Boletim Balint RoFilename: Balint e RMP.pdfmênia 43

Buletinul AsociAiei BAlint, vol. 11., nr. 43, septemBrie 2009

Septembrie, 2009, Volumul 11, Nr. 43

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

Coperta - Botond Mikls FORR

Adresa redaciei:

530.111 MIERCUREA CIUC, Str. Gbor ron 10.tel./fax 0266-371.136, 0744-812.900E-mail: [email protected], [email protected], www.balint.xhost.ro

Adresa lectorului:E-mail: [email protected]

Comitetul de redacie:

Tnde BAKA, Doina COZMAN, Dan Lucian DUMITRACU, Evelyn FARKAS, Liana FODORANU,

Ioan-Bradu IAMANDESCU, Cristian KERNETZKY (D), Mircea LZRESCU

Holger Ortwin LUX, Drago MARINESCUIoana MICLUIA, Csilla MOLDOVAN,

Aurel NIRETEAN, Iuliu OLTEANGheorghe PAINA, Ovidiu POPA-VELEA,

Almos Bela TRIF (USA)Ionel UBUCANU, va VERESS, Nicolae VLAD.

Editat de Asociaia Balint din RomniaTiprit la Tipografia Alutus, Miercurea-Ciuc

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INDEX: ISSN 1454-6051

BULETINUL ASOCIAIEI BALINT DIN ROMNIA

CUPRINS

PSYCHOSOMATIC ASPECTS OF ALLERGIC REACTIONS TO DRUGS (MEDICINES).............. 3Ioan Bradu Iamandescu, Liliana Diaconescu

TULBURRI MENTALE N SINDROMUL METABOLIC ............................................................. 0Delia Lupu, D. L. Dumitracu

THE ROLE OF THE BALINT GROUPLEADER ..................................................................... 7Andrew Elder

THE RELATIONSHIP BETwEEN THEHEALTH PROFESSIONAL AND THE PATIENTAS PERCEIvED BY THE MEDICAL ANDNURSING STUDENTS ............................................ 20Almos Bela Trif, Clara Wolman

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

2Buletinul 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 medic-bolnav 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, inter-universitar, multi-disciplinar, de formaie polivalent.

Obiective: Formarea psihologic continu a partici-panilor. 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 [email protected]: Istvn VRADI istvanvaradi1inbox.comSecretar: Csilla HEGYI [email protected]: Albert VERESS [email protected]: 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.

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.

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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).

Recenziile crilor trebuie s cuprind datele de identificare a crii n cauz - autorii, titlul, toate subtitlurile, anul apariiei, editura, oraul, numrul de pagini i ISBN-ul. Se trimite n fiier separat imaginea scanat a copertei.

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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.

CTRE AUTORI


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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

ANUNURI IMPORTANTE

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

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 (minor- itching, 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


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reaction to this unusual, stressful and threatening situation. This remark is valuable especially for allergic type I reactions.

Medical approach of patients with drug allergyThe 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 . Clinical manifestations in drug allergy

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.

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).

General reactions (multi-systemic)

Anaphylactic shockSerum disease Drug fever Hypersensitivity vasculitis

Organic reactions

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 disordersNeurological disorders


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Types of symptoms specific for allergy to drugsPreviously (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);

- 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 drugsThe 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 drug-

induced 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

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


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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 pseudo-allergy 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 allergic-type 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


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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.

One could maintain, on the basis of the above-mentioned 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 2To 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;


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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.

CONCLUSIONSThe 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 allergic-

type 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.

References1. 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

- 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


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

Science, 8, 1994, p.129-135;9. Iamandescu, I.B.; Popa-Velea, O.; Mazuru, G.

Psychological parameters in patients with allergic and pseudo-allergic 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;

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.

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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 tulburri-lor 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

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

TULBURRI MENTALE N SINDROMUL METABOLIC(AnAlizA publicAiilor din ultimii 10 Ani)

As. Univ. Dr. Delia Lupu, Prof. Dr. D. L. DumitracuUniv. de Medicin i Farmacie Iuliu Haieganu Cluj Napoca


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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

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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).

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

Pod peste uscat foto Trif Almos Bela

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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, demonstrndu-se 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


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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. 2003; 43: 60-66

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, 110, 1761-1766

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

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).

Concluziin 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 ).

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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THE ROLE OF THE BALINT GROUP LEADER

by Andrew Elder, United Kingdom

REZUMATArticolul 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.

SUMMARYThis 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.

IntroductionA 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 PatientsDoctors 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 doctor-patient 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 atmosphereThe 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


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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.

Freedom and disciplineThe 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 groupA 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

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 doctor-patient relationship and only to a secondary degree on the


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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.

ConclusionBalint 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.

Further Reading1. Balint Enid. Research, Changes and Development in

Balint Groups in While Im Here, Doctor: A study of the Doctor-Patient 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).

Reminescene? foto Trif Almos Bela

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THE RELATIONSHIP BETwEEN THE HEALTH PROFESSIONAL AND THE PATIENT AS PERCEIvED

BY THE MEDICAL AND NURSING STUDENTS

Almos belA trif *And clArA WolmAn**

ABSTRACTThe 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.

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

SampleParticipants 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

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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

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.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 wer

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