastanak kod pacijenata hospitalizovanih na nepsihijatrijskim odeljenjima, značajno utiču somatska bolest, terapija i doživljaji vezani za samu hospitalizaciju [11], tako i na kontrolne preglede pacijenata kojima je ranije postavljena dijagnoza nekog depresivnog poremećaja i započeto lečenje, a sada se nalaze na lečenju zbog neke somatske bolesti pa je konsultacija prijavljena u sklopu rutinske kontrole i eventualnog usklađivanja terapije sa aktuelnom somatskom bolešću i “somatskom terapijom”. U oba slučaja konsultativni pregled je veoma važan jer je od ranije poznato da rano dijagnostifikovanje depresije udružene sa nekom somatskom bolešću, ima velikog značaja u kasnijem lečenju pacijenta i faktor je bolje prognoze lečenja [12]. Odeljenje OB Užice koje je najčešće tražilo konsultativni pregled psihijatra je bilo Interno odeljenje. Ovako visoka učestalost konsultacija među internističkim

šoj bolnici, iako ne često, i definitivno ne dovoljno, ipak razmišlja o kompletnoj psihosomatskoj obradi pacijenta koji je hospitalizovan na nekom nepsihijatrijskom odeljenju. Što je još važnije, proističe zaključak da je i konsultantu psihijatru, ali i ordinirajućem lekaru somatičaru koji zahteva psihijatrijsku konsultaciju, blizak holistički pristup pacijentu i njegovim tegobama.

ZAKLJUČAK Tokom ispitivanog jednogodišnjeg perioda, najveći broj psihijatrijskih konsultacija obavljen je na Internom odeljenju a zatim na odeljenjima ortopedije, hirurgije i neurologije. Najčešće postavljana dijagnoza tokom konsultativnih pregleda bila je dijagnoza hroničnog psihoorganskog sindroma. Ovako dobijeni rezultati su u saglasnosti sa drugim sličnim istaživanjima kako u zemlji tako i u svetu, i govore u prilog činjenici da su kognitivni poremećaji i dalje glavno područje rada konsultativne psihijatrije. Relativno visoka učestalost dijagnostifikovanja psihičkih poremećaja povezanih sa somatskom bolešću u OB Užice je značajna jer ukazuje da i psihijatri i ordinirajući lekari somatske medicine obraćaju pažnju na kompletnu psihosomatsku obradu pacijenata hospitalizovanih na nepsihijatrijskim odeljenjima. Potrebno je dalje unapređivanje rada, kako konsultativne psihijatrijske službe, tako i saradnje psihijatara sa lekarima somatske medicine u cilju što adekvatnijeg zbrinjavanja i lečenja pacijenata.

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pacijentima nije u skladu sa podacima koji su dobijeni u nekim sličnim istraživanjima obavljenim u drugim zdravstvenim ustanovama u Srbiji [5, 8], ali i ne iznenadjuje, posebno kada se ima u vidu da se Interno odeljenje OB Užice sastoji od čak deset odseka i da svi oni posebno prijavljuju konsultacije. Među pomenutim odsecima, prvi po učestalosti traženja konsultacija je odsek gastroenterologije. Najčešće postavljena dijagnoza tokom konsultacija na odseku gastroenterologije, bila je dijagnoza psihičkih poremećaja povezanih sa somatskom bolešću (do 1/3 svih dijagnoza postavljenih na ovom odseku). Ukupan broj postavljenih dijagnoza psihičkih poremećaja povezanih sa somatskom bolešću na svim odeljenjima OB Užice iznosi 6,83% svih postavljenih dijagnoza. Ovaj relativno visok procenat dijagnostifikovanja ovih poremećaja, iako u suprotnostima sa podacima koji su dobijeni u nekim drugim sličnim istraživanjima obavljenim u našoj zemlji [8], smatramo značajnim i objašnjavamo na više načina. Prvo, imajući u vidu Aleksanderovih “sedam svetih bolesti” [1], od kojih dve pripadaju oblasti gastroenterologije, a i sve češće zastupljen problem alkoholizma koji se često manifestuje upravo bolestima gastrointestinalnog trakta, pre svega cirozom jetre, razumljivo je da baš na odseku gastroenterologije postoji veći broj psihijatrijskih konsultacija. Drugo, iako manje zastupljena nego na odseku gastroenterologije, ova dijagnoza prisutna je u značajnom broju i u konsultativnim pregledima na drugim odeljenjima. Ova činjenica pokazuje da se, u na-

LIAISON INPATIENT PSYCHIATRIC TREATMENT OF PATIENTS AT THE GENERAL HOSPITAL UŽICE

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Nebojša Popović Marina Ilić

Psychiatric department, General Hospital Uzice, Uzice, Serbia

Summary Introduction: Psychiatric symptoms are manifested in a large number of hospitalized somatic patients, therefore looking from professional and methodological, but also from the cost-benefit aspect, application of consultative psychiatry in the other fields of medicine is very important. Objective The aim of the research was to determine which department of the General Hospital Uzice had the highest number of psychiatric consultations and for which diagnoses, and to establish the prevalence of particular psychiatric disorders among the patients hospitalized on nonpsychiatric departments. Material and methods: This retrospective study included 893 patients hospitalized on non-psychiatric departments of the General Hospital Uzice, examined by consultant psychiatrists during the period from September 2013 to September 2014. The research instrument was the medical documentation of psychiatrists-consultants. Results: The greatest number of psychiatric consultations was carried out at the following departments: internal medicine (30,10%), orthopedics (16,57%), surgery (13,33%) and neurology (8,85%). The most frequent psychiatric diagnoses during the consultative psychiatry examinations were chronic psychoorganic syndrome (28,12%), depressive disorders (14,12%), different forms of dementias (10,07%), acute psychoorganic syndrome (9,97%), psychological disorders associated with somatic disease (6,83%), disorders associated with alcoholism (6,27%). All other diagnoses were present in 15 % of reported cases. Conclusion: The greatest number of psychiatric consultations was completed at departments of internal medicine, orthopedics, surgery and neurology. Psychiatric diagnoses, which were the most prevalent among hospitalized somatic patients, show that the cognitive disorders are still the main area of activity of consultative psychiatry. Keywords: liaison psychiatry, inpatients, diagnose

Literatura: 10. Jaffe MJ, Primeau F, McCusker J et all. Psychiatric outpatient consultation for seniors. Perspectives of family psysicians, consultants and patients/family: s descriptive study. BMC Fam Pract 2005: 6-15. 11. David M Clarce. The regognition of depression in patients reffered to a consultation – liaison service; Journal of psychosomatic research 1995; 39:327-334; 12. Cavanaugh S, Clark DC, Gibbons RD. Diagnosing depression in the hospitalized medically ill. Psychosomatics 1983:24:809815.

Marina Ilić Ulica Bože Smiljanića 36 31210 Požega Tel: +381 64 26 54 595 E-mail: marinailic031@hotmail.com

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1. Adamović V. Psihosomatska medicina i konsultativna psihijatrija: priručnik za kliničku praksu. Beograd: Službeni list SCG 2005:199-300. 2. Billings EG, McNary WS, Rees MH. Financial importance of general hospital psychiatry to hospital administrator. Hospitals 1937: 11:40-44. 3. Cavanagh S, Milne J. Recent changes in consultation-liaison psychiatry: a blueprint for future; Psychosomatics 1995: 36:95102. 4. Bourgeois JA, Wegelin JA, Servis ME, Hales RE. Psychiatric diagnoses of 901 inpatients seen by consultation-liaison psychiatrists at an Academic Medical Center in a menaged care environment. Psychosomatics 2005:46:47-57. 5. Stanković Ž, Ilić I, Milovanović S. Specifičnosti psihijatrijskih konsultacija kod hospitalizovanih gerijatrijskih pacijenata – prikaz devetomesečnog retrospektivnog praćenja. Engrami 2006:28:27-38. 6. Al-Huthail Y.R. Psychiatric consultations and lenght of hospital stay; Neuroscience 2008:2:161-164. 7. Rockwood K, Cosway S, Carver D, Jarrett P, Stadnyk K, Fisk J. The risk of dementia and death affter delirium. Ae Ageing 1999: 28:551-556. 8. Skakić O, Trajanović Lj. Konsultativni psihijatrijski pregledi hospitalizovanih pacijenata – prikaz dvanaestomesećanog retrospektivnog praćenja. Med Pregl 2009:LXI (11-12): 569-572. 9. Euba R. Negative behaviours as the reason for referral to a liaison old age psychiatrist. Journal of psychiatry 2005:19:155158.

Maja Pantović Stefanović1 Bojana Dunjić- Kostić1 Mirjana Gligorić2 Maja Lačković1,2 Aleksandar Damjanović1,2 Maja Ivković1,2

UDK: 614.253:616.89-008.44

Clinic for Psychiatry, Clinical Center of Serbia, Belgrade, Serbia

School of Medicine, University of Belgrade, Belgrade, Serbia

INTRODUCTION Empathy implies physicians’ ability to understand patient’s inner feelings and perspectives and the ability to show that understanding using cognitive, emotional and behavioral processes. It is an integral part of a quality doctor–patient relationship and one of the basic conditions for a quality patient care. Physicians who are able to develop a good, empathic doctor–patient relationship can easily communicate with their patients, thus leading to a better diagnostics [1], increased com-

Summary Background: Empathy is an integral part of a quality doctor–patient relationship and one of the basic conditions for a quality patient care. Aim: This study addresses the differences in empathy in the context of career decision making by future physicians. Materials and methods: A survey was administered to 363 medical students selected by a random cluster sampling. They answered questions regarding their socio-demographic data, personal or close family members’ medical history, and future career choice. A 16-item Toronto Empathy Questionnaire (TEQ) was administered to evaluate their empathy. Results: The results showed that high levels of empathy were related to the choice of people-oriented vs. technology-oriented medical disciplines as a future career, even when controlled for female gender and education. Conclusion: Empathy is a salient factor in medical education and professional orientation, principally connected to some medical disciplines and essential to be taken into account in the early phases of future physicians’ careers. Keywords: empathy, medical students, career choice, education

pliance, patient satisfaction, and better treatment outcomes [2]. This therapeutic relevance draws attention to the importance of fostering and sustaining empathy in physicians of all specialties, particularly in the early phases of their career development [3,4]. The Association of American Medical Colleges [5] points out that fostering empathy in medical students is a priority, and the Accreditation Council for Graduate Medical Education perceives empathy as one of the important qualities of professionalism [6]. Nevertheless, recent

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EMPATHY PREDICTING CAREER CHOICE IN FUTURE PHYSICIANS

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studies have shown that the level of empathy decreases during undergraduate medical education and residency [7-9]. At the very time they usually become involved with clinical subjects; future physicians became less related to the patients and more drawn to their senior colleagues, whom they perceive idealistically [10]. However, some factors (e.g., high personal well-being and better quality of life) seem to be protective of empathy in both students and residents [11]. Contrary to this, the factors associated with stress [12] and those related to inadequate role modeling in the academic and clinical environment can lead to a decrease in empathy [11,13]. In addition to education and environment related factors, certain biological and socio-demographic characteristics can also affect empathy. Studies have shown that female students are more empathic and that they show a more caring attitude compared to their male peers [14]. The authors agree that future physicians’ level of empathy is also related to their career choice. Physicians with high empathy tend to be drawn to the so-called people-oriented medical disciplines (e.g., psychiatry, pediatrics, gynecology, internal medicine, and primary care), while those with low empathy are more attracted to technology-oriented specialties, that is, the fields of medicine where the contact with patients is scarce or absent (e.g., surgery, radiology, and pathology) [15,16]. However, our understanding of how empathy is modulated in medical education is still fairly limited [17]. Although one hypothesis states that empathy is shaped by cultural factors and that it cannot be considered a universal phenomenon [18,19], so far there have been no studies dealing with the empathy

of medical students or residents, nor its impact on their career choice in Eastern Europe. Furthermore, there is a general lack of studies on previous personal or close family members’ experiences related to health-care needs as well as studies regarding the role of religious beliefs in physician’s empathy [17]. Taking into account, social learning theory of career decision making, suggesting that individuals learn about themselves, their preferences, and work environment thorough direct and indirect experiences [20], the assessment of the aforementioned social, and psychological factors might be of particular importance in career choice and development, within a health care setting. The present cross-sectional study addresses the differences in empathy scores between genders, between first year and senior medical students, and between medical students with different specialty preferences, as well as the association between personal or family members’ history regarding somatic or mental health problems and empathy. The research hypothesizes that 1) empathy scores of female students will be higher than those of male students and 2) the scores of first year students will be higher than those of senior medical students. We also hypothesize that 3) medical students with a personal or family history of a chronic somatic or mental disorder, or more frequent contact with the medical healthcare system, in the role of a patient or a caregiver, will have higher empathy scores. Our last hypothesis is that 4) a medical student’s preference for people-oriented specialties is associated with higher empathy scores as compared with a preference for technology-oriented specialties.

Participants The questionnaire was completed by 178 (RR = 88.56 %) and 185 (RR = 96.35 %) of first year and senior medical students, respectively. The average age of the participants was 22.36 ± 2.38, and 68.1 % were females. The socio-demographic characteristics of the sample are summarized in Table 1.

Sampling procedure Medical education in Serbia lasts six years. The first two and a half years are devoted to the preclinical medical disciplines, and in the middle of their third year, medical students devote themselves more to the clinical medical disciplines. The last year of studies also implies additional, semi-structured practical rotations in selected medical disciplines (i.e., gene-

ral practice, gynecology, surgery, and pediatrics), which do not imply the division of students by groups. The rotations vary in terms of the amount of training, often depending on the student’s preferences and personal interests, as it is common for students in this phase of their education to spend extra-curricular hours in the departments of their interest. Against this background, and in order to avoid the possible bias caused by exposure to potentially variable education in this period, we selected the first (freshmen) and the fifth-year medical students (seniors) for the purpose of this study. There were 500 first year students (divided into 25 groups based on the surname alphabetical order) attending the School of Medicine, University of Belgrade, in the academic year 2010–2011. We randomly selected 13 groups to distribute the study questionnaires. There were 428 seniors (divided into 20 groups based on the surname alpha-

Table 1. Socio-demographic characteristics of the participants Freshmen (%)

Seniors (%)

200.000

39.50

37.90

< 200.000

60.50

62.10

38.20

54.90

61.80

45.10

14.70 85.30 79.90

15.80 84.20 76.80 45.70 44.90 4.90 6.00 40.50 51.90

Characteristics Place of living

Emotional status

Living

Partner No partner Nema partnera Alone With family/friends

Religiosity (yes) Accademic years renewed (yes) Previous in-patient treatment (yes) Presence of a (chronic) somatic disease (yes) Familly member with a mental disorder (yes) Familly member with a somatic disease (yes) Stresfull event in life (yes)

31.50 6.20 3.40 21.30 47.20

Ȥ2

0.45

.832

9.376

.002

0.190

.890

0.348

.555

6.342 0.111 0.875 14.704 0.627

.012 .740 .350 .000 .428

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MATERIAL AND METHODS

betical order) attending their fifth year of studies at the School of Medicine, University of Belgrade, in the academic year 2010–2011. We randomly selected 10 groups to distribute the study questionnaires during the first week of the academic year.

Measures and covariates

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The study instrument was a questionnaire divided into two parts. The first part was the questionnaire, which contained the following: a) Questions regarding general sociodemographic information (i.e., sex, age, size of the participant’s hometown (– 200,000 or = 200,000), family information, emotional status (single or in a relationship), academic achievement (average grade), and religiosity (religious or non-religious)).

b) Questions regarding previous personal experience or the experience of close family members regarding healthcare (i.e., the number of visits made to doctors, information on the participant’s health status, and information on somatic or mental illness in the immediate family). c) A question about the participant’s affinity towards the offered medical disciplines (What residency would you prefer to take upon graduation?). We asked the students to rank the offered medical disciplines from 1 (most preferred) to 10 (least preferred). In subsequent data processing, the division of the offered medical disciplines into people-oriented (i.e., dermatology, gynecology and obstetrics, internal medicine, pediatrics, and psychiatry), and technology-oriented (i.e.,

Table 2. TEQ scor and participants’ socio-demographic characteristics Socio-demographic characteristics Year of studies Gender Living Emotional status Place of living Siblings Religiosity

First Fifth Female Male Alone With family/friends Partner No partner 200.000 inhabitants < 200.000 inhabitants Yes No Religious Non-religious

TEQ (M ± SD) 44.90 ± 7.08 45.33 ± 7.73 45.91 ± 7.39 43.46 ± 7.21 44.77 ± 6.76 45.12 ± 7.55 45.81 ± 7.21 44.71 ± 7.50 44.85 ± 6.92 45.31 ± 7.78 45.18 ± 7.37 44.64 ± 7.82 45.90 ± 6.68 42.77 ± 9.11

t -0.55

0.580

-2.93

0.003*

-0.31

0.758

1.40

0.163

-0.57

0.568

0.43

0.671

3.36

0.001*

Note. TEQ = Toronto Empathy Questionnaire; M = sample mean; SD = standard deviation. *p ࣳ 0.005

Statistical analysis We analyzed the data using the Software Package for Social Sciences for Windows v. 19.0 (SPSS Inc. Chicago, IL)

and G*Power 3.1.2. The internal consistency reliability of the questionnaire was assessed using the Cronbach’s alpha factor. The normality distribution of the numerical values was tested by the Kolmogorov–Smirnov test. For the description of the data, the classical methods of descriptive statistics were used (e.g., the frequencies and percentages for the attributive variables and the mean value with the standard deviation for the numeric variables). The t-test for the independent samples, Mann-Whitney test, Spearman’s rank correlation, chi-square test of independence with continuity correction according to Yates and binary logistic regression were used to analyze the data.

RESULTS Relationship between medical students’ socio-demographic characteristics and levels of empathy as measured by the TEQ An average score of the participants on the TEQ was 45.23 ± 7.02. The freshmen and senior students did not differ in their level of empathy. However, there was a difference in empathy between genders, with female students being more empathic. The participants who declared themselves religious had significantly higher TEQ scores (see Tables 1 and 2).

Relationship between personal or family members’ history regarding somatic or mental health problems and empathy The analysis also assessed variables related to previous personal experience or the experience of close family members regarding healthcare needs. Partici-

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forensic medicine, preclinical medical disciplines including laboratory work [e.g., anatomy, biochemistry, histology, physiology], preclinical medical disciplines with no laboratory work [e.g., epidemiology, hygiene, social medicine], radiology, and surgery) was made following the example of previous studies [15]. The second part of the questionnaire was the Toronto Empathy Questionnaire (TEQ) designed to measure emotional, cognitive, and behavioral components of empathy [21]. The questionnaire consisted of 16 items, 8 formulated positively and 8 negatively, and the respondents were asked to state how often they felt, thought, or behaved according to the statements according to a 5-point Likert scale from 0 (never) to 4 (always). The total possible score ranged from 0 to 64, with a higher score indicating a higher level of empathy. The internal consistency reliability of the TEQ was somewhat lower in comparison to the original study (Cronbach’s – = .70), but it was still satisfactory. All students who met the criteria for participation, attended lectures, and were willing to participate in the study on the day of the testing were approached to take the survey. The participants gave their informed consent to participate in the research prior to filling out the questionnaires. The questionnaires were administered anonymously, and it took approximately 10 to 15 min for the respondents to complete them.

pants’ empathy was not associated with the number of visits to the doctor they had made over the past year (ñ = .021, p = .714), the presence of chronic somatic disorder (t(358) = 0.484, p = .629), or previous inpatient treatment (t(361) = – 1.201, p = .230). Having a family member suffering from a mental disorder (t(359) = 0.809, p = .418) or chronic, somatic illness (t(361) = - 0.141, p = .890) was also unrelated to the level of empathy. Moreover, previous stressful experiences described as “very intense” for the participant had no influence on the TEQ score (t(359) = 1.532, p = .130).

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Empathy and medical students’ career choice

We divided the medical disciplines offered in the questionnaire into those requiring direct contact with patients and an active physician–patient relationship (people-oriented medical disciplines) and those where the contact with patients is scarce or absent (technology-oriented medical disciplines). The students who rated one of the people-oriented medical disciplines as most preferred (M = 45.91, SD = 6.97) showed a significantly higher level of empathy on the TEQ (t(324) = 2.403, p = .017) compared to students who selected a discipline involving little or no direct contact (M = 44.07, SD = 6.73). More emphatic students showed a stronger affinity toward gynecology (ñ = –.111, p = .039), and those with lower empathy showed a stronger affinity toward surgery (ñ = 0.123, p = 0.021). As in the case of more empathic students, female students (÷2 = 29.23, df = 1, p = .000, f = –0.307) and senior medical students (÷2 = 23.69, df = 1, p= .000, f = 0.276) were more inclined toward peo-

ple-oriented medical disciplines as their future career. In order to assess what factors predict career choice (people-oriented vs. technology-oriented medical disciplines) in future physicians, a logistic regression was performed, with career choice as the dependent variable, and TEQ score, female gender and senior year of studies as the independent variables. The analyzed model was statistically significant (÷2 = 60.597, p = .000). The proposed factors, together, accounted for between 23.1 % and 31.8 % of the variance of the career choice. The empathy (beta = 0. 49, p = .000, OR = 2.347), female gender (beta = 0. 28, p = .064, OR= 1.105) and year of studies (beta = 0.13, p = .092, OR= 1.002) had a positive effect on choice of people-oriented medical disciplines. However, only empathy, out of the three proposed factors, showed a statistically significant predictive effect.

DISCUSSION The present cross-sectional study detected differences in the levels of empathy of medical students in regard to their gender, education, religious beliefs, and preferred career choice. However, we did not detect a difference in the level of empathy between freshmen and senior medical students, nor between those with and without personal or family members’ negative previous experiences. So far, only Rahimi-Mediseh et al.’s [22] study in Iran has provided support for the idea of empathy remaining stable in the course of medical studies. The majority of the studies, for most of them conducted in the U.S., have sustained the findings on a significant decline of empathy in senior medical students [8], while others conducted

em to understand and experience of other people’s thoughts and feelings better. As empathy represents an important part of social cognition, contributing to the promotion of prosocial behavior [21], it is possible that religion influences the need to help others through mediating the effect of empathy. It is also thought that the personal negative experiences of females can lead to higher empathy for a person in a similar situation, while the level of empathy in men is not affected in these circumstances [31]. According to other studies, traumatic experiences can lead to the impairment of empathy and difficulties in sharing the affective and cognitive states [32]. Surprisingly, none of the variables related to personal or to family members’ negative life experiences were associated with the level of empathy, in our study. We offer the hypothesis that the future physicians’ empathy remains unaffected by the prospective taking experience as result of protective coping strategies. An additional explanation could lay in the fact that we mature throughout life [33]. Maintaining the average age of the medical students in our sample, it seems that they successfully prevailed in one of many challenges of the medical profession by dividing their personal from their professional life and that their previous experience did not affect their compassion for others. At a more practical level, another interesting point in our study is that more empathic medical students tended to choose their future careers among peopleoriented specialties. Newton et al. [16] reported that even if the gender variable is controlled, students who choose medical disciplines that have more contact with patients and rely less on technical di-

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in Japan, Korea [18, 23] and Portugal [24] have shown an increase in empathy. Winseman, Malik, Morison, and Balkoski [25] reported that both personal and educational factors influence medical students’ empathy in the course of their studies. Female students in our study showed more empathy than their male colleagues, as well as higher affinity towards medical disciplines involving a proactive doctor–patient relationship. This is consistent with the previous studies in the U.S., Europe, and Japan, which have disclosed higher levels of empathy in female medical students compared to their male colleagues [18, 26, 27]. However, some studies have noted the insignificant influence of gender on the empathy of medical trainees and specialists [28]. There are multiple possibilities regarding the role of gender in empathy. One explanation is based on the evolutionary theory of parental investment that sees women as more capable of caring for the offspring and more approachable for emotional signals than men [29]. The other explanation is that women are more inclined toward giving emotional support and more capable of developing intense interpersonal relationships [15, 18]. These differences may be additionally emphasized in our sample by the somewhat traditional and patriarchic perception of a woman as a compassionate and emotional caregiver in our culture [30]. Gender differences also cause the disparity in the value system. Female medical students were more likely to report appreciating the principles that rely on religion, while male students gave priority to economic values [27]. Studies of the direct impact of religion on physicians’ empathy are scarce, but our data indicate that religious medical students se-

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agnostic procedures have higher empathy scores than those who choose other specialties. The same was later confirmed by the studies of Hojat et al. [8, 14, 26]. However, more than 20 years ago, a similar study by Harsch et al. [34] did not find differences in empathy among medical students with different professional preferences. Inevitably, the question is raised as to what factors, if any, could justify this change in the role of empathy in the career choices of future physicians, over the course of the last decades. The research suggests that today’s college students show less empathy toward others compared with their peers in the past decades. This decline has been most prominent since 2000, and it is argued that it has been caused by the current global changes in communication and the value system as a consequence of the expanding use of technology [35]. It could be that these changes in empathy did not impair, but facilitated the career choices of today’s medical students by making them more confident in facing technology-oriented fields of medicine. Contrastingly, they could also be the consequence of shifting from a humanity-based to a technology-based approach in medicine and socially more desirable behavior [36]. As the se technological changes were more prominent in the West, this could also account for the decline of empathy in the course of studies noticed predominantly in these countries. Studies on the level of empathy among physicians of different specialties complement those that focus on medical students. It has been noticed that the psychiatrists and primary care specialists have a far higher mean score of empathy compared to orthopedics and anesthesiologists[15], while general practice physi-

cians [37] have shown the highest level of empathy, not only among healthcare staff in general (nurses and physicians of different specialties) but also among other nonmedical professionals (e.g., lawyers). The favoring of certain interpersonal skills during training may cause the difference in empathy of the physicians of some specialties [15]. Specialists, working in the fields that require more communication and better social skills, show higher empathy as a consequence of the close interaction with patients [14]. The psychological profile is an inseparable part of the complex phenomenon of empathy. In this regard, Compton, Frank, Elon, and Carrera [38] showed that students in their final years of medical school tend to choose more prestigious medical disciplines, one of which is surgery. The need for prestige may result from the narcissistic personality traits, and studies such as Ritter et al. [39] have suggested that narcissism is associated with a lack of emotional empathy. These could be grounds for the low level of empathy in students who, in our survey, opted for surgery as the “most preferred” career in medicine. Our study has some potential limitations to consider. Firstly, it was designed as a cross-sectional study, so the assessment of the change in students’ empathy, after five years of medical education, could be imprecise. This could be due to the potentially different baseline empathy of seniors, in their first year of studies, compared to the first year students included in the survey. However, the factors that could influence this change in empathy and the acquisition of medical knowledge and experience remained stable. Both groups were subjected to the same selection process prior to

ent attention is paid to the development of empathy and encompassing professional qualities. Empathy is a salient factor in patient care, medical education, and professional orientation, principally connected to some medical disciplines (e.g., surgery and gynecology) and necessary to be fostered across all academic and cultural contexts. Humanity-based activities and changes in “hidden” curriculum could encourage the growth of empathy in medical students. However, a systematic approach to reinforcement of empathy, as a career-long trait in physicians, is needed and should be targeted through implementation of specific programs (i.e., role modeling, identification, and communication skills) into formal curriculum and clinical practice. The clues for such interventions should be looked for particularly within the rare cultural settings where empathy has been evidenced to remain stable or even to increase in the course of medical education. Empirical research on the potential predictors and outcomes of empathy can additionally contribute to the enhancement of empathy, facilitate the career choice of young doctors, and serve as a basis for future professional orientation and career development.

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entering medical studies and received the same training at the beginning of their first year. Secondly, empathy was assessed using a self-reporting instrument; complementary methods and instruments (i.e., peer assessment, observational approach, and self-assessment instruments with overlapping constructs) could further contribute to understanding the variation of empathy during medical training. Finally, the sample consisted of students from only one university center (out of four available in the country). Nevertheless, this was the largest medical and university center in the country, with the greatest number of students coming from different geographical regions and socio-demographic backgrounds. Nonetheless, we believe that these restrictions do not reduce the value and importance of our study. The present study is the first of its kind in Eastern Europe that used a precise and internationally comparable methodological instrument, and we believe it will become a solid base for further research in this direction. Partly because of technological developments and partly because of the diversity in contemporary systems of medical education and healthcare, it has been argued that insuffici-

EMPATIJA KAO PREDIKTOR IZBORA SPECIJALIZACIJE KOD BUDUĆIH LEKARA

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Maja Pantović Stefanović1 Bojana Dunjić- Kostić1 Mirjana Gligorić2 Maja Lačković1,2 Aleksandar Damjanović1,2 Maja Ivković1,2

Klinika za psihijatriju, Klinički centar Srbije, Beograd, Srbija

Medicinski fakultet, Univerzitet u Beogradu, Beograd, Srbija

Kratak sadržaj Uvod: Empatija je sastavni deo kvalitetnog odnosa lekar-pacijent i jedan od osnovnih uslova kvalitetne brige o pacijentu. Cilj istraživanja: Ova studija se bavi razlikama u empatiji u kontekstu odlučivanja o specijalističkoj karijeri kod buducìih lekara. Materijal i metode: Istraživanje je obuhvatilo 363 studenata medicine. Ispitanici su odgovarali na pitanja vezana za svoje socio-demografske podatke, ličnu i porodičnu anamnezu i izbor zanimanja. Za procenu empatije ispitanika korišćen je Toronto Upitnik o Empatiji(Toronto Empathy Questionnaire - TEQ). Rezultati: Rezultati pokazuju da su visoki nivoi empatije u vezi sa izborom budućeg zanimanja koje podrazumeva kontak sa ljudima, nasuprot grupi zanimanja koja su prevashodno bazirana na tehnologiji, čak i kada su kontrolisani socio-demografski parametri (pol, obrazovanje). Zaključak: Empatija je važan faktor u medicinskoj edukaciji i profesionalnoj orijentaciji, uglavnom povezan sa odredjenim medicinskim disciplinama. Takodje, razmatranje empatije je neophodno uzeti u obzir u ranim fazama karijere buducìih lekara. Ključne reči: empatija, studenti medicine, izbor zanimanja, obrazovanje

References: 1. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA: The Journal of the American Medical Association 1997;277(7):553-9. 2. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ Empathy and Clinical Outcome for Diabetic Patients. Academic Medicine 2011;86(3):359-64.

3. Medina-Walpole A, Mooney CJ, Lyness JM, Lambert DR, Lurie SJ. Medical Student Attitudes Toward Patients in Diverse Care Settings: The Impact of a Patient Evaluation Course. Teaching and Learning in Medicine 2012;24(2):117-12. 4. Crow SM, O’Donoghue D, Vannatta JB, Thompson BM. Meeting the Family: Promoting Humanism in Gross Anatomy. Teaching and Learning in Medicine 2012;24(1):49-54.

pathy: definition, components, measurement and relationship to gender and specialty. American Journal of Psychiatry 2002;159(9):1563-9. 16. Newton BW, Savidge MA, Barber L, Cleveland E, Clardy J, Beeman G, et al. Differences in medical students empathy. Academic Medicine 2000;75(12):1215. 17. Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Academic Medicine 2010;86(8):996-1009. 18. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. Measurement of Empathy among Japanese Medical students: psychometrics and score differences by gender and level of medical education. Academic Medicine 2009;84(9):1192-7. 19. Ma-Kellams C, Blascovich J. Inferring the emotions of friends versus strangers: the role of culture and self-construal. Personality and Social Psychology Bulletin 2012;38(7):933-45. 20. Krumboltz JD, Nichols CW. Integrating the Social Learning Theory of Career Decision Making. In: Walsh WB, Osipow SH, editors. Career Counseling: Contemporary Topics in Vocational Psychology. New Jersey: Lawrence Erlbaum Associates Inc.; 1990. p. 159- 92. 21. Spreng RN, McKinnon MC, Mar RA, Levine B. The Toronto Empathy Questionnaire: Scale development and initial validation of a factor-analytic solution to multiple empathy measures. Journal of Personality Assessment 2009;91(1)62–71. 22. Rahimi-Madiseh M, Tavakol M, Dennick R, Nasiri J. Empathy in Iranian medical students: a preliminary psychometric analysis and differences by gender and year of medical school. Medical Teacher 2010;32(11):471-8. 23. Roh MS, Hahm BJ, Lee DH, Suh DH. Evaluation of Empathy among Korean medical students: a cross sectional study using the Korean version of the Jefferson Scale of Physician Empathy. Teaching and learning in Medicine 2010;22(3):167-71.

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5. The Medical School Objectives Writing Group. Learning objectives for medical student education-guidelines for medical schools: report I of the Medical School Objectives Project. Academic Medicine 1999;74:13-18. 6. Accreditation Council for Graduate Medical Education (ACGME). ACGME Board Resolution on Professionalism. ACGME; 2008. [cited 2014 Oct 11]. Available from: http://www.acgme.org/acgmeweb/Portals/0/PDFs/commonguide/IVA5e_EducationalProgram_ACGMECompetencies_Professionalism_Explanation.pdf 7. Bellini LM, Shea JA. Mood change and empathy decline persist during three years of internal medicine training. Academic Medicine 2005;80(2):164-7. 8. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic Medicine 2009;84(11):1182-91. 9. Stratton TD, Saunders JA, Elam CL. Changes in Medical Students’ Emotional Intelligence: An Exploratory Study. Teaching and Learning in Medicine 2008;20(3):279-284. 10. Wear D, Castellani B. The development of professionalism: curriculum matters. Academic Medicine 2000;(6):602-11. 11. Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. How do distress and well-being relate to medical student empathy? A multicenter study. Journal of General Internal Medicine 2007;22(2):177-83. 12. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy and burnout among Interns. Academic Medicine 2006;81(1):82-5. 13. Spencer J. Decline in empathy in medical education: How can we stop the rot? Editorials. Medical Education 2004;38(9):91620. 14. Hojat M, Mangione S, Gonnella JS. Empathy in medical education and patient care. Academic Medicine 2001;76(7):669. 15. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician em-

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24. Magalhăes E, Salgueira AP, Costa P, Costa MJ. Empathy in senior year and first year medical students: a cross sectional study. BMC Medical Education 2011;11:52. 25. Winseman J, Malik A, Morison J, Balkoski V. Students views on factors affecting empathy in medical education. Academic Psychiatry 2009;33(6):484-91. 26. Hojat M, Zuckerman M, Magee M, Mangione S, Nasca T, Vergare M, et al. Empathy in medical students as related to specialty interest, personality, and perceptions of mother and father. Personality and Individual Differences 2005;39:1205-15. 27. Pawełczyk A, Pawełczyk T, Bielecki J. Differences in medical specialty choice and in personality factors among female and male medical students. Polski Merkuriusz Lekarski 2007;23(137):363-6. 28. Di Lillo M, Cicchetti A, Lo Scalzo A, Taroni F, Hojat M. The Jefferson Scale of Physician Empathy: Preliminary Psychometrics and Group Comparisons in Italian Physicians. Academic Medicine 2009;84(9):1198–1202. 29. Trivers RL. Parental investment and sexual selection. In: Campbell B, editor. Sexual Selection and the Descent of Man, 18711971. Chicago: Aldine-Atherton; 1972. p. 136-79. 30. Pantovic M, Dunjic-Kostic B, Ivkovic M, Damjanovic A, Jovanovic AA. The framework of family therapy in clinical practice and research in Serbia. International Review of Psychiatry 2012;24(2):86–90. doi:10.3109/09540261.2012.657161 31. Batson CD, Sympson SC, Hindman JL, Decruz P, Todd RM, Joy L, et al. “I’ve Been there, Too”: Effect on Empathy of Prior Experience with a Need. Personality and Social Psychology Bulletin 1996;22(5):474482. 32. Nietlisbach G, Maercker A, Rössler W, Haker H. Are empathic abilities impaired in posttraumatic stress disorder? Psychological Reports 2010;106(3):832-44.

33. Davis MH. Measuring individual differences in empathy: evidence for a multidimensional approach. Journal of Personality and Social Psychology 1983;44:113-26. 34. Harsch HH.The role of empathy in medical students’ choice of specialty. Academic Psychiatry 1989;13:96-8. 35. Konrath SH, O’Brien EH, Hsing C. Changes in dispositional empathy in American college students over time: a meta-analysis. Personality and Social Psychology Review 2011;15(2):180-98. 36. Johna S, Rahman S. Humanity before Science: Narrative Medicine, Clinical Practice, and Medical Education. The Permanent Journal 2011;15(4):92–4. 37. Truax CB, Altmann H, Millis WA. Therapeutic relationship provided by various professionals. Journal of Community Psychology 1974;2:33-6. 38. Compton MT, Frank E, Elon L, Carrera J. Changes in U.S. Medical Students’ Specialty Interests over the Course of Medical School. Journal of General Internal Medicine 2008;23(7):1095-100. 39. Ritter K, Dziobek I, Preissler S, Rüter A, Vater A, Fydrich T, et al. Lack of empathy in patients with narcissistic personality disorder. Psychiatry Research 2011;187(12):241-7.

Maja Pantović Stefanović Clinic of Psychiatry, Clinical Center of Serbia Pasterova 2, 11000 Belgrade E-mail: majapantovic@yahoo.it

Ivana Jelić UDK: 616.89-008.454-02:616.24-008

Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia

INTRODUCTION Chronic obstructive pulmonary disease (COPD) is the most common respiratory disease in the population of working age people and represents a very serious health problem in both developed and developing world. The data on the prevalence of chronic obstructive pulmonary disease are very different, because the disease is often not recognized and not diagnosed, even in

Summary The prognosis of patients with chronic obstructive pulmonary disease is still uncertain, especially when the primary disease is further complicated with depression symptoms, the treatment of which represents a very complex therapeutic problem. Depression symptoms appear very often in patients suffering from chronic obstructive pulmonary disease, and the prevalence identified in different studies is from 16 % to 74 %. The variability in the study is caused by the different stages of the disease in which patients are found at the time of observation, assessment methods and the different diagnostic criteria for chronic obstructive pulmonary disease and depression. Chronic obstructive pulmonary disease is associated with numerous comorbidities, (including depression) and it is significant since it leads to more frequent use of health services, frequent hospitalizations and poor physical and social functioning. Patients suffering from chronic obstructive lung diseases are among the most accessible populations suitable for preventive work: they are the high-risk population and in constant contact with health professionals that can facilitate diagnosis and timely treatment of depression symptoms. Key words: chronic obstructive pulmonary disease, prevalence, depression

the range from 56 % to 85 % of the cases [1-2]. The substantial consumption of nicotine represents one of the major factors for chronic obstructive pulmonary disease [3]. The meta-analysis has shown that excessive consumption of nicotine, associated with a genetic predisposition, represents the major factor in causing lung damage. According to the metaanalysis being conducted in 28 countries during the period from 1990 to 2004, the prevalence of chronic obstructive pulmo-

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND DEPRESSION

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nary disease was said to be 7.6 %; COPD was reported to be higher in smokers and ex-smokers compared to non-smokers and noted to be prevalent in population over 40 years of age being present more in men than in women [4]. The BOLD study conducted in 12 world countries, both developed and developing ones, with 9425 respondents estimated10.1 % of prevalence of chronic obstructive pulmonary disease. In a study conducted in South America, the prevalence of chronic obstructive pulmonary disease was determined from 7.8 % to 20 % of cases [56]. According to the definition of the Global Strategy for the Diagnosis, treatment and prevalence of chronic obstructive pulmonary disease (GOLD) is characterized by airflow limitation which is not fully reversible, progressive and associated with an abnormal inflammatory lung response to harmful particles and gases. The airflow limitation is based on the inflammation occurring in the small airways and lung parenchyma. Chronic inflammation causes structural changes and narrowing of the small airways. The destruction of the parenchyma, occurring as a part of the inflammatory process, leads to the reduction of elasticity being followed by the destruction of the lung parenchyma and the development of emphysema [1,2,8]. The clinical diagnosis of chronic obstructive pulmonary disease is based on characteristic symptoms such as the existence of dyspnea, chronic cough and sputum production, and history and spirometric examinations. Forced expiratory lung capacity (FEV1) is the most commonly used parameter in assessing the lung function damage. The ratio of FEV1 / FVC < 70 % indicates obstructi-

ve lung ventilation, while the assessment of the severity of obstructive disorders is based on the FEV 1 value [1]. The assessment of severity of chronic obstructive pulmonary disease is performed on the basis of FEV1. In relation to the value of FEV1, there are mild, moderately severe, severe and very severe chronic obstructive pulmonary diseases. The value of FEV1 < 80 % characterizes mild chronic obstructive pulmonary disease, 50-80 % moderately severe, 30-50 % severe and < 30 % very severe chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease is often accompanied by depression symptoms. It is difficult to differentiate between depression and chronic obstructive pulmonary disease because their symptoms are intertwined. A large number of psychological and physical symptoms refer to both disorders: increased symptoms of fatigue, sleep disturbance, appetite, concentration difficulty, reduced mobility and deceleration [7-8]. People with depression, smoke more frequently and more intensely, so it reflects negatively on the smoking cessation. Depression in patients with chronic obstructive pulmonary disease reduces the quality of life and reduces work capacity [9]. A regular monitoring of the quality of life is an important parameter in the clinical management of patients, because indicators such as lung function are of limited value. The research results show that the respiratory and physical symptoms are associated with depression in patients with chronic obstructive pulmonary disease while that is not the case with the factors such as age, sex, education, FEV1 and comorbidities [10]. FEV1 is accepted as a reliable indicator of physiological severity of chronic obstructive pulmonary

increased in sputum, exhaled air and plasma of patients with chronic obstructive pulmonary disease, particularly during exacerbations. The concentration of IL-6 in plasma is correlated with increased Creactive protein (CRP) levels, being a major stimulator of CRP release from the liver. Since IL-6 is stable in the circulation, in contrast to other cytokines, it is considered to be involved in some of the systemic effects of chronic obstructive pulmonary disease. IL-6 is claimed to particularly contribute to the damage in endothelial cells functions, insulin resistance, osteoporosis and depression in patients with chronic obstructive pulmonary disease [19]. The symptoms of chronic obstructive pulmonary diseases such as dyspnea, inactivity and consequential condition loss are claimed to cause even greater inactivity, social isolation, anxiety and symptoms of depression. Such patients often feel useless, are dependent on others in terms of care and worry and lose interest in future events [23]. Several studies on development of depression in chronic obstructive pulmonary disease patients were conducted. The study by Polski and associates in 2005 that lasted ten years was one of the largest studies. 8387 adult patients were included and the emergence of depression symptoms after the diagnosis of one of the seven most common chronic diseases, including chronic obstructive pulmonary disease, was investigated. The control check-ups were performed every two years. Two years after the diagnosis of chronic obstructive pulmonary disease it was observed that the “hazard ratio” for the development of depression was 2.21, 3.55 for cancer and 1.45 for heart disease [25]. Patients with chronic ob-

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disease, according to many studies, but it correlates poorly with measurements of life quality and the results reported by the depressed patients [10-12]. The stable chronic obstructive pulmonary disease prevalence of depression ranges between 10-42 % [12-17]. The risk of depression is higher in patients with a more severe clinical picture of chronic obstructive pulmonary disease compared to the healthy population (15 %), with the highest percentage (62 %) found in patients with long-term oxygen therapy (DOT) [17]. In some studies, it is estimated that depression in chronic obstructive pulmonary disease occurs in the range from 6 % to 59 % [20]. The systematic analysis of 64 studies involving patients with severe clinical picture of chronic obstructive pulmonary disease showed that the prevalence of depression varied between 37-71 % in chronic obstructive pulmonary disease and was even higher than the prevalence of depression in patients with cancer, AIDS, heart disease and kidney disease [14-22]. In our research, conducted in primary health care in 2014, as an instrument of assessment of depression a screening questionnaire was used, created by the experts of the Ministry of Health of the Republic of Serbia. 835 patients were analyzed and fortified the prevalence of depressive symptoms higher than 9 % in patients with more severe clinical picture of chronic obstructive pulmonary disease. The mechanism of the development of depression in chronic obstructive pulmonary disease is multifactorial [17]. Nowadays there are more and more studies proving that systemic inflammation leads to the appearance of depression symptoms. Interleukin-6 (IL-6) plays a particularly important role because it is

structive pulmonary disease have a variety of symptoms, ranging from shortterm depression symptoms and clinically manifested depression. Several studies claimed that two thirds of patients with chronic obstructive pulmonary disease had a moderate to severe depression [2730]. The study by Johannes and associates in 2003 reported that about one-quarter of patients with chronic obstructive pulmonary disease had an unrecognized depression.

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Assessment of depression in chronic obstructive pulmonary disease

No diagnostic screening tool for the assessment of depression in patients with chronic obstructive pulmonary disease has been developed, so far, so the most commonly used instruments for depression symptoms assessment are the Beck Depression Inventory (BDI Beck Depression inventors) and Hamilton Depression (HRSD-Hamilton depression scale) [31]. According to the GOLD guidelines, a detailed medical history of each newly detected patient with chronic obstructive pulmonary disease is recommended to be taken,, including the assessment of depression symptoms [32-33]. The recommendations from the United States (United States Preventive Task

Force) state that all patients over 18 years of age should be screened for the presence of depression symptoms in primary care offices. All chronic patients and patients with chronic obstructive pulmonary disease should be included [33].

CONCLUSION Treatment of depression in patients with chronic obstructive pulmonary disease is multidisciplinary. The available medical treatment focuses on depression allievation symptoms, maintaining the basic functioning and improving the quality of life which would enable clinicians to recognize the disease deteriorations. Patients suffering from chronic obstructive lung diseases are among the most accessible populations suitable for preventive work: they are a high-risk population and in constant contact with health professionals that can facilitate diagnosis and timely treatment of depression symptoms. Bearing in mind the predictions of the World Health Organization, that by 2020 depression will have become the leading cause of mortality in the world and since it is now one of the medical conditions greatly affecting the deterioration of quality of life, adequate prevention is an imperative.

Ivana Jelić

Fakultet medicinskih nauka, Univerzitet u Kragujevcu, Kragujevac, Srbija

Sažetak Prognoza bolesnika sa hroničnom opstruktivnom bolešću pluća je i dalje neizvesna, pogotovo kada je osnovno oboljenje komplikovano simptomima depresije čije lečenje prestavlja vrlo složen terapijski problem. Simptomi depresije javljaju se veoma često kod pacijenata koji boluju od hronične opstruktivne bolesti pluća, a utvrđena prevalenca u različitim studijama kreće se od 16% do 74%. Varijabilnost u studijama potiče od faze bolesti u kojoj se pacijenti nalazili u trenutku opservacije, metodama procene kao i različitim dijagnostičkim kriterijumima za hroničnu opstruktivnu bolest pluća i depresiju. Hronična opstruktivna bolest pluća udružena sa brojnim komorbiditetima, među kojima je i depresija, zauzima značajno mesto jer dovodi do češćeg korišćenja zdravstvenih usluga, češćih hospitalizacija, lošim fizičim i socijalnim funkcionisanjem. Bolesnici koji pate od hronične opstruktivne bolesti pluća spadaju u veoma dostupnu populaciju pogodnu za preventivni rad, pre svega zato što su visoko rizična populacija, a zatim i zbog toga što su u stalnom kontaktu sa zdravstvenim radnicima što olakšava dijagnostikovanje i blagovremeno lečenje simptoma depresije. Ključne reči: hronična opstruktivna bolest pluća, prevalenca, depresija

References: 1. Barns PJ. Chronic Obstructive pulmonary Disease: Effect beyond the lungs. Plos Med 2. 2010;7(3):e1000220.doi10.1371/journal.pmed.1000220. 3. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global 4. Initative for Chronic Obstructive Lung Disease (GOLD) 2013. Available from: 5. http://www.goldcopd.org/. 6. Stang P, Lydick E, Silberman C et al. The Prelevance of COPD; Using Smoking Rates to Estimate Disease Frequency in the General Population. Chest 2000;117:354-359. 7. Halbert RJ, Natoli JL, Gano A, et al. Global burden of COPD: systematic review and meta-analysis. Eur Respir J 2006;25:523-32

8. Raherison C, Girodet PO. Epidemiology of COPD. Review. Eur Respir Rev 2009; 9. 18:114,213-221 10. Menezes AM, Perez-Padilla R, Jardim JR, et al. Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): a prelevance study. Lancet 2005;366:1875-1881 11. Buist AS, McBurnie MA, Vollmer WM, et al. International variation in the prelevance of COPD (the BOLD Study): a population-based prelevance study. Lancet. 2007;370:741-50. 12. Barnes PJ. Chronic obstructive pulmonary disease. N Engl J Med 2000;343:269-80. 13. Wilson lan. Depression in the patient with COPD. International Journal of COPD

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HRONIČNA OPSTRUKTIVNA BOLEST PLUĆA I DEPRESIJA

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14. 2006:1(1)61-64. 15. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176:532555. 16. United States Preventive Task Force http://www.uspreventiveservicestaskforce.org/about.htm. 17. Maurer J, Rebbapragada V, Borson S, et al. Anxiety and Depression in COPD. Chest 2008; 134:43-56. 18. Kunik ME, Roundy K, Veazey C, et al. Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 2005;127:1205-1211. 19. Van Manen JG, Bindels PJ, Dekker FW, et al. Risk of depression in patients with chronic obstructive pulmonary disease and its determinants. Thorax 2002;57:412-416. 20. Wagena EJ, Kant I, van Amelsvoort LG, et al. Risk of depression and anxiety in employees with chronic bronchitis: the modifying effect of cigarette smoking. 21. Psychosom Med. 2004;66:729-734. 22. Lacasse Y, Rousseau L, Maltais F. Prelevance of depressive symptoms and depression in patients with severe oxygen dependent chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2001;21:80-86. 23. Gudmundsson G, Gislason T, Janson C, et al. Depression, anxiety and health status after hospitalization for COPD: a multicentre study in the Nordic countries. Respir Med. 2006;100:87-93. 24. Van den Bemt L, Schermer T, Bor H, et al. The risk for depression comorbidity in patients eith COPD. Chest 2009;135:108-114. 25. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31:58-69. 26. Barns PJ. The Cytokine Network in Chronic Obstructive Pulmonary Disease. Am J Respir Cell Mol Biol 2009;41:631-638. 27. Yohannes AM, Baldwin RC, Connolly MJ. Depression and anxiety in elderly patients with chronic obstructive pulmonary disease. Age Ageing 2006;35:457-459. 28. Polsky D, Doshi JA, Marcus S, et al. Longterm risk for depressive symptoms after a medical diagnosis. Arch Intern Med 2005;165:1260-1266.

29. Yohannes AM, Baldwin RC, Connolly MJ. Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the Basdec screening questionnaire. Int J Geriatr Psychiatry. 2000;15:1090-1096. 30. Kim HF, Kunik ME, Molinari VA, et al. Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics. 2000;41:465-471. 31. Yohannes AM, Baldwin RC, Connolly MJ. Prevalence of sub-threshold depression in elderly patients with chronic obstructive pulmonary disease. Int J Geriatr Psychiatry. 32. 2003;18:412-416. 33. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med. 2000;160:32783285. 34. Sullivan M, Simon G, Spertus J, et al. Depression-related costs in heart failure care. Arch Intern Med. 2002;162:1860-1866. 35. Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000;23:934-942. 36. Timotijević I, Paunović V. Instrumenti kliničke procene u psihijatriji. Beograd: Institut za mentalno zdravlje 2003:130-134. 37. Stage K.B, Middelboe T, Pisinger C. Depression and chronic obstructive pulmonary disease (COPD). Impact od survival Acta Psychiat Scand 2005;11:320-323. 38. Norwood R.J. A review of etiologies of depression in COPD International Journal of COPD 2007:2(4) 485-491. 39. Glassman AH, Helzer JE, Covey LS, Cottler LB, Stetner F, Tipp JE, Johnson J. 40. Smoking, smoking cessation, and major depression. JAMA1990;264:1546-9. 41. Ng TP, Niti M, Tan WC. Depressive symptoms and chronic obstructive pulmonary disease. Arch Intern Med 2007;167:60-67.

Ivana Jelić Faculty of Medical Sciences Kragujevac Lepenički bulevar 23/4, 34000 Kragujevac Mob: 063 685 116 E-mail: jelicivana82@yahoo.com

Bojana Dunjić-Kostić1 Maja Pantović Stefanović1 Maja Ivković 1,2 Aleksandar Damjanović 1,2 Maja Lačković 1,2 Miroslava Jašović Gašić3 UDK: 616.895.8-02 1

Klinika za psihijatriju Klinički centar Srbije, Beograd,Srbija

Medicinski fakultet, Univerzitet u Beogradu, Beograd, Srbija

Akademija medicinskih nauka, Srpsko lekarsko društvo, Beograd, Srbija

UVOD-TEORIJSKI OKVIR Razvoj sofisticiranih tehnika detekcije strukturnih i biohemijskih abnormlnosti, u poslednjih nekoliko decenija, odigrao je važnu ulogu u preciznijem sagledavanju brojnih bioloških alteracija kod pacijenata uopšte. Ova činjenica je od posebne važnosti istraživačima u oblasti neuronauka, zbog često nepoznate i/ili multifaktorijalne etiopatogeneze neuropsihijatrijskih poremećaja, te svaki deo spoznaje kompleksnog „algoritma“ ima svoje značajno mesto. U poslednje vreme veliku pažnju istraživača privlače eksploracija imunoloških abnormalnosti kod obolelih od shizofrenije, kao i citokinima posredovani mehanizmi koji predstavljaju osnovu za niz hipoteza iznesenih na ovu temu [1-3]. U daljem tekstu fokusiraćemo se na nekoliko najvažnijih teorijskih pravaca koje se tiču inflamacije i imunoloških promena zapaženih u shizofreniji. Jedna od teorija je da je infekcija majke

Kratak sadržaj Poslednjih par decenija pažnju istraživača sve više privlače imunološke abnormalnosti uočene kod obolelih od shizofrenije. U prvom delu teksta prikazan je kratak pregled pojedinih teorijskih konstrukata predloženih u cilju boljeg uvida u povezanost shizofrenije i imunoloških alteracija, u drugom delu je razmotren uticaj citokina na pojedine neurotransmiterske sisteme i finalno izneta su zapažanja dobijena iz istraživanja u realnoj kliničkoj situaciji kao i pravci budućih istraživanja. Ključne reči: shizofrenija, citokini, neuroinflamacija, etiopatogeneza, mikroglija

tokom trudnoće (naročito tokom ranog perinatalnog perioda) značajan faktor rizika za dete za razvoj shizofrenije i drugih neurorazvojnih oboljenja [4,5]. Epidemiološke studije su pokazale da infekcija majke virusom influence tokom trudnoće povećava rizik za shizofreniju deteta za 37 puta [4,6]. Pored virusa influence i brojni drugi infektivni činioci su povezani sa povećanim rizikom za SCH medju kojima su i varicela zoster virus, polio, difterija, rubela itd [5]. Medjutim, patološki mehanizam odgovoran za povećan rizik za shizofreniju kod dece nakon izloženosti majke infekciji još uvek je nedovoljno jasan. Takodje otvoreno je pitanje, na koji način infekcija majke dovodi do citokinskog disbalansa kod fetusa; da li je u pitnju delovanje infektivnog činioca na specifične receptore koji dovode do produkcije i oslobadjanja različitih medijatora zapaljenja u periferni majčin imuni sistem koji onda prolaze placentu i ulaze u cirkulaciju fetusa [6,7], ili potencijalni iz-

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SHIZOFRENIJA I CITOKINI

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vori citokina u fetalnom okruženju vode poreklo od same placente ili pak samog fetusa [8,9]. Sa jedne strane važno je imati na umu faktore od kojih potencijalno zavisi efikasnost uticaja citokina kao što su vrsta citokina, gestaciona dob, transplacentarni prolaz [8], dok sa druge strane je važan period „najveće“ vulnerabilnosti za perinatalnu infekciju i posledice u adultnom periodu na kognitivnom i bihejvioralnom planu, a imajući u vidu vreme postizanja funkcionalne zrelosti imunog sistema [10]. Dalje, jedna od frekventno eksplorisanih teorija je „T helper hipoteza“ govori o disblansu izmedju T helper- tip 1(Th1)/tip 2 (Th2) imunog odgovora, u korist „prevage“ Th-2 odgovora kod obolelih od shizofrenije i posledičnih disregulacija u kinureninskom putu i glutamatergičko-dopaminergičkim promenama [11,12]. Saznanje o dva nova subtipa T ćelija - Th17 i T regulatornih ćelija (Tregs), su značajni faktori u rasvetljavanju etiologije ovog oboljenja kao i kontrolnih mehanizama, pogotovo imajući u vidu da povećana produkcija Th17 intenzivira inflamatornu reakciju i doprinosi oštećenju tkiva [13,14]. Jedna od interesantnih teorija je i „ mikroglijalna hipoteza shizofrenije“ prema kojoj aktivirana mikroglija oslobadja proinflamatorne citokine i slobodne radikale dovodeći do poremećene neurogeneze, neuralne degradacije, promena u beloj masi, a koje imaju krucijalnu ulogu u patogenezi shizofrenije [15,16].

UTICAJ CITOKINA NA NEUROTRANSMISIJU Predpostavlja se da inflamacija, oksidativni stres, mitohondrijalna disfunkcija imaju značajno mesto u rasvetljavanju etiopatogeneze shizofrenije, ali i drugih

neuropsihijatrisjkih poremećaja kao što su depresija, bipolarni poremećaj, Alchajmerova bolest itd. [17]. Poznato je da u shizofreniji postoji dopaminergičko-glutamatergička disfunkcija, čija je neuroanatomska osnova kortiko-strijato-talamusno-kortikalni krug [18]. Brojna istraživanja na animalnm modelima potvrdjuju predpostavku da citokini utiču na neurotransmitersku aktivnost [19]. Simplifikovano, pojedini citokini koji se frekventno dovode u korelaciju sa shizofrenijom dovode do neurohemijskih promena u ovom oboljenju npr.- IL-6 stimuliše povećavanje serotonina i dovodi do mezokortikalne dopaminske aktivnosti u hipokampusu i prefrontalnom korteksu [20], TNF-a ima stimulatorni efekat na kateholamine u slučaju akutnog oslobadjanja, dok hronično utiče na inaktivaciju kateholaminske sekrecije [21], IL-2 stimuliše dopaminsku neurotransmisiju sa jedne strane, akutno administriran utiče i na povečanje noradrenalina na funkcionalno značajnim mestima, a sa druge strane utiče i na inhibiciju oslobadjanja acetilholina u hipokampusu i prefrontalnom korteksu [22,23]. Nezaobilazno je pomenuti da disbalans Th1/Th2 (u smislu prevage Th2 odgovora kod obolelih od shizofrenije) je usko povezan sa enzimom indolamin-2,3-dioksigenaze (IDO), metabolizmom triptofan/kinurenin i nizom reperkusija na sistem neurotransmisije naročito na dopaminergički,serotonergički i glutamatergički sistem. Poslednji , glutamatergički sistem sve više postaje fokus istraživanja jer se predpostavlja da je u shizofreniji glutamatergička hipofunkcija ta koja je najznačajnija za dopaminergičku disfunkciju [24]. Pro-inflamatorni citokini utiču na glutamatergičku neurotransmisiju indirektno preko efekata na metabolizam triptofan/ kinu-

ALTERACIJE CITOKINA ZAPAŽENE KOD OBOLELIH OD SHIZOFRENIJE-KLINIČKE IMPLIKACIJE Alteracije citokina su zapažene kod pacijenata obolelih od shizofrenije u odnosu na zdrave subjekte [29]. Nekoliko studija je pokazalo povišene koncentracije pojedinih citokina u plazmi/serumu /cerebrospinalnom likvoru (interleukin (IL)-1 â, IL-2, IL-4, IL-6, IL-10, IL-12, IL-18, tumor necrosis faktora (TNF) alpha [30-35] kod obolelih od shizofrenije. Skorašnja opsežna meta analiza s Millera i sar. [36], pokazala je da je TNF-á “trait” marker za shizofreniju, jer je povišen u fazi akutne deterioracije bolesti, ali da ostaje isti i nakon tretmana, dok se predpostavljajući da IL-6 može biti “state” marker samog akutnog pogoršanja [37]. Zanimljivo je što su podaci često heterogeni kada je u pitanju posmatranje nivoa citokina u odnosu na kliničke varijable. Tako se povišene koncentracije IL6 dovode u vezu sa negativnom fenomenologijom, dužinom bolesti, teraporezistencijom, nepovoljnim ishodom bolesti, akutnom fazom bolesti, ali i sa hroničnim-rezidualnim formama shizofrenije [37-41]. Mali broj istraživanja se bavio razlikama u odnosu na “subgrupe” obolelih. Jedno od retkih istraživanja, bar što se tiče ovog poremećaja je rad Cazzull-a i sar. [42] koji su pokazali da je IL-10 bio snižen kod paranoidnih pacijenata u odnosu na ne –paranoidne, dok Inglot i sar.[43] evidentiraju različitu produkciju INF-ã u komparaciji sa predominantnom psihopatologijom. Nezanemarljiv je i uticaj terapije na citokinski disbalans, te tako Monji i sar [15] smatraju da antipsihotici utiču antiinflamatorno (delovanjem na mikrogliju). Oboljenja koja ima-

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renin [25] .Naime, IDO konvertuje triptofan u kinurenin. Preko ovog puta nastaje nekoliko jedinica hinolinska kiselina (QUIN) koja predstavlja ekscitotoksičnog NMDA receptorskog agonistu, zatim 3-hidroksikinurenin koji je generator slobodnih radikala i kinurenska kiselina (KYN-A) koji je do sada jedini otkriveni antagonist glutamatergičkih receptora. Pored toga smatra se i antagonistom nikotinskih receptora. Imuni odgovor u shizofreniji, je najverovatnije povezan sa ovim disbalansom, koji rezultuje povećavanjem kinurenske kiseline u mozgu obolelih i posledicama na glutamatergički sistem, odnosno rezultuje NMDA antagonizmom. Dalje, navedeni narušeni ekvilibrijum vodi hronifikaciji proinflamatornog statusa i povezan je sa povećanom produkcijim prostaglandina E2, ciklooxigenaze-2 (COX-2) i proinflamatornih citokina i finalno NMDA hipofunkcijom [25,26]. Istraživanja su pokazala, da su kod obolelih od shizofrenije povećane koncentracije KYN-A u prefrontalnom korteksu [27], što je sa kliničkog stanovišta značajno i čime bi se mogli barem delimično objasniti kognitivni deficiti u ovom oboljenju, ali i psihotična simptomatologija. Muller i sar. [28] su utvrdili značajno brže poboljšanje medju pacijentima koji su pored risperidona primali i celekoksi (selektivni inhibitor COX-2) u odnosi na placebom. Detaljnije upoznavavnje sa metabolizmom ovog puta kao i anti-inflamatornim svojstvima pojedinih lekova, značajno proširuju preventivne, ali i ciljane terapijske mogućnosti u lečenju shizofrenije, a upravo navedena studija Mullera i sar. [28] pruža jedan od čvrstih dokaza za razvijanje u tom pravcu.

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ju verovatno multifaktorijalnu etiologiju, teško je posmatrati dihotomno i u jednoj vremenskoj tački, te tako najveći doprinos svakako imaju longitudinalne studije koje nam mogu ukazati na eventualnu razliku izmedju ranih „suptilni“ promena i kasnih , već „rezidualnih“ promena. Jedna takva studija je i studija Narayan i sar. [44] koja upravo govori u prilog promene toka shizofrenije kako bolest napreduje i finalno dovodi do izmena u funkcionalnom smislu imunološkog statusa osobe. Posebno interesantno je polje koje ispituje uticaj citokina na kogniciju kod shizofrenih pacijenata, naročito sa aspekta njihovog delovanja na funkcionalno značajnim mestima za ovo oboljenje. Tako, najnovija studija Frydecka i sar. [45] čiji je cilj bio ispitati uticaj IL-6 zajedno sa polimorfizmom tog gena (IL6 -174G/C) i visoko osetljivog C-reaktivnog proteina na kliničke manifestacije i kogniciju kod obolelih od shizofrenije, je pokazala da IL6 -174G/C polimorfizam ne utiče na nivoe IL-6, ali da je isti povezan sa težinom pozitivnih simptoma. Takodje, autori smatraju da poviseni nivoi IL-6 mogu imati značajnu ulogu u kognitivnom oštećenju i biti inflamatorni marker deteorijacije kod ove grupe obolelih. S obzirom na poznatu činjenicu da mnogi faktori kao što su pol, starost, gojaznost, pušenje, terapija, somatske bolesti [46-48] mogu doprineti prmenama u nivou citokina, u istraživanjima je neophodno uzeti ih u razmatranje. Sa druge strane, ova činjenica pravi i izvesna ograničenja za istraživače u sticanju precizni-

jeg uvida upravo kod formi koje su nedovoljno precizno imunološki eksplorisane kao što su teraporezistentni pacijenti, pacijenti sa rezidualnom formom shizofrenije, stariji pacijenti itd. Zanimljiv kritički osvrt na temu citokina, odnosno markera inflamacije i shizofrenije daje Manu i sar [49] u skorašnjoj publikaciji kroz interesantan model koji služi pravilnijem sagledavanju da li neka povezanost može doprineti uzroku nekog patološkog fenomena. Model se sastojao iz nekoliko dimenzija: snaga i doslednost, prolaznost, stepen biološkog udela, uverljivost, koherentnost, specifičnost inflamatornih abnormalnosti. Sumarno, kako autori navode, jos uvek nemamo dovoljan broj dokaza koji bi bili čvrsti oslonci, te u tom kontekstu dalja istraživanja su imperativ. Posebno značajno je praćenje pacijenata od nivoa ”subsindromske” psihoze do potpuno razvijene kliničke slike, kao i merenje nivoa citokina kod onih pacijenata kod kojih je došlo do prelaska u potpuno razvijenu sliku. Takodje, smatramo neophodnim da buduća istrazivanja detaljnije eksplorišu neurotransmiterske i biohemijske osnove kod ovog oboljenja sa naglaskom na glutamatergički sistem i kinureninski put i njegove produkte, jer je jedno od važnih pitanja koje se nameću je utvrdjivanje činilaca, kao i mehanizma na koji oni deluju, a zbog kojih doalzi do remećenja balansa izmedju neurotoksicnosti i neuroprotekcije. Dublja analiza gore navedenih opservacija bi u mnogome pomogla razvijanju preventivnih strategija, ali i pravovremenom i preciznom tretmanu.

SCHIZOPHRENIA AND CYTOKINES Bojana Dunjić-Kostić1 Maja Pantović Stefanović1 Maja Ivković 1,2 Aleksandar Damjanović 1,2 Maja Lačković 1,2 Miroslava Jašović Gašić3

Clinic for Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia

School of Medicine, University of Belgrade, Belgrade, Serbia

Academy of Medical Science, Serbian Medical Society, Belgrade, Serbia

Summary In the last few decades, the researcher attention is more concentrated onto immunological abnormalities observed in patients with schizophrenia. In the first section, we make a brief review of some theoretical constructs proposed in order to understand better the connection between schizophrenia and immunological alterations. Afterwards, in the second section we discuss the influence of the cytokines on particular neurotransmitter systems and finally we present some of the observations obtained from the studies in a real clinical situation, as well further directions for the investigatiors in this field. Key words: schizophrenia, cytokines, neuro-inflamation, etiopathogenesis, microglia

1. Kirkpatrick B, Miller BJ. Inflammation and schizophrenia. Schizophr Bull 2013;39:1174-9. 2. Miller BJ, Buckley P, Seabolt W et al. Meta-analysis of cytokine alterations in schizophrenia: clinical status and antipsychotic effects. Biol Psychiatry 2011;70:663-71. 3. Miller BJ, Culpepper N, Rapaport MH et al. Prenatal inflammation and neuro-development in schizophrenia: a review of human studies. Prog Neuropsychopharmacol Biol Psychiatry 2013;42: 92-100. 4. Bilbo SD, Schwarz JM. Early-life programming of later life brain and behaviour: a critical role for the immune system. Frontiers in behavioral neuroscience 2009; 3:1-14. 5. Gilmore JH, Jarskog LF,Vadlamudi S, Lauder JM. Prenatal Infection and Risk for Schizophrenia: IL-1b, IL-6, and TNFa Inhibit Cortical Neuron Dendrite Development. Neuropsychopharmacology 2004;29:1221–9

6. Matsumoto M , Funami K, Oshiumi H, Seya T. Toll-like receptor 3: a link between toll like receptor, interferon and viruses. Microbiol Immunol. 2004;48:147-54. 7. Kawai T, Akira S. Innate immune recognition of viral infection.Nature Immunol 2006; 7:131-7. 8. Jonakait GM. The effects of maternal inflamation on neuronal development: possible mechanisms. Int J Dev Neurosci 2007; 25:415-25. 9. Abrahams VM, Mor G. Toll like receptors and they role in the trophoblast. Placenta 2005; 26: 540-7. 10. Holsapple MO,West LJ, Landreth KS. Species comparison of anatomical and functional immune system development. Birth Defects Res B Dev Reprod Toxicol 2003; 68:321-34.

Engrami  vol. 37  januar-mart 2015.  br. 1

Literatura:

Engrami  vol. 37  januar-mart 2015.  br. 1 60

11. Muller N, Schwarz MJ. Immunology in schizohrenic disorders. Nervenarzt 2007; 78: 253-6,258-60,262-3 12. Muller N, Riedel M, Schwartz MJ, Engel RR. Clinical effect of COX-2 inhibitors on cognition in schizophrenia. Eur Arch Psychiatry Clin Neurosci 2005; 255: 14951. 13. Dimitrov DH, Lee S, Yantis J, Valdez C, Paredes RM, Braida N et al. Differential correlations between inflammatory cytokines and psychopathology in veterans with schizophrenia: potential role for IL-17 pathway. Schizophrenia Research 2013; 151: 29–35. 14. Debnath M, Berk M. Th17 pathway–mediated immunopathogenesis of schizophrenia: mechanisms and implications. Schizophrenia Bulletin 2014; 40:1412–21. 15. Monji A, Kato T , Kanba S. Cytokines and schizophrenia: Microglia hypothesis of schizophrenia. Psychiatry Clin Neurosci 2009; 63: 257-65. 16. Busse S, Busse M, Schiltz K, Bielau H, Gos T, Brisch R et al. Different distribution patterns of lymphocytes and microglia in the hippocampus of patients with residual versus paranoid schizophrenia: further evidence for disease course-related immune alterations? Brain Behav Immun 2012;26:1273-9. 17. Berk M, Dean O, Drexhage H, McNeil JJ, Moylan S, O’Neil A, Davey CG, Sanna L, Maes M. Aspirin: a review of its neurobiological properties and therapeutic potential for mental illness. BMC Medicine 2013; 11:74. 18. Carlsson A, Waters N, Holm-Waters, Tedroff J, Nilsson M, Carlsson ML. Interactions between monoamines, glutamate, and GABA in schizophrenia: new evidence. Annu Rev Pharmacol Toxicol 2001; 41:23760. 19. Stöber G, Ben-Shachar D, Cardon M, Falkai P, Fonteh AN, Gawlik M et al. Schizophrenia: From the brain to peropheral markers. A consensus paper of WFSBP task force on biological markers. The World J Biol Psychiatry 2009;10:127-155. 20. Dunn AJ. Endotoxin-induced activation of cerebral catecholamine and serotonon metabolism: comparison with interleukin-1. J Pharmacol Exp Ther 1992; 261:964-9.

21. Soliven B, Albert J. Tumor necrosis factor modulates the inactivation of catecholamine secretion in cultured symptahetic Neurons. J Neurichem 1992; 58: 1073-8. 22. Lacosta S, Merali Z, Anisman H.Central monoamine activity following acute and repeated systemic interleukin-2 administraion.Neuroimmunomodulation 2000; 8:8390. 23. Awatsuji H, Furukawa Y, Nakajima M, Furukawa S, Hayashi K. Interleukin-2 as a neurotrophic factor for supporting the survival of neurons cultured from various regions of fetal rat brain. J Neurosci Res 1993; 35:305-11. 24. Muller N, Schwarz MJ. The immunological basis of glutamatergic disturbance in schizophrenia: towards an integrative view. J Neural Transm Suppl 2007;269-80. 25. Müller N1, Myint AM, Schwarz MJ. Kynurenine pathway in schizophrenia: pathophysiological and therapeutic aspects. Curr Pharm Des. 2011;17(2):130-6. 26. Muller N, Myint AM, Schwarz MJ. The impact of neuroimmune dysregulation on neuroprotection and neurotoxicity in psychiatric disorders-relation to drug treatment. Dialogues Clin Neurosci 2009; 11(3)319-32. 27. Wonodi I, Schwarcz R. Cortical Kynurenine Pathway Metabolism: A Novel Target for Cognitive Enhancement in Schizophrenia. Schizophrenia Bulletin 2010;36:211–8. 28. Muller N, Riedel M, Schwartz MJ, Engel RR. Clinical effect of COX-2 inhibitors on cognition in schizophrenia. Eur Arch Psychiatry Clin Neurosci 2005; 255: 14951. 29. Reale M, Patruno A, De Lutiis MA, Pesce M, Felaco M, Di GM et al. Dysregulation of chemo-cytokine production in schizophrenic patients versus healthy controls. BMC. Neurosci. 2011; 12:13 30. Chang SH, Chiang SY, Chiu CC, Tsai CC, Tsai HH, Huang CY et al. Expression of anti-cardiolipin antibodies and inflammatory associated factors in patients with schizophrenia. Psychiatry Res. 2011; 187:341-346. 31. Schmitt A, Bertsch T, Tost H, Bergmann A, Henning U, Klimke A, Falkai P. Increased serum interleukin-1beta and interleukin-6 in elderly, chronic schizophrenic patients on stable antipsychotic medication. Neuropsychiatr Dis Treat. 2005;1:171-7.

42. Cazzullo CL, Scarone S, Grassi B, Vismara C, Trabattoni D, Clerici M. Cytokines production in chronic schizophrenia patients with and without paranoid behaviour. Prog Neuropsychopharmacology Biol Psychiatry 1998; 22:947-57. 43. Inglot AD, Leszek J, Piasecki E, Sypula A. Interferon responses in schizophrenia and major depressive disorders. Biol Psychiatry. 1994 ;35:464-73. 44. Narayan S, Tang B, Head SR, Gilmartin TJ, Sutcliffe JG, Dean B et al. Molecular profiles of schizophrenia in the CNS at different stages of illness. Brain Res 2008; 1239:235-48. 45. Frydecka D, Misiak B, Pawlak-Adamska E, Karabon L, Tomkiewicz A, Sedlaczek P et al. Interleukin-6: the missing element of the neurocognitive deterioration in schizophrenia? The focus on genetic underpinnings, cognitive impairment and clinical manifestation. Eur Arch Psychiatry Clin Neurosci 2014; [Epub ahead of print] 46. Singh B, Bera NK, Nayak CR,Chaudhuri TK. Decreased serum levels of interleukin2 and interleukin -6 i Indian Bengalee schizophrenic patients.Cytokine 2009;47:1-5. 47. Haack M, Hinze-Selch D, Fenzel T, Kraus T, Kühn M, Schuld A, Pollmächer T. Plasma levels of cytokines and soluble cytokine receptors in psychiatric patients upon hospital admission: effects of confounding factors and diagnosis. J Psychiatr Res 1996; 33:407-18. 48. Himmerich H, Berthold-Losleben M, Pollmächer T. The relevance of the TNFalpha system in psychiatric disorders. Fortschr Neurol Psychiatr 2009; 77: 334-45 49. Manu P, Correll CU, Wampers M, Mitchell AJ, Probst M, Vancampfort D et al. Markers of inflammation in schizophrenia: association vs. causation. World Psychiatry 2014;13(2):189-92.

Bojana Dunjić-Kostić Clinic for Psychiatry Clinical Center of Serbia Pasterova 2, Belgrade, Serbia E-mail:bojanadunjic@yahoo.com

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32. Tanaka KF, Shintani F, Fujii Y, Yagi G, Asai Mtanaka KF, Shintani F et al.Serum interleukin-18 levels are elevated in schizophrenia. Psychiatry Res. 2000; 96:75-80. 33. Dunjic-Kostic B, Jasovic-Gasic M, Ivkovic M, Radonjic NV, Pantovic M, Damjanovic A et al. Serum levels of interleukin-6 and tumor necrosis factor- alpha in exacerbation and remission phase of schizophrenia. Psychiatria Danubina 2013;25:55-61. 34. Mittleman BB, Castellanos FX, Jacobson LK, Rapport JL, Sewdo SE, Shearer GM. Cerebrospinal fluid cytokines in pediatric neuropsychiatric disease. J Immunol 1997; 159:2994-9. 35. Na KS, Kim YK. Monocytic, Th1 and Th2 cytokine alternations in the pathopsysiology of schizophrenia.Neuropsychobiology 2007;56:55-63 36. Miller BJ, Buckley P, Seabolt W, Mellor A, Kirkpatrick B. Meta-Analysis of cytokine alternations in schizophrenia: clinical status and antipsychotic effects. Biol Psychiatry 2011; 70:663-71. 37. Naudin J, Capo C, Giusano B, Mčge JL, Azorin JM. A differential role for interleukin6 and tumor necrosis factor-alpha in schizophrenia? Schizophr Res 1997; 26: 22733. 38. Frommberger UH, Bauer J, Haselbauer P, Fräulin A, Riemann D, Berger M. Interleukin-6-(IL-6) plasma levels in depression and schizophrenia: comparison between the acute state and after remission. Eur Arch Psychiatry Clin Neurosci 1997; 247:228-33. 39. Zhang XY, Zhou DF, Zhang PY, Wu GY, Cao LY, Shen YC. Elevated interleukin-2, interleukin-6 and interleukin-8 serum levels in neuroleptic-free schizophrenia: association with psychopathology. Schizophr. Res 2002; 57: 247-58. 40. Akiyama K. Serum levels of soluble IL-2 receptor alpha, IL-6 and IL-1 receptor antagonist in schizophrenia before and during neuroleptic administration. Schizophr Res 1999; 37: 97-106. 41. Müller N, Riedel M, Gruber R, Ackenheil M, Schwarz MJ. The immune system and schizophrenia. An integrative view. Ann. N. Y. Acad. Sci. 2000; 917: 456-67.

Srđa Zlopaša UDK: 615.851

Klinika za psihijatriju, Klinički centar Srbije, Beograd, Srbija.

Kratak sadržaj Subjektivnost je pojam implicitno prisutan i uglavnom se previđa u mnogim aspektima psihijatrijskog i psihoterapijskog djelovanja. Poslednjih dekada u više oblasti koje se bave duševnim životom paralelno se povećao interes za proučavanje subjektivnosti. Pojam subjekta i subjektivnosti proističe iz filozofije i preuzet je od strane nauka koje se bave psihologijom i psihopatologijom. Dekartov obrt u tretiranju subjekta nastao je metodom sumnje u sva znanja koja nisu očigledna i jasna. Unutrašnja realnost je dominanto prebojena subjektivnim doživljajem. S obzirom da subjektivnost podrazumeva i deo koji nije moguće verbalizovati već se odnosi na kompleksan, individualan doživljaj unutrašnjeg retko je naučno proučavan. Učenje filozofa H. Bergsona o dualitetu spoznaje nudi mogućnost pomirenja dva aspekata psihičke realnosti koja su uglavnom bila međusobno isključivana. Spoznaja unutrašnje psihičke realnosti je moguća samo putem susreta sa drugom psihičkom realnošću, te se odnos više ne definiše kao odnos subjekta i objekta, već kao odnos dva subjekta iz čega proizilazi intersubjektivnost kao epifenomen. Sigmund Frojd je ukazivanjem na individualno značenje nesvesnih elemenata i simptoma otvorio put za formulisanje unutrašnjeg sveta i unutrašnje realnosti. Razumevanje unutrašnjeg sveta pa tim i subjektivnosti nije potpuno bez fantazija. Uvođenjem termina “intersubjekt” nadopunjuje se terminološka i logička praznina u teorijama intersubjektivnosti. Uključivanjem subjektivnog doživljaja u razne praktične i teoretske aspekte psihijatrijskog djelovanja ne isključuje se pozitivistička komponenta, naprotiv ona se nadopunjuje i obogaćuje. Reintegracija subjektivne perspektive utiče na proširenje polja razumevanja kompleksnosti psihičkog života i psihopatologije. Ključne reči: subjektivnost, intersubjektivnost, intersubjekt, psihoanaliza, filozofija

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SUBJEKTIVNOST U PSIHOANALIZI I PSIHIJATRIJI

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Subjektivnost je jedan od onih termina i fenomena koji se često koristi u vokabularu disciplina koje proučavaju različite aspekte psihičkog života a isto tako u svakodnevnom govoru. To je jedan od onih pojmova za koji se misli da se zna šta označava sve dok se ne podvrgne analizi i tek tada se ukaže širok spektar značenja koja se pod tim terminom mogu podrazumevati. Subjektivnost može imati više značenja i predstavljati ono što je: individualno, neponovljivo i autentično u doživljaju, privatano, ličan utisak, pristrasnost, jednostran sud, unutrašnji doživljaj, osećanje koje nije moguće verbalizovati, intuitivnost, nešto neprovjerljivo, nemerljivo, nepostojeće, zamišljeno. Može imati negativnu i pozitivnu konotaciju, smatrati se za neželjen ili poželjan artefakt duševnog života. Subjekt je u gramatici nosilac svojstva, vršilac radnje, glavni akter. U teoriji saznanja ono što spoznaje. U psihologiji aktivno središte svesti, psihičke delatnosti ili celokupne ličnosti i noslilac osećanja kontinuiteta. U empirijskim istraživanjima i humanističkim naukama- jedinka koja je predmet istraživanja i izvestilac o unutrašnjim, subjektivnim zbivanjima, u ovom smislu subjekt je uži pojam nego ispitanik [1]. Subjektivnost može biti individualna i grupna.

SUBJEKT I SUBJEKTIVNOST U FILOZOFIJI Subjektivnost proističe iz subjekta. Pojam subjekta i subjektivnosti proističe iz filozofije i preuzet je od strane nauka koje se bave psihologijom i psihopatologijom, te je bilo kakvo bavljenje tom temom nekompletno bez poznavanja bar dela filozofskog tumačenja. Subjekt (lat.

subiectum, grč. hypokeimenon)- predstavlja podmet, ono što je podmetnuto pod nešto, podloga, što leži ispod nečega. U filozofiji predstavlja nosioca stanja, svojstva i delovanja [2]. Noumenon predstavlja pojavu koja nije spoznatljiva čulima već samo umom za razliku od phaenomon što označava pojave koje se registruju čulima. Razvoj termina subjektivnost karakteriše njegova široka upotreba, što komplikuje jasno definisanje, tako su razni filozofi kroz istoriju koristili drugačiji termin misleći na istu stvar, ili obrnuto, koristeći isti termin podrazumevali drugačije značenje. Zvanično, smatra se da se od Dekarta subjekt odnosi na svesno znanje i svesno ja što je samo delimično tačno zbog razlike u poimanju subjekta odakle proizilazi pitanje- “na šta zapravo mislimo kada kažemo subjekt”? Rene Dekart (Rene Descartes, 1596-1650) je nauku i filozofiju smatrao kao delove jedne celine. U metafori “drveta znanja” koju Dekart koristi filozofija predstavlja koren, fizika stablo, a moral, medicina i mehanika grane tog drveta. Pitanje, koje možemo postaviti, gde je na tom drvetu izrasla psihoanaliza a kasnije i drugi psihoterapijski pravci? Iz same srži potrebe za spoznajom tj. iz korena filozofije (metafizike, metapsihologije) , iz intencije za lečenjem-medicine ili pak iz moralnosti kao potrebe za poboljšanjem i etičkim preispitivanjem? Granice je teško striktno odrediti i kao da moramo neminovno prihvatiti da je predmet bavljenja psihoterapije, koristeći dalje metaforu drveta “nakalemljen” na sve grane “drveta znanja”. Za Dekarta filozofija predstavlja “savršeno znanje” koje omogućuje upravljanje svojim životom i očuvanje zdravlja, kao i da bi se otkrio sve veštine [3]. Dakle, za Dekarta je subjektivnost svesna. Dekartov obrt u tretiranju subjekta

omogućava da se udubimo u suštinu života i njegov unutrašnji tok koji naziva “duree” [6]. Bergson smatra da intuicija predstavlja osvešćeni instikt, ili možemo reći da intuicija predstavlja psihološki reprezent instikta što je anticipacija Frojdovog shvatanja instikta kao graničnog fenomena između some i psihe. Po Bergsonu instikt je zarobljena životna energija i intuicija [7]. Intuitivnom spoznajom mi se povezujemo sa trajanjem kao “stvaralačkim vremenom”. Shvatanje vremena ovde se ne odnosi na hronološko već na kvalitativno, pa tim i subjektivno vreme. Na ovom mestu se otvara pitanje subjektivnog, unutrašnjeg ili psihološkog vremena. Intelektom shvatamo merljivohronološko a intuicijom subjektivnounutrašnje vreme. Bergson se ovim svrstava u iracionalizam, filozofski diskurs po kome se stvarnost ne može u potpunosti samo racionalno objasniti jer njeno osnovno načelo nije shvatljivo logičkim zakonima. Naučno saznanje se može primeniti na neorgansku materiju i fizičke predmete koji podležu merljivim zakonitostima i izražavanju mernim jedinicama [4]. Tu možemo iskoristiti komparaciju između zakonitosti njutnovske naspram kvantne i fizike relativiteta. Jedna ne isključuje drugu i paralelno funkcionišu različitim domenima realnosti. Česta poteškoća u promišljanju duševnog života je brkanje jedne i druge realnosti i isključivanje jednog aspekta. Najčešća greška je kada se principi fizičke realnosti pokušavaju transponovati na funkcionisanje unutrašnje realnosti. Unutrašnja realnost je dominanto prebojena subjektivnim pored percepcije spoljne stvarnosti fizičkih predmeta i pojava. Spoznaja unutrašnje realnosti je moguća samo putem druge realnosti, koja je samo delom objektivna, te se odnos više

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nastao je metodom sumnje u sva znanja koja nisu očigledna i jasna. Sumnja u očiglednost može ići tako daleko do toga da “čovek sanja u budnom stanju” [4]. Dekart ovde nehotično anticipira dnevno sanjarenje fantazije, fantazme i unutrašnji svet što će psihoanaliza formulisati oko 250. godina kasnije. Dekart je cilj da promoviše jasno racionalno znanje sažeo u jednoj od najpoznatijih sentenci zapadne filozofije “Cogito ergo sum” (Mislim, dakle jesam-postojim) čime je otvorio put za preispitivanje subjekta i subjektivnosti. Po Dekartu do opšte važećih istina se dolazi mišljenjem koje je oblik svesti koji je zajednički svim mislećim subjektima [5]. Istina ima objektivan smisao samo ako je potvrđena od strane racionalne subjektivnosti, subjektivne svesti [6]. Dalje, Dekart misli da je temelj saznanja u intuitivnoj svesti o sopstvenom postojanju. Dekartovo učenje o subjektu koje je promišljano u kontekstu ličnog, autobiografskog univerzuma i dotadašnjih znanja u filozofiji i nauci danas se može interpretirati u svetlu savremenosti. Psihoanaliza kao disciplina koja kako eksplicitno tako i implicitno problematizuje pitanje subjektivnosti može poslužiti kao pozicija za reinterpretiranje i repozicioniranje subjekta. Anri Bergson (Henri Bergson, 18591941) francuski filozof, nobelovac i protagonista intuicionizma bitno je doprineo razlikovanju vrsta saznanja. Za temu subjektivnosti je korisno Bergsonovo razlikovanje intuitivnog i naučnog saznanja [2]. Intuitivno je neposredno, unutrašnje saznanje suštine života koje prethodi intelektualnom i naučnom. To što intuicija prethodi intelektu, korespondira sa tim da je subjekt podmetnut kao temelj objekta koji se na njega naslanja i nadograđuje. Prema Bergsonu intuicija nam

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ne definiše kao odnos subjekta i objekta, već kao odnos dva subjekta iz čega proizilazi intersubjektivnost kao epifenomen. Pre Bergsona, Hegel odbacuje Dekartov dualizam i negira da ljudi moraju uvijek biti u sumnji da bi bili svesni, tj. da moraju neprestano biti u stanju osvešćenosti. Po njemu je za svest potrebno prisustvo drugog, a um postaje svestan tek kada se susreće sa drugim umom [2]. Edmund Huserl (Edmund Husserl, 1858-1938) je prvi koji je uveo koncept intersubjektivnosti u filozofiju. Po njemu svest je uvijek usmerena na drugoga ili opštije na živi svet [8]. Ego se može spoznati samo putem drugog ega ili alter-ega [4]. Svet i ego se međusobno konstituišu u intersubjektivnom fenomenološko-transcedentalnom matriksu. Po Martinu Hajdegeru (Martin Heidegger, 1889-1976) biće u svetu je biće sa i ka drugima a ne samo monada koja se prvo sama konstituiše pa tek ulazi u odnos sa svetom tj. drugima, što potencira sintagmom “biće-u-svetu”[7]. Glavni protagonist filozofije susreta i dijaloga je zasigurno Martin Buber koji formuliše pojam “između” kojim potencira prostor u kojem se događa susret iz kojeg proističu oba protagonist susreta (nem. Ich und Du, engl. I and thou). Buber je preteča svih humanističkih pravaca sa svojim vrednovanjem odnosa sa drugim kao smisla postojanja. Ludvig Binsvanger (Ludwig Biswanger, 18811966) je značajna figura za integraciju psihoterapije i filozofije, on nikada nije bio potpuni pristalica psihoanalize ali je sa Frojdom gajio obostrano poštovanje o čemu svedoči i njihova korespodencija, što dobija na važnosti kada se uzme u obzir da je to bilo vreme velikih šizmi u psihoanalizi i nepomirljivog udaljavanja njenih začetnika. Binsvanger zamera ondašnjoj psihoanalizi da čoveka posmatra

kao “homo natura” a da se on zapravo može shvatiti samo kao subjekt u svom individualnom kontekstu i sa svojim projekcijama sveta. Po njemu “kancer svih psihologija” je rascep između subjekta i objekta a egzistencija se formira u relaciji-u prostoru intersubjektivnog. Dualnost za Bisvangera ima primat u konstituisanju i predstavlja ontološku osnovu socijalnom, čime otvara vrata kasnijim socijalno orijentisanim i intersubjektivističkim pravcima u psihijatriji. Karl Jaspers (Karl Jaspers, 1883-1969) predlaže “ulaženje” u unutrašnji svet pacijenta što znači odustajanje od striktnih granica i apsulutne neutralnosti u odnosu sa pacijentom.

SUBJEKTIVNOST U PSIHOANALIZI Termin subjektivnost se ne sreće eksplicitno u Frojdovom rečniku, međutim svojim ukazivanjem na individualno značenje nesvesnih elemenata i simptoma Frojd otvara put za formulisanje “unutrašnjeg sveta” i “unutrašnje realnosti”. Promena paradigme koju unosi psihoanaliza u odnosu na dominantnu psihijatrijsku doktrinu tog doba leži u tome da psihoapatološki fenomeni imaju simbolično značenje i da nisu puke nuspojave obolelog mozga, te da imaju svoje individualno značenje i da su najvećim djelom nastali u kontekstu ličnog razvoja. “Fantazije poseduju psihičku realnost koja se suprostavlja materijalnoj stvarnosti, te smo postepeno spoznali da je u svetu neuroze psihička stvarnost odlučujuća” (S. Freud, 1917). Po Melceru (Meltzer) je Melani Klajn (Melani Klein): “.. došla do otkrića koja su revolucionarno dopunila teoriju uma činjenicom da mi ne živimo u jednom, već u dva sveta - u unutrašnjem,

mehanizama koja omogućuje subjektivni doživljaj drugog putem nesvesne komunikacije. Projektivna identifikacija može biti glavni medijum psihopatologije subjektivnosti ali i važno terapijsko sredstvo. Projekcijom svojih unutrašnjih sadržaja objekt postaje više poligon subjektovih fantazija nego što je objekt per se. Projekcije mogu biti na kontinuma od suptilnih, preko onih umerenog intenziteta i sadržaja pa do patoloških oblika sa idealizujućom, obezvređujućom, agresivnom, seksualnom te persekutornom komponentom. Kod psihotičnih struktura kao da postoji zamagljivanje granica koje može dosezati do nerazlikovanja selfa i drugog usled masovnih projekcija. “Ova skupina unutrašnjih imaga, koji su fantazmatski izmenjeni realni objekti, na osnovu kojih se te fantazije formiraju, bivaju instalirane ne samo u spoljašnji svet, već se inkorporišu u ego”. (Klein, 1935) [12]. Projektivna identifikacija je nesvesni mehanizam komunikacije koji je najvećim dijelom subjektivan. Projektivna identifikacija može biti sredstvo dobrog sporazumijevanja i izvor nesporazumima i konačno poprimiti svoju patološku formu. Patološka projektivna identifikacija je sastavni deo psihoterapije te prepoznavanje ovakvih elemenata i pokušaj da se oni iskoriste za dobrobit pacijenta može biti od velike koristi. Vilfred Bion (Wilfred Bion, 1897 –1979) sa svojom sintagmom ulaska u terapijski odnos “bez želje i sećanja” govori o oslobađanju od ličnog-objektivnog da bi se terapeut oslobodio za što autentičniji doživljaj pacijentove subjektivnosti. Bion minimizuje terapeutovu “objektivnost” zarad portage za pacijentovom subjektivnošću. Bion uvodi termin “reverie” (sanjarenje, maštanje, snatrenje) pod kojim podrazumeva stanje uma smirene receptivnosti objekta i pre-

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koji isto tako stvaran kao i spoljašnji svet. Psihička realnost se mogla od tada tretirati kao konkretno postojeća” [9]. Unutrašnja realnost se po Klajn temelji na realnosti unutrašnjih objekata koji su opet složeni precipitati iskustva nastali iz odnosa sa bitnim drugima počevši od primarnog objekta pa na dalje. Pacijentov unutrašnji svijet je kompleksna tvorevina introjekcija, sećanja, ideja, fantazija. Frojd je pod introjekcijom smatrao proces pounutrenja objekta u ego, tako spoljašnje postaje sastavni dio unutrašnjeg sveta. Ta internalizacija nije puko “unošenje” gotovog objekta već je podložno unutrašnjem radu emotivnog i fantazmatskog preoblikovanja. Klajn je smatrala da je unutrašnji svet ili “unutrašnje društvo” skup mnoštva unutrašnjih objekata koji služe kao podloge za identifikaciju. MekDugal (Mc Dougall) za unutrašnji svet koristi slikovitu metaforu “pozornica uma” čime naglašava slojevitost i složenost unutrašnje realnosti koja je naseljena sa više unutrašnjih objekata i reprezenata [10]. Razumevanje unutrašnjeg sveta pa time i subjektivnosti nije potpuno bez fantazija koje predstavljaju osnovu gotovo svih mentalnih procesa. Fantazije predstavljaju kompromisne mentalne formacije nastale u interakciji između somatskih potreba, libidinalnih i agresivnih dinamizama i odbrana od nagonskih impulsa [11]. Dobar deo terapijskog delovanja u psihoanalizi se odnosi na pretvaranje nesvesnih fantazija u osvešćene misli. Projektivna identifikacija predstavlja nesvesnu fantaziju kojom se delovi unutrašnje realnosti izbacuju u spoljašnju realnost tj. spoljašnji objekt [11]. Projektovani sadržaji mogu biti dobri, loši i proganjajući. U kontekstu subjektivnosti projektivna identifikacija se može shvatiti kao jedan od dominantnih

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uzimanje subjektivnih osećanja i davanje značenja tim istim osećanjima [11]. Znači, stanje uma otvorenosti i prijemčivosti za subjektivnost. Takođe Bionov pojam koji se nadovezuje na reverie je “container-contained” (sadržavaoc-sadržaj) koji predstavlja mentalni prostor (container) koji je dovoljno širok i ima kapacitet za prijem, izdržavanje i obradu projekcija, osećanja, somatskih poruka (contained) [10]. Ukoliko container ima dovoljno dobar kapacitet komunikacija je dvosmerna i rezultira razumevanjem, a ukoliko container zakaže dolazi do masovnih projektivnih identifikacija koje žele silom da prodru u neresponsivni objekt. Prevedno na jezik subjektivnosti, ukoliko intersubjektivna razmjena nije zadovoljavajuća javlja se osećanje besa i izolovanosti što se često sreće u svakodnevnom životu i u psihoterapiji. Istraživanja razvoja djeteta i centralnog nervnog sistema (CNS) su pokazala da se razvojni miljokazi postižu u procesu obostrane regulacije i relacije. Za razvoj kapaciteta za mentalizaciju neophodno je ogledanje u primarnom objektu. Na osnove ranih neurorazvojnih postignuća nadograđuju se zreliji oblici komunikacije što je Donald Vinikot (Donald Winnicot) anticipirao pedesetak godina ranije od savremenih neuronaučnih saznanja [12]. Vinikot je pojam subjektivnosti često koristio i ugradio u temelje svoje teorije i koncepte, pomenućemo samo neke. Vinikot prati razvoj deteta kroz sudbinu razvoja subjektivnosti. On čini pomak sa dotadašnje dijade “subjekt-objekt” u kojoj otpočinje razvoj ljudskog bića time što mijenja objekt u “subjektivni objekt” [13]. “Subjektivni objekt” predstavlja subjektivno iskustvo objekta (drugog) od strane bebe čime želi da naglasi razliku između percepcije i doživljaja deteta. U

ovoj fazi majka koja je “subjektivni objekt” nalazi se u stanju “primarne materinske preokupacije” čime podstiče iluziju omnipotencije da svojim željama upravlja objektom. Subjektivnošću prebojen objekt pripada fazi kada još ne postoji kapacitet bebe za distinkciju “ja” i “ne-ja”. “Subjektivni objekt” biva postepeno zamenjen odnosom sa objektima koji su objektivno percipirani [13]. Preživljavanje objekta je neophodno za bebu kao i za pacijenta u cilju pomaka od iluzije omnipotentne kontrole objekta (terapeuta). Međutim, “subjektivni-objekt” ne isčezava u potpunosti već funkcioniše na drugom nivou i predstavlja osnovu kapaciteta za unutrašnji život, kreativnost i igru. Između “subjektivnog objekta” i objekta otvara se potencijalni prostor u kom se razvija kapacitet za igru koji je i preduslov kreativnog življenja. Subjektivnost pripada maternalnom, dok ulazak u zakon i granice predstavlja paternalni edipalni raskid sa predeipalnim i simbiotskim. Subjektivnost kao precipitat preverbalnog i femininog čini osnovu empatije, neverbalne, nesvesne komunikacije, somato-psihičkog, kreativnosti. Objektivnost, zakon, spoljna stvarnost pripadaju paternalnom. Kod subjektivnog osiromašenja možemo govoriti i o patologiji subjektivnosti. Subjektivnost kod funkcionalne, “relativno zdrave” osobe funkcioniše unutar koordinata zakona i granica spoljašnje realnosti. Unutrašnja fluidnost, kapacitet za imaginaciju, kreativnost, igru, humor i prokreaciju u biološkom i psihološkom smislu počivaju na “dovoljno dobro” integrisanoj subjektivnosti u objektivnoj stvarnosti. Kristofer Bolas (Christofer Bollas, 1943) uvodi termin normatičnost pod kojim podrazumeva: “..osobe koje su abnormalno-normalne sa ciljem da desubjekti-

INTERSUBJEKTIVNOST Poslednje dve dekade skoro svi psihoanalitički pravci su se posvetili pozicioniranju u odnosu na intersubjektivnosti. Postoje neslaganja oko definisanja, uloge, obimnosti, funkcije, štetnosti intersubjektivističkog pristupa. Subjektivnost analitičara kao sredstvo razumevanja sastavni je deo kontratratransfera. Mit o neutralnom, distanciranom analitičaru je poodavno napušten. Ovaj koncept vuče svoje korene iz Salivanove (Sullivan) interpersonalne psihoanalize. Karakterisanje intersubjektivnosti se kreće od ekstremnih stajališta da je ona opasna po sam psihoanalitički metod pa do drugih krajnosti da je intersubjektivna relacija ne samo neophodna i korisna već da je objek-

tivna spoznaja pacijentove realnosti nemoguća. Većina psihoanalitičara traži svoju intersubjektivnost negdje na kontinumu između krajnosti. Svaki pojedinačni međuljuski odnos je neponovljiv, ali ima i opšte karakteriste koje deli sa drugim odnosima. Odnos ima svoju pojavnu, telesnu, ponašajnu, optičku i psihološku komponentu unutar koje podrazumevamo kognitivnu, verbalnu, afektivnu, te fiziološku dimenziju. Ima svesnu i nesvesnu stranu, jezikom kognicije-implicitnu i eksplicitnu, verbalnu i neverbalnu. Sve ove kompnente su komunikativne, pa čak i onda kada im to nije namera, zapravo svaka nekomunikativna intencija je bremenita komunikativnošću. U totalitetu odnosa svih pobrojanih komponenti, ali i onih neverbalizovnih, javlja se ono što nazivamo subjektivna dimenzija odnosa. Subjektivni doživljaj druge osobe je složen univerzum koji je samo delimično svestan i podložan verbalizaciji i definiciji. Taj deo koji nazivamo subjektivni, daje punoću i celovitost susretu. Dve individualne psihološke realnosti susrećući se tvore novu realnost koja je više od svake pojedinačne. Što je blisko definiciji geštalta, egzistencijalnog susreta, analitičkog trećeg. Tomas Ogden (Thomas Ogden) uvodi pojam „analitičko treće“ što predstavlja tvorevinu susreta analitičkog para i intersubjektivnu stvarnost koja je više nego što to čine njeni konstitutivni elementi [15]. Iskustvo „analitičkog trećeg“ označava i kapacitet za intimnost para koji ga konstituiše. Iskustvo „analitičkog trećeg“ je novo iskustvo i otvara mogućnost psihološkog rasta i promene. Medlin i Vili Barndžer (Madeleine & Willy Baranger) i Antonino Fero (Antonino Ferro) su protagonisti intersubjektivnosti formulisane kroz „dinamičko polje“ koje predstavlja skup si-

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vizuju self i budu stvar-objekt” i koje kao da sabotiraju mogućnost uživanja u subjektivnosti [14]. Zadatak terapeuta bi bio da pomogne pacijentu u pronalaženju i izgradnji subjektivnosti. Pronalaženje zadovoljstva u subjektivnom je preduslov da se pacijent “oseća dobro u svojoj koži”. Terapija se može opisati kao dinamika između subjektivizacije i desubjektivizacije. Tako na primjer kod opsesivnih, somatizujućih, aleksitimičnih struktura srećemo neku vrstu “atrofije subjektivnosti”, kada se komunikacija odvija preko simptoma i tela, tj. preko tela kao objekta. Sa druge strane psihotičnost se može opisati i kao “metastaza subjektivnosti” sa gubitkom granica i odsustva koherentnosti naspram spoljne stvarnosti. Unutrašnji subjektivni svet preplavljuje deo ega koji percipira realnost, socijalna adaptacija zakazuje a komunikacija biva preplavljena subjektivnim koje ne može da se uvede u polje logičkog.

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la koje ga konstituišu [16]. Akteri dinamičkog polja shvataju se u kontekstu polja i nesvesnih fantazija koje ga sačinjavaju. Subjekti polja nisu u prvom planu proučavanja već polje koje oni sačinjavaju. Antonino Fero je razvio svoju verziju dinamičkog polja u vidu „bi-personalnog polja“ i „analitičkog polja“ koje čini uvek više nego njegovi činioci [17]. Fero potkrepljuje svoju teoriju analitičkog polja i tehničkom specifičnošću da se rad ne mora uvek odvijati u „sada i ovde“ i transfernim interpretacijama. Polje ima kontekst vremena i prostora i svoju protežitost u svim smerovima prostorno-vremenskog kontinuma. Sve teorije polja zasnivaju se na nekoj vrsti intersubjektivnog matriksa koji nazivam „intersubjekt“. S obzirom da se objekt temelji na subjektu, a subjektivnost proističe iz subjekta, tako intersubjektivnost mora proisticati iz nečega što definišemo ovom prilikom kao intersubjekt. Intersubjekt je tvorevina susreta dva subjekta iz koje proističu njihove subjektivnosti. Ovaj termin nadopunjuje nedostajuću kariku u terminologiji subjektivnosti i otvara prostor za dalja teoretska razmatranja.

SUBJEKTIVNOST U PSIHIJATRIJI Subjektivni doživljaj ili iskustvo u psihijatriji važan za razumevanje i istraživanje stigme, kvaliteta života, psihofarmako-komplijanse, odnosa pacijent-terapeut, adaptacije, empatije, ispitivanja mentalnog statusa, doživljaja simptoma... U savremenoj psihijatriji poslednja decenija je označila potrebu za integrativnim tzv. bio-psiho-socijalnim pristupom. Ta potreba je proistekla iz više faktora. Prvi je, između ostalog, kriza „monoaminske paradigme“ kao pretpostavke uzroka velikih psihijatrijskih poremećaja. „Monoa-

minska paradigma“ je trasirala i pravac razvoja psihofarmaka i time formirala osnovne granice psihijatrije sa većim ili manjim odstupanjima. Razvijanje i usložnjavanje klasifikacionih sistema vršeno je s težnjom povećanja pouzdanosti i dijagnostičko-terapijske usklađenosti. Međutim, iz činjenice da i najdiferenciraniji klasifikacioni sistemi ne mogu obuhvatiti svu složenost psihičkog života proistekla je potreba za proučavanjem fenomena subjektivnosti. Kompleksnost psihopatoloških ispoljavanja, interakcije psihološkog, biološkog, socijalnog, porodičnog upućuju na važnost subjektivnog doživljaja pacijenta. Iz činjenice da psihijatrija zasnovana isključivo na testovima i statističkoj kvantifikaciji simptoma ne uzima u obzir pacijentovu individualnost, kontekst, relacije i svu složenost koja se sabira u subjektivnosti i koja može samo biti sagledana i doživljena u individualnom kontaktu. Izdvajaju tri osnovna pristupa u dijagnostifikovanju i sagledavanju psihičkog oboljenja: 1) pozitivistički, objektivistički-fokusiran na observabilne bihejvioralne manifestacije; 2) fenomenološki-orijentisan na subjekt i pacijentov svijesni doživljaj svojih tegoba, 3) hermeneutički-intersubjektivni pristup koji teži ka uzajamnoj konstrukciji narativa ispitivača i pacijenta, u obzir se uzimaju bitni odnosi, konflikti itd. [18]. Pozitivistički model pristupa ispitivanju počiva na težnji približavanja medicinske i psihopatološke deskripcije i kauzalnog povezivanja sa moždanim poremećajima. Uveden je od DSM-III klasifikacije na osnovu Hampel-Oppenheim sheme i ima za cilj operacionalizaciju dijagnostičkih kriterijuma. Ovaj pristup zanemaruje subjektivni doživljaj pacijenta, ispitivača ili terapeuta i teži da ga svede na minimum. Prednosti ovog pristupa su

nja i interpretacija se sažima u novi narativ koji bi mogao biti pomak u odnosu na prethodni, a koji se u ovom slučaju odnosi na psihopatološki fenomen. U odnosu na pozitivistički model koji poremećaj shvata jednosmerno od poremećene funkcije mozga ka simptomu koji se manifestuje u okolini, hermeneutički model koristi bidirekcioni model. Promene u okolini utiču na funkcije mozga i obratno. Psihodinamski model kao deo hermeneutičkog modela teži razumevanju kompleksnih interakcija između svesnih i nesvesnih procesa koji rezultiraju psihičkim oboljenjem i patnjom. Tako „Operacionalizovani psihodinamski dijagnostički sistem“ počiva na četiri glavne ose: 1. doživljaj bolesti i preduslovi tretmana, 2. subjektivni stepen patnje, individualni model bolesti, sekundarna dobit, motivacija za lečenjem, koping kapaciteti, socijalna podrška. Karakteristični obrasci odnosa pacijenta, sagledani iz perspektive pacijenta i terapeuta, 3. centralni intra- i interpersonalni konflikti koji se ponavljaju u više sfera života (porodica,vezivanje, posao, prijateljstvo), 4. struktura ličnosti, kapacitet za refleksiju, mentalizaciju, odbrane, koping stil, atačment, integrisanost itd.. Studije su pokazale zadovoljavajuću pouzdanost i korisnost ovog instrumenta za istraživačke i praktične kliničke svrhe. Na osnovu slične operacionalizacije nastao je i „ PDM-Psihodinamski dijagnostički priručnik“- Grupe Američkih psihoanalitičkih asocijacija“ [20]. U PDMpriručniku se u dijagnostifikovanju mentalnih poremećaja pored P-ose koja označava personalne obrasce i poremećaje, M-ose mentalnog funkcionisanja, uključuje i S-osa koja se koristi za označavanje specifičnosti obrazaca simptoma i subjektivnog iskustva. Individualnu subjek-

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eksperimentalna primenjivost, brzina i jednostavnost upotrebe a mane su zanemarivanje subjektivnog doživljaja, suptilnih psihičkih promena, užeg i šireg socijalnog konteksta. Dalja kritike se odnose na činjenicu da se operacionalizacijom psihopatologije zatvara put daljeg produbljivanja znanja o složenim ispoljavanjima psihičkih poremećaja, da mali broj pacijenata koji se sreće u kliničkoj praksi ispunjava operacionalizovane kriterijume a da veći broj „stoji između“ demarkacionih linija dijagnostičkih entiteta. Fenomenološki modus se zasniva na empatskom razumevanju, opisivanju i analiziranju pacijentovog subjektivnog iskustva [18]. Jaspers je koristio termin „intuitivne reprezentacije“ psihičkog statusa pacijenta putem unutrašnje elaboracije i imaginativne aktualizacije. Simptomi poremećaja nisu observirani izolovano već u kontekstu subjekta i njegovog doživljaja svojih iskustava i sveta koji ga okružuje. Jaspers se ograničavao na svesno iskustvo doživljaja pacijenta dok savremeniji fenomenološki pravci u polje interesa ukuljučuju i sublimalna, zbunjujuća iskustva, relacije, situacione elemente i sve ono što može predhoditi pacijentovom svesnom iskustvu i biti predmet deskripcije subjektivnog doživljaja. Hermeneutički model se zasniva na primatu relacije i analiziranju pacijentovih odnosa u socijalnom miljeu te stavljanja odnosa terapeut-pacijent u prvi plan. Shvatanje psihopatologije je moguće samo kroz interakciju [19]. Pretpostavka ovog pristupa je da nije moguće izolovati objekt ispitivanja od subjektivnih i intersubjektivnih elemenata. Kao osnova intersubjektivnog odnosa uzima se zajednička realnost koja se stvara u zajedničkoj konstrukciji i čitanju teksta, u ovom slučaju narativa pacijenta. Susret znače-

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tivnost PDM označava kao skup afektivnih obrazaca, mentalnih sadržaja, pratećih somatskih stanja i realcionih obrazaca. Kao primjer se tako navodi da isto oboljenje po zvaničnim klasifikacionim kriterijumima ima drugačiji subjektivni karakter za osobe koje se razlikuju po godinama starosti, socijalnom statusu, socijalnoj podršci, razvojnim iskustvima te iz toga proizilazi da terapija mora biti prilagođena spoljašnjem i unutrašnjem kontekstu pacijenta. Tako da uzimanje u obzir subjektivnog doživljaja ima i svoje praktične implikacije. Na osnovu navedenih nedostataka i prednosti navedenih modusa ispitivanja postoje predlozi da predstojeća Medjunarodna klasifikacija bolesti (MKB-11) uključi i neke aspekte fenomenološkog i hermeneutičkog modela. Subjektivnost i intersubjektivnost predstavljaju sastavni dio psihijatrijskog ispitivanja i klasifikacije te kao jedan važan aspekt realnosti psihičkog funkcionisanja ne bi smeli biti zanemarivani. Predlozi počivaju na potrebi integracije kvalitativnih elemenata u kvantifikacioni pristup psihičkim poremećajima [20]. Ovi predlozi korespondiraju sa mišljenjem fizičara i nobelovca Vernera Heisenberga (Werner Heisenberg, 1901-1976) koji piše: „Naučni metod analiziranja, tumačenja i klasifikacije se suočio sa ograničenjima koja se zasnivaju na činjenici da nauka sa svojim intervencijama menja i utiče na objekat istraživanja” [21].

ZAKLJUČAK Pregledom razvoja pojma subjektivnosti od filozofije preko psihoanalize do psihijatrije stiče se uvid u složenost ovog fenomena i njegovu široku zastupljenost. Integracijom znanja dobija se celovitiji uvid i mogućnost tačnijeg određenja i primene. Mogli bi smo reći da je subjektivnost ono od čega je nauka od pozitivističkog obrta htjela pobeći. Posmatrač je odvojen i van fenomena-eksperimenta koji posmatra, meri i objašnjava što je samo delimično istinito. Samo objašnjavanje traži interpretaciju i umetanje posmatrača između fenomena i tumačenja. Gde imamo posmatrača imamo i subjektivnost. S obzirom da subjektivnost podrazumeva i deo koji nije moguće verbalizovati već se tiče kompleksnog individualnog unutrašnjeg doživljaja uglavnom je previđan i odbacivan kao nenaučan. Učenje filozofa H. Bergsona o dualitetu spoznaje nudi mogućnost pomirenja dva aspekata psihičke realnosti koja su uglavnom bila međusobno isključivana. Jedan modus spoznaje koristi se za materijalnu realnost (spoljni, fizički, društveni, ekonomski) a drugi za spoznaju unutrašnje, subjektivne humane realnosti. Uključivanjem subjektivnog doživljaja u razne praktične i teoretske aspekte psihijatrijskog djelovanja ne isključuje se pozitivistička komponenta, naprotiv ona se nadopunjuje i obogaćuje. Reintegracija subjektivne perspektive utiče na proširenje polja razumevanja kompleksnosti psihičkog života i psihopatologije.

Srđa Zlopaša

Clinic for Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia

Summary Subjectivity is a term that is implicitly present in almost all aspects of psychiatric and psychotherapeutic areas of interest. It is a commonly neglected term. In the last decade we witnessed a growing interest for subjectivity. Psychology and psychopathology sciences use the terms subject and subjectivity which originated from philosophy. Decart made a turn over in understanding the subject by methodological suspicion of all knowledge that is obvious. Internal reality is highly subjective in spite of the existing outer reality. Because subjectivity is partially a non-verbal fact, it was commonly neglected by official science. The teachings of the French philosopher Henry Bergson could be useful in understanding the dual models of reality, perception, internal and external. Recognition of internal reality is possible only through meeting with other’s internal reality. It is a basis of intersubjectivity which could be traced through the history of philosophy and psychoanalysis. Freud never used term subjective, but he understood symptoms as a highly individual fact that arouse in internal reality. Introducing the term “intersubject” we complete the missing link in the spectrum of “intersubjective terminology”. With the reintegration of the subjective perspective we could broaden our understanding of the complex phaenomena of psychic life and psychoapatology. Key words: Subjectivity, intersubjectivity, psychoanalysis, philosophy

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SUBJECTIVITY IN PSYCHOANALYSIS AND PSYCHIATRY

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Literatura:

1. Trebješanin Z. Rečnik psihologije, Stubovi kulture, Beograd, 2000. 2. Blackburn S. The Oxford Dictionary of Philosophy Oxford: Oxford University Press 2008. 3. Sorell T. Descartes: A Very Short Introduction. Oxford University Press 2005. 4. Rasel.B. Istorija zapadne filozofije. Narodna knjiga. Beograd. 2000. 5. Descartes R Discourse on Method and Meditations on First Philosophy, 4th Ed. Hacket Publishing Company, Inc. 1998. 6. Savić M, Cvetković V, Cekić N. Filozofija. Zavod za udžbenike i nastavna sredstva Republike Srbije, Beograd 2001. 7. Herš Ž. Istorija filozofije. Svetovi. Novi Sad. 1998. 8. Kuper D. Svetska filozofija. Svetovi. Novi Sad. 2004. 9. Hinshelwood DR. A Dictionary of Kleinian Thought. Free Association Books; Updated edition 1998. 10. Mc Dougall J. Theaters of the mind. Basic Books 1986. 11. Spillius B E et all. New Dictionary of Kleinian Thought. Routlege. East Sussex. 2011. 12. Zlopaša S. Između igre i destrukcije Donald Vinikot. Engrami. 2007, vol. 29, iss. 34, pp. 65-70 13. Abram J. The Language of Winnicott: A Dictionary of Winnicott’s Use of Words. Karnac Books. London. 2007. 14. Bollas C. The Shadow of the Object: Psychoanalysis of the Unthought Known.Columbia University Press, New York. 1989.

15. Ogden T. Subject of Analysis. Karnac Books. London. 1994. 16. Baranger M. The analytic situation as a dynamic field. The International Journal of Psychoanalysis.Volume 89, Issue 4, pages 795–826, August 2008 17. Ferro A. The Analytic Field: A Clinical Concept. Karnac Books. London. 2009. 18. Fuchs T. Psychopatology 2010; 43:268274 19. PDM Task Force. “Introduction”. Alliance of Psychoanalytic Organizations. 2006. 20. Yakeley J et all. Psychiatry, subjectivity and emotion - deepening the medical model. Psychiatr Bull (2014). 2014 Jun;38(3):97101. 21. Heisenberg W. The Physicist’s Conception of Nature. London: Hutchinson. 1958.

Srđa Zlopaša Klinika za psihijatriju, Klinički centar Srbije Pasterova 2 11000 Beograd, Srbija E-mail: zlopasasrdja@hotmail.com

Svetlana Jovanović1 Srđan Milovanović2,3 Jelena Mandić1 Siniša Jovović4 UDK: 613.9

Stomatološki fakultet, Univerzitet u Beogradu, Beograd, Srbija

Medicinski fakultet, Univerzitet u Beogradu, Beograd, Srbija

Klinika za psihijatriju, Klinički centar Srbije, Beograd, Srbija

Zdravstveni centar „Marinko Marin“, Loznica, Srbija

Kratak sadržaj Zdravstveni sistem predstavlja jedan od najsloženijih sistema u bilo kojoj državi. Svaka država ima obavezu da vodi računa i brine o zdravstvenom stanju svog stanovništva. Sistem zdravstvene zaštite obuhvata zdravstvenu infrastrukturu koja obezbeđuje spektar programa i usluga i pruža zdravstvenu zaštitu pojedincima, porodicama i zajednici. Zdravstveni sistem mora da osigura fizički, geografski i ekonomski dostupnu i pristupačnu, integrisanu i kvalitetnu zdravstvenu zaštitu. Takođe, treba da obezbedi razvoj zdravstvenih kadrova, održivost finansiranja, decentralizaciju upravljanja i finansiranja zdravstvene zaštite i postavljanje građanina u centar zdravstvenog sistema. Svrha sistema zdravstvene zaštite je očuvanje i unapređenje zdravlja ljudi obezbeđivanjem zdravstvenih usluga stanovništvu kako moderne, tako i tradicionalne medicine na efikasan način, a koje su u isto vreme dostupne i prihvatljive ljudima. S obzirom na njegov značaj i uticaj na zdravstveno stanje stanovništva svake države, kao i zbog velikog ekonomskog uticaja, država sprovodi niz mera u planiranju i upravljanju zdravstvenim sistemom kako bi obezbedila stabilno finansiranje i racionalan i kvalitetan sistem pružanja zdravstvene zaštite, a sve to u cilju da se u okviru raspoloživih sredstava stanovništvu obezbedi osnovna zdravstvena zaštita. U svim zemljama je zbog starenja stanovništva i uvođenja novih i skupih tehnologija prisutno stalno povećanje troškova pružanja zdravstvene zaštite. Savremeni sistemi zdravstvene zaštite razlikuju se međusobno najviše u metodama prikupljanja sredstava za zdravstvenu zaštitu, kao i u načinima plaćanja davaoca usluga u zdravstvu. Problemi sistema zdravstvene zaštite retko, ili nikada, ne mogu se rešiti zauvek. Kako se zemlje razvijaju, tako i njihovi sistemi zdravstvene zaštite moraju da odgovore na nove izazove. Ključne reči: sistem, zdravstvena zaštita, modeli, finansiranje

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Pod sistemom podrazumevamo skup međusobno povezanih elemenata koji zajedno dovode do dostizanja ciljeva u sredini u kojoj sistem egzistira. Sistem obuhvata ukupnost ili kompleksnost elemenata ili pojedinačnih delova. Osnovne karakteristike društvenih sistema jesu da su oni dinamički (u stalnom kretanju), složeni (po strukturi) i hijerarhijski (po organizaciji) uglasta zagrada [1,2]. Zdravstveni sistem predstavlja jedan od najsloženijih sistema u bilo kojoj državi. Prema definiciji Svetske zdravstvene organizacije sistem zdravstvene zaštite obuhvata zdravstvenu infrastrukturu koja obezbeđuje spektar programa i usluga i pruža zdravstvenu zaštitu pojedincima, porodicama i zajednici [3]. Zdravstveni sistem mora da osigura fizički, geografski i ekonomski dostupnu i pristupačnu, integrisanu (vertikalnu povezanost primarnog, sekundarnog, tercijarnog nivoa i horizontalnu povezanost u sistemu i u odnosu na lokalnu zajednicu) i kvalitetnu zdravstvenu zaštitu (stalno unapređenje kvaliteta zdravstvene zaštite i pravo korisnika na izbor lekara i informisanost), razvoj zdravstvenih kadrova, održivost finansiranja, decentralizaciju upravljanja i finansiranja zdravstvene zaštite i postavljanje građanina u centar sistema zdravstvene zaštite [4]. Svrha sistema zdravstvene zaštite je očuvanje i unapređenje zdravlja ljudi obezbeđivanjem zdravstvenih usluga stanovništvu kako moderne, tako i tradicionalne medicine na efikasan način, a koje su u isto vreme dostupne i prihvatljive ljudima [5]. Sistemi zdravstvene zaštite su pod jakim uticajem važećih normi i vrednosti u društvu, često reflektuju socijalna i kulturalna očekivanja građana i pod uti-

cajem su jedinstvene nacionalne istorije, tradicije i političkog sistema S obzirom na njegov značaj i uticaj na zdravstveno stanje stanovništva svake države, kao i zbog velikog ekonomskog uticaja, država sprovodi niz mera u planiranju i upravljanju zdravstvenim sistemom kako bi obezbedila stabilno finansiranje i racionalan i kvalitetan sistem pružanja zdravstvene zaštite, a sve to u cilju da se u okviru raspoloživih sredstava stanovništvu obezbedi osnovna zdravstvena zaštita. U svim zemljama je zbog starenja stanovništva i uvođenja novih i skupih tehnologija prisutno stalno povećanje troškova pružanja zdravstvene zaštite. Sistem zdravstvene zaštite uključuje pored državnog sektora i privatni sektor zdravstva. Oba sektora treba da funkcionišu sinhrono, po istim etičkim, stručnim i ekonomskim principima. U cilju što većeg ujednačavanja funkcionisanja oba sektora, zasnovanih na pomenutim principima, potrebno je da se unapredi međusobna saradnja i uspostavi veće poverenje. Svaka država ima obavezu da vodi računa i brine o zdravstvenom stanju svog stanovništva. U sprovođenju zdravstvene politike zemlje veoma značajnu ulogu imaju i lekari. Postoji danas najmanje pet različitih aspekata moralne odgovornosti lekara u kreiranju i sprovođenju zdravstvene politike: 1. Prva odgovornost lekara mora biti da poštuje poverenje koje mu je dato tom ulogom i da se rukovodi interesima pacijenta. Ako bi ova tradicija poverenja bila izneverena onda bi i medicinska etika morala radikalno da se menja. 2. Kao tehnički ekspert, lekar obezbeđuje tačnu i pouzdanu informaciju onima koji kreiraju zdravstvenu politiku. Na

tet zdravstvenih usluga), sloboda izbora za korisnike zdravstvenih usluga i autonomija za davaoce zdravstvenih usluga [7,9]. Komponente svakog sistema zdravstvene zaštite čine resursi, organizacija i administriranje, menadžment, finansiranje i obezbeđivanje i pružanje zdravstvene zaštite. Resursi u sistemu zdravstvene zaštite obuhvataju ljudske resurse (kadrove), zdravstvene ustanove (zgrade i oprema) i sredstva (lekovi i sanitetski materijal). Ljudski resursi u zdravstvenom sistemu osnovna su njegova odrednica, i to u svim oblastima (promocija, prevencija i lečenje). Istovremeno, ljudski resursi predstavljaju najveći i najvredniji resurs zdravstvenog sistema, koji treba stalno razvijati.

FINANSIRANJE SISTEMA ZDRAVSTVENA ZAŠTITE Savremeni sistemi zdravstvene zaštite razlikuju se međusobno najviše u metodama prikupljanja sredstava za zdravstvenu zaštitu, kao i u načinima plaćanja davaoca usluga u zdravstvu. Troškovi za zdravstvenu zaštitu se razlikuju od zemlje do zemlje u zavisnosti od njene razvijenosti. Mere se po izdavanju materijalnih sredstava za zdravstvo po glavi (per capita) stanovnika ili prema procentu od ukupnog nacionalnog dohotka. Izvori finansiranja sistema zdravstvene zaštite su: državni budžet – opšti i specifični porezi, fond osiguranja - obavezno zdravstveno osiguranje (doprinosi), dobrovoljno/privatno osiguranje (premije osiguranja), participacija (lično učešće zdravstvenog osiguranika u troškovima korišćenja zdravstvene službe), puna cena usluge (privatna praksa) i donacije i

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ovaj način lekari participiraju u donošenju odluka od značaja za organizaciju zdravstvene službe i distribuciju zdravstvenog dinara. 3. Kao i svaki drugi građanin i lekar ima obavezu da radi u korist pravde i društvenog interesa. 4. Neki smatraju da je uslov za efikasnu zdravstvenu zaštitu, ograničenje opcija i samostalnosti izbora koje lekar uživa u svom svakodnevnom radu. Prema ovom viđenju, lekar je činovnik društvene zajednice i ekonomske prilike te mora voditi računa prema brižljivo propisanim i zakonom regulisanim pravilima. Tako opisani stav predominira u centralno planiranim ekonomijama ali sve više i u ekonomijama sa slobodnim tržištem, što je posledica nužnosti da se obuzdaju medicinski troškovi. Na ovaj način želja pacijenta i stručna procena njegovog lekara bivaju primerene socioekonomskim zahtevima. 5. Uz sve navedene uloge lekar je svakako i to primarno moralno odgovorna ličnost. U društvenim sistemima koje karakteriše moralni pluralizam mnogi konflikti mogu da proisteknu iz ovih složenih okolnosti [6]. Država je dužna da obezbedi zdravstvenu zaštitu svojih građana na što višem nivou, a prema ekonomskim mogućnostima (nacionalnom dohotku). Ovo podrazumeva i cilj da se što veći procenat stanovništva obuhvati pravom na korišćenje osnovne zdravstvene zaštite bez doplate. Osnovni ciljevi savremenog sistema zdravstvene zaštite su univerzalnost (obezbediti pristup pravima iz zdravstvenog osiguranja svim građanima), ekonomičnost (očuvanje troškova zdravstvene zaštite na određenom nivou), pravičnost (ljudima koji imaju jednake zdravstvene potrebe mora biti osiguran jednak kvali-

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dobrovoljni prilozi institucija, grupa i pojedinaca [10,11]. Porezi su oblici javnih prihoda koje država naplaćuje od fizičkih i pravnih lica kao obavezna i nepovratna davanja za pokriće opštih i zajedničkih društvenih potreba. Porezi mogu biti opšti (od zarade, samostalne delatnosti, autorskih prava, intelektualne svojine i sl., poljoprivrede i šumarstva, kapitala, nepokretnosti, kapitalnih dobitaka i ostalih prihoda) i specifični (porez na luksuz i drugi). Doprinosi predstavljaju naknadu za posebne koristi koje pojedinci ili pravna lica stiču na osnovu akcija pravnih organa koje oni čine u opštem interesu. Dohodak od doprinosa varira u zavisnosti od stepena zaposlenosti, inflacije i ekonomskog razvoja zemlje. U našoj zemlji na zaradu zaposlenog trenutna stopa doprinosa za zdravstveno osiguranje iznosi 12,3% (6,15% na teret zaposlenog i 6,15% na teret poslodavca) [12]. Kod privatnog osiguranja, umesto doprinosa plaćaju se premije osiguranja (novčani iznosi).

OSNOVNI MODELI ZDRAVSTVENIH SISTEMA Zdravstveni sistemi se mogu klasifikovati prema različitim kriterijumima: ekonomskim, društveno-političkim i administrativnoj strukturi. Prema Organizaciji za ekonomsku saradnju i razvoj (OECD) kriterijumi za podelu sistema zdravstvene zaštite su obuhvat stanovništva zdravstvenom zaštitom i prava iz zdravstvene zaštite, izvori finansiranja zdravstvenih sistema i vlasništvo nad zgradama i opremom u zdravstvu [13]. Razlikujemo pet osnovnih modela zdravstvenih sistema sa istorijske tačke gledišta:

Bizmarkov model (1883) osnovnog socijalnog (zdravstvenog) osiguranja, Semaškov model (1918) socijalističkog zdravstvenog osiguranja, Beveridžov model (1948) nacionalne zdravstvene službe, dobrovoljno/privatno tržišno orijentisan model osiguranja (šezdesetih i sedamdesetih) i obavezno otvaranje medicinskih/zdravstvenih štednih računa (Singapur 1984). Sistem socijalnog osiguranja (Bizmarkov model) - najstariji sistem zdravstvenog osiguranja koji je nastao sa uspostavljanjem prvog zakonodavstva iz područja zdravstva i socijalnog osiguranja u Nemačkoj (Prusiji) 1883. godine. Ovaj model nazvan je po Otu Bizmarku (Otto Bismarck), tadašnjem kancelaru Prusije. Osnovne karakteristike ovog modela su: finansiranje iz fonda osiguranja, doprinosi zaposlenih i doprinosi poslodavca od bruto prihoda, obuhvat 60 – 80% stanovništva obaveznim osiguranjem sa paketom osnovnih prava iz osiguranja, javna i neprofitna služba, javna kontrola i interna kontrola i različite metode plaćanja lekara/ustanova. Obavezno zdravstveno osiguranje počiva na principu solidarnosti i uzajamnosti, gde doprinose plaćaju svi, a koristi onaj ko je te godine bolestan. Država ima izraženu regulativnu i nadzornu ulogu u tom sistemu. Dominantno je državno vlasništvo nad zgradama i opremom u zdravstvu. Zemlje u kojima se koristi ovaj model su Nemačka, Holandija, Francuska, Austrija, Belgija, Irska, Luksemburg, Slovenija i druge. Sistem socijalističkog zdravstvenog osiguranja (Semaškov model) - nastao je u bivšim socijalističkim zemljama, sistem je koga više nema. Finansiranje zdravstvene zaštite je iz budžeta.

broju pacijenata i delimično prema broju obavljenih usluga. Takođe, svi stanovnici države (a ne samo zaposleni) imaju obezbeđen pristup do zdravstvenih usluga pod jednakim uslovima. Obim prava je dobro ograničen i stiče se sa državljanstvom. Primeri zemalja koji koriste ovaj model: Velika Britanija, Irska, Kanada, Danska, Finska, Švedska, Italija, Španija, Portugal i Grčka. U ovim zemljama je ovo osnovni model, što ne znači da ne postoje i drugi oblici plaćanja [14]. Finansiranje zdravstvene zaštite u Republici Srbiji u osnovi je zasnovano na Bizmarkovom modelu, pošto se preko 90% sredstava za ostvarivanje prava iz obaveznog zdravstvenog osiguranja obezbeđuje iz sredstava doprinosa za obavezno zdravstveno osiguranje. Međutim, Zakonom o zdravstvenoj zaštiti predviđeno je i finansiranje zdravstvene zaštite iz budžeta Republike za lica koja nisu obuhvaćena obaveznim zdravstvenim osiguranjem, a koja su izložena povećanom riziku obolevanja (neosigurana lica, izbeglice i interno raseljena lica sa teritorije Autonomne pokrajine Kosovo i Metohija, primaoci socijalne pomoći i drugi) što je inače karakteristika Beveridževog modela. Stoga se može reći da je u Srbiji prisutan mešoviti sistem finansiranja, koga karakteriše gotovo isključivo javan izvor finansiranja, jer se finansiranje najvećim delom ostvaruje iz sredstava doprinosa i iz budžeta [5]. Sistem privatnog zdravstvenog osiguranja (model “nezavisnih” korisnika) - primer za ovakav model su Sjedinjene Američke Države (SAD). Osnovne karakteristike ovog modela su: tržišni uslovi finansiranja, mali obuhvat stanovništva zdravstvenim osigura-

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Osnovne karakteristike ovog modela su sistem obaveznog socijalnog (zdravstvenog) osiguranja i potpun obuhvat stanovništva zdravstvenom zaštitom. Društveni sistem u ovim zemljama je počivao je na državnoj-društvenoj svojini. Privatna lekarska praksa nije bila moguća. Zdravstvena infrastruktura je u javnom vlasništvu, a sve zdravstvene usluge su bile javno dostupne. Odgovornost za planiranje raspoređivanja finansijskih sredstava i upravljanje investicijama je snosila državna administracija, koja je bila organizovana po nivoima: državnom, regionalnom i lokalnom. Najveći nedostaci ovog sistema bili su neprilagođenost zdravstvene službe i zdravstvenih usluga potrebama bolesnika, naglašena uloga bolničkog zbrinjavanja i lekara specijalista umesto vanbolničkih usluga i primarne zdravstvene zaštite, nedovoljan obim zdravstvenih usluga i veliki broj lekara na broj stanovnika (14). Sistem nacionalne zdravstvene službe (Beveridge-ov model) - počeci ovog modela sežu u početak dvadesetog veka, a formalno ga je u Engleskoj postavio Vilijam Beveridž (William Beveridge) 1942. godine. Osnovne karakteristike ovog modela su: finansira se iz državnog budžeta, potpun obuhvat stanovništva zdravstvenom zaštitom, slobodan pristup zdravstvenim uslugama, javno pružanje usluga i javna kontrola. Dominantno je državno vlasništvo nad zgradama i opremom u zdravstvu. Država preuzima ulogu vođenja i upravljanja, organizuje odgovarajuću mrežu zdravstvenih kapaciteta i propisuje aktivnosti i zadatke nacionalnoj zdravstvenoj službi (National Health Service). U centru zdravstvenog sistema je lekar opšte prakse. Lekar je plaćen po

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njem sa velikim brojem neosiguranih stanovnika i dominantno privatno vlasništvo nad zgradama i opremom u zdravstvu. Kod privatnog zdravstvenog osiguranja svako plaća za sebe, a visina premije određuje se prema zdravstvenom riziku koji određena osoba nosi. Tako će pušači, gojazni i oni koji ne brinu o svom zdravlju plaćati veće premije od onih koji vode zdrav život. SAD troše više novca po osobi na zdravstveno osiguranje nego bilo koja druga zemlja na svetu. Osnovni razlog za visoku cenu američkog zdravstvenog osiguranja je taj što su medicinske usluge, materijal, tehnologija i lekovi mnogo skuplji nego u drugim industrijalizovanim zemljama. Takođe, lekari primenjuju veći broj preventivnih dijagnostičkih procedura kako bi se zaštitili od mogućih tužbi pacijenata za pogrešno lečenje. Osiguranje koje lekari plaćaju da bi se zaštitili od mogućih kazni za pogrešno lečenje, sve je skuplje, i to zauzvrat povećava cenu zdravstvenih usluga. Upotreba skupih novih tehnologija za bolju i bržu dijagnozu i lečenje bolesti takođe povećavaju cenu zdravstvenog osiguranja. Zemlje u kojima se koristi ovaj model sem SAD su Švajcarska i Turska. Medicinski/zdravstveni štedni računi se mogu definisati kao dobrovoljni (SAD, Južna Afrika) ili obavezni (Sin-

gapur, Kina) personalni računi koji se mogu koristiti samo za troškove zdravstvene zaštite i služe da omoguće lakše podnošenje finansijskog tereta bolesti tokom vremena.

ZAKLJUČAK Sistemi zdravstvene zaštite u svetu su veoma različiti. Razlike među sistemima su u tome na koji način je stanovništvu obezbeđena dostupnost i pokriće troškova za zdravstvene usluge, uključenost u sistem solidarnosti, način upravljanja, organizacija, finansiranje i u raspoloživim resursima Zdravstveni sistemi su pod stalnim pritiskom očekivanja javnosti, socijalno-demografskih promena, promene u modelima bolesti i faktorima rizika, promene u naučnim saznanjima i širenja svesti o potreba donošenja odluka zasnovanih na dokazima. U svetu još uvek ne postoji ‘“savršeni” zdravstveni sistem ali postoji težnja ka istom koji će biti u stanju da zadovolji potrebe kako pacijenata, tako i zdravstvenih radnika i saradnika, ekonomista i političara. Takođe, problemi sistema zdravstvene zaštite retko, ili nikada, ne mogu se rešiti zauvek. Kako se zemlje razvijaju, tako i njihovi sistemi zdravstvene zaštite moraju da odgovore na nove izazove.

Svetlana Jovanović1 Srđan Milovanović2,3 Jelena Mandić1 Siniša Jovović4

School of Dentistry, University of Belgrade, Belgrade, Serbia1

School of Medicine, University of Belgrade, Belgrade, Serbia

Clinic for Psychiatry, Clinical Center of Serbia, Belgrade, Serbia

Health Centre “Marinko Marin”, Loznica, Serbia

Summary The health system is one of the most complex systems in any country. Each state has an obligation to take care and care about the health of its population. The health care system includes the health infrastructure that provides a range of programs and services, and provides health care to individuals, families and communities. The health system must ensure the physical, geographical and economical accessiblity and affordability of integrated and quality health care. It should also provide for the development of health personnel, finance sustainability, decentralization of management and financing of health care and placing the citizens at the centers of the health system. The purpose of the health care system is the preservation and improvement of human health by providing health services, modern as well as traditional medicine, in an efficient manner and at the same time accessible and acceptable to the people. Due to its importance and impact on the population of each country, as well as its large economic impact, the government implemented a series of measures in planning and managing the health care system to ensure stable funding and rational and a quality health care delivery system, and all this in order to provide within the available resources a basic health care. In all the countries, the aging of the population and the introduction of new and expensive technologies present a constantly increasing cost of health care delivery. Modern health care systems differ from each other mainly in the methods of raising funds for health care, as well as in methods of payment for the service providers in the health sector. Problems of health care systems rarely, if ever, can be solved forever. As countries develop, their health care systems must respond to new challenges. Keywords: system, health care, models, finance

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HEALTH CARE SYSTEMS

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Literatura:

1. Cucić V, Simić S. Bjegović V, Živković M, Doknić-Stefanović D, Vuković D. Socijalna medicina. Savremena administracija, Beograd, 2000. 2. World Health Organization. World Health Report 2000. Geneva, Switzerland. World Health Organization, 2000. 3. Evans DE, Tandon A, Murray CJL et al.The comparative efficiency of national health systems in producing health: an analysis of 191 countries. Geneva, Switzerland. World Health Organization, 2000 (Global Programme on Evidence for Health Policy Discussion Paper No.29). 4. Plan razvoja zdravstvene zaštite Republike Srbije. Službeni glasnik RS, Beograd, br.34/2010. 5. Zakon o zdravstvenoj zaštiti. Službeni glasnik RS, Beograd, br.107/2005, 72/2009, 88/2010, 99/2010, 57/2011, 119/2012 i 45/2013. 6. Milovanović D, Milovanović S. Etika savremenog sveta na početku XXI veka. Srp Arh Celok Lek. 2005 Jan-Feb;133(1-2):111-4. 7. Saltman, R.B., Figueras, J. European health care reform: Analysis of current strategies. Copenhagen: World Health Organization / WHO - Regional Office for Europe, 1997:277. 8. Saltman RB, Dubois HFW. Current reform proposals in social health insurance countries. Eurohealth, 2005; 11: 10-4. 9. Jacobs R, Godarrd M. Trade-offs in social health insurance systems. International Journal of Social Economics, 2002; 29 (11):861-75.

10. Zakon o zdravstvenom osiguranju. Službeni glasnik RS, Beograd, br. 107/2005. 11. Joksimović O. Osiguranje i zdravstveno osiguranje. Megatrend, Beograd 2005, 668. 12. Zakon o doprinosima za obavezno socijalno osiguranje. Službeni glasnik RS, Beograd, br. 47/2013. 13. Organization for Economic Cooperation and Development. The Health System of OECD Countries: Finansing and delivering Health Care – A Comparative Analysis of OECD Countries. Social Policy Studies No4, Paris OECD, 1987:24-32. 14. Joksimović Z, Joksimović M. Prikaz najznačajnijih sistema zdravstvenih osiguranja. Timočki medicinski glasnik, 2007; 32 (4):183-88.

Svetlana Jovanović Stomatološki fakultet Univerzitet u Beogradu Dr Subotića 1, 11000 Beograd, Srbija Tel: 011/2657830 E-mail: svetlanajr@ptt.rs

Kristina Brajović Car Patrick Ellerisch UDK: 615.85

Faculty for Media and Communication, Department of Psychology, Belgrade, Serbia

INTRODUCTION If normality is viewed as a continuum, which even Freud talked about, at the one end of that continuum there are personal adaptations, while at the other end there are personality disorders. The model of personal adaptations is one of numerous attempts to understand and classify individual differences. The model was developed by two innovative practitioners: Taibi Kahler [1] and Paul Ware [2], humanistically oriented psychiatrists and psychotherapists. According to it, these adaptive mechanisms do not refer to mental health or psychopathology, but above all reveal a specific adaptive style of a person. Besides test material, the basic way of diagnosing personal adaptations is on the basis of dominant motivational driver. Motivational

Summary The paper presented here demonstrates what transactional analysis can achieve in the treatment of mixed personality disorder and points out to the challenges. The approach in question is integrative transactional analysis which also incorporates, in its diagnostics and choice of interventions, the theories and techniques from other modalities, dynamic and systemic. The concepts from transactional analysis that have proven resistant to postmodernist critique, unlike other concepts, such as games, transactions, or ego states, are the concepts of life script and personal adaptations. Script analysis and working on changing one’s personal adaptations classify contemporary transactional analysis in the group of narrative therapies. Key words: mixed type personality disorder, personal adaptations, integrative transactional analysis, cultural script

drivers represent internalized parental moral and value judgments and messages which a child takes during his/her life and which trigger his/her behavior. Namely, a person thinks that he/she will be and will stay accepted as long as he/she respects these messages. According to the transactional analysis theory, each culture and subculture contains a repertoire of dominant drama twists accompanied by dialogues, drama characters and script themes [3]. Bern defines a script as a life plan developed in early childhood primarily under the influence of parents. Once formed, the script directs the behavior of a person in all important aspects of his/her life [4]. The initial diagnosis of the patient whose psychotherapy treatment will be presented was: mixed personality disorder

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TRANSACTIONAL ANALYSIS PSYCHOTHERAPY OF MIXED PERSONALITY DISORDER

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with elements of borderline syndrome accompanied by unspecified psychosexual developmental disorder. The dynamics of intrapsychic personality stagnation as well as behavioural indicators of disorder in mental functioning could be identical in many categories. For this reason, insisting on one specific diagnosis is not necessary in order to start a treatment. The symptoms of the following personality disorders are recognized in the patient: dissocial personality disorder, histrionic personality disorder, borderline personality disorder, as well as narcissistic personality disorder. Psychosexual developmental disorder is reflected through the presence of chronic dissatisfaction and disconcertment due to the repetitive pattern of sexual relationships without emotions, experienced intimacy and bonding. The patient regards her gender identity, youth and physical appearance as her only qualities, through which, by having numerous sexual relationships, she proves her worth and success. On the other hand, since perception in personality disorder is distorted, deviant sexual behavior can paradoxically represent for her a mechanism which she believes can help her to experience intimacy with another person.

CASE OUTLINE The patient is 30 years old, single and has no children. When she started the therapy she was not in an emotional relationship. She lives alone. From closer family members, she has a mother and a half sister, who do not live in the same city. At the time of starting the therapy, she was working as a “hot line” operator and was occasionally providing sexual services to a smaller number of familiar clients. The contacts with her closer family are rare, very often conflicting. As a dominant pro-

blem, she mentions fear of not being able to experience love. The difficulties have to do with unsatisfactory emotional and sexual experiences with men. The psychotherapeutic work was carried out through individual psychotherapy lasting for two years. The initial therapeutic contract was to establish social control of rage through learning and application of safe ways of showing emotions. Since uncontrolled escalation of emotions in personality disorders increases the risk of hurting oneself or someone else, the initial contract, formulated at the beginning of the psychotherapy, was the contract of selfprotection [5].

DISCUSSION Exteropsyche, neopsyche and archaeopsyche are phenomenologically manifested as taken over (imitative), operational and regressive ego states. Three ego states which we refer to in transactional analysis are Parent, Adult and Child [6]. According to the structural analysis of the patient’s Ego state, ego state Child contains fear supported by the fantasy about the possible repeated rejection by a close person [6], similar to the experience she had in childhood with her parents. Precisely because of this, in this phase of therapy it was important for the patient to have new correctional experience regarding that part of her personality which was falsely attributed as “bad”, ego state Child. Once she started to feel safe and empowered following corrective “transference” interventions which intensified her feeling of acceptance, protection and support [7], after the first two months of psychotherapy a stable contact with the patient was established. Looking from the outside, this was reflected in her readiness to authentically express and analyse anger when it

the psychotherapeutic session, but outside it as well. After the patient began leaving the phase of transference cure and entering the phase of script cure [9], what was opened was the theme of defining the indicators of contract fulfillment as criteria for establishing a suitable moment for the termination of therapy. Transference cure involves the patient’s perception of the psychotherapist as a substitute parent figure who prevents and stops him/her to follow the script dictate. Unlike transference cure, script cure is reflected in the patient’s ability to enact, independently analyse and stop the script [12]. In this phase the interventions were mainly directed at summarizing perceptions and transferring experiences from therapy into practical decisions and actions which led to the change of living conditions and quality social interactions. The patient said that she got acquainted with people with more enthusiasm than before, that she tolerated more easily the separation from and occasional absence of friends. She was actively working on developing a wider social network of support since she understood and felt the importance of having quality contact with others in order to improve her own well-being and functionality. For the same reason, she became motivated to put an effort into developing more quality communication with her closest family members, which she also succeeded in. Despite occasional arguments and small disappointments, she regained the sense of belonging to her family, to which they responded with acceptance according to their capacities and maturity. After establishing the therapeutic contract, the completion of psychotherapeutic process took six months. The dynamics of sessions during this period was once a month. The risk that exists in such perso-

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appears during the session. As Fanita English claims, a learned, often encouraged emotion from early childhood becomes a reflex response used to manipulate others, so-called racket feeling which is a substitute for other possible affective experiences [8]. Through the developmental - reparative therapeutic relationship, it happened occasionally that authentic sadness appeared after expressed anger. The sadness appeared after realizing who in fact the suppressed object of anger was. Usually it was her mother. In this phase, when a stable contact between the patient and the therapist had already been established, the periods of work on overcoming developmental deficits through purposeful “spot-reparenting” interventions alternated with the periods of decontamination of ego state Adult of the archaic ego syntonic content [9]. The mentioned therapeutic processes were used in order to improve emotional literacy and fluency [10]. The development of emotional literacy was one of the key elements of therapeutic contract since the same emotion can be experienced and communicated in a completely different way, with different social outcomes depending on which ego state was cathected. All mentioned interventions can be considered as preparatory cognitive work for the introduction to script change. Analyzing the racket system [8], confronting rejection, redefinition and passivity [11] represented part of psychotherapy process which gradually led to the desired change in behavior. Psychotherapeutic interventions which lead to script change involve re-examining and abandoning the distorted system of beliefs, opinions and behavior influenced by life script. Besides this, the psychotherapist, by combining a directive and nurturing approach, confronts the patient with that behavior which represents the script enactment in

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nality types is the development of symbiotic connections in long-term psychotherapeutic relationships or the sense of rejection due to the therapy termination followed by worsening of symptoms. Since one of the script themes was the fear of abandonment and disappointment, it was essential to give her time to realize that for her further psychological development it was important to finish one cycle of working on herself with the sense of realistic success and to learn, on her own initiative, to end a relationship showing mutual respect. Unlike other related regressive interventions, such as building new structures of ego state Parent and rejecting the old ones through psychotherapy (reparenting technique), working on building new ego state Parent involves something else. Namely, continuous work on building Self by the patient (self-parenting) is based on a conscious decision that for certain deficient developmental experiences the patient responsibly, that is from the ego state Adult, takes over the role of her “new parent” [13,14]. Of course, this phase did not go without challenges. It happened that the new parts of introjected Parent were in conflict during this phase with the relics of the pathological content in ego state Child, thus indicating the direction of further psychotherapeutic changes. After self-reparenting, relying on decontaminated and energetically invested ego state Adult, the patient continued to be persistent in resisting social provocations, even potential accidental insults, and by doing so she demonstrated a high degree of care and protection regarding herself and her surroundings. What preceded the termination phase of psychotherapy, and pointed towards the fulfillment of the contract, was establishing a satisfactory partner relationship which lasted for six months. This

was her first stable emotional experience. Her new behavior, assertiveness, warmth and openness contributed to her feeling loved and safe in this relationship. The patient’s way of thinking and acting in this relationship provided numerous indicators for the script change.

CONCLUSION From the presented case we can see that besides analyticity and unconditional acceptance, personality disorder therapy also requires a specific kind of support and directness in work, learning about the limits and consistency, while providing security and certainty in a relationship at the same time. Since persons with border personality organization have a tendency to project ego-ideal beyond the boundaries of Self, it was expected that the patient would look for motivation for transformation in the therapeutic relationship itself. The anger emotion which the patient demonstrated during the therapeutic work was sometimes very intensive and was too big for containing. Berne himself points out that transference and counter-transference are integral, spontaneous and unavoidable phenomena of a good psychotherapeutic relationship [6]. The way towards autonomy has just started for the patient. The period of testing and affirming her new decisions, convictions and goals is in front of the patient. We predict that in the future there will be strong emotional reactions in the situations provoking the theme of separation and disconnection, due to the activation of the memories of being rejected in childhood. The therapy does not erase early memories but only neutralizes their toxicity and changes their significance and meaning.

PRIKAZ TRANSAKCIONOANALITIČKE PSIHOTERAPIJE MEŠOVITOG POREMEĆAJA LIČNOSTI Kristina Brajović Car Patrick Ellersich

Odeljenje za psihologiju, Fakultet za medije i komunikacije, Univerzitet Singidunum, Beograd, Srbija

Kratak sadržaj Rad koji je ovde prikazan ilustruje primenu transakcione analize u psihoterapiji mešovitog poremećaja ličnosti. Radi se o integrativnom transakciono analitičkom pristupu koji, u dijagnostici i izboru intervencija takođe integriše teoriju i tehnike drugih modaliteta, dinamskih i sistemskih. Transakciono analitički koncepti koji su pokazali otpornost na kritiku postmoderne za razliku od drugih koncepata, kao što su igre, transakcije ili ego stanja, jesu koncept životnog skripta i personalnih adaptacija. Analiza skripta i rad na promeni personalnih adaptacija savremenu transakcionu analizu svrstavaju u red narativnih terapija. Ključne reči: mešoviti poremećaj ličnosti, personalne adaptacije, integrativna transakciona analiza, kulturni skript

1. Kahler T. Scripts: process and content. Transactional Analysis Journal 1975; 5: 3. 2. Joines, V. & Stewart. J. Personality Adaptations: A New Guide to Human Understanding in Psychotherapy and Counseling: UK, Life Space Publishing. 2002. 3. James M. Cultural consciousness: The challenge to TA. Transactional Analysis Journal 1983;13(4): 207-216. 4. Cornell, W.F. Life script theory: A critical review from a developmental perspective. Transactional Analysis Journal 1988; 18(4): 270-282. 5. Levin, P. Corrective Parenting: A Developmenal Odyssey. Transactional Analysis Journal, 1998; 28(1). 6. Berne, E. Intuition and ego states.The origins of Transactional analysis.San Francisco: Harper and Row. 1977. 7. Kohut H. The Restoration of the Self. New York. International Universities Press; 1977. 8. Erskine G.R, Zalcman M.J. The racket system. Transactional Analysis Journal; 1979, 9 (1):51-59.

9. Clarkson P.Transactional analysis psychotherapy: An integrated approach, London & New York, Routledge, 1992. 10. Steiner C. Emotional literacy. Transactional Analysis Journal; 1984, 14 (3):162-173. 11. Karpman, S.B. Sex games people play: Intimacy blocks, games and scripts. Transactional Analysis Journal, 2009; 39 (2): 103116. 12. Stewart I. Transactional analysis counselling in action. London. Sage Publication; 2000. 13. James, M. Breaking Free, London: Addison-Wesley Publishing Company. 1981. 14. James, M. Perspectives in Transactional analysis: San Francisco, TA Press. 1998.

Kristina Brajović Car Koste Jovanoviăa 16, 11000 Beograd, Srbija 011 2495 305, 011 2626 474, E-mail: kristina.brajovic.car@fmk.edu.rs

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References:

ISTORIJAT SPECIJALNE BOLNICE ZA PSIHIJATRIJSKE BOLESTI GORNJA TOPONICA Albina Stanojević Irena Popović Dragan Milošević Ivana Tešanović UDK: 616.89:614.2[091][497.11]

“Ništa ne može izlečiti dušu osim razuma, kao što ništa ne može izlečiti razum osim duše.” Oscar Wilde

Slika 1. Specijalni paviljon „Prinčeva Vila“

Ispisana žitija srednjevekovnih vladara u Srbiji, hagiografije i freske, građa su na osnovu kojih se može zaključiti da su u crkvama i manastirima boravili duševni bolesnici. Kraj manastira Dečani, Stefan Dečanski je podigao bolnicu. Nemirni bolesnici čuvani su u posebnim manastirskim sobama. U manastiru su bili

smešteni neizlečivi i duševni bolesnici. Izrazito uznemireni bili su vezivani u lance-bukagije i bičevani. U Deviču smeštani su u sobama bez prozora, lišavani hrane i vode, sve dok se nebi smirili. U manastiru Lesnovo bolesnici su se nalazili u specijalnim odeljenjima, lečeni su molitvama, ali i okivani, bičevani i stavljani u grob Gavrila Lesnovakog. Studenica je svojevremeno određena za čuvanje „s uma sedših” (onih koji su sišli s uma). Knez Mihailo, 3. marta 1861. godine potpisuje Zakon o „Ustrojeniju doma za s uma sišavše”. Za smeštaj bolesnika određena je kuća doktora Kuniberta (Doktorova kula) u blizini konjušnice Obrenovića. [1,2]. Kada je Kraljica Natalija supruga Kralja Milana Obrenovića, 1911.godine, nakon razvoda, prodala imanje površine 86 hektara, nekadašnje kraljevsko lovište, srpskoj državi, javila se ideja o formiranju psihijatrijske bolnice u Gornjoj Toponici, po ugledu na tadašnje kla-

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Specijalna bolnica za psihijatrijske bolesti „Gornja Toponica“, Gornja Toponica, Niš, Srbija

sične hospitale za zbrinjavanje psihijatrijskih pacijenata. Inače prvo pominjanje lečenja nervnih bolesnika vezano je za 1923.g.kada je ukazom Ministarstva zdravlja otvoreno nervno odeljenje pri niškoj okružnoj bolnici prvog reda [3].

ten iz bolnice sa rečima „Zar je potrebno da ceo moj narod izgubio slobodu da bih je ja dobio? I ko mi nudi slobodu? Onaj koji je porobio ceo moj narod.“ [5]

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Slika 2 Bolnica za psihijatrijske bolesti Gornja Toponica

Nastupajući ratovi 1912-1918.g. omeli su planove za realizaciju ove ideje. Posebno teške poratne godine odložile su početak izgradnje kompleksa bolnice sve do 1925.g. Tada je odlukom Ministarstva narodnog zdravlja predloženo ministarstvu finansija da se postojećih 86 hektara (ha) u Gornjoj Toponici ustupi ovom ministarstvu za potrebe izgradnje duševne bolnice. Započinju prvi radovi na izgradnji objekata za smeštaj pacijenata, upravne zgrade i ostalih pratećih objekata 1925.g. a za prvog Upravnika Državne Bolnice za duševne bolesti postavljen je Dr Dragoljub Popović [4]. Prethodno je sticajem posebnih okolnosti započeta izgradnja tzv. „Specijalnog paviljona“, čija je izgradnja započeta 1923.g. a završena 9.juna 1926.g. za smeštaj Princa Djordja Karadjordjevića koji je toga dana prevežen vozom iz Belja i useljen u kompleks tzv. Prinčeve vile. U njoj je Princ Djordje boravio sve do okupacije Srbije 1941.g.kada je je otpuš-

Početkom 1926.g. osnovni kompleks bolničkih objekata je bio završen ili je bio u fazi završetka radova. U funkciji su bila 3 paviljona za smeštaj pacijenata, stanovi za smeštaj upravnika i ekonoma, jedna upravna zgrada, jedna zgrada ekonomata, 3 zgrade za stanovanje osoblja, zgrade kuhinje i perionice, 5 magacina, i jedna zgrada za smeštaj el.centrale. bilo je predvidjeno da će u samom početku biti smešteno do 150 pacijenata [3]. Rešenjem G. Ministra Narodnog Zdravlja od 10.03.1926.g. otvorena je novopodignuta bolnica za duševne bolesti, ali je tek 1.maja 1927.g.je vozom iz Guberevca kraj Beograda doveženo i smešteno u bolničke paviljone prvih 160 pacijenata, tako da ovaj datum predstavlja zvanično početak rada Državne bolnice za duševne bolesti Gornja Toponica. 15.maja 1927.g. ukazom NJKV Aleksandra I Karadjordjevića za Upravnika Bolnice je postavljen Dr Jovan Klicov [4].

Prvobitni urbanistički koncept bio je zaokružen kada su 1935.g. završeni radovi na novom paviljonu za smeštaj posebno uznemirenih pacijenata. Na taj način je prvobitni koncept bolnice koji je uz pomenute objekte uključivao i električnu centrau, kotlarnicu, stambene objekte za smeštaj osoblja, dom kulture i upravnu zgradu, priveden kraju. Primarni urbanistički plan podrazumevao je i izgradnju moderno uredjenog ekstereijera i uredjene drvorede, tako da je već tada bolnički krug počeo da dobija izgled koji sada ima u stilu ukusno uredjenog parka [5]. Nakon zaokruženja izgradnje stambenih i pratećih objekata, u okviru bolničkog kruga preostalo je preko trideset hektara obradive zemlje. To je omogućavalo da se obradom ovog imanja obezbede dovoljne količine hrane za ishranu i pacijenata i osoblja bolnice. Bolničko imanje je obradjivano uz aktivno učešće radnika i pacijenta bolnice kao vid sociorehabilitacionog tretmana. Činjenica da je osoblje bolnice bilo smešteno u stambene objekte koji su se nalazili u krugu bolnice upućivalo je na organizaciju kompletnog života u smislu neprekitne interakcije pacijenata i osoblja [6]. Od upravnika bolnice izdvaja se i danas, ipak kao najznačajnija figura prof. dr Uroš Jekić [1]. On je u bolnici najpre

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Slika 3 Odeljenje sudske psijtrije

radio kao sekundarni lekar, potom kao primarijus, te kao šef odeljenja i najzad kao vršilac dužnosti upravnika. Tokom dve decenije provedene u bolnici stekao je uvid u usamljenost duševnih bolesnika. Smatrao je da je boravak u prirodi od suštinskog značaja za ozdravljenje njihove psihe, naročito stoga što jednolična bolesnička odeća, sivilo prostorija u kojima borave, monotonija života koji su prinuđeni da vode, slabi njihovo interesovanje za spoljni svet i život uopšte. Znajući to, dr Jekić je verovao da će se oboleli u okrilju prirode osvežiti kao što „vlaga prene sušom pokunjene biljke”. Želeo je da bolesnike dovode u stanje odgovarajućih ljudskih odnosa. U Toponici je stvorio veliku ekonomiju na kojoj je primenjivao radnu terapiju i time osmišljavao život bolesnika. Nedovoljno je reći da je dr Jekić za obolele ljude imao razumevanja, već bi se moglo zaljučiti da je, posvetivši život njihovom ozdravljenju i stavljajući kapacitete celokupne ličnosti njima u službu, s njima ostvario topli, ljudski, emotivni odnos. U prvoj posleratnoj srpskoj vladi dr Jekić biva postavljen za ministra zdravlja, a 1949. godine počinje da radi na Neuropsihijatrijskoj klinici Medicinskog fakulteta u Beogradu. Iste godine proizveden je u zvanje vanrednog profesora Medicinskog fakulteta pri Katedri za neurologiju i psihijatriju [1,7]. U vreme pre Drugog svetskog rata i neposredno nakon njega u bolnici je radila i grupa lekara entuzijasta koja je zajedno sa dr Jekićem sprovodila u delo najsvaremenije oblike psihofarmako i sociorehabilitacione terapije [1]. Sticajem okolnosti u to vreme su u bonici radile i dve doktorke poreklom van Srbije jedna Holandjanka dr Draga Matić [4], i jedna Ruskinja Dr Irina Putiline. Dr Draga Matić koja se tragom ljubavi našla u Srbiji, udala za Srbina, promenila veru a

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onda nakon razvoda ostala do smrti u Srbiji. Bila je jena od prvih lekara zapošljenih u Bolnici. Dr Irina Putilina nošena revolucionarnim promenama u Rusiji kao emigrant obrela se u Srbiji. Zajedno sa dr Dragom Matić i dr Urošem Jekićem praktično sačinjavala jedini tim lekara psihijatara u Bolnici [6]. Od početnih 200 pacijenata bolnica se sve više širila tako da je krajem 1940.g.već bilo izmedju 650 i 700 pacijenata. Osim toga tokom ratnih godina bolnica je zbog svoje dobre organizacije i posebno odličnog funkcionisanja ekonomije zbrinjavala ne samo pacijente i radnike bolnice veći stanovnike okolnih sela kao i pacijente niške gradske bolnice. Treba istaći da je radila za sve vreme rata i da je bila pošteđena nacističke torture [6]. Nakon rata broj pacijenata je sve više rastao zahtevajući i zapošljavanja novih kadrova, pre svega prvih medicinskih tehničara, koji su zajedno sa postojećim bolničarima nastavili dalje razvijanje svih do tada pozitivnih trendova predratnih radnika [4]. U to vreme odnosno od 1945.g. do 1955.g. je upravnik bolnice bio dr Kulić, koji jeuspeo da rekonstruiše i unapredi rad u cilju zbrinjavanja sve većeg broja pacijenata. Daljem razvoju bolnice doprinosi izgradnja novih smeštajnih kapaciteta 1955.g. kada su izgradjena 4 tipska odeljenja za smeštaj bolesnika ali i sportska hala sa pratećim objektima za unapredjenja psihosociorehabilitacionog tretmana [6]. Pokrenut je prvi projekat deinstiticionalizacije u psihijatriji planom za izgradnju zaštićenog smeštaja za bolesnike u bolesničko selo, a u okviru bolnice je formiran i Zavod za zaštitu mentalnog zdravlja u Nišu, kao centar vanhospitalnog tretmana pacijenata. Na mestu direktora bolnice smenjivali su se Branko Sadžak, prof. dr

Aleksandar Lazović, prof. dr Dragan Davidović [6]. Naredni period je obeležila grupa mladih stručnjaka koji su blagodareći iskustvima stečenim u inostranstvu počeli sa detaljim unapredjenjem lečenja i vanhospitalnog tretmana pacijenata [6]. Medju njima se posebno ističu dva imena prof. dr Srbobran Miljković i prof. dr Jezdimir Zdravković. Prof dr S. Miljković je sedamdesetih godina magistrirao u Parizu, dok je prof. dr J. Zdravković početkom osamdesetih u Londonu. Preneli su nova iskustva u radu priznate francuske odnosno britanske psihijatrijske škole, prvi u sferi novog psihofarmakološkog, odnosno liason psihijatrijskog pristupa, a drugi je postao osnivač i rodonačelnik bihevioralne psihoterapijske škole u Nišu i šire. Proširenjem smeštajnih kapaciteta bolnica je postala centar lečanja neuroloških i psihijatrijskih pacijenata tako da je prerasla u Institut za neuropsihijatriju Medicinskog fakulteta u Nišu. Formiranjem Kliničkog centra u Nišu bolnica je prerasla u Specijalnu psihijtrijsku bolnicu čiji je delokrug rada sada bio usmeren isključivo ka psihijatriji. Prvi direktor Specijalne psihijatrijske bolnice bio je Prof dr Božidar Krstić [6]. U svom desetogodišnjem mandatu od 1981. do 1991.g značajno je unapredio rad odeljenja forenzičke psihijatrije. Slede kao direktori dr Rade Popović, dr Slobodan Serafimović, a od 1996.g. dr sci med dr Dragan Vukić, u čije je vreme započeta reforma tj deinstitutializacija psihijatrije koja je nastavljena u vreme kada je direktor bolnice bio dr Milan Stanojković. Dalje unapređenje u sferi zaštite mentalnog zdravlja u zajednici i integracije psihijatrijskih pacijenata u socijalnu sredinu nastavljeno je od 2009.g. od kada na čelu bolnice mr sci med dr Albina Stanojević.

jatrije. Kao prva ustanova u regionu započela je i uspešno realizovala pilot projekat formiranja prvog Centra za zaštitu mentalnog zdravlja u zajednici.

Slika 4. Kolektiv lekara 1997.

Slika 5. Mentalno zdravlje u zajednici „Medijana“

Postignut je i značajan je napredak na planu smanjenja broja hospitalizovanih pacijenata sa trendom skraćenja dužine hospitalizacije i usmeravanjem posebne pažnje ka vanhospitalnom tretmanu. Planira se dalji nastavak aktivnosti na deinstitucionalizaciji i destigmatizaciji psihijatrijskuh pacijenata. Trenutni kapacitet bolnice je 800 postelja, u bolnici je angažovano 48 lekara od toga 18 neuropsihijatara 22 psihijatra, 1 internista 1 radiolog, 1 specijalista kliničke biohemije, 3 lekara na specijalizaciji i 2 doktora medicine, 196 sestara od čega 155 sestara sa srednjom stučnom spremom i 41 sestra sa višom školom, 9 kliničkih psihologa, 5 socijalnih radnika, 1 dipl.pedagog, 1 biblioterapeut i 1 fiskulturni terapeut. Današnje rukovodstvo bolnice kreće u novi milenijum prema tradicijama zasnovanim daleke 1927. godine. Kako je rekao otac medicine Hipokrat „za oporavak je potrebno vreme, ali i pravi uslovi“.

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U godinama najteže ekonomske krize bolnica je u smislu zbrinjavanja pacijenata bila na ivici egzistencije. Aktivnostima tadašnjeg i svih kasnijih rukovodstava bolnice obezbedjena je saradnja i pomoć mnogih humanitarnih organizacija i ljudi dobre volje. Obezbedjena su elementarna sredstva za rad i zbrinjavanje bolesnika a zahvaljujući humanosti NJKV Prestolonaslednika Aleksandra I Karadjordjevića i NJV Princeze Katarine Karadordjević rekonstruisane su i obnovljene dve zgrade iz prvobitne gradjevinske postavke bolnice. Postepeno je u bolnici izdvojilo nekoliko centara. Pre svih centar Forenzičke psihijatrije koji danas predstavlja jedan od najuticajnijih centara ove oblasti u Srbiji. Takodje se poslednjih dvadesetak godina izdvaja Odeljenje za bolesti zavisnosti, koje po svojim rezultatima i prihvatanju novih trendova lečenja postaje pravi regionalni centar za sve oblike zavisnosti. Poslednjih godina posebno se izdvaja i Odeljenje gerontopsihijatrije koje poprima oblik regionalnog centra za realizaciju zbrinjavanja i lečenja starih lica. Treba istaći i činjenicu da se bolnica danas aktivno uključila u realizaciju deinstituionalizacije i reorganizacije psihi-

HISTORICAL FACTS ABOUT THE SPECIAL PSYCHIATRIC HOSPITAL „GORNJA TOPONICA“ NIŠ, SERBIA Albina Stanojević Irena Popović Dragan Milošević Ivana Tešanović

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Psychiatric hospital G.Toponica

Literatura: 1. Milovanović S. Prvi srpski psihijatri. Srp Arh Celok Lek. 2006 SepOct;134(9-10):457-65 2. Bukelić J. Istorijski razvoj psihijatrije prikaz knjige. Medicinska revija 2012;4(2):231-235 3. Istorijski arhiv Srbije 4. Istorijski arhiv grada Niša 5. Munjiza M. Istorijski razvoj psihijatrije. Službeni glasnik, Beograd, 2011. 328. 6. Arhivska građa Specijalne bolnice za psihijatrijske bolesti „Gornja Toponica“ 7. Milovanović S, Jasović-Gašić M, Pantović M, Dukić-Dejanović S, Jovanović AA, Damjanović A, Ravanić D. The historical development of psychiatry in Serbia.Psychiatr Danub. 2009 Jun; 21 (2):156-65;

Summary The sale and the purchase of a large estate in the area of the village of Gornja Toponica near Niš, was officially closed on the 9th of September 1911, providing the area on which today’s Psychiatric Hospital was built.The land on which the hospital was constructed is known according to historical records and it was known as the “King Milan’s Estate”. It was the property of his exwife Natalija, who was divorced and banished from Serbia, the same lady who donated her spacious estate in Serbia to the University of Belgrade. The hospital started working in 1927. On that day 160 patients were transported from the Hospital for Mental Diseases in Belgrade to the railway station near Toponica. According to available data, in 1929, 320 patients were hospitalised in the hospital whose total number of beds was 160. Four doctors and 40 workers looked after and provided treatment to these number of patients. The number of applications for treatment kept increasing, so that in 1935 there were 492 patients, and in 1940 as many as 604 patients. The state hospital continued working also during World War II under very difficult, demanding and highly risky conditions for the patients, and in particular for the staff and management. The number of patients was increasing after building new pavilons in 1960. In 1970 the number of hospitalised patients was between 1200-1500. The current capacity of the hospital is 800 beds, the hospital has recruited 48 doctors (18 neuropsyhiatrists, 22 psychiatrics), 155 nurses, 41 senior nurses, 5 social workers and 9 psychologists. It should be noticed that the hospital are now actively involved in the implementation deinstituionalization and reorganization of psychiatry. As the first institution in the region,it has started and successfully implemented a pilot project of establishing the first Center for Mental Health in the community. There has also been significant progress in reducing the number of hospitalized patients with the trend of shortening the length of hospitalization and directing special attention to out-hospital treatment. It is planned to follow up the de-institutionalization and de-stigmatization psychiatric patients. The new management of hospital is moving into the new millennium according to the tradition based as far back in 1927. As the Hippocrates said “Recovery takes time, but the right conditions.”

ENGRAMI su časopis za kliničku psihijatriju, psihologiju i granične discipline. ENGRAMI se izdaju kroz 4 sveske godišnje. Časopis objavljuje: originalne radove, saopštenja, prikaze bolesnika, preglede iz literature, radove iz istorije medicine, radove za praksu, izveštaje s kongresa i stručnih sastanaka, stručne vesti, prikaze knjiga i dopise za rubrike Sećanje, In memoriam i Promemoria, kao i komentare i pisma Uredništvu u vezi s objavljenim radovima. Prispeli rukopis Uređivački odbor šalje recenzentima radi stručne procene (period recenzije 48 nedelja). Ukoliko recenzenti predlože izmene ili dopune, kopija recenzije se dostavlja autoru s molbom da unese tražene izmene u tekst rada ili da argumentovano obrazloži svoje neslaganje s primedbama recenzenta, najkasnije u periodu od dve nedelje. Konačnu odluku o prihvatanju rada za štampu donosi glavni i odgovorni urednik. Za objavljene radove se ne isplaćuje honorar, a autorska prava se prenose na izdavača. Rukopisi i prilozi se ne vraćaju. Za reprodukciju ili ponovno objavljivanje nekog segmenta rada publikovanog u ENGRAMIMA neophodna je saglasnost izdavača. Radovi se štampaju na srpskom ili engleskom jeziku, sa naslovnom stranom i kratkim sadržajem na oba jezika.

DOBRA NAUČNA PRAKSA Podnošenje rukopisa podrazumeva: da rukopis nije objavljen ranije (osim u obliku apstrakta ili kao deo objavljenog predavanja ili teze); da nije u razmatranju za objavljivanje u drugom časopisu; da je autor(i) u potpunosti odgovoran za naučni sadržaj rada; da je objavljivanje odobreno od strane svih koautora, ako ih ima, kao i od strane nadležnih organa ustanove u okviru koje je istraživanje sprovedeno. Kao uslov za razmatranje za objavljivanja, potrebna je registracija kliničkih ispitivanja u javnom registru kliničkih studija za odredjena istraživanja koja svojim dizajnom to zahtevaju. Kliničko ispitivanje je definisano od strane Međunarod-

nog komiteta urednika medicinskih časopisa (u skladu sa definicijom Svetske zdravstvene organizacije) kao i bilo koji istraživački projekat koji dodeljuje, učesniku ili grupi učesnika, jednu ili više intervencija u cilju procene zdravstvenog ishoda. Za više informacija posetite http://clinicaltrials.gov/ Neophodno je da originalni radovi, predati za publikaciju, koji uključuju humanu populacija, sadrže, u okviru sekcije Materijal i metode, izjavu da je studija odobrena od strane odgovarajućeg etičkog komiteta i time izvedena u skladu sa Helsinškom dekleracijom iz 1995. Takodje je neophodno jasno navesti da su svi ispitanici uključeni u istraživanje dali svoj informisani pristanak pre uključenja u studiju. Detalje koji bi mogli prekršiti pravilo o anonimnosti subjekata neophodno je izbeći. Eksperimeti koji uključuju životinje takodje moraju biti sporvedeni u skladu sa lokalnim važećim etičkim odredbama o pravima životinja i sadržati izjavu da su prilikom istraživanja ispoštovani principi laboratorijske nege životinja (NIH publikacija broj 86-23, revidirana 1985). Urednici zadržavaju pravo da odbiju rukopise koji nisu u skladu sa gore navedenim uslovima. Autor c´e biti odgovoran za lažne izjave ili neispunjavanja gore navedenih zahteva.

OPŠTA UPUTSTVA Tekst rada kucati u programu za obradu teksta Word, latinicom, sa dvostrukim proredom, isključivo fontom Times New Roman i veličinom slova 12 tačaka (12 pt). Sve margine podesiti na 25 mm, veličinu stranice na format A4, a tekst kucati sa levim poravnanjem i uvlačenjem svakog pasusa za 10 mm, bez deljenja reči (hifenacije). Ne koristiti tabulatore i uzastopne prazne karaktere (spejsove) radi poravnanja teksta, već alatke za kontrolu poravnanja na lenjiru i Toolbars. Posle svakog znaka interpunkcije staviti samo jedan prazan karakter. Ako se u tekstu koriste specijalni znaci (simboli), koristiti font Symbol.

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UPUTSTVO AUTORIMA

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Rukopis rada dostaviti elektronski na adresu uredništva: engrami1979@gmail.com. U slučaju poštanske dostave rukopis rada dostaviti odštampan jednostrano na beloj hartiji formata A4 u tri primerka. Stranice numerisati redom u okviru donje margine, počev od naslovne strane. Podaci o korišćenoj literaturi u tekstu označavaju se arapskim brojevima u uglastim zagradama – npr. [1, 2], i to onim redosledom kojim se pojavljuju u tekstu. Naslovna strana. Na posebnoj, prvoj stranici rukopisa treba navesti sledeće: • naslov rada bez skraćenica; • puna imena i prezimena autora (bez titula) indeksirana brojevima; • zvaničan naziv ustanova u kojima autori rade i mesto, i to redosledom koji odgovara indeksiranim brojevima autora; • ukoliko je rad prethodno saopšten na nekom stručnom sastanku, navesti zvaničan naziv sastanka, mesto i vreme održavanja; • na dnu stranice navesti ime i prezime, kontakt-adresu, broj telefona, faksa i e-mail adresu jednog od autora radi korespondencije. Autorstvo. Sve osobe koje su navedene kao autori rada treba da se kvalifikuju za autorstvo. Svaki autor treba da je učestvovao dovoljno u radu na rukopisu kako bi mogao da preuzme odgovornost za celokupan tekst i rezultate iznesene u radu. Autorstvo se zasniva samo na: • bitnom doprinosu koncepciji rada, dobijanju rezultata ili analizi i tumačenju rezultata, • planiranju rukopisa ili njegovoj kritičkoj reviziji od znatnog intelektualnog značaja, • u završnom doterivanju verzije rukopisa koji se priprema za štampanje. Autori treba da prilože opis doprinosa u rukopisu za svakog koautora pojedinačno. Finansiranje, sakupljanje podataka ili generalno nadgledanje istraživačke grupe sami po sebi ne mogu opravdati autorstvo. Svi drugi koji su doprineli izradi rada, a koji nisu autori rukopisa, trebalo bi da budu navedeni u zahvalnici s opisom njihovog rada, naravno, uz pisani pristanak. Kratak sadržaj. Uz originalni rad, saopštenje, prikaz bolesnika, pregled iz literature, rad iz istorije medicine i rad za praksu, na posebnoj stranici treba priložiti kratak sadržaj rada obima do 300 reči. Za originale radove kratak sadržaj treba da ima sledeću strukturu: uvod, cilj rada, metod rada, rezultati, zaključak. Svaki od navedenih segmenata pisati kao poseban pasus koji počinje boldovanom reči Uvod, Cilj rada, Metod rada, Rezultati, Zaključak. Navesti najvažnije rezultate

(numeričke vrednosti) statističke analize i nivo značajnosti. Ključne reči. Ispod kratkog sadržaja navesti ključne reči (od tri do šest). U izboru ključnih reči koristiti Medical Subject Headings – MeSH (http://gateway.nlm.nih.gov). Prevod na engleski jezik (za radove pisane na srpskom jeziku). Na posebnoj stranici otkucati naslov rada na engleskom jeziku, puna imena i prezimena autora, nazive ustanova na engleskom jeziku i mesto. Na sledećoj stranici priložiti kratak sadržaj na engleskom jeziku (Abstract) sa ključnim rečima (Key words), i to za radove u kojima je obavezan kratak sadržaj na srpskom jeziku, koji treba da ima 200-300 reči. Za originalne radove apstrakt na engleskom treba da ima sledeću strukturu: Introduction, Objective, Method, Results, Conclusion. Svaki od navedenih segmenata pisati kao poseban pasus koji počinje boldovanom reči. Za prikaze bolesnika apstrakt na engleskom treba da sadrži sledeće: Introduction, Case outline, Conclusion. Svaki od navedenih segmenata pisati kao poseban pasus koji počinje boldovanom reči. Prevesti nazive tabela, grafikona, slika, shema, celokupni srpski tekst u njima i legendu. Struktura rada. Svi podnaslovi se pišu velikim slovima i boldovano. Originalni rad treba da ima sledeće podnaslove: uvod, cilj rada, metod rada, rezultati, diskusija, zaključak, literatura. Prikaz bolesnika čine: uvod, prikaz bolesnika, diskusija, zaključak, literatura. Ne treba koristiti imena bolesnika, inicijale ili brojeve istorija bolesti, naročito u ilustracijama. Pregled iz literature čine: uvod, odgovarajući podnaslovi, zaključak, literatura. Pregledne radove iz literature mogu objavljivati samo autori koji navedu najmanje pet autocitata (reference u kojima su ili autori ili koautori rada). Tekst rukopisa. Koristiti kratke i jasne rečenice. Prevod pojmova iz strane literature treba da bude u duhu srpskog jezika. Sve strane reči ili sintagme za koje postoji odgovarajuće ime u našem jeziku zameniti tim nazivom. Za nazive lekova koristiti prevashodno generička imena. Skraćenice. Koristiti samo kada je neophodno, i to za veoma dugačke nazive hemijskih jedinjenja, odnosno nazive koji su kao skraćenice već

Grafikoni. Grafikoni treba da budu urađeni i dostavljeni u programu Excel, da bi se videle prateće vrednosti raspoređene po ćelijama. Iste grafikone linkovati i u Word-ov dokument, gde se grafikoni označavaju arapskim brojevima po redosledu navođenja u tekstu, sa nazivom na srpskom i engleskom jeziku. Svi podaci na grafikonu kucaju se u fontu Times New Roman, na srpskom i engleskom jeziku. Korišćene skraćenice na grafikonu treba objasniti u legendi ispod grafikona na srpskom i engleskom jeziku. Sheme (crteži). Sheme raditi u programu Corel Draw ili Adobe Illustrator (programi za rad sa vektorima, krivama). Svi podaci na shemi kucaju se u fontu Times New Roman, na srpskom i engleskom jeziku, veličina slova 10 pt. Korišćene skraćenice na shemi treba objasniti u legendi ispod sheme na srpskom i engleskom jeziku. Svaku shemu odštampati na posebnom listu papira i dostaviti po jedan primerak uz svaku kopiju rada (ukupno tri primerka za rad koji se predaje). Zahvalnica. Navesti sve one koji su doprineli stvaranju rada a ne ispunjavaju merila za autorstvo, kao što su osobe koje obezbeđuju tehničku pomoć, pomoć u pisanju rada ili rukovode odeljenjem koje obezbeđuje opštu podršku. Finansijska i materijalna pomoć, u obliku sponzorstva, stipendija, poklona, opreme, lekova i drugo, treba takođe da bude navedena. Izjava o konfliktu interesa. Neophodno je navesti potencijalni konflikt interesa ukoliko on postoji u slučaju bilo koga od autora rada. Ukoliko nema konflikta interesa, to je takodje potrebno naglasiti. Literatura. Reference numerisati rednim arapskim brojevima prema redosledu navođenja u tekstu. Broj referenci ne bi trebalo da bude veći od 30, osim u pregledu iz literature, u kojem je dozvoljeno da ih bude do 50. Reference se citiraju prema tzv. vankuverskim pravilima (Vankuverski stil), koja su zasnovana na formatima koja koriste National Library of Medicine i Index Medicus. Naslove časopisa skraćivati takođe prema načinu koji koristi Index Medicus (ne stavljati tačke posle skraćenica!). Za radove koji imaju do šest autora navesti sve autore. Za radove koji imaju više od šest autora navesti prva tri i et al. Stranice se citiraju tako što se navede početna stranica, a krajnja bez cifre ili cifara

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prepoznatljivi (standardne skraćenice, kao npr. DNK). Za svaku skraćenicu pun termin treba navesti pri prvom navođenju u tekstu, sem ako nije standardna jedinica mere. Ne koristiti skraćenice u naslovu. Izbegavati korišćenje skraćenica u kratkom sadržaju, ali ako su neophodne, svaku skraćenicu ponovo objasniti pri prvom navođenju u tekstu. Obim rukopisa. Celokupni rukopis rada – koji čine naslovna strana, kratak sadržaj, tekst rada, spisak literature, svi prilozi, odnosno potpisi za njih i legenda (tabele, fotografije, grafikoni, sheme, crteži), naslovna strana i kratak sadržaj na engleskom jeziku – mora iznositi za originalni rad, saopštenje i pregled iz literature do 5.000 reči, za prikaz bolesnika do 2.000 reči, za rad iz istorije medicine do 3.000 reči, za rad za praksu do 1.500 reči; radovi za ostale rubrike moraju imati do 1.000 reči. Tabele. Tabele se označavaju arapskim brojevima po redosledu navođenja u tekstu, sa nazivom na srpskom i engleskom jeziku. Tabele raditi isključivo u programu Word, kroz meni Table–Insert–Table, uz definisanje tačnog broja kolona i redova koji će činiti mrežu tabele. Desnim klikom na mišu – pomoću opcija Merge Cells i Split Cells – spajati, odnosno deliti ćelije. U jednu tabelu, u okviru iste ćelije, uneti i tekst na srpskom i tekst na engleskom jeziku – nikako ne praviti dve tabele sa dva jezika! Koristiti font Times New Roman, veličina slova 12 pt, sa jednostrukim proredom i bez uvlačenja teksta. Korišćene skraćenice u tabeli treba objasniti u legendi ispod tabele na srpskom i engleskom jeziku. Fotografije. Fotografije se označavaju arapskim brojevima po redosledu navođenja u tekstu, sa nazivom na srpskom i engleskom jeziku. Primaju se originalne fotografije (crno-bele ili u boji) ili fotografije drugih autora koje se prenose u originalu ili izmenjenoj verziji i za koje je neophodno dostaviti potvrdu autora da postoji dozvola za objavljivanje. Fotografije snimljene digitalnim fotoaparatom dostaviti na CD i odštampane na papiru, vodeći računa o kvalitetu (oštrini) i veličini digitalnog zapisa. Poželjno je da rezolucija bude najmanje 150 dpi, format fotografije 10×15 cm, a format zapisa *.JPG. Ukoliko autori nisu u mogućnosti da dostave originalne fotografije, treba ih skenirati kao Grayscale sa rezolucijom 300 dpi, u originalnoj veličini i snimiti na CD.

koje se ponavljaju (npr. od 322. do 355. stranice navodi se: 322-55). Molimo autore da se prilikom navođenja literature pridržavaju pomenutog standarda, jer je to vrlo bitan faktor za indeksiranje prilikom klasifikacije naučnih časopisa.

Primeri: 1. Članak u časopisu: Roth S, Newman E, Pelcowitz D, Van der Kolk, Mandel F. Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV field trial for posttraumatic stress disorder. J Traum Stress 1997; 10:539-55.

2. Poglavlje u knjizi: Ochberg FM. Posttraumatic therapy. In: Wilson JP, Raphel B, editors. International Handbook of Traumatic Stress Syndromes. New York: Plenum Press; 1993. p.773-83.

3. Knjiga: Maris RW, Berman AL, Silverman MM, editors. Comprehensive Textbook of Suicidology. New York, London. The Guilford Press; 2000.

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4. Elektronski dokument dostupan na Internetu:

Irfan A. Protocols for predictable aesthetic dental restorations [Internet]. Oxford: Blackwell

Munksgaard; 2006 [cited 2009 May 21]. Available from: http://cclsw2.vcc.ca:2048/login?url =http://www.netLibrary.com/urlapi.asp?action=summary Za način navođenja ostalih varijeteta članaka, knjiga, monografija, drugih vrsta objavljenog i neobjavljenog materijala i elektronskog materijala pogledati posebno izdanje Srpskog arhiva iz 2002. godine pod nazivom Jednoobrazni zahtevi za rukopise koji se podnose biomedicinskim časopisima, Srp Arh Celok Lek 2002; 130(7-8):293300. Propratno pismo. Uz rukopis obavezno priložiti pismo koje su potpisali svi autori, a koje treba da sadrži: • izjavu da rad prethodno nije publikovan i da nije istovremeno podnet za objavljivanje u nekom drugom časopisu, i • izjavu da su rukopis pročitali i odobrili svi autori koji ispunjavaju merila autorstva. Takođe je potrebno dostaviti kopije svih dozvola za: reprodukovanje prethodno objavljenog materijala, upotrebu ilustracija i objavljivanje informacija o poznatim ljudima ili imenovanje ljudi koji su doprineli izradi rada. Slanje rukopisa. Rukopis rada i svi prilozi uz rad dostavljaju se u tri primerka, zajedno sa disketom ili diskom (CD) na koje je snimljen identičan tekst koji je i na papiru. Rad se šalje preporučenom pošiljkom na adresu: Institut za psihijatriju, Klinički centar Srbije, Uredništvo časopisa ENGRAMI, ul. Pasterova 2, 11000 Beograd. Email: engrami1979@gmail.com.