NEUROPSYCHIATRY

I began my fourth year of medical school while attending the third year of psychology. Guided by a protocol prepared for medical students, I turned my attention to neuropsychiatry, which was essentially a combination of neurology we studied in the first semester and psychiatry left for the second, final semester. Two points of view that, at first sight, study and treat the same thing, the brain, that is to say, the nervous system. I had not explored the context and meaning of this connection between neurology and psychiatry because I grew up under the influence of dialectical materialism. I have regarded all mental content as having a material origin represented by the brain and body. That it was an expression of the function of the nervous system or its “heady” representative. As a result, I considered it “normal” to study neurology, where one knows exactly what the disturbed substrate is, manifested with specific symptoms and signs. I was familiar with the anatomy and pathology of the nervous system, so I mastered the neurological examination with relative ease. This was very important because at that time there were no diagnostic tools such as CT, MRI, PET, and other scanning devices that are so common nowadays.

Neurological examination

The neurological examination begins with the observation of the patient - the manner in which she/he speaks, thinks, walks, and communicates with the examiner. A knowledgeable observer learns a great deal about the condition of the nervous system from simple observations. The formal examination is carried out in a systematic way and consists of the following components: mental status (primarily state of consciousness, orientation, and speech), testing of the twelve cranial nerves, gait (casual, heel, toe, tandem), truncal stability, motor exam, visual fields, pupils and eye movements, sensory exam, coordination, and reflexes. I purchased a neurological hammer, a needle, a tuning fork, and a lamp so that I could be fully equipped for this specialized examination of patients. With practice, I was able to diagnose the common neurological conditions I encountered at the hospital. I met patients suffering from dementia, Parkinson's disease, epilepsy, brain tumors, multiple sclerosis, myasthenia gravis, and so on.

Rounds

I remember well the hospital rounds with Professor Nikolić. The entourage of doctors, residents, students and nurses led by Professor Nikolić began visiting patients in the morning. Typically, they were waiting in bed with a dose of anxiety because of the uncertain outcome of this daily hospital ritual. The group stopped at each patient in order for the attending physician to give a brief report on the previous 24 hours. Professor Nikolić then asked questions to those gathered around the bed. After the question-and-answer session, he would issue his “proclamation” on further treatment. That's how the trade was taught, from the most experienced “master” to the “apprentice.” It is an established tradition of “apprenticeship training” embedded within the medical profession. The knowledge of “experts” is inviolable, nearly a dogma handed down from “generation to generation” as a legacy to the shadows of deceased “high masters” who started a certain “school of thought.”I was part of that education system as well, but not completely because I had behind me an alternative model experienced and acquired during my psychology studies where egalitarianism was enabled and supported.

A remembered thought

I recall a “human” moment with Professor Gospavić, whom I appreciated the most not only for her expertise but also for the absence of narcissism, so present among her colleagues. Her physical appearance, characterized by short stature and limping, was not impressive, but her knowledge and skill more than made up for it. At one point, I met with her in her nicely decorated office and spoke about my ambitions and projects. She listened attentively and then told me, after a period of reflection, that, for her, everything had become routine, and that each day was the same. Nothing could surprise her, as she had already experienced it all. It is interesting that this expressed thought of her has impressed me so much that I have often thought of her reply, which may be a little depressing, but it is also the reality for many people who live according to a pattern that does not change, as if they have become the actors of a movie Groundhog Day in the role that made Bill Murray famous. In my “mature” years, I realize that it is not easy to live in the present moment unencumbered by all previous life events that have left a deep trace and even a scar in the virtual space of my psyche. They inevitably have a powerful filtering effect on each new sensation, wanting to shape and transform it into something that is known and recognizable. The awareness of this process and the frequent meditation helped me to cultivate a freshness of mind and a curiosity for the life that takes place and flows in a non-repetitive way. As some sages say, change is the only constant.

Usefulness of knowledge

After this short digression, let me return to neurology. The semester passed quickly. I felt enriched by the knowledge and experience that was useful to me when working with patients who had vague symptoms but were reminiscent of common mental disorders such as depression, mania, psychosis and others. Due to my training in neurology, I was able to identify when they were caused by head injuries, epilepsy, brain tumors, strokes, and so on. Therefore, it is always important to conduct a physical and neurological examination of each patient in order to determine if there is evidence of damage to any aspect of the nervous system. If this is established, a more thorough investigation is necessary before supposing that it is “all in your head,” as is often said by doctors who are quick to declare a patient hypochondriac or hysteric due to atypical symptoms. Semi-knowledge and arrogance is a dangerous combination that has brought much more harm and suffering than ignorance. I was very cautious, which helped me to make fewer errors in the cases I was told were, for example, hysterical blindness and paralysis, somatization, simulation, and similar “functional” presentations. It is as if the physicians, who are so often overly confident in their judgment, say, “There's nothing wrong with you, so now you go to the psychiatrist to deal with you.” In addition, my neurology background helped me with my first job at Vršac Neuropsychiatric Hospital, where at one time I worked in the neurology department and was in charge of treating patients with strokes, epilepsy, headaches and other diseases. My interest in neuroscience and especially in behavioral neurology, which I pursued in America, is also a result of what I learned during my medical studies and residency in neuropsychiatry eight years later. At the end of the day, I'm happy to have been a neurology student, to be able to do my psychiatric work better.

“Avala”

Finally, I made it to the second semester. The long-awaited moment. It is not easy to put in writing the excitement I experienced. All my previous training in psychology and medicine was to prepare for it; to meet psychiatric patients. And with that, in an institution which then had an enviable reputation. The psychiatric clinic “Avala” was set up in the western foothills of Mount Avala, on its slopes, 20 kilometers from Belgrade, in a forest transformed into a park on the premises of the pre-second world war private sanatorium Živković. Over time, it was transformed into an exclusive place because of its distance from the city, its unconventionality and the presence of internationally trained experts.

A first day hospital was established at this location, where psychoanalytic group psychotherapy was conducted. Soon, two separate units were formed: the department for neuroses and personality disorders and the department for reactive disorders and psychoses, where I was assigned and supervised by dr. Mirko Pejović. He was an unusual psychiatrist, a combination of opposites. On one side was a traditionalist who kept a Montenegrin fiddle in his office, and on the other, he advocated modern trends in treatment and behavior. White coats and hospital clothes, markers of the hierarchical separation between the healthy ones and the others, were nowhere to be seen. Patients moved around buildings and surroundings unrestricted. They considered this freedom to be a hugely important contribution to their treatment and recovery. All this was different from the restraint, conservatism and division that were then the norm in all other locations used for the education of students and residents. I felt like I was in a Swiss sanatorium where the natural environment, peace and tranquility, fresh air and healthy food were used as important elements of treatment. At “Avala” I met the therapeutic community for the first time, in which the spirit of a psycho-socio-therapeutic approach was nurtured. Here, patients and medical personnel participated equally in the organization of the life and work of the unit.

Experts

I was already familiar with the book What are neuroses? by dr. Mirko Švrakić, but at “Avala” I learned a lot more about his numerous contributions when he was head of the department. He introduced psychotherapy based on the principles of psychodynamic (depth) psychiatry, autogenic training, as well as the systematic training of junior doctors. During his relatively short leadership and thanks to his notable intellectual and professional abilities, the department gained an enviable reputation in wider social circles. Those who wished to hide their psychological suffering and the patient's position from the prying eyes of the public found refuge in the privacy of this place. Later, I discovered that his son Dragan Švrakić studied medicine at the same time as I did and that he subsequently emigrated to America where he completed a residency in psychiatry in 1998. Interesting coincidences.

In “Avala” I met some of the most respected experts in psychiatry and psychotherapy from Ljubljana, Zagreb, Sarajevo and other big cities. This was possible because the psychiatric clinic “Avala” organized professional symposia that drew a large number of participants who came from all over Yugoslavia. The latest achievements in the treatment of neuroses, personality disorders, interpersonal relationships, group psychotherapy, and many more were presented by the aforementioned experts.

I felt privileged to be ushered into the psychiatric territory of this extraordinary place. Although it was so unusual it was so appealing to my “liking.” The example of the creative use of traditional knowledge mixed with what the psychiatric movements of the world have thrown on the shore (i.e., land) of Mountain Avala. It was there that I learned to interview patients and examine their mental status in a detailed and systematic way. Dr. Pejović quickly noticed my strong motivation and desire to learn through hands-on work and observation of the operation of the clinic. He supported my efforts and guided me from time to time, so I am grateful. Our paths crossed once more in 2004 when I attended the 12th Congress of Psychiatrists of Serbia and Montenegro in the beautiful coastal city of Herceg Novi. Meanwhile, dr. Pejović had become a professor and was one of the organizers of the convention. I introduced myself to him because we hadn't seen each other for almost 30 years. He was pleasantly surprised that I, a student of his, had become a psychiatric expert in faraway America. We didn't talk much, but we both enjoyed this unforeseen encounter.

Lectures

Psychiatrist classes were held in one of the buildings of the School of Medicine. There I met a constellation of well-known psychiatrists who introduced us, students, to the world of mental illness by the way of lectures. My psychological studies allowed me to set myself apart by my interest and knowledge, which suited my vanity well. I mention it here because I have sometimes struggled to suppress the desire to prove myself. A rather childlike narcissistic need that was born, as Heinz Kohut would say, of the disgruntled exhibitionism of a small child due to the denied praise of the parents. Over time, however, I have learned that my somewhat compulsive need to demonstrate my knowledge may be perceived negatively by my colleagues. With this insight, and as I got past my insecurities about my own abilities, my need became less pronounced. External recognition, while nice, was never the main motivation that influenced my decisions and the way I treated others.

With the successful completion of the fourth year of medicine and the experiences acquired in “Avala”, my decision to become a psychiatrist became stronger. Deep down in my soul, I knew this was the path I was going to take. But back then, I still haven't figured out how this would manifest. I was aware of the recently established postdoctoral studies in psychotherapy, but I didn't think I would be accepted. In addition, I was ambivalent because it would delay obtaining employment and residency in psychiatry. I was learning how to stay patient in carving my psychiatric sculpture. I knew that at times I needed to stop, rest, look at what I had accomplished, and then, with renewed energy, forge ahead.