Psihijatrija Danas 2005-2

PSYCHIATRY TODAY
Official Journal of the Serbian Psychiatric Association
PSIHIJATRIJA DANAS
asopis Udruenja psihijatara Srbije
UDK 616.89 ISSN-0350-2538
PSIHIJAT.DAN. 2005/XXXVII/2/227-380/BEOGRAD
UDK 616.89
ISSN-0350-2538
PSIHIJATRIJA DANAS
INSTITUT ZA MENTALNO ZDRAVLJE
PSYCHIATRY TODAY
INSTITUTE OF MENTAL HEALTH
PSIHIJAT. DAN., 2005/XXXVII/2/227-380/BEOGRAD
Psihijatrija danas se indeksira u sledeim bazama podataka: PsychoInfo; Psychological Abstracts; Ulrich's International Periodicals Directory, SocioFakt
UDK 616.89
Psihijat. dan. 2005/37/2/227-380/
Bgd. ISSN-0350-2538
PSIHIJATRIJA DANAS GODINA 37 BEOGRAD BROJ 2, 2005
SADRAJ
PREGLEDNI RADOVI Da li su mentalno obolele osobe sklonije nasilnom ponaanju? /M. Mili................................................................................................................................227 ISTRAIVAKI RADOVI Prenatalne predstave oeva o privrenosti su prediktivne za vezu oca i deteta od petnaest meseci: australijsko iskustvo /M. Radojevi ........................................................................................................................ 257 Povezanost posttraumatskog stresa i kvaliteta ivota kod graana nakon vazdunih napada /J. Jankovi Gavrilovi, D. Lei Toevski, O. olovi, S. Dimi, V. ui, M. Pejovi Milovanevi, S. Popovi Deui, S. Priebe........................................................ 289 Evaluacija grupne kognitivne psihoterapije posttraumatskog stresnog poremeaja /T. avi, M. Pejovi............................................................................................................. 307 STRUNI RADOVI Likantropija u radovima vizantijskih lekara /V. P. Kontaksakis,D. G. Laskaratos, P. P. Ferentinos, M. V. Kontaksaki, D. N. Hristodulu ..................................................................................................................323 Dvojstvo ene /N. Petrovi Stefanovi, S. Petrovi ...................................................................................... 335 Obavetenja Madridska deklaracija (jun 2005) ......................................................................................... 349 Kalendar kongresa / Website / Publikacije ........................................................................... 357 Uputstva saradnicima ............................................................................................................ 377
UDK 616.89
Psihijat. dan. 2005/37/2/227-380/
Bgd. ISSN-0350-2538
PSYCHIATRY TODAY YEAR 37 BELGRADE NUMBER 2, 2005
CONTENTS
REVIEW ARTICLES Are the mentally ill more prone to aggressive behavior? /M. Milic................................................................................................................................ 241
RESEARCH ARTICLES Prenatal paternal representations of attachment predict of infant-father attachment at 15 months: an Australian study /M. Radojevic ........................................................................................................................ 271 Association of posttraumatic stress and quality of life in civilians after air attacks /J. Jankovic Gavrilovic D. Lecic Tosevski, O. Colovic, S. Dimic, V. Susic, M. Pejovic Milovancevic, S. Popovic Deusic, S. Priebe ....................................................... 297 Evaluation of group cognitive psychotherapy of post-traumatic stress disorder /T. Cavic, M. Pejovic............................................................................................................. 315
GENERAL ARTICLES Lycanthropy according to Byzantine physicians /V. P. Kontaxakis, J. G. Lascaratos, P.P. Ferentinos, M. V. Kontaxaki, G. N. Christodoulou .............................................................................................................. 329 Duality of woman /N. Petrovic Stefanovic, S. Petrovic ...................................................................................... 341 Announcements Declaration of Madrid (June 2005) ....................................................................................... 353 List of Congresses / Website / Publications ......................................................................... 357 Instruction to Contributors .................................................................................................... 377
Psihijat. dan. /2005/37/2/227-240/ Mili M. Da li su mentalno obolele osobe sklonije nasilnom ponaanju?
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Pregledni rad UDK: 616.89-008
DA LI SU MENTALNO OBOLELE OSOBE SKLONIJE NASILNOM PONAANJU?

Milan Mili Institut za neuropsihijatrijske bolesti Dr Laza Lazarevi, Beograd
Apstrakt: Verovanje u povezanost nasilnosti i mentalnih poremeaja ivi u narodima razliitih kultura od pamtiveka. Paradoksalno je da ovu povezanost strunjaci ni danas nisu u potpunosti prihvatili, iako istraivanja u poslednjih petnaest godina jasno ukazuju na njenu verodostojnost. U ovom radu dati su mogui argumenti i predstavljene etiri aktuelne perspektive u sagledavanju ove povezanosti. Najvei deo lanka sadri pregled mnogobrojnih istraivanja uraenih na ovu temu u poslednjih petnaest godina, koja su podeljena u tri osnovna metodoloka pristupa: ispitivanja uestalosti pomenutog ponaanja meu pacijentima koji su leeni, ili se nalaze na leenju u psihijatrijskim ustanovama; ispitivanja uestalosti mentalnih poremeaja meu osobama koje su poinile krivino delo nasilja i nalaze se u ustanovama zatvorskog tipa i, ispitivanja uestalosti kako mentalnih poremeaja, tako i nasilnog ponaanja u uzorku opte populacije u odreenoj drutvenoj zajednici. Rezultati veine istraivanja sva tri pristupa skoro ujednaeno ukazuju na znaajno vii rizik od nasilnog ponaanja u populaciji psihijatrijskih pacijenata u odnosu na optu populaciju, i to posebno kod odreenih dijagnostikih kategorija, kao to su poremeaji povezani sa upotrebom psihoaktivnih supstanci, antisocijalni poremeaj linosti, psihotini poremeaji, bipolarni afektivni poremeaj. U zakljuku su istaknute manjkavosti dosadanjih istraivanja i pretoene u predlog jednog kvalitetnog nacrta za sledea istraivanja na tu temu. Na kraju je naglaena vanost odnosa psihijatara prema ovom osetljivom pitanju, gde bi istraivanje faktora rizika i time preveniranje agresivnosti u ovoj populaciji bili daleko racionalnije od dosadanjeg neargumentovanog negiranja oiglednog, a opet u slubi tih istih pacijenata, jer se upravo prepoznavanjem takvih pojedinaca i pravi razlika u odnosu na veinu drugih koji nisu nasilni. Kljune rei: nasilnost, kriminal, mentalni poremeaji, stigma, epidemiologija
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Uvod Tokom istorije skoro svih poznatih kultura agresivnost i mentalni poremeaji (bolesti) su dovoeni u vezu. Sokrat je u jednoj od svojih rasprava komentarisao da broj mentalno obolelih u Atini mora biti nizak, jer ima vrlo malo nasilja [1]. Strah javnosti od duevnih bolesnika je oduvek prisutan i dobro je dokumentovan [2,3,4]. Telefonska anketa obavljena 1990. godine na podruju cele Amerike pokazuje da 80% uesnika potvruje bar jednu od sledeih izjava: mentalno oboleli su skloniji nasilnim radnjama od drugih ljudi; prirodno je plaiti se nekoga ko je duevni bolesnik; vano je imati na umu da bivi pacijenti duevnih bolnica mogu biti opasni [5]. Nasilni akti mentalno obolelih zastrauju nas vie nego neki drugi oblici nasilja. Obinom oveku oni deluju bezumno, nelogino, nepredvidivo, smrtonosno. udno, moda i ironino, ali ovu vezu koja je ljudima poznata vekovima strunjaci u oblasti mentalnog zdravlja poinju da prihvataju tek nekih deset do petnaest godina unazad. Na pitanje zato je to tako postoji nekoliko odgovora. Prvi se odnosi na nedovoljnu uverljivost istraivanja koja su se bavila ispitivanjem veze nasilnog ponaanja i mentalnih bolesti. Validnost takvih istraivanja esto je bila ograniena nestandardizovanim ili nejasnim definicijama agresivnog (violentnog) ponaanja, mentalnih bolesti, ili oboje; oslanjanjem uglavnom na slubene podatke, to vodi u posebnu vrstu zastranjivanja (videti dalje u tekstu); poreenjem sa osobama koje nisu mentalno obolele uz izostavljanje ili manjkavo ukljuivanje demografskih i situacionih inilaca; i vrstom istraivanja, koja su po pravilu bila retrospektivnog karaktera [1,5,6,7]. Drugo, nain na koji se drutvo postavlja prema mentalno obolelim agresivnim osobama, varira s vremenom, kako u odreenoj kulturi, tako i izmeu razliitih kultura. Tu moemo nai vrlo arolike oblike reavanja problema, od uvanja u okviru porodice, preko ignorisanja, smetaja u bolnicu, zatvor, pa ak i egzekucije takvih pojedinaca. Do ezdesetih godina dvadesetog veka, rezultati mnogih istraivanja su, oslanjanjem na slubene podatke o stopi hapenja zbog agresivnog ponaanja, pokazivali da duevno oboleli nisu skloniji nasilnim aktima u odnosu na optu populaciju [8]. Tada je, meutim, veina pacijenata provodila dobar deo ivota u raznim ustanovama. Politika deinstitucionalizacije koja je usledila nakon toga, dovela je do znaajnog porasta stope. Pritisak koji je tada poeo u smislu otputanja pacijenata i smanjivanja kapaciteta, mnogima od njih je uinio medveu uslugu jer su se nali na ulici. Neka istraivanja u Americi pokazuju da su mentalno obolele osobe i, uz to beskunici, visoko zastupljene meu nasilnim prestupnicima [9]. Osnovnim razlogom smatra se nedostatak adekvatnog psihijatrijskog leenja, s obzirom da sami ne dolaze na leenje, a nemaju porodicu, niti ikoga bliskog ko bi se starao o njima. Tree, tokom proteklih dvadeset godina, upotreba psihoaktivnih supstanci, kao to su kokain, heroin, halucinogeni, sedativi i druge, zajedno sa alkoholom,
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ula je na velika vrata u svakodnevicu i dovela do sveopteg poveanja stope nasilja. Naravno da se to odrazilo i na stopu kod mentalno obolelih [10]. etvrto, psihijatri su opravdano bili oprezni u vezi sa daljom stigmatizacijom duevno obolelih, sa neim to je tada delovalo kao vrlo tanka pria [8], a postoji i mogunost zloupotrebe. Neki autori [11] ukazuju da su mentalno oboleli esto bili rtveni jarci, neko na koga je bilo najlake baciti krivicu u sredinama u kojima je postojao izraen problem nasilja. Na kraju, pretpostavljena opasnost po druge i jeste osnovni uzrok stigme duevno obolelih, to onda utie na sve oblasti njihovog ivljenja. U proteklih petnaest godina znaajno je porastao broj dokaza o verodostojnosti veze duevnih bolesti i nasilnog ponaanja. Oni se ne mogu vie ignorisati, niti lako opovrgnuti. Odreene nedoumice ipak, jo uvek, postoje. S obzirom na nedovoljnu informisanost na tom planu u naim strunim krugovima i javnosti uopte, sledi pregled epidemiolokih radova koji tretiraju pitanje odnosa nasilnog ponaanja i mentalnih poremeaja. Moemo rei da, u celini, meu istraivaima postoje etiri perspektive u sagledavanju ovog odnosa. Prva, koja danas ima mnogo manje pristalica nego ranije, ne prihvata nikakvu vezu izmeu mentalnih bolesti i nasilja. Druga tu povezanost prihvata, ali je definie kao lanu, kao artefakt. Tree vienje podrava kauzalnu vezu izmeu nasilja i duevnih bolesti i pokuava da utvrdi ta je to to kod ovakvih bolesti dovodi do nasilja. Najzad, etvrta perspektiva takoe podrava kauzalni odnos, ali ga povezuje sa drutvenim prilikama. Pregled epidemiolokih istraivanja Mnogobrojna epidemioloka istraivanja, razliito zamiljena, manje ili vie uspeno, dokazivala su ili opovrgavala ove stavove. Nijedna istraivaka zamisao nije se pokazala kao idealna. Uopte uzev, moemo rei da postoje tri osnovna metodoloka pristupa u proceni mogue veze izmeu mentalnih poremeaja i nasilnikog ponaanja: prvi, ispitivanje uestalosti pomenutog ponaanja meu pacijentima koji su leeni, ili se nalaze na leenju u psihijatrijskim ustanovama; drugi, ispitivanje uestalosti mentalnih poremeaja meu osobama koje su poinile krivino delo nasilja i nalaze se u ustanovama zatvorskog tipa; i trei, ispitivanje uestalosti kako mentalnih poremeaja, tako i nasilnog ponaanja u uzorku opte populacije u odreenoj drutvenoj zajednici [12]. Istraivanja prvog metodolokog pristupa to se tie prvog pristupa, koriene su razliite strategije u istraivanju: retrospektivna istraivanja psihijatrijski leenih pacijenata, istraivanja praenja otputenih psihijatrijskih pacijenata, retrospektivna i prospektivna istraivanja psihijatrijskih pacijenata roenih u odreenom vremenskom periodu. Za procenu nasilnog ponaanja uzimani su podaci pre, za vreme ili posle bolnikog leenja. Svaki od ovih naina procene ima svoje nedostatke,
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i treba ih imati u vidu. Ako su uzimani pre prijema u bolnicu, greka koja esto onemoguuje uoptavanje rezultata je upravo to to je razlog prijema uglavnom agitirano ili nasilno ponaanje. Rezultati mogu biti nedostatni i ako se procena vri za vreme boravka u bolnici, kao i ako se za vreme leenja agresivno ponaanje koriguje. Sem toga, moe se pretpostaviti da se ee lee i hospitalizuju tei duevni poremeaji, kao to je shizofrenija, pa samim tim raste i njihov broj u uzorku. Najzad, validnosti procene nakon otpusta nedostaje to to se pacijenti otputaju kada vie nisu nasilni. S druge strane, prednost ovakvih istraivanja je to komuniciraju sa zvaninim podacima pa nisu podlona subjektivnosti. Pored toga, istraivanja roenih u odreenom vremenskom periodu ukljuuju sve registrovane pacijente, bez obzira na teinu oboljenja i broj bolnikih leenja, te se smatraju najvrednijima u smislu uoptavanja rezultata. Veina istraivanja ovog metodolokog pristupa nalazi povean rizik od nasilnog ponaanja kod odreenih psihijatrijskih poremeaja. Tako istraivanja Modestina i Amana [13,14], ispitujui uestalost prekraja sa nasilnikim ponaanjem na populaciji psihijatrijskih pacijenata univerzitetske bolnice u Bernu, vajcarska, nalaze tri do etiri puta povean rizik kod mukih pacijenata obolelih od shizofrenije i srodnih bolesti u odnosu na optu populaciju. Retrospektivno istraivanje shizofrenih pacijenata roenih u Stokholmu izmeu 1920. i 1959. godine ukazuje na 3.8 puta vei rizik za nasilno ponaanje [15]. Isti rizik nalazi i Vesli sa saradnicima [16] kod mukih shizofrenih pacijenata, koji su prvi put psihijatrijski leeni, u Londonu, u periodu od 1964. do 1984. godine. Najvei porast rizika od agresivnog ponaanja kod shizofrenih pacijenata nalazi Tihonen sa saradnicima [17]. Pratei kohortu roenih na severu Finske, oni nalaze da se mogunost osude zbog prestupa vezanih za nasilniko ponaanje uveava sedam puta u odnosu na osobe bez psihijatrijskih dijagnoza. Kada se procenjivao rizik kod psihotinih poremeaja u celini, naeno je poveanje od etiri puta za mukarce, a za ene i vie [18]. Sva istraivanja ovog tipa nalaze izrazito povean rizik od nasilnog ponaanja kod poremeaja vezanih za upotrebu psihoaktivnih supstanci. Hodinsova u ve pomenutoj analizi kohorte 15,117 roenih u Stokholmu, vedska, nalazi da relativni rizik kod mukaraca sa ovim problemom iznosi 15.4%, dok je u enskoj populaciji konzumenata taj rizik prisutan kod ak 54.6 % ispitanika [18]. Vidimo da je ta vrednost znatno vea od one kod psihotinih poremeaja. Komparativno istraivanje iste autorke sa saradnicima [19], uraeno u Danskoj, na velikoj neselektivnoj kohorti, dalo je sline rezultate. Nalaze pribline ovima dobili su i drugi istraivai [13]. Za antisocijalni poremeaj linosti naen je relativni rizik od 7.2 za mukarce i 12.1 za ene, tj. rizik je toliko puta vei u odnosu na optu populaciju [19]. Zanimljiv je neto stariji rad Rapkina, s kraja sedamdesetih [20], u kojom je dat pregled sedam istraivanja stope hapenih (privoenih) psihijatrijskih pacijenata, gde se pokazalo da istraivanja obavljena pre 1965. godine ne ukazuju na poveanu stopu hapenja psihijatrijskih pacijenata, za razliku od perioda od 1965.
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do 1979. godine, kada je u svakom istraivanju dobijen suprotan rezultat. Kada se kasnije objavljena istraivanja istog tipa [21,22,23,24] kombinuju sa Rapkinovim pregledom dobije se odnos 3:1 u odnosu na stopu hapenja psihijatrijski pacijenti: opta populacija [25]. Slede Tabele 1. i 2. sa pregledom znaajnijih istraivanja ovog pristupa.
Tabela 1. Retrospektivna istraivanja pacijenata primljenih na psihijatrijsko leenje (prvih pet) i retrospektivna kohortna istraivanja (poslednje dve)
Autori Hamfris i saradnici (1992) Modestin i Aman (1995) Modestin i Aman (1996) Volavka i saradnici (1997) Mantaner i saradnici (1998) Lindkvist i Alebek (1990) Weseli i saradnici (1994) Lokacija Nortvik Park Vremenski period ? N 253 Pol m+ Dg grupa Sch (ICD-9) Definicija agresivnosti ivotnougroavajue ponaanje (procena roaka) Slubeni podaci (policijski) Slubeni podaci (sudski) Fiziki napadi (procena drugih)
Bern Bern eka, Danska, Irska, Japan, VB, SAD, ZND Indija, Nigerija Baltimor Stokholm London
1987 1985-1987 1987
1,265 282 1,017
m+ m m
Svi poremeaji (ICD-9) Sch (RDC) Sch (ICD-9)
1983-1989 1971-1986 1964-1984
1,670 790 538
m+ m+ m+
Ppsihoze (DSM-III) Sch (ICD-8) Sch (ICD-9)
Podaci od ispitanika Slubeni (sudski) Slubeni (sudski) i podaci od ispitanika
Tabela 2. Istraivanja praenja leenih psihijatrijskih pacijenata (prve tri) i prospektivna istraivanja praenja kohorte roenih (poslednja etiri)
Autori Svonson i saradnici (1997) Stidmen i saradnici (1993, 1998) varc i saradnici (1998) Ortman (1981) Hodins (1992) Hodinsi i saradnici (1996) TIihonen i saradnici (1997)
a b
Lokacija Severna Karolina Pitsburg, Kanzas Siti Vorester Severna Karolina Kopenhagen Stokholm Danska
Vremenski period 1986-1991
N 169
Pol m+
Dg grupa Teki mentalni poremeajia Selekcionisani mentalni poremeajb Teki mentalni poremeajia Svi poremeaji Svi poremeaji Svi poremeaji Svi poremeaji
Definicija agresivnosti Slubeni (bolnica, sud) i od ispitanika Podaci od ispitanika Slubeni (sud, policija) i od ispitanika Slubeni podaci (sudski) Slubeni (sudski) Slubeni (sudski) Slubeni (sudski)
1992-1995
1,136
m+
331
m+
1953-1978 1953-1983 1944-1947
11,540 15,117 358,180
m m+ m+
Severna Finska
1966-1992
12,058
m+
Shizofrenija, paranoidne psihoze, afektivne psihoze Shizofreni spektar, afektivni spektar, paranoidne psihoze, zloupotreba supstanci
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Tabela 3. prikazuje rezultate nekih od pomenutih istraivanja.

Tabela 3. Relativni rizik od nasilnikog ponaanja kod mentalno obolelih (u odnosu na optu populaciju, gde se uzima da je 1.0)
Autori Teki mentalni poremeaji Organski poremeaji Shizofrenija m 3.1 m 3.9 Afektivni poremeaj m 8.8 Anksiozni poremeaj Poremeaji vezani za upotrebu supstanci m 6.5 Antisocijalni poremeaj linosti
Modestin i Aman, (1995) Modestin i Aman, (1996) Lindkvist i Alebek, (1990) Hodins, (1992) Hodins i saradnici, (1996) Tihonen i saradnici, (1997) Svonson i saradnici, (1992) Stuve i Link, (1997)
a
m 3.9
m 4.2 27.4 m 4.5 8.7
m 2.6
m 15.4 54.6 m 8.7 15.1 m 7.2 10.4
m 7.2 12.1
m 5.0
4.1
1.7
1.2
3.6a /10.1b 3.3a /6.6b

b
1.4a /1.5b
1.3a /1.2b
Rizik od fizikog napada;
Rizik od korienja oruja
Istraivanja drugog metodolokog pristupa Drugi metodoloki pristup je zastupljen uglavnom sa dva tipa istraivanja: onima koja su raena na prestupnicima koji su poinili ubistvo, i dijagnostika istraivanja reprezentativnog uzorka. Ovako postavljena istraivanja imaju jedan zajedniki nedostatak, kao i deo istraivanja prethodnog pristupa, koja analiziraju stopu privoenja psihijatrijskih pacijenata, odnosno da li se psihijatrijski pacijenti ree ili ee privode tj. hapse. Drugi problem, koji se tie samo istraivanja ovog tipa, odnosi se na izostavljanje u proceni onog dela psihijatrijskih pacijenata prestupnika kojima je izreena mera leenja na slobodi. I jedno i drugo uglavnom zavisi od zemlje i njenog zakonodavstva [26,27]. Trea slabost ovog pristupa je to ne ukljuuje lake agresivne nastupe, koji najee nisu razlog za smetaj u zatvorsku ustanovu. Dobra strana ovako osmiljenih istraivanja, slino kao i kod prethodnog pristupa, jeste rad sa slubenim podacima. Prvi primer istraivanja sa prestupnicima koji su poinili ubistvo dolazi iz Finske, koja je posebno pogodna za ovakve tipove istraivanja iz dva razloga. Prvo, procenat razreenja ubistava kod njih je vrlo visok, iznosi 97%, i drugo, svaki od prestupnika se detaljno psihijatrijski ispituje. U nekoliko objavljenih radova finski autori, na elu sa Markom Eronenom, nalaze da je rizik od ubistva osam puta vei kod mukaraca koji boluju od shizofrenije u odnosu na normalnu popu-
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laciju, kod alkoholiara se uveava vie od deset puta, i vie od jedanaest puta kod antisocijalnog poremeaja linosti, dok afektivni i anksiozni poremeaji ne uveavaju relativni rizik [28,29,30]. Tri sledea istraivanja, dva iz Skandinavije i jedno iz Kanade, takoe ukazuju da meu violentnim prestupnicima postoji veliki broj osoba sa teim mentalnim poremeajima. Gotlib i saradnici [31] su, prouavajui ubice u Kopenhagenu izmeu 1959. i 1983. godine, nali da je 20% mukaraca i 44% ena bilo dijagnostikovano kao psihotino. Meu njima je 41% mukaraca i 13% ena imalo poremeaj vezan za upotrebu psihoaktivnih supstanci. Rezultati ovog istraivanja pokazuju da se kod psihotinih osoba rizik od ubistva poveava est puta za mukarce, i ak esnaest puta za ene. Sledi Lindkvistovo istraivanje [32] uraeno u vedskoj na sveukupnoj populaciji osoba koje su poinile ubistvo u periodu od 1970. do 1981. kada je naeno 53% psihotinih prestupnika, a meu njima 38% poremeaja vezanih za upotrebu psihoaktivnih supstanci. Najzad, kanadsko istraivanje na reprezentativnom uzorku homicidnih prestupnika mukog pola, tienika zatvora u Kvebeku, ukazuje na znaajno veu frekvencu (35%) teih mentalnih poremeaja (psihoze i tei afektivni poremeaji) u odnosu na druge prestupnike iste ustanove. U toj grupi homicidnih prestupnika 83% je imalo predistoriju alkoholiarske, a 63% narkomanske zavisnosti. Interesantna su dalje, u istom kontekstu, istraivanja homicidnih recidivista. vedsko istraivanje obavljena na uzorku od dvadeset i jedne osobe koje su poinile ponovljeno delo ubistva, nalazi da su oni esto bili vinovnici i drugih nasilnikih ponaanja, i da se veina moe svrstati u dijagnostiku grupu poremeaja linosti. Mnogi od njih su bili zavisnici od droga i alkohola, a 10% je bolovalo od shizofrenije [33]. Tihonen i Hakola [34] su ispitivali trinaest repetitivnih prestupnika ubica, koji su svoj poslednji prestup poinili u poslednje tri godine, i od tada se nalaze u zatvoru ili u nekoj od psihijatrijskih ustanova sa visokim obezbeenjem. Kod svih ispitanika je dijagnostikovano mentalno oboljenje, i to kod jedanestoro njih teak alkoholizam kombinovan sa poremeajem linosti, a kod dvoje shizofreno oboljenje. Tabela 4. Neka istraivanja prestupnika koji su poinili ubistvo
Autori Lindkvist, (1986) Gotlib i saradnici, (1987) Kot i Hodins, (1992) Eronen i saradnici, (1996) a, b Lokacija Severna vedska Kopenhagen Kvebek Finska Vremenski period 1970-1981 1959-1983 1988 1984-1991 N 64 263 87 693 Pol m+ m+ m m+ Dijagnostiki kriterijum ? ICD-8 DSM-III DSM-III-R
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Tabela 5. Rizik od homicidnog ponaanja meu psihijatrijskim pacijentima mukog pola u odnosu na optu populaciju mukaraca
Dijagnoza Anksiozni poremeaj Distimija Mentalna retardacija Teka depresivna epizoda Shizofrenija bez alkoholizma Shizofrenija psihotini spektar Alkoholizam Antisocijalni poremeaji linosti Alkoholizam i ranije ubistvo Shizofrenija sa alkoholizmom Shizofrenija i ranije ubistvo Stopa na 100 1.5 1.4 1.2 3.0 3.7 6.4 39.2 11.3 2.9 Relativni rizik 0.3 0.6 1.2 1.6 7.2 8.0 10.7 11.7 13.3 17.2 25.8 95% interval poverenja 0.2-0.5 0.3-1.1 0.9-2.2 1.1-2.4 5.4-9.7 6.1-10.4 9.4-12.2 9.5-14.4 8.9-20.0 12.4-23.7 9.6-69.6
Suprotno do sad navedenim istraivanjima, istraivanja reprezentativnog uzorka opte populacije tienika zatvorskih ustanova, tj. uestalosti mentalnih poremeaja u istoj, imaju tu manu to ne prave razliku izmeu nasilnih i nenasilnih prestupa. Uprkos tom ogranienju i preko njih moemo dobiti nekakvu orijentacionu predstavu o odnosu mentalnih oboljenja i nasilnog ponaanja. Kod te zatvorske populacije, posebno enskog dela, naena je izrazito poviena stopa alkoholizma, narkomanije i antisocijalnog poremeaja linosti u odnosu na optu populaciju. esto su u komorbiditetu prisutna sva tri poremeaja [35]. O povienoj stopi za tee mentalne poremeaje, tipa shizofrenije ili teih afektivnih poremeaja, a u odnosu na optu populaciju, izvetava se u vie objavljenih istraivanja na zatvorenicima oba pola [36,37,38]. Za podruje nae zemlje ne postoje ovako ozbiljne epidemioloke analize. Moe se rei da, po podacima koji su nama bili dostupni, ne samo u ovom nego i drugim pristupima istraivanju ovog problema, praktino nema znaajnijih radova u poslednjih dvadeset do trideset godina.
Tabela 6. Dijagnostika istraivanja reprezentativnog uzorka osuenih prestupnika (zatvorenika)
Autori Tejlor, (1985) Hajd i Sajter, (1987) Nejbors i saradnici, (1987) Danijel i saradnici, (1998) Hodins i Kot, (1990) Teplin, (1990) Harli i Dan, (1991) Teplin i saradnici, (1996) Dordan i saradnici, (1996) Lokacija London, VB Ohajo, SAD Miigen, SAD Misuri, SAD Kvebek, Kanada Okrug Kuk, SAD Brizbejn, Australija Okrug Kuk, SAD Severna Karolina, SAD Vremenski period ? ? 1986 ? 1988 1983-1984 1989 1991-1993 1991-1992 N 203 509 1070 100 495 728 92 1272 805 Pol m m+ m+ m m DSMDSM-III-R DSM-III DSM-III DSM-III DSM-III-R DSM-III-R DSM-III-R Dijagnostiki kriterijum
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Tabela 7. ivotna uestalost psihijatrijskih poremeaja kod osuenih prestupnika (zatvorenika) bez selekcije ispitanika po osnovu nasilnost
Dijagnoza Nejbors (1987) m+ 2.8 11.3 6.4 0.5 1.1 12.0 1.6 22.0 0.9 Hajd i Sajter (1987) m+ 1.5 12.7 3.0 0.9 2.5 3.4 2 6 2 1.6 2.5 5.8 2.7 2.6 Teplin (1993) m 3.7 5.7 Kot i Hodins (1990) m 6.5 14.8 Harli i Dan (1991) Danijel (1991) 7 19 Teplin (1996) 2.4 16.9 9.6 Dordan (1996) 13.0 7.1
Shizofrenija Teka depresija Distimija Bipolarni afektivni poremeaj Manina epizoda Agorafobija Panini poremeaj Generalizovani anksiozni poremeaj Opsesivno kompulzivni poremeaj Antisocijalni poremeaj linosti Alkoholizam Narkomanija
5.6
50.1 46.5 28.6 28.7
61.5 66.9 48.9 zajedno sa 55.4
29 36 26
13.8 32.3 63.6
11.9 38.6 44.2
Istraivanja treeg metodolokog pristupa Poslednji, trei metodoloki pristup u istraivanju ove veze, odnosi se na istraivanja u odreenoj drutvenoj zajednici (optini, gradu, regionu). Za procenu se mahom koriste instrumenti tipa upitnika, koje najee popunjavaju sami ispitanici, a ponekad se kombinuju sa zvaninim podacima o privoenju zbog agresivnih ispada. Ovi tipovi istraivanja imaju nekoliko prednosti u odnosu na prethodne. Prva se tie eliminacije tzv. problema kriminalizacije psihijatrijskih pacijenata, odnosno, disproporcionalnog upuivanja istih na pravosudni sistem u odnosu na optu populaciju. Druga je slina prvoj, a odnosi se na tzv. medikalizaciju nasilja, tj. na ponekad neadekvatno upuivanje takvih pojedinaca na leenje, ime se poveava stopa nasilnih pojedinaca meu psihijatrijskim pacijentima. I jedna i druga prednost se postiu zahvaljujui nezvaninim podacima o nasilnikom ponaanju, koji se dobijaju od samih ispitanika. Trea prednost se odnosi na istu sredinu iz koje ispitanici potiu, pa se ne moe prigovoriti da je u razliitim sredinama takvo ponaanje manje ili vie prisutno. Mane ovog pristupa su subjektivnost dobijenih podataka i, u nekim istraivanjima, izostavljanje onih pojedinaca koji se nalaze u institucijama (zatvori ili bolnice) zbog ozbiljnijih bolesti ili prestupa. Do sad su objavljene tri znaajna istraivanja ovog pristupa. Prvo istraivanje o kome emo ovde govoriti je uraeno korienjem podataka jednog ireg amerikog epidemiolokog istraivanja (Epidemiologic Catchment Area Study), koje je uraeno na 20,000 ispitanika u pet regiona u Americi, sa ciljem da se odredi broj neleenih psihijatrijskih poremeaja. Svonson i sa-
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radnici [39] su obraivali ispitanike iz tri grada: Baltimora, Darama i Los Anelesa. Evaluirali su podatke dobijene od samih ispitanika, od kojih je traeno da se izjasne da li su u prethodnoj godini (godini koja je prethodila istraivanju) uinili neto od sledeeg: udarili suprunika ili partnera, udarili dete toliko da se stvorila modrica ili da se moralo ii lekaru, razmenjivali udarce sa nekim ko nije suprunik ili partner, koristili oruje u tui, ili se fiziki obraunavali u pijanom stanju. Osobe sa mentalnim poremeajima su, uopte uzev, znaajno vie uestvovale u nekom od pomenutih nasilnikih ponaanja. Za ispitanike sa dijagnozom shizofrenije taj rizik se poveava neto vie od etiri puta (4.1), a najvei rizik od nasilnikog ponaanja nose osobe koje pate od poremeaja vezanih za upotrebu psihoaktivnih supstanci, i on je u ovom istraivanju deset puta vei nego u optoj populaciji. Grafikon 1. pokazuje pretpostavljenu verovatnou nasilnikog ponaanja po polu i psihijatrijskim dijagnozama, dobijenu metodom logistike regresije u ovom istraivanju. Grafikon 1.
25 20 15 Verovatnoa ene 10 5 0 Bez oboljenja Anksioznost Afektivni poremeaj Shizofrenija Upotreba supstanci Upotreba supstanci i mentalni poremeaj Mukarci
Drugo istraivanje, koje su sproveli Link i saradnici [5] poredilo je psihijatrijske pacijente i ostale stanovnike Vaington Hajta, dela Njujorka sa etniki i socio-ekonomski vrlo heterogenim stanovnitvom, po osnovu vie slubenih i neslubenih podataka. Prvi su dobijeni iz policijske dokumentacije drave Njujork, a drugi preko izjava koje su davali sami ispitanici. Tokom formiranja uzorka populacija psihijatrijskih pacijenata podeljena je u tri grupe: oni koji su imali prvi kontakt sa psihijatrijom u godini koja je prethodila intervjuu, oni koji su leeni ranije, ali su bili na tretmanu i u godini koja je prethodila istraivanju i, najzad, oni koji su leeni ranije, ali ne i u protekloj godini. Poreenjem sa zdravom populacijom, u grupi psihijatrijskih pacijenata naena je znaajno via stopa privoenja zbog nasilnog ponaanja, i to kako po zvaninim, tako i po podacima koje su davali sami ispitanici, zatim via stopa fizikih napada na druge, tu, korienja oruja, tekih povreda nanesenih drugima. Vremenske koordinate su bile ili do sada u ivotu, ili u poslednjih pet godina. Dobijene razlike su opstale i posle stroge kontrole sociodemografskih inilaca. Najubedljiviju korelaciju sa nasilnikim ponaanjem kod psihijatrijskih pacijenata pokazala je psihotina simptomatologija. Ovakav rezultat, po miljenju autora, podrava verodostojnost veze nasilnikog ponaanja i duevnih bolesti.
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Treim istraivanjem [40] autori su pokuali da daju odgovor na neka pitanja koja su ili nedovoljno obraena, ili su promakla u prethodna dva. Jedno od tih pitanja je da li veina mentalnih oboljenja pozitivno korelira sa nasilnikim ponaanjem ili je ono ogranieno na odreene komplekse simptoma ili specifine poremeaje. Sledee se odnosi na mogunost da vei deo ove povezanosti moe biti pripisan specifinim kontekstualnim iniocima, npr. da li je u toj odreenoj drutvenoj zajednici interpersonalna agresivnost u reavanju sukoba uobiajena ili ne. Poslednja dilema se tie pretpostavke da se nasilniko ponaanje kod mentalno obolelih moe u celini objasniti komorbiditetom sa zloupotrebom psihoaktivnih supstanci i antisocijalnim poremeajem linosti. Istraivanje je obavljeno u Izraelu na 2,741 ispitaniku, starosti od 24-33 godine, korienjem istih instrumenata procene kao u prethodnom istraivanju. Psihijatrijske dijagnoze su bile rasporeene u sledeih pet kategorija: (1) psihotini poremeaji shizofrenija, shizoafektivni poremeaj, nespecifine funkcionalne psihoze i teka depresija sa psihotiim simptomima; (2) bipolarni afektivni poremeaj i ciklotimija; (3) teka depresija bez psihotine simptomatologije; (4) generalizovani anksiozni poremeaj; (5) fobije. Uz to je procenjivan i komorbiditet. Dobijeni rezultati su slini onima koje su dobili i drugi autori, i ukazuju na kauzalnu vezu odreenih tipova psihijatrijskih poremeaja i nasilnikog ponaanja. Psihotini poremeaji i bipolarni afektivni poremeaj su pokazali snanu udruenost sa podacima o fizikim konfliktima (tuama) (rizik se uveava 3.3 puta) i korienjem oruja (rizik uvean 6.6 puta). Znaajnost ostaje i pored kontrole komorbiditeta sa zloupotrebom supstanci, antisocijalnim poremeajem linosti, te sociodemografskim parametrima. Ista veza nije potvrena kod nepsihotinih depresija, generalizovanog anksioznog poremeaja i fobija. Takoe je pokazano da, iako ne kljuni, drutveni inioci kao to je nii obrazovni nivo, bitno utiu na ispitivanu povezanost.
Tabela 8. Rizik od nasilnikog ponaanja kod muke psihijatrijske i prestupnike populacije u odnosu na optu populaciju mukaraca
Dijagnostika kategorija Anksiozni poremeaj Distimija Opta populacija Mentalna retardacija Teka depresija epizoda Shizofrenija bez alkohola (1) Teki mentalni poremeaji Shizofrenija bez alkohola (2) Shizofrenija psihot. spektar Homicid recidivisti sa jednim ranijim homicidom Alkoholizam Antisocijalni poremeaj linosti Shizofrenija sa alkoholom (1) Shizofrenija sa alkoholom (2) Ubica prva godina po izlasku iz zatvora Sudski psihijatrijski pacijent prva godina po otpustu iz bolnice 11 (1.2%) u uzorku 910 ubica 27 (3.0%) u uzorku 910 ubica 3 pacijenta sa violentnim prestupima u kohorti roenih - 11,017 82 u kohorti roenih 7,362 48 pacijenata u uzorku 1,302 ubica 58 (6%) u uzorku 910 ubica 35 izmeu 1,584 ubica 357 (39.2%) u uzorku 910 ubica 103 (11.3%) u uzorku 910 ubica 38 (2.9%) u uzorku 1,302 ubica 4 pacijenta osuena za violentne prestupe u kohorti roenih 11,017 35 izmeu 1,584 ubica Studija praenja sa srednjim vremenom od 7.8 godina Broj ispitanika sa tom Dg u uzorku 14 (1.5%) u uzorku 910 ubica 13 (1.4%) u uzorku 910 ubica Relativni rizik 0.3 0.6 1 1.2 1.6 3.6 4.16 7.25 8.0 10.4 10.7 11 17.2 25.2 253.8 293.9 0.7-2.2 1.1-2.4 0.9-12.3 2.23-7.78 4.7-5.4 6.1-10.4 7.4-14.5 9.4-12.2 9.5-14.4 12.4-23.7 6.1-97.2 1,458-441.9 119,272.47 Interval poverenja 95% 0.2-0.5 0.3-1.0
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Na Tabeli 8. jo jednom dajemo pregled rezultata dobijenih u nekim ovde pomenutim istraivanjima, a tiu se rizika od nasilnikog ponaanja kod odreenih psihijatrijskih kategorija u odnosu na optu populaciju. Nai rezultati Kako je procena rizika od nasilnikog ponaanja u ovoj populaciji pacijenata nezadovoljavajua (uspenost predvianja 40-72%), u naem istraivanju pokuali smo da utvrdimo pomenute inioce rizika kod obolelih od shizofrenije. Istraivanje je uraeno u Institutu za neuropsihijatrijske poremeaje Dr Laza Lazarevi, gde se psihijatrijski zbrinjavaju pacijenti za oblast Beograda i ire okoline. Ispitanici su bili muki pacijenti sa dijagnozom shizofrenije (ICD-10), stari 18-45 godina, bez teih somatskih bolesti koje bi mogle uticati na rezultate biohemijskih analiza ili neurofizioloke nalaze. U prospektivnom istraivanju odabrano je 138 ispitanika kod kojih su prvo ispitani svi istraivani parametri: sociodemografski (polustrukturisani upitnik 14 stavki), kliniko-psihopatoloki (PANSS skala, Kalgarijska skala depresivnosti za shizofrene pacijente DSS, Skala prehospitalne agresivnosti u okviru porodice SPAUOP, pokuaji samoubistva, upotreba PAS), biohemijski (biogeni amini i njihovi metaboliti u plazmi NA, DA, A, 5-HT, VMA, HVA, MHPG, 5-HIAA HPLC tehnikom; testosteron u plazmi RIA-CT metodom; holesterol u plazmi), i neuroloko-neurofizioloki (NES skala, EEG). Nakon toga pacijenti su praeni svo vreme bolnikog leenja i po osnovu agresivnosti (Skala ispoljene agresivnosti OAS) izdvojene su dve grupe: I grupa shizofreni pacijenti koji su pokazali nasilniko ponaanje (nasilni, N = 50), i II grupa shizofreni pacijenti koji nisu ispoljili agresivnost (nenasilni, N = 40). Ostali pacijenti nisu mogli biti svrstani ni u jednu grupu, jer je ispoljena nasilnost bila tek naznaena. Kod pacijenata grupe nasilnih registrovani su znaajno loiji odnosi u primarnoj porodici, vea uestalost duevnih bolesti u porodici, a tendencija znaajnosti naena je kod parametara agresivnost u primarnoj porodici i loiji uspeh u koli. Kao najpouzdaniji u predvianju pokazali su se kliniko-psihopatoloki faktori, pogotovu stavke PANSS skale. Grupa nasilnih imala je izraeniju psihopatologiju (klaster opte psihopatologije i ukupni skor PANSS skale) i vee skorove na pozitivnom klasteru, gde je veza sa sumanutim idejama persekutornog tipa posebno naglaena. Istaknuto mesto meu prepoznatim prediktivnim iniocima zauzimaju i nedostatak uvida u svoje stanje, uznemirenost, grandioznost, sumnjiavost, hostilnost, nekooperativnost i slabost kontrole impulsa. Hipoteza o koegzistenciji auto- i heteroagresivnosti i ovde je potvrena u eim pokuajima samoubistva u predistoriji pacijenata grupe nasilnih. Prediktivni znaaj komorbiditeta sa poremeajima vezanim za upotrebu PAS prepoznat je u veoj uestalosti puenja i zloupotrebe drugih PAS u grupi nasilnih, to je tumaeno na vie nivoa, od biolokog do socijalnog. Od biohemijskih inilaca, prediktivnim znaajem izdvojile su se visoke vrednosti 5-HT, NA, i MHPG u plazmi nasilnih ispitanika, kao i negativna korelacija
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nivoa holesterola i fizike agresivnosti. Kao najmanje ubedljivi pokazali su se neuroloko-neurofizioloki inioci, to je verovatno vezano za izostanak ekstremnijih oblika nasilnosti kod nasilnih ispitanika, te dobijene znaajne razlike nisu imale potreban kvantitet da bi mogle biti tretirane kao validne. Nalazi idu u prilog stavu da je sklonost nasilnom ponaanju rezultat akumulacije inilaca rizika, od kojih nijedan zasebno nije niti neophodan, niti dovoljan za predvianje. I vie od toga, videli smo da je preporuljivo sagledavati razliite grupe varijabli, jer ne postoji samo jedan put kojim se moe objasniti nasilniko ponaanje. Zakljuak Na kraju ovog pregleda moemo rei da rezultati veine istraivanja u sva tri metodoloka pristupa jasno pozitivno koreliraju. Uprkos razliito osmiljenim istraivanjima, kod svih je dobijen znaajno vei rizik od nasilnikog ponaanja za populaciju psihijatrijskih pacijenata u odnosu na one koji to nisu. No, opet ne kod svih, nego samo kod odreenih dijagnostikih kategorija, kao to su poremeaji povezani sa upotrebom psihoaktivnih supstanci, antisocijalni poremeaj linosti, psihotini poremeaji i bipolarni afektivni poremeaj (Tabela 3, 5, 7, 8). Verovatno je da aktivni psihopatoloki sadraji, posebno oni koji se tiu poremeaja opaanja, miljenja i afekta, imaju veu vanost u proceni rizika nego dijagnoza sama po sebi. Moe se pretpostaviti da je ta veza psihijatrijskih oboljenja i violentnog ponaanja kauzalnog tipa, ali se moraju uzeti u obzir i specifine okolnosti, kontekst u kojem se meusobno prepliu psihopatologija i inioci sredine. Mora se ipak naglasiti da je obim udruenosti mentalnih oboljenja i nasilnikog ponaanja, ma koliko statistiki znaajan, ipak skroman u odnosu na inioce kao to su pol, starost, obrazovni nivo ili socioekonomski status [11]. Do sad reeno neizbeno vodi ka odbacivanju prva dva vienja ovog problema, gde se, da podsetimo, povezanost ova dva entiteta ili negira, ili smatra lanom. Potrebna su ipak dalja istraivanja koja e otkloniti mane dosadanjih i rezultate time uiniti validnijim. Po preporuci koju daju Link i Stuve [25], dobro epidemioloko istraivanje ovog problema trebalo bi da bude osmiljeno na sledei nain: (1) specifikovati psihijatrijsko oboljenje ili oboljenja od znaaja za istraivanje; (2) pratiti reprezentativni uzorak ljudi koji ne boluju od specifikovanog(nih) oboljenja, i one koji su prvi put oboleli od specifikovanog(nih) oboljenja; (3) uporeivati grupe na osnovu nasilnikog ponaanja (vrstu, uestalost, intenzitet) koje e se u perspektivi pojavljivati. To istraivanje bi dalje trebalo da ukljui sveobuhvatni paket pozadinskih varijabli (individualnih i kontekstualnih) koje mogu uticati na rezultate, i da nae nain da operacionalizuje procenu nasilnikog ponaanja koristei slubene i neslubene podatke. U zakljuku treba rei i to da je vrlo vano gde emo mi psihijatri postaviti ovaj odnos mentalnih bolesti i raznih oblika nasilnog ponaanja. Nain na koji mi to sagledamo obojie stavove zvaninih struktura drutva i,
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jo vanije, uticae na ukupni odnos drugih ljudi prema psihijatrijskim pacijentima. Ne smemo zaboraviti da veina mentalno obolelih nije nasilna, da su esto pre rtve nego napadai. I kada su nasilni, mnogo je verovatnije da e nasilje biti usmereno prema lanovima porodice nego prema ljudima na ulici, na poslu, u koli itd. Na alost, kako je problem nasilja, videli smo, prisutniji kod njih nego u optoj populaciji, nuno je prepoznati inioce koji do toga dovode. Time emo moi spreiti ovakva ponaanja, na vreme prepoznati takve pojedince i razlikovati ih od veine drugih koji nisu nasilni.
Psihijat. dan. /2005/37/2/241-256/ Milic M. Are the mentally ill more prone to aggressive behavior?
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Rewiew article UDK: 616.89-008
ARE THE MENTALLY ILL MORE PRONE TO AGGRESSIVE BEHAVIOR?

Milan Milic Institute of Neuropsychiatric Diseases Dr Laza Lazarevic, Belgrade
Abstract: Idea of the connection between aggressiveness and mental disorders is present in the people of different cultures since the beginning of time. Paradoxically, this connection is still not fully accepted in professional circles, although the studies conducted in the past fifteen or so years clearly indicate its credibility. This article presents possible arguments and four current perspectives on understanding this connection. Most of the article contains a review of numerous studies conducted on this subject in the past fifteen years, divided according to three basic methodological approaches: studies of prevalence of aggressive behavior among patients who have been or are still treated in psychiatric institutions; studies of prevalence of mental disorders among persons who committed violent criminal acts and were placed in correctional facilities, and studies of prevalence of both mental disorders and violent behavior in the general population sample in a specific community. The results of most studies in each of the approaches almost invariably indicate a significantly higher risk of aggressive behavior in the population of psychiatric patients as compared to the general population, particularly in specific diagnostical categories such as disorders connected with psychoactive substance abuse, psychotic disorders, bipolar affective disorder. In the conclusion, deficiencies of earlier studies are addressed, and a draft proposal is presented for the better quality of future studies on this subject. Finally, the author emphasizes the importance of the psychiatrists attitude to this delicate issue, where the study of risk factors and consequent prevention of aggressiveness in this population would prove a far more rational option than unsubstantiated denial of the obvious, which was the case so far, and yet, it would also prove beneficial for the patients themselves, since detecting the aggressive individuals would help differentiate them from the majority of patients, who are not aggressive. Key words: aggressiveness, criminality, mental disorders, stigma, epidemiology
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Introduction In almost all known cultures in the course of history, aggressiveness and mental disorders (illnesses) were brought into connection. In one of his discussions, Socrates commented that the number of the mentally ill in Athens had to be very small, since there was very little violence [1]. The public fear of the mentally ill has always been present and well documented [2,3,4]. A phone survey conducted in 1990 covering the entire territory of the USA demonstrated that 80% of participants supported at least one of the following statements: the mentally ill are more prone to acts of violence than other people; it is only natural to be afraid of a mentally ill person; it is important to keep in mind that former patients of mental institutions can be dangerous (Link BG, Columbia University, unpublished manuscript). Violent acts of the mentally ill are more terrifying to us than other forms of violence. To ordinary man, they seem mindless, illogical, unpredictable, deadly. Strangely, perhaps ironically, this connection that men have been aware of for centuries, began to be accepted by the mental health professionals only ten to fifteen years ago. There are several reasons for that. First of all, the insufficiently conclusive studies examining the connection between aggressive behavior and mental illnesses. Such studies often have limited validity, due to: non-standardized or unclear definitions of aggressive (violent) behavior, mental illness, or both; relying mainly on official data, which causes a specific type of deviation (see the following text); comparisons with persons who are not mentally ill, with the exclusion or partial inclusion of demographic and situational factors, and study designs that were, as a rule, retrospective in character [1,5,6,7]. Secondly, the attitude of a society towards the mentally ill aggressive persons varies in the course of time, both in a specific culture, and between different cultures. There are diverse ways of coping with the problem, from guarding the mentally ill within their families, to ignoring them, placing them in hospitals, prisons, and even executing them. Until 1960s, the results of many studies, relying on the official data on the arrest rate due to aggressive behavior, indicated that the mentally ill are not more prone to violent acts as compared to general population [8]. At that time, however, most patients remained institutionalized for the most of their lives. The subsequent policy of deinstitutionalization led to a significant increase in this rate. The pressure to downsize mental institutions and release the patients has done ill favor to many of them, leaving them at the street. Several studies in America indicate that the mentally ill individuals, who are also homeless, are highly prevalent among violent offenders [9]. The main cause is believed to be the lack of adequate psychiatric treatment, considering that they do not present for treatment on their own, and have no family or close persons to look after them. Thirdly, in the past two decades, the use of psychoactive substances such as cocaine, heroin, hallucinogens, sedatives and others, together with alcohol,
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made a grand entrance in the everyday life and led to the general increase in the rate of violence. It has also affected the rate of violence in the mentally ill [10]. Fourthly, the psychiatrists were right to be cautious about further stigmatization of the mentally ill by a story that at the time seemed highly unlikely [8] and linked with potential misuse. Some authors [11] indicate that the mentally ill have often been scapegoats, the easiest persons to blame in the societies with evident violence problems. The presumed danger to others has always been the basic cause of stigmatization of the mentally ill, which influences all aspects of their life. In the past fifteen years, the corpus of evidence on the credibility of the connection between mental disorders and violent behavior has significantly increased. This evidence cannot be ignored, nor easily refuted any more. Certain doubts, however, still stand. We will here present a review of epidemiologic articles on the relation between violent behavior and mental disorders, having in mind the lack of information on this issue among the professionals and the general public in our country. Generally speaking, there are four perspectives among the researchers on comprehending this relation. The first, with far less supporters than before, denies any connection between mental disorders and violence. The second perspective supports this association, but defines it as false, artificial. The third viewpoint supports causal connection between aggression and mental disorders and tries to identify the exact element of such disorders that causes aggressive acts. Finally, the fourth perspective also supports causal relation, but it connects it to social context. Review of epidemiological studies Numerous differently designed epidemiological studies have proved or refuted these ideas, with more or less success. Neither one of the study designs proved to be ideal for this area. On the whole, there are three basic methodological approaches in assessing the potential connection between mental disorders and violent behavior: first, studies of prevalence of violent behavior among patients who have been or are currently treated in psychiatric institutions; second, studies of prevalence of mental disorders among convicted and incarcerated felons and; third, studies of prevalence of both mental disorders and violent behavior in the general population sample in a specific community [12]. Studies of the first methodological approach In view of the first approach, different research strategies have been used: retrospective studies of treated psychiatric patients, monitoring studies of released psychiatric patients, retrospective and prospective studies of psychiatric patients born during a specific period of time. For the assessment of violent behavior, the records before, during or after the hospital treatment have been used. Each of these ways of assessment has its flaws that ought to
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be taken into account. If the data are collected prior to hospitalization, an error occurs that often makes generalization of the results impossible agitated or aggressive behavior is the usual reason for hospitalization. Similarly, results can be inconclusive if assessments are made during hospitalization, and also if aggressive behavior is corrected in the course of treatment. In addition, it can be assumed that severe mental disorders, such as schizophrenia, are treated and hospitalized more frequently, which causes their number in the sample to increase. Finally, assessment after the release is lacking in validity since patients are only released when they are no longer aggressive. On the other hand, the advantage of such studies is that they rely on official data, and are not compromised by subjectivity. In addition, studies of persons born during a specified time period include all registered patients, regardless of the severity of the disease and frequency of hospitalization, and for that reason they are considered to have the highest value in the generalization of the results. A great majority of studies conducted according to the above methodological approach detected the increased risk of violent behavior in specific psychiatric disorders. For example, the studies of Modestin and Amman [13,14], exploring the prevalence of criminal acts linked with violent behavior in the population of psychiatric patients at the University Clinic in Bern, Switzerland, point to the three to four times higher risk in male patients suffering from schizophrenia and related disorders, as compared to general population. The retrospective study of schizophrenic patients born in Stockholm between 1920 and 1959 points to the 3.8 times higher risk of violent behavior [15]. The same result was obtained by Wesley et al. [16] in male schizophrenic patients who received their first psychiatric treatment in London in the period of 1964-1984. The highest increase of the risk of aggressive behavior in schizophrenic patients was discovered by Tiihonen et al. [17]. Monitoring a cohort of persons born in Northern Finland, they found that the probability of convictions for violence-related criminal acts was seven times as high as compared to persons with no psychiatric diagnoses. When assessing the risk in psychotic disorders on the whole, the discovered increase was four times for men, and even higher for women [18]. All studies of this type detected a significantly higher risk of aggressive behavior in disorders related to psychoactive substance abuse. In the cohort analysis of 15,117 persons born in Stockholm, Sweden, Hodgins discovered that the relative risk in men with this problem was 15.4, while in female population of users the risk was present in even up to 54.6% [18]. As we can see, the rate is significantly higher than in psychotic disorders. Comparative study by the same author and her associates [19], conducted in Denmark on a large non-selective birth cohort, provided similar results related to the issue. Approximately equal findings were obtained by other researchers as well [13]. Relative risk for the antisocial personality disorder was found to be 7.2 for men and 12.1 for women, i.e. the risk is that much higher as compared with the general population [19]. A remarkable early paper by Rabkin, from the late 1970s [20],
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presenting a review of seven studies of the psychiatric patients arrest rate, demonstrated that studies conducted before 1965 do not indicate increased arrest rate in psychiatric patients, as opposed to the period of 1965-1979 when every study showed the opposite result. If the later published studies of the same type [21,22,23,24] are combined with Rabkins review, the result is the ratio of 3:1 related to the arrest rate psychiatric patients: general population [25]. The following Tables (1, 2) present a review of the more significant studies using this type of approach.
Table 1. Retrospective studies of patients admitted to psychiatric treatment (first five) and retrospective cohort studies (final two)
Authors Humphreys et al. (1992) Modestin & Amman (1995) Modestin & Amman (1996) Volavka et al. (1997) Location Northwick Park Time period ? N 253 Gender m+f Dg group Sch (ICD-9) All disorders (ICD-9) Sch (RDC) Definition of aggressiveness Life-threatening behavior (estimate of relatives) Official data (police) Official data (court) Physical assaults (estimate of others)
Bern
1987
1,265
m+f
Bern
1985-1987
282
Check Republic, Denmark, Ireland, Japan, GB, USA, USSR, India, Nigeria Baltimore Stockholm London
1987
1,017
Sch (ICD-9)
Muntaner et al. (1998) Lindquist and Allebeck (1990) Wessely et al. (1994)
1983-1989 1971-1986
1,670 790
m +f m+f
Psychoses (DSM-III) Sch (ICD-8) Sch (ICD-9)
Data obtained from the respondents Official (court) Official (court) and data from the respondents
1964-1984
538
m+f
Table 2. Monitoring studies of treated psychiatric patients (first three) and prospective monitoring birth cohort studies (final four)
Authors Swanson et al. (1997) Steadman et al. (1993, 1998) Schwartz et al. (1998) Ortmn (1981) Hodgins (1992) Hodgins et al. (1996) Tiihonen et al. (1997)
a b
Location North Carolina
Time period 1986-1991
N 169
Gender m+f
Dg group Severe mental disorders.a Selected mental disordersb Severe mental disordersa All disorders All disorders All disorders All disorders
Definition of aggresiveness Official (hospital, court) and respondents Data obtained fom the respondents Official (court, police) and respondents Official data (court) Official (court) Official (court) Official (court)
Pittsburgh, Cansas City Worchester North Carolina Copenhagen Stockholm Denmark North Finland
1992-1995
1,136
m+f
331
m+f
1953-1978 1953-1983 1944-1947 1966-1992
11,540 15,117 358,180 12,058
m m+f m+f m+f
Schizophrenia, paranoid psychoses, affective psychoses Schizophrenic spectrum, affective spectrum, paranoid psychoses, substance abuse
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Table 3. shows results obtained in some of the above studies.

Table 3. Relative risk of violent behavior in mental patients (as compared to general population, where the assumed risk is 1.0)
Authors Severe mental disorders Organic disorders Sch Affective disisorders m 8.8 Anxiety disisorders Disorders related to substance abuse m 6.5 Antisocial perersonality disorder
Modestin & Amman, (1995) Modestin & Amman, (1996) Lindquist & Allebeck, (1990) Hodgins, (1992) Hodgins et al., (1996) Tiihonen et al., (1997) Swanson et al., (1992) Stueve & Link, (1997)
a
m 3.1 m 3.9 m 3.9 m 4.2 f 27.4 m 4.5 f 8.7
m 2.6 m 5.0 m 7.2 4.1 1.7 1.4a /1.5b 1.2 1.3a /1.2b
m 15.4 f 54.6 m 8.7 f 15.1 10.4
m 7.2 f 12.1
3.6a /10.1b 3.3a /6.6b
Risk of physical assault; b Risk of using weapons
Studies of the second methodological approach The second methodological approach is represented by two types of studies: the studies conducted on convicted murderers and diagnostical studies of the representative sample. The studies established on these grounds, as well as a part of studies of the previous approach which analyze the arrest rate of psychiatric patients, have a common weakness: the unsolved dilemma whether the psychiatric patients are arrested more or less frequently. The second problem, affecting only this type of studies, refers to the fact that the evaluation does not include felons-psychiatric patients who were ordered compulsory treatment instead of prison sentence. Both rulings mostly depend on the country and its legislation [26,27]. The third weakness of this type of approach is that it does not include minor aggressive attacks, which are not a sufficient reason for placement in a correctional facility. The advantage of this type of studies, similarly to the previous approach, is working with official data. The first example of studies conducted on convicted murderers is coming from Finland, a country particularly suitable for this type of research, for two reasons. The first one is a high percentage of solved murders up to 97%, and the second is that every criminal is obliged to undergo a detailed psychiatric evaluation. In several published articles, the authors from Finland, primarily Mark Eronen, discovered that the risk of commiting murder is eight times higher in men suffering from schizophrenia as compared to the normal population, ten times higher in alcoholics, and even more than eleven times higher in antisocial perso-
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nality disorder, while affective and anxiety disorders do not cause the relative risk to increase [28,29,30]. The following three studies, two from Scandinavia and one from Canada, also indicate that among violent offenders there is a large number of persons with severe mental disorders. Gottlieb et al. [31], in their study of murderers in Copenhagen in the period of 1959 and 1983, found that 20% of men and 44% of women were diagnosed as psychotic. Among them, 41% of men and 13% of women suffered from a substance abuse related disorder. The results of this research showed that in psychotic persons, the risk of committing murder increases six times for men and even sixteen times for women. The following study conducted by Lindquist [32] in Sweden, on the overall population of persons who have committed murder in the period of 1970-1981, discovered that the percentage of psychotic criminals was 53%, and that 38% of disorders were related to psychoactive substance abuse. Finally, the Canadian study conducted on the representative sample of male homicidal criminals, convicts of the Quebec prison, points to a significantly higher frequency (35%) of severe mental disorders (psychoses and severe affective disorders) as compared to other offenders imprisoned in the same facility. In the group of homicidal criminals, 83% had a history of alcohol and 63% of drug addiction. The studies of homicidal recidivist, in the same context, were also highly significant. A Swedish study conducted on the sample of twenty-one repeat killers, found that they were also involved in other types of violent behavior, and that the majority fall into the diagnostic group of personality disorders. Many of them were also alcohol and drug addicts, and 10% was suffering from schizophrenia [33]. Tiihonen and Hakola [34] studied 13 repeat killers, who committed their last crime in the last three years and were imprisoned or placed in a high-security psychiatric institution since then. Mental disorders were diagnosed in all subjects, severe alcoholism combined with personality disorder in eleven of them, and schizophrenic disorder in the remaining two. Table 4. Same studies of homicidal offenders
Authors Lindquist, (1986) Gottlieb et al., (1987) Cote & Hodgins, (1992) Eronen et al., (1996) a, b Location North Sweden Copenhagen Quebec Finland Time period 1970-1981 1959-1983 1988 1984-1991 N 64 263 87 693 Gender m+f m+f m m+f Diagnostic criterion ? ICD-8 DSM-III DSM-III-R
Table 5. Risk of homicidal behavior among male psychiatric patients as compared with general male population
Diagnosis Anxiety disorder Dysthymia Mental retardation Severe depressive episode Sch without alcoholism Sch psychotic spectrum Alcoholism Antisocial personality disorders Alcoholism and previous homicide Sch with alcoholism Sch and previous homicide Rate in 100 1.5 1.4 1.2 3.0 3.7 6.4 39.2 11.3 2.9 Relative risk 0.3 0.6 1.2 1.6 7.2 8.0 10.7 11.7 13.3 17.2 25.8 95% Recidive interval 0.2-0.5 0.3-1.1 0.9-2.2 1.1-2.4 5.4-9.7 6.1-10.4 9.4-12.2 9.5-14.4 8.9-20.0 12.4-23.7 9.6-69.6
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A major deficiency of the studies of the representative sample of general population of prison inmates, i.e. of prevalence of mental disorders in this population, is that they do not differentiate between violent and non-violent offenses. In spite of this limitation, however, they can help us obtain a general image of the association between mental illnesses and violent behavior. An exceptionally increased rate of alcoholism, substance abuse and antisocial personality disorder was detected in the prison population, especially in female inmates, as compared to general population. The comorbidity of all three disorders is frequent as well [35]. The increased rate of more severe mental disorders, such as schizophrenia or severe affective disorders, as compared to the general population, is reported in a number of published researches conducted on prisoners of both sexes [36, 37,38]. Such serious epidemiological analyses have not been carried out for the territory of our country. We can say that, according to the information available to us, there were practically no significant studies in the last twenty to thirty years, not only considering this one, but also other approaches to this issue.
Table 6. Diagnostical studies of the representative sample of convicted offenders (prison inmates)
Authors Taylor, (1985) Hyde & Seiter, (1987) Neighbors et al., (1987) Danielet al., (1998) Hodgins & Cote, (1990) Teplin, (1990) Hurley & Dune, (1991) Teplin et al., (1996) Jordan et al., (1996) Location London, GB Ohio, USA Michigen, USA Missouri, USA Quebec, Canada Cook County, USA Brisbane, Australia Cook County, USA North Carolina, USA Time period ? ? 1986 ? 1988 1983-1984 1989 1991-1993 1991-1992 N 203 509 1,070 100 495 728 92 1,272 805 Gender m m+f m+f f m m f f f Diagnostical criteria DSMDSM-III-R DSM-III DSM-III DSM-III DSM-III-R DSM-III-R DSM-III-R
Table 7. Lifetime prevalence of psychiatric disorders in convicted offenders (prison inmates) without the aggressiveness-based selection of respondents
Diagnosis Neigbors, (1987) m+f 2.8 11.3 6.4 0.5 1.1 12.0 1.6 22.0 5.6 50.1 46.5 28.6 28.7 61.5 66.9 48.9 Together with 55.4 Hyde & Seiter (1987) m+f 1.5 12.7 3.0 0.9 Teplin (1993) m 3.7 5.7 Cote & Hodgins (1990) m 6.5 14.8 3.4 2.5 0.9 2 6 2 2.6 1.6 2.5 5.8 2.7 Hurley & Dune (1991) f Daniel (1991) f 7 19 Teplin (1996) f 2.4 16.9 9.6 Jordan (1996) f 13.0 7.1
Schizophrenia Severe depression Dysthymia Bipolar affective disisorders Manic episode Agoraphobia Panic disorders General anxiety disorders Obssesive compulsive disorders Antisocial personality disorders Alcoholism Substance abuse
6 29 36 26 13.8 32.3 63.6 11.9 38.6 44.2
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The studies of the third methodological approach The final, third methodological approach to the research of this association refers to the studies in a selected community (municipality, town, region). The instruments used for assessment are mostly questionnaires filled in by the subjects themselves and sometimes combined with the official data on the arrests due to aggressive outbursts. These types of studies have several advantages over the previous ones. First of all, they eliminate the issue of the so-called criminalization of psychiatric patients, i.e. disproportionate referral to the judicial system as compared to the general population. The second advantage, similarly, refers to the so-called medicalization of aggressiveness, i.e. to the occasionally inadequate referral of aggressive individuals to treatment, which increases the rate of aggressive individuals among psychiatric patients. Both advantages are achieved by means of unofficial data on violent behavior, obtained from the respondents themselves. The third advantage relates to the fact that all respondents come from the same environment, so it cannot be objected that in different environments aggressive behavior is present to a different extent. The limitations of this approach are the subjectivity of the information obtained and, in certain studies, exclusion of individuals placed in institutions (prisons or hospitals) due to severe illnesses or offenses. So far, three significant studies with this approach have been published. The first study we will address here was conducted with the use of data obtained in a wider American epidemiologic study (Epidemiologic Catchment Area Study), which included 20,000 respondents in five rgions in America, with the aim to establish the number of untreated psychiatric disorders. Swanson et al. [39] processed the respondents from three cities: Baltimore, Durham and Los Angeles. They evaluated the data obtained from the respondents themselves, who were asked to declare if they had done something of the following in the previous year: hit their spouse or partner, hit the child so hard it bruised or had to see a doctor, fought with someone other than their spouse or partner, used weapons in a fight or resorted to physical violence while intoxicated. Persons with mental disorder were, generally speaking, more frequently involved in the above aggressive behavior. In the respondents diagnosed with schizophrenia, the risk is over four times higher (4.1), and the highest risk of aggressive behavior is detected in persons suffering from disorders related to psychoactive substance abuse, according to this study, ten times higher than in the general population. Fig. 1. shows the presumed probability of aggressive behavior according to gender and psychiatric diagnoses obtained by the method of logistic regression.
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Fig. 1.
25 20 15 Probality 10 5 0 Sine morba Anxiet Affective disorders Schizophrenia Substance abuse Substance abuse and mental disorders orders Women Men
The second study, conducted by Link et al. [5] made a comparison between the psychiatric patients and other residents of Washington Heights, a part of New York with ethnically and socio-economically highly heterogenous population, based on a number of official and unofficial information. The former were obtained from the state of New York police records, and the latter from the statements obtained from the respondents themselves. In the course of forming the sample, the population of psychiatric patients was divided into three groups: those who had first contact with psychiatry in the year preceding the interview, those who were treated earlier, including the year preceding the interview, and, finally, those who were treated earlier, but not in the previous year. By the comparison with the psychiatrically unburdened part of the population, a significantly higher arrest rate due to aggressive behavior was detected in the psychiatric patients group, both according to official records, and according to the information provided by the respondents, as well as a higher rate of physical assaults on other people, fights, use of weapons, severe injuries to others. Time coordinates were either so far in my life, or in the past five years. The differences remained even with the strict control of sociodemographic factors. The most compelling correlation with aggressive behavior in psychiatric patients was observed in psychotic symptomatology. This result, in the authors opinion, supports the credibility of association between aggressive behavior and mental illnesses. In the third study [40] the authors attempted to provide answers to the questions that were either insufficiently considered, or omitted from the previous two studies. One of the questions is whether the majority of mental illness has positive correlation with aggressive behavior, or this behavior is limited to specific complexes of symptoms or specific disorders. The following question refers to the possibility that for the most part, this association can be attributed to specific contextual factors, e.g. whether interpersonal aggressiveness is a common way of resolving conflicts in a particular community or not. The final dilemma refers to the assumption that aggressive behavior in the mentally ill can be fully explained by the comorbidity with psychoactive substance abuse and antisocial personality disorder. In Israel, a
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study was conducted on 2,741 respondents, 24-33 years of age, with the use of the same assessment instruments as in the previous study. The psychiatric diagnoses were divided in the following five categories: (1) psychotic disorders schizophrenia, schizo-affective disorder, non-specific functional psychoses and major depression with psychotic symptoms; (2) bipolar affective disorder and cyclothymia; (3) major depression without psychotic symptomatology; (4) generalized anxiety disorder; (5) phobias. Comorbidity was assessed as well. The results were similar to those obtained by the other authors, indicating the causative association between specific types of psychiatric disorders and aggressive behavior. Psychotic disorders and bipolar affective disorder showed a considerable co-occurrence with the data on physical conflicts (fights) (the risk is 3.3 times higher) and the use of weapons (the 6.6 times higher risk). The significance remains even after controlling for comorbidity with substance abuse, antisocial personality disorder, and sociodemographic parameters. The correlation, however, was not confirmed in nonpsychotic depressions, generalized anxiety disorder and phobias. It was also demonstrated that certain social factors, such as lower educational level, have significant influence on the explored association. Table 8 presents an additional review of results obtained in some of the above studies, related to the risk of aggressive behavior in specific psychiatric categories as compared to the general population. Table 8. Risk of aggressive behavior in male psychiatric and criminal population as compared to the general male population
Diagnostical category Anxiety disorder Dysthymia General population Mental retardation Severe depressive episode Sch without alcohol (1) Severe mental disorders Sch without alcohol (2) Sch psychotic spectrum Homic recidivists with a prior homicide Alcoholism Antisocial disorder l. Sch with alcoholic (1) Sch with alcoholic (2) Murderer first year after release from prison Forenzic psychiatric patient first year after release from hospital No. of respondents with this Dg in the sample 14 (1.5%) in the sample of 910 murderers 13 (1.4%) in the sample of 910 murderers 11 (1.2%) in the sample of 910 murderers 27 (3.0%) in the sample of 910 murderers 3 birth cohort patients with violent crimes 11,017 82 in birth cohort 7,362 48 patients in the sample of 1,302 murderers 58 (6%) in the sample of 910 murderers 35 out of 1,584 murderers 357 (39.2%) in the sample of 910 murderers 103 (11.3%) in the sample of 910 murderers 38 (2.9%) in the sample of 1,302 murderers 4 patatients convicted for violent crimes in the birth cohort 11,017 35 out of 1,584 murderers Monitoring study with the average duration of 7.8 years Relative risk 0.3 0.6 1 1.2 1.6 3.6 4.16 7.25 8.0 10.4 10.7 11 17.2 25.2 253.8 293.9 Recidive interval 95% 0.2-0.5 0.3-1.0 0.7-2.2 1.1-2.4 0.9-12.3 2.23-7.78 4.7-5.4 6.1-10.4 7.4-14.5 9.4-12.2 9.5-14.4 12.4-23.7 6.1-97.2 145.8-441.9 119.2724.7
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Our results Since the prediction of risk of aggressive behavior in this population of patients is insufficient (40-72% of successful predictions), in our study we have tried to establish the above risk factors in persons suffering from schizophrenia. The study was conducted at the Dr Laza Lazarevic Institute of Neuropsychiatric Disorders, where psychiatric care is provided for the patients of this profile for the territory of Belgrade and the surrounding area. The respondents were male patients diagnosed with schizophrenia (ICD-10), 18-45 years of age, with no severe somatic illnesses that could influence the results of biochemical analyses of neurophysiological findings. In the prospective study, 138 respondents were selected and examined for all the tested parameters: sociodemographic (semi-structured questionnaire 14 items), clinical-psychopathological (PANSS scale, Calgary Depression scale for schizophrenic patients DSS, Scale of prehospital aggressiveness within family SPAUOP, sucide attempts, use of PAS), biochemical (biogenic amines and their metabolites in plasma NA, DA, A, 5-HT, VMA, HVA, MHPG, 5-HIAA HPLC technique; testosteron in plasma RIA-CT method; cholesterol in plasma), and neurological-neurophysiological (NES scale, EEG). The patients were subsequently monitored during the entire course of hospital treatment and based on aggressiveness (Overt Aggression Scale OAS) two groups were differentiated: group I schizophrenic patients with manifested aggressive behavior (aggressive, N = 50), and group II schizophrenic patients with no manifest aggressiveness (non-aggressive, N = 40). The remaining patients could not be assigned to any of the groups, since the aggressiveness they manifested was only minor. Significant deterioration of the primary family relations, and higher prevalence of mental illnesses in the family were registered in the group of non-aggressive patients, and the tendency of significance was also detected in the parameters aggressiveness in the primary family and poor school achievement. Clinicalpsychological factors turned out to be the most reliable predictors, particularly items of the PANSS scale. The group of aggressive patients had a more manifest psychopatholology (general psychopathology cluster and total score in the PANSS scale) as well as higher scores in the positive cluster, with a particular emphasis on the correlation with delusional persecutory ideas. Lack of insight in ones own condition, apprehension, grandiosity, suspiciousness, hostility, lack of compliance and poor control of impulses are also to be found among the recognized predictive factors. The hypothesis on the coexistence of auto- and hetero aggressiveness is also confirmed here, by more frequent sucide attempts registered in the history of patients in the aggressive group. Predictive significance of the comorbidity with disorders related to PAS abuse was recognized in the higher prevalence of smoking and abuse of other PAS in the aggressive group, which was interpreted in several levels, from biological to social. Among biochemical factors, high values of 5-HT, NA and MHPG in the plasma of aggressive respondents, proved to be
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of major predictive significance, as well as the negative correlation of cholesterol level and physical aggressiveness. The least conclusive were neurological-neurophysiological factors, which were probably connected with the lack of more extreme forms of violence in aggressive respondents, so the obtained significant differences did not have the required quantity to be treated as valid. The findings speak in favor of the opinion that the tendency toward aggressive behavior is a result of accumulated risk factors, and any of the factors individually is neither a necessary, nor a sufficient predictor. Whats more, different groups of variables ought to be taken into consideration, since there is clearly more than one way to explain aggressive behavior. Conclusion In the end of this review, we can say that the results of a vast majority of studies with all three methodological approaches have clear positive correlations. In spite of their different designs, all studies indicate a significantly higher risk of aggressive behavior in the population of psychiatric patients as compared to those who are not. However, not in all, but only in specific diagnostic categories, such as disorders related to psychoactive substance abuse, antisocial personality disorder, psychotic disorders, bipolar affective disorder (Tab. 3, 5, 7, 8). It is likely that active psychopathological contents, especially related to disorders of perception, thinking and affect, are of more importance for the assessment of risk than the diagnosis on its own. It can be presumed that the connection between psychiatric disorders and violent behavior is causative, but specific circumstances, context in which psychopathology and situational factors are intertwined, also have to be taken into consideration. Still, we have to emphasize that the scope of cooccurence of mental disorders and aggressive behavior, however statistically significant, is still minor as compared to factors such as gender, age, educational level or socio-economical status [11]. What is presented so far, inevitably leads to dismissal of the first two opinions on this issue, where the association between the two entities was either denied or considered false. However, further studies are needed to correct the deficiencies of the previous ones and make the results more valid. As recommended by Link and Stueve [25], a good epidemiological study of this issue should be designed in the following manner: (1) to specify the psychiatric illness or illnesses of interest to the study; (2) to monitor the representative sample of persons unaffected by the specified illness(es); (3) to compare the groups on the basis of aggressive behavior (type, frequency, intensity) to occur in the perspective. The study should further include a broad set of background variables (individual and contextual) that could influence the results, and to find the way to operationalize the assessment of aggressive behavior by using official and unofficial data. In conclusion, it should also be noted that it is of major importance where we, the psychiatrists, will position the association between mental ill-
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nesses and various forms of aggressive behavior. The way we consider this issue will influence the opinion of official structures of the society, and, more importantly, the overall attitude of other people toward psychiatric patients. We must not forget that the majority of the mentally ill are not aggressive, that they are victims more often than attackers. Even when they are aggressive, it is much more likely that the aggression would be aimed at their family members and not people in the street, at work, in school, etc. Unfortunately, since the problem of violence, as we have seen, is more present in them than in the general population, it is essential to identify such individuals in time and differentiate them from the majority of non-aggressive patients.
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Lindquist P, Allebeck P. Schizophrenia and crime. A longitudinal follow-up of 644 schizophrenics in Stockholm. Br J Psychiat 1990;157:345-50. Wessely SC, Castle D, Douglas AJ, Taylor PJ. The criminal careers of incident cases of schizophrenia. Psychol Med 1994;24:483-502. Tiihonen J, Isohanni M, Rassainen P, Koiranen M, Moring J. Specific major mental disorders and criminality: a 26-year prospective study of the 1966 Northern Finland birth cohort. Am J Psychiat 1997;154:840-45. Hodgins S. Mental disorder, intellectual deficiency and crime. Evidence from a birth cohort. Arch Gen Psychiat 1992;49:476-83. Hodgins S, Mednick SA, Brennan PA, Schulsinger F, Engberg M. Mental disorders and crime: evidence from a Danish birth cohort. Arch Gen Psychiat 1996;53:489-96. Rabkin JG. Criminal behaviour of discharged mental patients: a critical appraisal of the research. Psychol Bull 1979;86: 1-27. Harry B, Steadman HJ. Arrest rates of patients treated at a community mental health center. Hosp Community Psychiatry 1988;39:862-6. Holcomb WR, Ahr PR. Arrest rate among young adult psychiatric patients treated in inpatient and outpatient settings. Hosp Community Psychiatry 1988;39:52-7. Shuerman L, Kobrin S. Exposure of community mental health clients to the criminal justice system: client criminal or patient prisoner? In: Teplin LA. Mental Health and Criminal Justice. Beverly Hills, CA: Sage Publications; 1984. p. 87-118. Shore D, Filson CR, Rae DS. Violent crime arrest rates of White House case subjects and matched control subjects. Am J Psychiat 1990;147:746-50. Link BG, Stueve A. Evidence bearing on mental illness as a possible cause of violent behaviour. Epidemiol Rev 1995;17(1):17281. Teplin L. The criminality of the mentally ill: a dangerous misconception. Am J Psychiat 1985; 142:669-76. Hodgins S. Mental disorders and crime: an overview. Psychology, Crime and Law 1995;2:5-17. Eronen M, Hakola P, Tiihonen J. Schizophrenia and homicidal behaviour. Schizophrenia Bull 1996;22:83-9. Eronen M, Hakola P, Tiihonen J. Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland. Psychiat Serv 1996;47:403-6. Eronen M, Hakola P, Tiihonen J. Mental disorders and homicidal behaviour in Finland. Arch Gen Psychiat 1996;53:497-501. Gottlieb P, Gabrielsen G, Kramp P. Psychotic homicides in Copenhagen from 1959-1983. Acta Psychiat Scand 1987;76:285-92.
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Lindquist P. Criminal homicide in Northern Sweden 1970-1981: Alcohol intoxication, alcohol abuse and mental disease. Int J Law Psychiat 1986;8:19-37. Adler H, Lidberg H. Characteristics of repeat killers in Sweden. Crim Behav Ment Health 1995;5:5-13. Tiihonen J, Hakola P. Psychiatric disorders and homicide recidivism. Am J Psychiat 1994;151:436-38. Cote G, Hodgins S. Co-occurring mental disorders among criminal offenders. Bull Am Acad Psychiatry Law 1990;18:271-81. Teplin L. The prevalence of severe mental disorder among male urban detainees: comparison with epidemiologic catchment area program. Am J Public Health 1990;80:663-69. Teplin LA, Abram KM, McClelland GM. Prevalence of psychiatric disorders among incarcerated women. Pretrial jail detainees. Arch Gen Psychiat 1996;53:505-12. Jordan BK, Schlenger WE, Fairbank JA, Caddell JM. Prevalence of psychiatric disorders among incarcerated women. Convicted felons entering prison. Arch Gen Psychiat 1996,53:513-19. Swanson JW, Holzer ChE, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from epidemiological catchment area surveys. Hosp Community Psychiatry 1990;41:761-70. Stueve A, Link BG. Violence and psychiatric disorders: results from an epidemiological study of young adults in Israel. Psychiat Q 997;68:327-42.
___________________________ Milan MILI, dr sci med, psihijatar, naelnik mukog Odeljenja za akutne psihoze u Institutu za neuropsihijatrijske poremeaje Dr Laza Lazarevi, Beograd, Srbija i Crna Gora Milan MILIC, MD, PhD, psychiatrist, Head, Department for Male Acute Psychoses, Institute of Neuropsychiatric Diseases Dr Laza Lazarevic, Belgrade, Serbia and Montenegro E-mail: mv.milic@eunet.yu
Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...
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Istraivaki rad UDK: 159.9 : 17.023.32
PRENATALNE PREDSTAVE OEVA O PRIVRENOSTI SU PREDIKTIVNE ZA VEZU OCA I DETETA OD PETNAEST MESECI: AUSTRALIJSKO ISKUSTVO
Marija Radojevi
Sluba za zatitu dece, mladih i porodice, Bolnica Hornzbi i Ku-ring-gaj, Sidnej i Grem Rasel Fakultet bihejvioralnih nauka, Univerzitet Makvari
Apstrakt: Ovo istraivanje izvetava o moi predvianja Intervjua o privrenosti odraslih (Adult Attachment Interview) Dorda, Kaplana i Mejnove [12] o privrenosti oca i deteta u australijskom uzorku mukaraca koji e prvi put postati oevi (N = 44). Testirana su dva modela: onaj od tri kategorije (siguran, omalovaavajui, previe zaokupljen odrasli; sigurno, izbegavajue, odbojno dete) i od etiri kategorije (siguran, omalovaavajui, previe zaokupljen, neodluan odrasli; sigurno, izbegavajue, odbojno, dezorganizovano dete); svaki u svom binarnom (siguran/nesiguran) i potpuno ukrtenom obliku. Oba modela pokazala su znaajan uspeh u predvianju ovog odnosa. Najtanije predvianje postignuto je kada su klasifikacije roditelja i dece bile podeljene na suprotnosti sigurno/nesigurno [50.9% smanjenja greke (Percent Reduction in Error PRE)]. Binarni oblik modela sa tri kategorije imao je 45.1% smanjenja greke. Model unakrsne klasifikacije 4 x 4 imao je 40.4% smanjenja greke, i istovremeno sauvao najveu specifinost, ime se istie prediktivna korist kategorije neodluan roditelj. Kljune rei: privrenost otac-dete, predvianje, AAI
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Teorija privrenosti, i kasnija istraivanja koja je ona podstakla, rezultirala je tokom poslednjih dvadeset godina jednom od najboljih metodologija kako za proirenje teorije tako i za razumevanje drutvenog i oseajnog razvoja deteta. U oblasti istraivanja privrenosti radovi koje su pokrenuli Majkl Lemb i saradnici [1,2,3,4] bili su znaajni jer su pokazali i postojanje odnosa privrenosti oca i deteta i njihovu raznovrsnost. Meutim, i povrno ispitivanje tekstova o ovoj temi otkriva da je, jo od znaajnih Lembovih radova [uz neke izuzetke, 5,6,7] u istraivanjima privrenosti uoljiv stalan manjak usredsreenosti na oeve. Tekua istraivanja o ulozi oeva u ovom odnosu mnogo su produktivnija s obzirom na irinu paradigme razvojnog i psihoanalitikog pristupa [8,9,10,11]. Stvaranje Adult Attachment Interview (AAI) (Intervjua o privrenosti odraslih) i sistema za obradu rezultata ovog instrumenta pokrenulo je program istraivanja privrenosti odraslih [12,13]. Od nastanka ovog instrumenta jedno od sredinjih pitanja bilo je odreivanje razvojnih pokazatelja kod roditelja koji doprinose tome da oni budu dobri roditelji i, na taj nain, utiu na odnos privrenosti izmeu odraslog i deteta. U tom smislu sve je vie dokaza koji govore u prilog kontinuitetu izmeu naina na koji majka mentalno predstavlja i verbalno izraava sopstveno iskustvo odgajanja i naina na koji ona kasnije postupa sa svojim detetom [6,14,7,15]. Smatra se da je za prenoenje mehanizma kontinuiteta kljuan stepen u kojem je majka prijemiva za signale deteta da mu je potrebna uteha i sigurnost. Cilj ovog istraivanja je da ispita do koje mere sigurnost mentalne predstave buduih oeva o privrenosti moe da utie na kasniji kvalitet sigurne privrenosti oca i deteta u nerizinom, neklinikom uzorku. U jednoj nedavnoj metaanalizi prediktivne vrednosti AAI [16] izbor je pao na osamnaest istraivanja o odnosu izmeu AAI klasifikacija i klasifikacija privrenosti dece. Od ovih osamnaest istraivanja u samo etiri (ukljuujui i ovo istraivanje) bili su ukljueni i oevi. Relativno zanemarivanje oeva u tekuim istraivanjima privrenosti ukazuje na to da u njima i dalje postoji pretpostavka primata dijade majka-dete. Ovo je zbunjujua pretpostavka, iz nekoliko razloga. Prvo, i teorija privrenosti i istraivanja u toj oblasti ukazuju na to da e sigurna privrenost oca i deteta verovatno imati zatitno dejstvo ukoliko je privrenost majke i deteta nesigurna [17,5]. Takoe, ukoliko je privrenost oca i deteta takoe nesigurna, manji je broj mogunosti za interakciju koja e zatititi dete od oseajne i drutvene neprilagoenosti [17,18]. Tako priroda afektivne veze izmeu oca i deteta ima mogunost da funkcionie ili kao zatitni ili kao inilac ranjivosti u razvoju deteta. Na primer, istraivanja o uspenonosti dece iz razvedenih brakova konzistentno pokazuju loiji psihosocijalni razvoj kod porodica bez oca i u porodicama u kojima je otac deci skoro nedostupan [19,20]. Drugo, razmere drutvenih promena u zapadnim industrijskim drutvima, naroito u smislu sve eeg raspada porodice i izmenjenih uslova rada, predstavljaju znaajan izazov za mnoge pretpostavke koje se tiu priro-
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de i organizacije porodinog ivota i, naroito, roditeljstva. Ove pretpostavke, na primer, obuhvataju prvenstvo dijade majka-dete i sekundarnu ulogu oca kao pruaoca nege, za koga se smatra da ima manji uticaj na razvoj deteta. U Australiji je u ovom trenutku zaposleno 53% ena, a njih 48% ima najmlae dete staro deset godina [21]. Ova brojka verovatno ne odraava pravu sliku drutva jer se stalno poveava broj majki male dece koje se vraaju na posao. Osim toga, u junu 1996. godine bilo je 672,000 porodica sa samo jednim roditeljem, od ega je u 85% sluajeva taj jedan roditelj bila ena. Tako, uzimajui u obzir razmere i znaaj drutvenih promena, vano je bolje razumevanje prirode privrenosti deteta i oca (za koju se, kao i za privrenost izmeu majke i deteta, pretpostavlja da je promenljiva, kao funkcija prijemivosti roditelja za dete). Osim toga, moramo da razumemo prirodu i rane pokazatelje afektivne spone oca sa detetom, naroito zato to se oni ispoljavaju u razmiljanjima oeva o privrenosti, kao i u njihovom roditeljskom ponaanju. Instrument AAI napravljen je radi predvianja kvaliteta privrenosti roditelja i deteta koji se procenjuju u nepoznatoj situaciji [22]. Namera je da se nizom pitanja i testova utvrdi stav odraslog u pogledu privrenosti, naroito kako su ovu privrenost doiveli u detinjstvu. Klasifikacija se vie oslanja na koherentnost iskazanih misli i oseanja nego na njihov vidljivi sadraj. Intervjui su doslovce zapisani, a primenjena je jedna od etiri glavne klasifikacije privrenosti: autonomna (F), odbacujua (Ds), preterana zaokupljenost (E) i neodluna (U). Sigurni (autonomni) odrasli pruaju relativno koherentan, konzistentan i neodbrambeni izvetaj o svojim iskustvima u vezi sa privrenou, bez obzira na to da li su ta iskustva bila pozitivna ili negativna. Poto se relativno ugodno oseaju sa veim delom svojih afektivnih iskustava, smatra se da autonomni roditelji imaju vie slobode od nesigurnih roditelja da saoseajno reaguju na znake uznemirenosti deteta [23,24]. Tako deca oekuju brzu, oseajnu panju roditelja. Najznaajnija osobina nesigurnih/odbacujuih odraslih je njihov implicitan ili eksplicitan odbrambeni stav. Oigledna odbojnost odbacujuih odraslih da priznaju sopstvene potrebe za privrenou ini ih manje osetljivim i prijemivim na potrebe za privrenou sopstvene dece [24]. U takvim uslovima dete brzo naui da odvrati panju od sopstvenih potreba za privrenou, i tako izgleda (esto prerano) samodovoljno. Nesigurni/preterano zaokupljeni odrasli izgledaju kao da su jo uvek ljuti i preterano usredsreeni na zamiljene mane jednog ili drugog roditelja. Reagujui na potrebu deteta za utehom i/ili privrenou preterano zaokupljeni odrasli e verovatno biti nedosledan; ponekad nametljivo dostupan, ponekad zanemarujui. Ova strategija odgoja stvara kako naglaeno oprezno tako i prigueno ponaanje privrenosti kod deteta, verovatno zato to dete nije sigurno kako e negovatelj reagovati.
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Konano, odrasli klasifikovani kao nesigurni/neodluni pokazuju znakove nerazreenih traumatskih iskustava, koja obuhvataju ili gubitak zbog smrti ili neku zloupotrebu od strane figure privrenosti. Tvrdi se da e se neodluni roditelj verovatno nenamerno ponaati prema detetu na naine koji mogu da stvore prolaznu straljivost i sukobe u detetu [25]. Ipak, treba naglasiti da AAI nije jedini instrument kojim se meri privrenost odraslih ija je teorijska osnova u teoriji privrenosti. Rad Hejzena i ejvera (1990, 1994) svakako je nadahnuo niz istraivanja o privrenosti odraslih, zasnovanih na merenju samoprocene [26,27,28]. Iako razmatranje ovog znaajnog i paralelnog istraivanja nije predmet ovog lanka, o njemu elegantno diskutuju Fini i Noler (1996). Smatra se da su klasifikacije AAI sistematski povezane sa raznim oblicima privrenosti kod dece, a utvruju se testom nepoznate situacije [22]: siguran (B), izbegavajui (A), odbojan (C) i dezorganizovan/dezorijentisan (D) [29]. Sutina je u tome da deca pounutre obrasce ponaanja negovatelja tokom ponavljanih interakcija sa roditeljima. Ova pounutrenja zatim postaju deo predstavnih modela odnosa kod deteta. Ovi, pak, modeli, oblikuju i ponaanje deteta i njegova oekivanja u vezi sa ponaanjem drugih ljudi. Smatra se da ispoljavanje dejih obrazaca privrenosti u ponaanju predstavlja strategije ili za mobilisanje ili za ograniavanje svesti o afektima i saznanjima povezanim sa privrenou. Ukratko, to izgleda ovako: 1. deca koja nisu ambivalenta u traenju bliskosti, interakcije ili kontakta sa majkom koja ulazi u sobu klasifikovana su kao sigurna (grupa B). 2. deca koja oklevaju ili izbegavaju majku prilikom ponovnog susreta i koja pokazuju malo ili nimalo znakova da im je nedostajala dok su bili odvojeni odreena su kao nesigurna/izbegavajua (grupa A). 3. deca koja ispoljavaju ljutnju i ambivalenciju prema majci koja se vraa kui klasifikovana su kao nesigurna/ambivalentna (C). Ona plau i izgledaju kao da ele kontakt, ali ne mogu da se svrte i vrate igri. Oblikujui kategoriju nesiguran/dezorijentisan (D), Mejnova i Solomon [29] su uoili da deca koja se ne mogu svrstati u okviru sistema A, B, C ne izgledaju kao da... podseaju jedna na drugu na koherentan, organizovan nain. Ovoj deci su zajedniki naleti ponaanja kojima naizgled nedostaje vidljivi cilj, namera ili objanjenje (str. 122). Nae istraivanje je jedno od malog broja koje, do sada, ukljuuje i kategoriju nesiguran (D). Od tri istraivanja [6,7,30] koja su procenjivala privrenost i kod majki i kod oeva, i ispitala slaganje jednih, odnosno, drugih sa privrenou majke i deteta i oca i deteta, Mejnova i saradnici [6] i Van Ijzendorn i saradnici [7] nali su snaniju povezanost izmeu majki i dece nego izmeu oeva i dece. Stil i saradnici [30], koristei dihotomiju siguran/nesiguran odrasli, nali su da je za sigurnu privrenost deteta sigurnost oca isto toliko prediktiv-
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na koliko i sigurnost majke. Nesigurnost oca, pak, znaajno je manje od nesigurnosti majke poveavala anse da e privrenost oca i deteta biti nesigurna. S obzirom da su ova istraivanja obavljena u razliitim zemljama (SAD, Holandija, Engleska), moe se smatrati da obezbeuju ukrtene podatke za razliite nacije. Pokazalo se da su ovi podaci povezani sa razliitim kulturalnim pristupima u podizanju dece i, shodno tome, sa drugaijim raspodelama kategorija privrenosti otac-dete, uprkos injenici da su u veini zemalja majke primarni negovatelji [31]. Samo su Stil i saradnici [30] koristili prospektivni metod. Dok se mo predvianja jednog istraivanja smatra najboljim naunim pristupom, Van Ijzendornova [16] metaanaliza pokazala je da u osamnaest istraivanja upravo nacrt istraivanja (objanjenje unazad, objanjenje trenutnog stanja, predvianje) ne objanjava razliitosti u rezultatima. Mada su iz teorijskih, iskustvenih i klinikih razloga znaajne, u ovim istraivanjima nisu koriene ni kategorija neodluna privrenost odraslog ni dezorganizovano/dezorijentisano privreno dete, koju ovakva privrenost predvia, [32,33], niti se o njima izvetava. Sva tri istraivanja ukljuivala su nekliniki uzorak, solidno obrazovanje, srednju klasu, gde je majka bila (tako se smatralo) primarni negovatelj. Ukratko, s obzirom na mane istraivanja koja su ispitivala odnos izmeu privrenosti oca i privrenosti oca i deteta, zakljuci nisu mogui. Ova tri istraivanja su ipak pokrenula neka pitanja. Prvo, da li, tokom prvih osamnaest meseci deteta, u domainstvima u kojima je majka primarni negovatelj, oeva iskustva privrenosti mogu da budu manje uticajna od razvijanja odnosa privrenosti oca i deteta. Drugo, da li AAI (nezavisno od prenatalne primene) pouzdano mobilie i odraava duevno stanje oca u pogledu iskustava bitnih za privrenost. Tree, da li e etvorostruki nain sistema klasifikacije poboljati mo predvianja poveavanjem specifinosti klasifikacije privrenosti odraslih i dece. Preduzeli smo ovo prospektivno istraivanje u Australiji kako bismo ispitali odnos izmeu sigurnosti predstava buduih oeva o privrenosti i sigurnosti oca i deteta od petnaest meseci, koristei klasifikacioni sistem od etiri kategorije. Predvideli smo, na osnovu teorije privrenosti, da postoji veza izmeu sigurnog ili nesigurnog mentalnog modela privrenosti budueg oca s jedne strane i sigurne ili nesigurne privrenosti petnaestomesenog deteta ocu. Metod Prvobitni uzorak sastojao se od 66 parova u poslednjem tromeseju trudnoe, gde su oba roditelja ekala svoje prvo dete. etiri para su odustala posle prikupljanja prenatalnih podataka zbog selidbe (tri para) i prekida odnosa (poslednji par). Njihovi demografski podaci ipak su uzeti u obzir kako se ne bi smanjio uzorak, zbog demografskih razloga. Tako je u ukupnom uzorku bilo 62 para. Detaljan opis uzorka moe se videti na drugom mestu [34]. Prosena starost mukaraca bila je trideset godina (od 22 do 43). Ispitanici su bili iz srednje klase, i veina je bila solidno obrazovana. 85% muka-
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raca zavrilo je najmanje srednju kolu (jedanaesta i dvanaesta godina u Australiji), dok je 50% imalo neki oblik tercijarnog obrazovanja. Na skali prestinosti posla [36], rangiranoj od 1 do 7, srednja ocena oeva je bila 4.1 (1 = najvie sudija 1.2; 7 = najnie grobar 6.8). U vreme formiranja uzorka 94% parova bilo je u braku, ostatak je bio u stabilnim zajednicama koje uvaava obiajno pravo. Zbog novanih tekoa istraivanje predvianja obuhvatilo je poduzorak od 44 oca. Obavljena su i uporedna demografska istraivanja predvianja poduzorka oeva (N = 44), kao i ostatka uzorka oeva. Nije bilo znaajnih razlika meu grupama u pogledu starosti, nivoa obrazovanja ili radnog statusa. Meutim, etrdeset etvoro buduih oeva u istraivanju predvianja bili su oenjeni/u zajednici sa partnerkom due od ostalih oeva, 5.83 godine, odnosno, 3.54 godine. (kombinovano t = 2.90, d.f. = 63, p < .002). Poduzorak istraivanja predvianja inio je 21 deak i 23 devojice. Formiranje uzorka Parovi su izabrani iz dve velike dravne klinike u Sidneju, jedne velike privatne klinike i dve privatne organizacije za pripremu za poroaj. Parovima je reeno da e istraivanje ispitivati proces prelaska na roditeljstvo i da e jedan aspekt istraivanja pokuati da pojasni kako iskustvo roditelja iz njihovog detinjstva moe kasnije da utie na njihovo roditeljstvo. U ovom longitudinalnom istraivanju bilo je pet stadijuma: prenatalno ispitivanje i ispitivanje sa 6, 11, 12 i 15 meseci. Prilikom svakog testiranja i otac i majka su, nezavisno jedno od drugog, popunjavali niz instrumenata samoprocene (neki su se ponavljali). U poslednjem tromeseju intervjuisani su odvojeno, u svom domu, korienjem AAI [12]. U estom i jedanaestom mesecu napravljeni su video zapisi majke, oca i deteta, i oca i deteta u igri, kod kue. Sa dvanaest meseci sva deca su procenjena s majkom u nepoznatoj situaciji, a sa petnaest meseci isto je uinjeno s ocem. Ovde se govori samo o podacima iz prenatalnog AAI oeva i podacima o privrenosti otac-dete (u petnaestom mesecu). Dalje istraivanje nije bilo mogue zbog nedostatka sredstava. Instrumenti Intervju za ispitivanje privrenosti odraslih (Adult Attachment Interview, AAI) [12] je polustrukturisani intervju snimljen na audio traku, kojim se procenjuje i klasifikuje stav odraslog o privrenosti [13]. Instrument je opisan u u uvodu. Pomono osoblje u istraivanju napravilo je anonimne transkripte tonskih zapisa i dalo im nove brojeve kako bi se osiguralo da e kasnije kodiranje dece u nepoznatoj situaciji biti nasumino. Sva kodiranja obavio je autor. Pouzdanost za nae AAI kategorije bila je 80% (Kapa =.72, p < .001) na dvadeset nasumino izabranih transkripata, to je predstavljalo 32% od ukupnog uzorka (N = 62). Autor je prola obuku u primeni AAI kod Meri Mejn, Meri Ejnzvort i Erika Hesea.
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Test nepoznate situacije (Strange Situation Procedure, SS) [22]. Ovaj dvadesetominutni, standardizovani laboratorijski test ima dobro utvrenu pouzdanost i valjanost. Deca su posmatrana kako reaguju na dva kratka odvajanja od roditelja i na njihov povratak. Deca su razvrstana u kategorije prema svom ponaanju u nepoznatoj situaciji, uz naroit naglasak na ponaanje pri ponovnom susretu. Pouzdanost je utvrdio nezavisni ispitiva. Dogovoreno je da je za etiri primarne podele k = .86 (p < .001). Oba ispitivaa prola su obuku u skorovanju nepoznate situacije A, B i C kategorije kod Alena Srufa. Osim toga, autor je ustanovila sa Alenom Srufom interlaboratorijsku pouzdanost za kategorije A, B i C. Oba ispitivaa bila su ukljuena u jednonedeljni program obuke za kodiranje kategorije D kod Mejnove i Hesea [25]. Autor je provela tri nedelje 1993. godine radei sa Mejnovom i Heseom kako bi se obezbedila pouzdanost kodiranja za kategoriju D. Rezultati Ovde predstavljeni podaci u skladu su sa hipotezom da modeli privrenosti buduih oeva mogu da pomognu u predvianju prirode privrenosti deteta ocu petnaest do osamnaest meseci kasnije. Prospektivni modeli privrenosti oeva kao najava privrenosti deteta ocu sa petnaest meseci Postoji nekoliko merenja povezanosti koja doputaju tumaenje smanjenja greke u procentima (PRE) prilikom predvianja zavisne varijable uz poznavanja nezavisne varijable. To je, u stvari, slino pojmu varijanse. Delta PRE statistika [37] predstavlja najpreciznije merenje [38]. Poetna hipoteza da u predvianju nema smanjenja greke (koeficijent = 0) testirana je u odnosu na suprotnu hipotezu da smanjenje greke postoji (koeficijent > 0). U ovom istraivanju to znai da poznavanje AAI kategorije budueg oca smanjuje greku u predvianju kategorije privrenosti u kojoj e biti njegovo dete iznad bilo kog smanjenja greke u predvianju koje bi se dobilo da nije bila poznata AAI kategorija budueg oca. Izneti su i standardni stepeni konkordanse. Napravljena je dihotomija siguran/nesiguran i za unakrsni klasifikacioni model sa etiri kategorije AAI/SS i za tradicionalni model klasifikacije AAI/SS sa tri kategorije. Tako su obraene etiri Del PRE analize; u svakoj je primenjen razliit nivo specifinosti predvianja. Model unakrsne klasifikacije 4x4 (kategorije privrenosti za odrasle: D/E/F/U i dete: A/C/B/D) Sutina ovog istraivanja je utvrivanje moi predvianja potpunog modela unakrsne 4 x 4 klasifikacije. S obzirom da koristi kategoriju nesiguran/neodluan odrasli kao prediktor stanja deteta kao nesigurnog/dezorganizovanog, ovo je najsloeniji model.
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elijske frekvencije, osim elija predvianja i greke, u potpunom modelu 4 x 4 unakrsne tabulacije (40.4 PRE, p < .0001, konkordansa 56.8%) prikazane su u Tabeli 1. Greka u predvianju kategorije privrenosti kod deteta (od etiri mogue) smanjena je za 40.4% kada je predvianje pravljeno na osnovu poznavanja kategorije privrenosti (od etiri) budueg oca. elije sa sabranim skorom su elije predvianja. elije koje nisu sabrane predstavljaju elije greke. Tabela 1. Tabela unakrsne 4 x 4 klasifikacije sigurne privrenosti deteta i oca (N = 44)
Sigurna privrenost odraslog D F E U A 5 1 3 1 10 Sigurna privrenost deteta B C D 1 1 1 11 3 1 1 1 2 3 1 8 16 6 12 8 16 7 13 44
Konkordansa izmeu kategorije E kod odraslog i kategorije C kod deteta bila je veoma niska, 14.3%, to ukazuje da kategorija E kod odraslog (nesiguran/previe zaokupljen) ne predskazuje dobro stanje deteta C (nesigurno/odbojno). S druge strane, u skladu s predvianjem, budui oevi koji su klasifikovani kao nesigurni/neodluni (U) imali su decu koja su pokazivala nesigurnu/dezorganizovanu (D) privrenost oevima. Greka u predvianju sigurnosti, odnosno, nesigurnosti dece smanjena je za 50.9% kada je predvianje pravljeno na osnovu znanja da li je privrenost budueg oca bila sigurna ili nesigurna (dihotomija od etiri kategorije). Tabela 2. pokazuje elijske frekvencije izmeu prediktivnih i elija sa grekom u ovim uslovima (50.9 PRE, p < .0003, konkordansa 77.2%). Tabela 2. Tabela dihotomne unakrsne klasifikacije sigurne privrenosti oeva i dece (svedena iz etiri kategorije) (N = 44)
Sigurna privrenost odraslog Siguran Nesiguran Sigurna privrenosti deteta Sigurno Nesigurno 11 5 5 23 16 28 16 28 44
Model 3 x 3 unakrsne tabulacije (Odrasli D/E/F i dete A/C/B kategorije) Kada je predvianje pravljeno na osnovu znanja o tome koja je kategorija privrenosti dodeljena buduem ocu (od tri mogue), greka u predvianju kategorije u koju e spadati privrenost deteta (od mogue tri) pala je na skromnih 29.7%. Tabela 3. pokazuje elije frekvencije izmeu elija predvianja i greke u modelu 3 x 3 unakrsne klasifikacije (29.7 PRE, p < .007, konkordansa 54.5%).
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Tabela 3. Tabela unakrsne 3 x 3 klasifikacije sigurne privrenosti oca i deteta (N = 44)

A 8 1 5 14 Sigurna privrenost deteta B 1 14 6 21 C 3 4 2 9
Sigurna privrenost odraslog
D F E
12 19 13 44
Greka u predvianju sigurnosti deteta smanjena je za 45.1% kada je predvianje pravljeno na osnovu poznavanja da li je privrenost oca sigurna ili nesigurna (dihotomija iz tri kategorije). Tabela 4. pokazuje frekvencije izmeu elija predvianja i greke u ovakvim uslovima (45.1 PRE, p < .00014, konkordansa 72.7%). Tabela 4. Tabela dihotomne unakrsne klasifikacije sigurne privrenosti oca i deteta (izvedena iz tri kaegorije) (N = 44)
Sigurna privrenost deteta Siguran Nesiguran Siguran 14 5 Nesiguran 7 18 21 23
Sigurna privrenost odraslog
19 25 44
Kao i u modelu sa etiri kategorije, stepen konkordanse izmeu kategorija odrasli E i dete C bila je veoma niska 15.4%. Njen uticaj na smanjivanje moi predvianja u modelu 3 x 3 jo je vei jer opstaju samo dve mogue kategorije za dodeljivanje. Svi opisani modeli predvianja pokazali su znaajan uspeh u predvianju. Ova analiza ukazuje da, sve u svemu, poznavanje prirode modela privrenosti budueg oca prua dobar prediktivan kriterijum za organizaciju privrenosti njegovog deteta, nekih petnaest do osamnaest meseci kasnije. Meutim, najbolji rezultati predvianja postignuti su kada su klasifikacije i oeva i dece bile dihotomne siguran nasuprot nesiguran. Nedostatak ovog pristupa je smanjenje specifinosti predvianja. Prihvatljiv kompromis postignut je u modelu unakrsne klasifikacije 4 x 4, sa PRE = 40.4 uz ouvanje najvee mogue specifinosti. Ovaj model, osim toga, pokazuje korisnost kategorije oeva neodluan kao ranog pokazatelja budue dezorganizovane/dezorijentisane privrenosti deteta ocu. Ipak, ostaje znaajan nivo greke u predvianju, ak i u najboljem modelu.
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Diskusija Uoena je znaajna i umerena do umereno snana povezanost izmeu razvojne istorije oca i kvaliteta privrenosti deteta ocu posle petnaest meseci ivota. Tako, na najniem nivou analize, ak i pre nego to je dete roeno, mogli su se razlikovati oevi ija e deca razviti sigurnu nasuprot nesigurnoj privrenosti sa njima tokom prvih petnaest meseci svog ivota. ak i na nivou analize kategorija-po-kategorija predvien odnos ostao je znaajan, mada manje naglaen. Ovi nalazi u skladu su sa nalazima drugih istraivanja koja su ispitivala odnos organizacije privrenosti kod odraslih i kod dece, uz korienje AAI. Od tri istraivanja koja su ispitivala odnos otac-dete sa AAI/SS, Mejnova i saradnici [6] su nali da je povezanost znaajna, ali manje snana od povezanosti majka-dete sa AAI/SS. Meutim, Stil i saradnici [30] nalaze da su i sigurnost i majke i oca na AAI bile jednako prediktivne za sigurnost privrenosti deteta. Van Ijzendorn i saradnici [7] s druge strane, nisu nali da je usklaenost izmeu oeve i deje privrenosti statistiki znaajna, mada je usklaenost izmeu majine i deje privrenosti bila statistiki znaajna. Meutim, ovi autori istiu da je post hoc analiza procene privrenosti kod odraslih, nekoliko godina posle merenja deje privrenosti, mogla da utie na njihove podatke. Nalazi, uzeti zajedno, ukazuju da nain na koji roditelji doivljavaju i verbalno se priseaju svojih najranijih i trenutnih afektivnih veza direktno utie na kvalitet odnosa privrenosti izmeu roditelja i deteta, verovatno zato to ova shvatanja ili mentalne predstave o privrenosti utiu na ponaanje roditelja prema detetu. Proporcija sigurnih modela privrenosti (36% za etvorostruku i 43% za trostruku AAI klasifikaciju) uoena kod buduih oeva izgleda nisko za normativan uzorak. Meutim, ovi nalazi spadaju u okvir klasifikacije privrenosti kod odraslih kao autonomne, o kojoj izvetavaju drugi istraivai. Na primer, van Ijzendorn i saradnici [7], koristei sistem trostruke klasifikacije, oznaili su 48% svog uzorka kao kategoriju autonoman (N = 29). Autor na drugom mestu opirnije razmatra uporedne nalaze [34]. tavie, u metaanalizi van Ijzendorna [16] osamnaest AAI/SS istraivanja naeno je da podaci iz ovog istraivanja nisu anomalni. Dodatni kvalitativni podaci koji govore o moguim stilskim razlikama u reakcijama u AAI izmeu oeva i majki mogu da budu korisno sredstvo kojim bi se unapredilo razumevanje mentalnih procesa povezanih sa odnosom oca i deteta. Van Ijzendornova [16] metaanaliza nije nala da su oevi znaajno vie zastupljeni u odnosu na majke u kategoriji D. Nezvanino, ispitivai nisu pokazali bilo kakvu razliku u pristupu AAI izmeu buduih oeva i njihovih trudnih partnerki. Manjak sredstava onemoguio je da se obrade i podaci iz ispitivanja majki na AAI. Ovo istraivanje vano je iz nekoliko razloga. Prvo, prospektivni, longitudinalni stil istraivanja koji je koristio etvorostruku klasifikaciju privrenosti odraslih i dece uspeno je predvideo kontinuitet u prirodi i kvalitetu
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odnosa otac-dete kroz generacije. Ono stoga prua snanu podrku paradigmi privrenosti, zbog valjanosti AAI kao instrumenta, i zbog znaaja oca u drutvenom i oseajnom razvoju deteta. Dokazi da oevi nezavisno utiu na odnos privrenosti sa svojom decom, snani su [39], s obzirom da nije naen odnos izmeu relativnog roditeljskog angamana i sigurnosti privrenosti deteta. Nalazi ovog istraivanja podravaju nalaze Frodija i saradnika [39]. Oni ukazuju da, ak i u domainstvima u kojima je majka primarni prualac nege, istorija oca i njegove mentalne predstave o iskustvima privrenosti jednako utiu u odreivanju kvaliteta privrenosti izmeu oca i deteta koliko i istorija majke na privranost majka-dete. Stoga moemo da pretpostavimo da su mentalni procesi odraslih koji su u vezi sa privrenou i njihovo prenoenje isto. Naravno, to ostavlja otvoreno pitanje koje su postavili Mejnova i saradnici [6] o postojanju u detinjstvu hijerarhijskog rasporeda u organizaciji radnih modela privrenosti, koji favorizuje primarnog negovatelja. Sadanji nalazi ne mogu da daju odgovor na ovo pitanje. Meutim, oni ipak ukazuju na znaaj mentalnog stanja oca u vezi sa privrenou u drutvenom i oseajnom razvoju deteta, naroito s obzirom da je u ovom istraivanju otac sekundarni negovatelj. S tim u vezi, ovde opisani pozitivni prediktivni nalazi ukazuju da AAI moe pouzdano da mobilie i odrazi mentalna stanja oca u vezi sa privrenou, i razlike meu njima, podravajui tako valjanost AAI u uzorku oeva. Drugi vaan aspekt ovog istraivanja jeste u tome to je ono jedno od malog broja istraivanja koja su ukljuila kategoriju nesiguran/siguran odrasli u normalan uzorak prediktivnog istraivanja [40,25]. Dodatno je znaajno to to je ovo prvo prospektivno istraivanje sa oevima. Ono stoga dozvoljava procenu doprinosa u predvianju specifikovanije strukture unakrsne klasifikacije. S tim u vezi, a u pogledu privrenosti izmeu oca i deteta, treba rei da je samo 36% odnosa u nepoznatoj situaciji klasifikovano kao sigurno (vidi Tabelu 1). Logino, dodatak druge kategorije smanjie brojeve u ostalim kategorijama. Mejnova [41] ukazuje da je uvoenje kategorije dezorganizovano dete, uopte uzev, imalo efekat smanjenja broja dece klasifikovane u siguran odnos privrenosti. Na primer, Mejnova i Solomon [29] izvetavaju da je u istraivanju Mejnove i Vestona [5] (u kojem se ispitivala i privrenost otac-dete) 13 od 19 dece procenjeno kao teko za klasifikaciju, u kasnijem istraivanju sa 152 nepoznate situacije ...bilo identifikovano kao sigurno s roditeljem kada su korieni standardni postupci klasifikacije [25]. U ovom istraivanju uklanjanje kategorije nesiguran/dezorganizovan iz analize za rezultat je imalo da je 48% dece procenjeno da ima siguran odnos privrenosti sa ocem. Ovaj nalaz je u skladu sa podacima Mejnove i saradnika [5] i sa tvrdnjama Mejnove [29]. Mada ove proporcije sigurne privrenosti otac-dete mogu da izgledaju male one nisu u neskladu sa metaanalizom Ijzendorna i Kronenberga [31] kulturno razliitih obrazaca privrenosti. Osim toga, obrazac sigurne privrenosti otac-dete pojavio se kao model i u 3 x 3 i u 4 x 4 modelu unakrsne klasifikacije (vidi Tabele 2 i 4).
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S tim u vezi, 27% dece (N = 12) bilo je klasifikovano da pokazuje nesigurnu/dezorganizovanu privrenost oevima. Ovaj nalaz je u skladu sa nalazom Ejnzvortove i saradnika [40] koji imaju slinu proporciju D dece (33%) u svom neselektivnom uzorku dijada majka-dete. Zanimljivo je da su u naem istraivanju jedino nesigurna/dezorganizovana deca sa alternativnom klasifikacijom kao sigurna ona deca podklasifikovana kao B4 (N = 5); grupa iji je status u klasifikaciji siguran bio doveden u pitanje [42,43]. Neodluna privrenost oca (koja je u svim sluajevima osim jednog bila rezultat gubitka zbog smrti) naena je kao umereni pokazatelj da e dete biti nesigurno/dezoranizovano (konkordansa = 61.5%)1. Ovi nalazi mogu se porediti sa nalazima Mejnove i Hesea [25] koji izvetavaju o 60% slaganja u svom odabranom uzorku od 53 dijade majka-dete. Ejnzvortova i Ajhberg [40], s druge strane, izvetavaju o 100% slaganja u njihovom istraivanju sa neselektivnim uzorkom od 45 dijada majka-dete. Meutim, moda je najvanija stvar to da u tri istraivanja (ukljuujui i nae), roditelji koji ili nisu iskusili gubitak znaajne osobe ili, ako jesu, izgleda da su razreili taj gubitak, nisu imali decu koja bi u nepoznatoj situaciji bila procenjena kao dezorganizovana u odnosu sa njima. Tako izgleda da nedostatak prevladavanja tugovanja kod roditelja moe da bude vei inilac rizika za nepovoljne razvojne posledice kod deteta nego gubitak sam po sebi. Mejnova i saradnici [6] i Kesidi [38] izvetavaju o estogodinjacima koji su kao deca bili procenjeni kao nesigurni/dezorganizovani sa roditeljem, i pokazuju kontroliue ili kanjavajue ponaanje prema tom roditelju. Osim toga, ova deca su se ukljuila i u razvojno neprikladne odnose zamene uloga roditelj-dete. Novije teorije o prirodi razvoja mentalnog stanja dece klasifikovane kao dezorganizovana/dezorijentisana u detinjstvu spekuliu da ova deca mogu, kao odrasle osobe, da budu ranjivija na razvoj disocijativnih duevnih poremeaja [44].2 Ako priroda oevog odnosa sa detetom ima potencijal da deluje kao zatitni ili inilac ranjivosti u razvoju deteta, kao to se predlae u teoriji privrenosti i istraivanjima koja se bave privrenou [17,5,18] onda dete sa dezorganizovanom privrenou neodlunom ocu moe da bude naroito ranjivo. Dok su se u ovom istraivanju mogli razlikovati i pre roenja deteta oevi dece koja e razviti sigurnu, nesigurnu/izbegavajuu ili nesigurnu/dezorganizovanu pruvrenost, to nije bio sluaj sa oevima ija su deca razvila nesigurnu/odbojnu privrenost. Prospektivno istraivanje Fonagija i saradnika [15] niskorizinih dijada majka-dete iz srednje klase, uz korienje 3 x 3 modela unakrsne kilasifikacije, takoe je pokazalo da je majin status nesigurna/previe zaokupljena slabo predskazivao nesigurnu/odbojnu privrenost deteta. S druge strane, u visoko rizinom uzorku Vord, Botjanski,
1 Od 62 oca, 51 (83%) je, tokom svog detinjstva, mladosti ili kao mlai odrasli, iskusilo gubitak zbog smrti roditelja ili druge oseajno vane osobe. Mada su drugi, vie simbolini gubici (poput onih koji se pojavljuju u situacijama razvoda) smatrani vanim aspektima istorije privrenosti pojedinca, nije se smatralo da su odreujui za status neodluan. 2 Ova ideja dobija izvesnu podrku iz iskustva i nedavnih [44] i tekuih istraivanja koja ispituju odnos izmeu kategorije neodluan i psihopatologije disocijativnih poremeaja [33,44].
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Planket i Karlson [46] nalaze dobru predvidljivost u kategoriji nesiguran/previe zaokupljen odrasli, kao i Mejnova [lino saoptenje, 41] u svom uzorku niskog rizika. Mejnova i Solomon [33] su uoili da deji obrazac nesiguran/odbojan moe da bude manje dobro organizovan u poreenju sa drugim obrascima privrenosti. To moe da bude sluaj i sa mentalnim stanjem nesiguran/previe zaokupljen odrasli. Uoite da je u 4 x 4 modelu unakrsne klasifikacije previe zaokupljen roditelj bio dobar pokazatelj opte nesigurne privrenosti deteta (konkordansa = 85.7% A, D, C). Jasno je da budua istraivanja treba da razjasne mo predvianja ove kategorije. Ovo istraivanje je pokazalo dobru predvidljivost modela etvorostruke unakrsne klasifikacije (40.4 PRE) u poreenju sa skromnijim rezultatima modela trostruke unakrsne klasifikacije (29.7 PRE). Snaga etvorostrukog modela poiva na dobroj prediktivnoj moi kategorija siguran, nesiguran/omalovaavajui i nesiguran/neodluan s jedne strane i loe prediktivne moi kategorije nesiguran/previe zaokupljen, s druge strane. Do sada se kategorija neodluan upotrebljavala u malom broju istraivanja. Meutim, sadanji nalazi ukazuju na njen znaaj u buduim istraivanjima odnosa izmeu AAI i SS klasifikacija, naroito u svetlu sve vie dokaza koji su i sve snaniji, a izgleda da povezuju neodlunu privrenost odraslog i dezorganizovanu/dezorijentisanu privrenost deteta sa loim prilagoavanjem u odnosima. Tree, ovo istraivanje je znaajno jer je sprovedeno u Australiji, u kojoj do sada nije bilo istraivanja sa korienjem Intervjua o privrenosti odraslih. Uspeh predvianja u australijskom uzorku oeva ukazuje da je AAI kulturno valjan instrument za upotrebu u Australiji, barem u uzorku mukaraca srednje klase. On potvruje univerzalnost stanja duha u pogledu privrenosti koju AAI procenjuje. Zbog malog broja ispitivanja oeva sa AAI i zbog nunih ogranienja u nacrtu istraivanja, nalazi ovog istraivanja zahtevaju paljivo tumaenje. U sluaju neskladnih odnosa otac-dete, ponovljeno merenje analize o podacima iz samoizvetaja ukazalo je na trend da su sigurni oevi sa nesigureno privrenom decom iskusili vee intra- i interpersonalne tekoe tokom prelaska u roditeljstvo u odnosu na nesigurne oeve ija su deca bila sigurno privrena sa petnaest meseci. Budua istraivanja sa veom populacijom, mnogo raznolikijom u pogledu kulturnih i drutveno-ekonomskih inilaca, mogu bolje da ispitaju snanu ulogu psiholokog stresa, kao i psiholoke otpornosti. Osim toga, nije poznat stepen do koga je greka u predvianju mogla biti rezultat greaka u postupku ili obradi podataka, ili pak izmenjenih predstava oeva o privrenosti tokom prelaska u oinstvo. Ova kontingencija mogla bi se u buduim prospektivnim istraivanjima bolje obraditi uz upotrebu pretesta i retesta. Bez obzira na ova ogranienja, ovo istraivanje prua znaajne prospektivne podatke koji podravaju paradigmu privrenosti, pokazujui da postoje zakonomerni odnosi izmeu naina na koji oevi zamiljaju svoju sopstvenu razvojnu istoriju i kako podiu sopstveno dete. Osim toga, pokazalo se
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da je AAI sposoban da prenatalno razlikuje one oeve ija e deca kasnije postati sigurno ili nesigurno privrena. Naroito je vano da upotreba kategorija neodluan odrasli/dezorganizovano dete u ovom istraivanju prua prvi dokaz prospektivne iskustvene veze ovo dvoje u niskorizinom uzorku roditelja. Na kraju, usredsreivanje na dijadu otac-dete donelo je nove znaajne uvide u to kako oevo shvatanje sopstvenog razvoja oblikuje prirodu ovog za njega vanog odnosa. Izjave zahvalnosti Autor se zahvaljuje Meri Mejn na njenim promiljenim komentarima na ranije verzije ovog lanka, Dajeni Benoa i Donu Lordu na proveri pouzdanosti AAI, odnosno, dejeg SSP, i Alenu Tejloru za statistiku obradu.
Psihijat. dan. /2005/37/2/271-287/ Radojevic M. Prenatal paternal representations of attachment predict infant-father
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Research article UDK: 159.9 : 17.023.32
PRENATAL PATERNAL REPRESENTATIONS OF ATTACHMENT PREDICT OF INFANT-FATHER ATTACHMENT AT 15 MONTHS: AN AUSTRALIAN STUDY
Marija Radojevic
Child, Adolescent and Family Service, Hornsby and Ku-ring-gai Hospital, Sydney and Graeme Russell School of Behavioral Sciences, Macquarie University
Abstract: This study reports the power of the George, Kaplan and Main [12] Adult Attachment Interview (AAI) to predict infant-father attachment in an Australian sample of firsttime prospective fathers (N=44). Both the three category (Secure, Dismissing, Preoccupied adult; Secure, Avoidant, Resistant infant) and the four category (Secure, Dismissing, Preoccupied, Unresolved adult; Secure, Avoidant, Resistant, Disorganized infant) models were tested; each in its binary (Secure/Insecure) and in its full cross-tabulation form. All models demonstrated significant predictive success. Strongest prediction was achieved when paternal and infant classifications were dichotomized to Secure vs. Insecure (50.9 Percent Reduction in Error PRE). The binary form of the three category model yielded a 45.1 PRE. The 4x4 crossclassification model yielded a 40.4 PRE and preserved maximum specificity, thereby highlighting the predictive usefulness of the paternal Unresolved category. Key words: infant-father attachment, prediction, AAI
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Attachment theory, and the subsequent research activity it has generated has, over the last 20 years, has resulted in one of the most robust methodologies for both theory expansion and for the understanding of child social-emotional development. Within the attachment research domain, the body of work generated by Michael Lamb and his associates [1,2,3,4] has been of importance because it has demonstrated both the existence and the variability of the father-infant attachment relationship. However, a cursory inspection of the attachment literature reveals that, since Lamb's important corpus of work, a continuing sustained focus on fathers in attachment research has been notable by its absence in published work [with some exceptions 5,6,7]. However, ongoing research into the father's role has been more productive within broader developmental and psychoanalytic paradigms [8, 9,10,11]. The development of the Adult Attachment Interview (AAI), and its coding system, launched the adult attachment research program [12,13]. Since its inception, one of the central questions has been to determine developmental antecedents in the parent which contribute to caregiving and hence, to variable infant attachment outcomes. Within this framework, there is accumulating evidence for continuity between the way a mother mentally represents and verbally constructs her own experience of being reared on the one hand, and the way that she subsequently treats her child on the other [6, 14,7,15]. The transmission mechanism for continuity is considered to be the degree to which the infant's mother is responsive to its signals for comfort and security. The aim of this study is to examine the extent to which the security of expectant fathers' mental representations of attachment may influence the subsequent quality of infant-father attachment security in a low-risk, nonclinical sample. In a recent meta-analysis of the predictive validity of the AAI [16] the selection procedure yielded 18 studies on the relation between AAI classifications and infant attachment classifications. Of these 18 studies, only four (including the present study) involved fathers. The relative neglect of fathers in ongoing attachment research suggests that an assumption of the primacy of the mother-infant dyad continues to underlie attachment research endeavours. This is puzzling for several reasons. First, both theory and research within the attachment paradigm suggest that a secure infant-father attachment is likely to provide a buffering effect should the infant-mother attachment be insecure [17,5]. Alternately, if the infant-father attachment is also insecure, then fewer interactional opportunities exist to buffer the child against social-emotional maladaptation [7,18]. Thus, the nature of the affectional tie between father and child has the potential to function as either a protective or a vulnerability factor in the childs development. For example, studies of child outcome in divorced families consistently demonstrate poorer psychosocial outcomes in father absent families and in families in which children have minimal access to their father [19,20].
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Second, the degree of social change in Western industrial countries, particularly with respect to increasing family breakdown and changing work practices, poses significant challenges to many assumptions attending the nature and conduct of family life and in particular, of parenting. These assumptions include, for example, the primacy of the mother-child dyad and the secondary caretaker status of the father who is presumed to exert a reduced impact on infant development. Currently in Australia, 53% of women are in the paid work force and of these women, 48% had a youngest child of ten years of age [21]. This figure likely under-represents the current situation because of the continuing increase in the return of mothers of young children to the paid work force. Further, in June 1996 there were 672,000 one parent families and of these, 85% were headed by a woman. Thus, given the scale and significance of social change it is important to understand better the nature of the childs attachment relationship with his or her father (which, like infant-mother attachment, is presumed to vary as a function of paternal responsiveness to his infant). Additionally, we need to understand the nature and antecedents of the fathers affectional tie to his child, particularly as these are expressed in paternal reflections about attachment and in paternal behavior. The AAI was developed to predict the quality of infant-parent attachment relationships as assessed in the Strange Situation [22]. Via a series of questions and probes it is designed to assess an adults state of mind with respect to attachment relationships, particularly as these relationships were experienced in childhood. Classification relies more on the coherence of expressed thoughts and feelings than it does on actual content. Interviews are transcribed verbatim and one of the four major classifications is assigned: Autonomous (F), Dismissing of Attachment (Ds), Preoccupied by Attachment (E) and Unresolved with respect to Attachment (U). Secure (Autonomous) adults provide relatively coherent, consistent and non-defensive accounts of their attachment relevant experience, irrespective of whether it was actually positive or negative. In being relatively comfortable with the full range of their own affective experience, Autonomous parents are thought to be freer than Insecure parents to respond empathically to the childs distress signals [23,24]. Hence the child's expectation is of prompt affectionate attention. The most outstanding characteristic of Insecure/Dismissing adults is the defensiveness implicit and explicit in their discourse. The seeming reluctance to acknowledge their own attachment needs may make the Dismissing adult less sensitive and responsive to the affectional needs of the child [24]. Under these conditions the child learns quickly to deflect attention from its own attachment needs and thus appears (often precociously) self sufficient. Insecure/Preoccupied adults seem to still be angry and overinvolved with the perceived shortcomings of one or other parent. In response to the infant's attachment bids for comfort and/or affection, the Preoccupied adult is
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likely to be inconsistent; sometimes intrusively available, at other times neglectful. This caregiving strategy creates both hypervigilance as well as attenuated attachment behavior in the child, presumably because the child is not sure how the caregiver will respond. Finally, adults classified as Insecure/Unresolved show signs of unresolved experiences of trauma, involving either loss through death or else abuse suffered at the hands of an attachment figure. It is postulated that the Unresolved adult is likely to inadvertently behave towards the infant in ways which may engender transient fearfulness and conflict in the child [25]. Nevertheless, it should be noted that the AAI is not the only measure of adult attachment whose theoretical basis lies in Attachment Theory. Indeed, the work of Hazan and Shaver (1990, 1994) has inspired a corpus of adult attachment research based upon self report measures [26,27,28]. Whilst the elaboration of this significant and parallel research is beyond the scope of the present paper it is elegantly discussed by Feeney and Noller (1996). The classifications of the AAI are considered to be systematically related to infant patterns of attachment as assessed in the Strange Situation [22]; Secure (B), Avoidant (A), Resistant (C) and Disorganized/Disoriented (D) [29]. The rationale here is that infants internalize patterns of caregiving during repeated interactions with parents. These internalizations then become part of infants' representational models of relationships. The latter, in turn, shape both the infant's own behavior as well as its expectations of the behavior of others. The behavioral expression of infant patterns of attachment are considered to represent strategies for either mobilizing or else for restricting awareness of attachment related affects and cognitions. They may be summarized as follows: 1. Infants who are not ambivalent in seeking proximity, interaction or contact with the returning mother are classified Secure (Group B). 2. Infants who snub or avoid the mother upon reunion, and who show few if any signs of missing her during separation are classed as Insecure/Avoidant (Group A). 3. Infants who manifest anger and ambivalent toward their returning mother are classed Insecure/Ambivalent (C). They cry and seem to want contact but are unable to settle and return to play. In developing the Insecure/Disoriented (D) category, Main & Solomon [29] noted that infants who could not be classified within the A, B, C system did not appear... to resemble one another in coherent organized ways. What these infants share in common was instead bouts or sequences of behavior which seemed to lack a readily observable goal, intention or explanation (p. 122). The present study is one of a small number which, to date, incorporates the Insecure (D) category. Of the three studies [6,7,30] which have assessed both maternal and paternal patterns of attachment, and have examined their respective concordances with infant-mother and infant-father attachment, Main et al. [6] and
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Van Ijzendoorn et al. [7] found stronger associations between mothers as compared with that of fathers and their infants. Steele et al. [30], using the adult Secure/Insecure dichotomy, found that paternal security was just as predictive as maternal security of infant secure attachment. Paternal insecurity though was found to be considerably less likely than maternal insecurity to increase the chance of an insecure infant-father attachment. Given that each was undertaken in a different country (USA, The Netherlands and England respectively), these studies may also be considered to provide crossnation data. The latter have been shown to be associated with different culturally based approaches to childrearing and, subsequently, to different distributions of infant-parent attachment categories despite the fact that mothers are the primary caretakers in most societies [31]. Only Steele et al., [30] used a prospective method. While a true predictive design remains the preferred scientific design, Van Ijzendoorns [16] meta-analysis found type of design (retrodictive, concurrent, predictive) did not explain variability in effect sizes across the 18 studies. Although both the adult Unresolved attachment category and the infant Disorganized/Disoriented attachment category predicted by it are important from theoretical, empirical and clinical perspectives [32, 33], they were either not used or not reported in these studies. All three studies employed well educated, middle class, non-clinical samples wherein the mother was the (presumed) primary caregiver. Clearly, given the dearth of studies which have examined the relationship between paternal attachment status and infant-father attachment status, conclusive inferences are not possible. Rather, collectively, the three studies cited here raise several issues. The first relates to whether, during the first 18 months, the fathers history of attachment experiences may be less influential of the developing infant-father attachment relationship in primary maternal caretaking households. The second issue relates to whether, the AAI (irrespective of prenatal administration) reliably mobilizes and reflects the fathers mental state in terms of attachment relevant experiences. The third issue concerns whether a four way classification system will improve predicability by increasing the specificity of adult and infant attachment classification. We undertook an Australian prospective study to examine the relationship between security of expectant fathers representations of attachment and infant-father security at 15 moths using a four-way classification system. Based on attachment theory, the specific prediction was that there would be an association between the security or insecurity of prospective fathers mental models of attachment on the one hand and the security or insecurity of the infant's attachment to its father at 15 months on the other. Method The initial sample comprised 66 couples in the last trimester of pregnancy, in which both partners were expecting their first child. Four couples withdrew after the prenatal data gathering stage due to geographic relocation
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in the case of three couples and due to separation in the remaining case. However their demographic data was retained to maximize numbers for demographic purposes. Thus the total, ongoing sample consisted of 62 couples. This sample is described fully elsewhere [34]. Mens mean age was 30 years (range, 22 - 43). Respondents were middle class and the majority were well educated. 85% of men had completed a minimum of senior high school years (years 11 and 12 in Australia), whilst 50% had some form of tertiary education. On a scale of Occupational Prestige [36] ranked 1-7, the mean paternal ranking was 4.1 (1=highest; judge, 1.2; 7= lowest; mortuary attendant, 6.8). 94% of couples were married at the time of recruitment; the remainder were in stable common law relationships. Due to financial constraints, the current prediction study comprised a paternal sub-sample of 44. Comparative demographics of the paternal prediction sub-sample (N=44) and the remainder of the paternal sample were undertaken. There were no significant differences between these groups in age, educational level or occupational status. However, the forty four prospective fathers in the prediction study had been married/together with their partner for longer than the paternal remainder, 5.83 years and 3.54 years respectively (pooled t=2.90, d.f. = 63, p < .002). Infants in the prediction study sub-sample comprised 21 males and 23 females. Recruitment Couples were recruited from two major Sydney public teaching hospitals, one major private teaching hospital and two privately operated antenatal preparation organizations. Couples were informed that the study would investigate the process of the transition to parenthood and that an aspect of this aimed to clarify how the parents' experience of their own childhood may subsequently influence their parenting. There were five stages in this longitudinal study: prenatal, 6, 11, 12 and 15 months. At each point a series of self-report measures (several repeated) were completed and independently by father and mother. In the last trimester, they were separately interviewed in their own homes using the Adult Attachment Interview [12]. At 6 and 11 months home observations of mother, father and infant and of father and infant in free play were videoed. At 12 moths all infants were assessed with mother in the Strange Situation, then at 15 months they were all assessed with father. Only prenatal paternal AAI and father-infant attachment data (15 months) are reported here. Funds have not been available for further analysis at this stage. Measures Adult Attachment Interview (AAI) [12]. The AAI is a semi-structured audiotaped interview which assesses and classifies and adults state of mind with respect to attachment [13]. It has been described in the Introduction.
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Research assistants made transcripts anonymous and assigned new subject numbers to ensure that subsequent coding of infants in the Strange Situation Procedure would be blind. All coding was undertaken by the first author. Inter-rater agreement for four AAI categories was 80% (Kappa=.72, p<.001) on 20 randomly selected transcripts; representing 32% of the total sample (N = 62). The first author had received training in the scoring of the AAI by Mary Main, Mary Ainsworth and Erik Hesse. Strange Situation Procedure (SS) [22]. This 20 minute standardized laboratory procedure has well established reliability and validity. Infants are observed responding to two brief separations from and reunions with the parent. Infants are assigned to categories on the basis of their behavior in the SS, with a particular focus on reunion behavior. Inter-rater reliability was established with a coder unfamiliar with the project. Agreement for four primary classifications was k =.86 (p<.001). Both coders had received training in the scoring of the Strange Situation A, B and C categories from Alan Sroufe. Additionally, the first author has established inter-laboratory reliability with Alan Sroufe for A, B and C categories. Both coders attended a one week programme of instruction in D category coding provided by Main and Hesse [25]. The first author spent three weeks during 1993 working directly with Main and Hesse in order to establish reliability for D coding. Results The data presented here pertain to the hypothesis that a prospective father's working models of attachment can predict the nature of the infant's attachment to its father 15 to 18 months later. Prospective paternal working models of attachment as a predictor of infant attachment to father at 15 months There are several measures of association which permit an interpretation of percentage reduction in error (PRE) in predicting the dependent variable from knowledge of the independent variable. In effect, this is similar to the concept of variance explained. The Delta PRE statistic [37] is the most sophisticated of these [38]. The null hypothesis that prediction yields no error reduction (coefficient = 0) is tested against the alternate hypothesis that there is error reduction (coefficient > 0). In terms of the present study this is to say that knowing the prospective fathers AAI category reduces error in predicting his infant's attachment category over whatever predictive error reduction would obtain if prospective paternal AAI category was unknown. Traditional concordance rates are also reported. A secure versus insecure dichotomy was created for both the four category AAI/SS cross-classification model and the traditional three category AAI/SS cross-classification model. Hence, four Del PRE analyses were conducted; each employing different levels of prediction specificity.
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The 4x4 Cross-Classification Model (Adult D/E/F/U and infant A/C/B/D attachment categories) Assessing the predictive value of the full 4x4 cross-classification model has been a feature of this study. In employing the adult Insecure/Unresolved category as a predictor of infant Insecure/Disorganized status, it represents the most complex model. Cell frequencies amongst prediction and error cells in the full 4x4 cross-tabulation model (40.4 PRE, p<.0001, concordance 56.8%) are shown in Table 1. The error in predicting the infant's attachment category (from amongst four) was reduced by 40.4% when prediction was made on the basis of knowing the assigned attachment category (from amongst four) of the prospective father. Underscored entries are prediction cells. Non-underscored entries are error cells. Table 1. A 4 x 4 table of cross-classifications of infant and paternal attachment security (N = 44)
Adult Attachment Security D F E U A 5 1 3 1 10 Infant Attachment Security B C D 1 1 1 11 3 1 1 1 2 3 1 8 16 6 12 8 16 7 13 44
The concordance between adult E and infant C category was very low at 14.3% suggesting that the adult E/Insecure/Preoccupied category may be a poor predictor of infant C/Insecure/Resistant status. On the other hand, consistent with prediction, prospective fathers who had received an Insecure/Unresolved (U) classification tended to have children who displayed an Insecure/Disorganized (D) attachment to their fathers. The error in predicting infant security versus insecurity was reduced by 50.9% when prediction was made on the basis of knowing whether the prospective father's attachment status was secure or insecure (dichotomised from four categories). Table 2 shows the cell frequencies among the prediction and the error cells in this condition (50.9 PRE, p < .0003, concordance 77.2%). Table 2. Table of dichotomised cross-classifications of infant and paternal attachment security (reduced from four categories) (N = 44)
Adult Attachment Security Secure Insecure Infant Attachment Security Secure Insecure 11 5 5 23 16 28 16 28 44
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The 3x3 cross-tabulation model (adult D/E/F and infant A/C/B categories) When prediction was made on the basis of knowing the assigned attachment category (from amongst three) of the prospective father, the error in prediction the infant's attachment category (from amongst three) dropped to the modest 29.7%. Table 3 shows the cell frequencies among the prediction and error cells in the 3 x 3 cross classification model (29.7 PRE, p < .007, concordance 54.5%). Table 3. A 3 x 3 Table of cross-classifications of infant and paternal attachment security (N = 44)
Adult attachment security A 8 1 5 14 Infant attachment security B 1 14 6 21 C 3 4 2 9
D F E
12 19 13 44
The error in predicting infant security was reduced by 45.1% when prediction was made on the basis of knowing whether the father's attachment status was secure or insecure (dichotomised from three categories). Table 4 indicates the frequencies among the prediction and error cells in this condition (45.1 PRE, p < .00014, concordance 72.7%). Table 4. Table of dichotomised cross-classifications of infant and paternal attachment security (reduced from three categories) (N = 44)
Infant attachment security Secure Insecure 14 5 7 18 21 23
Adult attachment security
Secure Insecure
19 25 44
As in the four category model, the concordance rate between adult E and infant C category was very low at 15.4%. Its effect in reducing the predictive success in the 3 x 3 model is heightened because only two alternate predication categories remained. All the predictive models described demonstrated significant predictive success. These analyses suggest that, overall, knowledge of the nature of a prospective father's working models of attachment provides a good predictive criterion for his infant's attachment organization to him some 15-18 months later. However, the strongest prediction was achieved when both infant and paternal classifications were dichotomised to Secure versus Insecure. The disadvantage of this approach was the loss of specificity of predic-
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tion. An acceptable compromise was achieved in the 4 x 4 crossclassification model which yielded a 40.4 PRE, whilst preserving the maximum specificity. In particular, this model highlights the usefulness of the paternal Unresolved category as a predictor of infant Disorganized/Disoriented attachment to father. Nevertheless, a substantial degree of predictive error remains even considering the strongest predictive model. Discussion A significant and moderate to moderately strong positive relationship was found between a prospective father's developmental history on the one hand, and his infant's quality of attachment to him at fifteen months on the other. Thus, at the most molar level of analysis, and even before the child was born, it has been possible to distinguish between fathers who infants would develop a secure versus an insecure attachment relationship with them over the first fifteen months of their lives. Even at a category for category level of analysis, predicted relationships remained significant although less strong. These findings are consistent with other studies which have investigated the relationship between adult and infant attachment organization using the AAI. Of the three studies which have investigated the paternal AAI/ infant SS relationship, Main et al. [6] found the association to be significant but less strong than the maternal AAI/ infant SS relationship. However, Steele et al. [30] found that paternal and maternal AAI security were just as predictive of infant attachment security. Van Ijzendoorn et al. [7] on the other hand, did not find the correspondence between paternal and infant attachment to be statistically significant although that between maternal and infant attachment was significant. However these latter authors stress that the post hoc methodology of assessing adult attachment several years after measuring infant attachment may have confounded their data. Taken collectively, findings suggest that the way parents perceive and verbally recollect their earliest and more current affectional ties directly influences the quality of the parent-infant attachment relationship, presumably because these perceptions or mental representations of attachment influence parental behavior toward the child. The proportion of secure models of attachment (36% and 43% using the four way and the three way AAI classification system respectively) found amongst prospective fathers seems low for a normative sample. However, these findings fall within the range of Autonomous adult attachment classifications reported by other investigators. For example, van Ijzendoorn et al. [7], using the three way classification system assigned 48% of their paternal sample (N=29) to the Autonomous category. The first author has discussed comparative findings more fully elsewhere [34]. Furthermore, in van Ijzendoorn's [16] meta-analysis of 18 AAI-SS studies, data from the present investigation were not found to be anomalous.
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Additional qualitative data which address possible stylistic differences in AAI responses between fathers and mothers would be a useful means by which to advance understanding of mental processes associated with father-infant relationships. Van Ijzendoorn's [16] meta-analysis did not find that fathers were significantly more over-represented than were mothers in the D category. Anecdotally, interviewers did not report any differences between prospective fathers and their pregnant partners in the approach to the AAI. Resource constraints have prevented maternal AAI's being coded to date. The present investigation is important for several reasons. First a prospective, longitudinal design using the four-way adult and infant attachment classification systems successfully predicted continuity in the nature and quality of father-child relations across generations. It therefore offers powerful support for the attachment paradigm, for the validity of the AAI and for the importance of the father in the social-emotional development of his child. The evidence is compelling that fathers independently influence the attachment relationship with their children [39] found there to be no relationship between relative parental involvement and the security of infant attachment. The findings of this study support those of Frodi et al. [39]. They suggest that even in primary maternal caretaking households, the father's history and mental representation of attachment experiences is equivalently influential in determining the quality of the infant father attachment relationship as is mother's history for infant-mother attachment. We may therefore assume that the adult attachment related mental processes and their transmission are the same. This, of course, leaves open the question raised by Main et al. [6] of the existence in infancy of a hierarchical ordering in the organization of working models of attachment with favors the primary caretaker. The present findings cannot answer this question. They do, however, point to the salience for the child's socio-emotional development, of the father's attachment related mental state, particularly given the secondary caretaker status of the fathers in this study. Relatedly, the positive predictive findings described here suggest that the AAI does reliably mobilize and reflect paternal attachment relevant mental states, and differences amongst them, hence supporting the validity of the AAI in a paternal sample. A second important aspect of this study is that it is one of only a small number which has incorporated the adult Insecure/Unresolved category in a normal sample prediction study [40,25]. Of additional significance is that it is the first such prospective study with fathers. It therefore permits assessment of the contribution to prediction of a more highly specified crossclassification structure. In this regard, and with reference to infant-father attachment outcomes, it is noteworthy that only 36% of the strange situation relationships were classified as Secure (see Table 1). Logically, the addition of another category will reduce numbers in the other categories. Main [41] has suggested that the introduction of the infant Disorganized category has generally had the effect of reducing the number of infants classified as hav-
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ing Secure attachment relationships. For example, Main and Solomon [29] report that in the Main and Weston [5] investigation (which included assessment of infant-father attachment) 13 out of 19 infants judged difficult to classify in the latter investigation of 152 strange situation procedures ...would have been identified as Secure. with the parent had standard classification procedures been utilized [25]. In this study, removing the Insecure/Disorganized category from analysis resulted in 48% of infants being assessed as having Secure attachment relationships with their fathers. This finding is consistent with the Main et al. [5] data and with Main's [29] assertion. Although these proportions of secure-infant father attachment relationships may appear small they are not inconsistent with the van Ijzendoorn and Kroonenberg [31] meta-analysis of cross-cultural patterns of attachment. Additionally, the secure pattern of infant-father attachment emerged as modal in both the 3x3 and in the 4x4 cross-classification models (see Tables 2 and 4). Relatedly, 27% (N=12) of infants were classified as exhibiting Insecure/Disorganized attachment behavior towards their fathers. This proportion is consistent with Ainsworth et al. [40] who found a similarly high proportion of D infants (33%) in their unselected sample of mother-infant dyads. Interestingly, in the present study, the only Insecure/Disorganized infants with an alternate Secure classification were those infants sub-classified as B4 (N=5); a group whose status within the Secure classification has been questioned [42,43]. Paternal Unresolved status (resulting from loss through death in every case but one) was found to be a moderate predictor of infant Insecure/Disorganized status (61.5% concordance)1. This finding is comparable with that of Main & Hesse [25] who reported 60% agreement in their selected sample of 53 mother-infant dyads. Ainsworth & Eichberg [40], on the other hand reported 100% agreement in their study of 45 unselected motherinfant dyads. However, perhaps the most important point is that in the three studies (including this one), parents who either had not experienced loss of a significant figure or, if they had, appeared to have resolved that loss, did not tend to have infants judged Disorganized with them in the Strange Situation. It appears then that parental lack of resolution of mourning may be a greater risk-factor for unfavorable developmental sequelae in children than loss per se. Main et al. [6] and Cassidy [38] have reported that six year old children who, as infants were judged Insecure/Disorganized with a parent demonstrated controlling or punitive behavior towards that parent. Additionally, they engaged in developmentally inappropriate role-inverting parent-child
Of the 62 fathers, 51 (83%) had, during their childhood, adolescence or young adulthood, experienced the loss through death of a parent or other emotionally significant person. Although other, more symbolic losses (such as those occurring in relation to divorce) are considered important aspects of the individual's attachment history, they are not considered in determining Unresolved status.
1
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interactions. Recent theorizing about the nature of the developing mental state of children classified as Disorganized/Disoriented in infancy speculates that these children may, as adults, be more vulnerable to the development of dissociative mental disorders [44].2 If the nature of the father's relationship with his child has the potential to act as a protective or as a vulnerability factor in the childs development, as is suggested by attachment theory and research [17,5,18] then the child with a Disorganized attachment relationship to an Unresolved father may be particularly vulnerable. In this study, while fathers or infants who would develop a secure, an Insecure/Avoidant or an Insecure/Disorganized attachment were distinguishable before the child was born, this was not the case for the father whose child would develop an Insecure/Resistant attachment. Fonagy et al's [15] prospective study of low-risk, middle class maternal-infant dyads using the 3 x 3 cross-classification model also found that the maternal Insecure/Preoccupied status was a poor predictor of infant Insecure/Resistant attachment. On the other hand, in a high risk sample, Ward, Botyanski, Plunket & Carlson [46] found good predicability in the adult Insecure/Preoccupied category, as did Main (personal communication) in her low risk sample. Main & Solomon [33] have noted that the infant Insecure/Resistant pattern may be less well organized than the other attachment patterns. This may conceivably also be the case for the adult Insecure/Preoccupied mental state. Note that in the 4 x 4 cross-classification model, paternal preoccupied status was a good predictor of overall infant Insecure status (85.7% concordance - A, D, C). Clearly, further studies are required to clarify the predictive status of this category. This study has demonstrated the good predicability of the four-way crossclassification model (40.4 PRE) compared to the more modest predicability of the three-way cross-classification system (29.7 PRE). The power of the former model rested on the sound predictive performance of the Secure, the Insecure/Dismissing and the Insecure/Unresolved categories on the one hand and the poor predictive performance of the Insecure/Preoccupied categories on the other. To date, few studies have employed the Unresolved category. However, the present findings highlight its importance for future investigations of the relation between AAI and SS classifications, particularly in light of increasing and compelling arguments and findings which appear to implicate the adult Unresolved and infant Disorganized/Disoriented attachment states with relational maladaptation. Third, this investigation is important because it has been conducted in Australia where Adult Attachment Interview research has not been reported to date. The success in prediction in an Australian paternal sample suggests that the AAI is a culturally valid instrument for Australian use, at
This speculation is receiving some empirical support in recent [45] and current investigations examining the relationship between Unresolved status and the psychopathology of dissociative disorders [33,44].
2
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least with middle class male populations. It argues for the universality of the states of mind with respect to attachment which the AAI claims to tap. Due to the dearth of paternal AAI studies and due to necessary design constraints, the findings of this study require cautious interpretation. In the case of non-concordant father-infant relationships, repeated measures analysis of self report data suggested a trend for Secure fathers with Insecurely attached infants to have experienced greater intra and interpersonal strain over the transition to parenthood compared with Insecure fathers whose infants were Securely attached to them at 15 months. Future studies with larger, more culturally and socio-economically diverse populations could examine better the potentiating roles of both psychological stress and psychological resilience. Additionally, the degree to which prediction failure may have resulted from procedural or coding errors on the one hand or from altered paternal representations of attachment across the transition to parenthood is not known. The latter contingency could be addressed by further prospective studies employing a pretest-retest design. These limitations notwithstanding, this investigation has provided important prospective data which supports the attachment paradigm in demonstrating that lawful relations do exist between the way fathers construct their own developmental history on the one hand and how they go about nurturing their child on the other. Additionally, the AAI was shown to be able to discriminate prenatally, those fathers who children would subsequently become Securely or Insecurely attached to them. In particular, the use in this study of the adult Unresolved/infant Disorganized categories has provided the first evidence of a prospective empirical link between the two in a lowrisk paternal sample. Finally, in focusing on the father-infant dyad valuable new insights have been provided into how the father's perception of this own developmental history shapes the nature of this important relationship. Acknowledgments The authors wish to thank Mary Main for her thoughtful comments on an earlier version of this paper, Diane Benoit and John Lord for reliability checks on the AAI and infant SSP respectively, and Alan Taylor for his statistical support. References
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Hidlebrand DK, Laing J, Rosenthal H. Prediction analysis of crossclassifications. New York: Wiley; 1977. Cassidy J. Child-mother attachment and the self in six year olds. Child Dev 1988, 59: 121-134. Frodi AM, Lamb ME, Frodi CP. Father-mother infant interaction in traditional and nontraditional Swedish families: a longitudinal study. Alternative Lifestyles 1983; 5: 142-163. Ainsworth MDS, Eichberg CG. Effects on infant-mother attachment of mother's unresolved loss of an attachment figure or other traumatic experience. In: Marris P, Stevenson-Hinde J, Parkes C, (eds). Attachment across the lifecycle. New York: Routledge; 1991. p. 160-183. Main M. Personal communication. University of Minnesota: Minneapolis; 1990. Sagi A, Lamb ME, Lewkovicz KS, Shoham R, Dvir R, & Estes D. Security of infant-mother, - father, and - metapelet attachments in Kibbutzreared Israeli children. In: I. Bretherton, E. Waters (Eds.). Growing points in attachment theory and research. Monographs of the Society for Research in Child Development. 1985; 50, (serial No. 209): 257-275. Van Ijzendoorn, MH, Goossens, FA, Kroonenburg, PM, Tavecchio CWC Dependent attachment: B-4 children in the strange situation. Psychol Rep, 1985; 57:439-451. Liotti G. Disorganized attachment and dissociative experiences: an illustration of the developmental-ethological approach to cognitive therapy. In: H. Rosen, KT Kuehlwein (Eds.). Cognitive therapy in action. San Francisco: Jossey-Bass. In press. 2006. Ross CA. Multiple personality disorder: diagnosis, clinical features and treatment. New York: John Wiley & Sons; 1989. Ward MJ, Botyanski NC, Plunket SW, Carlson A. Concurrent validity of the AAI for adolescent mothers. Paper presented at the 1991 Biennial Meeting of the Society for Research in Child Development, April 18-20, Seattle (Washington).
___________________ Marija RADOJEVI, kliniki psiholog, Sluba za zatitu mladih i porodice, bolnica Hornzbi i Ku-ring-gaj, Sidnej Grem Rasel, Fakultet bihejvioralnih nauka, Univerzitet Makvari, Australija Marija RADOJEVIC, PhD, Senior Clinical Psychologist, Adolescent and Family Service, Hornsby and Ku-ring-gai Hospital, Sydney and Graeme Russell PhD, Associate Professor of Psychology, School of Behavioral Sciences, Macquarie University, Australia E-mail: mradoj@bigpond.com
Psihijat. dan. /2005/37/2/289-295/ Jankovi Gavrilovi J. Povezanost posttraumatskog stresa i kvaliteta ivota....
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POVEZANOST POSTTRAUMATSKOG STRESA I KVALITETA IVOTA KOD GRAANA POSLE VAZDUNIH NAPADA
Jelena Jankovi Gavrilovi1,2, Duica Lei Toevski2, Olga olovi2, Sara Dimi2, Veselinka ui3, Milica Pejovi Milovanevi2, Smiljka Popovi Deui2, Stefan Priebe1
1
Odeljenje za socijalnu i komunalnu psihijatriju Barts i Medicinski fakultet Queen Mary u Londonu, London, Velika Britanija 2 Institut za mentalno zdravlje, Beograd, Srbija i Crna Gora 3 Srpska Akademija nauka i umetnosti, Srbija i Crna Gora
Apstrakt: Iako su kvalitet ivota i posttraumatski stres detaljno prouavani, njihov meusobni odnos je retko ispitivan. Ovo istraivanje prouava odnos izmeu posttraumatskog stresa i kvaliteta ivota u relativno homogenoj i neselektivnoj grupi graana koji su bili izloeni vazdunim napadima. Kvalitet ivota (MANSA), posttraumatski stres (IES) i depresija/anskioznost (SCL-90-R) ispitivani su kod dve grupe studenata medicine (N1=139, N2=475) posle jedne, odnosno, dve godine vazdunih napada u Srbiji i Crnoj Gori. Rezultati pokazuju slabu do srednje izraenu vezu izmeu posttraumatskog stresa i subjektivnog doivljaja kvaliteta ivota. Nakon ispitivanja stepena depresivnosti i anksioznosti, jedino je veza izmeu posttraumatskog stresa i zadovoljstva mentalnim zdravljem statistiki znaajna u obema grupama. ini se da anksioznost i depresija imaju uticaja u velikoj meri, ali ne potpuno, na vezu izmeu posttraumatskog stresa i linog doivljaja kvaliteta ivota. Kljune rei: posttraumatski stres, kvalitet ivota, vazduni napadi, graani
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Uvod Koncept kvaliteta ivota je sve popularniji u psihijatrijskim istraivanjima u poslednje dve decenije [1] i postoji dosta literature koja se odnosi na kvalitet ivota razliitih grupa psihijatrijskih pacijenata [2]. Iako ne postoji definicija kvaliteta ivota koja je univerzalno prihvaena [3], veina strunjaka se slae da postoje subjektivni i objektivni pokazatelji kvaliteta ivota i da su subjektivni oni koji su kljuni. Koncept subjektivnog kvaliteta ivota dalje u tekstu SK (subjective quality of life SQOL) fokusira se na individualnu percepciju i procenu kvaliteta njegovog ili njenog kvaliteta ivota [4,5]. U proceni kvaliteta ivota koristi se veliki broj skala od onih koje se odnose na zdravlje, preko onih koje su specifine za bolest, do optih. U psihijatrijskim istraivanjima, u skladu sa optim konceptom, kao indikatori SK ustanovljeni su procena zadovoljstva ivotom u celini i procena zadovoljstva specifinim aspektima ivota [6]. U optoj populaciji, kao i u uzorku pacijenata, simptomi raspoloenja oznaeni su kao najznaajniji i stalni inioci koji utiu na SK. Razliita istraivanja pokazuju nie rezultate SK kod ispitanika sa viim stepenom depresivnih simptoma [7,8,9]. Zbog toga treba kontrolisati uticaj simptoma raspoloenja prilikom procene SK. Pa ipak, opta varijansa izmeu simptoma raspoloenja i SK retko prelazi 25% i SK se ne moe smatrati prateom pojavom depresivnih simptoma [5]. Iako postoji obimna literatura o posttraumatskom stresu i kvalitetu ivota, mali broj istraivanja prouava vezu izmeu ova dva pojma [4,10]. Ovo je u suprotnosti sa definicijom posttraumatskog stresnog poremeaja u DSM IV koja navodi uticaj drutvenog funkcionisanja kao kriterijum dijagnoze. Koncept drutvenog funkcionisanja razliit je od kvaliteta ivota, ali se preklapa sa njim i u vezi je sa njim. Osim toga, pokazalo se da kod generalizovanog anksioznog poremeaja i nakon utvrivanja postojanja psihopatolokih fenomena, postoji visok stepen oteenja. Rezultati Nacionalne vijetnamske studije o ponovnom prilagoavanju veterana mukog i enskog pola, pokazuje da su ispitanici sa PTSP imali znaajno povien rizik od smanjenog funkcionisanja u razliitim aspektima ivota [12,13]. Najvei broj retkih istraivanja koja se bave kvalitetom ivota i mentalnim zdravljem posle stresnog dogaaja posmatrala su ili psihijatrijske pacijente ili veterane. Zdravi ljudi retko su bili sistematski ispitivani. U ovom istraivanju posttraumatski stres ispitivan je u dve relativno homogene i neselektivne grupe studenata medicine, nakon jedne i nakon dve godine od vazdunih napada na Beograd. Napadi su trajali od 24. marta do 9. juna 1999. godine, izvodili su se skoro svake noi i uzrokovali su civilne rtve irom Srbije i Crne Gore. Procenjuje se je da je broj civilnih rtava iznosio oko 1,200 [14]. Ovo istraivanje postavlja sledea pitanja: 1. Kakva je povezanost posttraumatskog stresa i kvaliteta ivota? 2. Da li u ovoj povezanosti posreduju simptomi anksioznosti i depresivnosti?
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Metod Uzorak Grupa A sastoji se od 139 od ukupno 141 studenta etvrte godine Medicinskog fakulteta koji prate nastavu u jednoj psihijatrijskoj ustanovi u Beogradu (95 ena, 44 mukaraca), starosti izmeu 21 i 28 godina (srednja vrednost 23.8 god.; SD=1.3). U vreme izvoenja istraivanja, u prolee 2000. godine, oko godinu dana nakon vazdunih napada, etvoro studenata ivelo je sa partnerom i niko od njih nije imao decu. Nivo posttraumatskog stresa, naini za prevazilaenje stresa i line osobine ove grupe prikazane su na drugom mestu [14,15,16]. Grupa B sastoji se od 475 od oko 600 studenata druge godine medicine koji sluaju nastavu na Institutu za fiziologiju Medicinskog fakulteta u Beogradu (334 ene i 141 mukarac), starosti izmeu 20 i 29 godina (srednja vrednost 21.1 god.; SD=0.7). U vreme izvoenja istraivanja, u prolee 2001. godine, oko dve godine nakon vazdunih napada, est studenata ivelo je sa partnerom, i etvoro od njih imalo je decu. Svi ispitanici bili su izloeni vazdunim napadima, tokom prolea 1999, kao civili. Poto je nezavisni istraiva predstavio ciljeve istraivanja studentima, dobijen je pristanak za istraivanje. Instrumenti Kvalitet ivota ocenjivan je pomou Kratke Manesterske skale za procenu kvaliteta ivota (Manchester Short Assessment of Quality of Life MANSA) [18]. MANSA je kratka skala za procenu opteg nivoa kvaliteta ivota koja se koristi u mnogim ispitivanjima mentalnog zdravlja. Ova skala ima slinosti sa Intervjuom o kvalitetu ivota [19,20] i Lankairskim profilom kvaliteta ivota (Lancashire Quality of Life Profile LQLP), ali je i mnogo preciznija od njih [21]. Sve ove skale imaju isti koncept i veoma slina pitanja koja se tiu zadovoljstva, ukljuujui i skalu od 1 do 7, na kojoj 1 oznaava nepovoljni pol, a 7 povoljni pol. Nezavisno od prikupljanja podataka o linim detaljima i objektivnim okolnostima ivota, MANSA sadri esnaest pitanja od kojih se etiri smatraju objektivnim, a ostalih dvanaest su procena zadovoljstva ivotom u celini i u specifinim podrujima ivota. Korelacije izmeu SK zbira na upitnicima MANSA i LQLP bile su 0.83 ili vie; Kronbah alfa koeficijent za ocenu zadovoljstva bio je 0.74, a udruenost sa psihopatologijom je bila u skladu sa rezultatima dobijenim na LQLP, kao to se i navodi u literaturi [18]. Primenjena je Skala uticaja dogaaja (The Impact of Event Scale IES) [21], upitnik od petnaest stavki, koji meri simptome posttraumatskog stresa, nametanje i izbegavanje. Anksiozni i depresivni simptomi procenjivani su Preglednom listom simptoma (Symptom Checklist 90-R SCL-90-R9) instrumentom od devedeset stavki za samoprocenu opte psihopatologije na deset subskala [22].
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Statistika analiza T-test i Pirsonov koeficijent korelacije korieni su da bi se ispitala veza izmeu SK i posttraumatskog stresa. U sledeem koraku, bivarijantne korelacije koje su dostigle statistiku znaajnost proveravane su u odnosu na anksioznost i simptome depresivnosti tako to su izraunavani parcijalni koeficijenti korelacije, eliminiui uticaj anksioznosti i depresivnosti na rezultate IES i SQOL. Kako bi se smanjila greka I tipa a priori izraunavali smo parcijalne koeficijente samo kada je bivarijantna korelacija bila znaajna. Rezultati Kvalitet ivota i zbir simptoma Srednje vrednosti zbira zadovoljstva ivotnim oblastima (MANSA), IES i depresivnost (SCL-90R) prikazani su na Tabeli 1. Tabela 1. Srednje vrednosti i standardne devijacije za zadovoljstvo ivotnim oblastima (MANSA), IES, depresija i anksioznost (SCL-90R)
Grupa A (N=139) 4.2 (0.9) 4.6 (1.1) 3.8 (1.3) 5.2 (1.0) 4.1 (1.3) 5.1 (1.0) 4.8 (1.2) 5.4 (1.0) 4.6 (1.4) 5.5 (1.1) 5.3 (1.1) 5.8 (0.9) 4.9 (0.6) 13.6 (14.2) 0.7 (0.7) 0.6 (0.6) Grupa B (N=475) 4.1 (1.1) 4.3 (1.1) 3.9 (1.4) 5.0 (1.3) 3.5 (1.4) 5.0 (1.3) 5.0 (1.2) 5.4 (1.2) 4.3 (1.6) 5.5 (1.2) 5.1 (1.2) 5.6 (1.2) 4.7 (0.7) 20 (17) 1.2 (0.8) 1.1 (0.8)
ivot u celini Obrazovanje/edukacija Finansije Prijateljstva Slobodne aktivnosti Stanovanje Sigurnost Ljudi s kojima ivi Seksualni ivot Odnosi sa porodicom Zdravlje Mentalno zdravlje Srednji zbir IES SCL-90R depresija SCL-90R anksioznost
Odgovori na pitanja o objektivnim pokazateljima kvaliteta ivota ocenjivani su upitnikom MANSA i prikazani u Tabeli 2. Tabela 2. Odgovori na pitanja koja se odnose na objektivni kvalitet ivota studenata (u procentima)
Da 94.9 93.4 0 1.4 Grupa A Ne 5.1 6.6 100 98.6 Da 89.4 87.5 0.6 2.1 Grupa B Ne 10.6 12.5 99.4 97.9
Da li imate bliskog prijatelja? Da li ste posetili prijatelja tokom prole nedelje? Da li ste bili optueni za zloin prole godine? Da li ste bili svedok fizikog nasilja prole godine?
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Univarijantna prognoza U obe grupe IES visoko znaajno korelira sa anksioznou i depresivnou. Koeficijent korelacije izmeu IES i anksioznosti je r=0.62 (p<.001) u grupi A, i 0.47 (p<.001) u grupi B. Koeficijenti korelacije izmeu IES i depresije su 0.56 (p<.001) u grupi A, i 0.46 (p<.001) u grupi B. Tabela 3. pokazuje bivarijantne korelacije izmeu IES zbira i zadovoljstva posebnim ivotnim domenima. Svi znaajni koeficijenti korelacije su negativni, pokazujui da je vii nivo simptoma povezan sa niim SK. Tabela 3. takoe sumira parcijalne korelacije, npr. korelaciju izmeu IES i SK zbira, s tim to je eliminisan zajedniki uticaj anksioznosti i depresivnosti na obe varijable.
Tabela 3. Koeficijenti korelacije i stepeni znaajnosti bivarijantne korelacije i parcijalne korelacije ispitivani u odnosu na depresiju i anksioznosti iz SCL90R izmeu IES i zadovoljstva ivotnim domenima MANSA (parcijalna korelacija je izraunavana samo za korelacije koje su dostizale znaajni nivo u bivarijantnim korelacijama)
Grupa A (N=139) Bivarijantna Parcijalna korelacija korelacija IES IES -.16 ns -.11 ns -.10 ns -.16 ns -.10 ns -.02 ns -.14 ns -.16 ns .04 ns -.25** -.17* -.29*** -.15 ns -.42*** -.23** -.26** -.07 ns Grupa B (N=475) Bivarijantna Parcijalna korelacija korelacija IES IES -.22 *** -.05* -.15*** -.03 ns -.05 ns -.13** -.03 ns -.13** .03 ns -.09* -.04 ns -.23*** -.16*** -.15*** -.10* -.14** -.02 ns -.14** -.07 ns -.17*** -.03 ns -.33*** -.14** -.30*** -.09*
ivot u celini Obrazovanje/edukacija Finansije Prijateljstva Slobodna aktivnosti Stanovanje Sigurnost Ljudi sa kojima ivi Seksualni ivot Odnos sa porodicom Zdravlje Mentalno zdravlje Srednji zbir
Ns * ** *** Bez znaaja p<0.05 p<0.01 p<0.001
Kada je ispitivan uticaj anksioznosti i depresivnosti, najvei broj korelacija nije uspeo da dostigne statistiku znaajnost. Jedina korelacija IES koja ostaje znaajna je ona izmeu zadovoljstva odnosima u porodici i mentalnim zdravljem u grupi A, i zadovoljstva ljudima sa kojim ivi, sigurnou, mentalnim zdravljem i srednjom vrednosti zbira u grupi B. Prema tome, zadovoljstvo mentalnim zdravljem jedino je SK podruje ivota koje ostaje znaajno u obe grupe studenata kada je uticaj anksioznosti i depresivnosti kontrolisan.
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to se tie pokazatelja objektivnog kvaliteta ivota prikazanih u Tabeli 2, test za vezu sa IES pokazuje samo jedan statistiki znaajan rezultat: u grupi B, studenti koji su bili rtve fizikog nasilja, imali su vii IES zbir (t=2.44, df=471, p<.05). Diskusija Veza izmeu posttraumatskog stresa i kvaliteta ivota ispitivana je u dve grupe studenata. Uzorci su bili relativno veliki, neselektivni i homogeni, uz uvaavanje razliitih inilaca kao to su uzrast, obrazovanje, i zaposlenost. Stoga nije bilo potrebe da se kontrolie uticaj tih inilaca. Metodoloka snaga istraivanja je u tome to su svi ispitanici bili izloeni istim stresogenim dogaajima, i vremenski interval izmeu dogaaja i ispitivanja u okviru svake grupe bio je isti. Nivo pottraumatskog stresa varira u okviru obe grupe i srednji SK je bio slian onome naenom kod drugih neklinikih uzoraka [24]. Odslikavajui njihovu homogenost u odnosu na ivotne okolnosti, uzroci pokazuju vrlo ogranieno neslaganje u odnosu na objektivne pokazatelje kvaliteta ivota. Varijable sa tako malim nivoom neslaganja najverovatnije nisu u znaajnoj korelaciji sa drugim parametrima. Jedina statistiki znaajna veza koju smo identifikovali je vii IES zbir kod ispitanika koji su bili rtve nasilja u poslednjih godinu dana. Iskustvo doivljenog nasilja moe samostalno da uzrokuje posttraumatski stres, ili u kombinaciji sa delovanjem stresogenog dogaaja tokom vazdunih napada. Neka istraivanja ukazuju da izlaganje veem broju traumatskih iskustava poveava mogunost odgovora u skladu sa simptomima posttraumatskog stresa [25]. U obe grupe postojala je korelacija slabe do srednje jaine izmeu IES zbira i SK ocene. Zbog veeg uzorka u grupi B, vei broj koeficijenata korelacije dostigao je statistiku znaajnost. Srednja vrednost zbira ocene zadovoljstva moe se posmatrati kao najpouzdanija vrednost SK skora [12]. Postojala je sugestija da se, osim u sluaju kada postoji specifina hipoteza u odnosu na pojedinano podruje ivota, prvo testira srednja vrednost zbira. Samo kada postoji znaajan rezultat u pogledu srednje vrednosti zbira treba analizirati i interpretirati rezultate za pojedina podruja ivota. U obe grupe srednja vrednost zbira zaista znaajno korelira sa IES i koeficijenti su sline veliine. Veze su postojane, iako se srednje vrednosti nivoa posttraumatskog stresa razlikuju izmeu dve grupe zbog razloga koje nismo u stanju da istraimo na osnovu podataka sakupljenih prilikom istraivanja. Razliit vremenski period izmeu stresogenog dogaaja i ispitivanja, tj. jedna godina nasuprot dve godine, izgleda da nema kljuni uticaj na povezanost posttraumatskog stresa i SK. Meutim, izgleda da je ova jasna povezanost uglavnom, ali ne potpuno pod uticajem simptoma anksioznosti i depresivnosti. Posttraumatski stres moe biti povezan sa simptomima raspoloenja i anksioznosti za koje se zna da imaju uticaj na ocenu SK. Povezanost posttraumatskog stresa sa zadovoljstvom ispitanika sopstvenim mental-
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nim zdravljem najjaa je u bivarijantnim testovima, i jedina je koja ostaje statistiki znaajna u obe grupe nakon ispitivanja simptoma raspoloenja i anksioznosti. Ova povezanost, takoe, moe biti kvalitativno razliita, tako da je pratei simptomi raspoloenja i anksioznosti ne mogu potpuno objasniti. Nedostatak ovog istraivanja je u pristupu poprenog preseka, koji ne dozvoljava da se izvedu zakljuci na osnovu uzrone veze. Vii nivoi posttraumatskog stresa, uglavnom posredovani depresivnou i anksioznou, utiu na SK i, obrnuto, nii SK moe imati negativan uticaj na simptome. Budue prospektivno longitudinalno istraivanje trebalo bi da se bavi uzronou. Zakljuak Rezultati ukazuju da je posttraumatski stres povezan sa SK u relativno homogenim i neselektivnim grupama graana koji su doiveli stresogen i potencijalno traumatian dogaaj. Rezultati se slau u dva nezavisna, ali slina uzorka. S druge strane, trebalo bi ih ponoviti u drugim grupama ili kontekstima. U buduim istraivanjima bilo bi korisno ispitati pokazatelje kvaliteta ivota u uzorcima u kojima ispitanici imaju posttraumatski stres. Takvo ispitivanje moe pokazati da SK utie na posttraumatski stres, ili je njegova relevantna posledica, ili i jedno i drugo, i identifikovati ulogu simptoma raspoloenja u ovoj povezanosti. U svakom sluaju, simptomi anksioznosti i depresivnosti moraju se smatrati iniocima posredovanja. Priroda ove povezanosti jo uvek nije jasna, i dalje sistematino ispitivanje, primenom kvantitativnih i kvalitativnih metoda, neophodno je za razumevanje procesa koji su u korenu ovih povezanosti. Istraivanja intervencija trebalo bi da ispitaju da li terapijske intervencije primarno za cilj treba da imaju poboljanje posttraumatskog stresa ili simptoma raspoloenja da bi uticali na SK, ili bi poboljani SK naknadno vodio do smanjenja nivoa anksioznosti, depresivnosti i posttraumatskog stresa.
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Research article
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ASSOCIATION OF POSTTRAUMATIC STRESS AND QUALITY OF LIFE IN CIVILIANS AFTER AIR ATTACKS
Jelena Jankovic Gavrilovic1,2, Dusica Lecic Tosevski2, Olga Colovic2, Sara Dimic2, Veselinka Susic3, Milica Pejovic Milovancevic2, Smiljka Popovic Deusic2, Stefan Priebe1
1
Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Queen Mary, University of London, United Kingdom 2 The Institute of Mental Health, University of Belgrade, Belgrade, Serbia and Montenegro 3 Serbian Academy of Science and Art, Serbia and Montenegro
Abstract: Although quality of life and posttraumatic stress have been extensively studied, their relationship has rarely been investigated. This study explored the relationship between posttraumatic stress and quality of life in relatively homogeneous and nonselective groups of civilians who had been exposed to air attacks. Quality of life (MANSA), posttraumatic stress (IES), and depression and anxiety (SCL90-R) were assessed in two groups of medical students (N1=139, N2=475), one and two years respectively after air attacks in Yugoslavia. Results show weak to moderate associations between posttraumatic stress and subjective quality of life scores. After controlling for depression and anxiety, only the association between posttraumatic stress and satisfaction with mental health remains statistically significant in both groups. Anxiety and depression appear to mediate largely, but not fully - the association between posttraumatic stress and subjective quality of life. Key words: posttraumatic stress, quality of life, air attacks, civilians
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Introduction The concept of quality of life has become increasingly popular in psychiatric research over the last two decades [1], and there is a wide range of literature on quality of life findings in different groups of psychiatric patients [2]. Although no single definition of quality of life has been universally accepted [3], most experts agree that there are subjective and objective indicators of quality of life and that the subjective ones are central. The concept of subjective quality of life (SQOL) centres on the individuals perception and appraisal of the quality of his or her own life [4,5]. Numerous scales have been used to assess quality of life and the constructs range from health related and disease specific ones, to more generic ones. In psychiatric research, ratings of satisfaction with life as a whole and with different life domains have been established as indicators of SQOL in line with a generic concept [6]. In the general population, as well as in patient samples, mood symptoms have been identified as the most significant and consistent factor influencing SQOL. Various studies indicate lower SQOL scores in subjects with higher degrees of depressive symptoms [7,8,9]. Thus, the influence of mood symptoms should be controlled for in studies on SQOL. Yet, the common variance between mood symptoms and SQOL rarely exceeds 25%, and SQOL cannot be just regarded as an epiphenomenon of depressive symptoms [6]. Even though the literature on both posttraumatic stress and quality of life is vast, there has been relatively little research on the association of the two [4,10]. This is despite the definition of Posttraumatic Stress Disorder in DSM IV that mentions impact on social functioning as a criterion for the diagnosis. Social functioning is a concept different from, but related to and overlapping with quality of life. In addition, it has been shown that general anxiety disorder is associated with high impairment even after controlling for other psychopathology [11]. Research from the National Vietnam Readjustment Study, both of male and female veterans, showed that subjects with PTSD had significantly higher risk of diminished functioning in several aspects of life [12,13]. Most of the few studies on quality of life and mental health after a stressful event were conducted either in psychiatric patients or veterans. Non-patient civilian groups have rarely been systematically studied. In this study, posttraumatic stress was assessed in two relatively homogeneous and non-selective groups of medical students, one year and two years after experiencing air attacks in Belgrade. The attacks lasted from March 24 to June 9, 1999, occurred almost every night during that period of time and resulted in casualties among civilians throughout Serbia and Montenegro. The number of civilian deaths has been estimated at around 500 [14].
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The study addressed the following questions: 1. What is the association between posttraumatic stress and quality of life? 2. Is the association mediated through anxiety and depressive symptoms? Method Sample Group A consists of 139 out of 141 fourth year medical students in one psychiatric teaching hospital in Belgrade (95 women, 44 men). The age ranged from 21 to 28 years (mean=23.8; SD 1.3). At the time of the study in spring 2000 approx. 1 year after the air attacks, four students lived with a partner and none had children [15]. The level of posttraumatic stress, coping strategies and personality characteristics of this group are presented elsewhere [15,16,17]. Group B consists of 475 out of approximately 600 second year medical students taking a course at the Institute of Physiology in Belgrade (334 women, 141 men). Their age ranged from 20 to 29 years (mean=21.1; SD 0.7). At the time of the study in spring 2001 approx. 2 years after the air attacks, six students lived with a partner and four had children. All of the subjects were medical students at the University of Belgrades School of Medicine, and all had been exposed to air attacks as civilians in spring 1999. After a complete description of the study by an independent researcher to the students, informed consent was obtained. Instruments Quality of life was assessed on the Manchester Short Assessment of Quality of Life [18]. The MANSA is a brief instrument for obtaining a generic construct of quality of life widely used in mental health service research. It is similar to, but much more concise than the Quality of Life Interview [19,20], and the Lancashire Quality of Life Profile (LQLP) [21]. All of these tools share the same concept and have very similar satisfaction questions including 1 to 7 rating scales with 1 being the unfavourable and 7 the favourable end of the scale. Apart from collecting personal details and objective circumstances of life, the MANSA contains 16 questions of which four are considered objective and 12 are ratings of satisfaction with life as a whole and different life domains. Correlations between SQOL scores on MANSA and LQLP were all 0.83 or higher; Cronbachs alpha for satisfaction ratings was 0.74, and association with psychopathology is in line with results for LQLP as reported in the literature [18].
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The Impact of Event Scale [22], a 15-items questionnaire that measures intrusion and avoidance symptoms of posttraumatic stress was administered. Anxiety and depressive symptoms were self-rated on the Symptom Checklist 90-R [23] a 90 items instrument for self-rating of general psychological symptoms on 10 sub-scales. Statistical Analysis T-tests and Pearsons correlation coefficients were used to explore the association between SQOL and posttraumatic stress. In a next step, bivariate correlations that reached statistical significance were controlled for anxiety and depressive symptoms by calculating partial correlation coefficients, with the influence of anxiety and depression on both IES and SQOL scores eliminated. In order to reduce Type I error a priori we calculated partial correlations only when the bivariate correlation was significant. Results Quality of life and symptom scores Mean scores for satisfaction with life domains (MANSA), IES and depression (SCL-90R) are summarised in Table 1. Table 1. Mean scores and Standard Deviations (SD) for satisfaction with life domains (MANSA), IES, depression and anxiety (SCL-90R)
Life as a whole Training/education Finances Friendships Leisure activities Accommodation Safety People living with Sex life Relationship with family Health Mental health Mean score IES SCL-90R depression SCL-90R anxiety Group A (N=139) 4.2 (0.9) 4.6 (1.1) 3.8 (1.3) 5.2 (1.0) 4.1 (1.3) 5.1 (1.0) 4.8 (1.2) 5.4 (1.0) 4.6 (1.4) 5.5 (1.1) 5.3 (1.1) 5.8 (0.9) 4.9 (0.6) 13.6 (14.2) 0.7 (0.7) 0.6 (0.6) Group B (N=475) 4.1 (1.1) 4.3 (1.1) 3.9 (1.4) 5.0 (1.3) 3.5 (1.4) 5.0 (1.3) 5.0 (1.2) 5.4 (1.2) 4.3 (1.6) 5.5 (1.2) 5.1 (1.2) 5.6 (1.2) 4.7 (0.7) 20 (17.4) 1.2 (0.8) 1.1 (0.8)
Answers to the questions on objective quality of life indicators as assessed in the MANSA are shown in Table 2.
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Table 2. Answers to the questions that addressed objective quality of life-percent of students
Yes 94.9 93.4 0 1.4 Group A No 5.1 6.6 100 98.6 Yes 9.4 7.5 0.6 2.1 Group B No 0.6 2.5 99.4 97.9
Do you have a close friend Have you visited a friend last week Have you been accused of a crime last year Have you been victim of physical violence last year
Univariate Prediction In both groups, IES is highly significantly correlated with both anxiety and depression. The correlation coefficient between IES and anxiety is r=0.62 (p<.001) in group A, and 0.47 (p<.001) in group B. The coefficients for the correlation between IES and depression are 0.56 (p<.001) in group A and 0.46 (p<.001) in group B. Table 3 shows bivariate correlations between IES score and satisfaction with life domains. All significant correlation coefficients are negative, indicating that a higher level of symptoms is associated with a lower SQOL. Table 3 also summarises partial correlations, i.e. the correlations between IES and SQOL scores with the common influence of anxiety and depression on both variables eliminated.
Table 3. Correlation coefficients and significance level for bivariate correlations and partial correlations-controlled for depression and anxiety from SCL-90R between IES and satisfaction with life domains MANSA (partial correlations were calculated only for the correlations that reached significance level in bivariate correlations)
Group A (N=139) Bivariate Partial correlations correlations IES IES -.16 ns -.11 ns -.10 ns -.16 ns -.10 ns -.02 ns -.14 ns -.16 ns .04 ns -.25** -.17* -.29*** -.15 ns -.42*** -.23** -.26** -.07 ns Group B (N=474) Bivariate Partial correlations Correlations IES IES -.22*** -.05* -.15*** -.03 ns -.05 ns -.13** -.03 ns -.13** .03 ns -.09* -.04 ns -.23*** -.16*** -.15*** -.10* -.14** -.02 ns -.14** -.07 ns -.17*** -.03 ns -.33*** -.14** -.30*** -.09*
Life as a whole Training/education Finances Friendships Leisure activities Accommodation Safety People living with Sex life Relationship with family Health Mental health Mean score
Ns * ** *** non significant p<0.05 p<0.01 p<0.001
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When the influence of anxiety and depression is controlled for, most of the correlations fail to reach statistical significance. The only correlations of IES that remain significant are with satisfaction with relationship with family and mental health in group A, and with satisfaction with, people living with, safety, mental health and mean score in group B. Thus, satisfaction with mental health is the only SQOL life domain that remains significant in both groups of students when the influence of anxiety and depression is controlled for. As far as objective indicators for quality of life shown in Table 2 are concerned, tests for an association with IES reveal only one significant finding: in group B, students that were victim of physical violence had higher IES scores (t=2.44, df=471, p<.05). Discussion The association between posttraumatic stress and quality of life was tested in two groups of students. The samples were relatively large, nonselective and homogeneous with respect to various factors such as age, educational background and occupational status. Thus, there was no need to control for the influence of these potentially confounding factors. Further methodological strengths of the study are that all subjects had been exposed to the same stressful events and that the time interval between events and assessment were consistent within each group. The level of posttraumatic stress varied in both groups, and mean SQOL were similar to those found in other non-clinical samples [24]. Reflecting their homogeneity in life circumstances, the samples show very limited variance in objective quality of life indicators. Variables with so little variance are unlikely to be significantly correlated with other parameters. The only significant association we identified was a higher IES score in subjects who had been the victim of violence in the last year. The experience of violence may have caused posttraumatic stress alone or in combination with the effects of the stressful events during the air attacks. Some literature suggests that exposure to several traumatic events increases the probability of responding with posttraumatic stress symptoms [25]. In both groups, there were weak to moderate correlations between IES scores and SQOL ratings. Because of the bigger sample size, more of these correlation coefficients reached statistical significance in group B. The mean score of satisfaction ratings can be seen as the most reliable SQOL score [18]. It has been suggested that unless there is a specific hypothesis related to a particular life domain the mean score should be tested first. Only if there is a significant finding with respect to the mean score, results for single life domains should be analysed and interpreted. In both groups, the mean score is indeed significantly correlated with IES, and the coefficients are of similar size. Associations are consistent, although the mean lev-
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els of posttraumatic stress differ between two groups for reasons that we cannot explore on the basis of data collected in the study. The different period of time between stressful events and assessment, i.e. one year versus two years, appear not to have had a major impact on the association between posttraumatic stress and SQOL. This clear association, however, seems to be mainly though not fully mediated through symptoms of anxiety and depression. Posttraumatic stress can be associated with mood and anxiety symptoms which are known to impact on SQOL ratings. The association of posttraumatic stress with subjects satisfaction with their mental health is the strongest one in bivariate tests, and the only one that remains statistically significant in both groups after controlling for mood and anxiety symptoms. It seems plausible that satisfaction with mental health may be more closely linked with posttraumatic stress symptoms than satisfaction with other life domains, and a stronger correlation is less likely to be explained by the influence of third factors as in this case mood and anxiety symptoms. Also, this association might be qualitatively different so that concomitant mood and anxiety symptoms cannot fully explain it. A shortcoming of the study design is the cross-sectional approach which does not allow conclusions to be drawn on causal relationships. Higher levels of posttraumatic stress might mainly mediated through depression and anxiety impact on SQOL, and, vice versa, lower SQOL might have had a negative influence on symptoms. Future prospective longitudinal research should address the issue of causality. Conclusion The findings suggest that posttraumatic stress is associated with SQOL in relatively homogeneous and non-selective groups of civilians who experienced stressful and potentially traumatic events. The results are relatively consistent in two independent but similar samples. Yet, they should be replicated in different groups and contexts. It might be useful to assess quality of life indicators in future studies of samples suffering from posttraumatic stress. Such assessment may reveal that SQOL influences posttraumatic stress or is a relevant consequence of it, or both, and identify the role of mood symptoms in this association. In any case, symptoms of anxiety and depression need to be obtained and considered as mediating factors. The nature of the relationship is not clear yet, and further systematic research applying quantitative and qualitative methods is required to understand the underlying processes. Intervention studies might explore whether therapeutic interventions should primarily aim to improve posttraumatic stress or mood symptoms to affect SQOL, or whether an improved SQOL will subsequently lead to reduced levels of anxiety, depression and posttraumatic stress.
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References 1. Lauer G. Concepts of quality of life in mental health care. In: S. Priebe, Oliver J, W. Kaiser (eds.) Quality of life and mental health care. Petersfield: Wrightson Biomedical Publishing Ltd; 1999. pp.1-18. 2. Priebe S, Oliver J, Kaiser W. Quality of life and mental health care. Petersfield: Wrightson Biomedical Publishing Ltd; 1999. 3. Gill TM, Feinstein AR. A critical appraisal of the quality of life measurements. J Am Med Assoc 1994; 272: 619-626. 4. Mendlowicz M, Stein M. Quality of life in individuals with anxiety disorders. Am J of Psychiatry 2000; 157:669-682. 5. Dimenas ES, Dahlof CG, Jern SC, Wiklund IK. Defining quality of life in medicine. Scand J Prim Health Care 1990; 1:7-10. 6. Priebe S. Research in quality of life in mental health care: aims and strategies in quality of life and mental health care. In: Priebe S, Oliver J, Kaiser W (eds.) Quality of life and mental health care. Petersfield: Wrightson Biomedical Publishing Ltd; 1999. pp. 139-154. 7. Kaiser W, Priebe S, Hoffmann K, Isermann M, Roder-Wanner UU, Huxley P. Profiles of subjective quality of life in schizophrenic in- and out-patient samples. Psychiatry Res, 1997; 6, 153-166. 8. Pyne JM, Patterson TL, Kaplan, RM, Gillin, JC, Koch WL, Grant I. Assessment of the quality of life of patients with major depression. Psychiatr Serv 1997; 48: 224-230. 9. Kohen D, Burgess AP, Catalan J, Lant A. The role of anxiety and depression in quality of life and symptom reporting in people with diabetes mellitus. Qual of Life Res 1998; 7: 197-204. 10. Hansson L. Quality of life in depression and anxiety. Int Rev Psychiatry 2002; 14,3:185-189. 11. Wittchen HU, Carter RM, Pfiser H, Montgomery SA, Kessler RC. Disabilities and quality of life in pure and comorbid generalized anxiety disorder and major depression in a national survey. Int Clin Psychopharmacol 2000; 15: 319-328. 12. Zatzick DF, Marmar CR, Weiss DS, Browner WS, Metzler TJ, Golding JM, Stewart A, Schlenger WE, Wells KB. Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. Am J Psychiatry 1997a: 154:1690-1695. 13. Zatzick DF, Weiss DS, Marmar CR, Metzler TJ, Wells K, Golding JM, Stewart A, Schlenger WE, Browner WS. (1997b). Post-traumatic stress disorder and functioning and quality of life outcomes in female Vietnam veterans. Mil Med, 162; 10: 661-665. 14. Amnesty International. Amnesty International Report. London 2000. 15. Gavrilovic J, Lecic Tosevski D, Knezevic G, Priebe S. Predictors of posttraumatic stress in civilians one year after air attacks a study of Yugoslavian students. J Nerv Ment Dis 2002; 190: 257-262. 16. Gavrilovic J, Lecic Tosevski D, Dimic S, Pejovic Milovancevic M, Knezevic G, Priebe S. Coping strategies in civilians during air attacks. Soci Psychiatry Psychiatr Epidemiol 2003;38:128-133.
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17. Lecic Tosevski D, Gavrilovic J, Knezevic G, Priebe S. Personality factors and posttraumatic stress: associations in civilians one year after air attacks. J Personal Disord 2003; 17: 537-549. 18. Priebe S, Huxley P, Knight S, Evans S. Application and results of the Manchester Short Assessment of Quality of Life (MANSA). Int J Soc Psychiatry 1999; 45: 7-12. 19. Lehman AC, Ward NC, Linn LC. Chronic mental patients: the quality of life issues. Am J Psychiatry 1982; 139: 1271-1275. 20. Lehman AC, Possidente S, Hawker F. The quality of life in a state hospital and in a community residences. Hosp Community Psychiatry 1986; 37: 901-907. 21. Oliver JPJ. The social care directive development of a quality of life profile for use in community services for the mentally ill. Social Work and Social Science Review 1991; 3:5-45. 22. Horowitz MJ, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med 1979;41: 209-218. 23. Derogatis LR. SCL-90-R: Administration, scoring and procedures manual, II. Towson, MD: Clinical Psychometric Research. 1983. 24. Priebe S, Gruyters T, Heinze M, Hoffmann C, Jaekel A. Subjective evaluation criteria in psychiatric care methods of assessment for research and general practice. Psychiatr Prax 1995; 22: 140-144. 25. Follette VM, Polusny MA, Bechte AE, Naugle AE. Cumulative trauma: the impact of child sexual abuse, adult sexual assault and spouse abuse. J of Trauma Stress 1996; 9:257-262.
____________________________ Jelena JANKOVI GAVRILOVI, Odeljenje za socijalnu i komunalnu psihijatriju Barts i Medicinski fakultet Queen Mary u Londonu, London, Velika Britanija Jelena JANKOVIC GAVRILOVIC, Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Queen Mary, University of London, United Kingdom E-mail: j.jankovic@qmul.ac.uk
Psihijat. dan. /2005/37/2/307-313/ avi T. Evaluacija grupne kognitivne psihoterapije posttraumatskog stresnog poremeaja
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Istraivaki rad
UDK: 616.89 - 008.441 - 085.851
EVALUACIJA GRUPNE KOGNITIVNE PSIHOTERAPIJE POSTTRAUMATSKOG STRESNOG POREMEAJA

Tamara avi1, Mirko Pejovi2
1
Institut za neuropsihijatrijske bolesti Dr Laza K. Lazarevi, Beograd, Srbija i Crna Gora 2 Institut za psihijatriju Klinikog centra Srbije, Beograd, Srbija i Crna Gora
Apstrakt: Ljudski odgovor na psiholoku traumu jedan je od najvanijih zdravstvenih problema dananjeg sveta. Lekovito dejstvo grupne kognitivne psihoterapije potvreno je u mnogim istraivanjima. Cilj: ispitivanje mogunosti primene metode kognitivnog restrukturisanja u grupi izbeglica sa iskustvom psiholoke traume. Metod: rad se odvijao u srednjim grupama (15-18 lanova), poluotvorenog tipa, sa dinamikom od dvadeset jednoasovnih nedeljnih seansi, tokom perioda od est meseci. Pre i posle terapije primenjeni su sledei instrumenti: Hamiltonove skale za procenu anksioznosti i depresivnosti (HAMA i HAMD) i revidirana Skala uticaja dogaaja (IES-R). Rezultati: grupna kognitivna psihoterapija ublaava anksioznost i depresivnost, redukuje simptome posttraumatskog stresnog poremeaja i pomae u uspostavljanju kontrole nad trumatskim iskustvom i modifikovanju maladaptivnih obrazaca ponaanja. Diskusija: postoji potreba za dugoronim preventivnim programima namenjenim traumatizovanima koji bi ukljuivali i grupnu kognitivnu psihoterapiju. Kljune rei: stres, trauma, grupa, kognitivna psihoterapija
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Uvod Ljudski odgovor na psiholoku traumu jedan je od najvanijih zdravstvenih problema dananjeg sveta. Traumatizovane osobe esto razvijaju posttraumatski stresni poremeaj (u daljem tekstu PTSP), poremeaj u kojem seanje na traumatski dogaaj dominira sveu rtava, osiromaujui ivotni smisao i zadovoljstvo. Osobe sa PTSP prepoznaju se po tome to su praktino zaglavljene u traumu, jer nastavljaju da ponovno proivljavaju misli, slike i oseanja originalnog dogaaja. Onog momenta kada intruzije (nametanja) postanu dominantne, traumatizovana osoba svoj ivot poinje da organizuje oko razliitih naina izbegavanja [1]. Svesni svojih potekoa da kontroliu emocije, traumatizovani troe energiju na izbegavanje uznemirujuih unutranjih senzacija, umesto da odgovaraju na zahteve sredine. Tako, oni gube zadovoljstvo u stvarima koje su ih ranije radovale i oseaju se kao da su mrtvi. Ova otupelost moe se manifestovati kao depresija, anhedonija i manjak motivacije, kao psihosomatska reakcija ili disocijativno stanje. Ova pojava tokom psihoterapije spreava osobu da zamisli sebe u budunosti. Kognitivna psihoterapija Veina kognitivnih psihoterapija visoko je kompatibilna sa teorijom stresa Zeligmana i Pitersona [2]. Kognitivno restrukturisanje je tehnika kognitivne terapije koja omoguava osobi da identifikuje negativna, iracionalna uverenja i zameni ih istinitim, racionalnim stavovima. Vei deo teorije kognitivnog restrukturisanja [3] derivat je Elisove racionalno emotivne terapije RET. Ona ima svoje specifinosti: 1) zasnovana je na koherentnom kognitivnom modelu, 2) zasnovana je na otvorenoj terapijskoj saradnji, gde se pacijent posmatra kao ravnopravan partner u timskom reavanju problema, 3) kratka je i vremenski ograniena, 4) strukturisana je i direktivna, 5) orijentisana na problem i usmerena na inioce koji odravaju potekoe, 6) oslanja se na proces ispitivanja i voenog otkrivanja, a ne na ubeivanje, pridike ili polemiku, 7) bazirana je na induktivnim metodama, tako da pacijent naui da uvia misli i uverenja ija se istinitost testira i 8) edukativna je, jer predstavlja kognitivne tehnike kao vetine koje se osvajaju vebanjem. Kljuni element u ovom pristupu jeste ideja o kontranapadu, odnosno, zameni iracionalnih uverenja potpuno suprotnim racionalnim uverenjima. Terapeut upoznaje pacijente sa injenicom da su mnoge misli koje stvaraju probleme u sutini iracionalne ili pogrene. Pacijenti se podstiu da daju svoje predloge koji su naini da se takva uverenja promene. To moe biti: nova korisna informacija, polemika o problemu, nalaenje neloginosti ili nekonzistentnosti takvih stavova, nalaenje istomiljenika u osobi od autoriteta, ponavljanje alternativnog uverenja i njegova provera u konkretnim situacijama. Kontranapad sadri sve to. To su stavovi koji e inhibirati prvobitna negativna uverenja i, konano, zameniti ih. Prema tome, kontranapad deluje poput uvoenja nove vetine, ili boljeg naina da se neka vetina izvede. Najpre se menja nain obavljanja radnje, a zatim, nakon vebanja, ona postaje automatska. U kasnijem sledu treba pronai kontraudarce za sva negativna uverenja i upotrebiti ih [4].
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Grupa Emocionalno vezivanje prva je spontana zatita od traumatizacije. Svaka dobro integrisana, kohezivna grupa predstavlja snanu odbranu od negativnih oseanja. Bez obzira na prirodu traume ili strukturu grupe, cilj grupne terapije je pomo ljudima da aktivno prate zahteve trenutka, bez intruzija proteklih iskustava. Grupna terapija posmatra se kao metoda izbora za pacijente sa traumatinim iskustvom. Bila je koriena za rtve nasilja, prirodnih katastrofa, seksualnog zlostavljanja u detinjstvu, silovanja, branog nasilja, koncentracionih logora i ratne traume [5]. Zadatak grupne intervencije jeste da rtve ponovo zadobiju oseanje sigurnosti i kontrole. Karakteristika i ovih grupa jeste slobodna razmena informacija i suoavanje sa realnou. lanovi grupe se postepeno ohrabruju da toleriu anksioznost, a ne da bee od nje. Na taj nain stiu samopouzdanje i naputaju defanzivnu poziciju. Iako razliiti, pacijenti se okupljaju oko slinosti vezanih za traumu, to ih otvara jedne prema drugima da slobodno govore o svojim strahovima, gubicima i mogunostima nalaenja novih razloga za ivot i optimizam. Grupa je najpogodnije okruenje koje moe da dri i apsorbuje veliku koliinu agresije i depresije. Ona je posebno korisna za savladavanje traumatskih dogaaja. Najpre, u grupi klijent ima oseaj univerzalnosti, shvatajui da nije sam u svojoj patnji. Dalje, grupa obezbeuje delegirano uenje sluanjem kako drugi ljudi reavaju probleme. Uestvovanjem u grupi svaki pacijent prvi put se javno obavezuje na promenu. Grupa je prilika da se dobije pomo u borbi sa iracionalnim mislima. Cilj borbe sa iracionalnim mislima je da se alogine i maladaptivne misli zamene pozitivnim i loginim. Ciljevi Osnovni cilj ovog istraivanja bio je ispitivanje mogunosti primene metode kognitivnog restrukturisanja u grupi izbeglica sa iskustvom psiholoke traume. U sklopu navedenog postavljeni su sledei terapijski ciljevi: ublaavanje anksioznosti i depresivnosti, redukcija posttraumatskih simptoma, kognitivna korekcija traumatskog materijala, katarza, emocionalna prorada sadraja, uspostavljanje kontrole nad traumatskim iskustvom, kognitivna samoregulacija i osvajanje novih adaptivnih strategija za savladavanje traume. Metod U istraivanje je ukljueno sedamdeset osoba. Kriterijumi za ulazak u istraivanje bili su: izbegliko iskustvo, minimum osamnaest godina starosti, motivisanost za ulazak u terapiju, prisustvo psihikih, interpersonalnih ili telesnih problema i odsustvo prethodne psihijatrijske dijagnoze. Prva faza rada sastojala se iz upoznavanja, stvaranja osnovnog poverenja i klinikog intervjua. Cilj pregleda bio je: a) utvrivanje kriterijuma za ukljuivanje u uzorak, i b) procena psihikog statusa ispitanika. Druga faza sastojala se u popunjavanju baterije upitnika. Trea faza odvijala se kroz grupni rad. Kriterijumi za ukljuivanje u grupnu terapiju bili su sledei: 1) ukljuujui: moti-
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vacija za promenu, zajedniki zadaci i ciljevi i 2) iskljuujui: nesposobnost prihvatanja grupnog setinga i normi ponaanja. Najzad, etvrta faza istraivanja obuhvatila je zatvaranje grupa i retest istim instrumentarijumom. Korieni su sledei instrumenti: Hamiltonova skala za procenu depresivnosti [6], Hamiltonova skala za procenu anksioznosti [7] i Horowitz-ova revidirana Skala uticaja dogaaja [8]. Kognitivno restrukturisanje odvijalo se kroz rad u srednjim grupama, poluotvorenog tipa, sa po 15-18 lanova. Grupe su se sastajale jednom nedeljno u trajanju od jednog sata. U periodu od est meseci odrano je dvadeset seansi. Postupak je obuhvatio nekoliko faza: procena specifinih traumatskih seanja, kognitivno restrukturisanje specifinih seanja, procena stavova grupe prema svetu uopte i, najzad, restrukturisanje stavova grupe prema svetu. Tokom itavog procesa aktivno se koristila intervencija kontranapad, koja ima krucijalnu ulogu i u radu na problemima adaptacije. Kontranapad se koristio u skladu sa svojim osnovnim karakteristikama: direktno suprotan pogrenom uverenju, sadri uverljivu realnu tvrdnju, pacijent treba da sam da osmisli to je mogue vie kontraudaraca, mora da potie od pacijenta, a ne od terapeuta, mora biti koncizan, mora biti izreen samouvereno, agresivno i/ili emotivno i, mora biti intenzivan. Rezultati Anksioznost Pregled uestalosti pojedinih simptoma na Hamiltonovoj skali anksioznosti (HAM-A) pokazuje da su pre leenja u ukupnom uzorku najsnanije bili izraeni simptomi anksioznog i depresivnog raspoloenja, napetosti, nesanice, kognitivnih smetnji i motornog nemira (p=0.000). Anksioznost nakon terapije opada u ukupnom uzorku i na svakom pojedinom ajtemu. Trei ajtem na Hamiltonovoj skali anksioznosti (strahovi) pokazuje slabije poboljanje u odnosu na ostale, gde se poboljanje kree od 55-58%. Ukupan skor anksioznosti na Hamiltonovom testu pre terapije iznosio je X =29.3, SD=9.1, dok nakon terapije iznosi X =11.0, SD=9.9. p=0.000 (Grafikon 1).
Grafikon 1. Dejstva terapije prema nivou anksioznosti
45 40 35 30 25 20 15 10 5 0
Pre terapije Posle terapije HAMA skor
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Depresivnost Pre tretmana depresivnost se dominantno ispoljavala strepnjom, depresivnim raspoloenjem, samooptuivanjem, ranom insomnijom, gubitkom interesovanja, psihomotornom usporenou, loom koncentracijom, varijacijama raspoloenja, uz dobar uvid u problem (p=0.000). I pored visoke depresivnosti ispitanici nisu pokazali suicidalnost ni pre, ni posle terapije. Pre terapije ukupan uzorak (97%) pokazivao je umerenu do izraenu depresivnost (HAMD test X =30.8, SD=9.4). Nakon kognitivnog restrukturisanja opada intenzitet kako kod svakog pojedinog simptoma, tako i u ukupnom skoru (HAMD retest X =12.6, SD=10.9, p=0.000). Izrazito depresivnih bilo je 37.1% (skor preko 15), blago depresivnih 15.1% (skor 8-15), dok 47.1% ispitanika nije pokazalo znake depresivnosti. Razlike u vrednostima postoje za sve pomenute simptome i one su visoko statistiki znaajne, osim na ajtemima suicidalnost, depersonalizacija i derealizacija, paranoidnost i opsesivnokompulzivni simptomi, koji su nisko ocenjeni i pre i posle terapije. Posle leenja vrednosti depresivnosti znaajno opadaju i dobijaju kliniki blagu formu (Grafikon 2).
Grafikon 2. Dejstvo terapije prema nivou depresivnosti
45 40 35 30 25 20 15 10 5 0
Pre terapije Posle terapije HAMA skor
PTSP Pregledom uestalosti na IES-R, uoava se da su pre poetka terapije simptomi izbegavanja neto izraeniji u odnosu na simptome nametanja. Poreenjem srednjih vrednosti ukupnog skora i pojedinih klastera (IES-R) uoava se poboljanje nakon kognitivne grupne psihoterapije (Tabela 1).
Tabela 1. Simptomi PTSP na IES-R pre i posle terapije
Pre terapije
IES-ukupan IES-nametanje IES-izbegavanje 30.36 (SD=11.23) 14.74 (SD=5.35) 15.59 (SD=6.30)
Posle terapije
18.47 (SD=12.45) 8.64 (SD=6.23) 9.83 (SD=6.72)
p
0.001 0.001 0.001
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Ispitanici su pre poetka terapije kao najee navodili simptome sa ajtema 14 (sve to me podsea na taj dogaaj ponovo mi vraa oseanja vezana za dogaaj), 13 (pokuao sam da ne mislim o tome), 10 (te slike se same javljaju i kad mislim o neem drugom), 17 (ako ponem da priam o tome uini mi se kao da se sve ponovo dogaa), 2 (izbegavao sam da se uznemirim kad bih o tome mislio ili bi me neto podsetilo na to) i 3 (pokuao sam da to izbacim iz seanja). Simptomi koji opisuju kognitivne smetnje imali su kontinuirano niske vrednosti (26 ljudi mi kau da sam rasejan, 27 dogaa mi se da izaem iz kue, a da zaboravim da obuem neki deo odee, 28 ponekad se toliko zanesem da ne vidim ta se oko mene dogaa). Ovo govori o relativnoj ouvanosti kognitivnih funkcija, panje i koncentracije kod naih ispitanika sa PTSP (Grafikon 3).
Grafikon 3. Distribucija simptoma PTSP prema srednjim vrednostima pre terapije
3 2.5 2 1.5 1 0.5 0 IESRT1 IESRT2 IESRT3 IESRT4 IESRT5 IESRT6 IESRT7 IESRT8 IESRT9 IESRT10 IESRT11 IESRT12 IESRT13 IESRT14 IESRT15 IESRT16 IESRT17 IESRT18 IESRT19 IESRT20 IESRT21 IESRT22 IESRT23 IESRT24 IESRT25 IESRT26 IESRT27 IESRT28
Iz Grafikona 4. uoava se znaajno poboljanje PTSP simptoma posle terapije, gledano prema srednjim vrednostima, pri emu ono izostaje samo kod ajtema 6 (sanjao sam ono to se dogodilo) i ajtema 3 (pokuao sam da to izbacim iz seanja).
Grafikon 4. Distribucija simptoma PTSP prema srednjoj vrednosti posle terapije
3 2.75 2.5 2.25 2 1.75 1.5 1.25 1 0.75 0.5 0.25 0
IESRR1 IESRR2 IESRR3 IESRR4 IESRR5 IESRR6 IESRR7 IESRR8 IESRR9 IESRR10 IESRR11 IESRR12 IESRR13 IESRR14 IESRR15 IESRR16 IESRR17 IESRR18 IESRR19 IESRR20 IESRR21 IESRR22 IESRR23 IESRR24 IESRR25 IESRR26 IESRR27 IESRR28
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Znaajnost razlika simptoma PTSP pre i posle terapije nalazimo na veini ajtema. Ipak, odreeni simptomi ne menjaju se znaajno nabolje, kao npr. na ajtemu 6, 15 (snovi o dogaaju, zaleena oseanja) i 26, 27, 28 (ouvanost panje i koncentracije) (Tabela 2).
Tabela 2. Statistika znaajnost razlika simptoma PTSP (IES-R) pre i posle terapije
Ajtemi
IESRR1 IESRT1 IESRR2 IESRT2 IESRR3 IESRT3 IESRR4 IESRT4 IESRR5 IESRT5 IESRR6 IESRT6 IESRR7 IESRT7 IESRR8 IESRT8 IESRR9 IESRT9 IESRR10 IESRT10 IESRR11 IESRT11 IESRR12 IESRT12 IESRR13 IESRT13 IESRR14 IESRT14 IESRR15 IESRT15 IESRR16 IESRT16 IESRR17 IESRT17 IESRR18 IESRT18 IESRR19 IESRT19 IESRR20 IESRT20 IESRR21 IESRT21 IESRR22 IESRT22 IESRR23 IESRT23 IESRR24 IESRT24 IESRR25 IESRT25 IESRR26 IESRT26 IESRR27 IESRT27 Z -5.631 -5.333 -3.573 -4.506 -4.114 -1.496 -3.170 -3.512 -3.955 -5.129 -4.244 -3.614 -4.893 -5.388 -2.951 -2.840 -5.134 -4.904 -2.972 -3.052 -4.287 -4.767 -3.447 -3.356 -2.864 -2.402 -2.523 p .000 .000 .000 .000 .000 .135 .002 .000 .000 .000 .000 .000 .000 .000 .003 .005 .000 .000 .003 .002 .000 .000 .001 .001 .004 .016 .012
Diskusija U ovom istraivanju izbeglice su imale znaajnu stopu posttraumatskog stresnog poremeaja, anksioznosti i depresivnosti, to je u skladu sa nalazima iz literature. Nai ispitanici, meutim, nisu pokazali znaajan nivo suicidalnosti i pored tekih traumatskih iskustava i uslova ivota. Posttraumatski stresni poremeaj manifestovao se dominantno simptomima iz podgrupa nametanja i izbegavanja, dok su simptomi poveane uzbuenosti bili manje prisutni, to je u skladu sa nalazima ranijih slinih istraivanja [9,10]. Lekoviti efekti grupne kognitivne psihoterapije potvreni su u mnogim istraivanjima: rtava torture, u procesu prorade traumatskog materijala u tugovanju i u prevenciji hronifikacije PTSP [11,12]. Nae istraivanje potvrdilo je hipotezu da metoda grupne kognitivne psihoterapije ublaava anksioznost, depresivnost i redukuje simptome posttraumatskog stresnog poremeaja, da pomae u uspostavljanju kontrole nad traumatskim iskustvom i modifikuje maladaptivne obrasce ponaanja. Postoji potreba za dugoronim preventivnim programima namenjenim traumatizovanima koji bi ukljuivali i grupnu kognitivnu psihoterapiju.
Psihijat. dan. /2005/37/2/315-322/ Cavic T. Evaluation of group cognitive psychotherapy of post-traumatic stress disorder
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Research article
UDK: 616.89 - 008.441 - 085.851
EVALUATION OF GROUP COGNITIVE PSYCHOTHERAPY OF POST-TRAUMATIC STRESS DISORDER

Tamara Cavic1, Mirko Pejovic2 Institute of Neuropsychiatric Disorders Dr Laza K. Lazarevic, Belgrade, Serbia and Montenegro 2 Institute od Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia and Montenegro
Abstract: Human response to psychological trauma is one of the most important health problems today. Healing effects of group cognitive psychotherapy were confirmed in many studies. Aim: evaluation of cognitive restructuring in the group of refugees with psychological trauma. Method: work was conveyed in semi-open median groups (15-18 members), with a dynamics of 20 one-hour weekly sessions during a period of 6 months. Before and after therapy the following instruments were applied: Hamilton Scales for anxiety and depression (HAMA and HAMD) and Impact Event Scale-revised (IES-R). Results: group cognitive psychotherapy alleviates anxiety and depression, reduces symptoms of post-traumatic stress disorder and helps in regaining control over traumatic experiences and modifying maladaptive patterns. Discussion: There is a need for longterm preventive programs for traumatized people which would include group cognitive psychotherapy. Key words: stress, trauma, group, cognitive psychotherapy
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Introduction Human response to psychological trauma is one of the most important health problems today. Traumatized people often develop post-traumatic stress disorder (PTSD), disorder in which a memory of traumatic event dominates over consciousness of victims, empowering life meaning and joy. Persons with PTSD can be recognized by being practically trapped in trauma, because they continue to re-experience thoughts, images and memories of the original event. The moment intrusions become dominant, traumatized individual begin to organize his life around different ways of avoidance [1]. Aware of their difficulties to control emotions, traumatized invest energy in avoidance of internal distressing sensations, instead of responding to requests of the environment. Thus, they loose pleasure in things they enjoyed before and feel like dead. Such numbing can be manifested as depression, anhedonia and lack of motivation, as psychosomatic reaction and dissociative state. This phenomenon disables individual for future projection. Cognitive psychotherapy Most of cognitive psychotherapies are highly compatible with stress theory of Seligman and Peterson [2]. Cognitive restructuring is a technique of cognitive therapy that enables a person to identify negative, irrational thoughts and replace them with true, rational states. Most of theories of cognitive restructuring [3] are derived from Elliss Rational Emotional Therapy RET. It has its specific features: 1) based on coherent cognitive model, 2) based on open therapeutic alliance, where patient is recognized as an equal partner in problems solving team, 3) brief and time-limited, 4) structured and directive, 5) problem-oriented and focused on factors that maintain difficulties, 6) relied on the process of questioning and guided disclosure, not on persuasion, preaching and polemics, 7) based on inductive methods, so patient can learn to catch thoughts and attitudes and tests their truthfulness and 8) educational, presents cognitive techniques as a skills that can be conquered by practice. Key element in this approach is an idea of counterattack i.e. replacement of irrational beliefs with direct contradictory rational beliefs. Therapist introduces to clients the fact that many thoughts that are causing problems are, in fact, irrational and wrong. Clients are animated to give their suggestions what are the ways to change such beliefs. It can be: new useful information, polemics on problem, finding irrationality and inconsistency in such states, finding follower in person of authority, repeating of alternate belief and its checking in concrete situations. Counter attack contains it all. Those are attitudes that will inhibit previous negative beliefs and, finally, replace them. So, counterattack acts like implementation of a new skill or better way to perform some skill. First it changes a ways how an action is performed and then, after practice, it becomes automatic. In later sequence counters for all negative thoughts need to be found and used [4].
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Group Emotional bonding is the first spontaneous protection against traumatization. Every well integrated, cohesive group is a strong defense against negative feelings. No matter of the nature of trauma or structure of the group, the aim of group therapy is to help people to follow actively current requests, without intrusions of past experiences. Group therapy is a method of choice for patients with traumatic experiences. It was used for victims of interpersonal violence, natural catastrophes, sexual abuse in childhood, rape, marital violence, concentration camps and war trauma [5]. Task of the group intervention in victims is to regain feeling of safety and control. Characteristics of these groups are free exchange of information and facing the reality. Group members are encouraged to tolerate anxiety and not run away from it. In that way they achieve self-esteem and abandon defensive position. Although different, patients gather around similarities related to trauma which opens them one to another to speak freely about their fears, loses and possibilities of finding new reasons for life and optimism. Group is the most convenient environment that can keep and absorb large amount of aggression and depression. Group is especially useful for abreaction of traumatic events. There are many advantages of group cognitive psychotherapy. First, in the group client has a sense of universality, realizing he is not alone in his sorrow. Further, group provides delegated learning by listening how other people handle their problems. By participating the group client for the first time obliges to change in public. Group is an opportunity to get help in the battle with irrational thoughts. The aim of the fight with irrational thoughts is to replace illogical and maladaptive thoughts with positive and logical ones. Aims The main aim of this research was to investigate the possibility of application of cognitive restructuring method in the refugees with psychological trauma. In that sense, the following therapeutic aims are posed: ameliorating of anxiety and depression, reduction od post-traumatic symptoms, cognitive correction of traumatic material, catharsis, emotional workingthrough, taking control over traumatic experience, cognitive self-regulation and obtaining new adaptive coping strategies. Method Seventy people were included into study. Criteria for entering the study were: refugee experience, minimum 18 years of age, motivation for therapy, presence of psychical, interpersonal or somatic problems, and absence of previous psychiatric diagnosis. First phase consisted of acquaintance, formation of basic trust and clinical interview. The aim of the check-up was: a) to ascertain including criteria and b) assess psychical status of examinees. Second phase was application of instruments. Third phase was conveyed through group work. Criteria for entering group therapy were: 1) in-
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cluding: motivation for change, common tasks and aims, and 2) excluding: incapability to accept group setting and norms of behavior. The following instruments were used: Hamilton Rating Scale for Depression [6], Hamilton Rating Scale for Anxiety [7] and Horowitz Impact of Event Scale Revised [8]. Cognitive restructuring was conveyed through the work in semiopened median groups with 15-18 members. Groups used to meet once a week for one hour. During six months twenty sessions were held. Procedure included several steps: assessment of specific traumatic memories, cognitive restructuring of specific memories, assessment of group members attitudes towards the world in general and, finally, restructuring of groups attitudes towards the world. All along this process the intervention counterattack was used, that has crucial role in the work with adjustment problems, too. Counterattack was used in accordance with its basic characteristics: directly opposite to wrong belief, contains assuring realistic state, client has to create as much as possible more counterattacks, it has to come from the client and not from the therapist, has to be concise, has to be said with selfconfidence, aggressively and/or emotionally and, has to be intensive. Results Anxiety Review of symptoms frequencies on HAM-A show that the most prominent before treatment were symptoms of anxiety and depressive mood, nervousness, cognitive impairment and motor agitation (p=0.000). After treatment anxiety decreases in total sample, as well as on each item. Item 3 (fears) shows less improvement comparing with others, where it ranges 5558%. Total score on HAMA test was X =29.3, SD=9.1, while on HAMA retest was X =11.0, SD=9.9. p=0.000 (Fig. 1). Fig. 1. Effects of therapy by level of anxiety (p=0.000)
45 40 35 30 25 20 15 10 5 0 HAMA score Before therapy After therapy
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Depression Before treatment depression was manifested with anxiety, depressive mood, self-accusation, early insomnia, loss of interest, psychomotor retardation, poor concentration, mood variations and good insight (p=0.000). Although highly depressed, examinees did not show suicidality both before and after therapy. Before therapy total sample (97%) showed moderate to severe depression (HAMD test X =30.8, SD=9.4). After cognitive restructuring intensity decreases on each symptom, and in total score (HAMD retest X =12.6, SD=10.9, p=0.000). There was 37.1% of severely depressed (score over 15), 15.1% with mild depression (score 8-15), while 47.1% examinees did not manifest signs of depression. There are statistically significant differences for all symptoms, except on items for suicidality, depersonalization and derealization, paranoid thoughts and obsessive-compulsive behavior, which were low both before and after the treatment. After the therapy values of depression decreased significantly and took a mild clinical form (Fig. 2). Fig. 2. Effects of therapy by level of depression (p=0.000)
45 40 35 30 25 20 15 10 5 0
Before therapy After therapy HAMA score
PTSD Looking at the IES-R frequencies, one can notice that before therapy avoiding symptoms were slightly more expressed that intrusive symptoms. Comparing the medians of total score and both clusters (IES-R) we can see improvement after group cognitive psychotherapy (Table 1). Table 1. Symptoms of PTSD on IES-R before and after therapy Before therapy
(IES-total) (IES-intrusion) (IES-avoidance) 30.36 (SD=11.23) 14.74 (SD=5.35) 15.59 (SD=6.30)
After therapy
18.47 (SD=12.45) 8.64 (SD=6.23) 9.83 (SD=6.72)
p
0.001 0.001 0.001
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Before therapy examinees most frequently referred symptoms from the items 14 (everything that reminds me of that event brings me back feeling about it), 13 (I tried not to thing of that), 10 (that images appears event when I think of something else), 17 (if I start talking of that it looks like it happens again), 2 (I avoided to be disturbed when thinking or being reminded of that) and 3 (I tried to through it away from my mind). Symptoms of cognitive impairment had continually low values (26 people say I am distracted, 27 it happens to me to leave home, forgetting to put some clothes on, 28 sometimes I drift away and dont see what happens around me). This can be in favor of relative preservation of cognitive functions, attention and concentration in examinees with PTSD (Fig. 3). Fig. 3. Distribution of PTSD symptoms by medians before therapy
3 2.5 2 1.5 1 0.5 0 IESRT1 IESRT2 IESRT3 IESRT4 IESRT5 IESRT6 IESRT7 IESRT8 IESRT9 IESRT10 IESRT11 IESRT12 IESRT13 IESRT14 IESRT15 IESRT16 IESRT17 IESRT18 IESRT19 IESRT20 IESRT21 IESRT22 IESRT23 IESRT24 IESRT25 IESRT26 IESRT27 IESRT28
We can see significant improvement of PTSD symptoms after therapy, according to medians, on Fig. 4, except on the item 6 (I dreamt of what happened) and item 3 (I tried to through it away from my memory). Fig. 4. Distribution of PTSD symptoms by median after therapy
3 2.75 2.5 2.25 2 1.75 1.5 1.25 1 0.75 0.5 0.25 0 IESRR1 IESRR2 IESRR3 IESRR4 IESRR5 IESRR6 IESRR7 IESRR8 IESRR9 IESRR10 IESRR11 IESRR12 IESRR13 IESRR14 IESRR15 IESRR16 IESRR17 IESRR18 IESRR19 IESRR20 IESRR21 IESRR22 IESRR23 IESRR24 IESRR25 IESRR26 IESRR27 IESRR28
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Significant differences between symptoms of PTSD before and after therapy can be found on the majority of items. Some of them, however, did not change, i.e. on items 6, 15 (dreams of event, numbed feelings) and 26, 27, 28 (preserved attention and concentration) (Table 2). Table 2. Statistical significance of PTSD symptoms (IES-R) before and after therapy
Items
IESRR1 IESRT1 IESRR2 IESRT2 IESRR3 IESRT3 IESRR4 IESRT4 IESRR5 IESRT5 IESRR6 IESRT6 IESRR7 IESRT7 IESRR8 IESRT8 IESRR9 IESRT9 IESRR10 IESRT10 IESRR11 IESRT11 IESRR12 IESRT12 IESRR13 IESRT13 IESRR14 IESRT14 IESRR15 IESRT15 IESRR16 IESRT16 IESRR17 IESRT17 IESRR18 IESRT18 IESRR19 IESRT19 IESRR20 IESRT20 IESRR21 IESRT21 IESRR22 IESRT22 IESRR23 IESRT23 IESRR24 IESRT24 IESRR25 IESRT25 IESRR26 IESRT26 IESRR27 IESRT27
Z
-5.631 -5.333 -3.573 -4.506 -4.114 -1.496 -3.170 -3.512 -3.955 -5.129 -4.244 -3.614 -4.893 -5.388 -2.951 -2.840 -5.134 -4.904 -2.972 -3.052 -4.287 -4.767 -3.447 -3.356 -2.864 -2.402 -2.523
p
.000 .000 .000 .000 .000 .135 .002 .000 .000 .000 .000 .000 .000 .000 .003 .005 .000 .000 .003 .002 .000 .000 .001 .001 .004 .016 .012
Discussion Refugees in this study manifested significant rate of post-traumatic stress disorder, anxiety and depression, which is in accordance with findings from the literature. Our examinees did not show significant level of suicidality, no matter of severe traumatic experiences and living conditions. Posttraumatic stress disorder was presented predominantly with symptoms from the clusters intrusion and avoidance, while the symptoms of hyperarousal were less notable, which corresponds with findings of previous similar studies [9,10]. Healing effects of group cognitive psychotherapy were confirmed
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in many studies: of torture victims, in the process of working-through of traumatic material in mourning and in prevention PTSD chronification [11,12]. This research confirmed a hypothesis that a group cognitive psychotherapy method ameliorates anxiety and depression, reduces symptoms of PTSD, helps in regaining control over traumatic experience and modify maladaptive patterns of behavior. There is a need for a long-term preventive program for traumatized people, which would include group cognitive therapy, too. References
1. Van der Kolk BA, Ducey C. Clinical implications of the Rorschach in posttraumatic stress disorder. In: BA van der Kolk (Ed.). Post-traumatic stress disorder: psychological and biological sequelae. Washington, DC: American Psychiatric Press; 1984: 30-42. Peterson CH, Seligman M. Explanatory style and illness. J. Pers, 1987, 55. Foy DW. Treating PTSD: cognitive-behavioral strategies. London: Guilford; 1999. Free ML. Cognitive therapy in groups. Chichester: Wiley; 1999. Herman JL. Trauma and recovery. New York: Oxford University Press; 1992. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960, 23:56-62. Hamilton M. A diagnosis and rating of anxiety. Br J Psychiatry, Special Publication 1969, 3:76-79. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med, Vol. 41, 1979, 3: 209-18. Wiser S, Goldfried MR. Therapist interventions and client emotional experiencing in expert psychodynamic-interpersonal and cognitivebehavioural therapies. J Consult Clin Psychol 1998, 66(4): 634-40. Wolfe J, Keane TM, Kaploupek DG, Mora CA, Wine P. Patterns of positive readjustment in Vietnam combat veterans. J Traum Stress 1993, 6:179-93. Emmelkamp J, Komproe IH, Van Ommeren M, Schagen S. The relation between coping, social support and psychological and somatic symptoms among torture survivors in Nepal. Psych Med 2002, 32: 1465-70. Kramer S, Akhtar S. When the body speaks: psychological meanings in kinetic clues. New Jersey: Jason Aronson Inc; 1992.
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__________________________ Dr Tamara AVI, dr sc med, psihijatar, Institut za neuropsihijatrijske bolesti Dr Laza Lazarevi, Beograd, Srbija i Crna Gora
Tamara CAVIC, MD, PhD, psychiatrist, Institute of Neuropsychiatric Disorders Dr Laza K. Lazarevic, Belgrade, Serbia and Montenegro E-mail: tamarac@sbb.co.yu
Psihijat. dan. /2005/37/2/323-327/ Kontaksakis P. V. Likantropija u radovima vizantijskih lekara
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Struni rad UDK: 616. 89 - 008 (495.02) 616. 89 (091)
LIKANTROPIJA U RADOVIMA VIZANTIJSKIH LEKARA

Vasilis P. Kontaksakis1, Don G. Laskaratos2, Panajotis P. Ferentinos1, Maria-Irini V. Kontaksaki1, Dord N. Hristodulu1
1
Katedra za psihijatriju, Univerzitet u Atini, Grka 2 Istorija medicine, Univerzitet u Atini, Grka
Apstrakt: Svrha ovog rada je da napravi pregled tekstova o likantropiji iz vizantijske medicinske literature i da proceni njihov uticaj na medicinu od tog perioda do danas. Prouavani su originalni tekstovi na grkom jeziku vizantijskih lekara, kao to su Oribasije (IV vek n.e.), Ecije (VI vek n.e.), Pavle Eginjanin (VII vek n.e.), Pavle iz Nikeje (VII vek n.e.), Mihajlo Psel (XI vek n.e.) i Jovan Aktuarije (XIV vek n.e.). Autori su, takoe, pregledali i sauvane tekstove antikih grkih i rimskih lekara. Vizantijski lekari su pruili detaljne opise klinike slike likantropije, kao i predloge za njeno leenje. Smatrali su da likantropija predstavlja oblik melanholine ili psihotine depresije, a ne da je demonskog porekla, to je u skladu sa miljenjem rimskog lekara Marsilija Siditskog (II vek n.e.), koji je prvi opisao ovaj sindrom. Stavovi vizantijskih lekara o likantropiji su neposredno ili posredno uticali na nain na koji se arapska ili zapadnoevropska medicina kasnije bavila tim problemom. Kljune rei: vizantijska medicina, istorija medicine, likantropija, depresija, melanholija, psihoza
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Uvod Likantropija je sumanuto uverenje bolesnika da se preobraava u ivotinju, po tradiciji, u vuka [1,2]. Termin je nastao od grkih rei lycos = vuk i anthropos = ovek. Najraniji opisi ovog sindroma mogu se nai u grkoj mitologiji. Poluboga Likaona Zevs je za kaznu pretvorio u vuka, jer je pokuao da poslui Zevsa mesom rtvovanog mladia [3]. Jedan kasniji opis ovog sindroma nalazi se i u Bibliji. U Prvoj knjizi Danilovoj, Bog je kaznio vavilonskog kralja Nabukodonosora tako to ga je na sedam godina pretvorio u vola [4,5]. Poetkom XIX veka likantropija je smatrana duevnim poremeajem [6]. U svetskoj literaturi je tokom XX veka objavljeno nekoliko prikaza sluajeva likantropije. Veina se odnosila na pacijente koji su patili od afektivnih ili psihotinih poremeaja. Ostali sluajevi preobraaja oveka u ivotinju javili su se kod pacijenata sa drugim mentalnim poremeajima, meu kojima su bili poremeaji linosti, histerija, zloupotreba alkohola ili droga, organski modani sindromi, demencija i epilepsija [7-11]. Ovaj rad ima za cilj da pokae da su radovi vizantijskih lekara o likantropiji obezbedili nove podatke i ponudili jasnija tumaenja ovog stanja; tavie, oni pruaju dokaze da je likantropija od antikih vremena smatrana duevnom boleu. Vizantijska medicina, u stvari, predstavlja nastavak antike grke, helenistike i rimske tradicije u medicini, kao i vanu kariku koja je povezuje sa zapadnoevropskom medicinom na koju je uticala neposredno ili posredno, preko tekstova arapskih lekara. Prouavanje tekstova vizantijskih lekara je od velikog znaaja jer veina njih reprodukuje sutinu radova starogrkih lekara, od kojih je vei deo danas izgubljen, a u isto vreme, daje i svoj lini doprinos temi [12]. Veliki vizantijski doktori, od Posejdonija i Oribasija (IV vek n.e.) do Jovana Aktuarija (XIV vek n.e.), ostavili su za sobom mnotvo klinikih opisa od znaaja za psihijatriju, koje su preuzeli iz dela antikih lekara, posebno Hipokrata (V vek p.n.e.), Galena (II vek n.e.), Areteja (I-II vek n.e.), Sorana iz Efesa (I-II vek n.e.) i drugih. U njihovim delima je, osim likantropije, opisan i veliki broj drugih mentalnih poremeaja, kao to su manija, melanholija, katafora (duboka depresija), frenitis, ljubavna bolest, inkubus (nona mora), letargija, nesanica, senilna atrofija mozga (vrsta demencije), trovanje alkoholom i epilepsija [13]. Materijal Prvi vizantijski lekar koji se bavio likantropijom nije bio Ecije, kako tvrde neki autori [14], ve Oribasije (IV vek n.e.), koji je napisao prvo poglavlje u vizantijskoj medicinskoj literaturi na ovu temu, pod naslovom O likantropiji [15]. Oribasije je pisao da likantropi izlaze nou, uglavnom se zadravaju u blizini grobnica do zore, a njihovo ponaanje je nalik vujem. Ovakvi bolesnici su mogli da se prepoznaju uz pomo sledeih znaka i simptoma: bledi su, pogled im je prazan, oi suve i duboko usaene i bez suza.
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Jezik im je suv i ne mogu da lue pljuvaku. Uvek su edni, a potkolenice su im obino povreene jer se esto sapliu o stvari. Prema Oribasiju, ova bolest je dijagnostikovana kao vrsta melanholije. Leenje u toku hronine faze je ukljuivalo smirivanje pacijenta, dugotrajno putanje krvi dok bolesnik ne bi izgubio svest, kupanje u sveoj (ne i morskoj) vodi, a preporuivalo se unoenje tenosti. Nakon toga, pacijent je tokom tri dana morao da se pridrava ishrane zasnovane na obranom mleku i da uzima biljni purgativ uur, to je ponavljano tri puta (ukupno devet dana). Korieno je i bilje pomeano sa medom, to je u to vreme bio uobiajen lek za melanholiju. U akutnoj fazi bolesti, u ui i nozdrve bolesnika ukapavana su uspavljujua ulja koja su najee sadravala opijum. Jo jedan uveni vizantijski lekar bavio se likantropijom Ecije (VI vek n.e.), koji je napisao poglavlje pod naslovom O likantropiji, odnosno kinantropiji, prema Marsiliju [16], opisao je ponaanje bolesnika na isti nain kao Oribasije, dodavi da likantropi lutaju nou u februaru, oponaajui vukove ili pse. Dao je istu kliniku sliku kao Oribasije, dodajui da su rane na potkolenicama nastale kao rezultat estih padova i ujeda pasa, i da se ne mogu zaleiti. On je, takoe, smatrao da je ova bolest jedan oblik melanholije i predlagao je slian nain leenja kao Oribasije. Pridodao je neke nove purgative, kao to su sveti lekovi Rufusa, Arhigena i Justusa. Neposredno pre veernje krize, on je, takoe, preporuivao uspavljujue i sline supstance, posebno opijum, koji se davao ili u obliku ulja kroz nozdrve, ili u nekim retkim sluajevima per os. Pavle Eginjanin (VII vek n.e.) bio je saglasan sa dva prethodna autora. Jedno znaajno poglavlje koje je napisao naslovio je O likantropiji ili Likaonu, to je sa sobom nosilo konotacije inspirisane grkom mitologijom [17]. Anonimni pisac [18] jednog poglavlja o likantropiji slagao se sa stavovima Oribasija i Ecija, i dodao da su likantropi neuobiajeno mravi, to je karakteristino za melanholiju. Njihova melanholina konstitucija je ili uroena ili steena, nastala kao posledica nesanice, stresnih ivotnih situacija, loe ishrane ili skrivenih hemoroida, a kod ena zbog prestanka menstrualnog ciklusa. Nain leenja ove bolesti se, prema ovom autoru, poklapa sa onim za koji su se zalagali raniji vizantijski autori. Takoe je preporuivao uopteno leenje melanholije, i posebne simptomatske tretmane u sluaju hemoroida (operacija) i menstrualnih anomalija. Na kraju, autor je preporuivao diuretike i perspirante. Novija istraivanja [19,20] pruaju dokaze da je ovaj anonimni pisac verovatno bio Pavle iz Nikeje, uveni vizantijski lekar iz VII veka n.e. Mihajlo Psel, lekar i uveni filozof kasnijeg doba (XI vek n.e.), u svoju pesmu Carmen de re medica ukljuio je i opis u to vreme poznatih bolesti [21]. Kratko je primetio da je likantropija ne samo oblik melanholije, ve i mizantropije, poto je pacijent izolovan od drutva. Bolesnika je opisao kao bledog, potitenog, sparuenog i zaputenog izgleda.
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Poslednji uveni vizantijski lekar, Jovan Aktuarije (XIV vek n.e.), koji je objedinio znanja svih lekara dugog vizantijskog perioda, bavio se melanholijom u poglavlju O melanholinim bolestima [18]. U opis je ukljuio i sluajeve pojedinaca koji su verovali da poseduju boji dar predvianja budunosti, ili su se plaili bezopasnih svakodnevnih dogaaja, ili bezrazlono izbegavali drutvo ljudi ili razgovor sa njima, utljivi, tuni i povueni. Opisao je i druge, koji su se ili plaili smrti ili je prieljkivali, uz misli o samoubistvu. Klinika slika koju je pruio ista je kao kod ranijih lekara, posebno u sluajevima likantropije. Tvrdio je da bolesnici nou lutaju po grobljima i usamljenim mestima, poput vukova, a preko dana se vraaju svojim domovima, gde je njihovo ponaanje naizgled normalno. Diskusija Prvi opis likantropije dao je lekar Marsilije Siditski (tj. iz Sidije, grada u Maloj Aziji), koji je bio sledbenik aleksandrijske pneumatske kole i iveo u Rimu (II vek n.e.). Veina Marsilijevih dela je izgubljena. Meu onima koja su sauvana, moe se izdvojiti njegovo delo o likantropiji ili kinantropiji. U svojoj knjizi koja je sadrala razna medicinska miljenja o melanholiji, Galen je citirao znaajan izvod iz dela svog savremenika Marsilija [22]. Sam Marsilije je likantropiju smatrao jednim oblikom melanholije. Ova bolest je kasnije smatrana zooantropskim delirijumom, poto je pacijent bio uveren da se pretvorio u vuka [3]. Ovu vrstu transformacije ve je opisao Hipokrat [3]. Bila je poznata i u vizantijsko doba, i veliki vizantijski lekar, Aleksandar Tralski (VI vek n.e.), iako nije opisao likantropiju per se, predstavio je nekoliko sluajeva melanholije komplikovane raznim vrstama udnih fantazija [23]. Konkretno, opisao je pacijente koji veruju da su crepovi, ili ivotinjske koe, ili petlovi, i imitiraju njihovo kukurikanje. Neki drugi pacijenti su imali fantazije inspirisane grkom mitologijom; verovali su da su slavuji koji plau jer su izgubili Itija (mitoloka linost) ili da su Atlas koji podupire nebeski svod, i plaili se da bi on mogao da padne i uniti i njih same i ceo svet. Oribasije, koji je sastavio prvi medicinski opis likantropije u vizantijsko doba, bio je paganin i prihvatio je Marsilijev pristup. Kliniki opis i nain leenja koji su predloili bili su prilino slini, mada su se razlikovali u nekim takama. Meutim, uticaj starih naroda jo uvek je bio oigledan dva veka kasnije, kada je hrianin Ecije gotovo od rei do rei usvojio Marsilijeve koncepte i etioloki pristup. Marsilije je isticao da je likantropija mentalna bolest, a ne stvarni fenomen, poto je nemogue da se ljudsko bie fiziki preobrazi u vuka. Bolesnik veruje da se u njemu odigrala magina promena [3]. Prema tome, Marsilije je oigledno pokuao da obuzda magijska verovanja svog vremena u korist medicinske realnosti, zastupajui stav da je likantropija psihoza, a ne magijski preobraaj. Koncept likantropije su kasnije usvojili islamski doktori; prema Dolsu [14], iz Ecijevih tekstova. Mogue je, meutim, da su arapski lekari bili
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upoznati sa ovom temom preko radova Galena, Oribasija, Pavla iz Nikeje, ili ak Pavla Eginjanina, koji su opisali sline klinike slike i ija su dela bila poznata u islamskoj literaturi. Rad kasnijih vizantijskih lekara imao je snaan uticaj na medicinske koncepte kod Arapa [24]. Razes je doslovce prihvatio miljenja Vizantinaca; drugi su, kao Abulkasis, dodavali neke elemente terapije kao to je kauterizacija glave, metod koji se nije nalazio u vizantijskim ili Galenovim tekstovima. Drugi arapski lekari smatrali su da je ova bolest nasledna i teko izleiva [14]. Prema Dolsu [14], likantropija predstavlja dobar primer sindroma iz ovog perioda koji su iskljuivo teorijski. Ne postoji nijedan slian opis u srednjovekovnoj islamskoj literaturi. Prema tome, mogue je da je klinika slika likantropije izvedena iz grke medicine [13]. Kasnije je ovu kliniku sliku prihvatila i zapadnoevropska medicina, i to ili direktno iz vizantijskih medicinskih tekstova ili, to je ei sluaj, posredno, preko prevoda arapskih tekstova na latinski [13]. ini se da je ova bolest, koju karakteriu lutanje oko grobnica preko noi i vraanje u svakodnevnu rutinu preko dana, slina mitu o vampirima, koji se moe nai u mnogim kulturama irom sveta [25]. Da zakljuimo: mnogi vizantijski lekari detaljno su opisali kliniku sliku likantropije. Neki osnovni simptomi ovog poremeaja, kao to je drutvena izolacija, mizantropija, potitenost i nemar prema spoljanjem izgledu, ubrzo su ih naveli da ovo stanje klasifikuju kao mentalni poremeaj, u skladu sa shvatanjem Marsilija, koji ga je prvi opisao. Preciznije, vizantijski lekari klasifikovali su likantropiju kao oblik depresije (melanholini tip, ili psihotina depresija). Treba napomenuti da ni Marsilije, iako je bio paganin, ni hrianski vizantijski doktori, nisu verovali da je ovaj poremeaj magijskog ili demonskog porekla, ve su smatrali da je re o duevnoj bolesti. Njihovi stavovi su neposredno ili posredno uticali na arapsku i zapadnoevropsku medicinu.
Psihijat. dan. /2005/37/2/329-334/ Kontaxakis P. V. Lycanthropy according to Byzantine physicians
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General article UDK: 616. 89 - 008 (495.02) 616. 89 (091)
LYCANTHROPY ACCORDING TO BYZANTINE PHYSICIANS

Vassilis P. Kontaxakis1, John G. Lascaratos2, Panayotis P. Ferentinos1, Maria-Irini V. Kontaxaki1, George N. Christodoulou1
1
Department of Psychiatry, University of Athens, Greece 2 History of Medicine, University of Athens, Greece
Abstract: The purpose of this paper is to review texts about lycanthropy in Byzantine medical literature and to appreciate their impact on medicine thenceforth. The original Greek language texts of the Byzantine physicians, such as Oribasius (4th century A.D.), Aetius (6th century A.D.), Paul of Aegina (7th century A.D.), Paul of Nicea (7th century A.D.), Michael Psellus (11th century A.D.) and Joannes Actuarius (14th century A.D.), were examined. The existing texts of ancient Greek and Roman physicians were also reviewed. Byzantine physicians provided detailed descriptions of the clinical picture of lycanthropy as well as suggestions about its treatment. They believed lycanthropy to be a form of melancholic or psychotic depression and not demonic in origin, being in line with the Roman physician Marcellus Sidites (2nd century A.D.), who first described the syndrome. The views of Byzantine physicians about lycanthropy have directly or indirectly influenced the way Arabic and Western European medicine have later dealt with it. Key words: Byzantine medicine, history of medicine, lycanthropy, depression, melancholy, psychosis
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Introduction Lycanthropy is the delusional belief of having been transformed into an animal, traditionally a wolf [1,2]. The term lycanthropy originated from the Greek words lycos = wolf and anthropos = man. The first descriptions of the syndrome can be found in Greek mythology. Demigod Lycaon was transformed by Zeus into a wolf as a punishment for his attempt to feed Zeus with the flesh of a young boy he had sacrified [3]. A later description of the syndrome is found in the Bible. In the Book of Daniel a divine punishment was inflicted upon the Babylonian King Nebuchadnezzar; he was transformed into an ox for seven years [4,5]. In the beginning of the 19th century lycanthropy was considered as a mental disorder [6]. During the 20th century, several case reports of lycanthropy were published in the international literature. Most of them concerned patients suffering from affective or psychotic disorders. Further cases of man-animal metamorphoses were reported in patients with other mental disorders, including personality disorders, hysteria, alcohol or drug abuse, organic brain syndromes, dementia, and epilepsy [7-11]. The purpose of this study is to show that the works of Byzantine physicians on lycanthropy provided new data and offered clearer interpretations of this condition; moreover, they provide evidence that since ancient times lycanthropy had been thought to be a mental disease. Byzantine medicine is, in fact, the continuation of ancient Greek, Hellenistic and Roman medical tradition, as well as the vital link to Western European medicine, which it influenced directly or indirectly, via the works of Arab physicians. The investigation of the writings of Byzantine physicians is of significant interest because most of them reproduce the essence of the writings of ancient Greek physicians, many of which are now lost, without failing to supply their own contribution at the same time [12]. The great Byzantine doctors, from Possidonius and Oribasius (4th century A.D.) to Joannes Actuarius (14th century A.D.), provided many clinical descriptions of psychiatric interest, which they compiled from the works of ancient physicians, especially Hippocrates (5th century B.C.), Galen (2nd century A.D.), Aretaeus (1sl- 2nd century A.D.), Soranus from Ephesus (1 s t - 2nd century A.D.) and others. Apart from lycanthropy, a series of other mental disorders were described in their works, such as mania, melancholy, cataphora (profound depression), phrenitis, lovesickness, incubus (nightmare), lethargy, insomnia, senile cerebral atrophy (a type of dementia), alcoholic intoxication and epilepsy [13]. Material The first Byzantine physician to deal with lycanthropy was not Aetius, as referred to by some authors [14], but Oribasius (4th century A.D.), who wrote the first chapter of Byzantine medical literature on this topic, entitled On Lycanthropy [15]. Oribasius wrote that lycanthropes circulate at night, usually stay around tombs until dawn, and behave exactly like wolves. The
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recognition of these sufferers was achieved by noting the following signs and symptoms. They are pale and gaze vacantly with dry eyes deep in their sockets, without producing tears. Their tongue is dry and they do not produce saliva at all. They are always thirsty and their shins are usually injured because they often stumble against objects. According to Oribasius the disease was diagnosed as a form of melancholy. The treatment during the chronic phase included calming the patient, extended venesection until the sufferer fainted, baths in fresh (non-salt) water, while fluid-intake was encouraged. Later on, a fat-free milk diet and holy marrow herb purgatives were administered for three days. This was repeated three times (a total of nine days). Then, theriac-containing snakes, the usual remedy for melancholy in that time, were administered. In the acute phase of the disease, somniferous inunctions into the ears and nostrils, most often containing opium, were used. The second eminent Byzantine physician dealing with lycanthropy was Aetius (6th century A.D.), who wrote a chapter entitled On Lycanthropy, that is cynanthropy, according to Marcellus [16]. Aetius described the behavior of sufferers in the same way as Oribasius and added that lycanthropes wander at night in February, imitating wolves or dogs. He provided the same clinical picture as Oribasius, adding that the wounds of the shins are due to repeated falls and dog bites and are incurable. He also considered the disease as a form of melancholy and suggested a similar treatment as Oribasius. He went on to add some new purgatives, such as the holy drugs of Rufus, Archigenes and Justus. Before an imminent evening crisis, he also recommended soporifics and similar substances, in particular opium, administered either as inunctions into the nostrils or in some rare cases per os. Paul of Aegina (7th century A.D.) was in line with the two previous authors. He entitled his relevant chapter On Lycanthropy or Lycaon, implying connotations inspired from Greek mythology [17]. Another anonymous writer [18] of a chapter on lycanthropy agreed with the ideas of Oribasius and Aetius and added that lycanthropes are unusually slim, which is a characteristic of melancholy. Their melancholic constitution is either congenital or acquired, resulting from insomnia, life stressors, bad diet or blind hemorrhoids and, in women, a cessation of the menstrual cycle. According to the author, the treatment of the disease coincided with that advocated by earlier Byzantine writers. He further recommended general treatments of melancholia and special causative treatments in cases of hemorrhoids (surgery) and menstrual anomalies. Finally, the author suggested diuretics and perspirants. Recent researches [19,20] have provided evidence that the anonymous writer was probably Paul of Nicea, an eminent Byzantine physician of the 7th century A.D. A later physician and eminent philosopher, Michael Psellus (11th century A.D.), included in his poem Carmen de re medica a description of the known diseases in that time [21]. He noted briefly that lycanthropy is not only a form of melancholy but also misanthropy, since the patient is isolated
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from society. He described the sufferer as pale, dejected, dry, and careless of his appearance. The last famous Byzantine physician, Joannes Actuarius (14th century A.D.), who summarized the knowledge of all the physicians of the extensive Byzantine period, dealt with melancholy in his chapter On Melancholic Diseases [18]. He included cases of individuals believing that they had the divine gift of forecasting the future, or fearing harmless everyday events, or unreasonably avoiding the company of or conversation with people, remaining silent, sad and withdrawn from society. Finally, he described others who either feared death or desired it, having suicidal thoughts. In lycanthropy cases, in particular, he provided the same clinical picture as earlier physicians. He argued that at night sufferers wander around cemeteries and lonely places like wolves; while during daytime they return to their homes, where their behavior is apparently normal. Discussion The first description of lycanthropy was given by the physician Marcellus Sidites (i.e. from Sydia, a town in Asia Minor), who was a follower of the Pneumatic School of Alexandria and lived in Rome (2nd century A.D.). Most of Marcellus works have been lost. Among the remaining ones, his work on lycanthropy or cynanthropy can be singled out. Galen quotes a relevant extract of his contemporary Marcellus work in his book containing various medical opinions on melancholy [22]. Marcellus himself considered lycanthropy to be a form of melancholy. The disease was later considered to be zooanthropic delirium, as the patient thought he had been transformed into a wolf [3]. This kind of transformation had already been described by Hippocrates [3]. It was also known in Byzantine times, as a great Byzantine physician, Alexander of Tralles (6th century A.D.), presented several cases of melancholy complicated with different kinds of strange fantasies, although he did not describe lycanthropy per se [23]. In specific, he described patients who believed they were rooftiles, or animal skins, or cockerels, imitating their crowing. Some other patients had fantasies inspired from Greek mythology; they believed they were nightingales crying because they had lost Itis (a mythological figure) or they believed they were Atlas supporting the globe, fearing that it might fall and destroy themselves and the whole world. Oribasius, who compiled the first medical description of lycanthropy in Byzantine times, was a pagan and he adopted Marcellus approach. The clinical description and treatments they proposed were quite similar, although different in some points. However, the influence of the ancients was still evident two centuries later, when the Christian Aetius adopted, almost verbatim, Marcellus' concepts and etiological approach. Marcellus pointed out that lycanthropy was a mental disease and not a real phenomenon, as it is impossible for a human being to be transformed physically into a wolf. The sufferer
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believes that a magical change has taken place within him [3]. Thus, Marcellus obviously harnessed the magical beliefs of his time to the medical reality, advocating that lycanthropy is a psychosis and not a magical transformation. The concept of lycanthropy was later adopted by Islamic doctors; according to Dols [14], from the work of Aetius. It is, however, possible that Arab physicians could have known this from the works of Galen, Oribasius, Paul of Nicea or even Paul of Aegina, who described similar clinical pictures and whose works were known in the Islamic literature. The work of the later Byzantine physicians deeply influenced the medical concepts of the Arabs [24]. Razes adopted verbatim the opinions of the Byzantines; others like Abulcasis added some therapeutic elements such as cauterization of the head, a method not included in Byzantine or Galenic texts. Other Arab physicians considered the illness inherited and hardly curable [14]. According to Dols [14], lycanthropy represents a good example of the purely notional syndromes of this period. No similar description in the medieval Islamic literature exists. Thus, it is possible that the clinical picture of lycanthropy was derived from Greek medicine [13]. Later, this clinical picture was adopted by Western European medicine either directly from the Byzantine medical texts or, mainly, indirectly from translations of the Arabic works into Latin [13]. It seems that the disease, characterized by wandering around tombs at night and returning to everyday routine during daytime, resembles the myth of vampires, which can be found in many cultures worldwide [25]. In conclusion, many Byzantine physicians have described the clinical picture of lycanthropy in detail. Some main symptoms of the disorder, such as social isolation, misanthropy, dejection and carelessness of one's appearance, have led them to early classify this condition as a mental disorder, in line with the concepts of Marcellus, who first described it. In specific, Byzantine physicians have classified lycanthropy as a form of depression (melancholic type or psychotic depression). It is worth noting that neither Marcellus, though a pagan, nor Christian Byzantine doctors thought that the disorder was magical or demonic in origin, and they believed it to be a mental illness. Their views have directly or indirectly influenced Arabic and Western European medicine.
References
1. Coll PG, O' Sullivan G, Browne PJ. lycanthropy lives on. Br J Psychiat 1985 147: 201-202. 2. Verdoux H, Bourgeois M. A partial form of Lycanthropy with hair delusion in a manic-depressive patient. Br J Psychiat 1993 163: 684-686. 3. Roccatagliata G. A history of Ancient Psychiatry. New York: Greenwood Press; 1986. 4. Arieti S. American handbook of psychiatry. Vol. 3. New York: Basic Books; 1974.
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5. Rosner F. Julius Preuss' Biblical and Talmudic medicine. New York: Hebrew Publishing Company; 1983. 6. Esquirol J. Des maladies mentales. Vol. 1. Paris: Bailliere; 1838. 7. Keck PE, Pope HG, Hudson JI, McElroy SL, Kulick AR. Lycanthropy: Alive and well in the twentieth century. Psychol Med 1988 18:113-120. 8. Fahy TA. Lycanthropy: A review. J Roy Soc Med 1989 82:37-39. 9. Rao K, Gangadhar BN, Jayakiramiah N. Lycanthropy in depression: Two case reports. Psychopathology 1999 32:169-172. 10. Verdoux H, De Witt J, Benezeh M. La lycanthropie: Une pathologie contemporaine? Annales de Psychiatrie 1989 4:176-179. 11. Garlipp P, Godecke-Koch T, Dietrich DE, Haltenhaf H. Lycanthropy psychopathological and psychodynamical aspects. Acta Psychiatr Scand 2004 109:19-22. 12. Lascaratos J, Cohen M, Voros D. Plastic surgery of the face in Byzantium in the fourth century. Plast Reconstr Surg 1998 102:1274-1280. 13. Mettler CC. History of medicine. Philadelphia: The Blakiston Co.; 1947. 14. Dols MW. Majnun. The Madman in Medieval Islamic Society. Oxford: Clarendon Press; 1992. 15. Raeder I. Oribasii Synopsis ad Eustathium. Libri ad Eunapium. Amsterdam: Hakkert; 1964. 16. Olivieri A. Aetii Amideni Libri Medicinales V-VIII. Berolini: Academia Litterarum; 1950. 17. Heiberg IL. Paulus Aegineta. Vol. 1. Lipsiae et Berolini: Teubner; 1921. 18. Ideler IL. Physici et Medici Graeci Minores. Vol. 2. Amsterdam: Hakkert; 1963. 19. Zervos S. Identification of the authors of two anonymous medical texts. Athens, 20:1908 502-508. 20. Ieraci Bio AM. Paolo di Nicea. Manuale Medico. Napoli: Bibliopolis; 1996. 21. Ideler IL. Physici et Medici Graeci Minores. Vol. 1. Amsterdam: Hakkert; 1963. 22. Kuhn CG. Claudii Galeni Opera Omnia. De Melancholia ex Galeno, Rufo, Posidonio et Marcello, Sicamii Aetii Libellus. Vol. 19. Lipsiae: Cnobloch; 1830. 23. Puschmann T. Alexander von Tralles. I. Band. Amsterdam: Hakkert; 1963. 24. Ullmann M. Islamic medicine. Edinburgh: Edinburgh University Press; 1978. 25. Gonez-Alonso J. Rabies. A possible explanation for the vampire legend. Neurology 1998 51:856-859.
_____________________________ Doc. dr Vasilis P. KONTAKSAKIS, Univerzitet u Atini, Psihijatrijsko odeljenje bolnice Eginition, Grka Vassilis P. KONTAXAKIS, MD, PhD, Associate Professor of Psychiatry, University of Athens, Greece E-mail: bkont@cc.uoa.gr
Psihijat. dan. /2005/37/2/335-340/ Petrovi N. Dvojstvo ene
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Struni rad UDK: 159. 923 - 055.2
DVOJSTVO ENE
Nataa Petrovi Stefanovi1 i Stevan P. Petrovi
1
Institut za mentalno zdravlje, Beograd, Srbija i Crna Gora
Apstrakt: Lilit kao psiholoka datost prisutna je u podsvesti i svesnim sferama ljudi vie hiljada godina i, uprkos raznim transformacijama i metamorfozama, ostala je podjednako aktuelna do danas, reinkarnirajui pod svim podnebljima arhetipsku matricu nikada ponovljive, zastraujue i dijaboline enskosti. U mitologiji je poznata kao demonica, deraica mukaraca i ubica dece.U psiholokom smislu Lilit moe biti mrani aspekt enske seksualnosti, arhetipska enskost u ogoljenoj formi, koja nosi u sebi ogromne koliine zloudne agresivnosti i osvetniko ponaanje, nasuprot pokornoj i prijemivoj Evi. Njene moi najizraenije su na najvanijim raskrsnicama u ivotu ene: u pubertetu, pred menstruaciju, na poetku i kraju trudnoe, materinstva i menopauze. Kako je Lilit u velikoj meri prisutna u svakodnevnom ivotu kao i u psihopatologiji, pitamo se zasluuje li da u strunoj literaturi dobije poseban entitet, kakav su, recimo, dobili Edip, Don uan, Otelo. Kljune rei: Lilit, linost ene, prvobitna Eva
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Uvod Mrana i tajanstvena Lilit, kao psiholoki ideogram za mranu stranu ene, bez obzira na njena druga imena pod kojima se prikazuje i kao jedinstveno mitsko bie, prisutna je u nesvesnom oveka, irom planete, vie hiljada godina [1]. Iako se u svojim manifestacijama iskazuje kao strana i istovremeno neodoljivo privlana figura nejasnih komara, koji uasavaju mukarce i bude ih preplaene iz njihovih snovnih lutanja s onu stranu jave, sa prateom griom savesti zbog opsesivne pretpostavke da je nona mora sa Lilit u glavnoj ulozi kazna ili opomena za privlane fantazme o preljubi, Lilit je neprekidno iskuenje za sve mukarce koji pokuavaju da je izbegnu po svaku cenu, ali u tome nikako ne uspevaju, jer ona predstavlja otelovljenje svih njihovih potajnih poligamnih elja, kojih ne mogu da se odreknu, zbog njihovog teko kontrolisanog nagona za stalnim doivljavanjem novog i drugaijeg, onoga to nikada nisu doiveli sa svojim enama. Kada iracionalno preovlada u mukarcu, umesto razumne odbrane od smrtonosnih izazova Lilit, uz pakleno privlanu lepotu i pohotu koja zrai iz ove tajanstvene ene, tada nema ni govora o bilo kakvom vidu razumne odbrane od smrtonosnih izazova Lilit, koja upravo ide u susret svim njegovim potajnim eljama. Kada konano osvoji mukarca, maska neodoljivo privlane ene joj spada sa lica i ona se prikazuje u svojoj originalnoj slici, kao nakazna spodoba, ptijih nogu sa dugim kandama, iji spoljni izgled ledi krv u ilama mukaraca, koji su se u prvom trenutku predali neodoljivim izazovima njenih lanih ari, koje su prisutne sve dok ne osvoji i ne podjarmi mukarca. Ali tada je, najee, sve kasno. Povratka u prvobitno stanje nema. Kazni uasne Lilit ne moe se vie umai. U tom smislu, ona je prikazana kao Monada, jer je jedinstvena razorna sila, kao inkarnacija radikalnog i apsolutnog zla, koje ispunjava njeno kompletno bie. Dobrota je njenom biu nepoznata moralna kategorija, ak i u najskrivenijim naznakama. A to radikalno zlo, imanentno pripisano enama, potie od strane mukaraca koji su pisali mitologiju, i nije nimalo bez znaaja, jer se kroz ovakve enske likove esto, tokom istorije, ispoljavalo kroz mizoginiju, strah pomean sa mrnjom prema svojoj tajanstvenoj drubenici. ak i najbrutalniji mukarci zaziru od neega nepoznatog u svojim enama, koje ne mogu da dokue do kraja, ali koje doivljavaju kao neto latentno opasno. To je neto to mukarca tera na stalnu opreznost u odnosima sa enom. I, kako bi uspostavili kakvu-takvu ravnoteu sa svojim enskim partnerom, reaguju nasiljem. Mitska Lilit Jedinstvena pria o Lilit, onakva kakvu je danas znamo, nikada nije postojala u svetskoj mitologiji. Pojedinani zapisi o demonici noi ili mranoj strani ene koja se konano, nakon mnogo vekova, otelotvorila kao jedinstveni enski entitet pod nazivom Lilit, zaeli su se u razliitim delovima sveta, u razliitim vremenskim epohama. I, uprkos brojnim transformacijama i metamorfozama, ovo bie reinkarnira na svim podnebljima arhetipsku mat-
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ricu zastraujueg i dijabolinog aspekta enskosti, koje je u mitologiji raznih naroda poznato kao demonica, deraica mukaraca i ubica dece [2]. U apokrifnim spisima se moe nai pod raznim imenima, skrivena iza razliitih likova: kao kraljica Zamaragda, kraljica od Sabe, zmija Serpent iz Edenskog vrta, koja navodi Evu i, posredno, Adama na greh, Kali, Hekata, Morgan le Fej, Lorelaj, pa i ekspirova ledi Makbet, u dramskoj literaturi, i jo mnoge druge zastraujue figure. Dve figure koje su prethodile Lilit a koje su sa njom povezane na najoigledniji nain, i koje bismo posebno istakli, vavilonska su demonica Lamatu i njena grka verzija Lamija [3,4]. One se, takoe, vezuju za prodiranje mukaraca i edomorstvo. Ova dva primera, kao i mnogi drugi, uz Lilit, ivi su dokaz da postoji inkorporirana, ko zna kada, tokom evolucije ljudskog roda, neka kobna greka, duboko skrivena, koja se pokatkad budi u vidu radikalnog zla, usmerenog protiv svoga prirodnog para i njegove dece. Ova stvarna greka samo je personifikovana i zaogrnuta datost u plat mita, kako bi se njeno postojanje pribliilo obinom oveku. Tumaenja Lilit su brojna i kontroverzna, ali su, svakako, najpoznatija ona o prvoj Evi, iji se koreni mogu nai jo u drugom veku, u Midrau, koji predstavlja formu aktivnog promiljanja ili meditacije na temu biblijskih predanja, naroito onih iz Prve i Druge knjige Postanja, gde sreemo dve kontradiktorne verzije o stvaranju oveka [5]. Prema jednoj, ovek i ena su stvoreni istovremeno, takorei ni iz ega, ili iz praha zemnog, po obliju Tvorca, a prema drugoj, stvaranju Eve prethodilo je stvaranje usamljenog Adama. Kao to znamo, pravoverni Jevreji i hriani prihvatili su tu drugu verziju kao zvanian stav vere [6]. Prvo pisano objanjenje o postojanju Lilit, kao prvoj Adamovoj eni, dato je u jednom komentaru, poznatom kao Alfabet ben sira, za koji se veruje da je nastao izmedju VII i X veka nove ere [7]. Ova ideja je kasnije dalje razvijana, tako da u XIII veku dostie vrhunac u Kabali, posebno u klasinom tekstu jevrejskog misticizma, poznatom pod imenom Zohar [8]. Dakle, za razliku od starozavetnih biblijskih spisa, koji poznaju samo Evu, kao prvu Adamovu enu, u rabinskoj literaturi prvi put se spominje jedna druga ena, kao prva Adamova druica, pre nego to je Bog stvorio Evu i koja u jevrejskom folkloru nosi ime Lilit. Ona je smatrala da bi, kako su istovremeno stvoreni, iz praha zemlje, dakle, iz iste materije i od strane istog Tvorca, mukarac i ona u svemu trebalo da budu ravnopravni. Ali, Adam ne prihvata to obrazloenje, jer se povinuje savetima Tvorca, i nadalje zahteva pokornost i bespogovornu poslunost, tvrdei da je on kao slika Elohima, njen gospodar i vlasnik. Njeno suprotstavljanje jednoj nepravdi u osnovi je pravino, ali je izvedeno na pogrean nain, u kojem je unapred sebe osudila da bude gubitnica, suprotstavljajui se protivniku koji je bio prejak za Nju. Meutim, gnev koji je obuzima u tom trenutku pomuuje joj razum i ona pribegava iracionalnom ponaanju. U jednom trenutku obraa se reima Neizrecivom, razmahuje krilima i nestaje u nebeskom prostranstvu, putujui put demona, ka
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Crvenom moru, gde se nastanjuje i udaje za Samaela, slepog kralja demona, i sma postaje kraljica i majka demona. Bog alje tri anela da je vrate, to ona odbija i biva kanjena stranom kaznom da gubi stotinu dece svaki dan. Nad telima mrtve dece i sa oima bez suza, zaklinje se na venu osvetu Adamu, da e mu od sada ubijati svu decu i decu njegove dece, sve dok je roda ljudskog, jer ona je besmrtna. Nakon toga, Bog usliava molbu Adamovu, i stvara Evu iz rebra Adamovog, kao simboliki akt podvrgavanja ene mukarcu, ime se izbegava ponavljanje prvobitnog konflikta i dileme oko prvenstva i dominacije. Adam je, dakle, prvostepeno ljudsko bie, a tek zatim Eva iz dela tela njegovog, kao zaloga pripadanja i poslunosti svome oveku [9]. Naputajui Edenski vrt i Adama, Lilit zapravo zapoinje dugi put venog revana, nikada u potpunosti zadovoljenog, pa zbog toga i repetitivnog, zbog ponienja koja je doivela kao prva ena od svog Bojeg izabranika. Ona prema svim opisima, bez obzira na poreklo ili versku pripadnost, otelovljuje sutinsku vezu izmeu enskog i demonskog, drugim reima, ubitanu dimenziju nedeljivu od enskosti, sa osnovnom nakanom da ospori navodnu savrenost i neprikosnovenost mukog aspekta meu biima ljudskog roda. Psihologija ene Ako govorimo o psihologiji ene, neki aspekti mogu se nazreti ve u Zoharu, u kome se Lilit smatra Bludnicom, Prokletnicom, Grenicom ili Crnom, i upozorava mukarce da uvek budu na oprezu, jer svaka ena, pa ak i Evina ki, nosi u sebi skrivene moi Lilit, u svom delu Anime [8]. Dakle, s jedne strane imamo Evu, koja predstavlja roditeljsko-instinktivni aspekt enskog naela, koja titi, hrani i oliava ivot i, sa druge strane, Lilit koja je njena suprotnost, osvetoljubiva, zla i koja moe doneti i smrt. Ona je mrani aspekt enske seksualnosti, okeanska i arhetipska enskost u ogoljenoj formi, naglaavamo, ona je vie ideja o jednom aspektu enske prirode, nego sma priroda ene. Ona je, u svetlosti Jungove analitike psihologije, deo onog mranog dela Anime, koji je u stalnom sukobu sa boanskim i nepromenljivim poretkom stvari, koji enu svodi na korisnu animalnost i sredstvo muke naslade [10]. Ovo dvojstvo enske prirode najoiglednije je tokom menstrulanog ciklusa. U prvoj polovini, jaa je Eva. Oekujui ovulaciju i, moda, zaee, ena se osea otvoreno, prijemivo i povezano sa svetom i ivotom. Ukoliko do zaea ne doe, Eva se povlai a Lilit preuzima primat. Nada ustupa mesto oaju. Uopte, moi Lilit su najizraenije na najvanijim raskrsnicama enskog ivota: u pubertetu, na poetku i kraju trudnoe, materinstva i menopauze. U pogledu patologije Lilit bi mogla biti odgovorna za rane i kasne gestoze, spontane pobaaje, PMS, postpartalne psihoze i depresije, edomorstvo i sl. Isto tako, ona je personifikacija za neobjanjive dogaaje i fenomene koji se deavaju u realnom svetu kao to su none polucije ili SIDS (Sudden Infant Death Syndrome sindrom iznenadne smrti odojeta), koji se odnosi na smrt inae potpuno zdravih beba tokom sna i jo uvek je nepoznate etiologije.
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Bezbroj je pitanja koja se baziraju na zdravorazumskim promiljanjima, a Lilit im svima izmie i definitivno ostaje neuhvatljivi aspekt mrane strane ene, koji nema svoj pandan u okviru mukog pandemonijuma. Moda joj je po koliini zla koje nosi u sebi jedino priblian Asmodej, sin Name i amdona, demon i duh koji u mukarcima budi toliku poudu da ovi ne mogu odoleti da ne iznevere svoje suprunice, uvek spreman da ubije svakog mukarca koji bi mu bio prepreka u osvajanju ena [3]. Taj demon persijskog porekla, koji se pojavljuje i u hebrejskom predanju, bio je otelotvorenje zle energije i seja uasa. Ili, u lepoj knjievnosti, moda, mrani Hitklif. Nije iskljueno da je dvosmislena i vieznana linost Lilit, kraljice i majke demona, tano odreena, osvetljena, uzdignuta od celog svog mitskog dvora, u psihoanalitikom smislu ishod vanrednog simbolikog zgunjavanja. Ona je imaginarni i sintetiki spreg raznih, pa i protivrenih, pretpostavki ili predstava, koje upuuju na razliita arhetipska bia, ije matrice nosimo u sebi a da toga nismo ni svesni. Konano, moda jedno diskretno obeleje ove mitske ene nije manje znaajno, kada se razmatraju motivi njenih ponaanja. Lilit je u dubini svoje due ena koja je doivela razoaranje i poraz u ljubavi, ili u svojoj elji za ostvarivanjem materinstva sa voljenim ovekom; jer, ona je u poetku Adama odista volela nesebinom i snanom ljubavlju, a ni za jednog drugog mukarca nije mogla znati, izuzev za Adama, koji ju je nekada, na neki nain, neoprostivo uvredio i ponizio. A to razoaranje, bez oprosta, moda, objanjava mnoge stvari. Od svojih prapoetaka, ona se nikada ne eksponira kao borac koji treba da povrati svoje izgubljene pozicije kod voljenog oveka, ve iskljuivo kao surovi osvetnik. Neugasiva udnja za osvetom je njeno jedino duhovno obeleje. Nije li to znak njene primalne slabosti i straha od poraza ukoliko ue u otvorenu konfrontaciju sa mukarcem ili neuspeni pokuaj da se pomiri s njim? Strah da ne izgubi bitku sa Evom, koja ju je njenom krivicom potisnula, pomrauje njen noetski horizont i pretvara je u iracionalno zlo, koje ne poznaje nikakve granice i skrupule. Obraun sa decom uvek je u osnovi pomeren obraun sa njihovim ocem, nastavljaem loze Adamove. Ubijanje dece, koja su prirodni nastavljai ivota, i unitavanje mukog semena kroz none polucije, zapravo je borba protiv nastavka ivota, u jednom irem smislu. Na ovaj nain njeno zlo je jo ubitanije i ide jo dalje, a ona biva jo stranija i zlokobnija u svojim paklenim namerama, jer se ne bori samo protiv Ljudi, ve i protiv samog Tvorca ivota, i ivota, samog po sebi, na jedan posredan nain. I pored mnogih intelektualnih spekulacija o prirodi Lilit, koje mogu manje vie da imaju neku svoju logiku, ipak ne moemo do kraja da budemo zadovoljni naim poznavanjem porekla motiva za ovakva ponaanja zagonetne Lilit. Prinueni smo da se uvek iznova vraamo na isto pitanje: zato se Lilit tako lako odrekla svoje enskosti, u svim aspektima, a zadrala samo svoj demonski aspekt, neobino slina ekspirovoj ledi Makbet? Bespogovorno i zauvek. Zato se povukla pred Evom i prepustila joj da bude Velika
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majka i ena Adamova, iako je tu ulogu Tvorac primarno dodelio njoj? Da bude Pramajka ljudskog roda? Nigde se ne vidi njen primarni rivalski odnos prema novostvorenoj Evi, od istog Tvorca, koji je najpre stvorio nju. Zato se odrekla svoga materinstva? Iz ponosa ili uvreenosti, zadravi samo svoj nagonski seksualni i osvetniki aspekt, jer su seksualnost i strasna agresija dve veoma bliske psiholoke kategorije, koje lako prelaze jedna u drugu, i jedna sa drugom razmenjuju energije? Znaaj za psihopatologiju Lilit ivi i dela, i prisutna je u modernom vremenu, jer je ona jedino boanstvo kome je sueno da ivi sve do Dana Sudnjeg. I danas je ona mrani i razorni aspekt ene, podjednako opasan i za mukarce, ene i decu. Istina, danas Jevreji sve ee pokuavaju da je rehabilituju i njeno zlo sublimiu u feministiki aspekt, i prikau je kao borca za enska prava, ije je ponaanje reaktivnog porekla, zbog teke uvrede koju joj je priredio Mukarac. Nismo sigurni koliko e u tome uspeti. U ovom pokuaju vidimo samo neveti pokuaj njene rehabilitacije, jer ona i danas deluje kao zao duh, i to kao est gost u psihopatologiji i psihijatrijskim ordinacijama, to je ini aktuelnim zlom. Lilit-majka nije nepoznata psihoterapeutima i njihovim pacijentima, ije su rtve oliene u njihovoj deci, muevima, ljubavnim partnerima ili enskim rivalima. Na ovom terenu Lilit se moe pojaviti kao zavodnica svoje muke dece, uzronica njihove zaljubljenosti u svoje majke, krivac za homoseksualne nastranosti ili impotenciju svojih sinova. Lilit moe zavesti mueve svojih keri i tako se svetiti mitskoj Evi. Ona tera mueve da nou prosipaju svoje seme i na taj nain unitava njihov porod. Majka-Lilit, ili ona koja raa decu demone, zasluuje da u savremenoj psihopatologiji dobije svoju posebnu nozografsku oznaku, jer je sveprisutna i predstavlja permanentnu opasnost. A, pomalo je ima, veto skrivene, i u Senci svake ene. Iako potie iz mita, ona je u svakodnevnom ivotu i psihopatologiji toliko prisutna da bi meu brojnim entitetima trebalo da dobije svoje mesto i ime, na primer, kao Lilit kompleks. Slino kao Edipov kompleks ili, recimo, Elektra kompleks, ili kompleks Don uana. Nije iskljueno da pria o Lilit pokuava da svedoi i simbolizuje izvesno osporavamje mukog poretka, koji sm upravlja ak i valjanim funkcionisanjem Vaseljene. Ne samo to emo u njoj videti Lilit, prvu enu Adamovu, kako se buni protiv obaveze koju joj je nametnuo Upravlja svih stvari, da ostane ispod mukarca, nego emo videti i kako ona stie povlasticu da se vine u visine Univerzuma, prisvajajui time prednosti uspona, koji su krilo i njegov vertikalni polet do tada metaforiki uvani samo za mukarca. Moda je njena razornost, samo na pometen nain, shvaena kao njena teko dokuiva hermetika poruka. Nije iskljueno da e se u modernom vremenu, u nesigurnoj ravnotei putenosti i duha, ponuditi zavodljiva i plodna Lilit, kao vanvremena dimenzija izmeu uvek preteeg povlaenja nazad i ponekad izopaenog uzdizanja razuma.
Psihijat. dan. /2005/37/2/341-347/ Petrovic N. Duality of woman
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General article UDK: 159. 923 - 055.2
DUALITY OF WOMAN
Natasa Petrovic Stefanovic1, Stevan P. Petrovic
1
Institute of Mental Health, Belgrade
Abstract: Lilith as a psychological fact is present in the subconscious and conscious spheres of mankind for several thousand years and, in spite of various transformations and metamorphoses, she remained as much present to this day, reincarnating worldwide the archetypal matrix of the unique, terrifying and diabolic femininity. In mythology, she is known as the demoness, man-eater and murderer of children. In the psychological sense, Lilith can be the dark aspect of female sexuality, archetypal femininity in the naked form, carrying within herself immense quantity of malicious aggressiveness and vindictive behavior, as opposed to the submissive and receptive Eve. Her powers are at their highest during the crucial turning points in the life of a woman: in puberty, before menstruation, the beginning and end of pregnancy, in maternity and menopause. Having in mind the considerable presence of Lilith in the everyday life, as well as in psychopathology, the question is raised whether she deserves to attain a special entity in the expert literature, as did, for example, Oedipus, Don Juan, Othello.
Key words: Lilith, personality of woman, primordial Eve
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Introduction The dark and mysterious Lilith, as a psychological ideogram for the dark side of woman, regardless of other names she is presented by as a unique mythical being, exists in the unconscious man worldwide for several thousand years [1]. Although in her manifestations she is seen as a terrifying and at the same time irresistibly attractive figure from obscure nightmares, that horrify men and wake them from their dream-wanderings on the other side of reality, followed by guilty conscience due to obsessive presumption that the nightmare of Lilith is either a warning or a punishment for their attractive phantasms of adultery, Lilith is a never-ending temptation for all men who try to avoid her at any cost, but fail to do so, because she is the embodiment of all their secret polygamous desires they cannot renounce because of their uncontrollable urge to constantly experience something new and different, that they have never experienced with their wives. When the man is overpowered by the irrational, instead of the rational defense from the fatal temptation of Lilith and the infernally attractive beauty and lust radiating from this mysterious woman, there can be no rational defense from the fatal temptation of Lilith who is actually aiming to meet all his clandestine desires. When she finally conquers the man, the mask of the irresistibly attractive woman slips off her face and she is seen in her original image, as a monstrous creature, with birds legs and long claws, the mere sight of her freezing the blood in the veins of men who had surrendered to the irresistible temptation of her false charms, charms that are there only until she conquers and enslaves the man. But then it is too late. There is no turning back. The punishment of horrible Lilith cannot be escaped. In that sense, she is depicted as a Monade, for being a unique destructive force, as the incarnation of radical and absolute evil, filling her entire being. Goodness is a moral category unknown to her, even in its most hidden indications. And the radical evil, immanently ascribed to women, comes from the men, the writers of mythology, which is not insignificant since often in the course of history, through female characters such as this, misogyny was expressed, the fear mixed with hatred toward their mysterious companions. Even the most brutal men recoil from something unfamiliar they sense in their wives, something they cannot fully comprehend but feel it as a latent danger. This is what drives the man to constant caution in his relationship with woman. And, in trying to establish some kind of balance with their female partner, their reaction is violence. Mythical Lilith The singular story of Lilith, as we know it today, never existed in the world mythology. Individual texts about demoness of the night or the dark side of woman, which finally, after many centuries, embodied as a separate female entity named Lilith, were conceived in different parts of the world, in different epochs. And in spite of numerous transformations and metamorphoses, this creature reincarnates the archetypal matrix of terrifying and dia-
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bolical aspect of femininity worldwide, known in the mythology of various nations as demoness, man-eater and murderer of infants [2]. In the apocryphal texts it can be found under various names, hidden behind different personages: as queen of Zamargada, queen of Sheba, Serpent from the Garden of Eden, which led Eve and, consequently, Adam into sin, Kali, Hecate, Morgan le Fay, Lorelei, even Shakespeares Lady Macbeth in dramatic literature, and many other terrifying figures. Two figures preceding Lilith and connected with her in the most obvious way, which we would like to emphasize, are the Babylonian demoness Lamashtu and her Greek version Lamia [3,4]. They are also mentioned in reference with eating men and murdering children. These two examples, as many others apart from Lilith, are the living proof of the existence of a fatal error incorporated at some point during the evolution of mankind, deeply hidden, that sometimes emerges in the form of radical evil, aimed against the natural mate and his children. This actual error is only a personified fact masked as a myth, so its existence could be brought closer to the ordinary man. Interpretations of Lilith are numerous and controversial, but the best known are undoubtedly those of Lilith as the first Eve, originating from the II century Midrash, which is a form of active contemplation or meditation on the subject of biblical tradition, particularly the first and second Book of Genesis, where two contradictory versions of the creation of man are found [5]. According to one of them, man and woman were created at the same time, virtually out of nothing or out of earthly dust, in Gods image, and according to the other version, the creation of Eve was preceded by the creation of Adam alone. As we know, orthodox Jews and Christians accepted the second version as the official credo of the religion [6]. The first written account of the existence of Lilith as Adams first wife was given in a commentary known as Alphabet ben Sira, believed to have originated between VII and X century AD [7]. Later this idea developed further, reaching its peak in the XIII century, in the Kabbalah, particularly in the classic text of Jewish mysticism known as Zohar [8]. Thus, as opposed to the Old Testament, which refers only to Eve as Adams first wife, in the rabbinical literature another woman was mentioned for the first time, as Adams first companion, before Gods creation of Eve, and who, in the Jewish folklore, is known by the name of Lilith. She believed that, since they were created at the same time, from the dust of the earth, that is, from the same matter and by the same Creator, man and she should be equal in all. But Adam did not accept this explanation, following the advice of the Creator, and continued to demand submission and absolute obedience, claiming that he, as the image of Elohim, was her master and owner. Her standing up against the injustice was fundamentally right, but it was carried out in the wrong way, and she condemned herself beforehand to be the loser, by confronting the opponent too strong for her. However, the rage she felt at that moment blurred her
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mind and she resorted to irrational behavior. In a moment, she uttered the Ineffable Name, spread her wings and disappeared in the sky, fleeing to the demons, to the Red Sea, where she stayed and married Samael, the blind demon king, and became the queen and mother of demons. God sends three angels to bring her back, which she refuses, and she is then horribly punished - to losing one hundred of her children every day. Standing above the bodies of her dead children, with tearless eyes, she vows to eternal revenge over Adam, that from that moment on, she would kill all his children and his childrens children, as long as mankind exists, for she is immortal. Subsequently, in the answer to Adams pleading, God creates Eve from Adams rib, as a symbolic act of womans submission to man, in order to avoid the repetition of the first conflict and the dilemma regarding supremacy and domination. Adam is, therefore, the principal human being, and Eve comes later from a part of his body, to be obedient to her man and to belong to him [9]. By leaving Adam and the Garden of Eden, Lilith has embarked on a long journey of eternal retribution, never completely satisfied and therefore repetitive, for the humiliation she had experienced as the first wife from the one chosen for her by God. According to all descriptions, regardless of their source or religious origin, she embodies the fundamental connection between female and demonic, in other words, the fatal dimension undividable from femininity, with the basic intent to negate the alleged perfection and supremacy of the male aspect of human beings. Psychology of woman Referring to the psychology of woman, certain aspects can already be detected in Zohar, referring to Lilith as the Prostitute, the Damned, the Sinful or the Black, and warning men to be careful at all times, since every woman, even a daughter of Eve, carries within herself the hidden powers of Lilith, in her part of anima [8]. So, on the one hand there is Eve, representing the parental-instinctive aspect of the female principle, protecting, nurturing, a symbol of life, and Lilith on the other, her complete opposite, vindictive, evil and potentially fatal. She is the dark aspect of female sexuality, oceanic and archetypal femininity in the naked form; we have to stress that she is more of an idea of an aspect of female nature than the real nature of woman. In the light of Jungs analytic psychology, she is a part of the dark side of Anima, in constant conflict with the divine and unchangeable order that degrades the woman to useful animalism and the means for male pleasure [10]. This duality of female nature is the most obvious in the menstrual cycle. In the first half, Eve is the stronger one. Waiting for the ovulation and possible conception, the woman feels open, receptive and connected with the world and the life. If the conception does not occur, Eve draws back and Lilith takes over. Hope turns into despair. Generally speaking, the powers of Lilith are at their highest during the most important turning points in the life
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of woman: in puberty, beginning and end of pregnancy, maternity and menopause. When pathology is considered, Lilith could be responsible for early and late gestoses, spontaneous miscarriages, PMS, postpartum psychoses and depressions, infanticide etc. She is also a personification of inexplicable events and phenomena occurring in reality, such as nocturnal emissions or SIDS (Sudden Infant Death Syndrome), death of otherwise completely healthy babies during sleep, which is still of unknown etiology. There are numerous questions based on sound reasoning, and Lilith eludes them all and remains the unreachable aspect of the dark side of woman, with no counterpart in the male pandemonium. By the amount of evil he possesses inside, the only one similar to her could be Asmodeus, the son of Naamah and Shamdon, demon and spirit instigating such lust in men that they cannot resist and be disloyal to their spouses, always prepared to kill any man who presents an obstacle in conquering women [3]. The demon, of Persian origin, appearing also in the Hebrew mythology, was the embodiment of evil energy and terror. Or, in the literature, perhaps the dark Heathcliff. It is possible that the ambiguous and polysemantic personality of Lilith, the queen and mother of demons, clearly distinguishable, rising above her entire mythical suite, is, in the psychoanalytical sense, the product of an outstanding symbolic condensation. She is an imaginary and synthetic merger of various, sometimes contradictory assumptions or representations, pointing to different archetypal beings, the matrixes of which we carry inside ourselves, without being aware of it. Finally, a discrete feature of this mythical woman is perhaps none the less significant, when deliberating on the motives of her behavior. In the depths of her soul, Lilith is a woman who has experienced disappointment and defeat in love, or in her desire to achieve motherhood with the man she loved; because in the beginning her love for Adam was indeed selfless and strong, and she could not have known any other man except Adam, who had somehow offended and humiliated her, unforgivably. And this disappointment, without forgiveness, can perhaps explain many things. From the very beginning, she never acts as a fighter who is trying to regain her place beside the man she loves, but only as a cruel avenger. The unquenchable thirst for revenge is her only spiritual feature. Could this be a sign of her primal weakness and fear of defeat should she enter into an open confrontation with man, or of the failed attempt to make peace with him? The fear of losing the battle with Eve, who suppressed her by her own fault, darkens her noetic horizon and turns her into irrational evil, without any limits or scruples. Basically, conflict with the children is always a shifted conflict with their father, the successor of Adams bloodline. Killing of children, who are the natural prolongation of life, and destruction of male semen through nocturnal emissions, is actually a fight against the continuation of life in a wider sense. In this way, the evil of Lilith is even more deadly and goes even fur-
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ther, and she becomes even more terrifying and ominous in her infernal intent, because she fights not only against mankind, but also against the very Creator of life, and, ultimately, the life itself. In spite of numerous intellectual speculations on the nature of Lilith, following more or less their own logic, we still cannot be fully satisfied by our understanding of the origin of motives for the mysterious Liliths behavior. We are compelled to return to the same question over and over again: why did Lilith renounce her femininity so easily, in all aspects, and kept only her demonic side, unusually similar to Shakespeares lady Macbeth? Unquestionably and eternally. Why did she back away before Eve and let her take over the role of Great mother and wife of Adam, although originally the Creator bestowed this role on her? To be the ancient mother of mankind? Her primal rivalry with the newly-created Eve, made by the same Creator who first made her, is nowhere to be seen. Why did she renounce her motherhood? Out of pride or hurt feelings, keeping only her driving sexual and vindictive aspect, since sexuality and passionate aggression are two very close psychological categories, which easily transform into one another and exchange their energy? Significance for psychopathology Lilith is present in the modern times, living and active, because she is the only deity destined to live to the Judgment day. Even today, she is still the dark and destructive aspect of woman, equally dangerous for men, women and children. As a matter of fact, the Jews today are more often trying to rehabilitate her and sublimate her evil into the feministic aspect, representing her as a champion of womens rights, whose behavior is reactive in origin and comes as a result of the insult she received from Man. We cannot be sure if this effort would succeed. We see it only as an awkward attempt at her rehabilitation, because even today she appears as a malevolent spirit, and a frequent guest in psychopathology and psychiatrists offices, which makes her an existing evil. Lilith-mother is fairly known to psychotherapists and their patients, her victims being her children, husbands, lovers or female rivals. In this field, Lilith can appear as seductress of her male children, the cause of their being in love with their mothers, the culprit for homosexual deviations or impotence of her sons. Lilith can seduce husbands of her daughters and thus have vengeance over the mythical Eve, by taking their husbands from them. She makes the husbands spill their semen at night, thus destroying their offspring. Mother-Lilith, or the one who gives birth to demon children, deserves her own special nosographic mark in modern psychopathology, since she is ubiquitous and represents permanent danger. And she also exists, to a certain extent and carefully hidden, in the Shadow of every woman. Although she comes from a myth, her presence in everyday life and in psychopathology is so strong that she should also have her place and name among
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the numerous entities, such as the Lilith complex, similar to the Oedipus or Electra complex, or the Don Juan complex. It is also possible that the story of Lilith tries to relate and symbolize the opposition against the male order, which even regulates proper functioning of the Universe. Not only that we will see her as Lilith, the first wife of Adam, rebelling against the obligation imposed on her by the Ruler of all things, to stay beneath the man, but we will also see her as gaining the opportunity to rise to the heights of the Universe, thus taking the advantage of the rise, whose wing and vertical ascent were up to that moment metaphorically kept exclusively for the man. Perhaps her destructiveness was, in a deviated way, understood as her difficult to grasp hermetic message. In the modern times of fragile balance between sensuality and spirituality, the seductive and prolific Lilith offers herself as a timeless dimension between the constant threat of retreating and the sometimes twisted glorification of reason. References 1. Koltuv BB. The book of Lilith. York Beach. ME: Nicolas-Hays; 1986. 2. Farrar JS. The Witches Goddess: The feminine principle of divinity. London: Robert Hale; 1995. 3. Hajat V, Dozef V. Demoni. Beograd: Ateneum; 1996. 4. Graves R. The Greek myths. New York: Penguin Books; 1960. 5. Dan J. The Hebrew story in the Middle Ages. Jerusalem; 1974. 6. Milgrom J. Some second thoughts about Adams first wife. In Genesis 1-3 in the History of Exegesis, ed. G. Robbins. Lewiston. ME: Edwin Mellen; 1988. 7. Yassif E. Sippurey ben Sira be-yame ha Binayyim [The Tales of Ben Sira in the Middle Ages]. Jerusalem: Magnes Press; 1984. 8. Matt DC. Zohar: The book of enlightenment. New York: Paulist Press; 1983. 9. Ausbel N. A treasury of Jewish folklore. New York: Bantam; 1980. 10. Jung GK. Dinamika nesvesnog. Novi Sad: Matica srpska; 1996. _______________________________ Nataa PETROVI STEFANOVI, specijalista medicinske psihologije, Institut za mentalno zdravlje, Beograd, Srbija i Crna Gora Natasa PETROVIC STEFANOVIC, medical psychology specialist, Institute of Mental Health, Belgrade, Serbia and Montenegro E-mail: sterod@eunet.yu
Psihijat. dan. /2005/37/2/349-352/ Obavetenja
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IZMENE MADRIDSKE DEKLARACIJE I DODATNA UPUTSTVA U SPECIFINIM ETIKIM SITUACIJAMA

MADRIDSKA DEKLARACIJA (jun 2005) Svetsko udruenje psihijatara usvojilo je 1977. godine Havajsku deklaraciju u kojoj su data etika uputstva za psihijatrijsku praksu. Deklaracija je dopunjena u Beu 1983. godine. Da bi odrazilo uticaj promene drutvenih stavova i novih medicinskih dostignua na psihijatriju, Svetsko udruenje psihijatara je jo jednom izvrilo reviziju etikih standarda kojih bi trebalo da se pridravaju svi njegovi lanovi i sve osobe koje se praktino bave psihijatrijom. Medicina je istovremeno i isceliteljska vetina i nauka. Dinamika ove kombinacije najbolje se ogleda u psihijatriji, grani medicine koja je specijalizovana za negu i zatitu onih koji su bolesni ili nemoni usled mentalnog poremeaja ili oboljenja. Iako postoje kulturne, drutvene i nacionalne razlike, potreba za moralnim ponaanjem i neprestanim preispitivanjem etikih standarda je univerzalna. Kao lekari, psihijatri moraju biti svesni etikih implikacija svog poziva, kao i specifinih etikih zahteva vezanih za psihijatriju. Kao lanovi drutva, psihijatri se moraju zalagati za pravedno i ravnopravno postupanje prema mentalno obolelima, za socijalnu pravdu i ravnopravnost. Etinost se zasniva na individualnom oseanju odgovornosti psihijatra prema pacijentu i na njegovoj proceni pravilnog i odgovarajueg ponaanja. Spoljanji standardi i uticaji, kao to su kodeksi profesionalnog ponaanja, nauka o moralu ili zakonodavstvo, ne mogu sami po sebi biti garancija etinosti u medicini. Psihijatri uvek moraju imati na umu granice koje postoje u odnosu izmeu psihijatra i pacijenta, i da se, pre svega, rukovode potovanjem pacijenata i brigom za njihovu dobrobit i integritet. Upravo u ovom duhu, Generalna skuptina Svetskog udruenja psihijatara usvojila je 25. avgusta 1996. a dopunila 8. avgusta 1999. i 26. avgusta 2002. godine, sledee etike standarde, kojima bi trebalo da se rukovode psihijatri irom sveta. 1. Psihijatrija je medicinska disciplina koja se bavi prevencijom mentalnih poremeaja stanovnitva, obezbeivanjem najboljeg mogueg leenja mentalnih poremeaja, rehabilitacijom osoba koje pate od mentalnih oboljenja i unapreenjem mentalnog zdravlja. Dunost psihijatra je da prui pacijentu najbolju terapiju koja postoji, u skladu sa prihvaenim naunim saznanjima i etikim principima.
Izmene prihvaene na Generalnoj skuptini Svetskog udruenja psihijatara, odranoj u Kairu 12. septembra 2005. godine
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Psihijatri bi trebalo da primenjuju terapijske intervencije koje u najmanjoj meri ograniavaju slobodu pacijenta, i da potrae savet u onim oblastima rada koje ne spadaju u njihovu osnovnu struku. Pri tome bi trebalo da vode rauna o ravnopravnoj raspodeli sredstava u zdravstvu. Dunost psihijatra je da ide u korak sa naunim dostignuima u svojoj oblasti i da nova saznanja prenosi i drugima. Psihijatri edukovani za istraivaki rad treba da streme proirivanju naunih granica u psihijatriji. Pacijent ima pravo da bude prihvaen kao partner u terapijskom procesu. Odnos izmeu psihijatra i pacijenta mora biti zasnovan na uzajamnom poverenju i potovanju, kako bi pacijent mogao, na osnovu dobijenih informacija, slobodno da donese odluku. Dunost psihijatara je da pacijentu prue sve relevantne informacije, kako bi bio u stanju da donese racionalnu odluku, u skladu sa linim vrednostima i sklonostima. Kada je usled mentalnog poremeaja pacijent teko hendikepiran, onesposobljen i/ili nesposoban da pravilno rasuuje, psihijatri bi trebalo da se konsultuju sa porodicom i, ako je potrebno, potrae pravni savet radi zatite ljudskog dostojanstva i zakonskih prava pacijenta. Nijedno leenje ne bi trebalo da se sprovodi protiv volje pacijenta, osim kada bi njegovo nesprovoenje ugrozilo ivot pacijenta i/ili drugih osoba. Leenje uvek mora biti u najboljem interesu pacijenta. Kada se od psihijatara trai da izvre procenu neke osobe, njihova je dunost da joj prvo daju informacije i savet u vezi sa ciljem intervencije, nainom na koji e rezultati biti iskorieni, i moguim posledicama izvrene procene. Ovo je naroito vano kada su psihijatri ukljueni kao trea strana. Informacije dobijene u terapijskom odnosu su poverljive, spadaju u privatnost pacijenta i trebalo bi ih koristiti samo i iskljuivo u cilju poboljanja mentalnog zdravlja pacijenta. Psihijatrima se zabranjuje upotreba ovih informacija iz linih razloga ili radi line koristi. Krenje principa o poverljivosti informacija dozvoljeno je jedino u sluaju kada to zakon zahteva (npr. obavezno prijavljivanje zlostavljanja dece) ili kada bi zbog potovanja poverljivosti informacija telesno ili duevno zdravlje pacijenta ili tree osobe moglo biti ozbiljno ugroeno; psihijatri bi, kad god je to mogue, trebalo prvo da obaveste pacijenta o postupcima koji e se preduzeti. Istraivanja koja se ne sprovode u skladu sa naunim standardima i koja nisu validna sa naune take gledita, nisu moralna. Istraivake aktivnosti treba da odobri odgovarajui etiki komitet. Psihijatri bi trebalo da slede meunarodna i nacionalna pravila za sprovoenje istraivanja. Istraivanja treba da sprovode ili da njima rukovode jedino osobe koje za to imaju odgovarajuu edukaciju. Poto psihijatrijski pacijenti predstavljaju posebno ranjivu populaciju is-
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pitanika, mora se pokloniti posebna panja proceni njihove sposobnosti da uestvuju u istraivanju, i zatiti njihove slobodne volje i duevnog i telesnog integriteta. Etike standarde bi, takoe, trebalo primenjivati prilikom odabira populacionih grupa u svim vrstama istraivanja, ukljuujui epidemioloka i socioloka istraivanja, kao i kolaborativna istraivanja koja ukljuuju druge discipline ili vie istraivakih centara. NOVA POSEBNA UPUTSTVA DODATAK MADRIDSKOJ DEKLARACIJI Zatita prava psihijatara (30. jun 2005) 1. Psihijatri moraju da tite svoje pravo da, prema zahtevima struke i oekivanjima javnosti, lee svoje pacijente i da se zalau za njihovu dobrobit. 2. Psihijatri treba da imaju pravo da se bave svojom strukom na najviem nivou, pruajui nezavisne procene mentalnog stanja osobe i uspostavljajui efikasne protokole leenja i praenja u skladu sa najboljom praksom i medicinom zasnovanom na dokazima. 3. Postoje neki aspekti u istoriji psihijatrije, ali i uslovi rada u nekim dananjim totalitarnim politikim reimima i ekonomskim sistemima voenim profitom, koji pojaavaju opasnost od zloupotrebe psihijatrije, u smislu da su psihijatri primorani da pristanu na neprikladne zahteve i daju netane psihijatrijske izvetaje koji idu na ruku sistemu, ali tete interesima osobe ije se stanje procenjuje. 4. Psihijatri su takoe stigmatizovani kao i njihovi pacijenti i, slino njima, mogu postati rtve diskriminacije. Psihijatri treba da imaju pravo i obavezu da se bave svojom strukom i da se zalau za medicinske potrebe i drutvena i politika prava svojih pacijenata, a da zbog toga ne trpe odbacivanje kolega, ismevanje u medijima i progon. SAOPTAVANJE DIJAGNOZE ALCHAJMEROVE BOLESTI I DRUGIH DEMENCIJA (30. jun 2005) Pacijent ima pravo da zna da boluje od Alchajmerove bolesti, i to pravo je sada postavljeno kao prioritet koji zdravstveni radnici priznaju i prihvataju. Veina pacijenata eli da dobije sve raspoloive informacije i da bude aktivno ukljuena u donoenje odluka u vezi sa leenjem. U isto vreme, pacijenti imaju pravo i da ne znaju, ako je to njihova elja. Svima se mora pruiti mogunost da saznaju ili ne saznaju onoliko koliko ele.
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Promene u kogniciji pacijenta ugroavaju njegovu sposobnost rasuivanja i shvatanja. Takoe, pacijenti sa demencijom esto dolaze u pratnji lanova porodice, to u odnos izmeu lekara i pacijenta uvodi i treu stranu. Svi doktori, pacijenti i porodice, koji godinama meusobno dele odgovornost za borbu protiv Alchajmerove bolesti, moraju imati pristup informacijama o ovoj bolesti, ukljuujui i dijagnozu. Osim to je to njegovo pravo, informisanost pacijenta moe biti od viestruke koristi. Pacijentima i/ili porodicama trebalo bi saoptiti dijagnozu u to ranijoj fazi bolesti. Veoma je korisno ako su lanovi porodice (ili nezvanini pruaoci nege) ukljueni u razgovor prilikom saoptavanja dijagnoze. Lekar treba da prui precizne i pouzdane informacije, koristei jednostavne izraze. Takoe bi trebalo da proceni u kojoj meri pacijent i porodica razumeju situaciju. Kao i obino, posle loe vesti trebalo bi pruiti informacije o daljim planovima za leenje. Treba pruiti obavetenja o fizikalnoj terapiji ili terapiji govora, o grupama za podrku, centrima za dnevni boravak i drugim intervencijama. Takoe bi trebalo naglasiti da reorganizovana porodina mrea moe znatno olakati teret pruaoca nege i odrati kvalitet ivota koliko god je to mogue. Postoje neki izuzeci, od kojih su neki privremeni, kada je re o saoptavanju dijagnoze pacijentu sa demencijom: 1) teka demencija, kada pacijent najverovatnije ne bi razumeo dijagnozu, 2) kada je verovatno da bi se javila fobija od tog stanja, ili 3) kada je pacijent u stanju teke depresije. Dvostruka odgovornost psihijatara (30. jun 2005) Ovakve situacije se mogu javiti tokom zakonskog postupka (npr. sposobnost pacijenta da bude podvrgnut sudskom procesu, krivina odgovornost, opasnost, sposobnost svedoenja na sudu) ili drugih postupaka vezanih za potrebu da se utvrdi sposobnost, kao npr. za potrebe osiguranja, radi procene zahteva za olakice, ili za potrebe zaposlenja, kada se procenjuje radna sposobnost ili podobnost za obavljanje odreenog posla ili posebnog radnog zadatka. U toku terapijskih interakcija moe doi do konfliktnih situacija ako informacije koje psihijatar ima o pacijentovom stanju ne mogu ostati poverljive, ili kada su klinike beleke ili medicinska dokumentacija deo veeg dosijea radnika, pa prema tome nisu namenjene samo klinikom osoblju zaduenom za sluaj (npr. u vojsci, zatvorskim sistemima, medicinskim slubama za zaposlene u veim korporacijama u protokolima leenja koje plaa trea osoba). Kada se prilikom procene stanja neke osobe psihijatar suoava sa dvostrukim obavezama i odgovornostima, duan je da tu osobu obavesti o prirodi ovakvog triangularnog odnosa i odsustva terapijskog odnosa izmeu lekara i pacijenta, pored obaveze da podnese izvetaj treoj strani, ak i kada su rezultati negativni i mogli bi da tete interesima osobe nad kojom se vri procena. Pod ovakvim okolnostima, osoba moe odluiti da ne nastavi sa procenom. Pored toga, psihijatri bi trebalo da se zalau za razdvajanje podataka i za ogranienja pri saoptavanju informacija, kako bi samo elementi koji su neophodni za svrhe organizacije mogli da budu otkriveni.
Psihijat. dan. /2005/37/2/353-356/ Announcement
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ADJUSTMENTS OF THE MADRID DECLARATION AND ADDITIONAL SPECIFIC ETHICAL GUIDELINES

DECLARATION OF MADRID (June 2005) In 1977, the World Psychiatric Association approved the Declaration of Hawaii which set out ethical guidelines for the practice of psychiatry. The Declaration was updated in Vienna in 1983. To reflect the impact of changing social attitudes and new medical development on the psychiatric profession, the World Psychiatric Association has once again undertaken a review of ethical standards that should be abided to by all its members and all persons practicing psychiatry. Medicine is both a healing art and a science. The dynamics of this combination are best reflected in psychiatry, the branch of medicine that specializes in the care and protection of those who are ill or infirm, because of a mental disorder or impairment. Although there may be cultural, social and national differences, the need for ethical conduct and continual review of ethical standards is universal. As practitioners of medicine, psychiatrists must be aware of the ethical implications of being a physician, and of the specific ethical demands of the specialty of psychiatry. As members of society, psychiatrists must advocate for fair and equal treatment of the mentally ill, for social justice and equity for all. Ethical practice is based on the psychiatrists individual sense of responsibility to the patient and judgment in determining what is correct and appropriate conduct. External standards and influences such as professional codes of conduct, the study of ethics, or the rule of law by themselves will not guarantee the ethical practice of medicine. Psychiatrists should keep in mind at all times the boundaries of the psychiatrist-patient relationship, and be guided primarily by the respect for patients and concern for their welfare and integrity. It is in this spirit that the World Psychiatric Association approved at the General Assembly on August 25th, 1996, amended on August 8th, 1999 and on August 26th, 2002 the following ethical standards that should govern the practice of psychiatrists universally. 1. Psychiatry is a medical discipline concerned with the prevention of mental disorders in the population, the provision of the best possible treatment for mental disorders, the rehabilitation of individuals suffering from mental illness and the promotion of mental health. Psychiatrists serve patients by providing the best therapy available consistent with accepted scientific knowledge and ethical principles. Psychiatrists should devise therapeutic interventions that are least
Adjustments were approved at the World Psychiatric Association General Assembly, held in Cairo, September 12th, 2005
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restrictive to the freedom of the patient and seek advice in areas of their work about which they do not have primary expertise. While doing so, psychiatrists should be aware of and concerned with the equitable allocation of health resources. It is the duty of psychiatrists to keep abreast of scientific developments of the specialty and to convey updated knowledge to others. Psychiatrists trained in research should seek to advance the scientific frontiers of psychiatry. The patient should be accepted as a partner by right in the therapeutic process. The psychiatrist-patient relationship must be based on mutual trust and respect to allow the patient to make free and informed decisions. It is the duty of psychiatrists to provide the patient with all relevant information so as to empower the patient to come to a rational decision according to personal values and preferences. When the patient is gravely disabled, incapacitated and/or incompetent to exercise proper judgment because of a mental disorder, the psychiatrists should consult with the family and, if appropriate, seek legal counsel, to safeguard the human dignity and the legal rights of the patient. No treatment should be provided against the patients will, unless withholding treatment would endanger the life of the patient and/or the life of others. Treatment must always be in the best interest of the patient. When psychiatrists are requested to assess a person, it is their duty first to inform and advise the person being assessed about the purpose of the intervention, the use of the findings, and the possible repercussions of the assessment. This is particularly important when psychiatrists are involved in third party situations. Information obtained in the therapeutic relationship is private to the patient and should be kept in confidence and used, only and exclusively, for the purpose of improving the mental health of the patient. Psychiatrists are prohibited from making use of such information for personal reasons, or personal benefit. Breach of confidentiality may only be appropriate when required by law (as in obligatory reporting of child abuse) or when serious physical or mental harm to the patient or to a third person would ensue if confidentiality were maintained; whenever possible, psychiatrists should first advise the patient about the action to be taken. Research that is not conducted in accordance with the canons of science and that is not scientifically valid is unethical. Research activities should be approved by an appropriately constituted ethics committee. Psychiatrists should follow national and international rules for the conduct of research. Only individuals properly trained for research should undertake or direct it. Because psychiatric patients constitute a particularly vulnerable research population, extra caution should be taken to assess their competence to participate as re-
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search subjects and to safeguard their autonomy and their mental and physical integrity. Ethical standards should also be applied in the selection of population groups, in all types of research including epidemiological and sociological studies and in collaborative research involving other disciplines or several investigating centres.
NEW SPECIFIC GUIDELINES APPENDED TO THE MADRID DECLARATION Protection of the Rights of Psychiatrists (30 June 2005) 1. Psychiatrists need to protect their right to live up to the obligations of their profession and to the expectations the public has of them to treat and to advocate for the welfare of their patients. 2. Psychiatrists ought to have the right to practice their specialty at the highest level of excellence by providing independent assessments of a persons mental condition and by instituting effective treatment and management protocols in accordance to best practices and evidence-based medicine. 3. There are aspects in the history of psychiatry and in present working expectations in some totalitarian political regimes and profit driven economical systems that increase psychiatrists vulnerabilities to be abused in the sense of having to acquiesce to inappropriate demands to provide inaccurate psychiatric reports that help the system, but damage the interests of the person being assessed. 4. Psychiatrists also share the stigma of their patients and, similarly, can become victims of discriminatory practices. It should be the right and the obligation of psychiatrists to practice their profession and to advocate for the medical needs and the social and political rights of their patients without suffering being outcast by the profession, being ridiculed in the media and persecuted.
DISCLOSING THE DIAGNOSIS OF ALZHEIMERS DISEASE (AD) AND OTHER DEMENTIAS (30 June 2005) AD patients right to know is now a well established priority, recognised by healthcare professionals. Most patients want all information available and to be actively involved in making decisions about treatments. At the same time, patients have the right also not to know if that is their wish. All must be given the opportunity to learn as much or as little as they want to know. The alteration of patients cognition makes the ability to make judgments and insight more difficult. Patients with dementia are also often brought by family members which introduces into the doctor-patient relationship a third partner.
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Doctors, patients and families who share the responsibilities for fighting and coping with Alzheimers disease for years all require access to information on the disease, including the diagnosis. In addition to the patients right to know, telling the patient has many benefits. Patients and/or families should be told the diagnosis as early as possible in the disease process. Having family (or informal carer) involved in the discussion of the disclosure process is highly beneficial. The physician should give accurate and reliable information, using simple language. He also should assess the patients and the familys understanding of the situation. As usual, the bad news should be accompanied by information on a treatment and management plan. Information on physical or speech therapy, support groups, day care centres, and other interventions should be provided. It should also be emphasised that a reorganised family network can alleviate the carers burden and maintain quality of life as far as possible. There are some exceptions, some of them transitory, to the disclosure of the diagnosis to a patient with dementia: 1) severe dementia where understanding the diagnosis is unlikely, 2) when a phobia about the condition is likely, or 3) when a patient is severely depressed. Dual Responsibilities of Psychiatrists (30 June 2005) These situations may arise as part of legal proceedings (i.e. fitness to stand trial, criminal responsibility, dangerousness, testamentary capacity) or other competency related needs, such as for insurance purposes when evaluating claims for benefits, or for employment purposes when evaluating fitness to work or suitability for a particular employment or specific task. During therapeutic interactions conflicting situations may arise if the physicians knowledge of the patients condition cannot be kept private or when clinical notes or medical records are part of a larger employment dossier, hence not confidential to the clinical personnel in charge of the case (i.e. the military, correctional systems, medical services for employees of large corporations, treatment protocols paid by third parties). It is the duty of a psychiatrist confronted with dual obligations and responsibilities at assessment time to disclose to the person being assessed the nature of the triangular relationship and the absence of a therapeutic doctor-patient relationship, besides the obligation to report to a third party even if the findings are negative and potentially damaging to the interests of the person under assessment. Under these circumstances, the person may choose not to proceed with the assessment. Additionally, psychiatrists should advocate for separation of records and for limits to exposure of information such that only elements of information that are essential for purposes of the agency can be revealed.
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KALENDAR KONGRESA 2006. 14th Congress of the European Association for Psychotherapy July 1316, 2006, London, Great Britain E-mail: lisad@psychotherapy.org.uk 2nd Biennial Regional Group Conference of the International Society for Bipolar Disorders August 24, 2006, Edinburgh, Scotland E-mail: isbd@kenes.com Website: http://www.kenes.com/isbd 3rd Congress of the Asian Association for Psychotherapy August 28September 1, 2006, Tokyo, Japan E-mail: www.the-convention.co.jp/06icptj 3rd Annual International Mental Health at the IoP People on the Move August 30 September 1, 2006, London Website: www.iop.klc.ac.uk/international/conference E-mail: IMH@iop.kcl.ac.uk 10th Congress of the European Federation of Neurological Societies September 25, 2006, Glasgow, Scotland Website: www.kenes.com/efns2006 E-mail: efns06@kenes.com 9th Conference of the International Association for the Treatment of Sexual Offenders The Benefits of Sexual Offender Therapy September 69, 2006, Hamburg, Germany Website: http://www.iatso.org/Meetings/06hamburg 11th European Symposium on Suicide and Suicidal Behaviour From Greenland to the Caucasus, from the Urals to Iberia September 912, 2006, Portoro, Slovenia Website: www.esssb11-slo.org E-mail: scientific@esssb11-slo.org 6th International Congress of Neuropsychiatry The Coming of Age of Neuropsychiatry September 1014, 2006, Sydney, Australia Website: www.inacongress2006.com E-mail: abstracts@inacongress2006.com Autism & ADHD Symposium September 1214, 2006, Istanbul, Turkey Website: www.istanbulotizmsempozyumu.org E-mail: info@ar-ga.com
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Zavod za psihofizioloke poremeaje i govornu patologiju Prof. dr Cvetko Brajovi povodom 35 godina svoga postojanja organizuje meunarodni kongres sa temom Multidisciplinarni pristupi u specijalnoj edukaciji i rehabilitaciji Septembar 1517, 2006, Beograd Website: www.zgp.org.yu Informacije: 011/3617932 ili e-maila zav.zagp@eunet.yu 10th Anniversary Congress of Body-Psychotherapy Presented by the European Association for Body-Psychotherapy Bodies of Knowledge Resources for a world in crisis September 2124, 2006, Askov, Denmark Website: http://www.eabp.org/eabp2006.html E-mail: eabpcongress2006@eabp.org VIII Anual Meeting of the International Society for Addiction Medicine A World of Drugs, A Universe of Therapies September 2730, 2006, Oporto, Portugal E-mail: psiquiatria@med.up.pt
XV IFTA World Congress Reflection, Resilience and Hope; Strengthening Foundations
October 47. 2006, Reykjavk Iceland E-mail: ifta2006@removemenow.org Website: http://www.ifta2006.org Udruenje za kliniku neurofiziologiju Srbije i Crne Gore, Medicinski fakultet Univerziteta u Beogradu, Institut za mentalno zdravlje Beograd Godinji sastanak Udruenja za kliniku neurofiziologiju Srbije i Crne Gore sa meunarodnim ueem Oktobar 5, 2006, Institut za mentalno zdravlje, Beograd E-mail: yscn@sezampro.yu; jmtmilov@eunet.yu; Adresa: Prof. dr arko Martinovi, Institut za mentalno zdravlje, Odsek za epilepsije i kliniku neurofiziologiju, Palmotieva 37, 11 000 Beograd European Workshop on Traumatic Stress October 56, 2006, Madrid, Spain Website: www.tilesa.es/ewots2006 E-mail: ewots2006@tilesa.es Together Aganst Stgma 3rd Internatonal Conference A Decade of Progress October 58, 2006, Istanbul, Turkey Website: www.stigmaistanbul.org E-mail: stigma@stigmaistanbul.org 22nd Danube Symposion of Psychiatry Psychiatry today and tomorrow October 1115, 2006, Albena Resort, Bulgaria Website: www.privatepsychiatry.org www.albena.bg E-mail: ppsy@abv.bg
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International Conference on Engaging the Other The Power of Compassion October 2629, 2006, Kalamazoo, Michigan USA Website: www.cbiworld.org E-mail: SOlweean@aol.com XIV World Congress on Psychiatric Genetics October 28 November 1, 2006, Cagliari, Italy Website: www.wcpg2006.it E-mail: farmer@wcpg2006.it groeneweg@wcpg2006.it mosca@wpcg2006.it 6th International Forum on Mood and Anxiety Disorders November 29 December 1, 2006, Vienna Website: http://www.aim-internationalgroup.com/2006/ifmad E-mail: ifmad@publicreations.com 1st International Symposium on Therapeutic in Psychiatry Solving Problems in Clinical Practice: Schizophrenias November 30 December 1, 2006, Barcelona, Spain Website: www.geyseco.com/terapeutica.htm E-mail: controversias@geyseco.com The Second Dual Congress on: Psychiatry and the Neurosciences 1st European Congress of the International Neuropsychiatric Association 2nd Mediterranean Congress of the World Federation of Societies of Biological Psychiatry December 710, 2006, Athens, Greece E-mail: secretariat@ina-wfsbp-dualcongress.gr, easytravel@hol.gr Website: www.ina-wfsbp-dualcongress.gr IX IRCT International Symposium on Torture Providing Reparation and Treatment, Preventing Impunity December 910, 2006, Berlin, Germany Email: symposium@irct.org Website: www.irct.org 2007. European Symposium Psychiatry Psychology Psychotherapy Similarities and Differences February 16, 2007, Vienna, Austria E-mail: eap.headoffice@europsyche.org Website: www.psychotherapy.org.uk 2nd International Congress on Health and Work Cuba 2007 March 1216 2007, Havana, Cuba E-mail: cubawelcome@enet.cu 15th European Congress of Psychiatry March 1721, 2007, Madrid, Spain Website: http://www.kenes.com/aep2007 E-mail: aep2007@kenes.com
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World Psychiatric Association Regional Meeding International Psychiatrists on African Safari March 2123, 2007, Nairobi Website: www.wpa2007nairobi.com 2nd International Congress of Biological Psychiatry April, 1721, 2007, Santiago de Chile Website: www.wfsbp.org www.wfsbp-santiago2007.org E-mail: wfsbp2007@mci-group.com
6th European Conference of the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO) Nursing Communication in Multidisciplinary Practice April 1921, 2007, Amsterdam The Netherlands Website: http://www.acendio.net E-mail: conference.management@freeler.nl XIV International Symposium about Current Issues and Controversies in Psychiatry Risk Factors in Psychiatry April 2627, 2007, Barcelona, Spain Website: geyseco.com/controversias.htm E-mail: controversias@geyseco.com Conflict, Mental Health and Making the Peace May 1112, 2007, Lymassol, Cyprus E-mail: nd.minton@btinternet.com 15th World Contress of the World Association for Dynamic Psychiatry What is New in Psychiatry and Psychotherapy? Creative Dimensions in Modern Treatment May 15.18, 2007, St Petersburg, Russia Website: http://www.wadp-congress.de E-mail: wadpcongress2007@dynpsych.de 10th European Conference on Traumatic Stress June 59, 2007, Opatija, Croatia Website: www.ecots2007.com E-mail: conference@ecots2007.com 7th World Congress on Brain Injury of the International Brain Injury Association (IBIA) June 1721, 2007, Jerusalem, Israel E-mail: ibia07@kenes.com Website: www.kenes.com/ibia07 13th International Headache Congress June 28 July 1, 2007, Stockholm, Sweden E-mail: carl.dahlof@migraineclinic.se
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International Conference on Stress August 2326, 2007 Budapest, Hungary Website: www.stress07.com E-mail: organiser@stress07.com 13th International Congress Bridging the Gaps (Integrating Perspectives in Child and Adolescent Mental Health) August 2529, 2007, Florence, Italy Website: www.escap-net.org E-mail: escap2007@newtours.it X International ISSPD (International Society for the Study of Personality Disorders) Congress September 1922, 2007, The Hague, The Netherlands Website: www.isspdcongress2007.nl Globalization and Psychiatry September 2023, 2007, Shanghai, China Website: www.wpa2007shanghai.com The International Society on Brain and Behaviour 3rd International Congress on Brain and Behaviour (3rd ICBB)
November 29 December 2, 2007, Thessaloniki, Greece Deadlines: Abstract submission: March 1st, 2007 Website: http://www.psychiatry.gr/ E-mail: kfount@med.auth.gr, kfount@panafonet.gr
2008. XIV World Congress of Psychiatry, hosted by the Czech Psychiatric Association September 1925, 2008, Prague, Czech Republic Contact: Dr. Jiri Raboch E-mail: raboch@mbox.cesnet.cz 2009. 9th World Congress of Biological Psychiatry June 28July 2, 2009, Paris, France 2011. XV World Congress of Psychiatry, hosted by the Argentina Association of Psychiatrist (AAP), the Association of Argentinean Psychiatrists (APSA), and the Foundation for Interdisciplinary Investigation of Communication (FINTECO) August or September 2011, Buenos Aires, Argentina Contact: Mariano R. Castex E-mail: mcastex@congresosint.com.ar Website: www.congresosint.com.ar
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WPA Scientific Meetings

Professor Pedro Ruiz, Secretary for Meetings Professor and Vice Chairman University of Texas Medical School at Houston 1300 Moursund Street, Houston, TX 77030, USA Tel: +1 713 500 2799, Fax: +1 713 500 2757 E-mail: pedro.ruiz@uth.tmc.edu
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WPA International Congress Istanbul, Turkey July 1216, 2006 a) Psychiatric Association of Turkey b) Turkish Neuropsychiatric Society Dr. Levent Kuey kuey1@superonline.com www.wpa2006istanbul.org Symposium on Roles de Avanzada para el Psicoterapeuta ante la Violencia Global San Juan, Puerto Rico September 2, 2006, 2006 Wizards Continuing Education Dr. Victor Llado vjllado@prtc.net VIII Argentinean Congress of Neuropsychiatry, IV Latin American Congress of Neuropsychiatry and IX Alzheimers Disease Meeting Buenos Aires, Argentina September 58, 2006 Asociacion Neuropsiquiatrica Argentina International Neuropsychiatric Association Leandro Tortora info@stpweb.com.ar www.neuropsiquiatria.org.ar Urban Areas and Mental Health International Conference Bologna, Italy September 19, 2006 Italian Psychiatric Association WPA Section on Urban Mental Health Dr. Mariano Bassi bassisip@mailbox.dsnet.it
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Title: Place: Date: Organizer: Collaboration: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Website: Title: Place: Date: Organizer: Collaboration: Contact: E-mail: Website: Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Collaboration: Contact: E-mail: Website:
Conferencia: Integracion Psiquiatrica y Biopsychosocial Dentro del Humanismo Merida, Mexico September 2123, 2006 Federacion Latinoamercana de Psiquiatria Biologica a) Mexican Psychiatric Association b) Mexican Society of Neurology & Psychiatry Dr. Claudio Garcia Barriga claub99@axtel.net A World of Drugs, A Universe of Treatments Oporto, Portugal September 2630, 2006 International Society of Addiction Medicine (ISAM) Dr. Antonio Pacheco Palha apalha@sapo.pt www.isamweb.org VI World Congress of Depressive Disorders and International Symposium on Addictive Disorders Mendoza, Argentina September 2730, 2006 Dr. Jorge Nazar a) Instituto de Neurosciencias y Humanidades Medicas b) Universidad Nacional de Cuyo Dr. Jorge Nazar jorge_nazar@hotmail.com www.mendoza2006.0rg National Conference on Psychiatry Craiova, Romania September 28October 1, 2006 Romanian Psychiatric Association Dr. Tudor Udristoiu office@psycv.ro Third International Conference Together Against Stigma Istanbul, Turkey October 58, 2006 Psychiatric Association of Turkey Medical School of Istanbul Aslihan Polat stigma@stigmaistanbul.org www.stigmaistanbul.org
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Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Collaboration: Contact: E-mail: Website:
Pacific Rim College of Psychiatrists Congress Taipei, Taiwan October 68, 2006 Pacific Rim College of Psychiatrists Dr. Allan Tasman allan.tasman@louisville.edu 9th World Congress of Psychosocial Rehabilitation Athens, Greece October 1215, 2006 World Association for Psychosocial Rehabilitation Dr. Michael Madianos madianos@nurs.uoa.gr International Conference on Schizophrenia Chennai (Old Madras), India October 1315, 2006 Schizophrenia Research Foundation World Health Organization Dr. R. Thara scarf@vsnl.com www.scarfindia.org www.icons-scarf.org Annual Congress, Spanish Society of Psychiatry Sevilla, Spain October 1621, 2006 Spanish Society of Psychiatry Dr. Jose Giner jginer@us.es www.wpanet.org/meetings/m2006.doc 8th World Congress of the International Psychooncology Society Venice, Italy October 1821, 2006 WPA Section on Psycho-oncology International Psycho-oncology Society Dr. Carlo L. Cazzullo arsmilano@tiscalinet.it
Title: Place: Date: Organizer: Contact: E-mail: Website: Title: Place: Date: Organizer: Collaboration: Contact: E-mail:
WPA SPONSORED SECTION MEETING (Zone 8)
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Title: Place: Date: Organizer: Collaboration: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Website: Title: Place: Date: Organizer: Collaboration: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Collaboration: Contact: E-mail:
XXIV APAL Congress Santo Domingo, Dominican Republic November 14, 2006 Latin American Psychiatric Association (APAL) Dominican Society of Psychiatry Dr. Cesar Mella cesarm2@verizon.net.do 56th Annual Meeting of the Canadian Psychiatric Association Toronto, Ontario, Canada November 912, 2006 Canadian Psychiatric Association Dr. Alex Saunders asaunders@cpa-apc.org www.cpa-apc.org XI Meeting in Bipolar Disorders Lisbon, Portugal November 1011, 2006 WPA Section on Private Practice Portuguese Society of Psychiatry and Mental Health Professor Maria Luisa Figueira canessa@mail.telepac.pt Annual Meeting, Egyptian Psychiatric Association Alexandria, Egypt November 1517, 2006 Egyptian Psychiatric Association Dr. Tarek Okasha tokasha@internetegypt.com Second International Conference, South Asian Association for Regional Cooperation (SAARC) Psychiatric Federation Kathmandu, Nepal November 1719, 2006 South Asian Association for Regional Cooperation (SAARC) Psychiatric Federation Psychiatric Association of Nepal a) Professor Mahendra K. Nepal b) Professor Roy Abraham Kallivayalil a) mhp@healthnet.org.np b) ktm_roykalli@sanchanet.in
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Title: Place: Date: Organizer: Contact: E-mail:
Regional Meeting of the Royal College of Psychiatrists (Middle East Division) Beirut, Lebanon November 2325, 2006 Middle East Division, Royal College of Psychiatrists Dr. Fuad T. Antun antun@cyberia.net.lb
WPA SPONSORED REGIONAL MEETING (Zone 4)
WPA Regional Meeting Lima, Peru November 30December 3, 2006 Peruvian Psychiatric Association Dr. Marta Rondon @ Dr. Gabriela Kuroiwa app@apperu.org 2007.
Title: Place: Date: Organizer: Contact: E-mail: Website: Title: Place: Date: Organizer: Collaboration: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail:
WPA Regional Meeting Budapest, Hungary January 2324, 2007 Hungarian Psychiatric Association Dr. Tury Ferenc tury@axelero.hu www.mpt.iif.hu Psyche and Art Seminar Djerba, Tunisia February 1316, 2007 WPA Section on Art and Psychiatry Schattauer Verlag Publishers Dr. Hans Otto Thomashoff thomashoff@utanet.at WPA Regional Meeting Nairobi, Kenya March 2224, 2007 Kenya Psychiatric Association Dr. Frank G. Njenga fnjenga@africaonline.co.ke
WPA SPONSORED REGIONAL MEETING (Zone 13 & 14)
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Third International Congress on Hormones, Brain and Neuropsychopharmacology Marrakech, Morocco April 2225, 2007 WPA Section on Interdisciplinary Collaboration Dr. Uriel M. Halbreich urielh@acsu.buffalo.edu
Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Website: Title: Place: Date: Organizer: Collaboration: Contact: E-mail:
WPA Regional Meeting Seoul, Korea April 1821, 2007 Korean Neuropsychiatric Association Dr. Young-Cho Chung kpa3355@kornet.net 15th World Congress of the World Association for Dynamic Psychiatry St. Petersburg, Russia May 1619, 2007 World Association for Dynamic Psychiatry Dr. Monika Dworschak wadpcongress2007@dynpsych.de WPA Thematic Conference Coercive Treatment in Psychiatry: A Comprehensive Review Dresden, Germany June 68, 2007 Eunomia Study Group Prof. Thomas Kallert Thomas.kallert@mailbox.tu-dresden.de www.eunomia-study.net VI Simposio Internacional Aspectos Biologicos y Farmacoterapeuticos de los Transtornos Mentales Habana, Cuba June 1822, 2007 Cologio Cubano de Neuropsicoframacologia Cuban Society of Psychiatry Dr. Jose Perez Milan ccunp@infomed.sld.cu
WPA SPONSORED THEMATIC CONFERENCE (Zone 9)
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Title: Place: Date: Organizer: Contact: E-mail: Website: Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Collaboration: Contact: E-mail:
13th International Congress of the European Society for Child and Adolescent Psychiatry Florence, Italy August 2529, 2007 European Society for Child and Adolescent Psychiatry Cecilia Sighinolfi Cecilia.sighinolfi@azzurro.it www.escap-net.org WPA Regional Meeting Shangai, China September 2023, 2007 Shangai Mental Health Center Dr. Zeping Xiao xzpdgj@online.sh.cn
Annual Meeting of the Psychiatric Association of Serbia and Montenegro Novi Sad, Serbia and Montenegro October 47, 2007 Psychiatric Association of Serbia and Montenegro Dr. Dusica Lecic Toseviski dusica.lecictosevski@eunet.yu XIX World Association for Social Psychiatry Congress Prague, Czech Republic October 2125, 2007 World Association for Social Psychiatry Dr. Shridhar Sharma wasp@nda.vsnl.net.in Annual Meeting of the International Society Of Addiction Medicine (ISAM) Cairo, Egypt October 2328, 2007 International Society of Addiction Medicine (ISAM) WPA Section on Addiction Psychiatry Dr. Nady El-Guebaly nady.el-guebaly@calgaryhealthregion.ca
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Title: Place: Date: Organizer: Contact: E-mail: Website: Title: Place: Date: Organizer: Contact: E-mail: Website:
XIV Congress of the Argentinean Association of Psychiatrists Buenos Aires, Argentina October 2426, 2007 Argentinean Association of Psychiatrists (AAP) Dr. Nestor F. Marchant aap@aap.org.ar www.aap.org.ar WPA International Congress Melbourne, Australia November 28December 2, 2007 Royal Australian and New Zealand College of Psychiatrists (RANZCP) Sharon Brownie Sharon.brownie@ranzcp.org www.ranzcp.org 2008.
WPA SPONSORED THEMATIC CONFERENCE (Zone 8)
Title: Place: Date: Organizer: Contact: E-mail: Title: Place: Date: Organizer: Collaboration: Contact: E-mail:
WPA Thematic Conference on Depression and Relevant Psychiatric Condition in Primary Care Granada, Spain June 1921, 2008 Spanish Society of Psychiatry Dr. Francisco Torres ftorres@ugr.es XIV World Congress of Psychiatry Prague, Czech Republic September 1925, 2008 Czech Psychiatric Association World Psychiatric Association Dr. Jiri Raboch raboch@mbox.cesnet.cz 2009.
WPA SPONSORED WORLD CONGRESS OF PSYCHIATRY (Zone 9)
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Treatments in Psychiatry: A New Update Florence, Italy April 14, 2009 Italian Psychiatric Association Dr. Mario Maj majmario@tin.it www.psichiatria.it
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2010.
Title: Place: Date: Organizer: Contact: E-mail: Website:
WPA Regional Meeting Beijing, China September 15, 2010 Chinese Society of Psychiatry Dr. Yizhuang Zou yzouy@263.net www.psychiatryonline.cn 2011.
WPA SPONSORED WORLD CONGRESS OF PSYCHIATRY (Zone 5)
Title: Place: Date: Organizer:
Contact: E-mail: Website:
XV World Congress of Psychiatry Buenos Aires, Argentina August or September 2011 a) Argentina Association of Psychiatrist (AAP) b) Association of Argentinean Psychiatrists (APSA) c) Foundation for Interdisciplinary Investigation of Communication (FINTECO) Mariano R. Castex mcastex@congresosint.com.ar www.congresosint.com.ar
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WEBSITE
American Psychiatric Association (APA) http://www.psych.org/ American Psychological Association http://www.apa.org/ Anonimni alkoholiari www.anonimnialkoholicari.org Borderline and Beyond: Borderline and Beyond: A Program of Recovery from Borderline Personality Disorder (BPD) http://www.laurapaxton.com/ Borderline Personality Disorder Central http://www.bpdcentral.com/ Borderline Personality Disorder Research Foundation (BPDRF) New York State Psychiatric Institute http://www.borderlineresearch.org/ Borderline Personality Disorders, Richard J. Corelli, M.D. www.stanford.edu/~corelli/borderline.html Borderline Sanctuary http://www.mhsanctuary.com/borderline/ Center for Mental Health Services Substance Abuse and Mental Health Services Administration http://www.samhsa.gov/ Elektronsko izdanje asopisa Socioloki pregled www.socioloskipregled.org.yu Human Rights Tools http://www.humanrightstools.org/index.htm Institutu za zatitu zdravlja Srbije www.batut.org.yu International Society for the Study of Personality Disorders (ISSPD) http://www.isspd.com/ Intervention The International Journal of Mental Health, Psychosocial work and Counselling in Areas of Armed Conflict http://www.interventionjournal.com IRCT International Rehabilitation Council for Torture Victims http://www.irct.org/
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ISSPD International Society for the Study of Personality Disorders http://www.isspd.com/ Journal of Personality Disorders (Periodicals Psychology) http://www.guilford.com/ Lippincott, Williams and Wilkins http://www.lww.com National Institute of Mental Health (USA) http://www.nimh.nih.gov/ Obsessive Compulsive Foundation http://www.ocfoundation.org/ OCD Resource Center of South Florida http://www.ocdhope.com/ Oficijelni sajta Zdravstvenog centra Bor www.zcbor.org.yu PILOTS Index to Traumatic Stress Literature http://www.ncptsd.va.gov/publications/pilots/ Sexual Offender Treatment a new journal: scientifically based, practice oriented, useful online and free of charge. The second issue is available now: http://www.sexual-offender-treatment.org Treatment and Research Advancements, Association for Personality Disorder (TARA APD) http://www.tara4bpd.org/ World Federation of Societies of Biological Psychiatry (WFSBP) www.wfsbp.org World Psychiatric Association (WPA) http://www.wpanet.org/ WPA ONLINE Electronic Bulletin, June 2006 http://www.wpanet.org
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Institut za mentalno zdravlje Palmotieva 37, 11000 Beograd, Srbija Tel/faks 3236-353, 3226-925 www.imh.org.rs Institute of Mental Health Palmoticeva 37, 11000 Belgrade, Serbia Tel/fax 3236-353, 3226-925 www.imh.org.rs

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PSYCHIATRY TODAY

Official Journal of the Serbian Psychiatric Association

asopis Udruenja psihijatara Srbije

UDK 616.89 ISSN-0350-2538

Psihijat. dan. 2005/37/2/227-380/

PSIHIJATRIJA DANAS GODINA 37 BEOGRAD BROJ 2, 2005

Psihijat. dan. 2005/37/2/227-380/

PSYCHIATRY TODAY YEAR 37 BELGRADE NUMBER 2, 2005

DA LI SU MENTALNO OBOLELE OSOBE SKLONIJE NASILNOM PONAANJU?

1987 1985-1987 1987

1,265 282 1,017

Svi poremeaji (ICD-9) Sch (RDC) Sch (ICD-9)

1983-1989 1971-1986 1964-1984

1,670 790 538

Ppsihoze (DSM-III) Sch (ICD-8) Sch (ICD-9)

Podaci od ispitanika Slubeni (sudski) Slubeni (sudski) i podaci od ispitanika

Vremenski period 1986-1991

1953-1978 1953-1983 1944-1947

11,540 15,117 358,180

Tabela 3. prikazuje rezultate nekih od pomenutih istraivanja.

m 4.2 27.4 m 4.5 8.7

m 15.4 54.6 m 8.7 15.1 m 7.2 10.4

3.6a /10.1b 3.3a /6.6b

Rizik od fizikog napada;

Rizik od korienja oruja

50.1 46.5 28.6 28.7

61.5 66.9 48.9 zajedno sa 55.4

13.8 32.3 63.6

11.9 38.6 44.2

ARE THE MENTALLY ILL MORE PRONE TO AGGRESSIVE BEHAVIOR?

Psychoses (DSM-III) Sch (ICD-8) Sch (ICD-9)

Location North Carolina

Time period 1986-1991

1953-1978 1953-1983 1944-1947 1966-1992

11,540 15,117 358,180 12,058

m m+f m+f m+f

Table 3. shows results obtained in some of the above studies.

m 3.1 m 3.9 m 3.9 m 4.2 f 27.4 m 4.5 f 8.7

m 15.4 f 54.6 m 8.7 f 15.1 10.4

3.6a /10.1b 3.3a /6.6b

Risk of physical assault; b Risk of using weapons

6 29 36 26 13.8 32.3 63.6 11.9 38.6 44.2

15. 16. 17.

18. 19. 20. 21. 22. 23.

24. 25. 26. 27. 28. 29. 30. 31.

256 32. 33. 34. 35. 36. 37. 38. 39.

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Tabela 3. Tabela unakrsne 3 x 3 klasifikacije sigurne privrenosti oca i deteta (N = 44)

Sigurna privrenost odraslog

Sigurna privrenost odraslog

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...

Psihijat. dan. /2005/37/2/257-270/ Radojevi M. Prenatalne predstave oeva o privrenosti...