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Buletinul Asociaiei Balint, vol. 11., nr.

43, Septembrie 2009

BULETINUL ASOCIAIEI BALINT DIN ROMNIA


Comitetul de redacie:

Septembrie, 2009, Volumul 11, Nr. 43

Tnde BAKA, Doina COZMAN, Dan Lucian


DUMITRACU, Evelyn FARKAS, Liana FODORANU,
Ioan-Bradu IAMANDESCU,
Cristian KERNETZKY (D), Mircea LZRESCU
Holger Ortwin LUX, Drago MARINESCU
Ioana MICLUIA, Csilla MOLDOVAN,
Aurel NIRETEAN, Iuliu OLTEAN
Gheorghe PAINA, Ovidiu POPA-VELEA,
Almos Bela TRIF (USA)
Ionel UBUCANU, va VERESS, Nicolae VLAD.

Periodic trimestrial, apare n ultima decad a lunii a treia din


trimestru.
Fondat - 1999
Redactor ef - Albert VERESS M.D. Sc.D.
Lector - Almo Bela TRIF M.D., Sc.D., J.D., M.A.
Tehnoredactor - Istvn PARA

Editat de Asociaia Balint din Romnia


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INDEX: ISSN 1454-6051

CUPRINS

PSYCHOSOMATIC ASPECTS OF ALLERGIC


REACTIONS TO DRUGS (MEDICINES)..............
Ioan Bradu Iamandescu, Liliana Diaconescu

TULBURRI MENTALE N SINDROMUL


METABOLIC ............................................................. 10
Delia Lupu, D. L. Dumitracu
THE ROLE OF THE BALINT GROUP
LEADER ..................................................................... 17
Andrew Elder

The relationship between the


health professional and the patient
as perceived by the medical and
nursing students ............................................ 20
Almos Bela Trif, Clara Wolman

TIRI DIN VIAA ASOCIAIEI ............................ 24

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

Prezentarea
ASOCIAIEI BALINT DIN ROMNIA
Data nfiinrii: 25 iulie 1993
Michael BALINT: Psihanalist englez de origine
maghiar
Grupul BALINT: Grup specific alctuit din cei care se
ocup de bolnavi i care se reunesc sub conducerea a unui
sau a doi lideri, avnd ca obiect de studiu relaia medicbolnav prin analiza transferului i contra-transferului
ntre subieci.
Activitatea Asociaiei:
grupuri Balint,
editarea Buletinului,
formarea i supervizarea liderilor,
colaborare la scar internaional.

Specificul Asociaiei: apolitic, nereligioas, interuniversitar, multi-disciplinar, de formaie polivalent.


Obiective: Formarea psihologic continu a participanilor. ncercarea de a mbunti prin cuvnt calitatea
relaiei terapeutice medic-pacient i a comunicrii dintre
membrii diferitelor categorii profesionale. Rol de punte
ntre etnii, confesiuni, categorii sociale, regiuni, ri.

BIROUL ASOCIAIEI:
Preedinte: Tnde BAKA tundeb13@freemail.hu
Vicepreedinte: Istvn VRADI istvanvaradi1inbox.com
Secretar:
Csilla HEGYI cs_hegyi@yahoo.com
Trezorier:
Albert VERESS alveress@clicknet.ro
Membri: Rita-Lenke FERENCZ, Holger Ortwin LUX,
Attila MUNZLINGER, Ovidiu Popa-Velea, va VERESS.
Cotizaia se achit pn la 31 martie a.c. Cvantumul
ei se hotrte anual de ctre Biroul Asociaiei. n cazul
cnd ambii soi dintr-o familie sunt membrii Asociaiei,
unul din ei poate cere scutirea de la plata abonamentului
la Buletinul Asociaiei, al crui cost se stabilete anual.
Cei care nu achit cotizaia pn la data de 31 martie
a anului n curs nu vor mai primi Buletinul din luna iunie,
iar cei care nu vor plti cotizaia nici pn la data de 31
martie a anului urmtor vor fi penalizai cu o majorare de
50%!!! Cei cu o restan de doi ani vor fi exclui disciplinar
din Asociaie.
Studenii i pensionarii sunt scutii de plata cotizaiei,
fiind necesar doar abonarea la Buletinul Asociaiei.
Cotizaia pentru anul 2009 este de 20 EURO (la
cursul oficial BNR din ziua n care se face plata), n care
se include i abonamentul la Buletin.
Taxa de nscriere n Asociaie este de 20 EURO (nu se
face reducere nici unei categorii socio-profesionale).
Abonamentul cost 6 EURO.

CTRE AUTORI
Se primesc articole cu tematic legat de activitatea
grupurilor Balint din Romnia i din strintate, de orice fel
de terapie de grup, de psihoterapie, de psihologie aplicat
i de alte abordri de ordin psihologic al relaiei medic
- pacient (medicin social, responsabilitate medical,
bioetic, psihosomatic, tanatologie).
Materialele scrise la solicitarea redaciei vor fi
remunerate.
Buletinul este creditat de ctre CMR ca prestator de
EMC, deci orice articol publicat se crediteaz cu 25 de
credite EMC. Abonamentul la Buletin se crediteaz cu 5
credite.
Redactorul ef i / sau lectorul au dreptul de a face
cuvenitele corecturi de form, iar n cazul neconcordanelor
de fond vor retrimite articolele autorilor cu sugestiile
pentru corectare.
Deoarece revista se difuzeaz i n alte ri, articolele
care nu se limiteaz doar la descrierea evenimentelor
balintiene, trebuie s aib un rezumat n limba romn i
englez, de maximum 10 rnduri dactilografiate. Lectorul
i impune responsabilitatea de a face la nevoie corectura
rezumatului
Pentru rigoarea tiinific apreciem menionarea
bibliografiei ct mai complet i mai corect, conform
normelor Vancouver, att pentru articolele din periodice

ct i pentru monografii (citarea n text se noteaz cu cifre


n parantez, iar n bibliografie se nir autorii n ordinea
citrii nu cea alfabetic i doar acei autori care au fost
citai n lucrare).
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de identificare a crii n cauz - autorii, titlul, toate
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scanat a copertei.
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de 3,5, CD room, memory-stick sau prin e-mail ca fiier
ataat. Se vor folosi numai caractere romneti din fontul
Times New Roman, culese la mrimea 12, n WORD 6.0
sau 7.0 din WINDOWS.
Imaginile - fotografii, desene, caricaturi, grafice - vor
fi trimise ca fiiere separate, cu specificarea locului unde
trebuie inserate n text pentru justa lor lectur. Pentru
grafice este important s se specifice programul n care au
fost realizate.
Articolele trimise vor fi nsoite de numele autorului,
cu precizarea gradului tiinific, a funciei i a adresei de
contact, pentru a li se putea solicita extrase. Autorii vor
scana o fotografie tip paaport sau eseu pe care o vor
trimite ca fiier ataat sau pe o disket la adresa redaciei.

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

ANUNURI IMPORTANTE
Asociaia Balint are un site. Adresa: www.balint.xhost.ro
Autorii sunt rugai s se conformeze regulilor de redactare a articolelor.

PSYCHOSOMATIC ASPECTS OF ALLERGIC REACTIONS TO


DRUGS (MEDICINES)
Ioan Bradu Iamandescu, Liliana Diaconescu, Bucureti

REZUMAT
Alergia la medicamente este din ce n ce mai frecvent
i poate produce simptome severe ca oc anafilactic, edem
glotic sau urticarie sever sau astm bronic, avnd un
impact dramatic asupra psihicului pacienilor afectai.
Studii mai vechi (Iamandescu 1880 i 1984;
Iamandescu i colaboratorii, 1994 i 1998) au evideniat
faptul c pacienii cu reacii de tip alergic la medicamente
prezint deseori tulburri fizice, posibil n relaie cu
cantitatea mare de stres perceput de acetia.
Unii dintre aceti pacieni cu comorbiditate psihiatric
reacioneaz disproporionat prin tulburri psihosomatice

ce mimeaz simptomele psihice i somatice ale unei reacii


anafilactice sau anafilactoide anterioare, ce apar atunci
cnd li se administreaz un nou medicament sau chiar un
preparat placebo. Simptomele nevrotice, foarte frecvent
ntlnite la pacienii cu reacii de tip alergic la medicamente
(inclusiv la pacienii astmatici) par a fi induse secundar de
trirea anxioas a accidentului alergic medicamentos.
Vulnerabilitatea psihic la stres, alturi de evenimentele
stresante, pot reprezenta un potenial risc pentru apariia
reaciilor alergice. Marea lor problem este ns riscul
repetrii accidentului medicamentos la acei bolnavi cu
variate comorbiditi care necesit medicaie. Anxietatea
i mai ales depresia acestor bolnavi, dar i problemele
psihologice ale medicului curant (riscul accidentelor
letale, ca i cel al malparaxis-ului, conjugat cu sentimentul
de neputin) constituie subiecte, nc deloc sau parial
analizate, pentru grupurile Balint.
Cuvinte-cheie: alergie medicamentoas, simptome
nevrotice, vulnerabilitate psihic
Drugs become, more and more, necessarily imperious
for many persons. The increasing use of drugs has inevitably
determined the development of allergies, because of most
of them.
Drug allergy is defined as a drug reaction which results
from the interaction between the drug and the immune
system, with the appearance of a specific immune answer
against the respective drug.
The importance of drug allergy
The incidence is difficult to establish (it varies between
2% and 15%), because it is under-reported and is increasing
(due to the current excessive use of drugs) (1, 2, 3).
The clinical diagnosis is also difficult, for at least two
reasons: there are varied clinical manifestations (minoritching, urticaria or major-anaphylactic shock, glottal
edema), and they are not always specific for allergy.
The treatment implies sometimes emergency measures
and we must not forget that there are medico-legal aspects
(some of the allergic reactions have vital risks and may
cause patients death).
The drug allergy syndrome with a clinical
expression depending by affected target organ (skin,
respiratory mucosa, etc.) is always accompanied by a lot
of psychosomatic symptoms, as a strong psychological

REFERATE

ABSTRACT
Allergy to drugs (medicines) is more and more
frequent and could produce often severe symptoms such
as anaphylactic shock, glottal edema or severe urticaria
or asthma, having a dramatic psychological impact on
affected patients.
Previous studies (Iamandescu, 1980 and 1984;
Iamandescu et al., 1994 and 1995) revealed the fact that patients
with allergic-type reactions to drugs display very frequently
psychical disturbances, possibly in relation to the large
amount of stress perceived by them. Some of these patients
with psychiatric co-morbidity show a disproportionate
reaction, manifested as extensive psychosomatic disturbances,
mimicking the psychic and somatic symptoms of a previous
anaphylactic or anaphylactoid reaction, when a new drug
or even when placebo preparations are given. The neurotic
symptoms, very frequently encountered in patients with
allergic-type reactions to drugs (including asthma patients)
appear to be secondarily-induced by the anxious experience
of the drug-provoked accident.
The vulnerability to psychic stress, together with many
life stressors events may represent a potential risk for
developing drug allergy. Their main problem is the risk of
repeating the allergic accidents, especially in patients with
various co-morbidity which need medication. Patients
anxiety and depression and physicians psychological
problems (due to the lethal risk and to malpractice,
concomitant with helplessness) are topics less analyzed in
Balint groups.
Keywords: drug allergy, neurotic symptoms, psychic
vulnerability

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

reaction to this unusual, stressful and threatening situation.


This remark is valuable especially for allergic type I
reactions.
Medical approach of patients with drug allergy
The approach implies two aspects:
1) Positive diagnosis based on:
- Anamnesis. Is very important to establish a
relationship between the drug delivery and the onset of
allergic symptoms. The anamnesis must be detailed, for
a period as 2-4 weeks before the allergic accident has
occurred. All the data referring to all types of drugs taken,
including those without medical prescription, e.g. sleeping
pills, analgesics, cold relief, eye-drops, etc.) can prove to
be useful;
- Clinical examination. It reveals several clinic aspects
with different degree of seriousness. A classification of
clinic manifestations (4) is shown in table1.
Table 1. Clinical manifestations in drug allergy
General reactions
(multi-systemic)

Organic reactions

REFERATE

Specific lab investigations (skin tests, specific Ig E,


TTC, etc.)
2) Treatment which (briefly) consists of:
Cessation of drug administration,
Emergency treatment of the anaphylactic reactions,
Delivery of an alternative drug,
Desensitization (when alternative drugs are not
available).
Psychological approach of patients with drug
allergy
The literature data are scarce and lapidary presented.
In the following we review some of them:
- there are individual factors (stress load, stress
vulnerability) which determine the increase of allergic
reactions incidence (5);
- patients with drug intolerance showed that they
repress their emotions, but have a high capacity to express
their depressive mood (6);

- allergic patients have a five times bigger risk to develop


panic troubles and agoraphobia, compared to normal (7);
- patients with chronic urticaria are more anxious and
depressed (8);
- urticaria syndrome is associated to an extensive
psychological involvement; in idiopathic chronic urticaria,
pseudo-allergic reactions to drugs are frequent, the favorable
factor being the psychological vulnerability to stress (9);
- psychological troubles, secondary to allergy or
pseudo-allergic reactions to drugs (real somato-psychic
recoil) can be classified into (10):

reactions to symptom:
1. respiratory causes (nasal obstruction, asthma attack)
can determine irritability, depression, insomnia;
2. cutaneous causes (urticaria, angioedema) can
determine insomnia, anxiety, obsessive-compulsive
reactions to the allergens;
3. anaphylactic causes can determine vertigo, anxiety,
panic.
Anaphylactic shock
Serum disease
Drug fever
Hypersensitivity vasculitis
Cutaneous manifestations (urticaria, angioedema):
polymorphic erythema, Stevens-Johnson syndrome, Lyell
syndrome, contact dermatitis)
Pulmonary manifestations (bronchial asthma)
Hematological disorders (eosinophilia, thrombocytopenia,
hemolytic anemia)
Hepatic disorders
Renal disorders (nephritic syndrome, acute renal
insufficiency)
Cardiac disorders
Neurological disorders


reaction to situation:
1. reactive behavioral syndromes in adult (e.g. fear
of repetitive allergic accidents, inferiority complexes,
isolation);
2. behavioral syndromes in children (e.g. emotional
insecurity, need for protection, lack of self-confidence,
compensatory aggressiveness, isolation;
- at provoking tests, the emotional load may be
increased if the patient presents neurotic, hypochondriac or
hysteric symptoms (3);
- allergic outpatients have a high rate of anxious end
depressive troubles (11);
- female patients with drug allergy have a high score of
hysteria and depression (12);
- patients with drug allergy type reactions poses a
particular psychological background, with high stress
vulnerability. Their levels of vulnerability are higher than
the levels encountered with healthy patients, but lower than
the levels encountered at psychotic patients (13).

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

- release of neuro-vegetative mediators (acetylcholine,


substance P, neuropeptides);
- release of stress hormones which can lead to vasomotor
disorders;
- the action of cytokines (interleukins), liberated by
neurons;
- the conditioned reflex mechanism (which explain not
only the unleash of real clinic symptoms or urticaria attack,
but also atypical symptoms mimicking drug allergy).
There are different modalities in which the psychological
factors (distress, emotional strain, positive emotion) can
play a role in genesis and evolution of drug allergy type
reactions:
- the somatic terrain of allergic patients supposes,
beside a facile Ig E secretion, the presence of high trend
in releasing of the allergic reaction mediators, due of the
action of psychic stimulus ;
- psycho traumatic factors co-participate to the onset
of the allergic state (repeated stresses enclosed with the
frequent contact with the allergen rise the potential of the
allergic reaction onset);
- psychic factors increase the allergic reaction.
Acute and basic psychic features of patients with
allergic-type reactions to drugs
The main problem of the patient allergic to drugs, as
well as the problem of his physician, is the repeatability of
the allergic accident, a possibility that induces anxiety to
both, caused especially by the situation where drug therapy
cannot be avoided, because of the associated diseases the
patient may have.
In this respect, there are several particular aspects:
1.The situation of patients with allergic-type druginduced accidents that do not have to treat an associated
disease. These patients only develop anxiety regarding an
undefined future, when they will have to use drugs. The

REFERATE

Types of symptoms specific for allergy to drugs


Previously (5, 14) we have considered that this can
include the following clinical-pathogenic reactions:
(1) objective clinical manifestations mainly cutaneous,
but also respiratory, digestive or systemic syndromes,
effectively determined by drugs per se through allergic
mechanisms (allergia vera), or by pseudo-allergic ones
(with an identical clinical picture including asthma,
urticaria syndromes, shock, triggered by vasoactive
mediators and by muscular-constricting substances
liberated by effectors such as mast cells, basophiles and the
cells of inflammatory infiltrate without occurrence of the
antigen-antibody reaction, as is the case of AINS drugs or
of those who non-specifically and directly de-granulate the
mast cells, such as codeine, dextrane, etc.);
(2) subjective symptoms, presented or interpreted
as allergic appeared only in the context of a drug
administration. These are, in fact, neurotic reactions
(frequently reflex-conditioned), mimicking a previous true
allergic episode (including moderate fall in blood pressure
(14), but as a rule, neuro-vegetative disturbances with
subjective symptoms such as headache, vertigo, extreme
anxiety, fainting).
Most frequently clinicians consider the objective
symptoms described in the first group, as having only a
secondary psychic component, but later on the subjective
symptoms from the second group may generate serious
problems to professionals that are less used to allergologic
illnesses.
Psychological factors triggers in the onset of
allergic reactions
Psychological factors act through following
mechanisms:
- non specific release of the mediators of the allergic
reaction (histamine, serotonin);

Heather Suckling and Lenka Speigt at the 16th International Balint Congress, Brasov, Romania

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

REFERATE

most frequent situation is that of dental procedures, related


to administration of anesthetic and/or antibiotics and
analgesics.
2. The situation of patients that have suffered
severe allergic or pseudo-allergic episodes (especially
anaphylactic shock or glottis edema) and who need drug
therapy for some chronic disease. These patients may
present with two types of clinical-psychological pictures:
a. background psychological condition, in which
case one will find (9, 15):
- an increased degree of basal, non-specific anxiety;
- true phobia for illness in general (nosophobia), and
especially for drugs;
- an increased preoccupation (sometimes of neurotic
intensity) for the probability that a chronic illness may
occur, that will need to be treated with drugs;
b. acute psychic and neuro-vegetative manifestations,
during attempts to introduce new drugs (more rarely, even at
each administration of the respective drug), which include:
high anxiety, tachycardia, dyspnea , headache, vertigo and
cenestopathies. These symptoms will appear even when
placebos or innocent drugs are administered.
As a rule, neuro-vegetative symptoms (true
psychosomatic disturbances) mimic the clinical picture
of subjective manifestations induced by previous drug
administration, but can also be the clinical expression of
extreme anxiety, even panic attacks, as we have seen in
two patients with allergy to penicillin and norfloxacin,
respectively.
Personality type and psychic symptoms of patients
with allergic reactions to drugs
Two sub-populations can be distinguished, from the
viewpoint of personality features, corresponding to the two
clinical-pathogenic groups defined above:
1) Patients with pure allergy or with pseudo-allergy
to drugs (group A)
When the MMPI questionnaire (Minnesota Multiphase
Personality Inventory) was applied to these patients it
evidenced marked personality features in most of the
clinical scales, with amplitudes similar to that of other
control patients suffering from psychosomatic disturbances:
allergic patients (with asthma and urticaria), or non-allergic
patients (with ulcers and hypertension) (16, 17).
From the 79 patients that we investigated, 55,7% had
T values over 70 percentile on the Hs (Hipocondria), D
(Depression) and Hy (Hysteria) scales, constituting together
the so-called neurotic triad. Also, a record of events on
the Holmes and Rahe scale showed that 82,3% of these
patients had a total score over 300 points, with regard to
the summation of psycho-traumatizing events occurred in
the last 6 months preceding the allergic-type reactions to
drugs.(17).
Almost all the patients (73 pts. from 79) had neurotic
symptoms (according to the Predescu and Nica-Udangiu
questionnaire), but less numerous (less than 5 symptoms) than
the other sub-population with allergic-like psychosomatic
disturbances (group B) and there were 6 patients without

any neurotic symptoms. (18). The subgroup of 79 patients


with true allergic and pseudo-allergic reactions to drugs can
be considered as a mixed population from the viewpoint of
clinical symptoms and of nosologic classification of these
purely psychosomatic patients with no, or very few neurotic
symptoms.
Beside these non neurotic allergy patients, practically
with-out neurotic symptoms, the lot A included also 10
patients with allergic-type reactions to drugs showing
associated neurotic symptoms (more than 5 symptoms),
especially secondary to their reactions. There is a significant
correlation in these patients between the high values (>70
percentiles) on the scale of neurotic triad, and the increased
number of neurotic symptom.
2) Patients with psychosomatic disturbances mimicking drug allergy on repeated administration
of drugs (other than the initial ones, that had triggered
allergic-type reactions) (group B). This subgroup included
40 patients with characteristics indicating coexistence
of a true neurosis, both by the large number of neurotic
symptoms (>5) found in almost each patient (90% of all
cases), and by the high values of T levels on the neurotic
triad scales as evaluated with the MMPI Questionnaire
(96% of all cases).
All the patients had been submitted to psychical stress,
and had scores above 300 points on the Holmes and Rahe
Scale over the last 6 months that had preceded the first
episode of allergic-type intolerance to certain drugs.
Differentiation of the group B with psychosomatic
disturbances that mimic allergy or pseudo-allergy, from
that represented by patients with true allergy or pseudoallergy to drugs was made on the basis of the induction
tests with drugs that were well-tolerated afterwards by
the real drug allergic patients from the clinical viewpoint.
Psychosomatic disturbances manifested by the neurotic
patients (group B) occurred mainly in the first test, when
a placebo was given, that the patient believed to be a
clinically- active preparation , and to which laboratory tests
had indicated the probability of full tolerance.
Concluding on these relationships mentioned above the
following can be inferred (19):
a.) The permeability factor for the onset of allergictype reactions to drugs, as well as of neurotic disturbances
secondary to these reactions was the overall vulnerability
to stress of most of the patients, as demonstrated with
the psychological MMPI test, which showed values
characteristic for neurotic patients(the neurotic triad:
Hs+Hy+D) in 55,7% of the cases in the first group (A) (with
lower neurotic disturbances), and in 90% of the patients in
the second group (B) (with chronic neurotic disturbances
and noisy psychosomatic reactions to placebo testing).
b.) In the vast majority of patients with allergic-type
reactions to drug 82,3% of the 79 patients with exclusive
allergic or pseudo-allergic reactions to drugs group and in
100% of the 40 patients with initial allergic reactions followed
by psychosomatic disturbances to placebo administration
the presence of major stresses was noted, before the onset
of first allergic- type manifestations, and these stresses

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

One could maintain, on the basis of the abovementioned results, that patients with allergic-type reactions
to drugs are, in a large majority, truly neurotic patients:
1) Real neurotic patients with prior drug-like induced
allergy symptoms
Patients presenting with exclusive and extensive
psychosomatic disturbances (mimicking the anaphylactic
subjective symptoms), which occur at every administration
of drugs (or of a placebo), following an initial true allergic

or pseudo-allergic drug reaction (group B). These patients


constitute an almost totally neurotic population (with 95%
manifesting over 5 neurotic symptoms with the Predescu
and Nica-Udangiu Questionnaire). Their vulnerability to
stress is extreme and the period preceding the occurrence
of the first true allergic reaction to drugs was marked, in all
of these subjects, by major or numerous psychical stresses;
2) Patients with well-expressed allergic-type reactions
to drugs.
These patients have a lower mixed (non neurotic and
neurotic) population of a lower level of psychosomatic
disturbances. They do not react to placebo administration,
neither to other drugs that were given later (group A).
Even in these patients, a large number of major psychical
stresses were recorded in the period that preceded the first
reaction to drugs and an increased vulnerability to stress
was also demonstrated in this group , although not as high
as in neurotic patients or of those from group B. With regard
to the presence of neurotic symptoms, these authentic
allergic or pseudo-allergic patients can be separated in two

sub-populations:
- Neurotic patients but with a lower number of
symptoms than patients in the group B and without the
noisy psychosomatic disturbances when new drugs or
placebo preparations are given;
- Patients without/ or with low levels of neurotic
complaints.
What appears to be interesting is the difference from
the viewpoint of neurotic symptoms (however, only in a
low number of cases), between patients that are allergic
to drugs (for instance, to penicillin), and those with
pseudo-allergies to drugs (as a rule to aspirin and other
AINS). This difference consisted, in the patients that we
have investigated, in the low level or absence of neurotic
symptoms only in those with pure allergy to drugs.
However, these observations cannot be generalized because
we have examined before other patients, which were
highly neurotic and had antecedents of allergic reaction to
penicillin or to other drugs, different from AINS.
Table 2
To conclude (also see table 2):

- Patients with allergic-type reactions to drugs display


very frequently psychical disturbances, possibly in relation
to the large amount of stress perceived by them;
- Many of these patients are neurotic and a large part
of them show a disproportionate reaction, manifested as
extensive psychosomatic disturbances, mimicking the
psychic and somatic symptoms of a previous anaphylactic
or anaphylactoid reaction, when a new drug or even when
placebo preparations are given;
- The neurotic symptoms, very frequently encountered
in patients with allergic-type reactions to drugs (including
asthma patients) appears to be secondarily-induced by
the anxious experience of the drug-provoked accident.
This authentic somato-psychic reaction to drug allergy
can be conditioned in some patients (see group B), but it
achieves this secondary neurotic state only when certain
personality features already exist (that can even reflect
personality disturbances!), making these patients highly
vulnerable to psychical stress;

REFERATE

were later exacerbated by the psychologically-traumatizing


experience of drug-induced accidents, including the fear
for their possible recurrence.
c.) Neurotic symptoms evidenced by us in patients with
allergic-type reactions to drugs (considered at present to
be neurotic disturbances of personality) were present in
these patients. either in an isolated form of 1-2 symptoms
(for instance: anxiety and depression), with a transient
evolution, either as true neurotic syndromes with a
chronic evolution.
Drug allergy or pseudo-allergy patients as patients
prone to psychiatric syndromes.

REFERATE

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

- The vulnerability to psychic stress, together with


many life stressors events may represent a potential risk
for developing drug allergy in a predisposed patient, but
this hypothesis emerged from our studies has yet to be
demonstrated.
We want to emphasize that personality traits of patients
with drug allergy refer to two major aspects (19):
Psychological vulnerability to stress, which supposed
a high reactivity to stress, preexistent or secondary induced
by allergy. This vulnerability to psychic stress is formed
during the individuals life, in tight correlation with
immunogenic traits and depending on the experience of
stress and the manner of facing the stressor events. Also,
at patients with drug allergy, due the anticipation of an
allergic type-reaction, there is described a state called
helplessness- hopelessness, which diminish the coping
strategies (cognitive and behavioral conscious strategies
elaborated to tolerate and manage a stressful situation);
Anxiety, as a basal, non-specific anxiety (which
increases with the repeating of allergic accidents), or as an
anxious waiting for the allergic accidents that may occur.
Beside anxiety, patients with allergic-type reactions
may develop fear about a new allergic accident, phobia
of illness and drugs, depression, intense neuro-vegetative
manifestations, increase of vulnerability to stress, even
assuming high pain (to avoid medication).
These patients also develop psychological reactions to
treatment:
- psychological and psychosomatic manifestations:
once a new drug is administrated, the patient is at risk for
headache, dizziness, tachycardia, extreme anxiety, or even
panic attacks;
- adherence decrease, with or without appeal to
alternative medicine.
If drug allergy has or has not vital risk, patients with
allergic-type reactions will use adaptative strategies, such
as (20):
reorganization of the relationship with others;
reorganization of the self image;
affective and behavioral regression;
emotional reactions (anxiety, depression);
problem-centered coping (e.g. analyzing, resolving/
minimizing the situation) or emotion-centered coping (e.g.
denying, resignation, fatalism).
There is also an aspect which we must not overlooked
(and which is often disregarded) - the psychological impact
of allergic-type reactions on physicians: excessive alert
about patients with drug allergy, avoidance or further
referral of these patients, delaying the treatment, confusion
(e.g. neuro-vegetative and allergic reactions, dyspnea
and glottal edema/asthma attack), avoidance of multiple
medication.
A recent experimental research (21) found that the
average scores at anxiety and depression were significant
increased in patients with drug allergy comparing with
the control group. The scores at Stress Vulnerability
Scale (between 32 and 65 points) correlated with high
scores at Perceived Stress Scale (.408, p<0.01). Also this

research found a peculiar type of reaction of the cutaneous


perspiration to music (used as a psychosomatic stimulus):
sweat secretion was significant increased at the forehead
and palms in group of patients with drug allergy after the
audition of each musical fragment, but especially after the
fragment with sad music pieces. In control group sweat
secretion was significant increased only after the sad music
fragment, but the level was lower comparing with the
patients group.
Conclusions
The approach of patients with allergic-type reactions
implies (19):
analysis of the relation drug- allergic reaction;
complete investigation: anamnesis, clinic, biological;
caution for treatment and substances known with
allergic risk;
strict supervision of the medical treatment;
a placebo test before testing the drug;
supportive psychotherapy, encouragement, optimistic
attitude;
treatment of neurotic symptoms.
All of these are important and useful because allergictype reactions to drugs (19):
are influenced, beside the atopic terrain, by the
psychological characteristics (e.g. vulnerability to stress);
through various clinical manifestations, they develop
and strengthen the vicious psycho-somato-psychic circle;
need physicians attention to both clinical and
emotional aspects;
through their clinical and psychological correlates
affect quality of life and patients satisfaction;
require the association of supportive or special
psychotherapies.
References
1. Andreson, J.A.. Allergic and allergic-like reactions to drug
and other therapeutic agents, In: Allergic Diseases, Diagnosis and
Treatment, Ed. Liberman P. and Anderson J. A., Humana Press,
Totowa, New Jersey, 1997, 16, 275-294;
2. Vervloet, D., Durham, S. Adverse reaction to drugs, BMJ,
1998, 316, 1511-1514;
3. Alecu, M; Alecu Silvia Reacii alergice la medicamente,
Editura Medical, Bucureti, 2002;
4. DeSwarte, R. D., Patterson, R. Drug allergic diseases.
Diagnosis and management, Ed. R. Patterson, Edit. Lippincott
Raven Publishers, Philadelphia- New York, 1997, 17, 317-412;
5. Iamandescu, I.B. Considerations on some psychological
and psychiatric aspects of allergy, based on personal studies ,
Rev. Roum. Psychol. Sciences Sociales - Psychologie, 31,1, 1987,
p.81-84;
6. Patriarca, G.; Schiavino, D.; Nucera, E.; Colamonic,
P.; Montesrchio, G.;Saracini, C. Multiple drug intolerance:
Allergological and Psychological findings, J. Investig.Allergol
Clin Immunol, 1991, Apr, 1(2), 138-44;
7. Cicioglu, B. The interrelatioships of allergy, infections and
the psyche, in Mikrobiyoloji Buteni, 27(4), oct.1993, p.364-377;
8. Hashiro, M., Okumura, M. Anxiety, depression,
psychosomatic symptoms and autonomic nervous function
in patients with chronic urticaria, Journal of Dermatological

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16. Iamandescu, I.B. Corelaii psiho-somatice n astmul
bronic. Tez de doctorat, IMF Bucureti, 1980;
17. Iamandescu, I.B.; Popa-Velea, O. Neurotic
symptomatology in allergic and in non allergic asthma patients,
Allergy, 1995, 50, 26, 310;
18. Iamandescu, I.B., Horopciuc, M., Popa, D.P. - Incident
and Chronology of nevrotic trouble at rash patients. Psychiatrie
et condition humaine. Psihomnia Press. Publications de lHpital
Universitaire de Psychiatrie Socola, Iassy, Roumanie.1996,
pp.135-138;
19. Diaconescu, L., Iamandescu, I.B. Allergic-type
reactions to drugs, In: Psychoneuroallergology (second edition),
Ed. Iamandescu I.B., 2007, Amalteea Medical Publishing House;
20. Diaconescu, L.V. Psychological problems of patients
with drug allergy, 26th European Conference of Psychosomatic
Research, Dubrovnik, Croatia, 2006;
21. Diaconescu, L.V., Constantin, M., iplica, G.S.
Psychometric and experimental aspects (sweat secretion related
to music listening) in patients with drug-induced urticaria,
Dermathology, vol.54, nr.1, supl.1, 2009, Bucharest.

REFERATE

Science, 8, 1994, p.129-135;


9. Iamandescu, I.B.; Popa-Velea, O.; Mazuru, G.
Psychological parameters in patients with allergic and pseudoallergic reactions to drugs, Allergy, 1997, 52, suppl., 37, 127;
10. Iamandescu, I.B. Psychoneuroallergology, Editura
Romcartexim, Bucureti, 1998;
11. Stauder, A.; Kovacs, M. Anxiety symptoms in allergic
patients: identification and risk factors, Psychosom Med 2003,
Sep-Oct, 65(5), 816-23;
12. Berino, A.M.; Voltolini, S.; Biguardi, D.; Fasce, C.;
Minale, P.; Macchi, M.;Troise, C. Psychological aspects of drug
intolerance, Allerg Immunol (Paris), 2005, Mar, 37(3), 90-5;
13. Iamandescu, I.B.; Popescu, C.; Florea, M.; Vintil, I.;
Mihilescu, A. Stress vulnerability in patients with drug allergy
type reactions, 26th European Conference of Psychosomatic
Research, Dubrovnik, Croatia, 2006;
14. Seropian, E., Iamandescu, I.B. False reacii alergice la
medicamente induse de experiena psihotraumatizant a unor ocuri
anafilactice la peniciline, Viaa Medical, 1980, 37, 401-403;
15. Iamandescu, I.B. Principles of psychosomatic approach
of allergy patients, Rev.Roum.Psychol., T.37, nr.1, 1993, p.79-90;

Deschiderea festiv al celui de-al 16-lea Congres Internaional Balint

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

TULBURRI MENTALE N SINDROMUL METABOLIC


(Analiza publicaiilor din ultimii 10 ani)

As. Univ. Dr. Delia Lupu, Prof. Dr. D. L. Dumitracu


Univ. de Medicin i Farmacie Iuliu Haieganu Cluj Napoca

REFERATE

Rezumat:
Sindromul metabolic este un factor de risc
important pentru dezvoltarea diabetului zaharat, a
bolii cardiovasculare i pentru mortalitatea prematur.
Domeniul actual de cercetare prezint un interes n cretere
n studierea comorbiditii tulburrilor mentale i somatice
iar n ceea ce privete sindromul metabolic un interes
particular l prezint asocierea acestuia cu tulburrile
psihice. Pn recent, toat atenia cercettorilor a fost
dedicat aproape exclusiv studierii sindromului metabolic
la pacienii cu schizofrenie i legturii dintre acesta i
tratamentul antipsihotic. Mai recent, s-a ridicat problema
unor preocupri similare pentru pacienii cu tulburare
bipolar, depresie i sindromul distresului posttraumatic.
Toate aceste tulburri psihice sunt frecvent asociate cu
sindrom metabolic. Depresia major, sindromul tulburrilor de stres posttraumatic i schizofrenia sunt asociate cu
factorii de risc tradiionali cardiovasculari: hipertensiunea
arterial, obezitatea, dislipidemia aterogena, prevalena
crescut a diabetului zaharat, activitatea fizic sczut.
La muli pacieni psihiatrici, aceti factori de risc sunt
subestimai, tratai insuficient sau modest controlai.
Studiile care vor urma, care au ca obiect gradul asocierii
ntre componentele sindromului metabolic i diferitele
tulburri psihice, vor fi utile n implementarea metodelor
preventive i intervenionale la pacienii psihiatrici cu risc
pentru boli cardiovasculare i diabet zaharat tip 2.
Abstract:
Metabolic syndrome is an important risk factor for
the development of diabetes mellitus, cardiovascular
disease and premature mortality. Recent research presents
a growing interest in studying comorbid mental and
somatic disorders and regarding the metabolic syndrome
a particular interest presents the association between
this syndrome and mental disorders. Until recently full
attention has been devoted almost exclusively to the
metabolic syndrome in patients with schizophrenia and
its relationship to antipsychotic treatment. More recently,
similar concerns have arisen for patients with bipolar
disorders, depression and posttraumatic stress disorder.
All these mental disorders are frequently associated with
metabolic syndrome. Major depression, posttraumatic
stress disorder and schizophrenia are associated with the
traditional cardiovascular risk factors: elevated blood
pressure, obesity, atherogenic dyslipidemia, increased
prevalence of diabetes, low physical activity. In many
psychiatric patients, these risk factors are underestimated,
undertreated or poorly controlled. Further investigation
about the degree of association between the components

10

of metabolic syndrome and mental disorders could help in


implementation of preventive and interventional efforts for
psychiatric patients at risk for cardiovascular disease and
type 2 diabetes.
Sindromul metabolic este prin definiie o tulburare
multisistemica. Aceast denumire, cea de sindrom X sau
sindromul insulinorezistenei reprezint termeni destinai
s descrie grupul de anomalii metabolice i cardiovasculare
incluznd obezitatea abdominal, hipertensiunea arterial,
dislipidemia, hiperuricemia i anomaliile homeostaziei
glucozei (insulinorezistena, intolerana la glucoz, sau
diabetul zaharat) (1).
Conform criteriilor NCEP / ATP III (al IIIlea Raport
al Programului Naional de Educaie pentru colesterol,
Expert Panel n detecia, evaluarea i tratamentul
hipocolesterolemiant la aduli), sindromul metabolic este
definit prin prezena a minimum trei din urmtorii factori
de risc: obezitate abdominal (circumferina taliei peste
102 cm la brbai i 88 cm la femei), nivelul trigliceridelor
serice crescut ( 150 mg / dl ), nivelul HDL-colesterolului
seric sczut (< 40 mg / dl la brbai i < 50 mg /dl la femei),
TA 130 / 85 mm Hg, i nivel crescut al glicemiei jeun
( 110 mg /dl).
Modul cel mai bun de a defini i conceptualiza
sindromul metabolic este n continu dezbatere, astfel
nct asocierea sindromului metabolic cu alte laturi ale
morbiditii constituie subiectul unor importante arii de
cercetare.
Corelaii patogenetice ntre tulburrile mentale i
sindromul metabolic
Dovezi recente (2) au sugerat c dereglarea axului
hipotalamopituitar-adrenal (HPA) poate juca un rol
semnificativ n dezvoltarea variatelor componente ale
sindromului metabolic. n timp ce producia de cortizol este
un rspuns normal la stresul acut, diferite studii (3,4,5) au
demonstrat o ntrerupere n activitatea normal a axului HPA
i o relativ hipercortizolemie la pacienii cu schizofrenie.
Creteri cronice a nivelului cortizolului plasmatic pot
conduce la un pseudo-Cushing sindrom caracterizat
prin adipozitate visceral crescut, hiperinsulinemie,
insulinorezisten, dislipidemie i hipertensiune arterial
(6), markeri ai sindromului metabolic.
Mult mai recent, Shiloah i colegii si (7) au studiat un
grup de 34 pacieni nediabetici supui unui stres acut psihic
i au examinat efectele stresului psihic asupra homeostaziei
glucozei. Ei au demonstrat c pacienii expui unor situaii
acute stresante necesitnd tratament psihiatric de urgen,
au prezentat ntreruperi n funcia celulelor beta pancreatice
i sensibilitate la insulin care au fost corelate invers cu

gradul lor de stres, sugernd c severitatea bolii poate avea


un impact crescut asupra funciei axului HPA.
Veriga patogenetic comun ntre obezitate, diabet,
tulburrile mentale i sindromul metabolic poate fi
hipercortizolemia. Hipercortizolemia a fost observat la
pacienii cu diabet (8, 9) dar de asemenea i la pacienii
cu tulburare uni sau bipolar (10, 11). Hipercortizolemia
conduce la obezitate visceral care a fost observat i la
pacienii cu depresie major (12, 13). Obezitatea visceral
este asociat cu insulinorezisten i diabet (14). O ipotez
leag stresul din mediu cu hiperactivitatea hipotalamic i
secreia de cortizol care iniiaz perturbri fiziologice care
cauzeaz sindromul metabolic (15, 16).
Investigaiile clinice n ceea ce privete sindromul
metabolic la pacienii cu tulburri mentale uni sau bipolare
sunt limitate mai ales printr-un numr mic de subieci
studiai. Totui, asocierea dintre sindromul metabolic i
simptomele psihice a fost studiat, informaii considerabile
fiind disponibile mai ales n ceea ce privete interrelaia
dintre diferitele componente ale sindromului metabolic
ca obezitatea abdominal, hiperglicemia, diabetul zaharat
i tulburrile mentale. Sindromul metabolic este ntlnit
mai frecvent n tulburrile mentale i mai puin frecvent
n tulburrile de personalitate, dei este cunoscut faptul c
tulburrile de personalitate reprezint frecvent prodromul
unor tulburri psihice severe.
Tulburarea depresiv major (Major depressive
disorder)
Dei majoritatea studiilor anterioare au fost focalizate
asupra riscului sindromului metabolic la persoanele cu
schizofrenie, recent s-a demonstrat c persoanele cu
tulburare depresiv major (unipolar disorder) prezint un
risc asemntor pentru dereglri metabolice(17). Tulburrile
depresive majore sunt mai comune dect schizofrenia, sunt
tratate cu o categorie mai larg de medicamente psihotrope
prezentnd un interes particular n ceea ce privete obiectul
cercetrilor actuale.
ntr-un studiu efectuat i prezentat la a 160-a ntlnire
a Asociaiei Psihiatrilor Americani, a fost examinat
prevalena sindromului metabolic i a fiecruia din cele
cinci criterii pentru acest sindrom. Au fost studiai un
numr semnificativ de pacieni psihiatrici (n=912) cu
vrste cuprinse ntre 18 i 64 ani, cu diagnostic clinic de
tulburare depresiv major i un alt lot similar de pacieni
cu schizofrenie. Abuzul de alcool sau dependena de alte
substane a fost comorbid n 57% din cazurile cu tulburare
depresiv major i n 39 % din cazurile cu schizofrenie.
Cercettorii au demonstrat c n lotul cu tulburare
depresiv major, 22% din pacieni au ntrunit criteriile
ATPIII pentru sindromul metabolic i cel puin unul din
cele cinci criterii pentru acest sindrom au fost prezente
la 75% din pacieni. Nu au fost diferene n prevalena
sindromului metabolic n cele dou grupe de pacieni i n
proporia pacienilor care au avut cel puin un criteriu din
cinci dar aceste procente au fost cu mult mai mari dect
n populaia general. La cele dou loturi de pacieni,
cu tulburare depresiv major i cu schizofrenie au fost
diferene statistice doar n ceea ce privete prevalena

hipertrigliceridemiei la pacienii cu tulburare depresiv


major.
Dei grupurile de pacieni cu tulburare depresiv
major i cu schizofrenie nu au fost diferite n ceea ce
privete grupele de vrst, proporia de femei a fost
semnificativ mai mare. Sexul feminin a fost mult mai
aproape de a ndeplini criteriile circumferinei taliei i
s prezinte cel puin un criteriu din cinci. La pacienii
cu tulburare depresiv major, nici o medicaie nu a fost
asociat cu sindromul metabolic sau prezena unui criteriu
indirect. Chiar i n schizofrenie, cel puin cteva criterii
ale sindromului metabolic apar ca fiind independente de
expunerea la medicamente. Studiul menionat a demonstrat
c persoanele cu tulburare depresiv major pot prezenta un
risc mai crescut dect s-a crezut anterior, pentru dezvoltarea
sindromului metabolic. La femei dar nu i la brbai, o
istorie de tulburare depresiv major, dubleaz ansele
dezvoltrii sindromului metabolic (17). Exist o varietate
considerabil n ceea ce privete factorii de risc pentru
sindromul metabolic dar de asemenea i o variabilitate n
prezentarea acestuia. Prezena chiar a unui singur criteriu
pentru sindromul metabolic constituie un semnal pentru
evitarea progresiei spre sindromul complet.
n ceea ce privete relaia dintre sindromul metabolic,
stres i axul HPA s-a demonstrat c valori crescute ale
cortizolului plasmatic sunt strns asociate cu depresia (mai
puin i cu diabetul zaharat i hipertensiunea arterial) dar
nu i cu dislipidemia (17).
Tulburrile din Depresia Major sunt asociate cu
obezitate abdominal crescut. Aceast patologie este
acompaniat de tulburri endocrine i imune care au legtur
i cu patogeneza diabetului zaharat non-insulinodependent
i cu boala coronarian ischemic. Recent s-a demonstrat
c n patogeneza sindromului metabolic intervine i un
status proinflamator i procoagulant.
Un studiu efectuat la Departamentul de Psihiatrie a
Universitii din Luebeck a avut ca i obiectiv examinarea
la persoanele depresive a adipozitii viscerale,
insulinorezistenei i alterrilor cortizolului i citokinelor
plasmatice. La femei tinere cu depresie major, adipozitatea
abdominal a fost msurat utiliznd tomografia cu rezonan
magnetic, demonstrndu-se adipozitate viscerala crescut
la cazurile cu tulburri depresive majore. Concentraiile
serice a dou dintre citokinele plasmatice (Interleukina 6
i Factorul de Necroza Tumoral Alfa) au fost semnificativ
crescute la grupul cu depresie. Lotul de femei tinere
care a prezentat o cretere a obezitii abdominale poate
constitui un grup de risc pentru dezvoltarea diabetului
zaharat non-insulinodependent i a sindromului metabolic.
Datele acestui studiu sprijin ipoteza c dereglrile imune
i endocrine asociate cu tulburrile depresive majore pot
contribui la procesele fiziopatologice asociate cu diabetul
zaharat non-insulionodependent.
Un studiu efectuat la Universitatea din Utah, SUA
i prezentat la a 67-a ntlnire tiinific a Asociaiei
Americane de Psihosomatic, Chicago 2009, a studiat
relaia dintre mariaj, simptomele depresiei i sindromul
metabolic sugernd ipoteza c depresia poate avea rol de

11

REFERATE

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

Cortizolul, principalul hormon generat n stres,


este responsabil pentru activarea lipolizei, proteolizei,
gluconeogenezei i insulinorezistenei. Hipersensibilitatea
axului hipotalamopituitaradrenal ca o consecin a
evenimentelor nefavorabile din copilrie conduce la o
expunere frecvent a esuturilor organismului la nivele
nalte de cortizol care cel mai probabil sunt responsabile
pentru dereglarea rspunsurilor imune i a funciilor
metabolice, cu dezvoltarea sindromului metabolic
caracterizat prin obezitate, insulinorezistena comparabil
cu diabetul zaharat tip II, boala cardiovascular i
mortalitate prematur.
Evenimentele adverse din copilrie care se cunoate
c sunt implicate n dezvoltarea tulburrilor de grani
ale personalitii, constituie un factor de risc considerabil
i serios subestimat i pentru sindromul metabolic. n
cadrul unui studiu efectuat la Departamentul de Psihiatrie
a Universitii din Bruxelles, a fost urmrit metabolismul
cerebral al glucozei, la un grup de pacieni cu tulburare
de grani a personalitii demonstrndu-se un relativ
hipometabolism la nivelul ariilor corticale prefrontale i
la nivelul nucleilor cerebrali talamic, caudat i lenticulari
( 20 ). Studiul a demonstrat la aceti pacieni prezeni de
tulburri metabolice cerebrale semnificative i o dereglare
a sistemului hipotalamo-pituitar-adrenal.
Schizofrenia (Schizophrenic disorder)
Frecvena sindromului metabolic la pacienii cu
schizofrenie variaz ntre 19% i 63%. Pacienii cu
schizofrenie prezint un risc crescut de a dezvolta sindrom
metabolic datorit mai multor factori incluznd dereglarea
axului hipotalamo-pituitar-adrenal, stil de via inactiv,
resurse dietetice reduse, nivel mai sczut al testosteronului
plasmatic, comportament negativ n ceea ce privete
fumatul i efectele secundare ale medicaiei psihotrope
(21). Studii efectuate pe subieci cu schizofrenie, au
demonstrat c femeile cu schizofrenie prezint un indice
de mas corporal mai crescut comparativ cu pacienii cu

REFERATE

mediator spre dezvoltarea sindromului metabolic pornind


de la anumii factori psihosociali. Studiul a examinat
asocierea aspectelor pozitive (suport, prietenie, loialitate)
i negative (conflicte, ostilitate, dezacorduri) ale calitii
mariajului cu sindromul metabolic i rolul de potenial
mediator al depresiei n aceast asociere.
Chestionare incluznd simptome depresive i indicatori
ai calitii mariajului au fost completate de un numr de
276 cupluri. Participanii au fost supui unor msurtori
fizice (circumferina taliei, msurarea tensiunii arteriale) i
unor determinri de laborator a nivelului glucozei serice,
HDL-colesterolului i trigliceridelor serice, din aceste
determinri rezultnd diferite variabile pozitive i negative
ale procesului marital, simptome depresive i elemente
pentru sindromul metabolic.
Rezultatele au sugerat c pentru soii, aspectele negative
ale mariajului sunt asociate cu sindromul metabolic prin
relaia lor cu simptomele depresive. Concluzia studiului a
fost c depresia poate avea rol de mediator spre dezvoltarea
sindromului metabolic pornind de la factori psihosociali
adveri, doar pentru sexul feminin. Ecuaiile: procese
maritale negative simptome depresive sindrom
metabolic au fost semnificative pentru soii, iar pentru
soi a fost semnificativ exclusiv relaia procese maritale
negative-simptome depresive. Aceste constatri sugereaz
potenialul impact metabolic al distresului marital i al
simptomelor depresive, n special asupra persoanelor de
sex feminin de vrst medie sau naintat (18).
Tulburarea de grani a personalitii (Borderline
personality disorder)
O descoperire foarte interesant i deloc neglijabil
este corelaia puternic i foarte semnificativ ntre
numrul experienelor adverse nefavorabile din copilrie,
factor etiologic implicat n dezvoltarea tulburrilor de
grani ale personalitii i diferite tulburri somatice ca
obezitatea morbid, diabetul zaharat, hiperlipidemia i
boala coronarian ischemic (19).

Pod peste uscat foto Trif Almos Bela

12

schizofrenie de sex masculin la care corelaia cu obezitatea


abdominal nu a fost statistic semnificativ.
Datele unui studiu efectuat n perioada 1987-1996
sugereaz observaia c prevalena obezitii la pacienii
brbai cu schizofrenie este aceeai ca n populaia
general, n timp ce femeile cu schizofrenie au un risc
mai crescut pentru obezitatea viscerala (abdominal). n
schizofrenie s-au demonstrat valori serice crescute ale
citokinelor proinflamatoare dar studiile disponibile pn n
prezent nu au certificat dac aceste citokine crescute sunt
o component a bolii sau dac ele cresc n ser secundar
activrii stresului. Multe dintre aceste citokine secretate de
celulele adipoase, sunt aceleai citokine care sunt crescute
i n sindromul metabolic.
Alte studii au demonstrat c nivele serice crescute ale
dimetil argininei asimetrice sunt prezente i n sindromul
metabolic i n schizofrenie. Nivelul asimetric de dimetil
arginina este un inhibitor endogen al sintezei de oxid nitric,
acesta fiind un mediator intracelular al activrii receptorilor
NMDA (N-Metil D-Aspartat) cerebrali. Adiional aceasta
poate contribui la descreterea receptorilor NMDA de
la nivel cerebral. Creterea n ser a dimetilargininei
asimetrice se poate datora n parte homocisteinei care este
crescut i n sindromul metabolic i n schizofrenie. Valori
plasmatice crescute ale homocisteinei pot cauza sau pot
rezulta din insulinorezisten i pot indica risc vascular sau
pot fi implicate activ n procesul de aterogenez.Valorile
homocisteinei sunt mai crescute la pacienii cu sindrom
metabolic comparativ cu pacienii fr sindrom metabolic
i sunt crescute n funcie de prezena componentelor
sindromului.
Tulburarea bipolara (Bipolar disorder)
Exist studii care au raportat c pacienii cu
tulburare bipolar prezint o frecven crescut a bolilor
cardiovasculare n comparaie cu subiecii din populaia
general. Tulburarea bipolar este comun asociat cu
ntreruperi ale ritmului circadian, tulburri de somn,
modificri ale sistemului nervos simpatic, hiperactivitatea
axului hipotalamo-pituitaradrenal i tulburri ale
funciei imune. Se consider c toate aceste tulburri pot
avea consecine metabolice semnificative. De exemplu
hipercortizolemia susinut este asociat cu obezitate
visceral i insulinorezisten.
Diferite studii au demonstrat c prevalena tulburrilor
metabolice este crescut printre pacienii cu tulburare
bipolar. Medicaia care este frecvent utilizat pentru
controlul acestei tulburri nu se cunoate c ar contribui la
cretere n greutate, dislipidemie i diabet.
Sindromul distresului posttraumatic (Posttraumatic
stress disorder, PTSD)
Pacienii cu sindromul tulburrilor de stres
posttraumatic prezint o prevalen crescut a afectrilor
somatice i n special a diabetului zaharat i a bolii
cardiovasculare n comparaie cu populaia general. Acest
sindrom se asociaz cu hiperactivitatea sistemului nervos
simpatic, iritabilitate, insomnie, depresie, ntreruperi
ale ritmului circadian, tulburri care pot avea consecine
metabolice.

Studiile disponibile pn n prezent au fost efectuate


pe pacieni cu expunere anterioar la stres i traume
psihice, determinrile serice ale glucozei, trigliceridelor,
colesterolului i msurtorile tensiunii arteriale i ale
circumferinei taliei efectundu-se pe dou loturi de ofieri
de poliie, cu forme severe i forme subclinice de PTSD.
S-a raportat c aproximativ 16 % din ofierii de poliie care
ndeplineau criteriille ATPIII pentru sindromul metabolic,
ofieri cu forme severe de PTSD prezentau o prevalen de
trei ori mai mare a sindromului metabolic n comparaie cu
ofierii cu forme subclinice de PTSD.
n alt studiu efectuat pe dou loturi de veterani de
rzboi, sindromul metabolic a fost identificat la 66.7 % din
veteranii de rzboi cu forme severe de PTSD n comparaie
cu 23.3 % din veteranii cu forme uoare de PTSD.
Tulburarea anxioas generalizat (Generalized
anxiety disorder)
Doar cteva studii au explorat relaia dintre sindromul
metabolic i tulburarea anxioas generalizat, cel mai
relevant fiind un studiu larg cu participani brbai, veterani
americani (numr = 4256), recrutai din Studiul Experienei
din Vietnam, determinndu-se prevalena tulburrii
anxioase generalizate de-a lungul unui an, la cazurile
selecionate. Sindromul metabolic a fost diagnosticat
folosind indicele de mas corporal, nivelul glucozei serice,
msurtorile tensiunii arteriale, a HDL-colesterolului, a
trigliceridelor serice. Tulburarea anxioasa generalizat a
fost pozitiv asociat cu sindromul metabolic.
Sindromul metabolic, predictor al demenelor la
vrstnici
Conform unui raport al Academiei Americane de
Neurologie, brbaii care prezint simptome de boala
cardiac consecina asocierii insulinorezistensindrom
metabolic, aflai n jurul vrstei de 50 de ani, mult mai
probabil vor prezenta demen vascular n jurul decadei
a 7-a de vrst.
Pacienii cu boala Alzheimer au demonstrat o
ameliorare a memoriei dup infuzie de insulin ceea ce
sugereaz implicaia tulburrilor n metabolismul glucozei,
n fiziologia demenei i elemente patogenetice comune
cu sindromul metabolic, insulinorezistena. Majoritatea
studiilor au demonstrat c asocierea sindrom metabolic
boala Alzheimer este valabil exclusiv la subiecii
vrstnici.
Observarea asocierii ntre nivelul crescut al
trigliceridelor serice, diabet i demena vascular,
accentueaz necesitatea deteciei i tratamentului factorilor
de risc vasculari la persoanele vrstnice n scopul prevenirii
posibilitii apariiei demenei clinice (22 ,23).
Adiional, cteva studii au examinat relaia dintre
sindromul metabolic i factori de risc psihosocial, ca:
depresie, anxietate, tensiune, stres, suferin, demonstrnduse o asociere reciproc ntre variate tulburri afective i
sindromul metabolic. Exist o reciprocitate n relaia factori
de risc psihosociali sindrom metabolic. S-a demonstrat
c pacienii cu sindrom metabolic au experimentat mult
mai frecvent simptomele depresiei, anxietate, tensiune,
iar pacienii cu depresie, anxietate sau supui stresului au

13

REFERATE

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

dezvoltat mult mai frecvent sindrom metabolic, comparativ


cu populaia general.
Factorii de risc psihosociali pot afecta dezvoltarea
sindromului metabolic iar sindromul metabolic nsui
poate fi considerat un predictor al distresului psihologic.
Reducerea nivelului anxietii poate preveni dezvoltarea
sindromului metabolic la sexul feminin (24).
Concluzii
n concluzie putem aprecia c majoritatea studiilor
selecionate pentru a aprecia asocierea sindromului
metabolic cu diferite tulburari mentale, au demonstrat c
pacienii cu tulburari psihiatrice prezint o prevalen mai
crescut a sindromului metabolic sau a componentelor
acestuia, comparativ cu populaia general. Bazat pe acest
risc crescut, controlul periodic al parametrilor metabolici la
aceti pacieni, ar trebui s devin o component obligatorie
n managementul acestor boli.
Prezena chiar a unei singure componente a sindromului
poate impune msuri intervenionale pentru prevenirea
progresiei spre sindromul complet. Unele msurtori
metabolice pot fi mult mai importante dect altele la aceti
pacieni i anumite riscuri pot fi prevenite prin intervenii
terapeutice adecvate (statine, antihipertensive sau printr-o
schimbare a psihotropelor ).

REFERATE

Bibliografie
1. Toalson P, Ahmed S, Hardy T, Kabinoff G. The metabolic
syndrome in patients with severe mental illnesses. Prim Care
Companion J Clin Psychiatry. 2004; 6(4): 152-158
2. Rosmond R, Bjorntorp P. The hypothalamic pituitary
adrenal axis activity as a predictor of cardiovascular disease,
type 2 diabetes and stroke . J Intern Med. 2000; 247: 188-197
3. Thakore JH, Mann JN and Vlahos I. et al. Increased
visceral fat distribution in drug-naive and drug-free patients with
schizophrenia. Int J Obes Relat Metab Disord. 2002. 26:137- 141
4. Jakovljevic M, Muck-Seler D, and Pivac N. et al. Platelet
5-HT and plasma cortisol concentrations after dexamethasone

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supression test in patients with different time course of


schizophrenia. Neuropsychobiology. 1998.37:142-145.
5. Ryan MC, Collins P, Thakore JH. Impaired fasting glucose
tolerance n first-episode , drug-naive patients with schizophrenia
. Am J Psychiatry. 2003; 160: 284-289
6. Ryan MC, Thakore JH. Physical consequences of
schizophrenia and its treatment: the metabolic syndrome Lif Sci
: 2002 ; 71: 239-257
7. Shiloah E, Witz S, and Abramovitch Y. et al. Effect of acute
psychotic stress in nondiabetic subjects on beta-cell function and
insulin sensitivity. Diabetes Care. 2003. 26: 1462-1467.
8. Cameron OG, Kronfol Z, and Greden JF. et al.
Hypothalamic-pituitary-adrenocortical activity in patients with
diabetes mellitus , Arch Gen Psychiatry 1984. 48: 1090-1095
9. Hudson JI, Hudson MS, and Rothschild AJ. et al. Abnormal
results of dexamethasone supression tests in nondepressed patients
with diabetes mellitus. Arch Gen Psychiatry .1984. 41: 1086-1089
10. Rush AJ, Giles DE, and Schlesser MA. et al. The
dexamethasone supression test in patients with mood disorders .
J Clin Psychiatry .1996. 57: 470-484
11. Parker KJ, Schatzberg AF, Lyons DM. Neuroendocrine
aspects of hypercortisolism in major depression. Horm Behav.
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12. Thakore JH, Richards PJ, and Reznek RH. et al. Increased
intraabdominal fat deposition in patients with major depressive
illness as measured by computed tomography. Biol Psychiatry.
1997. 41: 1140-1142
13. Weber-Hamann B , Hentschel F , and Kniest A. et al.
Hypercortisolemic depression is associated with increased
intraabdominal fat. Psychosom Med. 2002. 64: 274-277
14. Goldstein BJ. Insulin resistance as the core defect in type
2 diabetes mellitus. Am J Cardiol. 2002 ; 90 : 3G- 10G
15. Bjorntorp P, Rosmond R. Hypothalamic origin of the
metabolic syndrome X. Ann NY Acad Sci .1999; 892: 297-307.
16. Rosmond R. Stress induced disturbances of the HPA axis: a
pathway to type 2 diabetes? Med Sci Monit. 2003; 9: RA35- RA39.
17. Everson-Rose SA, Meyer PM, Powell LH, et al. Depressive
symptoms, insulin resistance, and risk of diabetes in women at
midlife. Diabetes Care. 2004; 27: 2856-2862
18. Henry NJ, Smith TW, Butner J, Berg C, Uchino B.
Marriage, depressive symptoms and the metabolic syndrome:
a couples structural model. Psychosomatic Research and Care
Across the Life Course, Meeting Abs. 2009, Abs1117 - A115
19. Dong M, Giles W, Felliti VJ, Dube SR, Williams JE,
Chapman DP, et al. Insights into causal pathways for ischemic
heart disease: Adverse childhood experiences study . Circulation,
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20. De la Fuente JM, Goldman S, Stanus E, Vizuete C,
Morlan I, Bobes J. Brain glucose metabolism in borderline
personality disorder. J. Psychiatr. Res. 1997, 31(5): 531-41
21. Holt RIG, Peveler RC, Byrne CD. Schizofrenia , the
metabolic syndrome and diabetes, Diabet Med 2004; 21(6): 515-23
22. Vanhanen M, Koivisto K, Moilanen L, Helkala EL,
Hanninen T, Soininen H, Association of metabolic syndrome
with Alzheimer disease, Neurology 2006: 67: 843-847
23. Raffaitin C, Gin H, Empana J, Helmer C, Berr C, Tzourio
C, Metabolic syndrome and risk for incident Alzheimers disease
or vascular dementia: the three-city study, Diabetes Care 2008 ,
32: 169-174
24. Raikkonen K, Matthews KA, Kuller LH. The relationship
between psychological risk attributes and the metabolic syndrome
n healthy women: antecedent or consequence?, Metabolism.
2002; 51(12): 1573-7

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

THE ROLE OF THE BALINT GROUP LEADER


by Andrew Elder, United Kingdom

Summary
This article discusses the influence of psychoanalytic
ideas on the structure and function of Balint groups
and on the role of the leader in assisting the work of
the group. The article proposes that there are three
key areas of relationship that need to be the focus of
observation in a working Balint group, and further, that
the inter-relationship between these different areas is of
crucial importance: 1) the doctor-patient relationship as
expressed to the group by the presenting doctor discussing
his difficulties with a patient who is troubling him; 2) the
relationship that develops between the presenting doctor
and the other doctors in the group as a case is discussed,
and 3) the relationship between the leader and the work of
the group. Another important relationship for the leader
to consider is that between him and the presenting doctor,
although thoughts about this relationship would often not
be made explicit in a Balint group. Alongside the attention
given to the feelings expressed in these interweaving
relationships, the working method of a Balint group places
an emphasis on free association rather than prepared case
presentation, and on the value of discovering ideas about
things that are unknown or uncertain.
Introduction
A Balint group, when successful, can bring together
the conflicting feelings and semi-chaos of daily life in a
busy general practice, with a rather special atmosphere of
attention, openness to feelings, and attitudes of mind which
are derived from psychoanalysis. Provided care is taken in

establishing a disciplined structure for the group, such an


atmosphere then provides a freedom for the participating
doctors to experience and think about the many important,
and more personal, aspects of their professional work
that otherwise may remain unnoticed and unstudied. A
Balint group thus becomes a scientific instrument for the
observation of the doctor-patient relationship and the many
facets of medical care that it determines. Such groups can
have extensive application in the fields of training, research
and in the continuous need for further development in
professional functioning.
Doctors and their Patients
Doctors and patients may get to know each other over
quite a few years, and to some extent, develop a relationship
which resembles a marriage: some becoming old friends,
others more like old enemies, and often the doctor and the
patient seem stuck with each other in a way that can be
frustrating to both, and perhaps not healthy. For the doctors
in the group it is not easy to stay focused on the doctorpatient interaction, which is very different from their more
familiar way of making diagnoses and management plans
learned during medical education. A Balint group tries not
to focus solely on the patient as the object of interest, but
to include the doctors difficulties as well and to explore
what is going on between the patient and the doctor, much
of which is not at all clear to the doctor when he brings the
case to the group.
The group atmosphere
The doctor presenting a difficult case should have
a feeling that the leader and the group members know
what it is like to be a GP. The atmosphere should not be a
critical one. A Balint group is not expounding or teaching
a right way of doing things, but is concerned to help the
presenting doctor find out how things are between her and
the patient, not how they ought to be. For this there needs
to be a respectful atmosphere in which group members can
listen carefully to each doctors own way of doing things,
and allow space for the doctors feelings to be included as
well. The medical doctors who experience being listened to
in this way within a group become better able to listen to
their patients.
At the heart of the Balint method two disciplines
come together: there is a marriage between the practice
of medicine and psychoanalysis; the latter not as a body
of theory, but as an attitude of mind and an approach to
learning. Psychoanalysis knows about human relationships
and the unconscious mind, and the value of a stable setting
without which it is not possible to observe these areas of
life. Doctors, with their daily practice in technological

17

REFERATE

Rezumat
Articolul discuta influenele ideilor psihanalizei asupra
structurii si funciei grupurilor Balint i asupra rolului
conductorului de grup n moderarea activitii de grup.
In articol se propun trei domenii cheie ale relaiei asupra
crora trebuie s se concentreze munca de grup Balint,
domenii ntre care se stabilesc interrelaii de importan
crucial: 1) relaie medic-pacient adus de medicul care
prezint cazul, scond n eviden dificultile produse de
un pacient problematic; 2) relaia care se stabilete ntre
medicul care aduce cazul i ceilali medici din grup; 3)
relaia dintre conductorul de grup i ntreaga activitate a
grupului. O alt relaie demn de menionat este cea dintre
conductorul de grup i medicul care aduce cazul, dei
aceasta nu apare explicit de obicei. mpreun cu atenia
acordat sentimentelor exprimate n timpul acestor relaii
ce se ntrees, metoda balintian apreciaz mai degrab
asocierea liber de idei dect prepararea unei prezentri
de caz i emiterea de idei asupra unor lucruri necunoscute
sau incerte.

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

medicine, are well acquainted with a variety of patients,


blood tests, all kinds of scans and so on, but at the same
time can quickly feel disconcerted if a patient suddenly
opens up about their feelings, or somehow always manages
to leave the doctor feeling defeated. The atmosphere in a
Balint group can be one which allows doctors to experiment
in bringing these equally important strands of medical
practice together, psyche and soma, and doing so in such a
way that suits them as individuals. Listening and medicine,
side by side.

REFERATE

Freedom and discipline


The freedom engendered in a Balint group that enables
the doctors to learn in this way is dependent on the discipline
of clear boundaries for the group which are agreed by the
members and upheld by the leader. These will often include
such things as a stable membership, meeting at the same time
for a fixed length of time, in the same place and at regular
intervals. A group may also agree other ground rules for
its work. It is the leaders responsibility to keep comments
focussed on the doctor-patient relationship, avoiding quick
theories or psychodynamic lectures about what is wrong
with the patient. The leader models the working method for
the doctors and seeks to let ideas and reflections develop
from within the group; perhaps encouraging those that
seem likely to be productive, or picking up and articulating
some of the conflicts and tensions within the group and
bringing them forward for examination in the light of the
doctor-patient relationship. In this way, the leader sets an
approach which the doctors can absorb and develop in their
own work with their patients.
A working group
A Balint group begins when the leader says Has
anybody got a case? After a little hesitation, one of the
doctors will offer a new case and begin to tell the group
about their problems with a particular patient: very often
the doctor feels no room for maneuver with the patient, is
stuck with the patient - I dont know what to do, I am in a
bit of a mess, this patient is distressing me. As the doctor
describes their work with the patient, the doctor- patient
relationship arrives in the room, and the way the patient
inhabits the doctor becomes experienced in the group.
This is the first area of attention in a Balint group.
Freuds concept of free association influenced the
Balints in wanting the doctor to be as free as possible in her
presentation of a case. Doctors are trained in their medical
education to make formal, objective presentations of patients.
In contrast, Balint groups place importance on the doctor
making a freer, more subjective presentation. Partly this is
a training method, a way of introducing doctors to the more
personal side of their work. Talking about a patient without
the comfort and security of case notes is a significant step
for many doctors. The presentation of a case in this way
gives a freedom to talk spontaneously, and to include the
feelings that belong in the narrative account. There is then
an opportunity for the doctors in the group to learn to listen
in a deeper way too. One of the most important things to

18

learn in a Balint group is the ability to listen. Doctors need


to listen to their patients, but it is an active listening: not
only to words, but also to bodily language, to the patterns
of illness, to those remarks that the patient stops halfway
when making, and then may contradict. As a doctor in a
group you begin to learn about this by listening to your
colleagues, the same process as listening to a patient.
Once a case is presented - and the doctor comes to
a natural conclusion to whatever he wants to say - the
second area of attention in a group comes into play: the
relationship between the presenting doctor and the group
as they set out to understand the doctors predicament and
offer some help. After some initial responses, questions
and comments, something rather mysterious happens: the
doctor who has brought the case begins to behave a little
bit like the patient to the rest of the doctors in the group,
who themselves take on the role of the doctor. After an
early stage in which comments from the group help to open
things up, the group then begins to get a bit stuck with the
doctor, just as the doctor had got stuck with the patient.
The doctor feels perhaps that whatever he tries, the patient
blocks any progress in the treatment. And the doctor brings
that frustration to the group, and the group says, well,
have you tried this and that, but after five to ten minutes
of suggestions from the group, the doctor is beginning
to behave a bit like the patient, beginning not to want to
take it any further and blocking the groups suggestions.
So the conflict that exists in the doctor-patient relationship,
whatever it is, then often gets taken up unconsciously and
becomes re-enacted in the group. Without a leader, it is
likely that the group would get caught in whatever is the
unconscious dynamic that has led the doctor to present her
case in the first place. Not a lot of progress is likely to be
made.
The third sphere of attention, then, is the leaders
difficult task of trying to observe and think about how the
group process reflects the conflicts underlying the case
being discussed. Just as a doctor in his consulting room
will need to identify and feel something of the patients
predicament but also withdraw enough to think about
whatever might be a helpful professional response, so
also does the leader in relation to a Balint group. He must
allow himself to be drawn into the groups pre-occupations
(it would be hard to prevent!) but then also be detached
enough to think about what he feels and comment to the
group about this in a useful way. In a Balint group such
comments are made in relation to the case under discussion
and refer to the doctors professional difficulties and how
the group might be reflecting these, not in relation to the
doctors personal difficulties. By working in this way, the
leader provides a further layer of reflection through which
the group may be able to generate new perspectives to help
the presenting doctor gain a fresh view about his work with
the patient under discussion. Much of the leaders job is
to help the group stay on track and to concentrate on the
doctor-patient relationship.
The focus in a Balint group is primarily on the doctorpatient relationship and only to a secondary degree on the

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

personal life of the doctor. This means that less emphasis


is placed on the (transference) relationship between the
presenting doctor and the leader than would be the case if
a Balint group was a form of psychotherapy for the doctor
or a supervision group. The therapeutic focus in Balint
work is on helping the patient, through a development of
the doctors professional capacities. Clearly such a change
is likely to bring benefits in the doctors personal life as
well but these are not the primary aim of the work. A Balint
group is more a place of learning through discovery and
should not be a teaching group. Michael Balint referred to
the group meetings as seminars and the activity in them
as research-cum-training. So it is important for the leader
to hold back his natural tendency to teach or demonstrate
his knowledge and let the doctors discover something for
themselves. In this way, whatever an individual doctor
assimilates from the group is likely to be more enduring
and consonant with their own development.

Further Reading

1. Balint Enid. Research, Changes and Development in


Balint Groups in While Im Here, Doctor: A study of the DoctorPatient Relationship (eds A. Elder and O. Samuel, Tavislock,
1987) Reprinted in Before I was I: Psychoanalysis and the
Imagination (Eds: J. Mitchell and M. Parsons, Free Association,
London 1993)
2. Balint Enid. The work of a psychoanalyst in Balint groups
in The Doctor, the Patient and the Group: Balint Revisited.
Balint E, Courtenay, M et al, Routledge, London 1993.
3. Courtenay, M. A Plain Doctors Guide to Balint-Work.
Journal of the Balint Society Vol.20, 1992.
4. Courtenay, M. The Role of the Balint-Group Leader: A
Critical Re-Appraisal. Journal of the Balint Society Vol.14, 1986.
Courtenay, M. Thoughts on Different Intervals between Balint
Group Meetings. Journal of the Balint Society Vol. 30, 2002.
Gosling, R et al. The Use of Small Groups in Training (first
published Colmcote Press Ltd in conjunction with the Tavistock
Institute of Medical Psychology, 1967, republished Karnac Books,
London, 1999) Gosling, R. The General Practitioner Training
Scheme (chapter 8); GP Training and psychoanalysis (chapter
9) in Michael Balint: Object Relations Pure and Applied by
Harold Stewart (New Library of Psychoanalysis, 25, Routledge,
London, 1996).
5. Main, T. Training for the Acquisition of Knowledge or the
Development of Skill? in The Ailment and other Psychoanalytic
Essays, Free Association, London 1989
6. Samuel, O. Aims and Objectives and Balint-Training.
Journal of the Balint Society Vol. 15, 1987.
7. What is a Balint Group/ Statement by Council of Balint
Society. Journal of the Balint Society: vol. 22, 1994

This article is a summary of a talk given by Andrew


Elder to a group of GPs in Sostrup, Denmark, in 1999. It
was first published in Danish in Kaltoft, S and Thorgaard,
L. Laegen som Laegemiddel (2005).
*

REFERATE

Conclusion
Balint groups can help doctors tolerate and think about
much that is otherwise uncertain and unknown in their
daily work. In the current climate which places a strong
emphasis on evidence-based medicine and the scientific
method, it may seem unfashionable to remind readers
how much is unknown (and not amenable to conventional
scientific enquiry) about the meaning and significance of
a doctors daily contact with her patients. Perhaps another
valuable legacy from psychoanalysis to the Balint method
is a belief in the value of studying things that are not so easy
to know about, things that lie within ourselves, attitudes
and feelings that may influence the course of professional
work more than is recognized. Doctors are surrounded
these days by ideas of correct medical practice, about how
things should be done when patients are treated. In a Balint
group we may learn to explore how things really are in our
day-to-day doctor-patient relationships in order to be able

to change our medical practice to the benefit of our patients


and ourselves.

Reminescene? foto Trif Almos Bela

19

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

The relationship between the health


professional and the patient as perceived
by the medical and nursing students
Almos Bela Trif *and Clara Wolman**
Abstract
The purpose of this study was to investigate the
relationship between the health professional and the
patient as perceived by Nursing and Doctor of Osteopathic
(DO) Medicine students. Participants included 61 (51.3%)
Nursing and 58 (48.7%) DO students. An instrument was
developed to assess the importance that participants
attribute to knowing about a patients personal life,
their attitudes toward caring characteristics in health
care professionals, and their interest in participating
in organized group discussions. Nursing students gave
more importance than DO students to knowing about the
patients personality characteristics and predominant day
to day feelings, and were more interested in participating
in professional organized group discussions once employed
in their medical profession. After controlling for gender
differences, nursing students perceived significantly more
than DO students that emotional involvement in the health
caretaker can affect negatively the success of the patients
medical outcome. Most of the respondents indicated that
the average consultation length should be between 15 to
30 minutes.

REFERATE

Introduction
The doctor-patient communication and interpersonal
relationships have become topics of increasing importance
in patient care. Although patients value good medical
judgment, it is important for them that their physician has
strong interpersonal skills, is easy to talk to and take their
concern seriously. Moreover, a recent longitudinal study
(Newton, Barber, Clardy, Cleveland, & OSullian, 2008)
shown that undergraduate medical education may be a major
determinant differentially affecting the vicarious empathy
of medical students on the basis of gender and/or specialty
choice. The authors consider the significant decrease in
vicarious empathy to be of concern, because empathy is
crucial for a successful physician-patient relationship.
Hojat, Mangione, Nasca, Gonnella, and Magee (2005),
who developed a self-report empathy scale, the Jefferson
Scale of Physician Empathy, emphasized the importance
of health care professionals empathy in improving several
patient outcomes. However, Otani, Kurtz, Harris, and Byrne
(2005) found that patient satisfaction was less likely to be
influenced by the bedside manners of the physicians, showing
that the most important aspects in the physician care were the
explanation of the physician of what was done to the patient

and the length of time that the physician spent with the
patient. Interestingly, in the same study, the most important
aspect of the nurses that affected patients satisfaction was
the personal manner of the nurse. Nurses are perceived and
may be expected to be more nurturing than physicians, since
caring has been described by nurse professionals as the
essence of nursing (Cooper, 2005a; 2005b).
However, how can a doctor develop good interpersonal
relationships with his or her patients, if there is not
enough time to be with each patient? Indeed, one of the
problems in the United States and Canada is the limited
time that physicians devote to their patients consultation
(Anonymous, 2006; Payne, 2003). Patients are more and
more interested in talking with their physicians (Pritchard,
2003), and one of the variables affecting patient satisfaction
is the time that the physician spends with the patient (Otani
et al, 2005).
An emphasis on inter personal relationships astuteness
seen as healing skills was made in a recent interview study
conducted by bioethicists on physicians and complementary
and alternative medicine healers (Churchill and Schenck,
2008). They described eight pivotal skills: do the little
things; take time; be open and listen; find something to
like, to love; remove barriers; let the patient explain; share
authority; and be committed.
Thus, the overall purpose of our study was to investigate
the perceptions and attitudes of university students who
will become health care professionals, toward the health
caretaker-patient relationship. More specifically, Nursing
and Osteopathic Medicine students were surveyed to
address the following research questions:
1. What is the importance attributed by Nursing and
Osteopathic Medicine students to knowing about a patients
feelings, personal, familial, and work related life?
2. What are the participants attitudes toward caring
characteristics in health care professionals?
3. How interested will be the respondents to participate,
once employed in their profession, in organized group
discussions with their colleagues?
4. What are the participants perception about the
adequate consultation length of time between a primary
physician and a patient?
Methods
Sample
Participants in this study were 61 (51.3%) Nursing
and 58 (48.7%) Doctor of Osteopathic (DO) Medicine

* Assistant Professor, College of Medical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, USA
** Professor of Education, Barry University, Miami Shores, Florida, USA

20

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

Instrument
The empathy scale developed by Hojat, Mangione,
Nasca, Gonnella, and Magee (2005) and the literature about
patient-doctor relationship (Cooper, 2005; Otani, Kurtz,
Harris, & Byrne, 2005; Pritchard, 2003) served as sources
for item generation. The Health Care-Patient Relationship
Questionnaire, developed by the researchers, includes
eight background questions that assess the participants
gender, ethnic group, age, place of birth, degree, number of
courses taken, previous work, and preferred residence. The
attitude and opinion items are presented and grouped in the
following three domains: 1) Knowing about a patients
personal life, including 11 items (e.g., Knowing about the
effect of the illness on family relationships, Problems in the
family), 2) Empathic approach or feelings that could affect
the patients medical outcomes, which includes 9 items
(e.g., Being compassionate with the patients suffering,
Feeling connected to the patient), and 3) Interest in Group
Professional Development, which includes 5 items (e.g.,
Group discussions about new developments/research in
Medicine). All the items in the above domains consist of
Likert Scales ranging from 1 to 4, where 1 is the negative
end of the scale and 4 represents the most positive point
in the scale (with the exception of four negatively worded
items in the Empathetic approach domain). In addition, one
question assesses participants opinions about the ideal
length of a consultation.
First, the questionnaire was submitted for content
validity to four professors (in Nursing, DO, and Physician
Assistant programs), to receive feedback about the
appropriateness of the questions. After modifying two
items based on their comments, the questionnaire was pilot
tested (for clarity of the questions, fluidity, time to complete
the questionnaire) with five university students who did not
participate in this study.
As a measure of internal consistency, a Cronbachs
alpha was calculated for the entire sample op this study
with all the survey items (excluding the background
questions), indicating an overall good reliability coefficient

(.804); however, the Cronbachs alpha declined to .734 after


excluding an item from the Empathic Approach domain
that could not be easily classified as positive or negative.
Individual Cronbachs alphas were also conducted on
each of the domains, showing that the Knowledge about a
patients life items had a higher internal consistence (.825)
than the Empathic Approach items (.51) and the Group
Professional Development items (.67).
Procedures
After receiving permission from the Institutional Review
Board (IRB), students attending two classes in the Nursing
Department and one class in the School of Osteopathic
Medicine (DO), were announced by one of the researchers
before their classes started that a study about attitudes was
conducted and that they were invited to participate. The
questionnaires with a cover letter explaining the study were
left on the desk of the instructor of each class; students who
were willing to participate, completed the Health Caretaker
- Patient Relationship questionnaire, and returned it to the
desk of the instructor, who inserted all questionnaires in
an envelope. Each questionnaire took about 5-8 minutes to
complete. The envelopes were given to the researchers after
the classes finished. All data collected were anonymous.
One hundred and twenty students were attending the two
Nursing classes and 61 questionnaires were completed
(about 50% response rate), while about 100 students were
attending the DO class and 58 of them completed the
questionnaires (approximate response rate: 58%).
Results
Four negatively worded items presented in the Empathy
domain (e.g., Feeling overwhelmed with a difficult
patient), were codereversed before conducting the
analyses. Afterwards, total scores were calculated for each
of the domains by summing up the scores on the individual
items of each domain. Thus, each of the domains had a total
score variable: Knowing about Patients Life, Empathetic
Approach, and Professional Development.
To investigate whether Nursing students differed from
DO students in their perception about the importance of
knowing about a patients personal life, an independent
samples t-test was conducted on the Knowledge about
Patients Life total score. Overall, groups did not differ
in their willingness to know about personal issues of the
patient (M= 32.84, SD= 5.36 and M = 32.41, SD= 5.27, for
Nurses and DOs, respectively), t (111) = .426, ns. Differences
between groups, however, were observed in three individual
items. Nursing students gave more importance than DO
students to knowing about the Personality characteristics
(M= 3.34, SD= .704 and M = 2.95, SD= .718, respectively),
t (115.128) = 3.03, p< .01, with a middle effect size (ES= .54),
and the Predominant day to day feelings of the patient
(M= 3.67, SD= .56 and M = 3.36, SD= .69, respectively),
t (110.402) = 2.66, p< .01, with a small effect size (ES= .45).
DO students thought that it was more important to know
about the Sexual orientation of the patient (M= 2.72, SD=

21

REFERATE

graduate students attending a private university in South


East Florida. The Nursing students comprised significantly
more females (n= 49, 70%) than the group of DO students
(n=11, 23%), 2 (1) = 25.57, p<.001 (low effect size, ES=.46).
The Nursing students also included a significantly higher
proportion of minorities, including Blacks (n=12, 20%) and
Hispanics (n= 25, 41%), compared with the DO students
(Black, n= 3, 6%; Hispanic, n= 2, 4%), 2 (5) = 25.57, p< .001
(low effect size, ES=.41), and while about 31% (n= 19) of the
Nursing students were White, about 66% (n= 35) of the DO
students were White. A few students in both groups (5 and
13, respectively), classified themselves in other ethnic
groups. With respect to age, the Nursing students were, as a
group, significantly older that the DO students; 20 Nursing
students (32.8%) were at least 30 years old, compared to 2
(3.6%) DO students; 41 (67.2%) nursing students were 20 to
29 years of age, compared to 54 (96.4 %) DO students, 2 (1)
= 16.59, p<.001 (small effect size, ES= .38).

REFERATE

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

.93 and M = 2.07, SD= 1.02, for DOs and Nursing students,
respectively), t (115) = -3.645, p< .001, with a medium effect
size (ES= -.69).
To assess whether Nursing and DO students differed
in their Empathic Approach or in their opinions whether
certain attitudes or feelings in the health care provider
could affect the patients medical outcome, an independent
samples t-test was conducted. Results indicated that
Nursing students had a significantly lower Empathy score
than DO students (M= 24.40, SD= 3.19 and M = 26.09, SD=
2.30, respectively), t (102.01) = -3.205, p< .01. The effect size
was large (ES=-3.39). However, Nursing students included
significantly more females, more minorities, and more
students who were older than the DO students. Each one
of these demographic variables could explain the result that
Nursing students had lower levels of Empathy than DO
students. To address this issue additional analyses were
conducted based on the demographic variables. Three tests
of significance were conducted to explore whether students
differed in their Empathy based on gender, ethnic group,
and group age. No significant differences were found
between younger and older students (F(2, 106) =1.126, ns) or
between ethnic groups (F (4, 101) = 2.14, ns). However, males
were more empathetic than females (M= 26.02, SD= 2.44
and M = 24.74, SD= 3.08, respectively), t (105.94) = 2.430, p<
.05, with a small effect size (ES= 0.41). Based on these
findings, an Analysis of Covariance (ANCOVA) was
conducted on Empathic Approach by group (Nurses vs.
Dos), controlling for gender differences. Results indicated
that after controlling for gender differences, Nursing
students still had significantly more negative Empathy
scores than DO students (F(1, 107) = 5.042, p <.05).
With respect to the interest of the respondents in
participating in organized professional groups after they
are employed, Nursing students showed, overall, a stronger
interest than DO students in participating in professional
group activities (M= 16.80, SD= 2.57 and M = 15.31, SD=
2.89, respectively), t (116) = 2.957, p< .01, with a medium
effect size (ES =.51). The individual topics in which Nursing
students showed a higher interest than DO students, were
New developments/research in Medicine (M= 3.57, SD=
.59 and M = 3.31, SD= .79, respectively), t (104.716) = 2.04, p<
.05, with a small effect size (ES =.32), Quality of caretaker/
patient relationships (M= 3.52, SD= .67 and M = 3.00, SD=
.87, respectively), t (116) = 3.587, p< .001, with a medium
effect size (ES =.59), and Emotional involvement of the
health caretaker (M= 3.26, SD= .75 and M = 2.74, SD= .96,
respectively), t (107.59) = 3.275, p< .01, with a medium effect
size (ES =.54). Males and females did not differ in their
interest in participating in professional group activities (t
= -.978, ns).
(115)
The last item in the questionnaire assessed how long
should be the average face-to face meeting or consultation
time between a primary physician and a patient. No
significant differences were found between the two groups
of students, 2 (3) = .92, ns. Overall, about half of the students
(n=60, 50%) selected the average length of consultation of
15-20 minutes, and a substantial amount of students (n=44,

22

37%) selected the length of consultation of 25-30 minutes. A


small amount of participants selected the other two choices
representing consultation times, including 5-10 minutes
and 45minutes-1 hour. No differences were found between
foreign and American born respondents in the selection of
the ideal consultation time.
Discussion
The results of this study revealed that Nursing students
were significantly more interested than DO students in
participating in professional organized group discussions
once employed in their medical profession. In addition to
showing more interest in participating in group discussions
about new developments or new research in Medicine,
Nursing students were significantly more interested than
DO students in participating in professional discussions
pertaining to the quality of the caretaker/patient relationships
as well as focusing on the emotional involvement of the
health caretaker. In the same vein, Nurses indicated that
for them was significantly more important than for the DO
students to know about the personality characteristics and
the day to day feelings (e.g., depression, anxiety, happiness)
of the patient.
Thus, based on the items in two domains, Importance
about Knowing about the patients personal life, and
Interest in Participating in Professional Group Discussions,
Nursing students seemed to indicate a genuine interest in
knowing about the patient and in improving the healthcarepatient relationship. The quality of the caretaker - patient
relationships and the emotional involvement of the health
caretaker are the regular topics of the Balint group.
According to previous studies conducted by Suckling
(2005), students enter the Balint group sessions with sometimes very different amount of motivation, but there are
only few that afterwards think that such groups are totally
useless. We can hope that introduction of Balint type professional discussion groups will duplicate the qualitative
findings of Torppa, Makkonen, Mrtenson, and Pitkl
(2008), who showed that feelings related to patients and to
ones own role as a doctor were openly discussed in groups,
and that discussions often touched on professional growth
and future professional identity as doctors.
However, other findings indicated that nursing students
had a lower Empathic Approach toward the patient than
Osteopathic Medicine (DO) students. The results also
showed that females (who were overrepresented in the
Nursing group) had lower Empathic Approach scores than
males. Although this result may be surprising, this is not
the first time that women in the medical profession are
found to have lower empathy scores than males. Hojat,
Gonnella, Nasca, Mangione, Vergare, and Magee (2002)
found higher empathy scores among female physicians;
however, Newton et al. (2008) found that junior male
medical students had significantly higher empathy scores
than the normal population, while junior female medical
students had comparable scores to the norm, which with the
passing of time became significantly below the norm. In

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

the present study, after controlling for gender differences,


nursing students perceived significantly more than DO
students that emotional involvement in the health caretaker
can affect negatively the success of the patients medical
outcome. These results do not support previous findings
indicating that nurses are perceived or may be expected
to be more nurturing than physicians (Cooper, 2005a;
2005b).

REFERATE

References
Anonymous (2006). The doctor will see you for exactly
seven minutes. Pediatrics, 117(6), 1914.
Churchill, L. R., Schenck D. (2008). Healing Skills for
Medical Practice; Ann Intern Med.,149:720-724.
Cooper, P.G. (2005a). The essence of nursing: Caring and
coaching. Nursing Forum, 40(2), 43.
Cooper, P. G. (2005b). A call for return to patient-centered
care. Nursing Forum, 40(3), 73- 75.
Hojat, M., Gonnella, J.S., Nasca, T.J., Mangione, S., Vergare,
M., & Magee, M. (2002). Physician Empathy: Definition,
components, measurement, and relationship to gender and
specialty. American Journal of Psychiatry, 159(9), 1563-1569.

Hojat, M., Mangione, S., Nasca, T.J., Gonnella, J.S., &


Magee, M. (2005). Empathy scores in medical school and rating
of empathic behavior in residency training 3 years later. The
Journal of Social Psychology, 145(6), 663-672.
Newton, B.W., Barber, L., Clardy, J., Cleveland, & OSullivan,
P. (2008). Is there hardening of the heart during Medical school?
Academic Medicine, 83(3), 244-249.
Otani, K., Kurts, R.S., Harris, L. E., & Byrne, F.D. (2005).
Managing primary care using patient satisfaction measures:
Practitioner application. Journal of Healthcare Management,
50(5), 311-326.
Payne, D. (2003). U.S. MDs frustrated with time constraints
on care. Medical Post Toronto, 39(22), 38.
Pritchard, C. (2003). Patients seeking more talk, fewer
medications. Medical Post, Toronto, 39(13), 60.
Suckling H. (2005). What effect does a Balint group have
on medical students? Proceedings of the 14th International Balint
Congress, Stockholm 2005.
Torppa M.A., Makkonen E., Mrtenson C., Pitkl K.H. A
qualitative analysis of student Balint groups in medical education:
Contexts and triggers of case presentations and discussion themes.
Patient Education and Counselling 2008;72:5-11.

Grupul excursionist dup Congres

23

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

TIRI DIN VIAA ASOCIAIEI


Lunile de var erau petrecute cu concediile de
odihn. Cu excepia organizatorilor celui de-al XVI-LEA
CONGRES INTERNAIONAL BALINT, care, fiind pe
ultima sut de metri, au tras din plin crua organizrii
Congresului.
Au fost nregistrai 164 de participani cu 17 nsoitori
de pe 3 continente (Australia, SUA i Europa), 19 ri. Din
Romnia s-au nregistrat 55 de participani, dintre care 40
au fost membrii Asociaiei Balint.
AUSTRALIA 5
AUSTRIA
BELGIA
CANADA
DANEMARCA
FINLANDA
FRANA
GERMANIA 12
UNGARIA
ISRAEL
ITALIA
OLANDA
PORTUGALIA
SERBIA
SUEDIA
ELVEIA
ANGLIA
SUA
10
ROMNIA

CUVNTUL DE DESCHIDERE
al dr. Henry Jablonski,
preedintele Federaiei Internaionale Balint:

3
6
2
1
4
9
2
14
4
2
8
2
11
2
12
55

TIRI DIN VIAA ASOCIAIEI

Pe grupe de specialitate:
MEDICI DE FAMILIE
PSIHIATRI
PSIHOTERAPEUI, PSIHOLOGI
STUDENI
ALTELE

60
42
28
12
22

La excursia postcongres la mnstirile din Nordul


Moldovei au participat 62 de persoane.
S-au prezentat 23 de lucrri.
S-a inut un grup mare i de 4 ori au avut loc grupuri
mici, dintre care unul intit pe psihodram Balint.
S-a editat un volum de lucrri i altul de abstracte. Cel
de lucrri se poate cumpra la Conferina Naional Balint
din 6-8 noiembrie.
Pentru ajutorul acordat n nfiinarea i dezvoltarea
Asociaii Balint din Romnia s-a acordat Premiul VERESS
pentru ERICA JONES, JOHN SALINSKY, KORNLIA
BOBAY, MRIA SZIRTES, VA HARMATHY. Pentru
efortul i ajutorul lor n orgaizarea Congresului au prmit
Premiul HEATHER SUCKLING i HENRY JABLONSKI.

24

n decursul celor 2 ani de organizare al Congresului


am trimis i primit n total 3656 de mesaje e-mail, primit
de la Heather Suckling, secretara Federaiei 108 iar de la
Henry Jablonski, preedintele Federaiei 187 de mesaje.
10.000 RON oferii de ctre Asociaie cu titlu de
sponsorizare pentru membrii Asociaiei care vor participa
la Congres s-a mprit ntre 40 de membri, revenindu-le
fiecruia cte 250 RON.

Dear Romanian hosts and colleagues,


On behalf of the International Balint Federation I wish
to say how pleased we are to be here. Many thanks to the
members of Romanian Organising Committee fortheir
work creating this environment for our meeting and for
preparing the extensive scientfic and social programme.
In these four days, people from all over the world
who have gathered here, will be offered the challenge,
inspiration, excitement and comfort to share and discuss
Balint projects and and medical educational experiences.
We will have the opportunity in the Balint groups running
throughout the conference to cultivate our clinical senses in
the discussions of down-to-earth clinical experiences and
to develop the relations between each other
In this way the congress will be another milestone in
a continous process of developing and promoting Balint
group work.
We know the Romanian Balinters as active partners of
the International Federation and look very much forward to
make a deeper aquaintance with you during this congress.
So, dear Romanian Balint colleagues, many thanks for
hosting the Balint congress here in Poiana Brasov! Thank
you very much!
In short: on behalf of the IBF I expressed our thanks to
all the members of the Romanian Organising Committee.We
in the IBF who have been part of the extensive preparatory
work for the congress share their delight setting out on our
4 days congress journey. It is really wonderful to be here.
Thank you so much!
Dear delegates to the 16th International Balint
Congress, ladies and gentlemen
The old Greeks already knew that being a good enough
doctor is not only about finding out the disease and its cure.
It is equally important to know who is the patient suffering
from the illness. But it seems every new generation of
doctors has to make this old wisdom come alive again. This

is one important aspect of Balint work. The other and


even more difficult one - is: What kind of doctor and person
am I and how does it affect my relations to my patients?.
Michael Balint, the founder and inspirator of the
training method carrying his name, already, 60 years
ago advocated the idea that the doctor has to be trained
to integrate the medical technical aspects on the one
hand, with the personal understanding of the patient, the
interplay between the doctor and his patient on the other.
Balint envisaged a health care system in which the wise,
committed and competent GP/ family doctor is at the centre
of the health service. Since then, quite a few nations have
successfully implemented this idea in their health care
systems. Balint work is not a political movement But by its
focus on the doctor-patient relationship intrinsically and
quite unintentionally it does have a political twist since
the way the various national health sytems are designed
clearly affects the doctor-patient relationship.
There are many interesting places in life. But there are
very few places like the doctors consulting room. Here
you will find such density of all kinds of hope, joy, relief,
human dignity, ordinary and strange pleasures, respectful
intimacy and suspiciousness, all kinds of dispair and
anxiety, human pettiness, uncertainty and awe about life
and about diesease and threatening death. That is what
makes work so fascinating and challenging. That is also
what can make it so difficult and exacting and bring people
to exhaustion and burn-out.
One of the themes of our congress is Writing a
prescription is easy understanding your patient is not so
easy and we will hear more about this soon, and we will
work on it in during the congress. But you could just as
well see it from the perspective of the patient: Receiving
a prescription is easy but understanding what the doctor
actually meant by it is not always so easy.
The patient may ask after he/she has left the consulting
room with the prescription. What was this all about? Does
the doctor understand my problem, does he care?
Even if you are a person in a strong social position,
you may ask yourself these questions and you might
add: Does he dare taking the risk relating to me as a good
doctor should to an ordinary patient? Or is he governed by
exaggerated respect maybe even fear? Does he think I will
sue him, or file a complaint to the Medical Board, or strip
him off his privileges?

I am pretty sure that all of us the day we ourselves


become patients wish to have a doctor who is in touch
and professionally careful and independent. This is what
we primarily are trying to maintain and develop by Balint
group work.
Though the cathexis found in doctor-patient relationship
is very special it is certainly not unique. Michael Balint
knew about intense clinical relations from his own
experience as a dedicated psychoanalyst. That is why he
was able to highlight this aspect of doctoring to his GP
colleagues. There are also other professions in which you
will find highly cathected human relationships: clegymen,
nurses, teachers, physiotherapists, social workers, lawyers,
managers and human relation officers of companies and
organisations, policemen in democratic societies etc etc.In
all such areas Balint group work can be very useful for
professional development and maintainance of professional
standards.
You have chosen a beautiful and dramatic place for
our congress. We are surrounded by a landscape and an
ancient culture that make you humble. Two years ago in
Berlin when we decided to have the Congress here, by
coincidence, in a jazz club of all places, I heard a melody
from Transylvania which moved me deeply and has stayed
with me even stronger since I learnt the meaning of the
words.
The song is many many hundred years old, maybe 500,
maybe even more. It says something important about life
and also about the conditions that we have to recognise in
our work.
Love, love,
You are like a curse
Love, love,
You are like a curse
Szerelem, szerelem
tkozott gyrtrelem
Szerelem, szerelem
tkozott gyrtrelem
(Love!) Why do you not blossom from every tree
from every tree
From every leaf of the cedar tree?
Mirt nem virgoztl
Minden fa tetejn

25

TIRI DIN VIAA ASOCIAIEI

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

Minden fa tetejn
Cdrus fa leveln
There is no rose
That blossoms in a (too) small garden
There is no rose like the one
When you love one another

TIRI DIN VIAA ASOCIAIEI

Haj, de nem az a rzsa


Ki kis kertben nyilik
hanem az a rzsa
ki egy mst szereti
This is a song out of the longing for love. The unknown
authour of these lyrics tells us about true love and caring:,
which needs mutuality to develop. He or she also was
painfully aware of that love can be severely inhibited by
the tyranny of family and social rules (no rose rose can
blossom in too small a garden).
So many of our patients come to us with diffuse
symptoms and complaints. As doctors we meet many patients
who suffer from love deficits and love disappointments.
Human individuals are more or less vulnerable to lack
of love and care. People have - deeply imbedded in their
souls and bodies - various experiences from being loved
and cared for OR the reverse - being neglected or abused.
These experiences may be recent or belong to the remote
past of the patient. And our bodies are a timeless carriers
of drives and memories. Thus they are preserved, thus they
are hidden from us and thus they cause us discomfort. But
thus by being encapsulated as symptoms in the body
the individual can carry on in evryday life without being
overwhelmed. Until it becomes too much. That is when
many people pay a visit to their doctor.
It is not a new thought. yet meaningful for the caring
clinician to consider the relevance of love deficit or love
conflict expressions. But this idea is not to be trivialised
something to be known in a smug way as some
psychotherapists tend to do. And we cannot prescribe love,
adequate family and social relations which will cure our
patients though some of us might have tried. But we can
learn to relate to our patients and treat them with a deeper
understanding, adequte care and with respect and also
with respect for our own limitations. In this way we learn
something about ourselves too. In my own experience this
is the most difficult but at the same time the most rewarding
challenge of both doctoring and being a psychotherapist.
People who suffer from severe and incomprehensible
symptoms have a hidden agenda. Mostly it is also more or
less hidden to themselves.
Doctors who treat such patients also may have
corresponding hidden agendas. Such patients can be abused
(again!) by doctors consciously or unconsciously i.e.
when they take extreme measures to rule out, investigate
etc etc though they do not believe it is meaningful. Such
patients can also abuse doctors and push them to do things
they do not want to. But if we are to compare the health
service to a cedar tree forest it does happen that such

26

patients meet with a doctor a blossom of the cedar tree that manages to care for the patient medically and humanly,
and thus helps the patient to make life a little bit more
endurable, yes, miracles of improvement do also happen.
Does not the last phrase of the song
There is no rose
That blossoms in a (too) small garden
There is no rose like the one
When you love one another
say something about the conditions for the medical
profession too?. If we are to minimise the risk for mechanical
treatment and working too far from the state of our art,
then we as doctors must try as much as possible to free
ourselves from those aspects of the system that threaten
to undermine the doctor-patient relationship and medical
ethical standards. Such skews exist to a varying degree in
all health care systems.
I phrased some of them as questions in my address on
the congress homepage.
In short: Do diminishing social barriers tempt the
doctor to become the friend, lawyer or even accomplice
of his patients? Does the social welfare system or an
authoritarian system transform him into a representative of
the social authorities? Do the drugs available today and the
way they are marketed, combined with the work load and
lack of clinical presence of the doctor tempt him to prescribe
a more or less standardised, too often inadequate (and
costly) medication to his patients? Does the privatisation of
the previously publicly organised health care turn him into
a businessman rather than a doctor? Will evidence based
treatment programmes for various diseases make us lose
the assessment of the patient as a whole person? How is the
relationship affected when doctors and patients come from
vastly different cultural backgrounds?
All these issues can also be addressed in a personal
way by doctors relating to each other in a Balint group.
It will not solve all the problems but it will be helpful in
increasing the awareness and sensitivity of the doctor. In
this way tea-spoon by tea-spoon our clinical work can be
improved. Tea-spoon by tea-spoon such issues can also
be brought into the administrative and political process
of health care. One first administrative step is to make the
time for regular Balint group work available.
I am looking forward to exchanging thoughts, listening
to papers, and to participating in vivid discussions about
the doctor-patient relationship, about the development
of the Balint method as an important supportive tool for
all clincially engaged professionals, and about values in
contemporary medicine.
And again, many thanks to our Romanian hosts!
Dragi colegi i gazde din Romnia,
n numele Federatiei Internaionale Balint doresc s v
spun ct de bucuroi suntem c ne aflm aici. Adresez calde
mulumiri membrilor Comitetului Romn de Organizare

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

CUVNTUL DE DESCHIDERE
a dr. Baka Tnde, preedintele ABR:
Welcome everybody,
It is much easier to make a speech at the beginning of
an event like our Congress, than at the end of it.
Why is that so?
I think this is because now, at the beginning, on such
a wonderful morning, we are speaking about our plans,
our expectations and dreams with great enthusiasm and
optimism.
In fact, we are going to speak about the perfect
conference which gives us the feeling of having control.
However at the end of this Congress when your feedbacks,
opinions, impressions, memories will follow- which
will certainly be very different-we could also feel some
uncertainty, or even anxiety.
In fact, we will lose control!
This is the risk of any organisation!
In the beginning there was the idea
The idea to organize an International Congress of the
Balint Federation, here in Romania.
This idea was born in the mind of our ex- president,
Berci Veress, at Oxford, eleven years ago.
This idea, like a prematurely newborn child, was
unexpected, spontaneous, maybe it seemed a little
aggressive at that time, although full of life and vitality.
Berci and his wife Eva are very good parents and so the
idea became a fact.
After several years we are here in full opening of the
congress and say thanks for the board of the Federation to
offering us the opportunity of organizing this event here in
the center of Romania.
In my fantasy, Balint-work means for us a parallel

world, where dimensions are variable, dynamic and so


much different.
Our projection is very positive and authentic in this
parallel world and our participation at Balint congress is
like a teleportation.
For example yesterday distances on latitude and altitude
between London and Brasov, Stockholm and Brasov were
so significant, today they have totally disappeared.
The dimension of time will also expand during
the Congress: here every minute, every hour will gain
importance again.
So, I welcome you all, at the 16th International Congress
here in Brasov, Transylvania, Romania.
Transylvania, well-known as the land of ballads, a very
romantic region of the country which can certainly induce
a favorable state of mind for Balint activity.
Thank you all to be here with us!!
Bine ai venit!
Este mult mai uor s ii un discurs la nceputul unui
eveniment ca, congresul nostru, dect la sfritul acestuia.
De ce?
Fiindc la nceput, ca i n aceast superb dimineat,
vorbim despre planurile noastre, ateptrile i visurile
noastre, cu mare entuziasm i optimism.
De fapt vorbim despre conferina perfect, ceea ce ne
d sentimentul c deinem controlul.
ns la sfritul acestui congres, cnd vor urma feebackurile, opiniile, impresiile, amintirile voastre, fr ndoial
foarte variate, s-ar putea s simim incertitudine sau chiar
anxietate.
De fapt, vom pierde controlul!
Acesta este riscul oricrei munci organizatorice!
La nceput a fost ideea
Ideea organizrii unui congres internaional al
Federaiei Internaionale Balint aici, n Romnia.
Aceast idee s-a nscut la Oxford, cu unsprezece ani in
urm, n mintea lui Berci Veress, fostul nostru preedinte.
Ideea, asemeni unui nou-nscut prematur, a fost
neateptat, spontan, poate aparent un pic agresiv n acel
moment, dar n acela timp plin de via i vitalitate.
Berci i soia lui, Eva au fost buni prini i astfel ideea
a devenit fapt.
Dup ani buni, iat-ne aici n plin deschidere a
congresului, aducnd mulumiri Biroului Federaiei
Internaionale pentru c ne-a oferit ocazia de a organiza
acest eveniment aici, la noi, n centrul Romniei.
n fantezia mea, munca balintian nseamn pentru noi
o lume paralel, cu dimensiuni variabile, dinamice i foarte
deosebite.
n aceast lume paralel proiecia fiecruia dintre noi
este foarte favorabil i autentic, iar participarea noastr la
un Congres Balint este ca o teleportare.
Ca exemplu: ieri distanele pe latitudine i altitudine
ntre Londra si Braov, Stokholm si Braov, au fost att de
semnificative, aztzi acestea au disprut n totalitate.
Dimensiunea timpului se va dilata deasemenea pe

27

TIRI DIN VIAA ASOCIAIEI

pentru munca depus la crearea acestui mediu plcut n


care s ne desfuram ntlnirea de lucru, pentru pregtirea
programului tiinific extins i a activitilor sociale !
Ne-am adunat aici oameni din toate colurile lumii
ca n aceste patru zile care ni se ofer, s discutm despre
proiectele Balint, s ne mprtim experiena medical,
s ne confruntm ideile, s ne lsm inspirai, emoionai,
ncurajai!
Pe parcursul Conferinei, n cadrul grupurilor de lucru
Balint, vom avea ocazia s ne cultivm intuiia, judecata
clinic n discuii realiste despre experiene clinice, s
ne cunoatem i s dezvoltm relaii amicale. n acest
sens Congresul va fi un adevrat proces de dezvoltare i
promovare a grupurilor Balint.
Pe colegii romni i cunoatem ca parteneri activi
n cadrul Federaiei Internaionale i ateptm cu mare
nerbdare ca n timpul acestui Congres s consolidm
relaiile noastre. Dragi colegi romni, membri ai grupurilor
Balint, multe mulumiri pentru gzduirea Congresului
Balint aici la Poiana Brasov, v mulumesc foarte mult!

Buletinul Asociaiei Balint, vol. 11., nr. 43, Septembrie 2009

durata congresului; aici fiecare minut, fiecare ceas va


ctiga i mai mare importan.
V spun, deci, un clduros binevenit la al 16-lea
Congres Internaional Balint, aici n Braov, Transilvania,
Romnia.
Transilvania, binecunoscut ca ara baladelor, o regiune
foarte romantic, v va induce cu siguran o stare de spirit
favorabil activitii balintiene.
V mulumesc tuturora pentru c sntei aici cu noi!

Planuri de viitor:

TIRI DIN VIAA ASOCIAIEI

9-11 octombrie, Izvoru Mure: Curs de prefecionare


pentru liderii de grup
6-8 noiembrie: a XVI-a Conferin Naional Balint,
Miercurea Ciuc, Casa de Studii Jakab Antal. 20 credite
EMC. Tax de participare: 35 Euro (include pentru
membrii Asociaiei cina festiv). Cazare 14 E/pers./zi n
regim dubl, 22 E/pers./zi n regim single. nscriere prin
e-mail la alveress@clicknet.ro sau la telefon 0744-812.900
(Veress Albert). Termen limit de nscriere: 4 noiembrie.
Celor care se nscriu dup aceast dat nu le garantm
cazare. Cei care rein cazare i nu vor renuna la camere
pn pe 4 noiembrie vor trebui s achite c.v. camerei. FR
SUPRARE!!! Rezervarea camerelor se face n regim
Primul venit, primul servit
11-13 decembrie, Satu-Mare?: Weekend Interjudeean
cu Prerevelion Balint, 9 credite EMC, tax de participare:
25 Euro (include pentru membrii Asociaiei cina festiv).
15-17 ianuarie, 2010, Roman: Weekend Naional Balint
de iarn cu Postrevelion Balint. Termen de nscriere 13
ianuarie 2010 la e-mailul de mai sus. Tax de participare:
35 Euro.

Dorim s stabilim schimburi cu alte publicaii.


On dsir tablir lchange avec dautres
publications.
We wish to establish exchange with other
publications.
Wir wnschen mit anderen Herausgaben den
Austausch einzurichten.
Desideriamo stabilire cambio con alte
publicazioni.
Dseamos establecer intercambio con otras
publicaciones.

28

Muzicianul Asociaiei Balint, Bodor Csaba

n pauza de cafea